Art Caplan can be frustrating. He’s been everywhere in the media as the number 1 face and voice of bioethics here in the USA. He’s frustrating because his comments and analyses regarding bioethical issues vary in their quality and even accuracy. I think that part of that is due to the fact that part of his job at the University of Pennsylvania – and now at NYU – is to get himself out in the media and professional journals as often as possible, helping to increase the visibility and enhance the status of the institutions he works for. In short, he gets overextended, and sometimes he fails to give the time, research and care to a subject that deserves plenty of all three.
Shortly after the World Federation of Right to Die Societies conference in Chicago, Caplan published a video and article on Medscape that showed no awareness of the broad agenda celebrated at that conference. This article is so bad that I could go through almost every sentence and deconstruct it. In order to make it easier on myself and more readable for people who come to this blog, I’ll just hit some of the highlights (maybe “lowlights” would be a better word). From the article “Physician-Assisted Suicide: Only As a Last Resort“:
I favor legalization but I believe that it has to be done with careful restriction. I am not sure whether the British law is regulated or restricted enough to prevent it from being abused. Oregon, Washington, and Vermont have in place a couple of conditions that are essential to preventing abuse of patients who are terminally ill. One is that you have to be sure that the person is not depressed or psychiatrically impaired. You do not want people ending their lives when they have treatable depression. Certainly people who are terminally ill may well be depressed, but you can often help them. Once out of depression, they may not necessarily want to take their lives.
There is no attempt to “be sure” that persons who are depressed or have other psychiatric issues do not get lethal prescriptions in the USA. For example, the Oregon statute – and both the Washington state and UK legislation are based on this statute – says this about mental health “counseling” (evaluation) referrals:
If in the opinion of the attending physician or the consulting physician a patient may be suffering from a psychiatric or psychological disorder or depression causing impaired judgment, either physician shall refer the patient for counseling. No medication to end a patient’s life in a humane and dignified manner shall be prescribed until the person performing the counseling determines that the patient is not suffering from a psychiatric or psychological disorder or depression causing impaired judgment. [1995 c.3 s.3.03; 1999 c.423 s.4]
If you read the words above carefully, you’ll notice that suspicion of depression or other problems doesn’t mandate a referral. A referral should be made only if the non-psychologically trained physician believes the that the depression, etc. is bad enough that the individual has impaired judgment. Unsurprisngly, extremely few referrals are made in Oregon. Only two patients out of 71 patients who used their lethal prescriptions in 2013 had been referred for psychiatric evaluations. This is consistent with other years. In fact, Oregon researcher Linda Ganzini and colleagues published a study in 2008 that found a significant percentage of people dying by assisted suicide in Oregon met the criteria for clinical depression and anxiety:
Among patients who requested a physician’s aid in dying, one in four had clinical depression. However, more than three quarters of people who actually received prescriptions for lethal drugs did not have a depressive disorder. Our findings also indicate that the current practice of legalised aid in dying may allow some potentially ineligible patients to receive a prescription for a lethal drug; two of those who ultimately died by lethal ingestion had depression at the time they received a prescription for a lethal drug and died by ingesting the drug. A third patient was depressed at the time that she requested a physician’s aid in dying and probably received her prescription; she was successfully treated for her depression before she died by lethal ingestion.
Caplan finishes up with this:
Assisted suicide may work but only with adequate protections, adequate controls, adequate oversight, and adequate regulation to make sure that people do not think, “I better do this because I am a burden to others” or “I am going to do this because nothing else out there can help me with my pain, suffering, or depression.” Those are not adequate ethical circumstances to support someone ending his or her own life.
In the latest Oregon report, the following percentages for the top “end of life” concerns were given by the 71 people who died by using their lethal prescriptions, according to the prescribing doctors:
- Losing autonomy – 93%
- Less able to engage in activities making life enjoyable – 88.7%
- Loss of dignity – 73.2%
Significantly, over 49% of the patients reported “burden on family, friends/caregivers” as a concern.
Once you actually dig out this and other factual information, it’s clear that the states that have legalized assisted suicide don’t meet Caplan’s criteria for being acceptable, even though he implies that they do. And “right to die” societies don’t want to stop there. Final Exit Network, the organization that hosted the recent World Federation of Right to Die Societies conference, is a group that advises and facilitates suicides. The description of who is eligible for “help” from Final Exit Network is as follows:
We hold that mentally competent adults who suffer from a fatal or irreversible physical illness, from intractable physical pain, or from a constellation of chronic, progressive physical disabilities have a basic human right to choose to end their lives when they judge the quality of their life to be unacceptable.
“Terminal” not required with that organization.
What about other countries? Topics at the conference included “Old Age Rational Suicide,” “Dementia,” “Helping Children Die,” “Couples Who Want to Die Together” and “Help for the Mentally Ill.”
Let’s sum up – the broader group of organizations promoting assisted suicide want eligility requirements that are much broader; European countries have already gone much farther with eligibility.
American laws don’t require assisted suicide be a “last resort,” have no meaningful safeguards against people with depression getting medication, and concerns like “being a burden” are regarded as acceptable reasons to commit suicide. Caplan missed that, didn’t know or just plain misrepresented the reality.
As I said at the top (more or less), this is a piece of crap as an article meant to inform medical professionals about assisted suicide. Sadly, an ignorant reader will end up more ignorant about the topic after reading this. That’s not an easy thing to accomplish.
This is a serious debate and deserves real research and analysis – not to mention accuracy. Caplan should – and can – do better. Hopefully, he can manage something better next time. If he produces another piece of drek like this, we’ll treat it with all the respect the article deserves – as I did with this one.
Addendum – for another take-down of this mess, check out Wesley Smith’s ‘Assisted Suicide as a “Last Resort” Fantasy.’