Tag Archives: suicide

Ohhhhhhhh Colorado

A few weeks ago, I wrote of Canada’s decision to delay until 2027, implementation of Physician Assisted Suicide (“PAS”) for people whose primary diagnosis is a mental illness.

Reasons given included: Canada’s healthcare system was not ready to handle the increase in requests for PAS from patients with mental health issues; the expansion of PAS could undermine efforts to prevent suicide; politicians casting blame on the opposing party; and the risk of medical practitioners recommending assisted suicide as a cost-cutting measure to alleviate strain on Canada’s health care system.

And so reasonable, hopefully rational studies will be funded addressing the issue of PAS for patients with mental health issues.

Brava Canada!

In opposition to this reasoned, rational, logical approach, we have ‘Murica … specifically the State of Colorado.

In 2006, the movie, “Idiocracy” had a limited release in the U.S. It was directed by Mike Judge and co-written by Mr. Judge and Etan Cohen. Mr. Judge was the creator (or co-creator) of Beavis and Butthead, King of the Hill and Office Space.

The plot of Idiocracy follows U.S. Army librarian Joe Bauers, (played by Luke Wilson) who wakes up five hundred years in the future after a botched government hibernation experiment. He finds himself in a dystopian society run by corporations, where evolution has made humanity stupid because the benefits of technology made it unnecessary for people to be intelligent and physically fit to survive. Idiocracy serves as social satire that touches on issues including anti-intellectualism, commercialism, consumerism, dysgenics and overpopulation.

Colorado already has in place an overly liberal (or accommodating depending on your viewpoint) law on PAS. But then, certain Colorado politicians embraced some of the over the top aspects of the Idiocracy movie and are seeking to expand Colorado’s PAS law.

This is the proposed bill:

Click to access 2024a_068_01.pdf

The Colorado bill could have been drafted by Mike Judge as a script for an Idiocracy sequel entitled, “Idiocracy: How to Die in Colorado Without Really Trying.”  And yet, to date, there is no registered opposition to the bill in Colorado’s lobbying database.

So, let’s review some of the key provisions of this Idiocracy bill.

First, we know how busy Colorado medical doctors are. Overworked. Underpai.. well, overworked. So, let’s take some of the burden off them by allowing “Advanced Practice Registered Nurses” to make the determination that a patient qualifies for PAS. We also want to take even more burden off physicians so let’s allow Advanced Practice Registered Nurses to also serve as “consulting providers.”

Of course, this “consulting provider” must be qualified by specialty or experience to make a professional diagnosis and prognosis regarding a terminally ill individual’s illness. [emphasis added] Qualified by experience? That certainly gives an entirely new meaning to the phrase, “Expert by Experience.”

Naturally, with Colorado being an enlightened, beneficent land of opportunity, they surely cannot restrict their expanded PAS to residents of Colorado alone. When the bill is passed, ANY ADULT is eligible to apply for PAS. Even those who reside outside the State of Colorado. The bill does not restrict its implementation and activities to the State of Colorado. Which brings up a number of intriguing and troubling issues.

With the expansion and proliferation of the Interstate Medical Licensure Compact Act and the use of tele-health, the bill does not address whether a provider can make his/her diagnosis via telehealth and whether the opinion of the consulting provider may be provided via telehealth. If the attending provider has the requisite DEA certificate and complies with any applicable administrative rules, that provider can send the poison cocktail medications directly to the patient.

Then there is the current mandatory waiting period for PAS in Colorado which is 15 days. Presumably, that is far too long to consider and contemplate the end of one’s existence. So, let’s shorten that puppy up to 48 hours! After all, one can squeeze a lot of living in 48 hours … champagne, five-star dining, complaining about the latest Taylor Swift conspiracy. What more does one need? However, if the attending provider believes that death will come within that 48-hour window, even that waiting period can be waived.

But, what to do about those pesky life insurance companies which have exclusions in their policies for insureds who commit suicide? The Colorado bill thought of that too. The bill provides that a life insurance company doing business in Colorado cannot deny nor alter benefits otherwise available to its insured who chooses to undergo the Colorado PAS process.

At this point, we should also ask if this is merely a tempest in a teapot.  How prevalent is PAS in Colorado?

Since 2017, [when Colorado’s medical-aid-in-dying law went into effect] and 2022, according to data gathered by state health officials more than 1,090 patients were prescribed life-ending medication. Of those, 838 picked up the medication. [This information can be read by clicking on the link underlined in the prior sentence.] It’s unknown how many people used the medication to end their lives.

