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Hawke LD, Bastidas-Bilbao H, Cappe V, van Kesteren MR, Stewart DE, Gupta M, Simpson AIF, Campbell BH, Castle D, Stergiopoulos V. Medical Assistance in Dying for Mental Illness as a Sole Underlying Medical Condition and Its Relationship to Suicide: A Qualitative Lived Experience-Engaged Study: Aide Médicale à Mourir Pour Maladie Mentale Comme Seule Condition Médicale Sous-Jacente et Son Lien Avec le Suicide: Une Etude Qualitative Engagée Dans l'Expérience Vécue. CANADIAN JOURNAL OF PSYCHIATRY. REVUE CANADIENNE DE PSYCHIATRIE 2024; 69:314-325. [PMID: 37885204 PMCID: PMC11032095 DOI: 10.1177/07067437231209658] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/28/2023]
Abstract
OBJECTIVE This lived experience-engaged study aims to understand patient and family perspectives on the relationship between suicidality and medical assistance in dying when the sole underlying medical condition is mental illness (MAiD MI-SUMC). METHOD Thirty individuals with mental illness (age M = 41.8 years, SD = 14.2) and 25 family members (age M = 47.5 years, SD = 16.0) participated in qualitative interviews examining perspectives on MAiD MI-SUMC and its relationship with suicide. Audio recordings were transcribed and analysed using reflexive thematic analysis. People with lived experience were engaged in the research process as team members. RESULTS Four main themes were developed, which were consistent across individuals with mental illness and family members: (a) deciding to die is an individual choice to end the ongoing intolerable suffering of people with mental illness; (b) MAiD MI-SUMC is the same as suicide because the end result is death, although suicide can be more impulsive; (c) MAiD MI-SUMC is a humane, dignified, safe, nonstigmatized alternative to suicide; and (4) suicidality should be considered when MAiD MI-SUMC is requested, but suicidality's role is multifaceted given its diverse manifestations. CONCLUSION For patient-oriented mental health policy and treatment, it is critical that the voices of people with lived experience be heard on the issue of MAiD MI-SUMC. Given the important intersections between MAiD MI-SUMC and suicidality and the context of suicide prevention, the role that suicidality should play in MAiD MI-SUMC is multifaceted. Future research and policy development are required to ensure that patient and family perspectives guide the development and implementation of MAiD MI-SUMC policy and practice.
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Affiliation(s)
- Lisa D. Hawke
- Centre for Addiction and Mental Health, Toronto, Ontario, Canada
- Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
| | | | - Vivien Cappe
- Centre for Addiction and Mental Health, Toronto, Ontario, Canada
| | | | - Donna E. Stewart
- Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
- Centre for Mental Health, University Health Network, Toronto, Ontario, Canada
| | - Mona Gupta
- Centre Hospitalier de l'Université de Montréal, Montréal, Québec, Canada
| | - Alexander I. F. Simpson
- Centre for Addiction and Mental Health, Toronto, Ontario, Canada
- Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
| | | | - David Castle
- Department of Psychiatry, University of Tasmania, Hobart, Tasmania, Australia
- Statewide Mental Health Service, Hobart, Tasmania, Australia
| | - Vicky Stergiopoulos
- Centre for Addiction and Mental Health, Toronto, Ontario, Canada
- Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
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Fowler WC, Koenig HG. Should Physician-Assisted Suicide or Euthanasia be Legalized in the United States? A Medically Informed Perspective. JOURNAL OF RELIGION AND HEALTH 2024; 63:1058-1074. [PMID: 37938413 DOI: 10.1007/s10943-023-01939-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 10/16/2023] [Indexed: 11/09/2023]
Abstract
There is a pressing debate in the United States concerning the implied physicians' obligation to do no harm and the status of legalizing physician-assisted suicide (PAS). Key issues that underpin the debate are important to consider. These include: (1) foundational medical beginnings; (2) euthanasia's historical and legal background context; and (3) the key arguments held by those for and against legalization of PAS. This paper reviews the major claims made by proponents for the legalization of PAS and the associated complexities and concerns that help underscore the importance of conscience freedoms. Relief of suffering, respect for patient autonomy, and public policy arguments are discussed in these contexts. We argue here that the emphasis by healthcare providers should be on high quality and compassionate care for those at the end of life's journey who are questioning whether to prematurely end their lives. If medicine loses its chief focus on the quality of caring-even when a cure is not possible-it betrays its objective and purpose. In this backdrop, legalization of PAS harms not only healthcare professionals, but also the medical profession's mission itself. Medicine's foundation is grounded in the concept of never intentionally to inflict harm. Inflicting death by any means is not professional or proper, and is not trustworthy medicine.
