Psychological Aspects of Euthanasia and Assisted Suicide

By N. Gregory Hamilton, M.D.

All patients with a serious interest in assisted suicide suffered from depression and feelings of hopelessness (Journal of the American Medical Association, December 13, 2000). "The difference between the ordinary suicidal person and the terminally ill suicidal patient is the reaction he meets in the therapist" (Dale Olevitch, Protecting the Mentally Ill from the Assisted-Suicide Movement). The first publicly reported case of doctor-assisted suicide in Oregon, the only state where such a practice is legalized, was for a depressed person. Kate Cheney was found to be demented and was coerced by her family, yet Kaiser HMO gave her assisted suicide anyway. When Joan Lucas made a suicide attempt in Oregon, she was given assisted suicide instead of the psychiatric treatment she needed and deserved. Discriminatory wording in the Oregon doctor-assisted suicide law has removed protections for the seriously medically ill who suffer from suicidal desperation.

Patients with a serious interest in assisted suicide have depression and other mental illnesses A comprehensive medical study published in the Journal of the American Medical Association (December 13, 2000) found that all patients with a serious interest in assisted suicide suffer from symptoms of depression or feelings of hopelessness. This finding confirms a previous conclusion published in the Lancet medical journal (June 29, 1996) that interest in assisted suicide is correlated with depression, not pain. In the only state where such a practice has been legalized, the Oregon Health Division assisted suicide reports demonstrate that psychological and social concerns, not pain, lead to suicidal wishes in all the patients who were overdosed. The widespread misconception that advanced age or serious illness lead to suicidal despair is unfounded. In fact, epidemiological studies demonstrate that "even a serious physical illness such as cancer does not independently add risk to the relationship between depression and suicide" (N.G. Hamilton, M.D., "Suicide Prevention in Primary Care," Postgraduate Medicine 2000; 108:81-87, p. 83). Patients with an interest in assisted suicide, like other suicidal individuals, suffer from such disorders as depression, alcoholism, anxiety, and personality disorders. Medically ill suicidal patients are like other suicidal persons A prominent psychiatrist, Doctor Dale Olevitch, observed, "The difference between the ordinary suicidal person and the terminally ill suicidal patient is the reaction he meets in the therapist" ( Protecting the Mentally Ill from the Assisted-Suicide Movement, Westport CT: Greenwood Publishing, 2002). Yet, when assisted suicide is legalized, seriously medically ill persons are discriminated against and excluded from the protections against suicidal despair everyone else enjoys. Diane Coleman correctly observed that the issue for those succumbing to assisted suicide in Oregon has not been pain; "the issue was fear and prejudice about disability" (D. Coleman, "Not Dead Yet," in K. Foley and H. Hendin, eds., The Case Against Assisted Suicide: For the Right to End-of-Life Care. Baltimore MD: Johns Hopkins Press; 2002, pp. 213-237, p. 225). This fear and prejudice has led to discrimination against and stigmatization of the seriously ill and the overdosing of seriously ill patients with depression and other treatable psychiatric disorders. We can treat seriously ill patients who have suicidal symptoms, just like we can other suicidal patients. When the biological, psychological, social, and spiritual causes of suicidal despair are carefully assessed and a treatment plan is thoughtfully and empathically implemented, these patients recover from their fear and despair. Patients who may be nearing life's end can recover from depression or alcoholism or anxiety and find hope and meaning in this important phase of life. The first assisted-suicide case was a depressed woman The first woman to die by assisted suicide in Oregon was diagnosed as depressed. This elderly woman's first doctor apparently did not think assisted suicide was appropriate for her. She was subsequently sent to another doctor open to the possibility of assisted suicide for this woman, who had overcome breast cancer for

