There is something ironic and horrible in the notion that the first clear breach in the voluntariness of legal euthanasia – that all euthanasia be the result of a competent, capable choice – should be made in psychiatry. For we are accustomed to trust psychiatry with the defense and arbitration of choice itself. It is psychiatrists who have specific expertise in studying the voluntary operation of the will: capable, competent and unconstrained.
One of the traditional cornerstones of the determination of decision-making capacity in clinical settings is the observation of a patient’s attitude towards self-preservation. For although we praise self-sacrifice in the protection of others, the will for self-destruction in suicidal thinking has hitherto been understood as a sign of incapacity and incompetence. How then can psychiatrists now be asked to evaluate a “rational” desire for suicide? To assert that any form of self-destruction, in the context of medical care, can be a rational, normal and competent act, rather than the obvious manifestation of some putative pathology, is to stab at the heart of psychiatric science, practice and ethics.
In other medical fields, we have recently been asked to accept the suicidal will as a subjective mystery: most wish to survive; some do not; and we are simply told that each personal choice must be respected. However, psychiatry is the place where we would like to understand why those choices are different from one person to another; we would like to distinguish between normal healthy choice and its pathological cousin. And yet, emerging changes in social values and policy are now forcing us to subdue that inquiry. We are asked to simply accept suicidal choices as rational and perhaps even to contemplate the frightening prospect of a complete inversion in values.
A moment’s pause will reveal that this seismic shift, forced on psychiatry in some jurisdictions, threatens to have catastrophic implications for the application of euthanasia throughout the medical spectrum. For if suicide is benign and normal – not psychopathology, but rational wisdom – it will no longer be necessary for suicidal patients at the end of life to justify their desire to die. It will rather be, for all those in the same circumstances, to justify why they obstinately persist in a desire to live. And in a short time, this same logic will apply also to those who are non-terminal, chronically ill or disabled.
Setting aside, for a moment, these crucial macro-effects of condoning psychiatric euthanasia, there are also several challenging aspects to evaluating patient eligibility, inherent within the field of Psychiatry itself:
First, there are no physical or biological markers that provide another domain of validation for psychiatric disorders, which are basically assessed phenomenologically. There are, for example, no blood tests or brain images which can conclusively diagnose the majority of disorders. The reliance on a patient’s history to develop diagnostic conclusions makes the evaluation very vulnerable to patients’ lying about their histories (which actually has occurred several times in Belgium among patients being assessed for psychiatric euthanasia). Because of these and other factors, psychiatric diagnostic reliability rates are only 66 – 76 %. Yet even when there is diagnostic agreement, studies have shown that prognostic predictions about the future trajectory of a well-diagnosed psychiatric illness are even less reliable than the diagnoses themselves. In a word: all of this seems a little thin in justifying the administration of lethal medication.
However, the subjective element in the psychiatrist’s role as gatekeeper is further complicated by subtle issues of counter-transference (forces which are an issue not only in psychiatry but in all long-term treatment relationships). In 73 % of Dutch cases, euthanasia was performed by the patient’s treating psychiatrist: the very same physician who previously tried to prevent a patient’s suicide ends up providing that suicide. Surely this maximizes the vulnerability to subjectivity, counter-transference, projective identification, collusion and abuse – especially considering the natural human motivation to be rid of a particularly vexing case, even while celebrating a successful and appropriate “treatment” with euthanasia.
Moreover, once a primary diagnosis has been made, there are often multiple treatments for the same disorder which may or may not be effective (and may or may not have been tried), making the conclusion of an “incurable” condition all the more uncertain. In fact, 38 % of those euthanized in the Netherlands had not received any of the more robust psychiatric treatments such as electroconvulsive therapy, and fully 20% had never been treated as in-patients. There is even pending publication of data showing that a significant number of patients with personality disorders were deemed “untreatable” even though they were never treated with psychotherapy.
Finally, as in other areas of medicine, euthanasia candidates are not usually the sickest, nor is medical “suffering” their primary motivation: 66% claim their first concern is social isolation – a problem which is endemic among those with chronic mental disorders.
Unsurprisingly, the practical result of all these factors has been the euthanasia of all sorts of people, including even alcoholics and sufferers of post-traumatic stress disorder. But more troubling, as concerns the special duty of psychiatry to elucidate questions of competency, we also find psychotic patients euthanized, and those with anorexia, where suicidal motivations and refusal of treatment are themselves common symptoms of the disease. Indeed, even the pretense of serious medicine has been dropped in Belgium and the Netherlands, with an accelerating movement to normalize euthanasia for people who are simply “tired of living” due to a “completed life”.
With the imposition of euthanasia upon medical practice in Canada and elsewhere, the internal logic of medicine itself – as a healing science built upon a 2500-year-old community of values – has been ignored and trampled. But in psychiatry, this aggressive vandalism is still more evident. The prevention of suicide is a principal goal of psychiatric treatment, a fundamental ethos. How can psychiatrists now be asked to validate and promote suicide? If the business of clinical psychiatry is not to produce a more satisfying relation to the experience of life, as reflected in the strength of an individual’s desire to live (and to help find a path to a better future), then what is it for?
In Soviet Russia, political dissidents were often treated as psychiatric patients, on the grounds that their “irrationality” was demonstrated by their inability to understand the truth of Soviet doctrine. Once psychiatric diagnosis is subordinated to ideology, anything is possible. The fate of all sorts of people becomes as uncertain as their “official” mental state. In the present case, the weakening of the concepts of capacity and competency resulting from the euthanasia of psychiatric patients – namely, the confusion of who is, or is not, rational and normal – places people with cognitive disorders, and other disabilities, at great risk. Their deaths might now be expected, planned, and subtly encouraged in a new climate of suicidal anticipation where it is assumed, that if they were competent, that is, if they fully understood their wretched condition, they would rationally choose to die.
All of this stems from an extreme ideological desire, not only to permit suicide, or even to recognize it as a right, but to actually claim suicide as an objective benefit! Yet once medical theory and ethics are constrained by ideology, the perversion of medicine becomes inevitable in practice. And as we have stated many times: whatever social forces are working to validate the legitimacy of subjective suicidal choice, medicine as an independent scientific enterprise must not be contaminated by that agenda. The pursuit of medical science is fundamentally distinct from philosophical and political fashion, marching resolutely to the sound of its own, unique, drum beat.
As a sage has written, “Those who can make us believe absurdities can make us commit atrocities.”
Make euthanasia unimaginable.
*********************************************************************
With special thanks for the collaboration of Dr. Mark Komrad
*********************************************************************
Sincerely,
Catherine Ferrier
President