Highlights
- •What is the primary question addressed by this study?What are the ethical implications of emerging rapid-response treatments for depression for depressed patients who request physician-assisted-death?
- •What is the main finding of this study?The development of rapid-response treatments could have an important role in clarifying the decision-making quality of depressed patients seeking PAD, raise potential dilemmas for clinicians assessing the PAD eligibility criterion of irremediability in some jurisdictions, and challenge society's obligations for making such treatments available for patients in particularly vulnerable situations.
- •What is the meaning of the finding?Although the emergence of rapid-response treatments for depression will likely have important benefits to depressed patients requesting PAD, they also raise ethical challenges for those jurisdictions in which the practice is legal.
Abstract
Depression is common at the end of life, and there is longstanding concern that it
may affect terminally ill patients’ decisions to request physician-assisted death
(PAD). However, it is difficult for clinicians to determine the role of depression
in a patient's PAD request. A recent case series described rapid responses to intranasal
ketamine in three patients with terminal illness and comorbid depression who had requested
PAD. One patient withdrew her request (which, in retrospect, had been driven by her
depression) while the others maintained their requests; in all three, the rapid relief
clarified the role of depression in the patients’ decision-making. In addition to
ketamine, there are other emerging rapid-response treatments for depression, including
psilocybin with psychological support and functional connectivity-guided transcranial
magnetic stimulation. We examine three key ethical implications of such treatments:
their role in clarifying the decision-making capacity of depressed patients requesting
PAD; the potential tension between the legal definition of irremediability in some
jurisdictions and the ethical obligations of clinicians; and the likely obstacles
to treatment access and their implications for equal respect for autonomy of patients.
Key Words
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References
- Attitudes and practices of euthanasia and physician-assisted suicide in the United States, Canada, and Europe.JAMA. 2016; 316: 79-90
- Assisted dying around the world: a status quaestionis.Ann Palliat Med. 2021; 10: 3540-3553
- Oregon Death with Dignity Act 2021 Data Summary [Internet].Oregon Health Authority Public Health Division, 2022 (Available from:)
- Symptom prevalence in patients with incurable cancer: a systematic review.J Pain Symptom Manage. 2007; 34: 94-104
- Clinically significant depressive symptoms are prevalent in people with extremely short prognoses-a systematic review.J Pain Symptom Manage. 2021; 61: 143-166
- Prevalence of depression and anxiety in patients requesting physicians’ aid in dying: cross sectional survey.BMJ. 2008; 337: a1682
- Legal physician-assisted dying in Oregon and the Netherlands: evidence concerning the impact on patients in “vulnerable” groups.J Med Ethics. 2007; 33: 591-597
- Instability of attitudes about euthanasia and physician assisted suicide in depressed older hospitalized patients.Gen Hosp Psychiatry. 2001; 23: 326-332
- The effect of recovery from depression on preferences for life-sustaining therapy in older patients.J Gerontol. 1994; 49: M15-M21
- Mental capacity to make decisions on treatment in people admitted to psychiatric hospitals: cross sectional study.BMJ. 2008; 337: 40-42
- The psychometric properties of the competency interview schedule.Can J Psychiatry. 1994; 39: 368-376
- The assessment of competence to make a treatment decision: an empirical approach.Can J Psychiatry Rev Can Psychiatr. 1996; 41: 85-92
- Understanding the complex of suicide in depression: from research to clinics.Psychiatry Investig. 2020; 17: 207-221
- Suicide and physician-assisted death for persons with psychiatric disorders how much overlap?.JAMA Psychiatry. 2018; 75: 1099
- Is ketamine a litmus test for capacity in assisted dying with depression?.Psychooncology. 2021; 30: 417-420
- A systematic review and meta-analysis of the efficacy of intravenous ketamine infusion for treatment resistant depression: January 2009 - January 2019.J Affect Disord. 2020; 277: 831-841
- Ketamine for the treatment of mental health and substance use disorders: comprehensive systematic review.BJPsych Open. 2022; 8
- The efficacy of ketamine in the palliative care setting: a comprehensive review of the literature.J Palliat Med. 2019; 22: 1154-1161
- Psilocybin produces substantial and sustained decreases in depression and anxiety in patients with life-threatening cancer: a randomized double-blind trial.J Psychopharmacol Oxf Engl. 2016; 30: 1181-1197