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Affiliation(s)
- W Craig Fowler
- Campbell University School of Osteopathic Medicine, Lillington, NC, USA
- University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Harold G Koenig
- Department of Psychiatry, Duke University Medical Center, Box 3400, Durham, NC, 27710, USA.
- Department of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia.
- Ningxia Medical University, Yinchuan, People's Republic of China.
- Shiraz University of Medical Sciences, Shiraz, Iran.
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Jebari J, Masciari CF, Walsh E. Treatment-Resistant Psychiatric Conditions and the Ethics of Psychiatric Physician-Aid-in-Dying. AJOB Neurosci 2024; 15:61-64. [PMID: 38207181 DOI: 10.1080/21507740.2023.2292491] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2024]
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Bastidas-Bilbao H, Stergiopoulos V, Cappe V, van Kesteren MR, Stewart DE, Gupta M, Simpson AIF, Dawthorne M, Rajji TK, Castle D, Hawke LD. Walking Alongside: Views of Family Members on Medical Assistance in Dying for Mental Illness as the Sole Underlying Medical Condition. QUALITATIVE HEALTH RESEARCH 2023; 33:1140-1153. [PMID: 37773095 PMCID: PMC10626980 DOI: 10.1177/10497323231197365] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/30/2023]
Abstract
Medical assistance in dying (MAiD) was introduced into Canadian federal legislation in 2016. Mental illness as the sole underlying medical condition (MI-SUMC) is currently excluded from eligibility; such exclusion is scheduled to expire on March 17, 2024. Irremediability, capacity, quality of life, autonomy, family involvement, and healthcare system constraints have been debated intensively. Recent studies have not explored the views of family members of persons with mental illness on MAiD MI-SUMC. This study aimed to fill this knowledge gap. Twenty-five Ontario residents who had a loved one with mental illness participated. A persona-scenario exercise was designed to explore participants' views on MAiD MI-SUMC in hypothetical situations. Reflexive thematic analysis was used to analyze the data. A lived experience-advisory panel was engaged throughout the study. Seven themes were developed: Witnessing suffering; A road with barriers and limitations; Societal barriers; The unknowns of mental illness; Individual choices: the life or death that a person wants; MAiD MI-SUMC as an acceptable choice when suffering cannot be relieved with available treatments and supports; and The emotional outcome. Participants constructed their views based on their experience of supporting a loved one with mental illness. MAiD MI-SUMC was perceived as a multifaceted issue, whose acceptability and potential introduction required a concurrent exploration and discussion of the challenges arising due to limitations of the healthcare system, the opportunities and limits to family involvement, and the value of patient autonomy.
