 Dr. Dr. Roberts is the Catherine Dexter McCormick and Stanley McCormick Professor and Chair of the Department of Psychiatry at Stanford University. Dr. Roberts is a graduate of the Pritzker School of Medicine and was a McLean fellow in 1988. Laura has written or edited more than 20 books and hundreds of articles on psychiatry, medical education, professionalism and clinical ethics. Recently at Laura's insistence, she and I co-edited a book collecting my own favorite papers over the course of my career. Laura was the 2015 recipient of the McLean Center Prize for her work in clinical medical ethics and today she will talk to us about ethics of assisted dying in the context of mental illness. Dr. Laura Roberts. I'm going to ask a quick question. Who thinks that kleptomania is sufficient medical cause for assisted death? Just putting it out there, the foreshadow, kleptomania. So I'm not really an expert on this topic. I did do some of the early studies about 20 years ago on assisted suicide in the context of psychiatry. But I have taken care of patients for more than 20 years and in that time I've had all of these patients who express suicidal impulses and ideation at different times and these are physically ill, mentally ill and actually otherwise healthy people and these suicidal impulses and suicidal thoughts typically resolve especially if people receive appropriate treatment and treatment for pain. So I come at this question of assisted suicide in euthanasia in the context of mental disorders with a bias of having seen hundreds of patients reverse the wish to commit suicide. And so today we're going to cover really four core ideas. One is really thinking about the nature of mental disorders. I want to share with you a little bit about the current understanding of influences and factors leading to the impulse or the wish to end your life. Third, a little bit about euthanasia and assisted suicide that is happening in real time in Europe and is a very compelling and interesting set of ethical questions there. And then also just to think and my colleague Debra Spitz alluded to this earlier about what's distinct about the therapeutic role of the psychiatrist and the patient. So first let's just think about mental disorders. They really affect fundamental aspects of the human person, their feelings, thoughts, perceptions, motivation, insight, judgment and self-governance. They cannot be diagnosed even in the presence of really perhaps almost bizarre to other people experiences thoughts. They cannot be diagnosed unless there is a diminished sense of well-being and deficits in the ability to live in a social role, to contribute and to love. And it's often very difficult to recognize, especially in the prodromal phase. And so little or late or no care are very common in the care of people living with mental disorders. One in four adults in the United States and one in eight children in the United States meet criteria for a diagnosable condition. It typically hits early and hits hard. So the average age of onset for psychiatric conditions is age 14 years. But it can occur at any point and have new onset even in advanced age. Very, very diverse phenomenology can be misdiagnosed or underdiagnosed and this is going to be relevant to what's happening now in Belgium and the Netherlands because, for example, I asked you about kleptomania, shoplifting. Now loneliness is loneliness a sufficient medical cause for euthanasia or assisted death. It's mental disorders are typically episodic but it may be a single experience or it may be chronic. And in general, there are outstanding treatments, evidence-based treatments that lead to improved health outcomes and complete remission for many conditions. So the issue of euthanasia or assisted suicide occurring pretty much ethically only in a very futile, boundary condition is really a question when it comes to mental disorders. From a public health point of view, mental disorders are the leading cause of premature death and disability in economically established countries like our own and second only to infectious diseases worldwide. So when you think about access to care, there really are insufficient resources, insufficient infrastructure throughout the country, very little understanding, tremendous stigma and all of these factors contribute overall to inadequate care, scientific neglect and grave health disparities for individuals, communities and populations living with mental disorders. And one only needs to look at our prisons and our streets to know this. And if you look at the world, this photograph on the bottom is a picture of a prison chained where in rural India where there are no resources for severe and persistent mental illness. People living with mental illnesses are really go through periods of being vulnerable but taken together as populations, people living with mental illnesses may be understood to be a vulnerable population. Now I have to admit that usually I make a different argument that people with mental illness should not be viewed as an exception, but in this particular case because there is so much in terms of health disparities that plays into the issue of assisted suicide in the context of mental disorders, I think it's important to look at the differences rather than some of the similarities with other physical conditions. And more than 36,000 people in the United States and more than 800,000 people in the world each year complete suicide. So this is a large contributor to premature death and disability in these conditions. So let's now pivot and think a little