Guest post by Udo Schuklenk

We should not prevent some depressed people from access to assisted dying.

Deborah E Gray, whose depression is (according to her account) successfully managed today, describes vividly on her website the impact depression had on her.  She writes:

you don’t feel hopeful or happy about anything in your life.  You’re crying a lot for no apparent reason, either at nothing, or something that normally would be insignificant.  You feel like you’re moving (and thinking) in slow motion.  Getting up in the morning requires a lot of effort.  Carrying on a normal conversation is a struggle.  You can’t seem to express yourself.  You’re having trouble making simple decisions.  Your friends and family really irritate you.  You’re not sure if you still love your spouse/significant other.  Smiling feels stiff and awkward.  It’s like your smiling muscles are frozen.  It seems like there’s a glass wall between you and the rest of the world.  You’re forgetful, and it’s very difficult to concentrate on anything.  You’re anxious and worried a lot.  Everything seems hopeless.  You feel like you can’t do anything right.  You have recurring thoughts of death and/or suicidal impulses.  Suicide seems like a welcome relief.  Even on sunny days, it seems cloudy and gray.  You feel as though you’re drowning or suffocating.  Your senses seem dulled; food tastes bland and uninteresting, music doesn’t seem to affect you, you don’t bother smelling flowers anymore.

In many jurisdictions where the decriminalisation of assisted dying is debated, proponents of decriminalisation hasten to add that they would, of course, exclude patients that suffer from depression.  This may be a political move aimed at increasing the societal acceptability of assisted dying, but it is unjust towards patients suffering from treatment-resistant depression.  Many lay-people, and even doctors and nurses, fail to acknowledge the severe suffering that comes with depression.  Patients who suffer from long-term treatment resistant depression are not just ‘feeling a bit low’.  As the quotation above shows, these people really suffer existentially, and because their depression has proven to be untreatable (often over the course of decades) there is no relief for their suffering.

Treatment-resistant depressed people’s suffering is in some sense even worse than that of the patients who suffers from end-stage cancer, or other uncontroversially somatic ailment, since these patients know that they will die soon even if their request for assisted dying is not granted.  Often the only way out for treatment-resistant depressed patients is to end their suffering by means of committing suicide, often in a gruesome manner, if no humane alternatives are offered.  Major depressive disorder and bipolar mood disorder are reportedly the main drivers underlying about 60% of the estimated 800,000 annual suicides globally.  In addition to the hopelessness depressed patients feel, they often encounter a resistance from their psychiatrist to discuss the options of a death as a way out of their suffering.  This impossibility to discuss possible ways to achieve a good death, only adds to their loneliness and desperation.

We argue in our paper that assisted dying should be made available as an option to patients with treatment resistant depression, as much as it ought to be available to other patients that suffer unbearably and hopelessly.  We propose competence as a threshold criterion, this would exclude patients in a psychotic state.

We expect that being able to discuss the possibility of a humane end-of–life with their doctors will help these patients to cope better with their depression.  The knowledge that they will no longer have to bear it, once they decide it is too much, may in itself be therapeutic.  This in turn may well prevent violent deaths that leave their relatives, friends and even completely random bystanders distraught.  At the same time a public discussion about mental illness, including depression will contribute toward misperceptions of psychiatric diseases as something “not real”.  Suffering from psychiatric disease is very real, and should be acknowledged as such.  For some patients this suffering will be so severe, so debilitating, that not-to-live is the better alternative.  It is unjust to deny them the peaceful death we are willing to grant other competent patients whose lives have become not worth living to them, in their best considered judgment.

Read the full paper here.