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Affiliation(s)
| | - Vicky Stergiopoulos
- Centre for Addiction and Mental Health, Toronto, ON, Canada
- University of Toronto, Toronto, ON, Canada
| | - Vivien Cappe
- Centre for Addiction and Mental Health, Toronto, ON, Canada
| | | | - Donna E. Stewart
- University of Toronto, Toronto, ON, Canada
- University Health Network, Toronto, ON, Canada
| | - Mona Gupta
- Centre Hospitalier de L'Université de Montréal, Montréal, QC, Canada
| | - Alexander I. F. Simpson
- Centre for Addiction and Mental Health, Toronto, ON, Canada
- University of Toronto, Toronto, ON, Canada
| | | | - Tarek K. Rajji
- Centre for Addiction and Mental Health, Toronto, ON, Canada
- University of Toronto, Toronto, ON, Canada
| | - David Castle
- University of Tasmania, Hobart, TAS, Australia
- Statewide Mental Health Service, Hobart, TAS, Australia
| | - Lisa D. Hawke
- Centre for Addiction and Mental Health, Toronto, ON, Canada
- University of Toronto, Toronto, ON, Canada
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Favron-Godbout C, Racine E. Medical assistance in dying for people living with mental disorders: a qualitative thematic review. BMC Med Ethics 2023; 24:86. [PMID: 37875867 PMCID: PMC10594804 DOI: 10.1186/s12910-023-00971-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2023] [Accepted: 10/15/2023] [Indexed: 10/26/2023] Open
Abstract
BACKGROUND Medical assistance in dying (MAiD) sparks debate in several countries, some of which allow or plan to allow MAiD where a mental disorder is the sole underlying medical condition (MAiD-MD). Since MAiD-MD is becoming permissible in a growing number of jurisdictions, there is a need to better understand the moral concerns related to this option. Gaining a better understanding of the moral concerns at stake is a first step towards identifying ways of addressing them so that MAiD-MD can be successfully introduced and implemented, where legislations allow it. METHODS Thus, this article aims (1) to better understand the moral concerns regarding MAiD-MD, and (2) to identify potential solutions to promote stakeholders' well-being. A qualitative thematic review was undertaken, which used systematic keyword-driven search and thematic analysis of content. Seventy-four publications met the inclusion criteria. RESULTS Various moral concerns and proposed solutions were identified and are related to how MAiD-MD is introduced in 5 contexts: (1) Societal context, (2) Healthcare system, (3) Continuum of care, (4) Discussions on the option of MAiD-MD, (5) MAiD-MD practices. We propose this classification of the identified moral concerns because it helps to better understand the various facets of discomfort experienced with MAiD-MD. In so doing, it also directs the various actions to be taken to alleviate these discomforts and promote the well-being of stakeholders. CONCLUSION The assessment of MAiD-MD applications, which is part of the context of MAiD-MD practices, emerges as the most widespread source of concern. Addressing the moral concerns arising in the five contexts identified could help ease concerns regarding the assessment of MAiD-MD.
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Affiliation(s)
- Caroline Favron-Godbout
- Pragmatic Health Ethics Research Unit, Montreal Clinical Research Institute, 110 av. des Pins O, Montreal, QC, H2W 1R7, Canada
| | - Eric Racine
- Pragmatic Health Ethics Research Unit, Montreal Clinical Research Institute, 110 av. des Pins O, Montreal, QC, H2W 1R7, Canada.
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Nicolini ME, Jardas EJ, Zarate CA, Gastmans C, Kim SYH. Irremediability in psychiatric euthanasia: examining the objective standard. Psychol Med 2023; 53:5729-5747. [PMID: 36305567 PMCID: PMC10482705 DOI: 10.1017/s0033291722002951] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Revised: 08/22/2022] [Accepted: 08/31/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND Irremediability is a key requirement for euthanasia and assisted suicide for psychiatric disorders (psychiatric EAS). Countries like the Netherlands and Belgium ask clinicians to assess irremediability in light of the patient's diagnosis and prognosis and 'according to current medical understanding'. Clarifying the relevance of a default objective standard for irremediability when applied to psychiatric EAS is crucial for solid policymaking. Yet so far, a thorough examination of this standard is lacking. METHODS Using treatment-resistant depression (TRD) as a test case, through a scoping review in PubMed, we analyzed the state-of-the-art evidence for whether clinicians can accurately predict individual long-term outcome and single out irremediable cases, by examining the following questions: (1) What is the definition of TRD; (2) What are group-level long-term outcomes of TRD; and (3) Can clinicians make accurate individual outcome predictions in TRD? RESULTS A uniform definition of TRD is lacking, with over 150 existing definitions, mostly focused on psychopharmacological research. Available yet limited studies about long-term outcomes indicate that a majority of patients with long-term TRD show significant improvement over time. Finally, evidence about individual predictions in TRD using precision medicine is growing, but methodological shortcomings and varying predictive accuracies pose important challenges for its implementation in clinical practice. CONCLUSION Our findings support the claim that, as per available evidence, clinicians cannot accurately predict long-term chances of recovery in a particular patient with TRD. This means that the objective standard for irremediability cannot be met, with implications for policy and practice of psychiatric EAS.
