Topic of Choice

             In our class discussion regarding ethical issues related to healthcare, we briefly touched upon the topic of physician-related suicide. We didn’t have our most substantial discussion on this topic, which is understandable; it is an extremely sensitive topic, and suicide in general is in many ways a taboo subject in our society. I do believe it is an important topic though, as it drives at the question of what the fundamental role of a healthcare provider actually is. Is the primary ethical responsibility of the medical professional to preserve life, or is it to alleviate patients’ suffering?

I don’t think that the question has an easy answer, and I won’t attempt to provide one here. I will, however, posit that for many centuries of human existence the medical profession focused primarily on the latter. Before the advent of vaccines, antibiotics, antivirals, and chemotherapy agents, how was infectious disease or cancer treated? Amputation or surgery may have been an option in some cases; to my knowledge though, treatment was primarily focused on trying to reduce the symptoms that interrupted quality of life with the hope that the body might heal itself. This form of healthcare remains far from extinct in the world of modern healthcare: what are the goals of treatment for chronic pain? For mental illness? Despite our understanding of some of the biologic underpinnings of these disease states, our knowledge remains woefully inadequate and the prospect of having a definitive cure remains a pipe dream. Take for instance depression, which has been studied extensively for many years and which we’re fairly confident has a biological basis resulting from neurotransmitter imbalances (serotonin, norepinephrine, and dopamine being the most studied). For some patients, SSRIs may be very efficacious, for some SNRIs might work, for some the only effective agents are those with mechanisms of action we don’t really understand, and for some pharmacotherapy doesn’t work at all. In disease states such as this, our focus is wholly on improving quality of life, preserving “normal” functioning, and trying to advance our understanding of the disease so we may more effectively accomplish these goals. Even in many cases of infectious disease or cancer, this moral predicament fails to present itself; if we can cure the disease, we are necessarily both prolonging life and improving its quality. It is only when directly faced with the inevitability of life’s end that the question comes into focus: is death the primary antagonist, or is it suffering? Furthermore, do we allow patients the agency to answer that question for themselves, and do we act based on their decisions?

Physician-assisted suicide is currently legal in 10 U.S. states: California, Colorado, Hawaii, Maine, Montana, New Jersey, New Mexico, Oregon, Vermont, and Washington, as well as in the District of Columbia. In all except Montana, the conditions under which it is legal are explicitly codified. Patients must be at least 18 years old, have terminal illness with a life-expectancy of six or fewer months, and must be certified competent and capable of making and communicating their own healthcare decisions. Many also require multiple physicians to approve the request, a psychiatric patient evaluation, and communication of alternative options such as palliative care and hospice. They also protect the legal right of providers to refuse the request and provide legal protection for both physicians and pharmacists that participate in the process. The disparities in legality, as well as the legal protections offered to those that choose to abstain, signify that the ethicality of physician-assisted suicide in the terminally ill is far from a clear-cut issue. What I would like to discuss though, is probably an even more sensitive and morally controversial issue, and that is whether healthcare professionals have the ethical obligation to prioritize the preservation of life, against the patients’ wishes and when death is not imminent, under the pretext that prolonging life has the potential to alleviate patient suffering.

In March of 2021, Canada joined a small group of countries, including Belgium, Luxembourg, the Netherlands, and Switzerland, that offer euthanasia or assisted suicide to suicidal individuals. There are differences in the legal prerequisites between the different nations, but the general idea is that patients with mental issue that find their psychological suffering to be unbearable and untreatable by means that they find acceptable may voluntarily choose to end their lives. I do not think we have the time in this class, nor I the space in this blog post to have a nuanced discussion of the ethical or legal questions surrounding these laws, much less the idea of suicide in this patient population in general. I would like to, however, propose the challenge: “So you find these laws to be abhorrent? Prove it.”

The primary crux of the argument against physician-assisted suicide in mental illness centers on the insistence that treatment always holds the potential for these patients to improve their quality of life. I don’t wish to dispute the validity of that argument in principle; however, I would like to suggest that the assertion that “it can get better” is a hollow platitude that offers no comfort to these patients. It is all bark with no bite, all wretch with no vomit. The insistence that they could try this SSRI or that SNRI, CBT rather than psychoanalysis, group therapy rather than one-on-one, increasing the frequency or duration of their talk therapy, trying electroconvulsive therapy or whatever new therapy is proving promising in psychiatric circles these days, all these suggestions ignore the actual reality of this patient population. In our previous discussion on issues of the healthcare system in the U.S. I brought up what I consider some of the inadequacies as it pertains to mental health: namely, long wait times, ineffective drug therapy that requires extensive trial and error, and a lack of insurance coverage for the necessary therapies. I would like to extend that discussion to talk about social determinants of health, and particularly how they apply to this specific patient population. Patients with severe refractory mental illness are significantly more likely to have financial troubles, to be unemployed, to lack sufficient health insurance, to have poor diets, to struggle with drug and/or alcohol abuse, to lack a robust social support network, and to face discrimination tied to the stigma that still exists within the current cultural paradigm, although that thankfully seems to be improving. Suggesting treatment options to try ignores the fact that these patients often lack the time, money, or motivation to pursue these opportunities. I would like to be clear that I am not suggesting that affluent individuals cannot struggle with suicidal ideation, nor that a robust social network cannot coexist with these struggles, nor that I endorse physician-assisted suicide as a morally just act in this population. I simply wish to point out that if we, as healthcare providers, are unable to unequivocally guarantee access to our best therapeutic options for these patients, free from the promise of looming debt or discrimination, then we are failing in both of our objectives of prolonging life and alleviating suffering now aren’t we?