Legalising euthanasia and assisted suicide send mixed messages about suicide

Despite concern about New Zealand’s high suicide rate, pro-euthanasia advocates are campaigning for a law change that would allow depressed or lonely people to kill themselves with government help. That would seriously erode the valuable work of suicide prevention.

Depression and loneliness are not included in the eligibility criteria of any proposed legislation, such as the End of Life Choice Bill. However, people who are lonely or depressed are not excluded either. Even if a law would expressly exclude lonely or depressed people, they may still slip through the cracks and access death instead of care and treatment. Loneliness cannot be objectively measured. Depression can easily be hidden, misdiagnosed or ignored as ‘understandable depression’ and remain untreated. A person may not meet the diagnostic criteria for clinical depression, but may still suffer from symptoms of depression that affect their judgement and decision making.

The reason given to request death may be different from the real reason a person finds their suffering unbearable. For example, a person may request euthanasia or assisted suicide based on a cancer diagnosis, but loneliness and/or depression may be the underlying reason why he or she wants to die.   

 

The Voluntary Euthanasia Society denies that legalising assisted suicide will send out to the community mixed messages about suicide in general. In so doing they make some remarkable assertions. [1] 

  • They attempt to make a distinction between ‘rational’ and ‘irrational’ suicide in which ‘rational’ suicide describes the assisted suicide of a person “who is already dying” and ‘irrational’ suicide refers, one supposes, – since no definition is offered, to – lone suicide.
  • They maintain that people with depression would not be victimised because either most of them can be treated and would therefore not qualify for assisted suicide or, if deeply depressed would be found not competent to apply for euthanasia.
  • Loneliness they say, “is not a criterion for voluntary euthanasia”.

Why is the VES desperate to differentiate lone suicide from assisted suicide?  It is because they are attempting to ward off the charge that a society that approves one type of suicide –‘good’, ‘rational’ assisted suicide for some, cannot logically at the same time disapprove of another type: ‘bad’, ‘irrational’ ‘lone’ suicide for others.  It is also attempting to avoid responsibility for the much – feared phenomenon of ‘contagion’ leading to ‘cluster’ suicide: the phenomenon whereby one suicide triggers a ‘cluster’ of copy-cat suicides in the community [2]. 

With respect to the distinction between rational and irrational suicide, the focus of the enormous and confusing debate about these categories is about whether or not one can classify lone suicide into ‘rational’ forms and ‘irrational’ forms, not whether lone suicide is distinguished from assisted suicide as an irrational act v. a rational act.  The majority view appears to be that lone suicide can be irrational or rational; the former more likely when the act is performed on the ‘spur of the moment’ as, for instance on the receipt of very bad news, or whether the suicide has been planned over a lengthy period.  However, this judgement about the rationality or otherwise of an act of suicide is one made by outside observers: presumably suicide appears to the individual to be a rational response to whatever distress is causing him / her to plan to end their own life.

In this respect it has been noted that people are the most susceptible to considering euthanasia in the days immediately following receipt of a diagnosis of some grave disease that carries with it the possibility of termination of life. Michael Caton portrays this phenomenon very well in the film Last cab to Darwin. [3]  As Macleod points out [4] this suggests that many potential applicants for euthanasia at the very least pass through periods characterised by chaotic thought, possibly the result of a panic reaction.  Yet Geddis, attempting to make a case for legalising assisted suicide quotes with approval testimony given by the New Mexico Psychological Association [5]. 
 

that purports to be able to differentiate lone suicide from assisted suicide on the grounds that “(lone) suicidal motivation arises from an emotional crisis which interferes with logic and planning… patients tend to be severely depressed. …the unifying response is a mispIaced cognition that the situation will never improve…”  They contrast this with a picture of an applicant for euthanasia as being “mentally competent,” able to assess their future accurately, not irrationally, able to “come to grips with their terminal condition”. Such an analysis totally ignores the reality that there are significant levels of psychological distress in dying patients, with most terminally ill people plagued with fear and anxiety [6], and 15% – 26% experiencing major depression [7].  It is well recognised that there is a strong association between clinical depression and a desire to die amongst terminally ill people [8]. Thus, when examined in depth, the opinions of the New Mexico Psychological Association are found to be superficial and unsafe. It is not possible to distinguish lone suicides from assisted suicides on any notion of rationality.  The notion is made even more farcical when those who plead for legalisation of assisted suicide do so on the grounds that in its absence, some sufferers will be ‘forced’ to undertake lone suicide.