bit about suicide from a clinical perspective. You know the wish to end one's life can be a symptom of mental illness and its presence can be a clinical sign. It's related to other negative cognitions that accompany mental illness such as hopelessness or a sense of utility or a foreshortened future. In addition, authentic volunteerism and decisional capacity can be affected by these cognitions or threat to cognitive processing and threats to decisional capacity can be a signature feature of many mental disorders, but not all. And the urge to complete suicide is typically impulsive, transient and reversible. And I think most people in my field believe that in this context, it represents kind of a fluid, disordered, off problem solving of an ill and distressed brain. And I want to share this lovely poem by Emily Dickinson where I think she captures very much this kind of fluid quality of despair. As many of you know, Emily Dickinson suffered from very severe depression, episodes of very severe depression throughout her life. And she wrote, on the bleakness of my lot, bloom I strove to raise, late my acre of rock has yielded grapes and maize. I think it's a beautiful example. And actually all of the art that I'm presenting today are people who have lived with mental disorders. So the point is that mental disorders should really be thought of as having a fluid dynamic nature and often the impulse to end one's life as a clinical phenomenon associated with that. So what we've learned really quite tragically from the young veterans coming back and ending their lives and numbers much higher than our dying in conflict overseas is that we really are getting new insights into suicide. In the past, scholarship has really focused on what are relatively fixed characteristics such as gender or age, race, ethnicity, marital status, the presence of other physical conditions. And more recent work now has really looked at different elements that lead to the moment when a person has the impulse to end his life. And there are three elements that are thought to kind of contribute to this intense unbearable state of mind that leads a person to act on the impulse. The first is the existence of extreme distress due to some pre-existing mental illness or perhaps a situation. Second is access to and familiarity with the means of self-harm. And third is a feeling or sense of emotional rupture and experience of what we refer to as thwarted belongingness. So a loss of sense of place in the world, a loss of relationships and love, a loss of belonging. And this model is fabulous, I think, because it gives you intervention points, identify the source of distress, identify whether there's pre-existing mental illness, try to understand the situation, try to eliminate access to means of self-harm, try to create a sense of connection and to repair that rupture. So the model has tremendous value in terms of the interventions that it suggests. So just to bring it to the ethical argument then. So because people living with mental illness are marginalized in society have lessened healthcare resources and represent therefore a vulnerable population, and because mental disorders are not per se terminal conditions, and because intermittent and reversible negative cognitions including suicidal thoughts and impulses are part of the fundamental clinical phenomenology of many mental disorders, and further, because intermittent and reversible threats to volunteerism and decisional capacity are signature features of many mental disorders, it's my belief that assisted suicide in euthanasia in the context of mental illness requires far greater ethical scrutiny than in other contexts. So I don't know where I thought Belgium was and the Netherlands, it sounded sort of nether, it was like way up there, way nether, but if you actually look at the map, it's right there in Europe, wow, and it's right next to Germany, it's right next to France, it's like a short boat ride away from the United Kingdom, I mean this is not some extreme place that people don't have access to, this is the place where all of this tourism for assisted death is occurring, right there, highly accessible and a little geography lesson for everyone here, and if you look right now in Belgium and the Netherlands, assisted suicide in euthanasia is permissible for psychiatric conditions, and just again a little bit more information, Belgium is a population of about 11 million, in 2014 to 15 there were almost 4,000 euthanasia cases, euthanasia, and 124 of those were for people with a mental and behavioral disorder, so that's 3%, and it represents the 21% of the 600 non-terminal patients to whom Belgium doctors administered lethal injections in that period, so very overrepresented in the cases of non-terminal conditions. The Netherlands is a larger population, 16.8 million, euthanasia rose 75% in the last five years from 3,136 cases in 2010 to now 5,500 in 2015. The psychiatric cases rose from just 2, it was I think really not considered socially supported in 2010, but then 56 people were euthanized for psychiatric reasons in 2015, now 1% of the overall cases, and in particular dementia is going up, so it seems to be getting some traction, so let's go over the criteria by which termination of life may occur in the Netherlands. The attending physician must be satisfied that the patient's request is voluntary and well considered, so I just talked with you about threats to volunteerism, threats to decisional capacity, must be satisfied that the patient's suffering is unbearable with no prospect for improvement, so