Should People Who Are ‘Only’ Severely Depressed Be Eligible for Physician-Assisted Suicide?

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Supporters of proposed legislation allowing doctors to prescribe life-ending medication to terminally ill patients hold up signs of support during a hearing on the bill in the Senate Health Committee at the Capitol in Sacramento, California, Wednesday, March 25, 2015.Photo: Rich Pedroncelli

When should the state help someone die? That’s the question at the heart of the most recent episode of VICE, Vice’s mini-documentary series on HBO. Here’s the trailer:

In the episode, correspondent Vikram Gandhi explores the issue at the policy level, running down the legislative battles that have raged on in the U.S.— where only a handful of states have legalized physician-assisted suicide — and on a personal level, interviewing several people who plan on taking their own lives and bringing us inside the home of one woman on the day she does.

In most of the States, physician-assisted suicide is illegal, and a growing group of nationwide advocates are seeking to change this. In those states where it has been legalized — Oregon is the most famous example — the rules are pretty strict. Only those who face terminal physical illnesses can qualify, and there is a pretty careful process in place in which an overseeing physician has to approve the patient’s wishes. Often, patients who seek this route have diseases that are degenerative, and they choose to end their lives rather than face months or years of increasing helplessness, immobility, and pain — many of them speak of wanting to avoid putting a burden on their family.

Something like 70 percent of Americans support this version of physician-assisted suicide, according to Gallup, and that number has risen steeply in recent years. Things get a little trickier in parts of Europe. Belgium and the Netherlands, for example, take a much different stance on the question of euthanasia. Not only is euthanasia legal in cases of hopeless physical illness there, but there are also fairly liberal policies governing euthanasia in cases of psychological distress.

In July, a wonderful New Yorker article by Rachel Aviv explained the differences between the situation in the U.S. and in these European countries:

Opponents have warned for years that legalization will lead to a “slippery slope,” but in Oregon fewer than nine hundred people have used lethal prescriptions since the law was passed, and they represent the demographic that is least likely to be coerced: they are overwhelmingly white, educated, and well-off. In Belgium and in the Netherlands, where patients can be euthanized even if they do not have a terminal illness, the laws seem to have permeated the medical establishment more deeply than elsewhere, perhaps because of the central role granted to doctors: in the majority of cases, it is the doctor, not the patient, who commits the final act. In the past five years, the number of euthanasia and assisted-suicide deaths in the Netherlands has doubled, and in Belgium it has increased by more than a hundred and fifty per cent. Although most of the Belgian patients had cancer, people have also been euthanized because they had autism, anorexia, borderline personality disorder, chronic-fatigue syndrome, partial paralysis, blindness coupled with deafness, and manic depression. In 2013, Wim Distelmans euthanized a forty-four-year-old transgender man, Nathan Verhelst, because Verhelst was devastated by the failure of his sex-change surgeries; he said that he felt like a monster when he looked in the mirror. “Farewell, everybody,” Verhelst said from his hospital bed, seconds before receiving a lethal injection.

The most striking and sad character in Aviv’s piece is mentioned in the very first sentence. Godelieva De Troyer was a middle-aged woman who “taught anatomy to nurses” for a living and who “had been in therapy since she was nineteen.” She divorced her first husband, and he ended up killing himself, leaving her as a single parent of a boy and a girl. She suffered from depression for decades, enjoying a brief span of what seemed to those close to her like happiness when she found a loving boyfriend in her 50s, only to have that man break her heart. Godelieva’s condition seriously interfered with her relationships with her son and daughter, leading to estrangement and a lack of trust.

In mid-2011, Godelieva saw Dr. Wim Distelmans, a “leading proponent[]” of Belgium’s 2002 euthanasia law. She visited him at his clinic in September, and four months later she notified her children via email that she had filed a request to be euthanized. Three months later, her wish was carried out — without either of her children having been notified or consulted by Distelmans. Her son, Tom, found out via “a short letter from his mother that was written in the past tense.” He eventually met with Distelmans to ask why he had approved the request without looping him or his sister into the process, and the encounter didn’t go well. “You went along with the madness of my mother!” Tom shouted at Distelmans, according to the doctor. “You went along with her tunnel vision, her defeatism. You’ve just taken away the suffering of one person and transposed it to another!”

The VICE episode contains a similar case (spoiler alert, I guess). Gandhi meets Antoinette Westerink, an older Dutch woman who has suffered from anxiety, depersonalization, and PTSD for years but doesn’t have any terminal physical illness bearing down on her. Westerink has decided she doesn’t want to live anymore and has scheduled the date of her death. Neither of her children are happy about this — she’s surprised to see her son even show up the day of her death, when she has a small gathering at her home. In a pretty difficult scene, we watch as she is injected with the chemicals that will kill her, surrounded by friends.

These two cases involving mental illness are so much trickier than ones involving a terminal illness with a clear, devastating course. In both of them, the women involved had suffered for decades with unrelenting psychological pain. Even though their bodies worked fine, they had simply given up on the idea of their lives ever improving. Should a doctor respect their wishes to die in the same way he or she might respect the wishes of a patient with stage IV cancer? Should a doctor factor in the wishes of adult children who will be affected by a parent’s choice, but who can’t know exactly what that parent is going through, especially given that in any other instance, the children of a competent adult patient don’t get to make major medical decisions for them? And these cases, in which the women had suffered for decades, are in a sense “easier” than some of the others that have gained attention — they’re less prickly than, say, the case of Nathan Verhelst, who opted for euthanasia in the wake of his sexual-reassignment surgeries.

But in all of them, the medical Establishment is carrying out a wish — “I want to die” — that is generally only fully “respected” in the case of terminal illness, and sometimes not even then. The question of whether that’s something we in the United States would want the medical Establishment to do is really, really complicated.

That said, it’s important not to buy too easily into slippery-slope arguments: At the moment, in most of the United States even terminally ill patients are ineligible for physician-assisted suicide. And as we’ve seen from the small handful of states that have passed laws legalizing the practice, these laws can be written in a way that respects the wishes of terminally ill patients without turning pockets of the U.S. into Belgium or the Netherlands. So maybe the first step is bringing other state laws in line with national opinion on the issue.