- Psilocybin and psilocin (Magic mushrooms) [Internet].2012 ([cited 2022 May 2]. Available from:)
Terminally ill patients the first in B.C. to consume legal supply of magic mushrooms [Internet]. vancouversun. [cited 2022 Apr 27]. Available from:https://vancouversun.com/news/local-news/terminally-ill-patients-the-first-in-b-c-to-consume-legal-supply-of-magic-mushrooms
- Stanford neuromodulation therapy (SNT): a double-blind randomized controlled trial.Am J Psychiatry. 2022; 179: 132-141
Nicol J, Tiedemann M. Legislative Summary of Bill C-7: An Act to amend the Criminal Code (medical assistance in dying) [Internet]. [cited 2022 Apr 28]. Available from:https://lop.parl.ca/sites/PublicWebsite/default/en_CA/ResearchPublications/LegislativeSummaries/431C7E
Death with dignity act [Internet]. ORS 127.127-800.995. Available from:https://www.oregon.gov/oha/ph/ProviderPartnerResources/EvaluationResearch/DeathwithDignityAct/Pages/ors.aspx
- Dutch law on Termination of life on request and assisted suicide (complete text) - The World Federation of Right to Die Societies [Internet].2011 ([cited 2022 Apr 28]. Available from:)
- Review Procedures in Practice.Regional Euthanasia Review Committees, 2018
- Competence of depressed patients for consent to research.Am J Psychiatry. 1999; 156: 1380-1384
- Mental capacity, diagnosis and insight in psychiatric in-patients: a cross-sectional study.Psychol Med. 2009; 39: 1389-1398
- Depression and decision-making capacity for treatment or research: a systematic review.BMC Med Ethics. 2013; 14: 54
- Emotions, autonomy, and decision-making capacity.AJOB Neurosci. 2011; 2: 62-63
- Temporal inabilities and decision-making capacity in depression.Phenomenol Cogn Sci. 2015; 14: 163-182
- Emotion and value in the evaluation of medical decision-making capacity: a narrative review of arguments.Front Psychol. 2016; 7https://doi.org/10.3389/fpsyg.2016.00765
- Physician-assisted death psychiatric assessment: a standardized protocol to conform to the California end of life option act.Psychosomatics. 2018; 59: 441-451
- Capacity evaluations of psychiatric patients requesting assisted death in the Netherlands.Psychosomatics. 2016; 57: 556-565
- Effects of psilocybin-assisted therapy on major depressive disorder: a randomized clinical trial.JAMA Psychiatry. 2021; 78: 481-489
- Synthesizing the evidence for ketamine and esketamine in treatment-resistant depression: an international expert opinion on the available evidence and implementation.Am J Psychiatry. 2021; 178: 383-399
- The rapid rise in investment in psychedelics—cart before the horse.JAMA Psychiatry. 2022; 79: 189-190
- The impact of national health care reform on adults with severe mental disorders.Am J Psychiatry. 2011; 168: 486-494
- National Survey on Drug Use and Health [Internet].Substance Abuse and Mental Health Services Administration, 2020 ([cited 2022 May 2]. Available from:)
- How often do individuals with major depression receive minimally adequate treatment? A population-based, data linkage study.Can J Psychiatry Rev Can Psychiatr. 2016; 61: 394-404
- Ways of debating assisted suicide and euthanasia: implications for psychiatry.Perspect Biol Med. 2021; 64: 29-43
Death with dignity [Internet]. [cited 2022 May 3]. Available from: https://deathwithdignity.org/about/
- The way forward for medical aid in dying: protecting deliberative autonomy is not enough.Supreme Court Law Rev. 2018; 85
- Choosing death: autonomy and ableism.Autonomy, oppression, and gender. Oxford University Press, Oxford2014
- Saying goodbye to Archie Rolland, who chose to die: “It is unbearable.”.Montreal Gazette [Internet], 2016 ([cited 2020 Sep 11]. Available from:)
- B.C. man with ALS chooses assisted suicide after years of struggling to fund 24-hour care [Internet].Patients Rights Action Fund, 2019 ([cited 2022 May 3]. Available from:)
Favaro A. Medical assistance in dying: Woman with chemical sensitivities chose death [Internet]. CTV News. [cited 2022 Apr 28]. Available from:https://www.ctvnews.ca/health/woman-with-chemical-sensitivities-chose-medically-assisted-death-after-failed-bid-to-get-better-housing-1.5860579
- Regional Euthanasia Review Committees Annual Report 2021.Regional Euthanasia Review Committees, The Hague2022
- Euthanasia and AssistedSuicide of Patients With Psychiatric Disorders in the Netherlands 2011 to 2014.JAMA Psychiatry. 2016; 73: 362-368
- Euthanasia requests, procedures and outcomes for 100 Belgian patients suffering from psychiatric disorders: a retrospective, descriptive study.BMJ Open. 2015; 5e007454
Article info
Publication history
Published online: July 10, 2022
Accepted:
July 5,
2022
Received in revised form:
July 1,
2022
Received:
May 16,
2022
Identification
Copyright
Published by Elsevier Inc. on behalf of American Association for Geriatric Psychiatry.
