Physician-assisted suicide in psychiatry: developments in The Netherlands

Physician-assisted suicide can now be officially and legally carried out for psychiatric patients in The Netherlands who request it, provided that criteria are met. The authors describe two recent cases of psychiatric patients whose suicides were assisted by their psychiatrist. They critically examine the guidelines for physician-assisted suicide in psychiatry. The criteria address the decision of the patient to be assisted with suicide, which must be voluntary and well considered, and the patient's desire to die, which must endure over time. The patient's suffering must be unacceptable, and the disorder incurable. The authors conclude that important aspects of psychiatric practice are not addressed in the guidelines, which were originally developed for use in somatic medicine. The assessment of treatment prognosis in psychiatry is not accurate enough to allow a final decision about incurability. Boundaries of the psychiatric therapeutic relationship are violated in physician-assisted suicide. The therapist's inability to objectively assess the patient's wish to die is overlooked. Because the general public will continue to ask for clarity on the issue of euthanasia and physician-assisted suicide, the authors believe that an open discussion of both ethical and professional issues is the best option.     

Bioethics for clinicians: 11. Euthanasia and assisted suicide

Euthanasia and assisted suicide involve taking deliberate action to end or assist in ending the life of another person on compassionate grounds. There is considerable disagreement about the acceptability of these acts and about whether they are ethically distinct from decisions to forgo life-sustaining treatment. Euthanasia and assisted suicide are punishable offences under Canadian criminal law, despite increasing public pressure for a more permissive policy. Some Canadian physicians would be willing to practise euthanasia and assisted suicide if these acts were legal. In practice, physicians must differentiate between respecting competent decisions to forgo treatment, providing appropriate palliative care, and acceeding to a request for euthanasia or assisted suicide. Physicians who believe that euthanasia and assisted suicide should be legally accepted in Canada should pursue their convictions only through legal and democratic means.     

The effect of sotalol hydrochloride therapy on atrial signal-averaged ECG in patients with paroxysmal atrial fibrillation

BACKGROUND: There has been a continuing public debate about assisted suicide and the proper role, if any, of physicians in this practice. Legislative bans and various forms of legalization have been proposed. METHODS: We mailed questionnaires to three stratified random samples of Michigan physicians in specialties likely to involve the care of terminally ill patients: 500 in the spring of 1994, 500 in the summer of 1994, and 600 in the spring of 1995. Similar questionnaires were mailed to stratified random samples of Michigan adults: 449 in the spring of 1994 and 899 in the summer of 1994. Several different questionnaire forms were used, all of which included questions about whether physician-assisted suicide should be banned in Michigan or legalized under certain conditions. RESULTS: Usable questionnaires were returned by 1119 of 1518 physicians eligible for the study (74 percent), and 998 of 1307 eligible adults in the sample of the general public (76 percent). Asked to choose between legalization of physician-assisted suicide and an explicit ban, 56 percent of physicians and 66 percent of the public support legalization, 37 percent of physicians and 26 percent of the public preferred a ban, and 8 percent of each group were uncertain. When the physicians were given a wider range of choices, 40 percent preferred legalization, 37 percent preferred "no law" (i.e., no government regulation), 17 percent favored prohibition, and 5 percent were uncertain. If physician-assisted suicide were legal, 35 percent of physicians said they might participate if requested--22 percent would participate in either assisted suicide or voluntary euthanasia, and 13 percent would participate only in assisted suicide. Support for physician-assisted suicide was lowest among the strongly religious. CONCLUSIONS: Most Michigan physicians prefer either the legalization of physician-assisted suicide or no law at all; fewer than one fifth prefer a complete ban on the practice. Given a choice between legalization and a ban, two thirds of the Michigan public prefer legalization and one quarter prefer a ban.     

Attitudes of Oregon psychologists toward physician-assisted suicide and the Oregon Death With Dignity Act.