Over that six-year period, aid-in-dying prescriptions were provided by 219 Colorado doctors.

Interestingly, a survey was published in January 2022 of 583 physicians in Colorado carrying for potential medical-aid-in-dying patients. This survey can be found here:

https://link.springer.com/article/10.1007/s11606-021-07300-8

This survey provides some fascinating insight into those providers who are involved in medical-aid-in-dying for their patients.

The survey’s general conclusions were, “Many physicians in our sample are both willing and prepared to discuss MAiD with patients and to provide MAiD referrals. Fewer are prepared and willing to serve as an attending or consultant and fewer have provided these services. MAID consultants and attendings largely report the experience to be emotionally fulfilling and professionally rewarding, but all respondents reported multiple barriers to participation.”

The survey was transparent about the ethical concerns which included: “Ethical concerns include, but are not limited to, issues of equity and justice, patient autonomy, the nature of human suffering, slippery slope arguments, the proper roles of physicians, and the potential for devaluing human life. Religious beliefs have led some religiously affiliated hospitals to prohibit employed physicians from providing MAiD.”

For diseases like cancer, the availability and applicability of MAiD is much more compelling. Medical knowledge has shown the human body constantly produces new cells. Normal cells follow a typical cycle: They grow, divide and die. Cancer cells, on the other hand, don’t follow this cycle. Instead of dying, they multiply out of control and continue to reproduce other abnormal cells. These cells invade body parts, such as the breast, liver, lungs and pancreas. They may also flow through the blood and lymphatic system and spread to other parts of the body. Within a reasonable medical likelihood, death can be estimated.

But PAS for mental illnesses? For Anorexia Nervosa? Without having any objective medical criteria to determine a person’s capacity to make a life-or-death decision? Not even requiring a licensed psychiatrist or physician to be involved? Our wisdom and knowledge have not expanded to address mental health issues and PAS. To believe otherwise is clearly Idiocracy material.

One day, will our understanding of the human body, the brain, the complexities of our psyche reach a level which turns Physician Assisted Suicide into Medical-Aid-in-Dying for mental health issues? Perhaps so. But that day is certainly not today. Today, we are subjected to Idiocracy bills like Colorado’s law, short on wisdom and long on pedantic naivete.

Without the need of a physician to oversee the process, opening the process to everyone, and shortening the mandatory wait period to 48 hours, Colorado could become a mecca for PAS tourism.

Imagine Colorado’s new state slogan:

Medical Aid in Dying or Physician Assisted Suicide?

Words matter. Words are one of the strongest ways in which we communicate. We use words to express every human emotion. When words are used passionately and honestly, they can inspire us to greatness. Motivate us to dare mighty deeds. To, in the name of humankind, be open to exploring the greatest mystery facing us, that is, our very existence.

Close your eyes. Now, embrace the rapture you feel when the most special person in your life holds you in his/her arms, looks you in your eyes and says, “I love you.” Revel not just in those words, but the feelings and emotions they evoke.

Contrarily, words can also be used to inflict the deepest, darkest scars on a person’s soul. Words can cause such pain, such rage … such defeat, that they can push us prematurely closer to our graves.

Again, close your eyes. And try to imagine how you may feel when the most special person in your life looks you in the eyes and says, “I do NOT love you.” One word. One small word. One word changes everything. It changes feelings, emotions. That one small word changes … life.

Recently, end of life issues in the mental health community have come to the public’s attention, not just domestically, but internationally. Are physicians in the Netherlands prescribing death-inducing medications for autism? Is the UK government allowing life support measures to be removed from a child against a parent’s and their doctor’s wishes? Canada’s recent decision to delay until 2027, end of life measures for persons whose primary diagnosis is a mental health issue. And of course, here in the U.S., end of life options for persons suffering from severe and enduring anorexia.

And yet for these great emotional debates and issues, we cannot even agree which term of art to use … Medical-Aid-in-Dying (MAiD) or Physician Assisted Suicide (PAS). Each phrase engenders very different thoughts and feelings. Granted, this was not much of a debate when MAiD was first being considered for biologically based diseases for which the medical community did not have viable cures. It is now.

Dr. Matthew Wynia, director of the University of Colorado’s Center for Bioethics and Humanities, states: “There is a significant, a meaningful difference between someone seeking to end their life because they have a mental illness, and someone seeking to end their life who is going to die in the very near future anyway.”

