In the wake of Brittany Maynard’s highly publicized death, many advocates are pressing for the legalization of physician-assisted suicide for patients in the throes of terminal illness. The claim to such a right raises many questions, not the least of which is this: if there is a “right to assisted suicide,” why would such a right be restricted only to those in the throes of terminal illness? What about the elderly person suffering a slow but non-terminal decline, or the young adult in the throes of depression, demoralization or despair?
Once we adopt the principle that assisted suicide is acceptable, then the fences erected around it—having six months to live, or having mental capacity, for example—are inevitably arbitrary. These restrictions will eventually be abandoned, as the situation with assisted suicide in Belgium and the Netherlands demonstrates: to cite just a few examples, in Belgium assisted suicide has been granted to a man with “untreatable depression” and to a prisoner suffering “psychological anguish;” in the Netherlands, assisted suicide has been granted to a woman because she did not want to live in a nursing home.
As psychiatrists, we see patients every day who demonstrate suicidal thinking and behavior, people whose life stories are every bit as heartbreaking as Maynard’s, and whose “reasons” for suicide may seem every bit as compelling. And yet, as medical professionals, we are duty-bound to intervene on their behalf, to take measures to prevent such persons from taking their own lives.
The recent debates on physician-assisted suicide have largely ignored what research in psychiatry and the social sciences has demonstrated about suicide. We know, for example, that suicide is typically an impulsive and ambivalent act; we know that it requires not just suicidal intent but easy access to means. The number-one suicide “hot spot” in the world is the Golden Gate Bridge in San Francisco, where 1,400 people have died. A journalist tracked down the handful of individuals who had survived the jump and asked them what was going through their minds during the four seconds when they were falling. Every one of them responded that they regretted the decision to jump, with one saying, “I realized that all the problems in my life that I thought were unsolvable were actually solvable—except for having just jumped.”
Suicidal individuals typically do not want to die; they merely want to escape what they perceive as intolerable suffering. When comfort or relief is offered, in the form of more adequate treatment for depression, better pain management, or more comprehensive palliative care, the desire for suicide typically wanes. There are marvelous models for better palliative care, and more effective care for the elderly, as described in Dr. Atul Gawande’s splendid new bestselling book, “Being Mortal” (Metropolitan Books, 2014). When death becomes inevitable and further medical interventions become excessively burdensome, hospice and palliative care offer compassionate alternatives to assisted suicide or euthanasia.
We know that the vast majority of suicides are associated with clinical depression or other treatable mental disorders; yet alarmingly, less than 6 percent of the 752 individuals who have died by assisted suicide under Oregon’s law were referred for psychiatric evaluation prior to their death. This constitutes gross medical negligence. We also know that there is a “social contagion” aspect to suicide, which leads to copycat suicides—particularly for well-publicized cases portrayed by the media with romanticized overtones. Some have called Maynard’s death “courageous” and “inspiring,” but we worry that her death will indeed “inspire” other vulnerable individuals—particularly the young—to follow her example. Many would like to believe that Maynard’s death was a purely private and personal affair, affecting only her and her family. But given what we know about suicide’s social effects, and given the media portrayal around her death, we anticipate that her decision will influence other vulnerable individuals to choose likewise.
Suicide rates constitute a public health crisis: suicide is currently the second leading cause of death among adolescents and young adults (behind motor vehicle accidents) and the 11th leading cause of death overall in the U.S. Not all suicides can be prevented, but many can, and our collective efforts at suicide risk reduction have the capacity to save many lives. The social acceptance of physician-assisted suicide will undermine these efforts and place vulnerable individuals at risk.
Dr. Aaron Kheriaty is an Associate Professor of Psychiatry and Director of the Program in Medical Ethics at the UC Irvine School of Medicine. Dr. Paul McHugh is a University Distinguished Professor of Psychiatry at Johns Hopkins University.