Vignette: You are a physician who lives in a jurisdiction that allows for euthanasia for
psychiatric conditions. Mary is seeking your help regarding physician-assisted
euthanasia. She says that she has come to this decision on her own accord. Mary is in
her mid 70s and, for the last five years, has had severe, treatment-resistant depression.
This past year, she lost her husband. Shortly following his death, Mary ingested a bottle
of pills and tried to kill herself, but she was not successful. She claims living with
depression is impossible and she no longer wishes to continue living, especially
following the death of her husband. In the past, Mary has tried several anti-depressants
without any improvement in her depression. She has refused psychotherapy and
counselling to treat her depression on several occasions. Despite the knowledge that
they may help, she has refused these treatments as well as other medications (such as
other drugs that have been shown to treat depression). She has also refused
electroconvulsive treatment for depression. In addition to all of this, in the last year,
Mary is showing signs of forgetfulness. (Liu, 2024)
Mary’s request to die is not voluntary, well-considered or competent fundamentally
because the condition itself prevents her from having these factors. For Mary’s request to die to be voluntary, she would have to meet three necessary and sufficient criteria relative to her: understanding information about her condition, decision making-capacity, and being free from coercion. (Riisfeldt, 2023) Feelings of suicide are symptoms of the condition of depression and not justification of the act of killing oneself. (Burns, 1999) To understand the condition of depression, would be to understand that one’s cognitions are the cause of the depression. Dealing with one’s unhealthy thinking patterns has been shown to relieve the symptoms of suicide. (Burns, 1999) Mary does not demonstrate an understanding of depression and her request for euthanasia is a result of the depressive symptom. It is reasonable that she is free from coercion, for there is no evidence that another person is forcing her to make any decisions.
An understanding of depression would mean the individual comprehends the causes
and is capable of making a decision to alleviate those causal factors to remove the symptoms. To say that her depression is treatment resistant is ambiguous, she is resistant to try treatments that have proven to work. It is not that treatments are ineffective but that she, because of the depression, is unwilling to help herself. This motivational factor is a different phenomena than stating that treatments are not effective. Her refusal of treatments that will help her is an indication that she does not understand her condition and her decisions to not be helped are a product of the condition.
Ganzini et. al. (2000) identifies four elements that determine a person’s competence: an
ability to communicate their choice, an understanding of the facts of the issue, situational and consequential appreciation, and the ability to rationally manipulate relevant information. Mary has demonstrated that she is communicating the choice to die, however she does not demonstrate the latter three elements of competency. She does not show an understanding of the facts of depression nor an understanding of the cognitive distortions she is expressing like living with depression is impossible. This is clearly showing the cognitive distortion of catastrophizing (Burns, 1999).
A true understanding of depression, the situation and its consequences, and rational
manipulation of information would mean she is able to understand how her thoughts and actions greatly influence the condition of depression. These thoughts, or cognitions, can be changed and her inability to do so is ultimately involved in the cause of her condition. To fully understand the situation she is in and the consequences of it, she would have to have a sense of how to think in a healthy way instead of simply refusing to change her ways.
The rational manipulation of relevant information would be to identify what cognitive
distortions are involved in her thinking patterns and replace them with rational cognitions. For example, the cognition ‘living with depression is impossible therefore I will kill myself,’ is distorted because she has the capacity to make changes that would give her the ability to overcome her depression. An example of a rational or realistic response would be, ‘Depression may seem impossible now but that is because I am unwilling to do anything about it. If I make an effort to help myself with my medical team, my condition will be manageable. At the least, I can try and see how things work out.’ This second cognition expresses an appreciation of the situation and her role within it as well is a rational manipulation of relevant information.
Even though Mary is showing signs of forgetfulness, it can be both positive and negative. On the positive side, she may forget about that which depresses her and her depression may lift naturally. The negative side may be that it will be more difficult for her to learn CBT due to the forgetfulness. Either way, it does not change her lack of autonomy due to her illness.
