Thursday, February 11, 2016

Assisted suicide study questions its use for depression, autism

By Louise Kinross

A study published yesterday about doctor-assisted suicide in the Netherlands for patients with depression and other conditions, including autism, raises alarming questions.

The JAMA Psychiatry study looked at 66 cases between 2011 to 2014, including two involving people with autism. Depression was the most common diagnosis.

The practice of helping patients to die was initially limited to those with terminal illness who were mentally competent and had intractable suffering. In the Netherlands and Belgium it's been expanded to include psychiatric patients.

The researchers raise several red flags about their findings. 

In one-quarter of the cases, doctors disagreed about whether criteria in the areas of 'unbearable suffering,' competency and futility had been met, but the deaths proceeded.

Most patients were women (70 per cent) and in over half, doctors cite loneliness as a factor. For example, "The patient indicated that she had had a life without love and therefore had no right to exist" and "The patient was an utterly lonely man whose life had been a failure."

Distorted, all-or-nothing thinking is common in depression, but these statements appear to have been accepted as fact.

In 56 per cent of cases, patients refused at least some recommended treatment, calling into question whether the condition was in fact intractable. 

In more than a quarter of the cases, patients sought help from a doctor who wasn't a psychiatrist and hadn't been involved with their care. Typically, this was a physician with a mobile clinic funded by a local euthanasia advocacy group.

The scientists conclude that the granting of requests for assisted death "involve considerable physician judgment, usually involving multiple physicians who do not always agree, but the euthanasia review committees generally defer to the judgments of the physicians performing" assisted death.

In their discussion, the authors note that in a recent study of 100 people requesting assisted death from a Belgian psychiatrist, 19 per cent had autism.

A JAMA Psychiatry editorial that runs alongside the Netherlands study finds the results troubling.

"Will psychiatrists conclude from the legalization of assisted death that it is acceptable to give up on treating some patients?" Dr. Paul Appelbaum of the New York State Psychiatric Institute asks.

"There is also understandable anxiety about the secondary consequences of an assisted death option for people with mental disorders, including inducing hopelessness among other individuals with similar conditions and removing pressure for an improvement in psychiatric and social services."

Indeed, given that loneliness was a common theme, Dr. Appelbaum questions whether assisted death "served as a substitute for effective psychosocial intervention and support."

The study authors note that requests for assisted death to relieve suffering from depression and other psychiatric conditions require special scrutiny, given that these conditions "contribute to suicides, can sometimes impair decision-making, and are stigmatized."