Autism, Mental Illness, Euthanasia and the WaPo

There was a piece in the Washington Post the other day with a striking headline: Where the Prescription for Autism can be Death.

Normally, if we’re saying that the prescription for x is y, we mean to say that y is being suggested as a treatment for x.  Painkillers are the prescription for a bad back, a steroid cream the prescription for eczema, and so on.  Even if you find that phrasing a bit clunky, “prescription” implies the recommendation of a medical expert.  On that basis, the implication here is that somewhere in the world, doctors are seeing patients, diagnosing autism, and saying, “I wonder if the best thing would be to kill you”.  That would be uiruite a Big Deal.

The place in question is Holland.  But a quick look at the article shows – surprise, surprise – nothing of what’s hinted at in the headline.  Here’s the opening few sentences, edited slightly for formatting:

In early childhood, the Dutch psychiatric patient known as 2014-77 suffered neglect and abuse.  When he was about 10, doctors diagnosed him with autism.  For approximately two decades thereafter, he was in and out of treatment and made repeated suicide attempts.  He suffered terribly, doctors later observed, from his inability to form relationships: “He responded to matters in a spontaneous and intense, sometimes even extreme, way. This led to problems.”

A few years ago, 2014-77 asked a psychiatrist to end his life.  In the Netherlands, doctors may perform euthanasia — not only for terminal physical illness but also upon the “voluntary and well-considered” request of those suffering “unbearably” from incurable mental conditions.
The doctor declined, citing his belief that the case was treatable, as well as his own moral qualms.  But he did transmit the request to colleagues, as Dutch norms require.  They treated 2014-77 for one more year, determined his case was, indeed, hopeless and, in due course, administered a fatal dose of drugs.  Thus did a man in his 30s whose only diagnosis was autism become one of 110 people to be euthanized for mental disorders in the Netherlands between 2011 and 2014.

So, then, it’s a story about a man, who happened to be autistic, and who asked a psychiatrist for euthanasia.  After a little to-ing and fro-ing, that request was granted.  There is no reason to believe that this was a case of death being prescribed for autism.  It’s just that he happened to be autistic and to want to die, and a prescription for assistance was provided.  Phrasing is important.

Dutch law on assisted dying is famously liberal; in considering the permissibility of euthanasia for psychiatric as well as somatic illnesses, it is in the minority of the minority of jurisdictions that consider the permissibility of any euthanasia.  I have addressed the question of psychological suffering in relation to euthanasia elsewhere, and shan’t rehearse the details here; suffice it to say, I don’t see any reason in particular to think that mental illness and physical illness should be treated all that differently in principle:

[T]he arguments about physical distress [as a reason to seek assisted dying] seem to me to rely – to at least some extent – on a notion of psychological distress anyway.  After all, a person who was terminally ill but unmoved by that fact would – presumably – be less likely to seek assistance than someone for whom it did make some kind of emotional impact.  There’s likely to be more to it in real life; but I think that, all the same, some kind of psychological distress is reasonably likely to be found in people who seek assistance to die for ostensibly physical reasons.  That being the case, it’s not clear why psychological distress mightn’t be a reason to seek assistance in its own right.

For sure, we might be a bit more worries about the authenticity of a desire to die in the case of mental illness; but so long as we are satisfied that the desire to be dead is genuine, then I don’t really see why mental illness should be a special case when it comes to euthanasia.  In fact, I don’t see why illness should be a criterion at all.  If a Smith wants to be dead, and would prefer assistance, and someone is willing to allow it, then – subject to fairly straightforward regulations about who that someone is – for as long as we take seriously individuals’ rights to run their lives as they see fit, the moral case seems to be there to be made.

