The Slippery Slope to Euthanizing Psychiatric Patients

Imagine that your adolescent son or daughter suffers from a serious and intractable depressive illness. Every treatment short of electroconvulsive therapy has been tried, but nothing has really worked. After years of misery, your teenage child tells you, “That’s enough. I’m done! I’m gonna end this, one way or another.” How would you feel if your child’s doctor now offered to help your child commit suicide by prescribing a lethal drug?

If you think this scenario is the stuff of Orwellian fiction, think again. So-called “physician-assisted dying”—even for people with nonterminal illnesses, like major depression—is now accepted practice in parts of Europe. Extending this “right” to youth with intractable mental illness could eventually become legal in Canada. And if current trends favoring “physician-assisted suicide” (PAS) in the United States accelerate, we could find ourselves in a similar position.

Let’s be clear: I am not talking about a terminally ill, mentally competent adult’s right to refuse useless treatment as death approaches—a right clearly recognized by U.S. courts. Nor am I talking about physicians prescribing a lethal drug to a mentally competent adult who wishes to end his life, in the context of a terminal illness like pancreatic cancer. Indeed, five U.S. states already permit PAS in this context. I am talking about vulnerable young people with potentially treatable psychiatric disorders who have decided that “enough is enough”—even though their competence to make such decisions is highly questionable.

I am writing about this in the face of several recent developments. First, Canada is now considering assisted suicide for “mature minors” with psychiatric illnesses causing “intolerable suffering.” The basis for this proposal is a recent report to Canadian lawmakers from the Special Joint Committee on Physician-Assisted Dying. This clear expansion into the realm of adolescent mental illness seems to validate the “slippery slope” argument that many medical ethicists have raised with regard to physician-assisted suicide.

The proposal regarding PAS for mature minors with mental illness has not yet been enacted into Canadian law. However, Canada’s Parliament recently passed Bill C-14, which provides for “one or more independent reviews relating to requests by mature minors for medical assistance in dying”— potentially including “requests where mental illness is the sole underlying medical condition.” If, after review, the mental illness clause is enacted into law, this could mean that young people with potentially reversible conditions like major depression would be able to receive a physician’s “assistance” in committing suicide.

It is far from clear how “maturity” will be determined in such cases or what that term means in the context of the normal adolescent’s stormy emotions and incompletely developed brain. Furthermore, while psychiatric illness does not preclude competence to make medical decisions, it is often extremely difficult to establish competence in the presence of serious psychiatric illness. Thus, the adolescent with severe major depression who hasn’t responded to several antidepressants may wrongly conclude, “There’s no hope for me. I’m finished. My only option is suicide!” even though there are still many potentially effective remedies available.

The expanding notion of PAS for persons with mental illness is not confined to Canada. In Belgium and the Netherlands, PAS is legally permitted for cases of “unbearable suffering” due to “untreatable” mental illness—despite controversy over how these terms are defined and how patients are selected.

Fortunately, in the United States, the slippery slope toward euthanizing psychiatric patients may have been roughened. Recently, after being approved by the APA Assembly with no objections, the following proposal was endorsed by the APA Ethics Committee: “The American Psychiatric Association holds that a psychiatrist should not deliberately prescribe or administer any intervention to a non-terminally ill person for the purpose of causing death.”

The proposal does not represent a position of APA until it is approved by APA’s Board of Trustees. The Board is scheduled to address the proposal at its October meeting.

It is one thing to argue that mentally competent adults with demonstrably terminal illnesses ought to be at liberty to end their own lives. It is another to argue that physicians ought to be willing participants in that process. And it is truly a bridge too far to argue that physicians ought to “assist” vulnerable, mentally unstable youth in taking their own lives. ■