Chronic Depression and Assisted Suicide

Chronic Depression and Assisted Suicide: Who Deserves the Right to Die?

By Alexa Kolakoski

Table of Contents

• Introduction
• Factual Background
• Treatments
• Issues Surrounding Treatments
• Depression and Suicide
• Societal Perceptions: A Cross-Cultural Comparison of Belgium and the United States
• Fairness
• Personal Accounts
• Autonomy
• Beneficence, Nonmaleficence, and Compassion
• Conclusion

“Death with dignity” is such a catch-phrase right now in the media. But for those of us who suffer in our dark thoughts everyday, we are living “life with dignity.” Each day we live, and make it through, is a success. It may not be pretty. But it’s still life. So my purpose in starting this thread was to encourage and challenge those who may have struggled with the wishful thinking of ending this life (like I did), and acknowledge the life of dignity and bravery we live everyday in our suffering. Most of the “outside” world will never know. But it doesn’t matter. We know. So my friends, I’m saying this not to you, but to myself: Instead of wishing for death with dignity, how about realizing we live each day with bravery? And each day we successfully do, is a gift. Just a perspective change I realize I have to make. Perhaps it’s overly optimistic. But I have to be. I have to bring some flicker of light into my dark … And I’ll take it anyway I can!”

Everyday Health

Depression is an extremely complicated mental illness that, to this day, remains much of a mystery to the medical community. For those who suffer from depression, everyday is a fight against their own mind; a struggle to survive.  This type of all consuming mental anguish cannot be quantified or measured. Although their perseverance and bravery in the face of this debilitating illness is very admirable the questions must be asked: to what extent should we preserve life?  How much pain is too much?

This paper will address whether or not chronic treatment-resistant depression should be a legitimate reason for physician-assisted suicide. I am going to focus purely on those who suffer solely from depression as those with additional illnesses may have wildly different experiences and motivations for seeking out physician assisted suicide. This paper will focus on the morality and effect of legalizing physician-assisted suicide for patients with depression while taking into account the ethical issues of fairness, competence, autonomy, beneficence, quality of life, and compassion. This is a very prominent issue in today’s political and medical landscape. Assisted suicide has been legalized in Switzerland, Germany, Albania, Colombia, Japan and in the US states of Washington, Oregon, Vermont, California, and Montana. Since 2014, law-makers in 23 states have introduced bills to legalize assisted suicide. Opinion polls have also shown many people to be in favor of legalizing physician aid in dying. Both Belgium and Switzerland allow patients with chronic treatment resistant depression access to physician-assisted suicide. Using scientific research and personal accounts,  this paper will attempt to analyze the culture surrounding current laws on the issue particularly Belgian and American opinions. This paper will propose that greater opportunities are granted to those suffering from depression who desire access to life-ending treatments, with stricter regulations put into place to prevent misuse.

Before going into the ethical issues surrounding depression and assisted suicide, it is important to have some background information about depression and the severity of this issue.  Approximately 1 in 10 Americans will suffer from depression at least once during their lifetime. (Healthline) Those with depression experience feelings of extreme sadness, unhappiness, and misery that can interfere with their ability to live a full and productive life.   

The types of depression that I’m focusing on include those that tend to be recurring throughout a person’s lifetime and/or cannot be “cured”, as patients who suffer from chronic depression are more likely to seek out assisted suicide. As a disclaimer, mental health is a complicated issue and the pain people feel is legitimate no matter how long it lasts. However, in today’s culture, dying, and in particular physician assisted suicide, is not viewed as just another treatment because it cannot be reversed. It is a permanent solution to a long-lasting (or what doctors perceive or estimate to their greatest ability to be permanent) problem. Those who suffer from major depression undergo severe symptoms that interfere with their ability to work, sleep, study, eat, and enjoy life. Persistent depressive disorder involves a depressed mood that lasts for at least two years. A person diagnosed with persistent depressive disorder may have episodes of major depression along with periods of less severe symptoms, but symptoms must last for two years. Treatment Resistant Depression occurs when at least two trials with antidepressants from different pharmacologic classes fail to produce a significant clinical improvement. (Treatment-Resistant Depression)

Scientists believe that depression is caused by a combination of genetic, biological, environmental, and psychological factors. Depressive illnesses are disorders of the brain as proven by PET or positron emission tomography scans, which show that the brain of a depressed person is visibly different from a healthy person. In addition, trauma, loss of a loved one, a difficult relationship, or any stressful situation may trigger depression.

