The right to die and physician-assisted suicide medical, legal, and ethical aspects (Part I)

Part 1 of this paper examines the issue of the "Right to Die", and its relationship to the discipline of Bioethics and the doctrine of Informed Consent. The discussion underlines the role and rights of the patient. A number of relevant judgments are quoted, with their implications. Part 2, to be published in our next issue, continues the discussion, with emphasis on the subject of physician-assisted suicide and the activities of Dr. Kevorkian. Further legal cases are quoted with relevant analysis, together with proposed legislation under the title "Death with Dignity". Finally, the author points to possible future developments in this controversial issue.     

Assisted suicide and equal protection: in defense of the distinction between killing and letting die

The author argues that the distinction between intentionally killing oneself and intentionally letting oneself die is both coherent "as a matter of principle" and morally relevant. This principled distinction then provides a benchmark for courts considering equal protection arguments to distinguish one patient seeking to commit suicide from another wishing to free herself of unwanted life-sustaining medical treatment, and to conclude that these two individuals are not similarly situated for purposes of the Equal Protection Clause. These two situations are morally distinct--the deaths are caused by different means and those involved have different intentions. The intention of the doctor and patient to hasten the patient's death is material, and the intention relates to understanding what it means to treat people equally. Doctors who participate in assisted suicide intend their patients to die by their own acts, i.e., intentional killing. The author concludes that those who ask their doctors to commit assisted suicide and those who forego treatment are not similarly situated for purposes of the Equal Protection Clause. The afterward comments on the Supreme Court's recent assisted suicide decision. It affirms the author's analysis.     

The Chabot case. Assisted suicide from the psychiatric viewpoint

The international discussion on physician-assisted dying as well as the recent development in North Australia and Oregon point to a growing tendency to favour assisted suicide as against killing on request--last not least for reasons of public acceptance. The decision of the Supreme Court of the Netherlands in a case of suicide assisted by a psychiatrist gives the opportunity to discuss the problem from the psychiatric point of view.     

Early Christian martyrdom and the psychology of depression, suicide, and bodily mutilation.

Stories of Christian martyrdom during the 2nd and 3rd centuries provide an opportunity for understanding the psychology of this kind of religious enthusiasm and its relevance for the contemporary experiences of depression, suicide, and bodily mutilation. The historical and religious features of the martyr's world are described, along with familial, social, bodily, cognitive, and emotional dimensions of the martyr's psychology. Clinical case studies of 3 Ss (aged 32–53 yrs) with major depression, borderline personality disorder, and self-mutilation are described from the perspective of martyrdom. Implications for psychotherapy are included. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

'Ageism' and right to die litigation

This study examines 88 reported judicial decisions involving adult patients and decisions about life-prolonging medical treatments. The patient's age by itself does not appear to be a factor influencing findings of mental competency or incompetency or findings of the appropriateness or inappropriateness of abating life-prolonging medical treatments. Neither can an explicit ageist bias be extracted from an analysis of the text of judicial decisions in this arena. Various potential explanations for the lack of apparent ageist bias are suggested.     

Psychopathology of adolescent suicide: Hopelessness, coping beliefs, and depression.

Two studies of adolescents examined the relation of several cognitive variables and depression to suicide-related behaviors. Study 1 compared hopelessness and depression in 281 high school students. Unlike research with adults, depression was significantly related to suicidal behaviors, even after hopelessness was statistically controlled. When depression was controlled, hopelessness was unrelated to suicidal behaviors for boys and only modestly related for girls. Study 2 examined depression, hopelessness, survival–coping beliefs, fear of social disapproval, and social desirability in relation to suicidal behaviors in 53 male juvenile delinquents. Again, hopelessness did not account for a significant proportion of the variance in suicide. Depression was uniquely related to past suicide attempts. Survival–coping beliefs were associated with self-predicted future suicide and other suicidal behaviors. Survival–coping beliefs are discussed as a cognitive buffer to suicidal ideation in adolescence. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The role of defeat and entrapment in depression, anxiety, and suicide.

Defeat and entrapment are psychological constructs that have played a central role in evolutionary accounts of depression. These concepts have since been implicated in theoretical accounts of anxiety disorders and suicidality. The current article reports on a systematic review of the existing research investigating the links among defeat, entrapment, and psychopathology in the domains of depression, suicidality, posttraumatic stress disorder (PTSD), and other anxiety syndromes. Fifty-one original research articles were identified and critically reviewed. There was strong convergent evidence for a link with depressive symptoms, across a variety of clinical and nonclinical samples. Preliminary support for an association with suicidality was also observed, with effects not readily explainable in terms of comorbid depression. There was strong evidence for an association between defeat and PTSD, although this may have been partly accounted for by comorbid depression. The findings for other anxiety disorders were less consistent. There was, however, evidence that social anxiety in individuals with psychosis may be related to perceptions of entrapment. Overall, there was evidence that perceptions of defeat and entrapment were closely associated with various forms of human psychopathology. These effects were often in the moderate to large range and superseded the impact of other environmental and psychological stressors on psychopathology. We provide a unified theoretical model of how defeat and entrapment may contribute to these different psychopathological conditions. Clinical implications and avenues for future research are discussed. (PsycINFO Database Record (c) 2011 APA, all rights reserved)     

Assisted suicide in dementia. Ethical considerations between paternalism and autonomy

This article discusses the problem of euthanasia presenting the case of an 82-year-old man with progressive dementia. Difficulties encountered during daily clinical work are described and analysed, in order to clarify decisions on ethical, legal and professional medical grounds. General decisions concerning life-sustaining measures may be qualitatively improved if the situation of the individual is constantly assessed and considered within the treatment process.     

