GESTIÓN EN SALUD PÚBLICA: Is suicide different from physician assisted death?

domingo, 12 de agosto de 2018

Is suicide different from physician assisted death?

Is suicide different from physician assisted death?

Bioedge

Is suicide different from physician assisted death?

by Xavier Symons | 11 Aug 2018 | 1 comment

Bioethicists have for several decades discussed whether Physician Assisted Death (PAD) can be distinguished from other forms of suicide. The question is of critical importance for suicide prevention initiatives in countries where PAD is legal, as it may be the case that the practice of PAD is undermining the work of organisations committed to reducing suicide rates.

A major intervention into the debate was made late last year by the American Society for Suicidology (ASS) -- the peak association in the United States that advocates for suicide prevention -- when the organisation released a statement declaring that “suicide is not the same as “physician aid in dying””. In that statement, the organisation suggested that certain features of “traditional” suicide -- such as the lack of competency of the suicider; the loss of meaning in one’s life; and the sense of hopelessness experienced by the individual -- make it a distinct sociological, medical and legal phenomenon from state sanctioned forms of PAD. The statement describes PAD as a relatively peaceful means to end one’s life, and suggests that it is closely scrutinised in all jurisdictions where it is legal (both in the US and abroad). The statement concluded with a bold assertion that a commitment to suicide prevention has “no bearing” on one’s attitude to PAD, and, furthermore, that the term “physician assisted suicide” should be deleted from use.

Yet three US psychiatrists have just published scathing critique of the statement in the journal JAMA Psychiatry, arguing in particular that the practice of PAD for psychiatric disorders is in many cases very difficult to distinguish from other forms of suicide. The authors of the paper -- Drs Scott Kim (NIH), Yeats Conwell (Rochester) and Eric D. Caine (Rochester) -- argue that the features of “traditional” suicide may indeed be present in cases of euthanasia for psychiatric disorders. The authors write:

“persons who receive psychiatric PAD share these characteristics [with persons who die by suicide]: they all have some form of mental illness; most also have personality disorders, have attempted suicide, and are socially isolated or lonely”.

The cite a series of papers published on PAD for psychiatric disorders in the Netherlands and Belgium, indicating a gross lack of oversight and concern for patient autonomy. One case cited in the article includes a man in the Netherlands who “jumped off a building, survived the fall with broken thighs, and then received PAD during the ensuing hospitalization”.

Importantly, the authors note that, even in cases where euthanasia is requested on the grounds of a terminal illness, patients often report psychological pain and despair and a fundamental loss of meaning.

Saturday, August 11, 2018

Every year, about 1.5 million cases of euthanasia take place in the United States. Does this have a negative impact on healthcare workers? Sorry, about 1.5 million cases of cat and dog euthanasia take place. But the question is still relevant. Veterinarians, veterinary assistants and shelter workers experience great stress at having to put animals down.

The emotional connection between the work of human doctors and animal doctors is closer than you might think. Owners often react to a pet’s death with the intensity of grief which appears equivalent to the loss of a beloved relative.

So the moral stress which vets experience is relevant. Suicide amongst vets has been the topic of several studies. “Veterinarians are four times more likely than members of the general population and two times more likely than other health professionals to die by suicide,” according to a 2012 study in the journal of The American Association of Suicidology, Suicide and Life-Threatening Behaviour.

Why? Performing euthanasia day in, day out, also appears to make some vets less able to resist the temptation to commit suicide. The authors of the 2012 study found that “... all else being equal, veterinarians may be more likely than members of other professions to enact a lethal attempt when they desire suicide because their exposure to euthanasia has rendered them less fearful of death."

Aren’t there lessons in these finding which are relevant to doctors who euthanize their patients? Sometimes doctors in Belgium or the Netherlands are quoted as saying that the death they helped was beautiful or peaceful. Could that be bravado masking their own nonchalance about human death?

How many times have we all heard the argument, “You wouldn’t let a dog suffer like this...” Its logic is that if the suffering of animals and humans is essentially the same, they both should be released from suffering in the same way. But if the animal-human parallel works for the patient, why not for the doctor? If we allow euthanasia, surely we can expect the same burn-out rates and the same suicide rates as veterinarians ... at least the same. That should scare us all – especially the doctors who will be responsible.