Since the passage of the Oregon Death With Dignity Act (ODDA), psychologists have been grappling with how to fulfill their legally specified role in the process of physician-assisted suicide. We surveyed 423 Oregon psychologists (aged 31–76 yrs) to elicit their views on assisted suicide and the process of assessing patients who request such assistance. There was a high degree of support for assisted suicide and the ODDA, but also a minority who were highly opposed. Most survey respondents raised ethical or practical concerns with their role as assessors. Many important questions about how evaluations in this complex area should be conducted remain unanswered. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Nurse anesthetists'' perspectives on improving the anesthesia care of culturally diverse patients

This report of a 1995 survey presents data regarding nurses' attitudes and beliefs about assisted suicide in AIDS. The authors surveyed 428 nurses working at facilities serving AIDS patients in the San Francisco Bay Area, using an anonymous, self-administered questionnaire. They received 215 responses (50%). There was a high level of agreement with statements that place assisted suicide in the context of humane action to relieve suffering. An AIDS diagnosis did not change respondents' attitudes toward assisted suicide, although many nurses said that the relentless suffering and specific nature of the AIDS epidemic did influence their thinking.     

Advance directives and other medical decisions concerning the end of life in cancer patients in Japan

The purpose of our survey was to investigate the experience of physicians regarding advance directives and other medical decisions concerning the end of life. A postal questionnaire was sent to 500 Japanese physicians who were most involved in medical care of terminal patients. A total of 339 (68%) physicians responded. In dealing with terminal patients, approximately half gave priority to their patients' wishes for medical care, if known, regardless of the patient's competency. Of the respondents, 149 had been presented with advance directives by their patients and 35% followed all advance directives presented in their practice. Cardiopulmonary resuscitation (CPR) for arrested patients to enable their family to be at the bedside at the time of the death was common. More than 60% of the respondents thought that active euthanasia and assisted suicide were never ethically justified. Our study indicates that the wishes of patients are currently not always given top priority in medical decisions concerning the end of life.     

Is "involuntary childlessness" within the realm of family medicine responsibility of the general practitioner?

The aim of the study was to assess whether or not management of infertility is within the domain of the general practitioner in his capacity as a family physician. All accredited family physicians in the wider area of Goettingen were invited to take part in our survey. A total of 57 doctors (84%) participated. In personal interviews the family physicians were encouraged to frankly discuss the following main topics: the frequency of infertility in their own practice as well as their care for and attitudes towards infertile patients. Many family physicians interviewed were reluctant to address involuntary childlessness and underestimated its frequency. According to their patients' needs and demands, however, family doctors--above all in rural practices--have been participating in the screening and counseling of, and providing emotional support for, involuntarily childless patients. A qualitative analysis of the interview data revealed that many family physicians regarded infertility as the patients' private matter and placed it within the domain of specialists. About one-third of the physicians expressed negative attitudes towards infertile patients. Moreover, assisted reproduction techniques were sometimes rejected as "unnatural" methods. If a family-oriented approach should be amplified in family practice by offering supportive counseling for infertile patients, continuing medical education will have to take these attitudes into account.     

The relevance of data on physicians and disability on the right to assisted suicide: Can empirical studies resolve the issue?

Opponents of a right to physician-assisted suicide rely heavily on the results of several empirical studies, particularly data concerning physicians and other health professionals. This commentary on C. J. Gill's article examining the suitability of people with irreversible disabilities to be candidated for assisted suicide (see record 2001-17060-021) concludes that values, not empirical data, must ultimately determine the legality of assisted suicide. Studies cannot resolve the fundamental issue. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Perioperative TNF alpha and IL-6 concentrations correlate with septic state, organ function, and APACHE II scores in intra-abdominal infection

BACKGROUND: Routine diagnostic endoscopy is commonly obtained for low-risk patients with acute upper gastrointestinal bleeding despite evidence from controlled trials that it does not improve patient outcome. OBJECTIVE: To determine whether endoscopy is being overutilized for these patients or whether considerations not addressed in the trials could justify its widespread use. METHODS: Twenty-five patients recovering from a recent hemorrhage and 22 primary care physicians used the analytic hierarchy process to perform an individualized analysis regarding the diagnostic management of acute upper gastrointestinal bleeding. The results were used to determine whether routine endoscopy was consistent with each subject's interpretation of relevant data and judgments regarding the relative importance of five management goals. The authors then compared the proportion of subjects in each group who preferred endoscopy over two non-endoscopy strategies (upper gastrointestinal series and no routine diagnostic test) with 85%, the current rate of endoscopy at the authors' hospital. RESULTS: Endoscopy was preferred by 92% (97.5% CI: 70%-98%) of the patients and 55% (97.5% CI: 31%-77%) of the physicians. The patients ranked identifying the cause of bleeding the second most important management goal after avoiding a poor outcome from the acute bleeding episode. CONCLUSIONS: The current rate of diagnostic endoscopy is higher than would be expected based on physicians' preferences but quite consistent with patients' preferences. Patients regard knowledge of the bleeding site as important, even if this information will not affect management or prognosis. Attempts to assess the use of diagnostic endoscopy and other diagnostic tests should take both patient preferences and the pure value of diagnostic information into account.     

