Letters
beneficial to human health and the approach to be used in fiber that is intrinsically part of food ingredients and did not
reviewing the science.
The final regulation explains in considerable detail the
changes made and the underlying rationale for each.2
Susan T. Mayne, PhD
Douglas A. Balentine, PhD
Author Affiliations: Center for Food Safety and Applied Nutrition, US Food and
Drug Administration, College Park, Maryland.
Corresponding Author: Susan T. Mayne, PhD, Center for Food Safety and
Applied Nutrition, US Food and Drug Administration, 5001 Campus Dr, Room
4B-064, HFS-1, College Park, MD 20740 (susan.mayne@fda.hhs.gov).
Conflict of Interest Disclosures: The authors have completed and submitted
the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were
reported.
1. Malik VS, Willett WC, Hu FB. The revised Nutrition Facts label: a step forward
and more room for improvement. JAMA. 2016;316(6):583-584.
2. Federal Register. Food labeling: revision of the Nutrition and Supplement
Facts labels. https://www.federalregister.gov/articles/2016/05/27/2016-11867
/food-labeling-revision-of-the-nutrition-and-supplement-facts-labels. Accessed
July 1, 2016.
In Reply Drs Mayne and Balentine disagree with our state-
ment about the inclusion of purified additives such as inulin
and cellulosic fibers on the fiber line of the revised Nutrition
Facts label. We believe that inclusion of these isolated or syn-
thetic constituents on the label together with naturally occur-
ring fibers from fruits, vegetables, and whole grains can be mis-
leading to consumers and misused by food manufacturers to
portray otherwise unhealthy products as healthy.
We understand that the FDA has revised the definition
of dietary fiber as part of the updated label regulation to in-
clude isolated or synthetic nondigestible carbohydrates dem-
onstrated to have a single physiological benefit such as
cholesterol-lowering effects or “improved laxation.” Thus
“cellulosic fiber,” with the nutritional value of cardboard, can
be included on the fiber line if it is shown to improve laxa-
tion. This can be misleading to consumers because a major rea-
son for promoting foods that are high in fiber is that they con-
sistently are associated with a lower risk of diabetes and
cardiovascular disease.1 These relationships are probably
driven in part because the fiber component is a marker for
myriad minerals, vitamins, and phytonutrients that travel with
the fiber, and there is no evidence that the addition of cellu-
lose or inulin will have the same benefit. In other words, a food
made with whole grains is not the same as a food made with
refined grains and added cellulose. The FDA’s new definition
of fiber does not make this distinction and will therefore con-
tribute to confusion, especially when gauging the quality of
carbohydrate foods using the ratio of total carbohydrates to
fiber. This ratio has been recommended by the American Heart
Association as a guide for identifying whole grains.2 The cur-
rent dietary guidelines for Americans recommend consum-
ing a combination of fruits, vegetables, and whole grains to in-
crease fiber intake,3 but there is no evidence that increasing
fiber (as defined by the FDA) will provide the same benefits
as consuming these fiber-rich whole foods.
We believe that the Nutrition Facts label would better
guide consumer choices if it only included on the fiber line
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include isolated or synthetic constituents. There may be
some exceptions to this such as bran, which could be consid-
ered a food ingredient because it comes with the naturally
accompanying nutrients. This is not to say that pure cellulose
or other synthetic, isolated nondigestible carbohydrates
should not be allowed in foods, but rather that they should
not be included on the fiber line. If such ingredients are to be
included on the Nutrition Facts label, they should be on a
separate line for “isolated or synthetic fiber.”
Vasanti S Malik, ScD
Walter C. Willett, MD, DrPH
Frank B. Hu, MD, PhD
Author Affiliations: Department of Nutrition, Harvard T.H. Chan School of
Public Health, Boston, Massachusetts.
Corresponding Author: Frank B. Hu, MD, PhD, Harvard T. H. Chan School of
Public Health, 665 Huntington Ave, Boston, MA 02115 (nhbfh@channing
.harvard.edu).
Conflict of Interest Disclosures: The authors have completed and
submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest.
Dr Hu reports receiving grant funding from Metagenics and the California
Walnut Commission and personal fees from Metagenics. No other disclosures
were reported.
1. Dahl WJ, Stewart ML. Position of the Academy of Nutrition and Dietetics:
health implications of dietary fiber. J Acad Nutr Diet. 2015;115(11):1861-1870.
2. Lloyd-Jones DM, Hong Y, Labarthe D, et al; American Heart Association
Strategic Planning Task Force and Statistics Committee. Defining and setting
national goals for cardiovascular health promotion and disease reduction: the
American Heart Association’s strategic Impact Goal through 2020 and beyond.
Circulation. 2010;121(4):586-613.
3. US Department of Health and Human Services and US Department of
Agriculture. Dietary guidelines for Americans 2015—2020 8th edition.
https://health.gov/dietaryguidelines/2015/guidelines/. Accessed September 29,
2016.
Euthanasia or Assisted Suicide in Patients With
Psychiatric Illness
To the Editor Drs Olié and Courtet1 commented on the report
by Dr Kim and colleagues2 on euthanasia or assisted suicide
(EAS) of psychiatric patients in the Netherlands, highlighting
the challenges surrounding the legalization of EAS in pa-
tients with a psychiatric illness.
