September 2017. Periodically there are gradual shifts in our attitudes and practices in the health care world that, when they reach a critical point, develop traction and result in revisions, sometimes profound, in our thinking. One example is the transition from the days long ago when homosexuality was classified as an illness, to the present recognition that sexual orientation is, for some of us, a defining component of “who we are” rather than a reflection of pathology. In the realm of “what we do” rather than “who we are,” another transition well underway is the legalization of marijuana—initially for medicinal purposes, but increasingly for recreational use. Ironically, opening this door is occurring against the backdrop of a remarkable social recognition of the health risks from cigarette smoking, and the massive regulation and restriction of smoking in public and, increasingly, private places.
Most of these types of change involve controversy. Another change that is well underway is the growing attention focusing on end-of-life care. As longevity has increased, the population of late-life citizens has grown, leading to intensified concerns about quality of life in the final stages of life. A central, thorny controversy that has emerged is the role of the physician in hospice or palliative care, particularly when it comes to the request from a terminal patient, or from a patient with unendurable and mostly untreatable pain, for assistance from the physician to carry out a planned death. The emotional impact of older terms for this process (euthanasia, physician-assisted suicide) illustrates the challenge involved in considering this topic in a measured and thoughtful way. More often, the terms used these days include “death with dignity” or “preplanned death.”
Recently, the International Association for Hospice and Palliative Care issued a position statement, recommending that “no country or state should consider the legalization of euthanasia or physician-assisted suicide until it ensures universal access to palliative care services and to appropriate medications, including opioids for pain and dyspnea.”1 Do we agree? Such a position would be quite difficult to implement in our country, though perhaps less so in smaller countries with very different health care systems, such as the Netherlands or Belgium, where physician-assisted suicide has been legal since 2002. Like it or not, however, things are changing. In our country, the first state to legalize physician-assisted death was Oregon, in 1994. Although other states were slow to follow, it has now become legal or court-approved in California, Colorado, Montana, Vermont, Washington, and Washington, DC.
Even if we endorse a position such as the one above as a goal, there are numerous other important considerations, such as cognitive clarity, capacity to consent, uncertainty about whether a patient’s condition might improve, ethical considerations, and many more. What about “serious and persistent mental illness” characterized by miserable quality of life, hopelessness, and negligible response to treatment? In such a case, some would ask, “Has everything really been tried?” “Is it the illness or the flawed health care system that is the problem?” And so on. I could go on, but there’s a better option. In the Law and Psychiatry column in this issue of the Journal, Hal Wortzel has invited guest columnist Joel Yager to present a deeply thoughtful commentary on this topic, focusing on its many challenges in our field of psychiatry. He calls it “Contending with preplanned death: questions for clinicians.” He includes 2 compelling examples from his own experience, and he poses questions that apply to each and every one of us, whether we like it or not. Read it. Even if it’s tough sledding, you’ll be glad you did.
JOHN M. OLDHAM, MD
1. De Lima L, Woodruff R, Pettus K, et al. International Association for Hospice and Palliative Care position statement: euthanasia and physician-assisted suicide. J Palliat Med. 2017;20:8–14.