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The commentaries responding to our article on treatment-resistant depression and assisted dying focus on the following issues: epistemological questions about death, patient competence, the role of doctors, the moral basis of the right to an assisted death, safety and security of patients, and questions about various cases that occurred in the Netherlands. We will address in our response each of these concerns, beginning with the last issue first.
Review of cases
Dr den Hartogh mentions a case in the Netherlands where the Dutch review committee deemed ‘the doctor … not careful’.1 This case was published after we submitted our paper. The case was judged ‘not careful’ because no psychiatrist had been consulted to consider the competence of the patient, and to review whether the patient's situation was truly of a hopelessness nature. In this case, the doctor who performed the euthanasia and the consultant were general practitioners. This case does not undermine our argument. The review committee did not suggest that the patient was incompetent. In our paper, we are careful to consider only treatment-resistant competent patients.
Dr Cowley mentions the so-called Chabot case and the Brongersma case.2 In the Netherlands, the Brongersma case is not discussed under the label ‘depression’, but as a case of a patient who was ‘tired of life’.3 Eighty-six-year-old former politician Edward Brongersma did not suffer from a mental or other illness. It deserves a separate discussion and is outside the scope of our paper. The Chabot case was extraordinary because the patient had no wish to be cured from her depression because she felt depression to be an appropriate state to be in after the premature deaths of her two sons.4 This case also falls outside the scope of our paper.
Epistemological uncertainty about death
Drs Broome and de Cates begin their discussion with an epistemological argument suggesting that we can never rationally choose death over living because in order for us to do so we would need to know what it is like to be dead.5 According to them, since we cannot have sound knowledge of that state of existence (or non-existence), we are unable to make a considered choice. Given that we are only addressing our paper to those who have already accepted that we can rationally prefer death over a particularly miserable existence, this line of reasoning is beyond the scope of our argument. Drs Broome and de Cates acknowledge that they mount here en passant an in-principle argument against any kind of assisted dying.
If asked, we would consider a line of reasoning along Plato's version of Socrates’ Apology i to be defensible. Socrates, having been sentenced to death by a jury, explains that death is not something that he is fearful of because it can only mean one of two things, non-existence and the eternal peace and tranquility that comes with it, or a kind of afterlife that he does not fear either because he thinks he committed no crime. Socrates assumes that the latter possibility would entail meeting up with Orpheus, Homer and Hesiod. Christians likely would—or should—cheerfully look forward to meeting their creator. However, based on everything that we know today, it is not unreasonable, in our view, to take the stance that non-existence is what death means. Our biological life comes to an end and that is all there is to it. Socrates welcomes this possibility as ‘the absence of perception and the kind of sleep when someone sleeps without having any dreams’.6 He would welcome this kind of death as a gift. Our quality of life would turn to zero, it is neither good nor bad. Epicurus, as is well known, came to a similar conclusion. In his Letter to Menoeceus, he set out his reasons.7 Essentially he proposes a materialistic view of the world, whereby there would be no soul surviving our biological expiration. Once that challenge is dealt with, we have little reason to fear death, partly for the reasons already alluded to, but also because it is clear then that we have no reason to fear afterlife punishment activities including hell fire and similar prospects. Death then can be preferable to a biological existence that we do not consider worth living.
Even if the argument from epistemological uncertainty had any real-world bite, and we do not think that it has, it might still not lead to the conclusion desired by those opposed to assisted dying. After all, by their own account, we could not know whether we would be better off living or being dead. If that were the case, no argument would exist in favour of our continuing existence either. We would still maintain then that we might as well leave it to competent patients themselves to decide which way to go. Pace Wittgenstein, Broome and de Cates.
Most of the commentaries understandably struggle with the issue of competence in the case of patients suffering from severe long-term depression. However, just as we acknowledged in our paper, the comments express the concern that it is the very essence of a depression that patients have a bleak view of their future. ‘People with high scores on depressive symptoms are unduly pessimistic and have difficulty discriminating between more or less likely events’, writes Dr den Hartogh. And because their affective states are distorted, we should not attribute decision-making authority to some or to all of such patients, or so the argument goes. However, Drs Broome and de Cates concede that there may be depressed patients who are competent, but they think such patients are extremely rare. Dr Cowley also notes that ‘with depression there is always an initial question about competence and about authenticity’. His main focus is on the purported inability of doctors to distinguish between competent and incompetent patients. We agree that a life and death decision is grave and therefore rightly demands a high level of patient competence. Being ‘unduly pessimistic’ is a possible characterisation of someone with a severe depression, but it is also well-founded in the case of someone with a severe long-term depressive disorder.