Olié and Courtet1 mentioned the option of palliative care
for terminally ill patients as a possible alternative to EAS.
We believe that the achievements of contemporary palliative
care indicate relevance beyond the context of terminal
somatic illness for the group of people suffering from severe
persistent mental illness. For these patients, we advocate a
shift toward patient-oriented palliative care, centered on the
ethical principle of patient self-determination. Given its
focus on empowering people with mental illness, the
recovery movement is already heading in this direction.3
However, some people with severe persistent mental illness
may have a long history of failed functional recovery. Their
suffering may be unbearable and their therapeutic options
exhausted. In such specific cases, a reorientation of care
goals toward symptom relief as the main focus of care—
possibly without modifying the course of the disease—may
be a legitimate option.
(Reprinted) JAMA November 22/29, 2016 Volume 316, Number 20 2153
 Letters
The authors1 also mentioned the possibility of EAS evalu-
ations in the interests of suicide prevention. Although suicide
prevention has a long history in psychiatry, there are poten-
tial risks in focusing mainly or exclusively on impeding sui-
cide without taking into account the risks of overly aggres-
sive care or even coercion. The severe adverse effects and
interactions of polypharmacy, as well as the patient’s (and
physician’s) possible sense of failure, may result in an even
poorer quality of life for the patient.4 We agree with Dr Yager5
that hyperinterventionism (especially against the patient’s
wishes) and treatment excesses are not supportable; and that
even patients with partially impaired decision-making capac-
ity retain some capacity to make prudent decisions regarding
their long-term desires.
We are aware of the controversy surrounding futility and
palliative care for patients with severe persistent mental
illness.4,5 However, a palliative approach in psychiatry does not
mean giving up on a patient but rather involves redefining the
goals of care. This entails accepting the reality that mental ill-
ness can be fatal. With improvements in the quality of care,
there might be fewer requests for EAS.
Martina A. Hodel, MSc
Manuel Trachsel, MD, PhD
Author Affiliations: Institute of Biomedical Ethics and Medical History,
University of Zurich, Zurich, Switzerland.
Corresponding Author: Manuel Trachsel, MD, PhD, Institute of Biomedical
Ethics and Medical History, University of Zurich, Winterthurerstrasse 30, 8006
Zurich, Switzerland (manuel.trachsel@uzh.ch).
Conflict of Interest Disclosures: The authors have completed and submitted
the ICMJE Form for Disclosure of Potential Conflicts of Interest. Dr Trachsel and
Ms Hodel report receiving grant funding from the Swiss Academy of Medical
Sciences, the Stanley Thomas Johnson Foundation, and the Gottfried and Julia
Bangerter-Rhyner Foundation. No other disclosures were reported.
Disclaimer: The views expressed in this letter are those of the authors and not
necessarily those of the Swiss Academy of Medical Sciences, the Stanley
Thomas Johnson Foundation, or the Gottfried and Julia Bangerter-Rhyner
Foundation.
1. Olié E, Courtet P. The controversial issue of euthanasia in patients with
psychiatric illness. JAMA. 2016;316(6):656-657.
2. Kim SY, De Vries RG, Peteet JR. Euthanasia and assisted suicide of patients
with psychiatric disorders in the Netherlands 2011 to 2014. JAMA Psychiatry.
2016;73(4):362-368.
3. Jacobson N, Greenley D. What is recovery? a conceptual model and
explication. Psychiatr Serv. 2001;52(4):482-485.
4. Berk M, Berk L, Udina M, et al. Palliative models of care for later stages of
mental disorder: maximizing recovery, maintaining hope, and building morale.
Aust N Z J Psychiatry. 2012;46(2):92-99.
5. Yager J. The futility of arguing about medical futility in anorexia nervosa: the
question is how would you handle highly specific circumstances? Am J Bioeth.
2015;15(7):47-50.
In Reply We agree with Ms Hodel and Dr Trachsel when they
conclude, “With improvements in the quality of care, there
might be fewer requests for EAS.” According to the article by
Dr Kim and colleagues,1 most patients receiving EAS for psy-
chiatric conditions did not receive accurate treatment for their
mental state and level of suffering that could have led to avoid-
ing EAS. Dr Trachsel and colleagues2 suggested palliative care
in psychiatry for severe persistent mental illness, including
2154 JAMA November 22/29, 2016 Volume 316, Number 20 (Reprinted)
Copyright 2016 American Medical Association. All rights reserved.
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long-term residential care patients with severe chronic schizo-
phrenia and insufficient quality of life; those with therapy-
refractory depression; and persons with severe, long-
standing, therapy-refractory anorexia nervosa. Most EAS
psychiatric patients in the series by Kim and colleagues did not
meet these criteria.
A common definition of palliative interventions includes
that they help to stabilize or improve quality of life without
necessarily modifying disease progression in the long term.