This PET scan compares brain activity during periods of depression (left) with normal brain activity (right). Signs of decreased brain activity caused by depression are an increase of blue and green colors along with a reduced number of white and yellow areas. 

Symptoms and personal accounts show the reality of what life is like for those suffering from depression. People who are better informed as to what those with depression endure may be better able  to empathize with them. Symptoms of depression include: persistent sad, anxious, or “empty” feelings, feelings of hopelessness or pessimism, feelings of guilt, worthlessness, or helplessness, irritability, restlessness, loss of interest in activities or hobbies once pleasurable, fatigue and decreased energy, difficulty concentrating, remembering details, and making decisions, insomnia, early-morning wakefulness, or excessive sleeping, overeating or appetite loss, suicidal thoughts or suicide attempts, aches or pains, headaches, cramps, or digestive problems that do not ease even with treatment. (National Institute of Mental Health)

Because depression is a mental illness and presents itself internally, it is often difficult to imagine how one who suffers from depression might be feeling. I’m including various personal accounts throughout my paper to give a voice to those suffering from depression and to provide insight into the mindset of those facing this complicated illness. Personal Accounts were taken from Beyond-Blue and other internet sources typically used for suicide prevention. Because of this, these accounts may present a biased and one-sided view of depression as not everyone may be comfortable with sharing their experience online.  It is important to keep this in mind as the paper is read. 

“It was an especially black moment. I felt as though I was trapped in between a brick wall and a pane of glass, like a jail cell that kept on shrinking, suffocating me as the space grew more confining. I wanted so badly out of life that I would have done just about anything to get there.”

Therese Borchard, founder of Project Beyond Blue an online community for people with chronic depression and anxiety 

“I used to wake up every morning and wonder if there was any point in getting out of bed and starting the day I had ahead of me. I avoided social situations and had self-image issues. I was scared of everything and didn’t want to live life anymore.”

Amanda, 17 (Beyond Blue)

Although there is treatment available such as behavioral therapy and medication those with depression may not seek help and even if they do,  it may not be effective. Anywhere from 15 to 30 percent of patients with Major Depressive Disorder will be considered treatment resistant or unresponsive to multiple interventions. (American Academy of Family Physicians). 

Antidepressants primarily work on brain chemicals called neurotransmitters, especially serotonin and norepinephrine. Other antidepressants work on the neurotransmitter dopamine which controls the pleasure and motivation centers of the brain. Scientists have found that these particular chemicals are involved in regulating mood, but they are unsure of the exact ways that they work. 

For mild to moderate depression, psychotherapy may be the best option. However, for severe depression or for certain people, psychotherapy may not be enough. Psychotherapy helps patients to: restructure negative thought patterns, interpret their environment and interactions with others in a positive and realistic way, recognize things that may be contributing to the depression, change behaviors that may be worsening the depression, and work through troubled relationships that may cause their depression or make it worse.

Electroconvulsive therapy and other brain stimulation therapies are also effective and may be used as a last resort if medication or psychotherapy doesn’t work as these are more invasive procedures.  New methods (not yet commonly used, but research has suggested that they show promise) include: vagus nerve stimulation (VNS), and repetitive transcranial magnetic stimulation (rTMS). (Treatment-Resistant Depression)

Up to 80% of those treated for depression show an improvement in their symptoms generally within four to six weeks of beginning medication, psychotherapy, attending support groups or a combination of these treatments. (National Institute of Health, 1998) Nearly two out of three people suffering with depression do not actively seek nor receive proper treatment. (DBSA, 1996) Between ⅓  and ⅔ of patients will not respond to the first antidepressant prescribed and 15 to 33 percent will not respond to multiple interventions. An estimated 50% of unsuccessful treatment for depression is due to medical non-compliance which occurs when patients stop taking their medication too soon due to unacceptable side effects, financial factors, fears of addiction and/or short-term improvement of symptoms, leading them to believe that continuing treatment is unnecessary. (DBSA, 1999). These facts help bring to light some of the key ethical issues surrounding physician aid in dying and depression, for example. Should we force those with depression to undergo treatment before physician assisted suicide is presented as an option? How can we be sure that the reason patients are not getting better is not due to medical non-compliance? Should treatment be mandatory? If so, to what extent? (eg. invasive procedures such as electroconvulsive therapy) Later on in my report, I will go into further detail surrounding these issues. 