Therapeutic death: A look at Oregon's law.

Oregon voters approved the first American statute authorizing physician-assisted suicide, the Oregon Death With Dignity Act, in 1994. The authors of this article identify some positive and negative psychological effects of laws such as Oregon's on patients. Generally, they conclude, on the basis of psychological theory and the available data, that laws such as Oregon's benefit patients psychologically. Undoubtedly, however, there exist important possible antitherapeutic effects on patients, and the authors hope that discussion of both therapeutic and antitherapeutic consequences will stimulate future research by social scientists in this area. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Physician assisted suicide and the Supreme Court: putting the constitutional claim to rest

Like the debate about many controversial questions of ethics and medical care in America, public debate about physician assisted suicide became focused on questions of constitutional law. On June 26, 1997, the United States Supreme Court unanimously rejected any constitutional right of terminally ill patients to physician assisted suicide. An analysis of the Court's reasoning reveals that its decisions resolved only a narrow constitutional question that affects relatively few people--mentally competent, terminally ill patients who wish to hasten their imminent deaths by having a physician prescribe medication that they intend to use to commit suicide. Although suicide is not a crime, states remain free to prohibit assisted suicide. One consequence of the Court's decisions may be renewed debate on state laws. A more productive result would be to address the broader public health concerns that gave rise to support for physician assisted suicide--inadequate care for the terminally ill and prevention of suicide.     

A call for civility in the disability/assisted suicide debate.

The debate over legalization of physician-assisted suicide is inherently controversial, particularly where disability issues and physician-assisted suicide intersect. This is the area addressed by C. J. Gill (see record 2001-17060-021) and A. I. Batavia (see record 2001-17060-022) in this journal's recent special issue on hastened death. In replying to Batavia's commentary, Gill accused Batavia of generally misrepresenting Gill's positions and distorting facts. Here Batavia replies to the alleged errors that Gill identified. Batavia defends his assumption that, without state interference in the private relationship between individuals and their physicians, such individuals would be able to end their suffering with the assistance of their physicians. There was very little data to cite on the level of support of disabled people for a right to assisted suicide. Individuals who lack adequate opportunity to adapt to their disabilities cannot exercise real autonomy in choosing to end their lives. Batavia contends that most people with disabilities support the right to remove life-sustaining equipment, mirroring a strong consensus in American law and ethics that individuals should be allowed to refuse care they do not want. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Physician-assisted suicide and the Supreme Court: the Washington and Vacco verdicts

In June 1997, the Supreme Court decided that statutes proscribing physicians from providing lethal medication for use by competent, terminally ill patients do not violate the Due Process or Equal Protection Clauses of the Constitution. The Court returned the question of physician-assisted suicide to the states, but did not foreclose future review of state laws that may be too restrictive of care at the end of life. The conceptual distinctions between assisted suicide, refusal of life-sustaining treatment, and administration of pain medication to terminally ill patients were endorsed as important guideposts for future analyses.     

Common pediatric dental problems

Physicians who provide primary care for children have a unique position to provide diagnostic, triage, educational, and preventive dental care for patients. Several papers have been published regarding primary pediatricians' participation in the preventive dental health care of their patients. One publication, a survey of physicians in Alabama focusing on physicians' overall awareness of dental issues, concluded that most physicians believe they have a role in the oral health of their patients, yet most were not aware of the American Academy of Pediatric Dentistry's recommendations. Most physicians report that they routinely perform oral examinations during physical examinations of children and deliver preventive, oral information by the age of 6 months or earlier; however, most recommend that infants' first visit should be at 3 years of age, not at the time of first-tooth eruption as the authors recommend. Furthermore, many primary care physicians do not talk about oral health during prenatal counseling. Many physicians understand the preventive advantages of fluoride, yet most do not prescribe vitamin combinations that contain fluoride. If an understanding of the aforementioned issues of dental care, as well as aspects of preventive care in infants and children, become more uniform among primary care physicians, the prevention-based practice of pediatric dentistry will become much more successful, and children and adults will enjoy better dental health.     