The currently applicable guidelines for Dutch psychiatrists state: ‘a patient with severe recurring episodes of a psychosis or a depression may in the relatively symptom free interval be considered to have a good insight into the nature of their illness and make a well-considered decision with regard to suicide’.ii We do not advocate assisted suicide being made available to just any depressed patient, but only to patients suffering from long-term depression and in whose case their bleak assessment of their future prospects is corroborated by a psychiatrist.
It seems to us that all correspondents who raised this argument accept that a certain number of treatment-resistant depressed patients are in fact competent—by a standard that they would accept—to make autonomous decisions with regard to assisted dying. That is all that matters to our analysis. It is possible that we would eventually differ in our respective evaluations of particular patients’ competence. However, there is apparently a consensus that not all patients with depressive disorder are incompetent to make decisions with regard to an assisted death. These patients ought to be able to access assisted dying if they wish. We disagree with the current in-principle exclusion of these patients in many jurisdictions where assisted dying has been decriminalised. It goes without saying that processes designed to evaluate competence should be improved where that is indicated. Dr den Hartogh notes, for instance, that the Dutch health minister proposes to include psychiatrists in the evaluation of psychiatric patients’ competence. That seems a defensible approach to us.
Err on safety
Drs den Hartogh and Cowley urge us to err on the side of caution. Two points are worth mentioning in this regard. One is that the nature of depression permits us to exercise sufficient caution because we have time to evaluate the mental state and state of suffering of patients asking for assisted dying. It also permits us to monitor the stability of the assisted dying request over time. These two criteria are rightfully proposed in the guidelines of the Dutch Society of Psychiatry that Dr den Hartogh mentions in his comments. The long-term nature of treatment-resistant depression implies that clinicians would never be faced with the pressure to reach a decision unduly quickly.
Erring on the side of caution, as Drs den Hartogh and Cowley urge us to do, would imply also to let a fair number of patients suffer possibly indefinitely. Their proposition is not cost neutral as far as avoidable suffering is concerned. In our view, this is too high a price to pay for treatment-resistant depressed people who might wish to avail themselves of assisted dying, who display appropriate levels of competence and who show consistency with regard to their request over a reasonable period of time. Dr den Hartogh notes in his commentary that ‘the present number of cases of assisted suicide is still very low’. He is correct. To us this status quo suggests that the medical profession in the Netherlands is already erring on the side of caution. A prohibition on assisted dying in all cases of treatment-resistant depression seems unreasonable to us. Sufficient safeguards can be put in place to ensure that only patients capable of demonstrating competence, unbearable suffering and a consistency of their request over time are granted their assisted dying requests.
Autonomy and suffering
Some commentators seem to have read our article as if we defended a right to assisted dying solely based on respect for autonomy – the right of self-determination. However, we note in our paper that the suffering experienced by these patients provides us with another foundation for our argument, namely compassion.
Are doctors needed?
Dr den Hartogh states that if patients have the mental capacity to plan and execute their decision, there is no need for doctors to be involved. He suggests that it is well possible to take your own life in a humane way if we have the mental capacity to plan and execute your decision. We doubt that he had someone like Mario Cooper in mind, a recently deceased HIV-infected African-American civil rights activist. Cooper reportedly ‘died in hospice care after he had stopped eating because of depression’.8 It is doubtful that Mario Cooper died a peaceful death by starving himself to death. Or did Dr den Hartogh have a couple in their 80s in mind who reportedly jumped to their deaths from the 18th story of a condo building in Toronto. A friend of the couple is quoted in a news report, ‘there's got to be an easier way than jump off the balcony’.9 We could go on with many other examples like these to support our argument that it does make a difference that a doctor is present, even in the case of assisted suicide, to make sure the right drugs are ingested in the right dosage. It is in nobody's interest that patients (have to) resort to starving themselves to death, jumping off buildings or resorting to any number of more or less gruesome means to bring about their deaths. We disagree with Dr den Hartogh on this issue. It is not obvious to laypeople how to obtain the means to guarantee a peaceful death. Dr Sagan also rightly mentions in this context that depressed patients suffering from other conditions such as quadriplegia would be unable to actively end their lives.10
Competing interests None declared.
Provenance and peer review Commissioned; internally peer reviewed.
↵ iWe thank Abe Schwab for recalling The Apology in this context, and for bringing it to our attention.
↵ ii“Een patiënt met ernstige recidiverende psychosen of depressies kan in de tussenliggende goede perioden vaak wel in staat geacht worden om met volledig ziektebesef tot een weloverwogen besluit tot zelfdoding te komen.“ Paragraph 2.2.2., page 32 in A.J. Tholen, R. L.P. Berghmans, J. Huisman, J. Legemaate, W.A. Nolen, F. Polak, M.J.W.T. Scherders (NVvP-commissie Hulp bij zelfdoding). 2009. Richtlijn omgaan met het verzoek om hulp bij zelfdoding door patiënten met een psychiatrische stoornis. De Tijdstroom, Utrecht.