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Affiliation(s)
- Marie E Nicolini
- Department of Bioethics, National Institutes of Health, 10 Center Drive, Room 1C118, Bethesda, Maryland 20892, USA
- Center for Biomedical Ethics and Law, KU Leuven, Kapucijnenvoer 35 - Box 7001, 3000 Leuven, Belgium
| | - E J Jardas
- Department of Bioethics, National Institutes of Health, 10 Center Drive, Room 1C118, Bethesda, Maryland 20892, USA
| | - Carlos A Zarate
- Section on the Neurobiology and Treatment of Mood Disorders, Experimental Therapeutics and Pathophysiology Branch, National Institutes of Mental Health, 6001 Executive Boulevard, Room 6200, MSC 9663, Bethesda, MD 20892, USA
| | - Chris Gastmans
- Center for Biomedical Ethics and Law, KU Leuven, Kapucijnenvoer 35 - Box 7001, 3000 Leuven, Belgium
| | - Scott Y H Kim
- Department of Bioethics, National Institutes of Health, 10 Center Drive, Room 1C118, Bethesda, Maryland 20892, USA
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Bastidas-Bilbao H, Stergiopoulos V, van Kesteren MR, Stewart DE, Cappe V, Gupta M, Buchman DZ, Simpson AIF, Castle D, Campbell BH, Hawke LD. Searching for relief from suffering: A patient-oriented qualitative study on medical assistance in dying for mental illness as the sole underlying medical condition. Soc Sci Med 2023; 331:116075. [PMID: 37441977 DOI: 10.1016/j.socscimed.2023.116075] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Revised: 06/28/2023] [Accepted: 07/02/2023] [Indexed: 07/15/2023]
Abstract
Medical assistance in dying (MAiD) was introduced into Canadian legislation in 2016. Mental illness as the sole underlying medical condition (MI-SUMC) is excluded from eligibility; this is expected to change in 2024. Incurability, intolerable suffering, capacity to make healthcare decisions, and suicidality have been publicly debated in connection with mental illness. Few studies have explored the views of persons with mental illness on the introduction and acceptability of MAiD MI-SUMC; this study aimed to fill this gap. Thirty adults, residing in Ontario, Canada, who self-identified as living with mental illness participated. A semi-structured interview including a persona-scenario exercise was designed to discuss participants' views on MAiD MI-SUMC and when it could be acceptable or not. Reflexive thematic analysis was used to inductively analyze data. Codes and themes were developed after extensive familiarization with the dataset. A lived-experience advisory group was engaged throughout the study. We identified six themes: The certainty of suffering; Is there a suffering threshold to be met? The uncertainty of mental illness; My own limits, values, and decisions; MAiD MI-SUMCas acceptable when therapeutic means, and othersupports, have been tried to alleviate long-term suffering; and Between relief and rejection. These themes underline how the participants' lived experience comprised negative impacts caused by long-term mental illness, stigma, and in some cases, socioeconomic factors. The need for therapeutic and non-therapeutic supports was highlighted, along with unresolved tensions about the links between mental illness, capacity, and suicidality. Although not all participants viewed MAiD MI-SUMC as acceptable for mental illness, they autonomously embraced limits, values, and decisions of their own along their search for relief. Identifying individual and contextual elements in each person's experience of illness and suffering is necessary to understand diverse perspectives on MAiD MI-SUMC.