years and was not in serious pain. He found her to be depressed, however, and gave her antidepressants instead of an overdose. But doctor shopping by her family, with the assistance of the Compassion in Dying organization, led her to a doctor who determined over the telephone that he thought she was rational. Based on this scanty information, she was sent to a series of assisted suicide doctors and was given an overdose in less than three weeks (N.G. Hamilton and C.A. Hamilton, "Therapeutic Response to Assisted Suicide Request," Bulletin of the Menninger Clinic, 1999; 63:191-201). According to national experts, "No information is provided to indicate that the physicians recommended by Compassion in Dying were trying to find any feasible alternatives to suicide" (K. Foley and H. Hendin, "The Oregon Experiment," in K. Foley and H. Hendin, eds., The Case Against Assisted Suicide: For the Right to End-of-Life Care. Baltimore MD: Johns Hopkins Press; 2002, pp.144-174, p. 148). Kate Cheney was demented and coerced by her family Kate Cheney was an elderly woman with dementia who developed cancer. When her doctor seemed hesitant about giving her an overdose, her daughter insisted that she see another doctor. That doctor referred her for psychiatric evaluation, not because it was required by the Oregon law, which it was not, but to fill a requirement of Kaiser HMO, where Mrs. Cheney got her medical care. That psychiatrist found her suffering from dementia and under pressure from her daughter who answered all questions for her mother, despite being asked not to do so. The mother accepted the opinion that she was not eligible for assisted suicide. But the daughter became angry and demanded another opinion, which the HMO granted. This time, a psychologist admitted the woman was suffering from dementia and was pressured by her daughter, but authorized the assisted suicide anyway. The final decision came down to Kaiser HMO administrator Robert Richardson who chose the consultation authorizing assisted suicide over the consultation protecting the patient. (N.G. Hamilton, M.D., "Oregon's Culture of Silence," in K. Foley and H. Hendin, eds., The Case Against Assisted Suicide: For the Right to Endof-Life Care. Baltimore MD: Johns Hopkins Press; 2002, pp.175-191). Richardson later complained that suggestions that financial considerations by him or his HMO may have played a part in the decision to give this mentally ill woman assisted suicide were "deeply offensive" ("Killing Grandma," Brainstorm Magazine, November 1999). Assisted suicide as a response to a suicide attempt Joan Lucas was a 65-year-old woman who made a suicide attempt using sleeping pills she had hoarded. Her adult children described how they watched her as she lay on her bed throughout the day; they couldn't make up their minds what to do. When Mrs. Lucas eventually awakened, instead of getting evaluation and treatment for her suicidal despair, her family called a politically active assisted-suicide group to help arrange their mother's assisted suicide in Oregon, the only state where such a practice is legal. They could do this, because their mother had a serious neuromuscular condition that may have qualified her. The doctor told a news reporter he decided to get a mental health opinion about this suicidal patient, although such an evaluation is not required in Oregon, to cover himself. The psychologist he picked sent an MMPI to the patient, because Mrs. Lucas could not easily come into the office. There is no evidence the psychologist ever evaluated Mrs. Lucas in person. Instead, her family helped her fill out the paper and pencil test, a test which was not designed to assess competence, but to determine factors that might be contributing to suicidal desperation in a seriously ill patient. Then, the psychologist cleared her for a second, more effective overdose. This one killed her (N.G. Hamilton, "Foreword," in D. Olevitch, Protecting the Mentally Ill against the Assisted Suicide Movement. Westport CT: Greenwood Publishing, 2002). Doctor-assisted suicide law does nothing to protect the mentally ill Although it is well known that virtually all patients with a serious interest in assisted suicide suffer from symptoms of depression, hopelessness, or other psychiatric disorders, assisted suicide doctors seldom refer patients for psychiatric evaluations and even less often for treatment. An Oregon Health Division report indicates that only 14% of reported doctor-assisted suicide cases were referred for psychiatric evaluations in 2001. There is every indication that when such evaluations were performed, they were often pro forma and intended to protect the HMO or the assisted suicide doctor more than the patient. The Oregon doctor-assisted suicide law does not require psychiatric evaluation at all, but leaves that up to the decision of the assisted suicide doctor. An often quoted guidebook favorable to assisted suicide claims, "If the mental health professional finds the patient competent, refusal of mental health treatment by the patient

does not constitute a legal barrier to receiving a prescription for a lethal dose of medication" ("Mental Health Consultation and Referral," The Oregon Death with Dignity Act: A Guidebook for Health Care Providers , Portland OR: OHSU, 1998, p. 31). The authors of this guidebook make the astounding claim that the causes of suicidal ideation in the seriously ill, unlike for all other individuals, do not require treatment before the doctor overdoses the patient. They make this claim despite their admission on the same page that, "Depression treatment, however, did increase the desire for life-prolonging medical treatment," and that, "Treatment of psychiatric disorders in those who attempt suicide is very effective in abolishing suicidal ideation." This failure to protect the depressed and mentally ill who also suffer from serious medical illness against the dangers of assisted suicide reveals how the legalization of assisted suicide discriminates against and devalues the lives of this vulnerable and stigmatized population. Legalization of assisted suicide deprives vulnerable individuals of the protections against suicidal despair all the rest of us enjoy.
Posted on June 26, 2004.