Four Reasons Why Assisted Dying Should Not Be Offered for Depression

Abstract

Recently, several authors have argued that assisted dying may be ethically appropriate when requested by a person who suffers from serious depression unresponsive to treatment. We here present four arguments to the contrary. First, the arguments made by proponents of assisted dying rely on notions of “treatment-resistant depression” that are problematic. Second, an individual patient suffering from depression may not be justified in believing that chances of recovery are minimal. Third, the therapeutic significance of hope must be acknowledged; when mental healthcare opens up the door to admitting hopelessness, there is a danger of a self-fulfilling prophecy. Finally, proponents of assisted dying in mental healthcare overlook the dangers posed to mental-health services by the institutionalization of assisted dying.

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References

  1. Berghmans, R., G. Widdershoven, and I. Widdershoven-Heerding. 2013. Physician-assisted suicide in psychiatry and loss of hope. International Journal of Law and Psychiatry, 36(5–6): 436–443.

    Article  PubMed  Google Scholar 

  2. Bowes, L., C. Joinson, D. Wolke, and G. Lewis. 2015. Peer victimisation during adolescence and its impact on depression in early adulthood: Prospective cohort study in the United Kingdom. British Medical Journal 350: h2469.

    Article  PubMed  PubMed Central  Google Scholar 

  3. Brådvik, L., and L. Crona. 2009. Long-lasting recovery in chronic severe depression. Follow-up of two cases, 46 and 50 years after their first admissions for depression. Medical Science Monitor 1(10): 31–35.

    Google Scholar 

  4. Chiles, J.A., and K.D. Strosahl. 2008. Clinical manual for assessment and treatment of suicidal patients. American Psychiatric Association Publishing.

  5. Ciarrochi, J., L. Bilich, and C. Godsell. 2010. Psychological flexibility as a mechanism of change in acceptance and commitment therapy. In Assessing mindfulness and acceptance processes in clients: Illuminating the theory and practice of change, edited by R.A. Baer, 51–75. New Harbinger Publications.

  6. Crona, L., and L. Brådvik. 2012. Long-term course of severe depression: Late remission and recurrence may be found in a follow-up after 38–53 years. Mental Illness 4(2), e17.

    Article  PubMed  PubMed Central  Google Scholar 

  7. De Carlo, V., R. Calati, and A. Serretti. 2016. Socio-demographic and clinical predictors of non-response/non-remission in treatment resistant depressed patients: A systematic review. Psychiatry Research 240: 421–430.

    Article  PubMed  Google Scholar 

  8. Dunlop, B.W. 2015. Prediction of treatment outcomes in major depressive disorder. Expert Review of Clinical Pharmacology 8(6): 669–672.

    CAS  Article  PubMed  Google Scholar 

  9. Fekadu, A., L.J. Rane, S.C. Wooderson, K. Markopoulou, L. Poon, and A.J. Cleare. 2012. Prediction of longer-term outcome of treatment-resistant depression in tertiary care. The British Journal of Psychiatry 201(5): 369–375.

    Article  PubMed  Google Scholar 

  10. Fried, E.I. 2015. Problematic assumptions have slowed down depression research: Why symptoms, not syndromes are the way forward. Frontiers in Psychology 6: 309.

    Article  PubMed  PubMed Central  Google Scholar 

  11. Hayes, S.C., J.B. Luoma, F.W. Bond, A. Masuda, and J. Lillis. 2006. Acceptance and commitment therapy: Model, processes and outcomes. Behaviour Research and Therapy 44(1): 1–25.

    Article  PubMed  Google Scholar 

  12. Hayes, S.C., K.G. Wilson, E.V. Gifford, V.M. Follette, and K. Strosahl. 1996. Experiential avoidance and behavioral disorders: a functional dimensional approach to diagnosis and treatment. Journal of Consulting and Clinical Psychology 64(6): 1152.

    CAS  Article  PubMed  Google Scholar 

  13. Hindmarch, T., M. Hotopf, and G.S. Owen. 2013. Depression and decision-making capacity for treatment or research: a systematic review. BMC Medical Ethics 14(1): 54.

    Article  PubMed  PubMed Central  Google Scholar 

  14. Joiner, T.E. 2010. Myths about suicide. Cambridge, Mass.: Harvard University Press.

    Google Scholar 

  15. Kendell, R., and A. Jablensky. 2003. Distinguishing between the validity and utility of psychiatric diagnoses. American Journal of Psychiatry 160(1): 4–12.