Mary’s refusal to try treatments that are shown to work, not demonstrating an
understanding of her condition, the situation or consequences, and an inability to rationally
manipulate information shows that she is not competent to make a voluntary decision. This also means that her request is not well-considered because primarily of her refusal to try treatments that have good prospects of helping her. To be well-considered would be to make an effort to attempt the options that are available. Within this case, there are treatments or therapeutic alternatives (Dierickx, 2017) that do have reasonable grounds for improving Mary’s condition and hence reduces the legitimacy of her request. To be well-considered is when one thinks carefully about something, which she has not demonstrated in her lack of understanding of the treatment alternatives.
van den Berg et. al. (2020) lists a table of the elements of suffering, where three of
the eight categories could apply to Mary’s case: social isolation, loss of meaning in daily life and loss of quality of life. Ortega-Galan et. al. (2022) defines unbearable suffering as suffering that the patient cannot endure. It would be true that Mary’s suffering is unbearable because it would be subjected to the patient (Ortega-Galan et. al., 2022). The suffering being long-lasting and not having a prospect for improvement is contingent upon Mary’s acceptance to end the suffering. Mary’s refusal of treatment options that would improve her depression and subsequent feelings of suicide are within her capacity and control. It would be a different matter entirely if all available treatment options were attempted and none existed that could improve her condition. Assuming that no treatment or therapeutic practice is administered, Mary’s suffering is unbearable, long-lasting and does not have any prospect of improvement.
To be informed about one’s situation and prognosis, as stated above an individual
must demonstrate an understanding of relevant information, ability to make decisions and be free from coercion. (Riisfeldt, 2023) As similar to the point about the voluntariness of her
request, Mary is not fully informed about her situation and prognosis because she does not
demonstrate an understanding of depression and the symptom of suicide. An understanding of the causal nature of suicide and depression would mean a person’s decision making frame would be to eliminate the causal factor of the symptom of their condition, not enable the symptom of their condition. As an analogy, a person with a treatable virus that has little to no side effects would opt for the treatment with sufficient understanding of the condition of the virus. To allow oneself to die from a treatable virus with little to no side effects is demonstrable lack of an understanding of one’s condition or the situation of the human condition in general. Being human necessarily means one will confront suffering and the creation of meaning is found within the ability to overcome that suffering. Allowing the suffering to kill oneself when available options are available is indicative of a mental illness and not one’s autonomous decision making based on informed consent. The paradox of depression is that Mary can improve her condition but she lacks the motivation to do so.
It is clear that Mary has refused her options of care including antidepressants and
different therapies. It is understandable if a person refuses a treatment that has negative side
effects or would be uncomfortable like electroconvulsive therapy or some anti-depressants, but there is no reason why a person cannot make an active effort to learn cognitive behavioural therapy and implement the wisdom from that practice to reduce depressive symptoms. Sklar (2011) identifies how the New York Court of Appeals determined in 1914 a person’s right of autonomy to refuse medical treatment and explicitly states that the right of refusal is excluded from people who are mentally ill. In the case of Mary, one could justify some form of involuntary cognitive behavioural intervention that challenges her distorted thinking patterns based on the premise that she is mentally ill and is not making autonomous decisions in their best interest.
Two challenges faced as a physician in Mary’s case are ethical. The first challenge has
to do with the principle of nonmaleficence and the second challenge is the principle of
autonomy.
1) Nonmaleficence is the principle that is challenging for physicians which is seen in the
hippocratic oath of ‘do no harm.’ (Clarke et. al., 2017) Physicians are professionally and duty
bound to not cause harm to their patients. Killing a person, in the context of euthanasia, can be seen as the ultimate harm because actions taken would end the person’s life. The definition of harm can be expanded to include concepts like quality of life that is based on suffering. To conduct euthanasia, a physician could understand nonmaleficence as in the negative way of relieving or the removal of suffering. To allow a patient to suffer would be to cause harm and hence violate the hippocratic oath.
2) The second challenge for a physician is Mary’s autonomy. Autonomy is the ethical
principle where people have the right to make informed decisions about their healthcare and not be imposed upon by the medical institution to do things against their will. (Pirotte and Benson, 2023) In this case, determining whether Mary has autonomy to decide to die and refuse treatment that would help her is a clear challenge for the attending physician. If Mary does not have autonomy, then the physician can argue her request to die is denied and her refusal for treatment, like cognitive behavioural therapy, not be followed. Since Mary has a mental illness and that illness is the cause of her request to die, she does not have autonomy in this case. One could argue from the principle of beneficence, the duty to do good, that violating her autonomy and having some cognitive behavioural intervention by challenging her distorted thinking, would have produced more good by reducing the cause of her depression.
