HemOnc Today interviews Diane E. Meier, MD, about physician-assisted suicide

Oregon was the first state in the United States to approve a physician-assisted suicide law, and that law included safeguards to prevent mentally ill people from getting prescriptions to end their lives. The results of a recent study of 58 terminally ill Oregonians there found that some clinically depressed patients were seeking and getting prescriptions for lethal drugs despite those legal protections. Diane E. Meier, MD, director of the Center to Advance Palliative Care in New York, a professor of geriatrics and internal medicine at the Mount Sinai School of Medicine and the school’s Catherine Gaisman Professor of Medical Ethics, talked to HemOnc Today about the difficulty in diagnosing depression in terminally ill patients, her reasons for switching sides in the assisted suicide debate and an overlooked issue in medical ethics.

We know that depression is underdiagnosed, is it an overlooked factor in assisted suicide?

It is tough to measure the presence of clinical depression in people who are seriously ill. The usual diagnostic tools we use to detect major depression are things like weight loss, change in appetite, or change in sleep patterns, all of which are affected by the illness the person is living with. So you lose those criteria in seriously ill people. Then the criteria that we have to use to identify serious depression in the seriously ill are narrower, such as things like a sense of hopelessness, guilt, rumination or inability to take any pleasure in life. You can see how those are more subjective than things like having lost 10 lb and not eating and not being able to sleep. Nonetheless, those are the criteria that we have to use in this particular medically ill patient population. So the fact that 15 patients met criteria for depression and 13 met criteria for anxiety, in a way, you have to be surprised that it wasn’t all of the patients given how inclusive the criteria were. The researchers used broad definitions to identify and include as many people with depression and anxiety as they could. That’s likely to over diagnose rather than under diagnose. To me, the surprising finding is that they did not find a higher level of depression.

Diane E. Meier

Is that a good thing or a bad thing?

I think that it is a good thing. Our big fear, obviously, with legalization of assisted suicide is that people who are suicidal because of depression, which is treatable, or anxiety, which is treatable, are being helped to end their lives instead of being offered effective counseling and psychopharmacology.

Is it possible to be clinically depressed, but still make a rational decision to die?

That is where there is a lot of debate in the field and I don’t think there is a right answer. Many people on either side feel very strongly about their position. For example, many people say that, by definition, a person who meets diagnostic criteria for depression and is suicidal cannot be considered to be making a rational decision because their decision is, of course, going to be influenced by the co-existing presence of depression.

On the other side, people arguing for self-termination would say, “Just because I am depressed does not mean I am not still in control of my own life and my own decision-making. Do we say to depressed people, you can’t vote, you can’t drive, you can’t drink? Do you lose your civil rights when you’re depressed? No. So why would you lose your legal right to determine the timing and nature of your own death?”

My view as a clinician would be that if a patient approached me — and it’s not legal in New York — for help in dying and I identified signs or symptoms of depression, I would not even consider assisting them and would strongly encourage them, bordering on insisting, that they accept treatment. And I would usually offer a combination of psychopharmacology and psychotherapy or counseling.

Does it make a difference if they’re depressed and making this decision? They’re already terminally ill; it may just be a matter of time.

Right and that is true for all of us — every one of us is going to die and we don’t know when. But there are major risks to helping people with remedial problems — that is, people whose problems can be addressed with tools within our reach, established and safe psychopharmacology or effective and safe counseling methods. To assist people to hasten their death in that circumstance smacks of … almost an indifference to the genuine needs of patients. Particularly in an environment of intense cost-containment pressures and an intense financial crisis in health care, anything that makes it easy to stop taking care of someone whose problems are challenging and might be expensive to address, such as depression and psychotherapy for depression … Yes, it is a lot easier and faster to help them kill themselves but it is absolutely wrong. Our job as physicians is to convey to our patients that their life is precious to us as physicians. How will patients ever trust us and be persuaded that our goal is to do our best by them if we are convinced during periods of depression that their life is no longer worth living?

You were at one point a supporter of assisted suicide. How did you come to change your mind?

I was younger and less experienced when I was an advocate of legalization and thought about it primarily as a medical ethical issue: that is, the rights of individuals to self-termination. The more experience I had as a physician taking care of very sick, fragile people with multiple illness who had all kinds of physical and emotional symptoms, all kinds of stress on their families, all kinds of financial challenges, it became clearer and clearer to me that it was impossible to meet the criteria for assisted suicide. That is, that a person is not doing it because they feel like a burden to their family or their society, they are not asking for it because they have a treatable depression, they are not asking for it because they have symptoms that have not been addressed.

The health care system is so dysfunctional and so broken that it’s impossible to separate these things out; or it is very, very difficult to separate them out. The level of sophistication and judgment and experience required of physicians who are approached by patients who have a serious illness within this health care system, with all that is wrong with it … For a doctor to distinguish a settled, rational conviction in someone that was not based on untreated pain or untreated depression or families that are overwhelmed and not getting adequate help asks too much of doctors.

You have to make public policy based on your average doctor and your below average doctor, because not every doctor is way above average and yet this policy applies to every physician in Oregon and Washington now, many of whom are not adequately trained nor sophisticated enough to handle the nuances of this request, nor to identify and treat depression. We are notoriously bad as a profession at identifying and treating depression.

Do you foresee a day when physicians have tools to make that determination?

I do not know if I can answer that. Public policy is a fairly blunt instrument — it has to apply to the entire bell curve of patients and their physicians. It cannot depend on very sophisticated, highly trained individuals to make sure it’s safe. I’m not sure I could ever foresee a time when every physician could go through this complex differential diagnosis when a patient approached them for aid in dying. That makes me very nervous because this an extremely vulnerable, extremely costly patient population.

Should there be specialists who deal with this issue?

Again, let’s think about the ethos of the medical profession and the profound trust that required ill patients to come to a physician and say, “Help me, doctor.” That trust is predicated on, really, an unconscious, almost unexamined belief that the doctor is on the side of your life and is there to advocate for the preciousness and the infinite value of your life. That doctor is not going to force you to stay on a feeding tube or a ventilator if you do not want that, but it is a very big step away from that for that doctor to say de facto to the patient, “I agree with you. Your life isn’t worth living. Let me give you this prescription for seconol.”

Is it too big of a question?

In part I feel that way. In part I feel that the harm to trust of the public in the medical profession is potentially enormous if doctors begin to take a routine role, whether it’s a separate specialty group or all doctors who take care of seriously ill patients, that you cannot always trust doctors to be on the side of your life. That might be too big of a price to pay.

The other point I should make is that it is a tiny, tiny fraction of people dying in Oregon who either seek a prescription or use it. We ought to remember where the really big ethical issues are in health care in this country. It is about access to care. It is about equity. It is about quality. It is not about a right to assisted suicide. Sometimes I get frustrated that this seems to be a sexy topic, but in the big picture it is not an important topic. The important topic is making sure everyone has access to decent health care. I wonder why that is not what we’re writing about all the time as opposed to something that is relevant to a minute fraction of people with serious illness in the United States. We are counting angels on the head of a pin while the ship is sinking.