As Lee Corso, a college football pundit and legend is fond of saying, “Not so fast my friend!”

Now, a once relatively clear line is being blurred.

In the United States, ten states and the District of Columbia allow patients to receive life ending medication. However, among these states, I could locate no provision specifically including, or excluding mental health issues. 

Instead, the statutory language focuses on the requirement of a “competent, terminally ill patient.” A vague, ambiguous term. When a person’s life hangs in the balance, there are few things as egregious as including terms which are vague, subjective to numerous interpretations and which are not readily definable.

So, what is the difference, if any, between MAiD and PAS?

Some health advocates and medical professionals insist that a terminally ill patient with a recognized, biologically based, somatic disease taking medication to hasten the end of their life is doing something fundamentally different than suicide. The term “medical aid in dying,” they say, is meant to emphasize that someone with a terminal diagnosis is not choosing whether to die, but how to die. Their death is immediate and inevitable.

Anita Hannig, an anthropologist at Brandeis University and author of the book, “The Day I Die: The Untold Story of Assisted Dying in America,” stated, “A phrase like “medical aid in dying” would reassure patients that they were taking part in a process that was regulated and medically sanctioned. Medicine has that legitimating power, like it or not, that really removes a lot of the stigma.”

Now, look at the language used by Ms. Hannig.

A process that was regulated.

A process that was medically sanctioned.

I would add, a process focused on a biologically based, somatic diseases, thoroughly researched and studied. Diseases in which relatively objective findings, treatment regiments and outcomes had been thoroughly vetted and are considered reliable. A disease, which in an advanced state, medical science cannot effectively combat nor cure.

For this, yes, Medical Aid in Dying may very well be accurate, understandable and compassionate.

But for circumstances in which a mental health issue is the primary diagnosis? Particularly, Severe and Enduring Anorexia? A legion of questions abound.

When did Anorexia become terminal? Does the medical community even have a remotely accurate understanding of the manner in which eating disorders impact the brain? And if so, why haven’t effective, biologically based treatments been researched, studied and implemented?

For that matter, regarding eating disorders, we also know the following:

There are no generally accepted standards of care. The “experts” in the community cannot even agree about the most effective medical and mental health interventions to treat this deadly mental health illness. For that matter, should anorexia even be classified primarily as a mental health illness?

There is no effective collaboration with any other medical or mental health community.

Private equity companies have been allowed to dictate residential “standards of care” and the way this mental health illness is treated. Emphasizing profits over patient safety. Even a former CEO of a residential treatment center is now admitting to this reality.

There are no pharmaceutical drugs which have been specifically researched, trialed and then approved to treat eating disorders. The drugs being used today were all designed to be used for other mental health and medical issues.

If the statistics can be believed, the mortality rate for eating disorders is worsening.

It is with this background, despite these harsh facts, that some people are attempting to legitimize end of life options for Severe and Enduring Anorexia.

Seriously. What criteria and protocol would be utilized to establish that which constitutes the highest level of treatment care before patients are welcomed into the warm embrace of death? Some pro PAS professionals may even look upon death as not being a failure or even a bad outcome.

How many years would a patient have to be afflicted with Severe and Enduring Anorexia before a death protocol is appropriate for them?

What objective testing exists to determine brain atrophy? Testing which would give more objective evidence showing that a patient either has or does not have the capacity to make life and death decisions?

As it is, no state has set forth any minimum, objective biological standards which must be met before a death protocol is made available for patients suffering from mental health issues.

With many biological based, somatic diseases such as cancer, objective testing and decades of research support a medical finding that death is inevitable. And as a compassionate society, Medical Aid in Dying, with effective oversight and clear protocols, very well may be in humanity’s best interest.

However, with Physician Assisted Suicide for mental health issues, because of the dearth of medically objective criteria, the diagnosis of “terminal” is based not so much on whether a patient will die, but how they will die.  

That patient’s death may not be pending, may not occur soon and may not be inevitable. That is the heart of Physician Assisted Suicide. Besides subjective criteria experienced by some mental health providers, there appears to be no medically recognized protocols or standards supporting those person’s views.  That is not and should not be acceptable.

For the treatment of Severe and Enduring Anorexia, the brightest and the best medical and mental health doctors cannot collaborate and come up with treatment standards utilizing the latest technological and science-based knowledge and innovation. There are no protocols to preserve life.

When the community cannot come up with and implement a legitimate, generally accepted protocol for life, how can anyone seriously consider a protocol for death?