Moral injury is an emotional and cognitive response people have to an event that
violates their moral or ethical code. (Williamson et. al., 2021) The people who would suffer moral injury in Mary’s case could be someone from the medical staff, like the physician or a nurse, or someone who is personal to Mary, like a member of her family. Williamson et. al. (2021) discuss how both the medical staff and the family of the person who a morally ambiguous procedure occurs to are both at high risk of moral injury. The medical staff or her family are at risk for moral injury because they may disagree that the application of euthanasia was valid in Mary’s case because she did not have autonomy due to her mental illness. In contrast, euthanasia in the context of a terminal illness, where the person only has one week to live and is constantly in unbearable physical pain, meaning all of their attention is directed towards the experience of physical pain, is a very different case from Mary’s. Mary is actively refusing the treatment that could help her and because there is the possibility that she can recover from her depression and live the remaining years of her life with meaning, it is not ethical to allow her to kill herself with euthanasia. Suicide is a symptom of depression and not a justification of the act in itself. (Burns, 1999)
The appropriate response is to begin with small cognitive behaviour interventions that
challenge her distorted thinking so that she can see the world differently and find realistic ways to develop meaning in life. The justification for violating her autonomy by involuntarily giving her incremental cognitive behavioural discussions is that she lacks autonomy due to her condition of depression and the ethical outcome with reference to beneficence and nonmaleficence of her living a good life for her remaining years, outweighs her autonomy of refusal to get better. (Sklar, 2011)
References
Burns, D. D. (1999). Feeling good (2nd ed.). Harper.
Clarke, G., Fistein, E., Holland, A., Barclay, M., Theimann, P., & Barclay, S. (2017). Preferences
for care towards the end of life when decision-making capacity may be impaired: a large
scale cross-sectional survey of public attitudes in Great Britain and the United States.
PLoS One, 12(4). doi.org/10.1371/journal.pone.0172104.
Dierickx, S., Deliens, L., Cohen, J. & Chambaere, K. (2017). Euthanasia for people with
psychiatric disorders or dementia in Belgium: analysis of officially reported cases. BMC
Psychiatry, 17(203). https://doi.org/10.1186/s12888-017-1369-0.
Ganzini, L., Leong, G. B., Fenn, D.S., Silva, J.A., & Weinstock, R. (2000). Evaluation of
competence to consent to assisted suicide: views of forensic psychiatrists. American
Journal of Psychiatry. 157(4), 595-600. doi.org/10.1176/appi.ajp.157.4.595.
Liu, J. (2024) Assignment instructions. CPSY 802: Psychology of Death, Dying and Bereavement. Toronto Metropolitan University.
Ortega-Galán, Á. M., Ruiz-Fernández, M. D., Roldán-Rodríguez, L., Ramos-Pichardo, J. D.,
Cabrera-Troya, J., Gómez-Beltrán, P. A., & Ortiz-Amo, R. (2022) Unbearable suffering: a
concept analysis. Journal of Hospice & Palliative Nursing, 24(3), 159-166.
Pirotte, B. D., & Benson, S. (2023, July 24). Refusal of care. National Library of Medicine.
Riisfeldt, T.D. (2023). Overcoming conflicting definitions of “euthanasia,” and of “assisted
suicide,” through a value-neutral taxonomy of “end-of-life practices”. Bioethical Inquiry,
20, 51–70. doi.org/10.1007/s11673-023-10230-1
Sklar, R. B., (2011). The “capable” mental health patient’s right to refuse treatment. McGill
Journal of Law and Health, 5(2), 291-293.
van den Berg, V., van Thiel, G., Zomers, M., Hartog, I., Leget, C., Sachs, A., Uiterwaal, C., &
van Wijngaarden, E. (2021) Euthanasia and Physician-Assisted Suicide in Patients With Multiple Geriatric Syndromes. JAMA Internal Medicine, 181(2), 245-250.
Williamson, V., Murphy, D., Phelps, A., Forbes, D., & Greenberg, N. (2021). Moral injury: the
effect on mental health and implications for treatment. The Lancet Psychiatry, 8(6), 453-455. https://doi.org/10.1016/S2215-0366(21)00113-9
Comments