Oregon's department of human services released its annual report on physician assisted suicide in the state March 9. As with previous reports, the Eight Annual Report on Oregon's Death with Dignity Act revealed a troubling, low rate of psychiatric evaluations performed for patients.
Only five percent of the 38 people who died of physician assisted suicide in 2005 were referred for psychiatrist evaluation, the same rate as 2003 and 2004. In comparison, during the first two years after PAS was legalized in 1997, 27% and 37% of patients were referred for evaluation.
Over the course of the eight years the Act has been in place, only 14% of patients have been referred for psychiatric assessment. The number of patients being sent for mental health evaluation has dropped dramatically as the number of patients choosing PAS has risen.
The desire to end one's life is a common symptom of depression. According to the American Foundation for Suicide Prevention, 95% of people who commit suicide are experiencing depression, mental breakdown or mental illness.
"Most individuals who contemplate or succeed at suicide are depressed or have other psychiatric comorbid conditions," said Lois Snyder, JD and Daniel P. Sulmasy, OFM, MD, PhD, in an article on physician assisted suicide published in 2001 by the Ethics and Human Rights Committee of the American College of Physicians--American Society of Internal Medicine. "Among terminally ill patients who desire death, the wish fluctuates significantly over time."
Most of the Oregon patients who died of PAS last year indicated mental distress or the fear of mental distress as the reason for seeking suicide. The primary end of life concerns listed in the report were loss of autonomy (79%), loss of ability to engage in activities making life enjoyable (89%) and loss of dignity (89%).
Almost half (45%) were concerned with losing control of bodily functions. 42% were concerned with becoming a burden on family or friends and caregivers.
Although one of the strongest arguments for assisted suicide is the need for compassionate relief of unbearable physical suffering, only one fourth of the patients who died from PAS in Oregon last year said physical pain was the primary reason for ending their life. 24% indicated inadequate pain control or concern about it as a motivation in requesting PAS.
The Oregon Death with Dignity Act states that before a patient receives a lethal prescription, the primary physician must refer the patient for a mental health assessment if he believes a psychiatric disorder may be present. Lethal medication cannot be prescribed if the mental health professional finds that the patient is "suffering from a psychiatric or psychological disorder, or depression causing impaired judgment."
However, in a 1997 report by doctors Linda Ganzini and Melinda A. Lee, published in the New England Journal of Medicine, only 6 percent of Oregon doctors said they were confident they could determine if a person was under the influence of a mental disorder when they requested suicide, within the limits of a single consultation. The Oregon report showed the average length of time for a physician/patient relationship between the first meeting and the patient's death was eight weeks. When a doctor has little or no previous knowledge of the patient, how can he make an accurate assessment of the patient's mental capacity?
"A depressed person may articulate a coherent set of values and a convincing analysis of the benefits versus the burdens of continued life, even when hopelessness, poor self-esteem, and pessimism permeate the decision," say doctors Ganzini and Lee. "Successful treatment of a mood disorder may alter the patient's outlook and therefore the desire for death."
The study goes on to warn that the physician's assessment of the mental capability of the patient is highly subjective and has been shown to be heavily influenced by the physician's personal opinion on PAS. Doctors may not be motivated to get patients the mental health they need, if they believe suicide is a legitimate option.
"A psychiatrist who is asked to evaluate a patient's request for assistance with suicide is forced to classify the patient as either competent or incompetent, even though, in reality, competency and incompetency occupy a continuum," says the study. "There is no established threshold for determining whether a person is competent to choose suicide. In the absence of a standard, the psychiatrist's evaluation may reflect his or her personal values and beliefs about this contentious issue more than psychiatric expertise. "
In theory, doctors are supposed to be motivated in the best interests of the patient. If a doctor believes in killing the unwell, unfit and unhappy, is it possible to ensure his patients are not unduly influenced by his beliefs?
Is it in fact possible to ensure that sufficient care is taken to address the mental health issues of those requesting suicide, once the option of offering lethal medication is available to doctors?
Since physician assisted suicide was legalized in Oregon eight years ago, 246 patients have died after taking lethal medication given to them by their doctors.
First published in Action Life News, Spring 2006