Non-Maleficence and Assisted-Dying

"It is unethical to create a process that will populate cemeteries with such patients under the guise of respect for patient autonomy because we failed to conduct the research necessary for truly informed decisions."

Non-Maleficence and Assisted-Dying
Photo by Sharon McCutcheon / Unsplash

"It is unethical to create a process that will populate cemeteries with such patients under the guise of respect for patient autonomy because we failed to conduct the research necessary for truly informed decisions."

Opinion: Changes to assisted-dying rules put psychiatrists in an impossible position
Soon people with incurable mental illness will be able to apply for a medically assisted death. But experts can’t know for sure which patients will recover.

This is a very interesting read and something I've written much on in the past.  Clearly, I'm a strong proponent of personal autonomy.  I am also a mental health provider.  So, I'm forced to reconcile views on suicide as non-equivocal to assisted-dying.

As a brief aside, the rules and laws that bind my professional practice are subject to the culture / country they're developed in.  As such, it is worth noting that not all cultures view suicide as pathological, and indeed I've made this case myself – something I was not always in agreement with.

There's a lot of context here so I'd recommend checking out some of my other posts as well.  At one time suicide was illegal in the United States, meaning that if you killed yourself, your family would be criminally prosecuted.  Fast forward, and there are still many stipulations in the states that do legally allow assisted-dying.

Those preparatory laws are actually a good thing in my opinion because they get at the meat of the argument here.  When / under what conditions is wanting to die or to kill one's self pathological?

Before anyone jumps to a conclusion, let's consider two hypotheticals:

  • John: 94 years old, raised during depression, served in two world wars, survived two recessions, survived COVID, now has stage 4 cancer, widower of 15 years, no signs of degenerative brain disease, depression, or psychosis.
  • Jared: 23 years old, Iraq veteran, struggles with PTSD, poly-substance abuse to self-medicate, divorced, family history of bipolar disorder and schizophrenia, has struggled with suicidal ideation since age 13.

Of course, my aim isn't to twist anyone's arm into one decision or another.  But, clearly we're looking at very different circumstances.  To the point of the linked opinion piece, who are we to tell a patient that their suffering is irremediable?  Would that not be enabling their pathological hopelessness?

Semantics matter here.  Both John and Jared may be actively pursuing their own death.  How hopeless is either?  How "pathological" is their condition?  Of course, pathology itself may be defined culturally, but as stated above we are talking about culturally specific legality (opposed to universal, or even personal, morality).

To this end, I have to agree with the above author.  The legal and ethical quagmire created by such legalization of assisted-dying for chronic (mental) health conditions is inexplicable.  Albeit, just because something is legal, my (or your) ethical or moral virtues may go beyond or even counter to what the law dictates.

Don't confuse this with vigilantism.  I'm talking about about a legal allowance (i.e. minimum standard) versus ethical obligation (best practice).  Legal intoxication levels (say for alcohol while driving a vehicle) are dictated by blood levels of a particular substance; however this speaks nothing to the level of impairment in one's driving; only the concentration of a particular substance in their blood.

Again, the semantics matter.  Whether drinking (how much?) and driving is "right or wrong" (a moral, not a legal issue) is one thing.  Me telling them (ethical / moral) so is another.  At any rate, you see how muddy these water can become?

In the United States, we have a right to refuse medical treatment – pertinent information regarding other topics – though again there are caveats regarding mental competency.  Another cultural consideration is that in the Western World we've become ironically enamored with longevity with no attention to quality of life (e.g. "healthspan" vs. lifespan).  This ironic because of our reflexive model of healthcare and willful ignorance (in mainstream treatment) of preventative models of health.

My hope is for people to live beautifully satisfying, fulfilling, adventurous, and connected lives.  As with any mental health or deeply human issue, such as life and the end of it, there's a much more nuanced discussion needing to be had between provider-patient in addition to what a certain legal or cultural dictum may suggest.

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