OHHHHHHHHH Canada …

A number of countries set aside March 17 as a celebration of St. Patrick’s Day.

The first St. Patrick’s Day parade in Ireland was held in Waterford in 1903. Strangely enough, this came hundreds of years after the first parade in North America. 

One of the longest-running and largest Saint Patrick’s Day parades in North America occurs each year in Montreal whose city flag includes a shamrock in its lower-right quadrant. This yearly celebration has been organized by the United Irish Societies of Montreal since 1929.

The parade has been held yearly without interruption since 1824. St. Patrick’s Day itself, however, has been celebrated in Montreal since as far back as 1759 by Irish soldiers in the Montreal Garrison following the British conquest of New France.

But this year’s St. Patrick Day promised a much darker, very somber day of international concern. This was the day Canada was prepared to implement medically assisted suicide for people whose primary health issue was a mental health disorder.

In 2015, Canada introduced medically assisted dying after its Supreme Court ruled that requiring people to cope with intolerable suffering infringed on fundamental rights to liberty and security. In 2021, the Canadian law was expanded after the Superior Court of Quebec struck down the government’s original assisted death law on constitutional grounds because it only applied to people whose deaths were “reasonably foreseeable.”

The 2021 law then expanded eligibility to people experiencing “grievous and irremediable” conditions. It included a separate provision for people suffering from mental illnesses. This provision was added to the law by Canada’s unelected Senate.

Perhaps understanding that the mental health aspect of the law was not just controversial but beyond the pale of the act of a compassionate, informed society, the implementation of this aspect of the law was postponed until 2023. It was then again postponed until March 17, 2024.

In the last two weeks, Canada announced it was postponing implementation of the mental health aspect of the law until 2027.

The reasons given were varied. The official, governmental explanation was, “… a special parliamentary committee studying the law concluded that there are not enough doctors, particularly psychiatrists, in the country to assess patients with mental illnesses who want to end their lives and to help them do so.” A committee spokesperson stated, “The system needs to be ready, and we need to get it right … It’s clear from the conversations we’ve had that the system is not ready, and we need more time.”  

 Many other reasons for this delay have been speculated. These reasons include:

It is a consequence of the inability of Canada’s public health care system to offer adequate psychiatric care, which is chronically underfunded and facing demand that outstrips its availability.

Many psychiatrists say the plan would undermine efforts to prevent suicide, and they have expressed fear that patients with complex problems will abandon treatments that can take years to achieve results in favor of a medically assisted death.

Not wanting to be left out, political viewpoints have entered the fray. The opposition Conservative Party charged that the liberal government of Prime Minister Justin Trudeau is promoting a “culture of death.” Some on the left oppose the expansion for mental illnesses and have said they want to focus on further expanding psychiatric care. At least one conservative member in Parliament favors an indefinite extension stating, “I don’t see any indication that the fundamental issues that are at the heart — or should be at the heart — of putting a pause on this expansion will be resolved.”

There are still other speculations. Canada has a socialized health care system. One analysis conducted in 2020 estimated a potential annual health care cost savings of $66 million. Certainly, the risk of medical practitioners recommending assisted suicide as a cost-cutting measure to alleviate strain on the health care system is alarming.

Then, there are religious aspects being taken into consideration. In Canada, in every province but one, the government exempts taxpayer-funded religious institutions from providing services deemed contrary to their beliefs. In 2016, these exemptions were extended to specifically cover assisted suicide. Last week, a Catholic archbishop filed a challenge to Canada’s law on physician-assisted death, which includes both medically assisted suicide and euthanasia.

Lack of access to quality care has been a baseline, foundational issue for as long as there has been a health care system. If you are wealthy or have health insurance coverage, you have the keys to unlock the door of the healthcare system. If you do not have that key, you are confronted with a “No Trespassing” sign. Shouldn’t a compassionate enlightened society be known not for how it treats the elite in its society, but the downtrodden?

In addition, readily being presented with assisted dying services—instead of treatments or alternatives—can create a sense of being undervalued or marginalized. It implies that end-of-life choices should be prioritized over efforts to provide care, support, or treatments that could improve one’s quality of life or extend their lifespan.

I have the good fortune of being included in a small group of professionals studying eating disorders and end of life options. The issues are many and daunting. Any real progress is problematic, albeit not impossible, at best.

And then, I read a question which so eloquently encapsulated a fundamental concern about physician assisted suicide. That is …

“Why is their suffering acknowledged enough for euthanasia but not enough to fund clinical research?”

Why indeed.