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See reply by Yager et al and article by Yager et al

Assessing Competency for Physician-Assisted Suicide Is Unethical

To the Editor: Unlike Yager and colleagues,1 we do not believe that psychiatrists face end-of-life issues with “knee jerk reactions that consider all intentions to end one’s life as irrational and to be stopped at all costs.” Rather, psychiatrists approach the desire to end one’s life from the perspective of venerable, well-reasoned principles of Hippocratic medicine, wrought over two millennia. Similarly, when patients request “assistance” in ending their lives, psychiatrists bring a specialized skill set to bear on the request, independent of any particular DSM diagnosis and without presumption of “mental illness.” Our aim is to help patients mitigate suffering, find some path to a better future, and, ideally, find meaning, even in the face of terminal illness. This approach is no mere reflex; rather, it represents the fundamental ethos of psychiatry, deployed with deep reflection and devotion.

A central question raised by Yager et al1 is whether it is ethical for psychiatrists to be involved in competency assessments in the context of so-called “physician assisted death.” (We endorse, and herein employ, the terminology advocated by the American College of Physicians and the American Medical Association’s Council on Ethical and Judicial Affairs; ie, “physician-assisted suicide” [PAS]).2,3

If, as we believe, PAS is inherently unethical—a position also taken by the World Medical Association4—then it is perforce unethical for psychiatrists to be involved in performing competency assessments on patients requesting PAS. By analogy: the American Psychiatric Association has taken the position that psychiatrists should not perform competency assessments on prisoners slated for execution, though psychiatrists are permitted to relieve the prisoner’s “acute suffering” while he is awaiting execution.5

Again, by analogy, we believe that, where PAS or euthanasia is legal in the United States and internationally, the psychiatrist’s role vis-à-vis patients requesting PAS should be limited to (1) determining if the patient is at immediate risk of self-harm, in which case emergency procedures could be initiated, and (2) alleviating acute suffering, such as panic attacks or extreme emotional distress, using appropriate psychiatric interventions. We also envision the possibility that a connection with a psychiatrist may help the patient work through existential and psychosocial issues that may underlie the wish for death or assisted suicide.

However, in our view, performing a competency assessment entails colluding with a process (PAS) that violates the most basic tenet of Hippocratic medicine—one that has sustained it through two millennia and a multitude of societies that have come and gone, namely, “I will not give a fatal draught to anyone if I am asked, nor will I suggest any such thing.”6

References

1. Yager J, Ganzini L, Nguyen DH, et al. Working with decisionally capable patients who are determined to end their own lives. J Clin Psychiatry. 2018;79(4):17r11767. PubMed CrossRef

2. Sulmasy LS, Mueller PS. Ethics and the legalization of physician-assisted suicide. Ann Intern Med. 2018;168(11):834–835. PubMed CrossRef

3. Council on Ethical and Judicial Affairs, American Medical Association. Study Aid-in-Dying as End-of-Life Option (Resolution 15-A-16) and The Need to Distinguish “Physician-Assisted Suicide” and “Aid in Dying” (Resolution 14-A-17). https://www.ama-assn.org/sites/default/files/media-browser/public/hod/a18-ceja5.pdf. Published 2018.

4. World Medical Association. WMA Statement on Physician-Assisted Suicide. https://www.wma.net/policies-post/wma-statement-on-physician-assisted-suicide/. Revised May 2005. Reaffirmed April 2015.

5. American Psychiatric Association. Position Statement on Capital Punishment: Adoption of AMA Statements on Capital Punishment. https://www.psychiatry.org/File%20Library/About-APA/Organization-Documents-Policies/Policies/Position-2008-Capital-Punishment.pdf. Approved July 2008.

6. Lloyd GER, ed. Hippocratic Writings. London, UK: Penguin Books; 1983.

Mark S. Komrad, MD, DFAPAa

Ronald W. Pies, MDb

Annette L. Hanson, MDc

Cynthia M. A. Geppert, MDd

ethicdoc@comcast.net

aDepartment of Psychiatry, Johns Hopkins University; Department of Psychiatry, University of Maryland; and Department of Psychiatry, Sheppard Pratt Hospital, Baltimore, Maryland

bDepartment of Psychiatry, SUNY Upstate Medical University, Syracuse, New York

cDepartment of Psychiatry, University of Maryland, Jessup, Maryland

dDepartment of Psychiatry, University of New Mexico School of Medicine, Albuquerque, New Mexico

Potential conflicts of interest: None.

Funding/support: None.

Published online: November 27, 2018.

J Clin Psychiatry 2018;79(6):18lr12566

To cite: Komrad MS, Pies RW, Hanson AL, et al. Assessing competency for physician-assisted suicide is unethical. J Clin Psychiatry. 2018;79(6):18lr12566.

To share: https://doi.org/10.4088/JCP.18lr12566

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