Cornelia Geerts, a fifty-nine year old woman who struggled with mental illness in Belgium, asked her psychiatrist to help her end her own life. In 2014, about one year after her initial request, a physician administered a lethal dose of drugs that killed her. Euthanasia is currently legal in only five countries: Canada, Colombia, Luxembourg, the Netherlands, and Belgium, where Ms. Geerts’ death occurred. Euthanasia is not legal anywhere in the U.S., but six states and Washington D.C. have legalized physician assisted suicide, which allows physicians to prescribe lethal drugs to terminally ill patients for patients to administer themselves. Belgium and Luxembourg permit euthanasia of people suffering from terminal illnesses as well as people suffering from mental illnesses, who may not be at the end of life.
The number of patients euthanized because of psychological suffering makes up a small percentage of euthanization cases in Belgium—of the approximate 2,000 euthanasia deaths that occur per year, only about 40 involve those who were suffering from mental illness. Though these cases are few, they highlight the bioethical dilemmas that physicians and lawmakers face in dealing with mental health issues and an individual’s right to make his or her own healthcare decisions. Advocates argue that individuals suffering from mental illness should be afforded the same rights as those who suffer from a physical illness. Yet, others believe that it is nearly impossible to know when a mentally ill individual decides to end his or her own life with sound mental capacity and not as a result of their underlying mental health disorder. Opponents believe that society has a responsibility to help those suffering from mental illness and to find help through means other than euthanasia.
Stewart Dolin began to take an antidepressant called Paxil five days before he committed suicide. His wife, Wendy Dolin, who had noticed a change in his behavior when he started taking the drug, remembers her husband being abnormally agitated in the days prior to his death. Ms. Dolin alleged that a side effect of Paxil, called akathisia, played a role in his decision to commit suicide. Akathisia brings on a state of acute physical and psychological agitation. Ms. Dolin sued the manufacturer of Paxil, GlaxoSmithKline, claiming that the company had not sufficiently warned of the dangerous side effects.
Evidence that surfaced during the trial brought to light results of early clinical trials conducted on Paxil in 2006. According to the studies, “the frequency of suicidal behavior was higher in patients treated with paroxetine compared with placebo” among adults of all ages with major depressive disorder. Though the label on Paxil had once reflected the risk to adults of all ages, the newer label only stated that the increased risk was seen among people under 25 years old. Both labels failed to capture, however, was the true magnitude of the heightened risk. The frequency of suicidal behavior in patients being treated with Paxil was found to be 6.7 times higher than the frequency for those being treated with the placebo. There have also been studies that have found a correlation between akathisia and suicidal behavior.
Ms. Dolin was successful in her lawsuit against GlaxoSmithKline, and a jury awarded her $3 million dollars in damages. This verdict is particularly unusual, as many lawsuits involving suicides are either dismissed or settled outside of court; it serves as a stark reminder to pharmaceutical companies that labels on antidepressants must adequately reflect the risks associated with them.
Ms. Dolin started an organization called The Medication-Induced Suicide Prevention and Education Foundation (Missd) in memory of her husband and to raise awareness of akathisia. You can learn more about Missd at: http://missd.co/
To those who consider patient autonomy one of the most important concepts in modern healthcare, being able to choose when to die is respected as part of that autonomy. However, euthanasia is a hotly contested issue and is especially debated with respect to mental illness. Euthanasia for untreatable psychiatric illness is currently permitted by law in the Netherlands, Belgium, and Switzerland. However, a recent study by the National Institutes of Health (NIH) has shown that many psychiatric patients euthanized in the Netherlands may have suffered from treatable mental illnesses, such as depression. In fact, of the patients whose case files were studied, more than half had previously refused at least one form of treatment with many of those patients citing “lack of motivation” as the reason for their refusal. Moreover, the study found that many of the psychiatric patients who requested to be euthanized were motivated by “loneliness” or “social isolation,” often symptoms of depression.
Although Dutch law requires that a “disorder be intractable and untreatable” to warrant euthanasia, the study also found that patients are able to seek out euthanasia after being refused, from other physicians, non-psychiatrists, and on-call mobile euthanasia clinics, sometimes on rather questionable grounds. As a result, the study questions whether the Dutch system “provides sufficient regulatory oversight” and casts doubt on diagnostic criteria that allow a symptom of an underlying, possibly treatable condition to determine whether the condition itself is untreatable. While the ethical use of euthanasia for patients suffering from mental illness will undoubtedly continue to be debated, the NIH study certainly makes clear that questions about the treatability of “untreatable” mental conditions must be resolved to protect an already vulnerable population from falling victim to its own self-fulfilling prophecy.
A recent study published in the Journal of the American Medical Association (JAMA) found that 29% of medical residents suffer from depression, which is a significantly high number when compared to the 8% of the general public that suffers from depression. The meta-analysis study, conducted by Dr. Douglas Mata, reviewed a total of 54 studies from 1963 to 2015. The analysis consisted of over 17,000 residents and relied mostly on self-reports. Additionally, Dr. Mata found that depression among residents had not only increased since 1963, but also increases throughout a physician’s residency. By tracing the mental health before and during the doctors’ residencies, the study found that the symptoms of depression in the residents being tracked increased by 15%. Dr. Mata, who is a resident himself, believes that the demanding hours play a significant role on residents’ mental health. He explained that many residents do not even have time to go grocery shopping.