And this is how we can answer he case of Tine Nys, also cited in the WaPo article.  Nys, who has a history of mental illness, sought assistance to die after a romantic breakup.  It might be that, after all, the medics who helped in this particular case were too easily persuaded – I don’t know enough about her or the case – and it might even be that virtue would count against assisting in every actual similar case; but that won’t make the principled argument, which is that mental distress need not be any worse a cause for assisted dying than anything else, not least because – as I suggested above – it’s implicit in wanting to die in response to physical illness as well.  That procedures can be ignored is evidence that there are procedures; and there’s no reason to believe that such procedures have to be sinister.  exceptio probat regulam in casibus non exceptis, and all that.

Back to the main thrust of the WaPo piece, though.  It’s claimed that

In 37 cases, patients refused possibly beneficial treatment, and doctors proceeded anyway.

But it’s not clear why that should matter.  If a person refuses treatment, then that’s fine.  (Imagine that someone is seeking an abortion, and is told not to worry because the pain of childbirth can be nullified with drugs.  That might, I suppose, make a difference where fear of pain is at the root of the desire for termination; but it’d be strange to treat it as an all-things-considered knockdown argument against providing any abortions at all.  Or someone who refuses intubation, even though it isn’t going to be forever – again, we’d take that seriously, and Ms B showed that the law would be on the refuser’s side.  The same sort of reasoning would seem to apply here.)

Contrary to the tone in the WaPo article, there is no reason to suppose that someone with a mental illness or who has a disorder like autism is by definition especially vulnerable in this sort of situation.  They might be vulnerable, of course; and there might even be a higher chance of that than there is for most people.  But they might not be.  It strikes me as rather patronising to assert otherwise.

The article continues, to report that

[a]mong the obvious risks [of providing euthanasia to psychiatric patients], Columbia University psychiatrist Paul S. Appelbaum writes […], is “inducing hopelessness among other individuals with similar conditions and removing pressure for an improvement in psychiatric and social services.”

“Will psychiatrists conclude from the legalization of assisted death that it is acceptable to give up on treating some patients?” Appelbaum asks.

A perennial warning I have to give to my students is against rhetorical questions: someone might answer them, and not as you expect.  Instead of answering head-on, though (and at risk of falling foul of my own exhortations), I shall respond to this one with a couple of my own:  Why should it?  Why should the possibility of doing A at someone’s request make it less likely that standard practice B would be rejected in circumstances when A is not requested?

The problem with this article is not that it’s just poorly argued, but that it’s actually dangerous.  Why?  Because between the tendentious headline and the leading rhetorical questions, patients are at risk of being made more worried than they need to be; and, at the outside, this might mean that they’re less likely to seek treatment for mental or neurological disturbances out of an unwarranted fear that the prescription will be for a lethal injection.

That strikes me as being a bad thing.

  • Keith Tayler

    You say: ‘For sure, we might be a bit more worried about the authenticity of a desire to die in the case of mental illness; but so long as we are satisfied that the desire to be dead is genuine, then I don’t really see why mental illness should be a special case when it comes to euthanasia.’

    You do not appear to have the slightest understanding of ‘mental illness’ or learning difficulty, the function of psychiatrists, mental healthcare workers and the law. Much of what you say makes no sense. In one sentence you say ‘there is no reason to suppose that someone with a mental illness or who has a disorder like autism is by definition especially vulnerable in this sort of situation’, in the next ‘[t]hey might be vulnerable…might even be a higher
    chance of that than there is for most people.’ You then say ‘they might not’ and then top it all off with, ‘[i]t strikes me as rather patronising to assert otherwise.’ I grant you that there might be a small minority of “patients” that could be described as being not vulnerable (the vast majority of these because they are ‘boarder line’); but to suggest that we should instigate a policy to make AS available to all patients because there might be a few that fall into this group is absurd.

    To answer your rhetorical questions: assisted suicide would radically alter ‘standard practice’. Now I am the first to say that the ‘standard practice’ should be radically altered, but AS would divide psychiatrists, clinical psychologists, mental healthcares and, by no means least, patients. As Appelbaum warns, the existing ethos and methodologies of treatment and therapy would be disrupted by the
    belief that all patients can be classed as untreatable (we should be mindful of the problems this classification has created for Personality Disorder). I can assure you this malaise is already a problem and certainly does not require further underpinning.

