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Join us as we delve into the controversial topic of assisted suicide with our guest, Nicholas S. Tito, a medical student. This thought-provoking episode will explore the Western world’s growing support for legally assisted euthanasia and the redefinition of “immense suffering.” Our guest argues that considering mental health disorders eligible for assisted euthanasia is a pathology of reason and questions the idea of absolute patient autonomy. He also touches on the role of psychiatrists in defining “the good” and the importance of rejecting the current postmodern craze. This is a must-listen for anyone interested in the ethics of medical practice and the future of end-of-life care.
Nicholas S. Tito is a medical student.
He shares his story and discusses his KevinMD article, “The slippery slope of legal assisted suicide and euthanasia.”
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Transcript
Kevin Pho: Hi, and welcome to the show. Rate and review at KevinMD.com/rate. Subscribe at KevinMD.com/podcast. Today on the show, we have Nicholas Tito. He’s a medical student. His KevinMD article is titled “The slippery slope of legal assisted suicide and euthanasia.” Nicholas, welcome to the show.
Nicholas S. Tito: Hey, thank you so much. It’s a pleasure to be on. Glad to be here.
Kevin Pho: All right, we’ll get into your article in a little bit. First off, briefly share your story and journey to where you are today.
Nicholas S. Tito: Sure. I’m originally from Mississippi, and then Clarence moved over to California. I followed him after high school for undergrad, joined the Army, spent four years there, and then decided to further myself more after that and go to medical school. I’m in my fourth year. I’m applying to psychiatry pretty soon here, or already applied, I suppose, and I’ll be matching in about a month. I’m pretty excited for that.
In the course of this final year, I got an interesting case where I came to write the article that I submitted to your site, because I didn’t really have a view on assisted suicide, and after interacting with this patient, it really changed my mind, as you probably know, against it, as I wrote in the article. So it’s been a fascinating field, going through the ethics of suicide. There’s a long, long history going back thousands of years on this topic, so there’s a plethora of reading to do, and it’s a great talk.
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Kevin Pho: All right, so let’s talk about how this article came together. You said it started with some type of patient interaction, so tell us about the background and lead into your article.
Nicholas S. Tito: Well, sure. We had a 60- to 70-year-old patient come in to the adult inpatient psychiatry unit, so usually a three- to five-day stay, and this was called in by her family initially, because she had threatened suicide by way of traveling to another country. This one is not Canada, but it’s another country that has an actually more liberal, or more forgiving, I suppose, euthanasia policy, and I’ll keep the exact country anonymous for the patient. But she threatened to travel there and commit suicide, which is legal there really for any reason, so long as you sign off on it and you’re happy. She had presented the plane ticket, the hotel room, all the arrangements that had been made to go and do this, to the family, and so they called EMS. The psychiatrist at the ER convinced her to come into the ER for evaluation, and she wound up on our voluntary unit. Through that course, she actually ended up coming on to our involuntary unit.
This is a lady who is almost 70 at this point. She’s had major depressive disorder on and off since 2004, she’s been on Lexapro, and she’s been mostly euthymic. I mean, true, it’s not that there were no warning signs at all in terms of pathology, and so for her to end up in an involuntary unit, that was quite an experience for her, and unfortunately not a very good one, as it can be for most people in that instance.
But we were in a legal kind of gray area, because in the United States there’s not a state at all, there are no states right now, where it’s legal to commit suicide and not really be held. And she held firm in the belief, “No, I can do this if I want to go to another country and perform this act.” And so we really didn’t know what to do, so involuntary was the route that we did decide to go. Luckily, she was there very, very briefly. She did agree to abandon the idea, and we had a safety plan for her on discharge. About eight months later, I followed up with her, and she thanked me profusely, and the physicians I was involved with, because she was very happy to still be here.
And so, with the new Canadian laws including mental disease, coming up right here in March, as qualifying for legalized euthanasia participation, I’m just going to have to keep telling this patient’s story, because she wouldn’t be here if she was in Canada. So it’s a little scary to me, which is why I’ve started to write these articles and spread the word about what’s going on, and the gray area, I think, we’re going to start seeing more and more as it makes its way through the popular culture.
Kevin Pho: Now take us into that time when she was held involuntarily. You mentioned that you and your team didn’t quite know what to do; it was a little bit of a gray area. So take us into a little bit of those conversations, in terms of who you talked to. What were those discussions like?
Nicholas S. Tito: Sure. In the state that we’re in, and it’s pretty similar to most other states, an involuntary commitment isn’t just the psychiatrist writing a signature and you go straight there. It’s actually a state screener, a screener by the state, a mental health worker. It’s in combination with another psychiatrist, but also a non-psychiatrist state mental health worker that really gives the OK: “We’re going to do the involuntary.”
We recommended her for screening for involuntary not so much because we believed that she didn’t have capacity, but because she was a danger, potentially, to herself, I mean in the truest sense. And two, some people would say unfortunately, but we do have to legally cover ourselves while practicing clinically. So had we said, “OK, we understand that you are going to go do this on soil where it’s technically legal,” what if you were to just walk out of our hospital and commit suicide tomorrow? We wouldn’t have been doing our job. So that was the quandary that we were in.
