domingo, 5 de noviembre de 2017

BioEdge: Is euthanasia for psychological suffering changing Belgian medicine?

BioEdge: Is euthanasia for psychological suffering changing Belgian medicine?

Is euthanasia for psychological suffering changing Belgian medicine?
Belgium’s debate over euthanasia for psychological suffering is heating up. On Tuesday 42 psychiatrists, psychologists and academics published an open letter calling for a national debate on euthanasia and mental illness.

Euthanasia because of unbearable and futile psychological suffering is very problematic. It is about people who are not terminal and, in principle, could live for many years. Therefore, extreme caution is appropriate both clinically and legally. The essence of the case seems to us that in estimating the hopelessness of one's suffering, the subjective factor cannot be eliminated ...
The current law, the signatories say, is far too vague and flexible:

"The law does not indicate the exact criteria for unbearable and psychological suffering. Any complaint about any carelessness in this area will only end in a legal ‘no man's land’.
"More and more, no matter how many criteria there are, it depends simply on how an individual psychiatrist interprets or tests them, aided by the doctor's own assumptions and the patient's account of his symptoms."
Some people are dying unnecessarily, the signatories claim. To stand silently on the sidelines is a crime of neglect.

Euthanasia for psychological suffering is not a topic which greatly interests the Belgian media. But it was jolted out of its slumber by an exclusive article (in English) from Associated Press which also appeared in the Washington Post. This prompted a number of articles in the local press.

The article in the Washington Post highlighted a conflict between Wim Distelmans, the head of the federal euthanasia commission, and Lieve Thienpont, a psychiatrist who has processed a number of patients who wanted euthanasia on the basis of psychological suffering. According to the AP’s report, Distelmans believed that she had allowed patients to be euthanised who did not fulfil the criteria set down by Belgium’s euthanasia legislation.

Thienpont denied this and blamed some of her patients for misrepresenting her. “These patients are very desperate, stressed,” she said. “They say things that are not always correct.”

This week Ignaas Devisch, a bioethicist at Ghent University, questioned the argument put forward by Thienpont.

Talk about paternalism! Suddenly, people who were previously able to achieve full self-determination and who just requested euthanasia, were no longer able to articulate their thoughts in an appropriate way.
This argument reveals a gigantic problem: if a psychiatrist who deals with requests for euthanasia due to a psychiatric disorder doubts at the same time whether those same people can make a clear judgment about themselves, that is so much as saying that their euthanasia request is a highly problematic case.
A long feature in the magazine Knack this week illustrates some of the difficulties that Belgian psychiatrists now find themselves in. One experienced psychiatrist complained that it had changed her relationship with her patients, even though she supports the idea of euthanasia.

"Strangely enough, people with less severe and readily treatable mental disorders – such as borderline personality disorders – request euthanasia more often than seriously ill patients. The offer really creates the question. Euthanasia has become a new symptom. Often it's a cry for help: 'Am I still worth living, or are you giving up on me?' But it is a symptom with particularly dangerous consequences...
"If you refuse to take the euthanasia question seriously, you put the relationship with the patient at risk and lose your trust...
"Since the euthanasia law there has been some kind of madness in our work. After the threat of suicide, for which you must be constantly on guard as a psychiatrist, there is now the threat of euthanasia. " 


Sunday, November 5, 2017

Songs about loneliness are legion and range from the soppy and sentimental, like Ray Orbison’s “Only the Lonely” to the irony of the Beatles’ “Eleanor Rigby”. I’ve always been a sucker for Ralph McTell’s “The Streets of London”, with its piercing lyrics about homeless people in a big city.

Perhaps the reason loneliness is such a potent theme is that we instinctively realise how dangerous it is.

It turns out that loneliness is (a) a major social and health issue and (b) a widespread phenomenon. One US researcher has even estimated that it affects as many as 45% of retired Americans. This seems far too much, but the levels are certainly high. And since it increases the odds of an early death by 26%, I’d call it a challenge for bioethics. How can we heal the frayed and broken bonds of social cohesion?

A feature in this week’s JAMA examines the cost of loneliness – and the lack of solutions. We report on it below.

Michael Cook
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