  • Robyn

    I have been reading articles such as this all day now, and while I agree with the author, I would still very much like to share my thoughts.

    My Credentials: I have a Bachelor’s degree in Sociology and a Master’s in Human Relations. More importantly, I am “unemployable” receiving veterans benefits and social security, I have Borderline Personality Disorder (easier to find help online if you “know” one, than if you are one, most often advice to anyone who knows me is “RUN”), I have PTSD, I have Major Depressive Disorder, Anxiety Disorder, Pyschotrophic-Drug-Induced Hypothyroidism, I am estranged from my three adult children (who will have something to do with me when I am “nolonger mentally ill”), My family has nothing to do with me, I have not one single friend.

    There is no cure for Borderline Personality Disorder. It has the highest suicide rate of all mental illnesses. Borderline Personality Disorder has the heaviest burden on individuals from age 14 to 60 years of age (I will be 43 in June).

    I have been in and out of treatment for the past 15+ years.

    Let me list the positive gains I have experienced from over a decade of treatment:

    1. NOTHING My problems became exponentially worse since beginning treatment over a decade ago.

    After years of treatment, I have gained NOTHING POSITIVE.

    So, if the “Mental Health Care” that I’ve received hasn’t helped me, has it hurt me?

    1. PHYSICAL HEALTH PROBLEMS: I was diagnosed with Hypothyroidism while I was taking Citalipram, Lithium, and Seroquil (all provided by a single Psychiatrist, taken together, and all proven to have adverse effects on the thyroid). Shortly after this diagnosis, I was diagnosed with TB (common). Shortly after this diagnosis, I was diagnosed with HSV II (while in a relationship with only one man).

    2. My diagnosis of Borderline Personality disorder was kept from me by the VA for a decade, I found out because someone typed it onto a discharge summary in 2012 (More than a year after my children stopped having ANYTHING to do with me at all).

    3. I was a profit machine for the mental health industry and the drug industry, yet I got no benefit.

    4. I took MANY different drugs prescribed by different psychologists at different times and also had 7 Electro-Convulsive-Therapy treatments. Drugs that caused things such as pitting edema, vertigo, huge weight-gain, hair loss, tremors (people have told me that they thought that I was an alcoholic and I don’t even drink) and other physical manifestations.

    5. I endured countless acts of emotional abuse by practitioners and assistants as an inpatient on numerous Psych wards.

    6. Treatment eventually caused my life to revolve around my mental illness and nothing more.

    That’s enough for now. I believe in euthanasia for people who suffer as I do. I’ve tried to kill myself a few times, my best attempt, less than two years ago, gave me a three-day-coma which was admit-ably “THE BEST SLEEP I’VE EVER HAD!” For those curious, I was taken to the hospital by my husband. I was in the ICU for two days and woke up on the third day on a medical ward. There was no “tunnel,” no “white light,” no conversations with saints, Jesus, or a god. It was absolute nothingness and thereby, ABSOLUTE PEACE.

    People who are not suicidal love to say things like “you don’t need euthanasia or assisted suicide, killing yourself is easy” but to my knowledge, not one of them has ever shown by example how easy it is.

    If killing one’s self was easy, there would not be people from all over the world looking for someone to kill themselves with every day online. There wouldn’t be people fighting for a right to die with dignity through assisted suicide. Killing oneself is most assuredly NOT EASY, if you think it is and want to be considered the expert on the subject, that you obviously believe yourself to be, prove it! YOU CAN’T.

    People like to talk about the “Slippery Slope” and conjure images of Hitler and Nazi Germany. Was Euthanasia ever a choice in Germany? I have tried to find the slippery slope where Hitler invited the suffering to die with dignity, and then everything “Slipped” and everyone who was deemed unworthy of life was suddenly killed. In my searches, I have not been able to see where Hitler ever instituted euthanasia by choice. If you know something I don’t, please give me a link.