Depression is the cause of over two-thirds of the 30,000 reported suicides in the U.S. each year. To put this statistic in perspective- the death rate from suicide (11.3 per 100,000) remains higher than the death rate for chronic liver disease, Alzheimer’s, homicide, arteriosclerosis or hypertension. (Deaths: Final Data for 1998, Center for Disease Control) As shown by the following statistics, depression does not discriminate. It affects people of all ages and genders.  The suicide rate for older adults is more than 50% higher than the rate for the nation as a whole. Up to two-thirds of older adult suicides are attributed to untreated or misdiagnosed depression. (American Society on Aging, 1998) Untreated depression is the number one risk for suicide among youth. Suicide is the third leading cause of death in 15 to 24 year olds and the fourth leading cause of death in 10 to 14 year olds. Young males age 15 to 24 are at highest risk for suicide, with a ratio of males to females at 7:1. (American Association of Suicidology, 1996) Suicide can have a tremendous impact on the family and friends of the deceased.  Some consequences of this include: extreme guilt for not preventing the suicide, failure because they were unable to save them, anger or resentment at the person who chose to take his or her own life, and confusion and distress over unresolved issues. (Healthyplace)

These statistics show a clear correlation between depression and suicide and showcase the magnitude and effect of suicide as a national and familial  issue. After reading these facts the following ethical questions come to mind: Since suicide is already prevalent, why not make it legal? Would suicide’s emotional impact on the family be minimized if assisted suicide was legal and  the family was informed and engaged in the process?    

Depression is a very serious and pervasive issue. Treatment, while available is not always effective which may prompt people to consider suicide as an alternative. Suicide can have a very harmful impact on those who play an unwilling part in the death, the family, and the patient themselves if the suicide does not go as planned. Assisted suicide in itself is a complex issue but it becomes an even murkier problem when non “terminal” diseases such as depression are considered. Another important aspect is society’s impact on the decision making process which I will discuss next. 

It is an undeniable truth that the society in which we live greatly impacts our opinions about the world and affects every decision we make. Therefore it is important to realize that   different cultural or religious views on assisted suicide and the stigma of depression may greatly alter how a patient handles their illness and what laws are put into place to help regulate such practices. Disclaimer: Although cultural generalizations are typically not applied in a report like this, in order to analyze the impact that society has on the individual’s decision making process it was important to reference such generalizations. 

Cultural Beliefs and Practices of Belgium

In 2002, euthanasia was legalized in Belgium. The legalization of euthanasia was viewed by the people as a  symbol of enlightenment and progress. Belgium’s aversion to paternalism stems from the country’s “rebellion from Catholicism”, which is forming  as the country takes leave of its religious roots.  Belgium also has a very liberal government that emphasizes secular humanism (principles of autonomy, free inquiry, democracy, ethics based on reason and science). These principles are taught in schools and used in hospital decision making. A common attitude in Belgian society is “binnenvetter”, meaning ‘a person who holds emotions inside’, taking this into consideration along with Belgium’s  poor quality of psychiatric care, helps to explain Belgium’s high suicide rate. The amount of deaths by euthanasia in Belgium has increased by 150% since its legalization due to loose unspecific regulations and cultural acceptance (The Death Treatment). To qualify for euthanasia in Belgium patients must meet a variety of requirements. Applicants must: reside in Belgium, be in constant and unbearable physical or mental pain, be at least 18 years old, make specific voluntary and repeated requests that their lives be ended, put this request in writing, wait for at least one month to elapse between the written request and mercy killing, have a discussion with their physician regarding their current state of health, life expectancy, request for euthanasia, and available treatment options.  Also, the doctor must ensure that there is no other reasonable solution to the situation and the patient’s request is entirely voluntary. Additionally  patients must have multiple meetings (reasonably spaced) with their doctor to determine if euthanasia is still the best option. Some argue that there are not enough regulations in Belgium’s laws to prevent abuse. By law all euthanasia cases must be presented to the Federal Control and Evaluation Commission but in reality only about half are reported and there are no repercussions for failing to report euthanasia deaths. Another visible issue is the corrupt regulatory council, almost half of the 16 members of the commission are associated with right-to-die organizations (The Death Treatment).

