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Daybook, Medicine, Quotage

Suicide by TLA

This editorial has too many TLA (Three Letter Anacronyms).

  • AAS is the American Academy of Suicidology
  • PAD is physician assisted deat: a form of euthanasia

What the author identifies, correctly, is that there is a slippery slope to freeing up euthanasia for the inconvenient, including those who have treatable conditions… at the very time when somatic treatments for severe depression are in renaissance. and (b) that the American Academy does not want anything to do with this.

The AAS statement lists many features of persons who die by suicide (eg, mental illness, isolation, loneliness, personality disorders) which purportedly distinguish them from those seeking PAD. However, persons who receive psychiatric PAD share these characteristics: they all have some form of mental illness; most also have personality disorders, have attempted suicide, and are socially isolated or lonely. Indeed, some receive PAD shortly after a suicide attempt, like a man who jumped off a building, survived the fall with broken thighs, and then received PAD during the ensuing hospitalization.

Still, sharing risks or characteristics of those who die by suicide need not mean PAD is the same as suicide. It could be that even persons seeking psychiatric PAD have different mindsets and motivations—just as persons with terminal illness seeking PAD are said to have different motivations2—from those who die by suicide. Thus, the AAS statement notes that “[s]uicide… typically stems from seemingly unrelenting psychological pain and despair; the person cannot enjoy life or see that things may change in the future….[and] suffers from…loss of meaning.”2 However, research shows that these common features of suicide are not only present in psychiatric PAD but are cited as justifications for PAD (to show that a person is suffering intolerably, as defined in and required by the Dutch law and Code of Practice1). Consider, for example, this characterization of a patient by a physician who provided her psychiatric PAD: “She suffered from the meaninglessness of her existence, the lack of a prospect of a future and the continuous feeling of finding herself in a black hole… she experienced deep despair and loneliness [Patient 2015-32].”

This patient shares another feature with persons with suicidal thoughts. As the AAS statement notes, in suicide, “the person often ‘sees no way out’ of their desperate situation.” The statement’s assumption is that the perspective of a person with suicidal thoughts is distorted, that the person’s experiences can be made tolerable and the will to live restored with treatment. Thus, it might be thought that psychiatric PAD would be granted only to those who have exhausted all reasonable treatment options. While in theory a patient and the physician together must agree that there is “no prospect of improvement,”5 the criterion is now overstretched to emphasize the subjective component, according to psychiatrists interviewed in a Dutch government study.

Kim SYH, Conwell Y, Caine ED. Suicide and Physician-Assisted Death for Persons With Psychiatric DisordersHow Much Overlap?. JAMA Psychiatry. Published online August 08, 2018. doi:10.1001/jamapsychiatry.2018.2065

Watch this space. Expect those who are evil to try to turn the helping professions into agents of abuse. This has happened before. But, it appears, that history is now deeply unfashionable. I hope that the euthanasia bill before our parliament fails. The contradiction of simultaneously holding physicians accountable for preventing suicide while encouraging them to kill the unworthy is a sign that the liberal project has no further utility.

It is time to react. To refuse to take part. And not to be like them.

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