Abstract
In this chapter, I consider the idea that physician-assisted death might come into question in the cases of psychiatric patients who are incapable of making autonomous choices about ending their lives. I maintain that the main arguments for physician-assisted death found in recent medical ethical literature support physician-assisted death in some of those cases. After assessing several possible criticisms of what I have argued, I conclude that the idea that physician-assisted death can be acceptable in some cases of psychiatric patients who lack autonomy ought to be taken into account in assessing the moral and legal acceptability of physician-assisted death.
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Notes
- 1.
According to The Royal Dutch Association of Medicine—which allows that physical illnesses and injuries can provide grounds for physician-assisted death—suicide based on psychiatric reasons should not be treated differently from assisted suicide in medicine generally. In Belgium, also, suffering unrelated to physical illness or injury is acknowledged in law as a valid basis for physician-assisted death (see The Royal Dutch Medical Association 2011, 21–22 and, e.g., Naudts et al. 2006). On the legal status of physician-assisted death for patients suffering from physical illnesses or injuries see, e.g., the chapter by Jocelyn Downie and Georgia Lloyd-Smith in this volume.
- 2.
Though it has often been considered clear that mentally ill patients lack decision-making ability, it has also recently been emphasized that even a severe mental disorder need not preclude at least periodical competence (see, e.g., Hewitt 2010a). Accordingly, it may be that psychiatric patients who are altogether unable to autonomously decide about their treatment are rarer than has commonly been supposed. Yet that does not preclude the possibility that patients such as Charlie exist (cf. also, e.g., Hardcastle and Stewart 2002, 431–432) nor makes them morally unimportant. Also, the possibility that a patient such as Charlie may be able to make some choices autonomously—such as choosing between tea and coffee at breakfast—does not entail that he is autonomous in the sense that he can make an autonomous choice about ending his life.
- 3.
Pain is among the topics of the burgeoning neurosciences but at least so far the prospect of completely objective assessment of pain and suffering remains rather distant (see, e.g., Giordano 2010; and also Button et al. 2013). If it became possible, objective pain assessment could imply that mental pain and suffering is as objective as physical pain and suffering.
- 4.
It might be objected that if mental suffering is deemed relevant in the end-of-life context, then the request for euthanasia made by a heartbroken teenager who has just lost the person she believes to be the love of her life must be obeyed (cf., e.g., Young 2014). However, as has already been pointed out (see, e.g., Varelius 2014), accepting the above conception of morally acceptable physician-assisted death, the teenager does not qualify as a candidate. For, in cases like hers, the suffering typically is not enduring and unavoidable in that there is no way of adequately alleviating it other than that of ending her life.
- 5.
As it does not affect the main argument of this chapter, I will not now go into the question whether a masochist actually enjoys her ability to endure suffering rather than the suffering itself (or both).
- 6.
It might be objected that ending the life of a terminal patient is not as bad as terminating the life of a non-terminal patient because the former would soon die anyhow. However, this presupposes that ending the life of a patient in unbearable suffering is a bad thing. It is deeply regrettable that there are cases in which people suffer so horribly that they want to end their existence. But when the situation is as severe as that, ending the patient’s life is arguably not a bad thing. Therefore, this possible objection is unconvincing.
- 7.
That some of such cases involve misdiagnoses does not lessen their relevance here.
- 8.
Of course, the notion of human dignity can be understood in significantly different ways. Accordingly, someone might argue that the common understanding of human dignity employed above should be replaced with a different one, one that would also imply that assisting Charlie to end his life would be more undignified than its alternatives. However, as I am unable to here assess whether there could be a justifiable notion of human dignity of the kind it refers to, I must now put this possible objection aside.
- 9.
An affective disorder, such as depression, would appear to influence agency differently than a delusional disorder from which Charlie suffers. Yet it would seem that sometimes an affective disorder can also make a patient incompetent to make autonomous end-of-life choices (cf., e.g., Meynen 2011). The above considerations support physician-assisted death in such cases too, provided, again, that the patient is suffering incurably and unbearably and wants to end her existence.
- 10.
I thank Michael Cholbi for valuable comments on an earlier version of this chapter and Marion Lupu for revising my English. All remaining errors are mine.
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Varelius, J. (2023). Mental Illness, Lack of Autonomy, and Physician-Assisted Death. In: Cholbi, M., Varelius, J. (eds) New Directions in the Ethics of Assisted Suicide and Euthanasia. The International Library of Bioethics, vol 103. Springer, Cham. https://doi.org/10.1007/978-3-031-25315-7_4
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