Physician Aid-in-Dying: Practical Considerations

The legalization of physician aid-in-dying in multiple jurisdictions in the United States as well as globally has introduced the need to investigate the role of psychiatrists in mental health evaluations and capacity assessments among patients requesting physician aid-in-dying. In Belgium and the Netherlands, the practice of medically assisted suicide is legal, even among minors (i.e., patients aged ≥12) and individuals with psychiatric disorders (1). This raises concern that the practice of physician aid-in-dying might undergo similar expansion worldwide and highlights the need for psychiatry as a field to engage in education on the topic and to become involved in the development of standardized assessment tools. This article provides an overview of the current status of physician aid-in-dying in the United States and worldwide, with discussion of several practical considerations pertaining to legalization and ethics, especially with regard to patients with psychiatric disorders and the effect on the mental health care field.

The Oregon Death with Dignity Act, established in 1997, requires four major criteria for a patient to request lethal medications as a means to voluntarily end his or her own life: the patient must be an adult, be a resident of Oregon, demonstrate capacity, and have been diagnosed with a terminal illness that will lead to death within 6 months (2). Similar legal stipulations exist in other states that have legalized physician aid-in-dying since Oregon's Death with Dignity Act. California, Colorado, Vermont, and the District of Columbia have legalized physician aid-in-dying via legislation or voter-approved ballot initiatives that mirror Oregon's legislation (3). Additionally, Hawaii recently approved legalization that is scheduled to take effect in 2019 (4). Montana approved legal physician aid-in-dying via a court ruling from the Supreme Court case of Baxter vs. Montana in 2008 (5). Alabama, Massachusetts, and West Virginia have common-law prohibition of physician aid-in-dying, whereas Wyoming, Utah, and North Carolina have no common law or specific statute. All other states prohibit physician aid-in-dying through state legislature (6).

Since the passing of the Oregon Death with Dignity Act, the majority of patients approved for physician aid-in-dying had cancer, while a small number had progressive, fatal neurodegenerative diseases (mostly amyotrophic lateral sclerosis). Among these patients, many were already enrolled in hospice or receiving palliative care. In 2016, surveys of individuals requesting physician aid-in-dying in Oregon noted that "the three most frequently mentioned end-of-life concerns were loss of autonomy (89.5%), decreasing ability to participate in activities that made life enjoyable (89.5%), and loss of dignity (65.4%)" (7).

An important component of the assessment of patients requesting physician aid-in-dying is decision-making capacity. For patients with psychiatric disorders, proper assessment of decision-making capacity is crucial given that psychiatric disorders can affect capacity. Referral for psychiatric evaluation should originate from the physician primarily responsible for the patient's care if there are concerns that the patient has a psychiatric disorder that has acutely impaired his or her capacity. A cross-sectional study conducted by Ganzini et al. (8) examined the prevalence of depression and anxiety among patients with terminal conditions who requested physician aid-in-dying in Oregon. It is noteworthy that one in four patients had clinical depression per standardized assessment. The study raises the concern that depression may be missed in some individuals requesting physician aid-in-dying, and therefore they will not be referred to a psychiatrist for evaluation.

Voluntary Active Euthanasia

Voluntary active euthanasia is when a physician gives a medication to a mentally competent patient with the intent to end the patient's life, as requested by the patient (9). Voluntary active euthanasia is legal in the Netherlands, Belgium, Luxembourg, Colombia, Switzerland, and Canada. Similar to Oregon, in Belgium, patients with end-stage cancer comprise the majority of the population requesting and receiving physician aid-in-dying or voluntary active euthanasia, with a minority of patients with irreversible neurodegenerative diseases (10). First-year data from the Dutch End-of-Life-Clinic (which is staffed by physicians and nurses funded by the Right to Die NL, a euthanasia advocacy organization) showed that 6.8% of all patients requesting physician aid-in-dying or euthanasia were categorized as "tired of living," and another 49.1% felt isolated (11). In Belgium and the Netherlands, clinicians (psychiatrists and others) have provided physician aid-in-dying or voluntary active euthanasia to individuals with depression, personality disorders, eating disorders, psychotic disorders, and anxiety disorders (12). In 2015 in the Netherlands, 59% of all voluntary active euthanasia involving a patient with a psychiatric disorder was performed by the End-of-Life Clinic (13).