Suicide rates in New Zealand are high by world standards.  The Ministry of Health in 2011 reported the results of research which found that in that year, 478 people had committed suicide. This represented 10.6 /100 000 population, age standardised [9].  At 33.5/100000 populations, suicide rates were highest amongst men older than 85.  New Zealand suicide rates for young people are higher than for most other countries for which data are available.  For example, the rate for 15 – 24 year olds was 36.4/100 000.  For Maori youth the figure was a worrying 36.4 / 100 000 in 2011 [10]. 

Concern about the high youth suicide rates lay behind the New Zealand Suicide Prevention Strategy 2006 – 2016.  In 2013 the chief coroner, Judge Neil MacLean went public with his deep concern about the suicide rate amongst older New Zealanders [11].  He expressed frustration with the ‘stubbornly’ high figures and said: “We cannot seem to make inroads into our unacceptably high suicide rate”.  Well, if we can’t make progress in reducing suicide rates now, there are two reasons why it will be an impossibility if assisted suicide is ever legalised.  The first is because it would be discriminatory to maintain that suicide is right and acceptable for one group – or several groups – of people, but it is not acceptable for all.  The second is because of the well – accepted phenomenon of ‘contagion’.

‘Contagion’ refers to the links that are commonly observed between reports of the suicide of an individual and the subsequent suicide of a number of others in a close time-frame [12].  It was in an attempt to reduce this phenomenon that the media refrained from reporting deaths by suicide as such.  Surveys have shown that the relative risk of suicide amongst late teenagers is up to four times higher than in other age groups following the suicide of an acquaintance [13].  These additional deaths may occur in ‘clusters’.

Psychiatrists agree that diagnosing depression is difficult even for specialist psychiatrists in debilitated persons [14].  The diagnosis may be missed in people requesting assisted suicide [15].  This is one reason why the VES’ assertion that depressed people would not be “victimised” is false.  A second is that over time there is a tendency to circumvent the legislation and fail to order a psychiatric assessment for applicants who the primary physician suspects might be depressed.  In Oregon for example, where such assessments are supposed to be mandatory, the report on the Death with Dignity Act for 2014 showed that there were 105 ‘assisted deaths’.  On the basis that 20 – 26% of these were suffering some level of depression, one would have expected about 25 referrals for psychiatric assessment would have been made.  Only three were. Of course in Oregon there is the additional problem that if a doctor refuses an application, the voluntary group Compassion and Choices may well step in and locate a euthanasia – friendly physician to complete the paper work.  So there is probably not much of an incentive to do more than a basic assessment.   A third reason, which is becoming apparent in the Netherlands and Belgium, is that euthanasia is becoming accepted as a way of managing depressed and other psychiatric patients.  In 2010, two patients with psychiatric diagnoses were euthanased in the Netherlands.  This rose to 13 in 2011 and 45 by 2013 [16]. The Dutch Minister of Health, Edith Schippers, was quoted as saying that this rise in cases of psychiatric euthanasia could be explained on the increased willingness of doctors to offer euthanasia in these cases – hardly an earth-shattering conclusion.  This increase in psychiatric euthanasia recently caused Professor Boudewijn Chabot, a psychiatrist who in 1994 euthanased the first psychiatric patient, to write that the Dutch Euthanasia law has “derailed”.

No credence can be given then to the VES’ assertion that patients with depression will not be “victimised” by legalised assisted suicide.  On the contrary it is likely that they will be increasingly endangered as the interpretation of the euthanasia laws become yet more all-embracing.

Finally, with respect to the VES’ further assertion that “loneliness is not a criterion for euthanasia”, one has only to look at the way Euthanasia and Assisted Suicide enabling legislation works overseas to discover the truth.  First though, it is important to understand that proposed legislation such as the End of Life Choices Bill, allows applications for euthanasia from persons who suffer from “an irreversible physical or mental condition that, in the person’s view renders his of her life unbearable.”  Note that the arbiter is the patient not the doctor and that there is no way to independently measure levels of ‘unbearableness.’  Some people will find loneliness ‘unbearable’ by their own measure and there will be no grounds for a doctor to refuse assisted suicide or euthanasia.