I've just told you about how mental disorders have extraordinary treatments, that there are almost always alternatives, I will acknowledge that many times the suffering is absolutely unbearable, but it does tend to be transient. The physician has to have informed the patient about a situation of prognosis, and they have come together, the physicians and the patients, that there's no reasonable alternative in the patient's situation, which I've argued is almost a priori impossible in mental disorders. In this process they have to have consulted with at least one other independent physician who must see the patient and give a written opinion about whether do-care criteria have been fulfilled, and then in the act of doing euthanasia or physician-assisted suicide they have to have shown do-care. So this was a study published in JAMA Psychiatry this past year conducted by my wonderful colleague Scott Kim at University of Michigan, who looked at 66 patients who had been euthanized or had received assistance in death for psychiatric conditions. And the pieces that I want to really emphasize are that of these 66 cases most are women, most are older, many have had psychiatric admissions, many have some degree of dependence or institutionalization, and social isolation and loneliness, which I think is a reversible condition, figures heavily into these cases. The conditions were depression, anxiety, PTSD, psychotic disorders, somatiform disorders, bipolar depression, substance abuse, eating disorders, neurocognitive impairment including mental retardation, prolonged grief, autism, and there it is, kleptomania is among the causes. Now what about the role of the psychiatrist? So in these 66 cases 41% had the involvement of a psychiatrist as the primary physician engaged in euthanasia. The psychiatrist was a consultant in or was the primary person in a larger proportion, however, in 11% of the cases no psychiatrist was engaged at all and often there were disagreements, so if you remember the Netherlands criteria, there was no requirement that the primary and the consulting physicians actually agreed on the decision. And in fact that's what they found in these cases was there was disagreement about whether it was well considered, competent, whether it was really a hopeless case or not. There was a follow up study done by Dr. Kim with others of the cases which the Dutch Regional Euthanasia Review Committee, so the oversight body that's looking at all of these cases and they found a subset of cases where they felt this oversight commission felt that due care criteria were not met. And Scott looked specifically at the psychiatric cases. 69% of these improperly conducted cases related to improper medication administration or consultation that was not sufficient. There were cases in which there were financial ties between the physicians that were rendering the opinion on the assisted suicide or euthanasia. 31% failed to meet substantive criteria related to no reasonable alternative, being tired of life was in one case the sufficient medical cause in the satisfied physician's view. Reversible psychiatric issues are patients without capacity. And the review committees don't say whether it was right or wrong, but just whether the procedures were followed and they found many that were not. So I just want to give you a few examples. Example one is an 80 to 90 year old woman who suffered from depression but was otherwise healthy. An end of life clinic physician saw the patient twice over three weeks. He did not interview the patient alone. The patient was with her family. They did not consult with a psychiatrist. And he told the commission that he had not a single doubt about the patient meeting criteria and therefore did not consult with a psychiatrist. The commission felt that the commission felt that the physician did not act with caution that would be appropriate in the psychiatric case. And this is a person's already dead. You got that part, right? Okay. The physician should have interviewed the patient not in the presence of her children and should have consulted with a psychiatrist. Second example, a 90 year old woman who was lonely but healthy. There was disagreement between the attending physician and the consultant. The commission concluded that her suffering cannot be primarily attributed to a medically classified disease or disorder. There was no sufficient medical cause or psychiatric cause. Therefore the physician could not have come to the conclusion that it was a matter of unbearable suffering and that there was no reasonable alternative solution. The third example is the most disturbing. A 70 to 80 year old woman who suffered from Alzheimer disease lacked capacity and had an advanced directive. In her advanced directive she said, when the time is right, I would like assistance in dying. Other people decided that the time was right and the patient was given a sedative covertly in her coffee to prevent her from resisting. During the insertion of the infusion line, the patient sat up, tried to fight them, tried to withdraw, was restrained and was then euthanized. The commission determined that the patient's advance directive suggested that the patient wanted to be able to choose when and the commission felt that the physician crossed a line with her actions. Kim and Miller concluded that evaluating patients' requests requires complicated judgments and implementing criteria that are intentionally open-ended, evolving and fraught with acknowledged interpretive difficulties. Our review suggests that the Dutch review system's