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Affiliation(s)
| | - Vicky Stergiopoulos
- Centre for Addiction and Mental Health, Toronto, Ontario, Canada; Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
| | | | - Donna Eileen Stewart
- Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada; Centre for Mental Health and Toronto General Hospital Research Institute, University Health Network, Toronto, Ontario, Canada
| | - Vivien Cappe
- Centre for Addiction and Mental Health, Toronto, Ontario, Canada
| | - Mona Gupta
- Centre hospitalier de l'Université de Montréal, Département de Psychiatrie, Montréal, Québec, Canada
| | - Daniel Z Buchman
- Education and Professional Practice Office, Centre for Addiction and Mental Health, Toronto, Ontario, Canada; Dalla Lana School of Public Health and University of Toronto Joint Centre for Bioethics, University of Toronto, Toronto, Ontario, Canada
| | - Alexander I F Simpson
- Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada; Forensic Division, Centre for Addiction and Mental Health, Toronto, Ontario, Canada
| | - David Castle
- Centre for Addiction and Mental Health, Toronto, Ontario, Canada; Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
| | | | - Lisa D Hawke
- Centre for Addiction and Mental Health, Toronto, Ontario, Canada; Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada.
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Two Views of Vulnerability in the Evolution of Canada's Medical Assistance in Dying Law. Camb Q Healthc Ethics 2023; 32:105-117. [PMID: 36503576 DOI: 10.1017/s0963180121000943] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Canada is six years into a new era of legalized medical assistance in dying (MAiD). The law continues to evolve, following a pattern in which Canadian courts rule that legal restrictions on eligibility for MAiD are unconstitutional and Parliament responds by gradually expanding eligibility for MAiD. The central tension underlying this dialogue between courts and government has focused on two conceptions of how to best promote and protect the interests of people who are vulnerable by virtue of intolerable and irremediable suffering due to an illness, disease, or disability. Do we, as a society, have a duty to protect vulnerable people from seeking certain medical procedures that are contrary to their interests, as those are perceived by others? Or do we have a duty to uphold their rights to autonomy, including the right to make choices within a range that may be constrained by many factors, some of which may be socially unjust? This is a recurrent problem in bioethics and medical law, which we explore through the lens of how Canadian courts and Parliament have grappled with defining eligibility for MAiD.
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Dholakia SY, Bagheri A, Simpson A. Emotional impact on healthcare providers involved in medical assistance in dying (MAiD): a systematic review and qualitative meta-synthesis. BMJ Open 2022; 12:e058523. [PMID: 35840304 PMCID: PMC9295670 DOI: 10.1136/bmjopen-2021-058523] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Medical assistance in dying (MAiD) traverses challenging and emotionally overwhelming territories: healthcare providers (HCPs) across jurisdictions experience myriad of affective responses secondary to possible tensions between normative and interwoven values, such as sanctity of life, dignity in death and dying and duty to care. OBJECTIVE To determine the emotional impact on HCPs involved in MAiD. METHODS Inclusion restricted to English language qualitative research studies from four databases (OVID Medline, EMBASE, CINAHL and Scopus), from beginning until 30 April 2021, and grey literature up to August 2021 were searched. Key author, citation and reference searches were undertaken. We excluded studies without rigorous qualitative research methodology. Included studies were critically appraised using the Joanna Briggs Institute's critical appraisal tool. Analysis was conducted using thematic meta-synthesis. The cumulative evidence was assessed for confidence using the Confidence in the Evidence from Reviews of Qualitative Research approach. RESULTS The search identified 4522 papers. Data from 35 studies (393 physicians, 169 nurses, 53 social workers, 22 allied healthcare professionals) employing diverse qualitative research methodologies from five countries were coded and analysed. The thematic meta-synthesis showed three descriptive emotional themes: (1) polarised emotions including moral distress (n=153), (2) reflective emotions with MAiD as a 'sense-making process' (n=251), and (3) professional value-driven emotions (n=352). DISCUSSION This research attempts to answer the question, 'what it means at an emotional level', for a MAiD practitioner. Legislation allowing MAiD for terminal illness only influences the emotional impact: MAiD practitioners under this essential criterion experience more polarised emotions, whereas those practising in jurisdictions with greater emphasis on allaying intolerable suffering experience more reflective emotions. MAiD practitioner's professional values and their degree of engagement influence the emotional impact, which may help structure future support networks. English language literature restriction and absence of subgroup analyses limit the generalisability of results.
