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Ethicist and Psychiatrist Testifies on the Problems of Assisted Suicide

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April 1, 2015
The following testimony was delivered before the California Senate Health Comittee by Aaron Kheriaty, MD, Associate Professor of Psychiatry, Director, Program in Medical Ethics, UC Irvine School of Medicine:

I speak as a physician, a medical ethicist, and a psychiatrist with expertise in suicide.  In my medical practice, I treat suicidal patients routinely whose life stories are every bit as heartbreaking as Brittany Maynard’s, and whose reasons for wanting to die might seem just as compelling.  But suicide is nearly always a cry for help, not a desire to die.  As a physician I have a duty to intervene to try and prevent suicidal behavior. 

A law allowing assisted suicide for some individuals creates two groups of patients, who no longer enjoy equal protection under the law and who no longer receive equal medical care.  Assisted suicide is therefore discriminatory, and the basis for discrimination is the patient’s health status.  Under SB 128, I intervene to save Robin Williams and get him through a crisis, but I assist Brittany Maynard in taking her own life?  These two approaches to suicide are incompatible and cannot long coexist within medicine and mental health care—something will have to give.

1.  Physician-assisted suicide introduces discriminatory practices into medicine, undermines equal protection for all patients, and weakens necessary efforts aimed at suicide prevention.

If there exists a “right” to assisted suicide, why would it be restricted only to those in the throes of terminal illness?  Once we adopt the principle that suicide is acceptable, then the fences we might try to erect around it—having six months to live, or having mental capacity, for example—are inevitably arbitrary.  These restrictions will eventually be abandoned, as the situation with assisted suicide in Belgium and the Netherlands demonstrates.  The experiences here are instructive as these countries have longer experience with this than Oregon or Washington.  In Belgium assisted suicide has been granted to a man with “untreatable depression,” and to a prisoner suffering “psychological anguish” due to his imprisonment; in the Netherlands, it has been granted to a woman because she did not want to live in a nursing home. 

2.  We see here not only a practical slippery slope—that restrictions will be difficult to enforce or monitor; more than this, there is a relentlessly logical slippery slope—because once we adopt the supposed “right” to assisted suicide, restrictions are seen as groundless and are eventually abandoned. 

Suicide is now a public health crisis: alarmingly, it is now the 3rd leading cause of death among adolescents and young adults.

We know that suicide is typically an impulsive and ambivalent act.   A journalist tracked down the few dozen individuals who survived jumping from the Golden Gate Bridge, and asked them what was going through their minds in the four seconds between jumping and hitting the water.  Every one of them responded that they regretted the decision to jump, with one saying, “I realized that all the problems in my life that I thought were unsolvable were actually solvable—except for having just jumped.”

Those who work in palliative care will confirm: when a terminally ill person professes that they want to die, it is a cry for help.  When comfort or relief is offered, in the form of more adequate treatment for depression, better pain management, or more comprehensive palliative care, the desire for suicide vanishes. 

Nearly 90% of suicides are associated with clinical depression or other treatable mental disorders, including for individuals at the end-of-life.  Yet alarmingly, less than 6% of the individuals who have died by assisted suicide under Oregon’s law were referred for psychiatric evaluation.  Similarly, SB 128 does not require physicians to refer for psychiatric consultation to rule-out common mental disorders that contribute to suicidal thinking.  Based on what we know about suicide risk factors, this constitutes gross medical negligence.

Suicide completion generally requires not just intent (which typically waxes and wanes over time) but also easy access to means.  Suicidal individuals tend to fixate on one specific suicide plan.  If that particular means isn’t readily available, they typically choose to live.[i]  I had this experience recently with a 79-year-old patient who requested physician assisted suicide: he gave up on his suicidal plan entirely when he discovered that neither I nor my colleagues at UC Irvine would provide this for him.

3. Assisted suicide will lead to medical abandonment of vulnerable individuals, especially those suffering from treatable mental illnesses like depression or anxiety.

Assisted suicide advocates claim we need this option to deal with situations of intolerable pain and suffering.  But in the data from Oregon, most patients who requested assisted suicide did not cite concerns about pain and suffering as their motivating reason (only 23%).  Much more common reasons included loss of autonomy (91%) and the fear of becoming a burden on others (40%).[ii]  We must communicate to each and every patient: you are not a burden, and we will continue to care for you, even when cure is no longer possible.

Assisted suicide advocates insist that this is a purely private decision or an exercise in personal autonomy—that it does not affect others.  But scientific research has repeatedly demonstrated a “social contagion” aspect to suicide, which leads to copycat suicides.  Our individual decisions profoundly impact the decisions that others make.  This law will have social effects that adversely impact vulnerable individuals.

It is noteworthy that the overall suicide rates in Oregon rose dramatically in the years following the legalization of physician assisted suicide in that state in 1997: after Oregon’s suicide rates had declined in the 1990s, they rose alarmingly between 2000 and 2010, surpassing the rate of increase nationally.  Suicide rates are now 35% higher in Oregon than the national average.[iii]

4.  The legalization of physician-assisted suicide sends a message that some lives are not worth living.  The law is a teacher: if assisted suicide is legalized, this message will be heard by everyone who is tempted by suicidal thoughts or tendencies.

Advocates are trying to redefine suicide.  “Compassion and Choices” (formerly known as the Hemlock Society) claims that “physician aid in dying” is not really suicide, simply because the means employed—taking a deadly drug—are “nonviolent” and “peaceful.”  This attempt to manipulate language, and do to an end-run around hard realities, is irresponsible and deceptive.  The definition of suicide is clear, and it does not depend on the particular means employed. 

We need to call this by its name: the most precise and accurate language to describe SB 128 is actually “physician prescribed suicide”.

Senate Bill 128 is not a modest proposal.  It is not one small step in expanding end-of-life medical options.  It is not an extension of already existing palliative care practices.  

No.  It is a radical departure from sound medical practice.  The American Medical Association’s Policy states that, “physician-assisted suicide is fundamentally incompatible with the physician’s role as a healer, would be difficult or impossible to control, and would pose serious societal risks.”[iv]  To maintain our professional integrity, medicine’s mandate must remain this: When possible to cure.  Always to care.  But never to kill.

SB 128 is not only bad law for the profession of medicine; more importantly, it is bad law for the patients we serve.