Cultural Beliefs and Practices of America

In general Americans have strong religious beliefs as around 75 percent of Americans consider themselves religious (Pew Research Center). In America, there is also a stigma attached to having a mental illness and it can be seen as ‘weak” to seek treatment. In general there also exists a poor quality of psychiatric care which leads to high suicide rates. Many Americans also view suicide in a negative light although this is changing due to the appearance of a younger more  liberal demographic. Strict regulations regarding assisted suicide laws keep the death count low.

In general, to qualify for assisted suicide in America applicants must be: 18 years of age or older, a resident of the state, capable of making and communicating health care decisions for him/herself, and diagnosed with a terminal illness that will lead to death within six months. (Death with Dignity)

The goal of these personal accounts is to provide a first person perspective on the American culture surrounding mental illness and stigma of depression.  These personal accounts also work to highlight societal problems like our approach on mental illness.

“Getting the diagnosis was hard. Really hard. I mean there is so much stigma surrounding mental health and I didn’t have a lot of friends as it was let alone with the label of “mental nutcase”. I was really worried about how it would affect my life and, in particular, my relationship with my boyfriend at the time. In a lot of ways I was right to be worried. The few friends I had left, people at school ignored me, my boyfriend told me I was too stressful for him and left, and even my family didn’t quite know how to deal with it.”

Amanda, 17 (Beyond Blue)

“I had known I needed help for a long time; I just couldn’t bring myself to say or do anything about it. The social stigma attached to speaking up about depression was more frightening to me than the notion of having to continue dealing with my condition. Fortunately, I was pushed into getting help and I don’t know if I would still be here now if I hadn’t been.”

Hollie (Beyond Blue)

In America, suicide is illegal and typically considered shameful due to conservative cultural and religious influences. This may prevent those who are suffering and in pain to not consider suicide as an option. Legalizing assisted suicide may lessen the cultural stigma so the patient and the family may be able to consider physician assisted suicide as a legitimate option. Also due to the strict regulations, those with depression are unable to have access to this treatment even though their illness can be just as painful as any physical illness. This sends a subtle message to the public that mental illness is not as serious an issue  as a  physical illness. 

In Belgium, they may have the opposite problem due to its very liberal and humanist cultural perspective. Assisted suicide is viewed in a very favorable light by the public, media, government, and healthcare system all of which can heavily impact an individual’s decision in favor of assisted suicide. As a result of these biased opinions, the regulatory system for euthanasia is ineffective and corrupt which spells huge issues for those practicing and considering euthanasia. Some patients may be manipulated or cheated by the system, some may refuse to support a corrupt system (even though they have the same values), and an ineffective system may damage the image of physician aid in dying for other countries considering its legalization. 

But both Belgium and America have two huge problems in common: high rates of suicide and poor quality of mental health care. If the quality of mental health care is addressed and improved then the suicide rate should also go down as depression is a leading cause of suicide. Both of these problems should be investigated before the issue of assisted suicide and depression may be discussed as mental health care can play an integral role in a patient’s decision. To further examine these issues I will explore the key values of fairness, autonomy, and beneficence. 

Fairness is an important value to consider when discussing depression and assisted suicide. One big issue in particular has to do with equal access. Is it fair that people with physical ailments are allowed access to euthanasia/assisted suicide but people suffering from mental illnesses are not? Another main issue surrounds treatment. People who suffer from depression are entitled to respect- respect as individuals, as sufferers of mental illness and as capable decision makers. It is only fair to treat them the same way as those who suffer from physical ailments and to treat their decisions with the same validity of those who do not suffer from mental illness. An example of this is is the ADA or Americans with Disabilities Act. This governmental law prevents discrimination in the workplace against those who suffer from mental illness and ensures that those who suffer from mental ailments are treated with the same respect afforded to those who suffer from physical ailments. 

When looking at these ethical issues it is important to view them from multiple perspectives to gain a varied and more accurate viewpoint. One perspective on the issue contends that it is not fair to treat physical ailments different from mental illness. People with mental illness face just as much suffering as any patient with a physical ailment. People dealing with depression must also face the stigma that comes along with having a mental illness which can undervalue the pain and suffering they undergo. Those on the other side say that it is fair to treat those with mental illness differently from those suffering from physical ailments as they are two totally different problems and therefore could require totally different solutions.   One example of the perceived differences between physical and mental illness is the permanence or treatability of the issue. In our culture there seems to be this prevailing stereotype that depression is just a passing feeling instead of a serious mental handicap. But research repeatedly shows that  depression is a serious mental health issue that significantly affects a person’s ability to function and  is often difficult or impossible to treat.   

