Assisted dying: legal ambiguity lets down families as well as patients

There are several ways of responding to the claims Dr Twycross makes about the mental state of patients requesting Medically Assisted Rational Suicide (MARS). The first is to point out that particularly in the case of depression, psychiatric diagnosis is far from an exact science and fundamental differences exist among psychiatrists about its classification. The increasing tendency in successive editions of the DSM to medicalise and pathologise varieties of ordinary human experience and unhappiness, such as bereavement, has drawn particular criticism. [1]

On standard depression inventories, ‘caseness’ levels may be reached simply because terminally ill patients requesting MARS achieve maximum scores on items such as ‘I feel my future is hopeless and will only get worse’, ‘I can’t get any pleasure from the things I used to enjoy’, ‘I am too tired or fatigued to do most of the things I used to do’ and ‘I would kill myself if I had the chance’. Given the overwhelming public support for MARS, such feelings are neither abnormal nor pathological in this situation. Invoking the crucial distinction between what used to be called ‘reactive’ and ‘endogenous’ depression has become unfashionable on the grounds that their symptoms often overlap but their conceptualization and management involve some very important differences.

An even stronger argument against Dr Twycross’s claims is that many of the people who request MARS formed their views long before they became seriously ill. Far from reflecting a temporary mood disorder that will respond to treatment, their requests are nearly always the logical culmination of many years of reflection about how they would like to die – and how they would not. I have yet to meet a MARS-contemplating patient who does not fit this description. Encouraging everyone to reflect at leisure on their ultimate fate and register their views is one way of answering fears about pressuring patients. If I thought that someone had a genuine depressive illness that was likely to be transient and treatable, I would of course say so. That is mainly because I prefer honesty to dishonesty but also because I know that my reports might come under close and very public scrutiny.

Given that opposition to both abortion and MARS comes predominantly from organized monotheisms and their adherents, there are ironic and revealing differences in their attitudes to psychiatric illness in these situations. Taking a rather narrow view of psychiatry that ignored psychosocial factors and almost equated psychiatric illness with the major psychoses, anti-abortionists commonly claimed that women requesting abortion had no true psychiatric grounds for the request. (‘I can tell from the end of the bed that you’re not mentally ill’, as one gynaecologist informed a patient of mine.) In contrast, patients requesting the option of MARS – which many terminal cancer patients activate only if palliative care proves inadequate – are being told by people like Dr Twycross that their perfectly understandable distress and pessimism about the way the next few weeks or months might unroll for them are actually symptoms of a disease – depression – that can and should be treated. In both cases, this enables opponents to pretend that the problem is not ‘real’ or is greatly exaggerated and can thus be ignored. Or, in the case of MARS, medicated away with antidepressants that, in controlled trials, are only marginally more effective than placebos and sometimes not even that. I have previously described the case of a woman with full Mental Capacity who was nevertheless sectioned and threatened with Electro-Convulsive Treatment after deciding to starve herself to death, since other methods were not available to her. After my intervention, the hospital agreed that she could starve to death on the ward but only if she took fluids, thus prolonging her distress by several weeks.[2]

It is no wonder that some British palliative care specialists have broken ranks and now admit the need for MARS [3] but it is also very telling that some people in the specialty are so frightened of being bullied by their colleagues that they feel they can only publish their views anonymously.[4] Those of us who support MARS do not presume to tell Dr Twycross how he should die, or try to limit his options. He should accord the same respect to the large majority of British people who disagree with him and his like-minded colleagues. He should also ask himself why palliative care physicians and nurses in countries less than an hour’s flight from Britain, as well as in Oregon, have come to take such a different position.

REFERENCES.

1 Greenberg G. Manufacturing depression. London. Bloomsbury. 2015, passim.

2 Brewer C. The story so far: from King George V to Dignitas In: I’ll See Myself Out, Thank You. (Eds: C Brewer, M Irwin) Shipston-on-Stour. Skyscraper, 2015 23-4

3 Ahmedzai S. My journey from anti to pro assisted dying BMJ 2012; 9 July 2012 345:e4592

4 http://www.theguardian.com/voluntary-sector-network/2015/aug/02/hospice-...