Drug-induced depression and attempted suicide

Sixty-eight patients who had attempted suicide were matched with non-suicidal patients with similar diagnoses to assess the extent to which excessive drug ingestion by the suicidal group might have contributed to their behaviour. It was found that the suicidal patients were consuming more drugs, particularly those of a potentially depressing kind. The implications of this finding are discussed.     

Physician-assisted suicide and older patients'' perceived duty to die

The Lambert-Eaton syndrome is an autoimmune disease affecting the presynapse of the neuromuscular junction. Proximal muscle fatigue of the limbs is improved by repeated maximal voluntary contractions. Generally, patients present hypo or areflexia and frequently a dry mouth syndrome. In 50% of the cases, the Lambert-Eaton syndrome is associated with small-cell bronchogenic carcinoma. The different treatments proposed in the literature for Lambert-Eaton paraneoplastic syndrome focus on treatment of the primary tumor. Symptomatic treatment of the junctional disorder are based on cholinergic drugs, immunosuppression and immunomodulation, useful in case of unsuccessful antineoplastic therapy.     

Assisted suicide after discharge from the psychiatric clinic

Assisted suicide has become a topic often and controversally discussed in international literature. Psychiatry and mentally ill, however, have been neglected, probably because the question of competence of judgement and will are a major issue in this matter. Two cases are reported, one of a 60-year old man and a women of 87 years, who have committed suicide a few days after having been dismissed from stationary psychiatric care. The reason of admission had been a psychotic event with manifest AIDS-disease in the first, the public utterance of her wish to die with support of, the swiss "Help to Die" organization "Exit", in the latter. Ethics and means of preentive interventions in such cases are discussed.     

Assisted suicide: implications for nurses and nursing

Assisted suicide is an issue of great importance to nurses. This issue reflects our values and beliefs as a society, calls for a clear and precise response as a profession, and challenges individual nurses to think about their own moral views. The history of the debate and the compelling moral arguments on both sides attest to the complexity of the issue and also suggest that it will not soon be resolved. The current position of the profession, as expressed in the ANA Code for Nurses and a specific position statement, were reviewed. The dilemma faced by the individual nurse who perceives an obligation to adhere to the guidelines specified by his or her profession's code and yet whose conscience dictates an act in violation of this code has been discussed as an instance of conscientious objection. While this analysis has been necessarily brief, it was intended to illustrate the importance of being clear about one's personal moral views and equally clear about one's duty to fulfil the obligations stemming from the profession's public statements. It is essential that the profession continue to explore the moral issues involved in requests for assistance in dying and provide additional guidelines for practicing nurses, with sound rationale for the profession's position.     

Assisted suicide: clinical realities and ethical challenges

The increasing attention to assisted suicide, as evidenced by recent legislation, initiatives, court decisions, and research, propels the issue to a new level of importance and urgency within society and the health professions. Nurses cannot help but be confronted by and struggle with the complex moral and professional quandaries related to assisted suicide. Critical care nurses must continue to evaluate the implications of the possible legalization of assisted suicide and to define the boundaries of morally acceptable professional practice. The challenges to the roles and responsibilities of critical care nurses that might occur if assisted suicide were legalized must be thoughtfully and responsibly explored.     

Learning from Amy. A remarkable patient provokes anguished debate about rationality, autonomy and the right to die

Accommodative spasm usually encompasses a classical triad of pseudomyopia, esodeviation and pupillary constriction. Accommodative spasm is most often psychogenic in nature; however, it may be associated with other organic diseases of which a rare cause is that of intracranial catheter complications. We report a case of dorsal midbrain syndrome with pseudomyopia in a patient with a blocked ventriculo-peritoneal shunt inserted for aqueductal stenosis. Clinical presentation was unusual in this patient as pseudomyopia occurred with exodeviation and without pupillary constriction.     

Association of childhood parental loss with attempted suicide and depression.

Compared the parental loss of adult depressed inpatient suicide attempters, nonsuicidal depressed patients, and normal controls. Findings suggest that a childhood characterized by intentional parental separation from the child is associated with attempted suicide in adult life, whereas the loss of a parent through natural causes in unrelated to suicide. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Late-life suicide and depression in the primary care setting

Late-life depression and suicidal behavior in the primary care setting is a significant public health concern. The prevalence of depression in this population is substantial, yet rates of detection and treatment are far from adequate. Untreated depression has significant consequences with regard to morbidity and mortality. Although suicide is a relatively low-base-rate behavior, a substantial proportion of late-life suicides have contact with their primary care provider prior to their death; thus this offers an avenue for suicide prevention. There is a growing knowledge base concerning what constitutes barriers to the recognition and treatment of late-life depression as well as what constitutes useful screening tools and treatments for the depressed elderly. Important new findings with regard to the functional effects of subsyndromal depression, possible subtypes of late-life depression, the clinical utility of SSRIs and psychotherapeutic interventions, and innovative and collaborative models of care hold promise for advancing the science and practice of treating late-life depression.     

Assisted circulation to the right ventricle through pulmonary counterpulsation using a biological method

The association between asthma exacerbations and use of antiasthmatics has been studied with a drug dispensing database. Exacerbations were identified through use of oral corticosteroids and the risk was determined for each medication. use of fenoterol and oral xanthines increases the frequency of exacerbations, but a channelling phenomenon is not excluded. This method could be used in the study of treatment combinations or new treatments, facilitating the monitoring of asthmatic populations. A second study collects ambulatory drug use data (POM and OTC drugs) of elderly patients. These data are analysed for the distribution of several variables, such as concomitant use of several medications of the same therapeutic class. As an example, about 15 per cent of NSAIDs users also use aspirin, exposing themselves to increased risk for gastrointestinal effects. These studies illustrate the use of drug dispensing databases in monitoring populations at risk and assessing treatment quality.