These personal accounts express the often  dismissed or ignored thoughts and opinions of those suffering from depression.  Because they themselves suffer from depression they are uniquely qualified to bring a genuine and extremely valid perspective to this issue.

“PTSD and depression are illnesses that need to be taken seriously and treated accordingly. This was the problem I had as there was no outward sign of illness such as a broken limb, but the fact that my mind had let me down and some people didn’t believe I was sick was a much harder thing to deal with than any broken bone.”

– Brett (Beyond Blue)

“I think, if we are going to make assisted suicide an option for people, we have to make it an option for all people with serious and chronic illnesses. By denying this avenue to those who suffer from depression and other mood disorders insinuates, however subtly, that those illnesses “aren’t that bad.” I would add that it implies that these people are not capable of rational thought. While I am a firm believer that depression lies, are we really to believe that someone who has just received a diagnosis of a terminal illness that is so vile, so painful, so debilitating, and so dignity-robbing is more capable of rational thought surrounding it than anyone else?”

– Cynthia Schrage

A lot of these issues relate back to the cultural comparison of Belgium and America. Belgium seems to possess the understanding and sympathy about mental illness that America lacks when giving their citizens the autonomy to make life-ending decisions. But to fully respect those suffering from depression as people, both countries need to better understand their needs which translates to better healthcare for those suffering from mental health issues which both countries desperately need to improve upon.   

After reading many personal accounts and researching about the effects of depression, I personally believe that depression should be afforded the same respect and considerations as any other illness, physical or otherwise.  Although depression isn’t technically considered terminal it can definitely become terminal (resulting in suicide) if left untreated. People with depression may feel just as much pain as those who suffer from a physical ailment and they deserve to have their suffering acknowledged and their decisions respected.

Because depression is a mental illness, every person will be affected differently. However, in most cases a patient suffering from depression has the right to choose which treatment they desire and their wish is respected. This decision sets a precedent- patients with depression are competent (to a degree). This leads us to the conclusion that individuals with depression are competent enough to choose to undergo physician assisted suicide. The other viewpoint believes that patients with any type of mental disorder cannot be considered competent as they have a compromised frame of mind. Therefore a depressed patient does not have the mental capacity to consent to such a procedure. But it is important to remember that mental illnesses operate on a spectrum- some may have little to no impact on the patient while others may totally inhibit a person’s ability to function. The severity of the mental illness has a direct effect on the decision making ability of the individual.  

Generally depression isn’t terminal (definitionally)and treatment is available. Should we force potentially invasive  treatments such as electroshock therapy before allowing assisted suicide- even though this would be in violation of the patient’s autonomy? There are two opposing principles evaluated when viewing this issue- safety and autonomy. Before these points may be discussed it is important to define safety. Defining safety is difficult because it can mean different things to different people. A few interpretations of safety include: the preservation of life at all costs and the total well-being of someone both physically and mentally. These varying interpretations of safety lead to conflict as people attempt to make decisions for those suffering from depression.  Should the patient’s mental health be valued over the preservation of their life? Is there more to life than just being alive? Is life not worth living if one is not satisfied with their physical or mental well-being?  

Another prevalent issue concerning autonomy and assisted suicide asks the question- Should it be mandatory to inform the family, friends, or next of kin prior to assisted suicide? At the age of 18 you are legally considered an adult, but those in a compromised mental state can greatly benefit from familial support when making tough decisions. On the other hand this would be a huge violation of the patient’s autonomy and it might upset those estranged from or who lack close friends and family.

I personally believe that patients suffering from long-term, treatment-resistant depression can be considered competent even though they are suffering from a mental illness. This is because competency is defined as the ability to make your own decisions while understanding the consequences of your actions. Although patients suffering from depression may have an altered perspective, this state of mind is normal for them as they may have lived and might have to live with this condition for the rest of their life. Living life entails making important decisions such as these. Also I personally believe that assisted suicide itself is not a treatment but a solution to a problem that cannot be fixed by any other means. So, I think a non-invasive treatment such as medication or psychotherapy should be a prerequisite to physician assisted suicide. Lastly, while I don’t believe that contacting family and friends of the patient before undergoing assisted suicide should be mandatory, I definitely think it should become common practice or strongly recommended to the patient. Hopefully notifying the family can prevent heartache and possibly motivate the patient to reconsider their decision. 