In October 2011, the Royal Dutch Medical Association (KNMG) released new guidelines for interpreting the 2002 Euthanasia Act [17]. The guidelines included allowing mental and psychosocial ailments such as loss of function, loneliness and lack of autonomy to be acceptable criteria for euthanasia.  It concluded that the “concept of suffering” is “broader” than its ‘interpretation and application by many physicians today.”  Belgium is similarly disposed to allowing euthanasia for a wide range of psychosocial conditions. [18]  There is no doubt that legalising euthanasia and assisted suicide in New Zealand will soon be followed by requests for its application in psycho-social contexts.  Pro assisted suicide campaigners actually approve of its use for psycho-social conditions but feel the necessity of denying it to make euthanasia seem less scary to the population in general.

References

[1]  Voluntary Euthanasia Society of New Zealand Inc.  Answers to eight assertions about legal euthanasia. A pamphlet available on the VES website and distributed at VES-run meetings.

[2]  Haw, C., Hawton, K., Niedzwiedz, C., Platt, S., (2013). Suicide Clusters: A Review of Risk Factors and Mechanisms, Suicide and Life-Threatening Behaviour, 43(1), 97-108.

[3]  Cribb, R., & Sims, J. (Writers), Sims, J. (Director). (2015). Last cab to Darwin [Film]. Screen Australia in association with Screen NSW.

[4]  Macleod, S. (2012, Jan 16) Assisted dying in liberalised jurisdictions and the role of psychiatry. A clinician’s view. Aust. NZ J. Psychiatry 2012 Oct;46(10):936-45. doi: 10.1177/0004867411434714. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/23028195.

[5]  Geddis, A., (2015). How to win a death with dignity.  Pundit. Retrieved Sept 14, 2015, from http://www.pundit.co.nz/content/how-to-win-a-death-with-dignity.

[6]  Macleod, A.D. (2012). The psychiatry of palliative medicine. The dying mind. 2nd edition, Oxford, New York: Radcliffe.

[7] Ganzini, L., Goy, E. R., Dobscha, S. (2008). Prevalence of depression and anxiety in patients requesting physicians’ aid in dying.  BMJ, 337, a1682.

[8]  Guy, M., Stern, T. A. (2006). The desire for death in the setting of terminal illness.  Prim. Care Companion J Clin. Psychiatry,   81(5) 299-305.

[9]  Ministry of Health. (2014, January 27). Suicide Facts: deaths and intentional self-harm hospitalisations, 2011. Retrieved from http://www.health.govt.nz/publication/suicide-facts-deaths-and-intentional-self-harm-hospitalisations-2011.

[10]  Ministry of Youth Development: Youth Statistics.  A statistical profile of young people in N.Z. suicide.  Retrieved from http://www.youthstats.myd.govt.nz/indicator/healthy/suicide/international.html.

[11]  Experts ponder euthanasia link in old age suicide rate. (2013, August 27). The Dominion Post, Wellington, p.3.

[12]  Crepeau-Hobson, M. F., Leech, N. L. (2014, February). The Impact of Exposure to Peer Suicidal Self-Directed Violence on Youth Suicidal Behavior: A Critical Review of the Literature.  Suicide and Life-Threatening Behavior, 44 (1).

[13]  Haw, C., Hawton, K., Niedzwiedz, C., Platt, S. (2013). Suicide Clusters: A Review of Risk Factors and Mechanisms. Suicide and Life-Threatening Behaviour, 43(1), 97-108.

[14]  Macleod A.D. (2012). op cit.

[15]  Ganzini, L., Goy, E. R., Dobscha, S. (2008). op cit.

[16]  Schadenberg, A. (2014, February 12). Dutch Health Minister Confirms 45 Euthanasia Deaths of Mentally Ill Patients. Life news.com. Retrieved from  http://www.lifenews.com/2014/02/12/dutch-health-minister-confirms-45-euthanasia-deaths.

[17]  KNMG. (2011, June) Position paper. The Role of the Physician in the voluntary termination of life.  Retrieved from http:/www.consciencelaws.org/archive/documents/2011-08-30%20KNMG-position paper.pdf

[18]  Cohen-Almagor, R. (2015) First do no harm: intentionally shortening lives of patients without their explicit request in Belgium.  J. Med Ethics,  0, 1-5. doi:10.1136/medethics-2014-102387.

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