primary mode of handling this difficulty is a trust-based system that focuses on procedural thoroughness and professionalism of physicians. So let's just spend a minute thinking about trust and professionalism and psychiatry. This is a poem I read to my residents at their graduation every year. It's called Crown. It's by Kay Ryan, who's a California poet laureate. And she says, too much rain loosens trees. In the hills, giant oaks fall upon their knees. You can touch parts you have no right to. Places only birds should fly to. And I invite my young psychiatrist, who are gonna do amazing work and hard emotional work throughout the course of their careers, to think about this sacred relationship that actually I believe all physicians have with their patients, but especially psychiatrists where we enter into this intimate life of feelings, love and behavior, choices, motivations. There's something unique about what happens in this interpersonal healing with a psychiatrist, whether they use biological agents or just their soul and techniques. So I'd like to leave you with the thought that, as Helen Keller said, although the world's full of suffering, it's full also of the overcoming of it, systematically depriving people with mental disorders of the opportunity to overcome their life experience, gain the wisdom, share their art, share their poetry, share their perspective is our loss and really a devastating injustice. And I hope that this moves you to activism. As I had one patient tell me, she said, we wanna get rid of mental illness, we don't wanna get rid of the mentally ill. Thank you. I know it's lunch, I'm happy to answer any questions. Visit with people at lunch. I just assume a cray from the University of Toronto. Thank you so much for that stimulating presentation. Canada, as many of you know, has recently embarked upon this journey of medical assistance and dying. And at this very moment, a lot of negotiations are happening about how that's gonna be applied to children as well as the mentally ill. I personally work in one of the leading trauma therapy programs in Toronto at Women's College Hospital. And I was really happy to see, well, happy to see, I was happy to see it acknowledged that post-traumatic stress was on that list because I think that what a lot of people who don't work with people who have post-traumatic stress don't appreciate it and I know that you know this from your practice is chronic suicidality is so much a part of the work that I face every day. People, I would say 90% of the clients that I work with have chronic suicidality that's very significant in the room. But with proper strategies and understanding and therapeutic technique, those people often can identify that chronic suicidality as a last resort fight response that they may have had to build as a coping in their life. And it's very appropriate in that protective context. So I also really worry for people with chronic trauma, psychological trauma, that these kinds of things that we're seeing happen overseas could really impact a large number of people very significantly. So thank you for your advocacy. I really appreciate it. Yeah, thank you for the beautiful comment. I think understanding suicidality is a clinical sign and not getting confused in these rationalist arguments. I think our obligation is physicians first. I'll put it that way. Thank you so much. I don't know if you would have expected that there would be a Dutch person in the crowd. I'm Rene Eicholt. I work as a clinical ethicist and a bio ethicist at Michigan State University. And I actually stand by the legislative regime in the Netherlands now. It's very challenging to translate cultural context in these things. And so that is something that hurts me because the way that the Dutch system is portrayed is very inhumane. And I think it requires a very long talk on my end to explain some of the differences that why I stand behind our legislative scheme. I don't think it would be appropriate to translate it to the US the way we practice it. There's a very different mental health care system. There's a very different population, a very educated, rich population. And so it creates a very different context for these individuals. A couple of years ago, there was a physician who he was prosecuted. He actually committed suicide after he had been traced by one of the committees for not having fulfilled all the criteria. And the widow of the individual that he had assisted in dying, and I think there was euthanasia, actually was extremely upset with the committees. Because they said, you know, my loved one has been struggling with the mental illness for his whole life. And he did not fulfill all the criteria for undergoing this euthanasia. Instead of him committing suicide, in the Netherlands we do not have guns. Instead of him choosing a train, he chose to go to a professional and the professional work was bound to these sets of criteria to fulfill this. And he was not allowed to undergo it officially. So actually it was a very compassionate act from the physician that he overstepped the boundaries. Anyway, it's very challenging to translate the cultural context here, but I want to say that there's more to the story. I hear a lot of people go like, oh, outrageous. But there is a lot more to the story than the way how you've translated it. And I've actually, yeah, I feel uncomfortable with Kim's study or his conclusions. It just needs a little bit more social political context to make, you know, clear what's actually happening. Thank you for your comment. Yeah, thank you.