    How can anyone use what Hitler did to deny suffering human beings a humane departure from suffering? Maybe we should charge anyone who has ever euthanized an animal because it is cruel and it represents the top of the hill with regard to the “Slippery-Slope.” There is absolutely no connection except that the topics all include that big, long, scary “E” word (euthanasia).

    I was on a psychology page on euthanasia today where they only allowed the professionals in the field of “Mental Health” to comment. That would be like deciding there was something inherently wrong with corporations and going to CEO’s for their thoughts on the matter only to find out that the problem was not “based in reality” (because CEO’s profit from their corporations). It is in the best interest of every “Mental Health Professional” to continue to have “Customers” like me and NOT SUPPORT A RIGHT TO DIE.

    While reading these practitioners words on the subject, I found myself with a new idea. MHP’s believe that they are helping people, after all they go to work every day and they see clients every hour or so. I would like to know how much MHP’s are actually helping. I would suggest the following academic study.

    Have a “Mental Illness Lottery” where everyone who is severly mentally ill (maybe on disability too) and would like help can put their name in a hat. I would put my name in the hat because the chance at a happy life would be worth forgoing suicide in the short run. Anyone who wants to be dead would rather be healthy and happy in life.

    Offer psychiatrists compensation of $200,000.00 (enough to live on while contributing to their field) for one year of their time (a required sabbatical from their current jobs). Allow each MHP to be paired with a single patient who exhibits severe symptoms for each MHP’s specialty (i.e. Bi-Polar Disorder, Schezophrenia, Borderline Personality Disorder, PTSD, whatever) for a period of one year.

    Allow each doctor to author his/her own treatment plan for each of his/her single patients. One Patient, One Doctor, One Year, if a doctor cannot make a difference in one patient’s life over the course of a year, we can throw all that is the “Mental Health Field” in the trash. If it works, we can discover what made it work and apply the fix to other victims on a larger scale.

    At the conclusion of the study, we will be able to determine, beyond a shadow of a doubt, whether or not “Mental Health Treatment” actually helps and if so, in what percent of cases for each diagnosis. If a doctor cannot improve their single patient’s life substantially in a year’s time, it makes a strong case for those of us suffering after decades of mental illness and stigmatization.

    I suggest an INTENSIVE STUDY to determine the EFFECTIVENESS of the ENTIRE FIELD of Mental Health Practicioners. Make it a world-wide study. Have a panel of psychiatrists that compile and oversee submission of the practitioner’s treatment plans and notes, and each sufferer’s required journals over the entire study period. Have a second panel of Statisticians who will translate raw data into workable data and statistics.

    I don’t believe this will ever actually happen but I would love to see the results. The only reason not to conduct such a study is because the results would likely bring great harm to the profession as a whole and the professional’s pocketbooks (the bottom line) as a result (we shouldn’t forget BIG PHARMA either).

    According to USA Today, I am 16 times more likely to be killed by a police officer than “normal” people. Only because I am mentally ill. If I am 16 times more likely to be killed by a police officer, how much more likely am I to be killed by someone in the majority who is not a police officer (when compared to “normal people”)? How much more likely is it that I will end up in prison when compared with “normal people”? How much more likely am I to end up with a death penalty than “normal people”? I not only live in pain, I also live in fear. Fear is only paranoia when it is unfounded.

    I think that it is much more likely that I will be killed by eugenics in America than to ever have the option of assisted, non-violent suicide. It seems to be widely accepted that every female serial killer, if not every female killer, suffered from a mental illness, most often times Borderline Personality Disorder. When I am disgusted with life, I sometimes entertain the idea of taking a few evil people out with me. Should anyone ever feel safe around me? My friends and family don’t, why should you?

    According to a 2011 article in “psych-gripe” it is stated that a study revealed that an estimated 25 to 50 percent of the female prison population suffers from Borderline Personality Disorder. So, my government would rather make me a literal prisoner (orange jumpsuit and all) than to allow me to “gracefully” drop out of life assisted by euthanasia. At least then I support For Profit Prisons.