Using this definition, several clinical approaches in psychia-
try can be considered palliative because they aim at reducing
symptoms and suffering from mental illness rather than
seeking to achieve disease remission. But quality of life is
often improved and suicide risk is reduced when palliative
support takes place in addition to curative or disorder-
specific treatments. Under no circumstances should the term
“palliative” be used to justify negligent or careless treatment
of patients.
We do not agree with the assessment that suicide pre-
vention consists of overly aggressive care. Promising results
have already been reported for the use of ultra–low-dose
buprenorphine to reduce psychological pain and suicidal
ideation with a favorable safety profile.3 Beyond pharmaco-
logical treatments that may be not well tolerated by some
patients, specific psychotherapies have also begun to be
developed to reduce death and promote recovery of psychi-
atric patients. For example, a short-term program of accep-
tance and commitment therapy has suggested efficacy in
suicide prevention with a high acceptability rate.4
In addition, empowering people with mental illness
applies to suicide prevention. The Suicide Attempt Survi-
vors Task Force of the National Action Alliance for Suicide
Prevention 5 proposes to involve individuals who have
attempted suicide in active prevention efforts so that per-
sons currently contemplating suicide “may gain hope and a
sense of empowerment through connection to … experience
of those who have ‘been there.’”
Another issue is mental competence of persons with psy-
chiatric illness requesting EAS. Psychiatric disease increases
the risk of impaired decision-making capacity. Capacity-
specific abilities consist of abilities to understand relevant facts,
apply those facts to oneself, reason and weigh the facts, and
evidence a stable choice. Among the 66 psychiatric patients
receiving EAS in the Netherlands, only 5 had information about
these 4 components mentioned in their medical records.6 Most
often, capacity-specific discussion consisted of only global as-
sertion of a patient’s capacity without details. More explicit dis-
cussion of how such patients are able to meet the various ca-
pacity-specific criteria, despite their symptoms, should be
expected. As guarantors of health, not of death, physicians
should trust further advances in psychiatry to promote new
alternatives to EAS.
Emilie Olié, MD, PhD
Philippe Courtet, MD, PhD
Author Affiliations: Department of Psychiatric Emergency and Acute Care,
Centre Hospitalier Universitaire Montpellier, Montpellier, France.
jama.com

Corresponding Author: Philippe Courtet, MD, PhD, Department of Psychiatric
Emergency and Acute Care, Centre Hospitalier Universitaire Montpellier,
Lapeyronie Hospital, 191 Avenue Doyen Gaston Giraud, 34295 Montpellier
cedex 5, France (p-courtet@chu-montpellier.fr).
Conflict of Interest Disclosures: The authors have completed and submitted
the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were
reported.
1. Kim SY, De Vries RG, Peteet JR. Euthanasia and assisted suicide of patients
with psychiatric disorders in the Netherlands 2011 to 2014. JAMA Psychiatry.
2016;73(4):362-368.
2. Trachsel M, Irwin SA, Biller-Andorno N, Hoff P, Riese F. Palliative psychiatry
for severe persistent mental illness as a new approach to psychiatry? definition,
scope, benefits, and risks. BMC Psychiatry. 2016;16:260.
3. Yovell Y, Bar G, Mashiah M, et al. Ultra-low-dose buprenorphine as a
time-limited treatment for severe suicidal ideation: a randomized controlled
trial. Am J Psychiatry. 2016;173(5):491-498.
4. Ducasse D, René E, Béziat S, Guillaume S, Courtet P, Olié E. Acceptance and
commitment therapy for management of suicidal patients: a pilot study.
Psychother Psychosom. 2014;83(6):374-376.
5. Draper J, Vega E. The way forward: pathways to hope, recovery, and wellness
with insights from lived experience. http://actionallianceforsuicideprevention
.org/sites/actionallianceforsuicideprevention.org/files/The-Way-Forward-Final
-2014-07-01.pdf. Accessed October 26, 2016.
6. Doernberg SN, Peteet JR, Kim SY. Capacity evaluations of psychiatric
patients requesting assisted death in the Netherlands [published online June
29, 2016]. Psychosomatics. 2016;S0033-3182(16)30060-3.
CORRECTION
Incorrect Section Headings in Figures: In the US Preventive Services Task
Force Evidence Report entitled “Primary Care Interventions to Support Breast-
feeding: Updated Evidence Report and Systematic Review for the US Preventive
Services Task Force,” published in the October 25, 2016, issue of JAMA,1 section
headings were incorrect in figures. In Figures 3, 4, and 5, the heading for the top
section should have read, “Timing of intervention: combination of prenatal,
perinatal, or postnatal,” and the heading for the bottom section should have
jama.com
Copyright 2016 American Medical Association. All rights reserved.
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Letters
read, “Timing of intervention: only prenatal, perinatal, or postnatal.” This article
has been corrected online.
1. Patnode CD, Henninger ML, Senger CA, Perdue LA, Whitlock EP. Primary care
interventions to support breastfeeding: updated evidence report and
systematic review for the US Preventive Services Task Force. JAMA. 2016;316
(16):1694-1705.
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Section Editor: Jody W. Zylke, MD, Deputy Editor.
(Reprinted) JAMA November 22/29, 2016 Volume 316, Number 20 2155