Assessment of Capacity and Evaluation for Psychiatric Disorders

What guidelines and practices exist for evaluation of capacity and psychiatric disorders among patients requesting voluntary euthanasia in Belgium and the Netherlands? The criteria of due care (as legally noted in the Termination of Life on Request and Assisted Suicide Act) state that the physician must 1) be satisfied that the patient's request is voluntary and well-considered; 2) be satisfied that the patient's suffering is unbearable, with no prospect of improvement; 3) have informed the patient about his or her condition and prognosis; 4) have come to the conclusion, together with the patient, that there is no reasonable alternative; 5) have consulted at least one other independent physician who has evaluated the patient and provided written opinion on whether the criteria of due care have been fulfilled; and 6) exercise due medical care and attention in terminating the patient's life or assisting in his or her suicide (12).

What role do psychiatrists play in capacity evaluations concerning voluntary active euthanasia requests from patients with impaired cognition or psychiatric diagnoses? A review of 66 cases of psychiatric voluntary active euthanasia in the Netherlands showed that 41% of physicians performing voluntary active euthanasia were psychiatrists, 47% of case subjects had a second opinion provided by a psychiatrist, and 59% of the SCEN [Support and Consultation on Euthanasia in the Netherlands] consultations involved a psychiatrist as one of the consultants (12). These statistics raise questions regarding the role of psychiatrists in administering voluntary active euthanasia or physician aid-in-dying and the evaluation of capacity, because a large number of the physicians who administered voluntary active euthanasia were psychiatrists and less than half of the case subjects with a psychiatric diagnosis had a second opinion from a psychiatrist. Another review of these same 66 case subjects concluded that there was no evidence of a mandatory high threshold of patient capacity before administration of euthanasia (14). Documentation of capacity-specific criteria among these case subjects has shown that 55% demonstrated global assertion of capacity and 46% had at least one capacity-specific ability (e.g., understanding information, ability to reason, or appreciation of the consequences to self), but there is no evidence that all four Appelbaum capacity criteria were met (14, 15) (see box). This raises concern that individuals who may not have full decision-making capacity are eligible to receive voluntary active euthanasia or physician aid-in-dying.

Additionally, voluntary active euthanasia among persons with impaired cognition or psychiatric disorders raises questions pertaining to uncertain medical futility as well as treatment refusals by patients that may occur as a result of impaired judgment secondary to the disease itself (16). As long as treatable causes of distress are not adequately addressed, there will be concern surrounding the inappropriate use of physician aid-in-dying, particularly for treatment-refractory psychiatric conditions, since symptoms that may not respond to currently available treatments may be responsive to a new treatment as our understanding of the pathophysiology of many psychiatric disorders improves.

Further Considerations

As the practice of physician aid-in-dying is legalized further in the United States and gains momentum globally, multiple practical concerns arise, particularly regarding its implementation among patients with impaired cognition or psychiatric disorders and clarification of the role of psychiatrists.

In the United States, what role should psychiatrists play regarding capacity assessments? Is the current standard for capacity (the Appelbaum criteria) sufficient? Is a new framework needed? What regulations and oversight should be in place to ensure adherence to a gold standard of capacity assessment? Would psychiatrists perform capacity evaluations for all individuals who request physician aid-in-dying or voluntary active euthanasia in an effort to not miss the influence of unrecognized psychiatric illness on an individual's decision to die? Would this place more burden upon a profession that is already overwhelmed?

What regulations should be in place, and who would monitor the practice of physician aid-in-dying to ensure maintenance of ethical integrity? In the United States, because physician aid-in-dying is approved on a state level, there is variability in the regulatory agencies overseeing the practice. Lack of strict regulations in the Netherlands has led to cases in which medically assisted suicide was done for patients with impaired cognition or psychiatric disorders (14) and to extension of the practice among vulnerable populations (9). Thus, what should the role of psychiatrists be in ensuring that depression is adequately screened among individuals requesting physician aid-in-dying?

As physician aid-in-dying becomes legalized in more states as well as internationally, it is crucial to explore this evolving practice and its current and future impact on psychiatry through education surrounding legal, ethical, and professional aspects. Exploring these issues in psychiatry training is needed.

Key Points/Clinical Pearls