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• Patients with psychosis should not be disqualified from assisted dying on grounds of mental incompetence.
  Kevin R. Smith
  Published on: 18 May 2017
• Depression is not the only treatment-resistant psychiatric condition.
  Colin Brewer
  Published on: 18 May 2017

• Published on: 18 May 2017

  Patients with psychosis should not be disqualified from assisted dying on grounds of mental incompetence.

  • Kevin R. Smith, Senior Lecturer

  Dear Editor.

  Schuklenk and van der Vathorst's feature paper articulates powerful and persuasive arguments to the effect that denying patients with treatment-resistant depression (TRD) assistance in dying results in unnecessary suffering and amounts to unfair discrimination against TRD patients.

  Beyond TRD, the same arguments can readily (and in my view appropriately) be used to support assisted dying...

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  Dear Editor.

  Schuklenk and van der Vathorst's feature paper articulates powerful and persuasive arguments to the effect that denying patients with treatment-resistant depression (TRD) assistance in dying results in unnecessary suffering and amounts to unfair discrimination against TRD patients.

  Beyond TRD, the same arguments can readily (and in my view appropriately) be used to support assisted dying more generally, wherever intractable severe mental distress pertains. This point is also made by psychiatrist Colin Brewer in his letter in response to the paper [1].

  In establishing the case that patients with depression should not necessarily be considered incompetent, Schuklenk and van der Vathorst's paper contains the assumption that mental competence is a prerequisite for access to assisted dying. While most prochoice ethicists take this position to be axiomatically correct, I suggest that an insistence on competence - at least as it is usually conceived in medicine - may lead to unfair discrimination and unnecessary suffering amongst patients suffering from a particular class of psychiatric disorder, namely those deemed to be 'psychotic'.

  As Schuklenk and van der Vathorst describe, even the most prochoice jurisdictions stipulate mental competence as a prerequisite for assisted dying. So in the Netherlands, while patients suffering from TRD can obtain assistance in dying, those with psychotic depression do not qualify, because treatment decisions by these patients are considered to be often 'not arrived at competently and should be overridden/ignored'. The fundamental assumption here - and it is a commonplace notion in medical ethics - is that psychosis equates with mental incompetence. Presumably, the basis for this position is that psychosis entails disordered or delusional modes of thought.

  TRD can be very severe, as is made very clear by Schuklenk and van der Vathorst's paper; however, various forms of intractable psychosis can be at least as -and in some cases possibly even more- difficult to endure. Psychotic depression, as above, might be one such case; treatment- resistant severe schizophrenia would also appear to be an extremely difficult to endure form of psychosis, entailing great suffering - indeed many of those affected end up committing suicide. While such patients (by definition) suffer from disordered or delusional thinking, it is not clear that the desire to end their lives should be deemed irrational.

  As with TRD, denial of assisted dying to patients enduring intractable psychosis is responsible for a great deal of unnecessary suffering and amounts to unfair discrimination. I suggest that the assumption 'psychotic = incompetent' should no longer be accepted axiomatically. Prochoice medical ethicists ought to explore principled ways by which our conceptions of 'competence' may be refined such as to permit fair access to assisted dying for those afflicted by intractable psychotic disorders.

  REFERENCES. 1. Brewer, C. Depression is not the only treatment-resistant psychiatric condition. eLetter, Journal of Medical Ethics, 2 June 2015.

  Conflict of Interest:

  None declared

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  Conflict of Interest:
  None declared.

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• Published on: 18 May 2017

  Depression is not the only treatment-resistant psychiatric condition.

  • Colin Brewer, psychiatrist

  Dear Editor. I do occasional psychiatric assessments for people contemplating medically-assisted rational suicide (MARS) in Switzerland and broadly agree with Schuklenk and van der Vathorst's arguments. Usually, my role is limited to assessing mental capacity and excluding the existence of a treatable psychiatric condition that might be influencing the patient's decision to include MARS in the list of acceptable options....

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  Dear Editor. I do occasional psychiatric assessments for people contemplating medically-assisted rational suicide (MARS) in Switzerland and broadly agree with Schuklenk and van der Vathorst's arguments. Usually, my role is limited to assessing mental capacity and excluding the existence of a treatable psychiatric condition that might be influencing the patient's decision to include MARS in the list of acceptable options. Most of these patients have conditions such as motor neurone disease or early dementia in which death within six months would not be expected. Recently, I was asked to see a patient with purely psychiatric diagnoses and have thus been thinking very hard about the issues discussed in their paper.

  It seems difficult to argue that intractable mental distress is intrinsically less worthy of our concern than intractable somatic distress. Most people who kill themselves do so as a result of psychological rather than physical distress. Much of that distress proves to be transient and/or tractable (and frequently aggravated by various intoxications) but some of it is neither. The largest and most comprehensive survey of suicides in a single 'western' country during the entire 20th century [1] concluded that many suicides were due to eminently 'understandable' combinations of circumstance and personality or world- view. Obvious mental illness was a less important factor.

  The present era of DSM-5 imperialism is associated with sometimes ludicrous claims for the effectiveness of antidepressants, despite consistent evidence that placebo and non-specific mechanisms are much more prominent than pharmacological ones. Personality disorders are, almost by definition, resistant to both drugs and psychotherapy. When someone has reached their mid-thirties without relief and despite such appropriate interventions as exist, psychiatry should perhaps show a little therapeutic humility.

  Much of the organised opposition to MARS is religious and I think it goes back to the Augustinian view that suicide is a worse sin than homicide because it implied criticism of the world that God had created [2] - a position that led to the ritual desecration of the corpse until 1825 in Britain. Even today, both the main churches officially deny Christian burial in consecrated ground to suicides, though the Church of England voted this year to revoke the relevant Canon Law. They get round the prohibition in practice by claiming that all suicides must have been suffering from insanity. The official position of psychiatry seems rather similar.

  REFERENCES. 1.Weaver J. Sorrows of a Century: interpreting suicide in New Zealand 1900 -2000.Montreal. McGill-Queen's university press. 2014.

  2. Brewer C. Christian attitudes to suicide. In: C Brewer and M Irwin Eds. I'll See Myself Out, Thank You. Thirty personal views in support of assisted suicide. Newbould on Stour. Skyscraper. 2015

  Conflict of Interest:

  None declared

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  Conflict of Interest:
  None declared.

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