    Article  PubMed  Google Scholar 

  16. Kenny, M., and J. Williams. 2007. Treatment-resistant depressed patients show a good response to mindfulness-based cognitive therapy. Behaviour Research and Therapy 45(3): 617–625.

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  17. Kissane, D.W., and B.J. Kelly. 2000. Demoralisation, depression and desire for death: Problems with the Dutch guidelines for euthanasia of the mentally ill. Australian and New Zealand Journal of Psychiatry 34(2): 325–333.

    CAS  PubMed  Google Scholar 

  18. Kogstad, R., Ekeland, and J. Hummelvoll. 2011. In defence of a humanistic approach to mental health care: Recovery processes investigated with the help of clients’ narratives on turning points and processes of gradual change. Journal of Psychiatric and Mental Health Nursing 18(6): 479–486.

    CAS  Article  PubMed  Google Scholar 

  19. Krupnick, J.L., S.M. Sotsky, S. Simmens, et al. 1996. The role of the therapeutic alliance in psychotherapy and pharmacotherapy outcome: Findings in the National Institute of Mental Health Treatment of Depression Collaborative Research Program. Journal of Consulting and Clinical Psychology 64(3): 532–539.

    CAS  Article  PubMed  Google Scholar 

  20. Lambert, M.J. 2013. Bergin and Garfield’s handbook of psychotherapy and behavior change. Hoboken, NJ: John Wiley & Sons.

    Google Scholar 

  21. Leichsenring, F., and S. Rabung. 2008. Effectiveness of long-term psychodynamic psychotherapy: A meta-analysis. JAMA 300(13): 1551–1565.

    CAS  Article  PubMed  Google Scholar 

  22. Linehan, M. 1993. Cognitive-behavioral treatment of borderline personality disorder. Guilford Press.

  23. Luoma, J.B., and J.L. Villatte. 2012. Mindfulness in the treatment of suicidal individuals. Cognitive and Behavioral Practice 19(2): 265–276.

    Article  PubMed  Google Scholar 

  24. Malone, K.M., M.A. Oquendo, G.L. Haas, S.P. Ellis, S. Li, and J.J. Mann. 2000. Protective factors against suicidal acts in major depression: Reasons for living. American Journal of Psychiatry 157(7): 1084–1088.

    CAS  Article  PubMed  Google Scholar 

  25. Maltsberger, J.T., and D.H. Buie. 1974. Countertransference hate in the treatment of suicidal patients. Archives of General Psychiatry, 30(5): 625–633.

    CAS  Article  PubMed  Google Scholar 

  26. Markanday, S., J. Data-Franco, L. Dyson, et al. 2012. Acceptance and commitment therapy for treatment-resistant depression. Australian and New Zealand Journal of Psychiatry: 0004867412446491.

  27. Materstvedt, L.J. 2013. Palliative care ethics: The problems of combining palliation and assisted dying. Progress in Palliative Care 21(3): 158–164.

    Article  Google Scholar 

  28. McIntyre, R.S., Filteau, L. Martin, et al. 2014. Treatment-resistant depression: Definitions, review of the evidence, and algorithmic approach. Journal of Affective Disorders 156: 1–7.

    CAS  Article  PubMed  Google Scholar 

  29. Meyer, B., Pilkonis, J.L. Krupnick, M.K. Egan, S.J. Simmens, and S.M. Sotsky. 2002. Treatment expectancies, patient alliance and outcome: Further analyses from the National Institute of Mental Health Treatment of Depression Collaborative Research Program. Journal of Consulting and Clinical Psychology 70(4): 1051–1055.

    Article  PubMed  Google Scholar 

  30. Miller, J.F. 1985. Inspiring hope. The American Journal of Nursing 85(1): 22–28.

    CAS  PubMed  Google Scholar 

  31. Mueller, T.I., M.B. Keller, A.C. Leon, et al. 1996. Recovery after 5 years of unremitting major depressive disorder. Archives of General Psychiatry 53(9): 794–799.

    CAS  Article  PubMed  Google Scholar 

  32. Piet, J., and E. Hougaard. 2011. The effect of mindfulness-based cognitive therapy for prevention of relapse in recurrent major depressive disorder: A systematic review and meta-analysis. Clinical Psychology Review 31(6): 1032–1040.

    Article  PubMed  Google Scholar 

  33. Plakun, E. 2012. Treatment resistance and psychodynamic psychiatry: Concepts psychiatry needs from psychoanalysis. Psychodynamic Psychiatry 40(2): 183.