Health professionals, disability, and assisted suicide: An examination of relevant empirical evidence and reply to Batavia (2000).

Prominent disability rights groups have adopted positions opposing the legalization of assisted suicide. That physicians and other health professionals would assist in suicides of persons with incurable conditions while offering suicide prevention to "healthy" individuals is, they maintain, evidence of social discrimination and an unwarranted devaluation of the quality of life of people with disabilities. This article examined empirical literature relevant to the question: Is there evidence that disability affects life in a manner that justifies an exception to the general practice of preventing rather than endorsing suicide? Research findings are discussed in terms of their bearing on the disability rights opposition to physician-assisted suicide and the need for research addressing the dynamics of death requests of persons with disabilities. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Cerebral blood flow and personality: a positron emission tomography study

OBJECTIVE: To determine current practice patterns of obtaining informed consent for infertility treatment by reproductive endocrinologists and to assess changes in response to reports of an association between ovulation induction and ovarian cancer. METHODS: Board-certified reproductive endocrinologists (n = 575) were surveyed by mail regarding how they informed patients and obtained consent for infertility treatments and how their practices had been influenced by studies suggesting a link between ovulation induction and ovarian cancer. Data were analyzed using chi2 and logistic regression analyses. RESULTS: The return rate was 62.1% (357 of 575 surveys). Most respondents (92%) used discussions with physicians to inform their patients of risks and benefits of all infertility treatments. Additional means, such as audiovisual aids, were used significantly more often for assisted reproductive technologies (including intracytoplasmic sperm injection and use of donated eggs) than for less invasive therapies (31-43% versus 4-11%, P < .001). Most physicians (46-66%) used verbal consent alone for hysterosalpingogram, intrauterine insemination, and ovulation induction. Formal written consent was used significantly more often for the various assisted reproductive technologies than for hysterosalpingogram, intrauterine insemination, or ovulation induction (94-95% versus 26-44%). Although most physicians (70%) did not believe that ovulation induction increases the risk of ovarian cancer, 83% addressed this risk when obtaining consent and 47% reported changing their practices since an association was reported. Common changes included limiting length of treatment and addressing ovarian cancer risk. CONCLUSION: Current practice patterns of obtaining informed consent for various infertility treatments by board-certified reproductive endocrinologists show, as expected, that informed consent is more rigorous for assisted reproductive technologies. Although most surveyed did not believe that ovulation induction increases risk of ovarian cancer, the majority of physicians addressed that risk when obtaining consent and nearly half changed their practices on the basis of a possible association.     

Assisted suicide, depression, and the right to die.

The debate surrounding the legalization of assisted suicide continues despite a limited body of empirical research. Relatively few studies have addressed interest in assisted suicide or the desire for hastened death (rather than approval of legalization) among medically ill patients, and this literature is plagued by methodological limitations. In general, this research has demonstrated a significant association between depression and desire for death; however, the magnitude of this association is unclear. Nevertheless, psychological and social factors have typically appeared more influential in determining patients' desire for death than physical symptoms such as pain. The impact of these findings on future legislative efforts to legalize assisted suicide is discussed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

How to deal with requests for assisted suicide: Some experiences and practical guidelines from the Netherlands.

In the Netherlands, physician-assisted suicide may be justifiable for patients with physical illness as well as for patients with unbearable mental suffering. Explicit requests for physician-assisted suicide are frequently made, but in psychiatric practice they are infrequently granted. In this contribution, some information on the Dutch practices related to assisted death is presented, with emphasis on assisted suicide in patients with unbearable mental suffering. The aim of this contribution is to demonstrate that the Dutch law and jurisprudence permit clinicians to deal effectively with requests for assisted suicide. (PsycINFO Database Record (c) 2010 APA, all rights reserved)