Beneficence and nonmaleficence both play a large part in the debate surrounding the legalization of physician-assisted suicide. Beneficence is defined as  the doing of good; active goodness or kindness; charity and nonmaleficence is defined as an obligation not to inflict harm intentionally. The following arguments are both tailored to the question of whether or not physician assisted suicide should be legal under any circumstances, which, although it isn’t the main focus of my paper, are important considerations to note. 

The ambiguity of the “do no harm” principle that doctors must abide by is very evident in this situation. There are two main viewpoints: to relieve the patient from their suffering is the best outcome or to instigate death, as a doctor, is never okay. Physicians must ask themselves: Is there a difference between helping someone to die and killing them? While depression is not technically considered terminal, it can be deadly when a depressed person is driven to suicide. Another important consideration when thinking about assisted suicide is how it should be viewed: as a treatment in itself or as a last resort for those who cannot be healed. This is one of the main issues with Belgium and its general opinion and use of euthanasia. They heavily emphasize dignity in dying and compassion for those going through difficult pain which is very forward thinking but has its drawbacks. Euthanasia should not be viewed as just another treatment but as a  last resort to a problem that cannot be solved through quality mental healthcare. Also, euthanasia and death is often glorified in Belgium, but it should also be viewed, realistically, as both permanent and potentially painful for the family.  Therefore, patients should be aware to avoid influence by the opinions and views of their doctors.    

How can we measure ‘’quality of life’? Who gets to decide what is “quality of life”? 

Mental illnesses, like depression, are commonly misunderstood and very difficult to empathise with as we can never be sure exactly how the patients themselves are feeling. Therefore, it should be up to the patient to self-assess and decide what quality of life they have and what they want it to be. If they are not satisfied with their current quality of life, it should be their decision to either seek treatment or find a means to end their suffering. 

Suicide is typically thought to be a rash decision that people make without much regard to the consequences. Patients with depression are fully capable of taking their lives through traditional means but there are also those who are willing to seek out physician assisted suicide. These people are not just making a rash decision as there are strict requirements (eg: Belgium) such as the approval of three separate doctors and repeated specific and voluntary requests in writing that their lives be ended. Through this process, applicants are shown alternate treatment options and forced to evaluate the consequences and effects of their decision. Assisted suicide is also a long drawn out process requiring at least one month to elapse between the written request and mercy killing; this provides the  family time to intervene and the patient time to seriously reevaluate their decision.  But even if they go through with it, assisted suicide is still better than traditional methods as it removes the element of surprise and does not involve any unwilling parties.

Depression, like any mental illness, has its ups and downs. We want to believe that there is always a light at the end of the tunnel- that these feelings of sadness are not necessarily permanent but that is not always the case. For some people, there is no light at the end of the tunnel and the moment of sadness is a continuum.    But while it is important to be positive, we also must have compassion for those who cannot handle the pain. But no matter what, physician assisted suicide should always be a last resort- used as a final solution to a problem that cannot be solved by any other means.  Assisted suicide is more effective and less painful than traditional methods of ending one’s life.  Assisted suicide may also lessen the emotional pain and suffering faced by the family and friends as they are given warning and an opportunity to say goodbye.  In conclusion, when taking into accounts the values of autonomy, fairness, and beneficence I believe that better systems need to be put into place to treat those with depression and others facing mental illness. Additionally we must provide greater opportunities to those suffering from depression who desire access to life-ending treatments in America and enforce stricter regulations and penalties to regulate misuse of the Belgian system. I also believe that some sort of noninvasive treatment such as psychotherapy or medication should be mandatory before physician assisted suicide is considered. Additionally it should become common practice to inform close friends and family of the patient’s decision prior to assisted suicide. These measures should also work to eliminate the cultural stigma surrounding suicide and mental illnesses such as depression. Expanding upon this idea, I also believe that the same respect and privileges should be afforded to those suffering from other permanent untreatable  mental illnesses. Although the political climate in America has not yet fully embraced physician assisted suicide in the same way as Belgium, I believe in the future further advances in policy making will help to legalize physician aid in dying across the U.S. Only then may depression and other mental illnesses be considered for physician assisted suicide.