    Article  PubMed  Google Scholar 

  34. ———. 2006. A view from Riggs—Treatment resistance and patient authority: I. A psychodynamic perspective on treatment resistance. Journal of the American Academy of Psychoanalysis and Dynamic Psychiatry 34(2): 349–366.

    Article  PubMed  Google Scholar 

  35. Pull, C.B. 2009. Current empirical status of acceptance and commitment therapy. Current Opinion in Psychiatry 22(1): 55–60.

    Article  PubMed  Google Scholar 

  36. Regier, D.A., Narrow, D.E. Clarke, et al. 2013. DSM-5 field trials in the United States and Canada, Part II: Test-retest reliability of selected categorical diagnoses. American Journal of Psychiatry 170(1): 59–70.

    Article  PubMed  Google Scholar 

  37. Regionale toetsingscommissies euthanasie. 2015. https://www.euthanasiecommissie.nl. Accessed June 23, 2016.

  38. Schatzberg, A.F., A.J. Rush, B.A. Arnow, et al. 2005. Chronic depression: Medication (nefazodone) or psychotherapy (CBASP) is effective when the other is not. Archives of General Psychiatry 62(5): 513–520.

    CAS  Article  PubMed  Google Scholar 

  39. Schuklenk, U., and S. van de Vathorst. 2015a. Treatment-resistant major depressive disorder and assisted dying. Journal of Medical Ethics 41(8): 577–583.

  40. ———. 2015b. Treatment-resistant major depressive disorder and assisted dying: Response to comments. Journal of Medical Ethics 41(8): 589–591.

  41. Segal, Z.V., Williams, and J.D. Teasdale. 2012. Mindfulness-based cognitive therapy for depression. Guilford Press.

  42. Shamseddeen, W., G. Clarke, K.D. Wagner, et al. 2011. Treatment-resistant depressed youth show a higher response rate if treatment ends during summer school break. Journal of the American Academy of Child & Adolescent Psychiatry 50(11): 1140–1148.

    Article  Google Scholar 

  43. Smith, J.M., L.B. Alloy, and L.Y. Abramson. 2006. Cognitive vulnerability to depression, rumination, hopelessness, and suicidal ideation: Multiple pathways to self-injurious thinking. Suicide and Life-Threatening Behavior 36(4): 443–454.

    Article  PubMed  Google Scholar 

  44. Souery, D., G.I. Papakostas, and M.H. Trivedi. 2006. Treatment-resistant depression. Journal of Clinical Psychiatry 67(suppl. 6): 16–22.

    PubMed  Google Scholar 

  45. Tsou, J.Y. 2015. DSM-5 and psychiatry’s second revolution: Descriptive vs. theoretical approaches to psychiatric classification. In The DSM-5 in Perspective, edited by S. Demazeux and P. Singy, 43–62. Springer.

  46. Vevatne, K. 2006. Selvmordsforsøket—Søken mot livet. University of Bergen, Norway.

    Google Scholar 

  47. Walser, R.D., Garvert, B.E. Karlin, M. Trockel, D.M. Ryu, and C.B. Taylor. 2015. Effectiveness of acceptance and commitment therapy in treating depression and suicidal ideation in veterans. Behaviour Research and Therapy 74: 25–31.

    Article  PubMed  Google Scholar 

  48. Wiles, N., L. Thomas, A. Abel, et al. 2013. Cognitive behavioural therapy as an adjunct to pharmacotherapy for primary care based patients with treatment resistant depression: Results of the CoBalT randomised controlled trial. The Lancet 381(9864): 375–384.

    Article  Google Scholar 

  49. Zettle, R.D., J.C. Rains, and S.C. Hayes. 2011. Processes of change in acceptance and commitment therapy and cognitive therapy for depression: A mediation reanalysis of Zettle and Rains. Behavior Modification 35(3): 265–283.

    Article  PubMed  Google Scholar 

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Correspondence to Morten Magelssen.

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Blikshavn, T., Husum, T.L. & Magelssen, M. Four Reasons Why Assisted Dying Should Not Be Offered for Depression. Bioethical Inquiry 14, 151–157 (2017). https://doi.org/10.1007/s11673-016-9759-4

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Keywords

  • Assisted dying
  • Euthanasia
  • Major depression
  • Physician-assisted suicide
  • Treatment-resistant depression