However, there is no conclusive finding that determines the source of the residents’ high depression rates. The JAMA article includes an editorial by Dr. Thomas L. Schwenk, who speculates on the probable causes for the depression. Dr. Schwenk states that the main causes of depression among residents include the need to reconcile old-school training methods with modern technology, the lack of mental health care for residents, and the long hours and sleep deprivation. The cap on resident work hours, as is established by the Accreditation Council for Graduate Medical Education, is currently set at 80 hours per week. Due to these long hours, many residents are also socially isolated. In the United States, 400 doctors die of suicide every year. To combat this problem, Dr. Schwenk proposes a change to the work environment, such as providing ways for medical residents to de-stress from the traumatic life or death events they often endure.
A few days after Daniel St. Hubert was released from prison, he allegedly went on a stabbing spree resulting in the death of a 6-year-old boy. Hubert’s past is checkered with violence. In fact just before his release, he had been incarcerated for five years for choking his mother with an electrical cord. Moreover, Hubert’s time in prison was filled with violence against inmates and correctional workers. The correctional system would seem to have been aware of Hubert’s propensity for violence. Indeed, it took three years before he was deemed psychologically fit to stand trial for the assault on his mother.
While in prison, Hubert underwent years of therapy that resulted in improvement in his behavior including six months without any citations for violence. On May 23, 2014, after a psychiatric evaluation, Hubert was released without a structure in place to ensure the safety of Hubert and the public.
Currently, the criminal justice system focuses on ensuring that the mentally ill are competent to stand trial, but little has been done to combat mental illness once mentally ill prisoners are released. New York’s “Kendra’s law” gives the state the authority to order outpatient treatment for individuals who have had a violent past and have refused treatment. However, this law does not ensure thatmentally ill people released from prison will receive needed treatment. Hubert’s case forces us to ask whether or not six months without a citation for violence is enough time to deem a prisoner stable enough to re-enter society. Further, is there a better way to keep tabs on released prisoners with mental illnesses? Whatever the solution, there are civil liberty issues that must be balanced with public safety.
Soon, Congress will hear testimony concerning the Helping Families in Mental Health Crisis Act. Republican representative, Tim Murphy, from Pennsylvania, sponsored the bill, and, though many agree that the mental health care system requires revamping, some provisions in the bill have sparked controversy. Among the more controversial provisions is one that supports the increased use of involuntary outpatient treatment—via court-ordered therapy for “certain mentally ill people with a history of legal or other problems.” Detractors of this provision claim that it will erode trust in doctor-patient relationships, and that it presents a civil rights issue. However, 45 states have compelled treatment programs already, one of which is New York.
New York’s compelled treatment program, Kendra’s Law, was passed in 1999. Since the implementation of Kendra’s Law, studies show that the percentage of patients returning to the hospital or getting arrested has greatly decreased. The statistic is significant, as “about 350,000 Americans with a diagnosis of severe mental illness…are in state jails and prisons” and the availability of psychiatric beds meets only 10 percent of that need.
The Joint Behavioral Health and Firearms Safety Task Force of Rhode Island approved a final report for submission to the General Assembly, which concerns how Rhode Island should submit mental-health records to the National Instant Criminal Background Check System (NICS). Ultimately, the Task Force recommends that Rhode Island submit only the names of patients committed involuntarily because a judge deemed them a danger to themselves or others. Sen. Frank Lombardi, D-Cranston, believes that the Task Force’s determination strikes the correct balance between: the right to privacy; public safety; and, “the recognition of mental health as an illness and not as a stigma.”
Dr. Sandeep Jauhar, a cardiologist, offers anecdotal evidence in support of his argument that even though autonomy is, and should be, medicine’s guiding principle, paternalism has its place. The principle of autonomy in medicine encompasses a patient’s right to direct care his or her care, and requires the doctor to fully inform the patient regarding medical treatment. Dr. Jauhar reflects on his early belief that autonomy was “an absolute good, an ethical imperative that trumped all others.” After some years practicing medicine, his belief has changed.
Dr. Jauhar has come to believe that “no ethic in medicine is absolute.” Though the consequences of a breach of trust between a physician and a patient are severe, the consequences of full disclosure can be adversarial to the doctor’s duty to select the best course of treatment for his or her patients. However, Dr. Jauhar states that if a doctor believes that a paternalistic approach is necessary to a patient’s care, a soft approach is most appropriate. He describes hard paternalism as “coercive,” while soft paternalism “involves negotiation.”
The bill to streamline the involuntary commitment process for mental health patients in Vermont is not finished yet. However, some are concerned that the bill does not sufficiently protect the rights of patients committed involuntarily under the new, streamlined process. The head of Vermont Legal Aid’s Mental Health Law Project, Jack McCullough, requested that the Vermont Senate Judiciary Committee add language to the bill that would preclude a patient’s name from being added to the federal registry’s list of individuals who should not own firearms, at least until a preliminary finding of mental illness was adjudicated fully. Lawmakers indicated that they would not add the requested language in this bill, and would rather deal with that issue in separate legislation.