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.

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