Security is both a feeling and a reality, and they don’t always match. Security Theater is when you make things look safe in order to make people feel safe even if they are not.
One of the supposed “safeguards” in assisted suicide laws relates to patients that may be depressed. This is usually optional and rarely done in states where PAS is legal. The Massachusetts proposed law requires it for all patients.
Section 8. Counseling Referral
(1) An attending physician shall refer a patient, who has requested medication under this chapter, to counseling to determine that the patient is not suffering from a psychiatric or psychological disorder or depression causing impaired judgment. The licensed mental health professional must submit a final written report to the prescribing physician.
(2) The medication may not be prescribed until the individual performing the counseling determines that the patient is not suffering from a psychiatric or psychological disorder or depression causing impaired judgment.
Feel safe? Are you really?
Note that this section of the bill is short on details. It requires a licensed mental health professional—typically a social worker—to determine “that the patient is not suffering from a psychiatric or psychological disorder or depression causing impaired judgment.” Seems simple. (No wonder the MA chapter of the National Association of Social Workers supports this bill.)
The reality is that not even psychiatrists find it easy. It involves what we call in medicine Decision-Making Capacity (DMC). Everything we know about DMC is being ignored by those involved with PAS.
- “Only 6% of psychiatrists were very confident that in a single evaluation they could adequately assess whether a psychiatric disorder was impairing the judgment of a patient requesting assisted suicide.” (Ganzini et al. 1996 survey of Oregon psychiatrists)
- Psychiatrists’ own ethical views on PAS may influence the level of scrutiny used in assessment. (Ganzini et al. 2000 survey of forensic psychiatrists)
- 2/3 of consultation psychiatrists find DMC evaluations more challenging than other types of evaluations they perform. (Seyfried et al. 2013).
- Diminished decision-making capacity at the end of life is common. A study of adults age 60 years or older (n >3700) who died found that decisions about treatment in the final days of life were necessary for 42 percent, but that capacity was impaired in 70 percent. (Silveira, Kim, & Langa. NEJM 2010)
- A high level of DMC is not needed to get PAS in the Netherlands, and there are known disagreements among physicians assessing DMC in psychiatric patients receiving PAS. (Doernberg et al. 2016)
- Nearly half of elderly terminally ill cancer patients failed a measure of capacity. ”Without thorough and reliable evaluation methods, doctors may fail to recognize decision-making impairments even when they are pronounced.” (Sorger et al. 2007)
Besides DMC, another key measurement not being taken into consideration is Demoralization. Demoralization is a maladaptive coping response conceptualized as a loss of meaning and purpose, with feelings of hopelessness and helplessness. Here is what research in Demoralization is showing.
- Demoralization has more influence on suicidal ideation than depression. (Fang CK, et al. 2014)
- Moderate levels demoralization can be present without any clinical depression. (Robinson et al. 2016)
- Because of the sense of impotence or helplessness, those with the syndrome predictably progress to a desire to die or to commit suicide. (Kissane et al. 2001)
- Depression, loss of meaning and purpose, loss of control, and low self-worth are strong clinical markers for desire to hasten death. Targeting these symptoms through existentially oriented therapies, such as meaning-centered therapy, may ameliorate suicidal thinking. (Robinson, Kissane, et al. 2017)
Still feel safe?
Interestingly, “spirituality” is being increasingly recognized as a component of health, even without an agreed definition of spirituality. It is a vast concept that includes a transcendent dimension. Since one of the core features of demoralization is a loss of meaning, spirituality is of central aspect of treating it. Doctors should offer prayer, not lethal prescriptions.
The only people who are made truly protected by PAS laws are doctors. As Dr. Scott Kim at the NIH, an expert in DMC, said at a recent PAS conference:
“Because PAD laws’ primary function is protection of MDs, no country has a monitoring system that can assess whether these types of expansions in practice occur.”
In other words, no one checks if the safeguards are really keeping patients safe, and likely they are not. It’s just Security Theater.
Watch this interesting talk about security and see how many ploys Compassion and Choices are using in the security theater they present to legislators and the public.