    Honestly, I find it so difficult to stomach the simple fact that all people with BPD are criminalized online whether or not they have ever committed a criminal act. How can anyone see the articles that come up from a simple “Borderline Personality Disorder” search (once you get beyond Mayo, NAMH etc), and not allow those afflicted to be euthanized by their own choice?

    CAN A NORMAL PERSON UNDERSTAND, OR COMPREHEND, WHAT LIFE WOULD BE LIKE FOR THEM IF SUDDENLY ALL OF THE FOLLOWING APPLIED TO THEIR CURRENT LIFE:

    They could not keep a job.

    They were estranged from their entire family.

    They literally had zero friends.

    They were labled as “Mentally Ill.”

    They could no longer drive a car even though they had not had an at fault accident in more than 20 years of driving (entire history).

    Could not make casual conversation with anyone.

    They could almost never leave their home.

    People professed to be able to help, at great sacrifice on the part of the individual, but NEVER actually did.

    Their physical health was compromised because of pharmaceutical treatment for “mental health issues” that were never actually treated.

    They had a stigma hanging over their heads that would absolutely destroy their credibility, thereby their career regardless of credentials, as an intelligent being among other humans.

    “Normal” people feel better about themselves because people like me exist in absolute misery. Many even profit from my existence. It is so easy for “normal” people to laugh at people like me while sipping on a $5.00 cup of coffee, or a fancy juice with friends and yet, when I see “normal” people having fun in groups in public, IT PISSES ME OFF because it is impossible for me.

    I would very much like to be accepted by any level of society and I would venture to say that if I felt at all accepted by any group in society, I wouldn’t want to be euthanized. I am a social pariah (a person who is hated and rejected by other people). An outcast. You should allow me to die in peace so that I don’t one day get pissed at the rest of you and decide to do something about it and actually engage in unleashing my fury and vengeance upon one of your family members.

    Speaking like that though, I am called a terrorist. Don’t dare tell the truth! I am more likely to be imprisoned for the rest of my life, tortured by professional torturers, rather than being afforded the peaceful exit I’ve been requesting for many years now. If not tortured, then shot, hanged, electrocuted, or otherwise caused a great deal more pain and suffering to add to that which I am already in.

    My country would rather kill me violently than allow me to be euthanized. I think that they should re-consider their position on the matter. I hope that they do before I am forced to die a painful death because I am mentally ill and honest about my experience being mentally ill. I used to try to change people’s minds about people like me, but it is too late and “normal” people will use anything, including another person’s absolute misery, just to feel better about themselves living “normal” lives.

    In a better world, I would be relieved of my suffering in a peaceful manner having suffered enough in life. My brain would be shipped to pathologists who could try to discover anything that might help to protect, or treat, others with problems like mine. Everyone loves to rattle off the popular lie “mental illness is caused by a chemical imbalance in the brain.” Sounds very scientific however, none of my diagnoses were made (nor can they be made) via a BLOOD CHEMISTRY TEST and nobody I’ve met in inpatient mental health has had a brain biopsy in order to identify their individual imbalance.

    This “CHEMICAL IMBALANCE” hoax would make since if there was a mental illness that could be diagnosed through any kind of chemical test. It is a lie of drug companies so that you will make sure that your mentally ill family and friends take their “medicine” chemicals. Medications that are likely responsible for far more human death than any number of suicides.

    Most people who attempt suicide do not succeed the first time unless they go hardcore on the first attempt. No FEAR. My aunt tried many options before finally jumping from the Coronado Bay Bridge in San Diego and being successful. Many psychotropic drugs can kill quite quickly “without any intent to do harm.” So what I take from this fact when applied to the euthanasia argument, is that my government would rather provide me as a lab rat to big business pharmaceutical companies than give me the peace that will free me from my suffering.

    I would happily take their drugs in the hospital for a week at a time, once a month, to enjoy an all I can sleep one week coma. One never knows, maybe Jesus, a god or a saint would talk some sense into me while I sleep. They won’t give me that either, I’ve asked.