So the discussion was, do we have the screener come? Because we thought the screener would definitely recommend involuntary, and that is what happened. But we didn’t see a way in which we could address the needs of this patient without recommending the screener come and do the involuntary screening.
Kevin Pho: Now, you mentioned that eventually she had changed her mind. So why do you think she did that?
Nicholas S. Tito: I think she wanted to get out of the psychiatric hospital, which I don’t blame her for by any means. When you go to an inpatient adult psychiatric hospital, on the voluntary side there’s a wide range of pathology. We try to keep the atmosphere friendly and relaxed. It’s clinical, but the more clinical it becomes, sometimes the more distrustful patients can be, and so we really try not to keep it like in the 1950s. But when you go to the involuntary side, unfortunately, and at the time that she was with us, you do sometimes have people that have a history of violent assault and things like that, and so it’s a tough place to be. With the capacity that she had and the clinical pathology that she had, it was a very atypical case to go to the involuntary side.
And so I think she largely was still resolute in her vision to continue with the euthanasia at that point, but to get out of the hospital, she understood she needed to say these certain things to the state screener, and then to the judge, to make sure she could be released. And so she did do that.
But as I spoke with her on follow-up, she was put into the care of a nephew, and they were able to speak at length, and she was closely followed up with mental health workers after that. From what I gathered after speaking through it, she came to realize some of the reasons that she wanted to commit the euthanasia, and there was a long list. It’s a hard conversation to have. Reasonable people can have great arguments on really both sides of that coin about what constitutes a reasonable means for euthanasia, and that’s really a conversation for society to have, less so a single clinician speaking to a patient, at least in my view, I suppose. But eight months later, she did really regret ever having that thought.
And so I take the more classical approach, that suicidal ideation is a psychopathology in itself, and it’s a symptom of some other, greater mental health issue. Sometimes a patient can seem to be completely reasonable, with capacity, and yet still resolutely want to commit euthanasia. I think those instances are rare. But as we’re seeing, and as I’m reading through the case reports in Canada, as it becomes popular in the mainstream culture, for every suicidal patient that’s had suicidal ideation, at that moment life was at a low, it was a difficult time, or whatever was causing that pathology. As mental health clinicians, I think we need to make sure that we see suicidal ideation as a psychopathology.
I know it gets a little gray when it comes to less than six months to live, and there’s a long history of ethical research into that and what’s ethical in that case. But as far as major depressive disorder and some of these more common mental health issues that Canada is considering including, I think we just need to be prepared for potential ethical conflicts in the workplace.
Kevin Pho: Now, I want to talk about how this case affected you. Before you encountered this case, did you have any preconceived beliefs or notions about euthanasia, and if so, how did this case change you?
Nicholas S. Tito: Sure. With less than six months to live, a hospice patient, I was completely for it. I was in the military, and if you spend enough time in health care, death can be a very ugly thing, unfortunately. And so we have the means to make that less so.
When it comes to morphine, there’s something called the rule of double effect, and the idea is that if you’re giving morphine, you’re not actually trying to euthanize the patient; you’re just trying to relieve suffering, and death is a consequence of it. But in terms of a hospice patient saying, “Well, actually, I want to take this pill on this day to end my life,” versus the morphine route, I’ve changed my view on that. I’ve now come to think that the morphine route is fine, which I originally thought as well, but I used to also think that the pill would be fine as well, physician-assisted suicide.
But after this case, I think just as clinicians we should stay away from it. I think you get into murky territory in terms of ethics, in terms of what our job is to do, to heal. For a patient that has less than six months to live but isn’t receiving morphine for pain, I’m sure there are instances where it would maybe make sense, even to me. But if you’re going to ask me for a broad policy belief, I’m against physician-assisted suicide.
Kevin Pho: After you encountered this case, did you guys have a debrief with your team to discuss all the various ethical questions that arose from it?
Nicholas S. Tito: Absolutely. And what’s interesting and frustrating and fascinating is that every single member of the team has a different belief and came away with something different. I do think that we all kind of agree that, eight months later, she is very happy to have not gone through with the decision, and that we definitely need to have some more caution in terms of how we’re going to do this in the United States. Because I think if it happens up there, and there are advocates who want it to come down here, it’s only a matter of time before that becomes a bigger conversation, I think. But some of the team who disagree with me, they definitely will acquiesce that this needs to have a very considered conversation before we go forward.
Kevin Pho: And my final question, Nicholas. What are some of your take-home messages that you want to leave with the KevinMD audience?
Nicholas S. Tito: It’s natural to have a visceral gut reaction, and I found that with the latest ethics research on this topic, you have to go back to our Greek and Roman forebears and what they believed, because it’s quite interesting how they delineated what the names were back in their time, and they didn’t even have morphine and those things. So I think, really taking the time to think through, why do I believe what I believe on this subject, and what’s going into that conclusion, I think they’ll actually walk away with a few other beliefs, either changed or more affirmed, across the health care ethics spectrum.
Kevin Pho: All right, Nicholas, thank you so much for sharing your story, time, and insight, and thanks again for being on the show.
Nicholas S. Tito: Thank you.
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