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Affiliation(s)
| | - Alireza Bagheri
- Research affiliate Center for Healthcare Ethics, Lakehead University, Thunder Bay, Ontario, Canada
| | - Alexander Simpson
- Forensic Psychiatry, Centre for Addiction and Mental Health, Toronto, Ontario, Canada
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Abstract
PURPOSE OF REVIEW Over the last 30 years, medical assistance in dying (MAiD) including euthanasia (EU) and physician-assisted death (or suicide, PAS) has become the center of a large debate, particularly when these practices have involved people with psychiatric illness, including resistant depression, schizophrenia, personality, or other severe psychiatric disorders. We performed a review utilizing several databases, and by including the most relevant studies in full journal articles investigating the problem of MAiD in patients with psychiatric disorders but not in physical terminal conditions (non-terminal, MAiD-NT). RECENT FINDINGS Literature has shown that a small percentage of people with psychiatric disorders died by MAiD-NT in comparison with patients with somatic diseases in terminal clinical conditions (e.g., cancer, AIDS). However, the problem in the field is complex and not solved yet as confirmed by the fact that only a few countries (e.g., the Netherlands, Belgium, Luxemburg) have legalized MAiD-NT for patients with psychiatric disorders, while most have maintained the practices accessible only to people with somatic disease in a terminal phase. Also, how to make objective the criterion of irremediability of a mental disorder; how to balance suicide prevention with assisted suicide; how to avoid the risk of progressively including in requests for MAiD-NT vulnerable segments of the population, such as minors, elderly, or people with dementia, in a productive-oriented society, are some of the critical points to be discussed. The application of MAiD-NT in people with psychiatric disorders should be further explored to prevent end-of-life rights from contradicting the principles of recovery-oriented care.
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van Veen SMP, Ruissen AM, Widdershoven GAM. Irremediable Psychiatric Suffering in the Context of Physician-assisted Death: A Scoping Review of Arguments: La souffrance psychiatrique irrémédiable dans le contexte du suicide assisté : Une revue étendue des arguments. CANADIAN JOURNAL OF PSYCHIATRY. REVUE CANADIENNE DE PSYCHIATRIE 2020; 65:593-603. [PMID: 32427501 PMCID: PMC7457463 DOI: 10.1177/0706743720923072] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
OBJECTIVES Physician-assisted death (PAD), also known as medical assistance in dying, of patients with a psychiatric disorder (PPD) is a global issue of debate. In most jurisdictions that allow PAD, irremediable suffering is a legal requirement, how to apply the concept of irremediability to PPD remains challenging. The aim of this article is to identify the main arguments concerning irremediability in the debate about PAD of PPD and give directions for further moral deliberation and empirical research. METHODS Systematic searches in MEDLINE, Embase, and PsycINFO were combined with 4 additional search strategies. All conceptual-ethical articles, quantitative and qualitative empirical studies, guidelines, case reports, and commentaries that met the inclusion criteria were included, and a qualitative data synthesis was used to identify recurring themes within the literature. The study protocol was preregistered at the Open Science Framework under registration code: thjg8. RESULTS A total of 50 articles met the inclusion criteria. Three main arguments concerning irremediability were found in the debate about PAD of PPD: uncertainty, hope, and treatment refusal. CONCLUSIONS Uncertainty about irremediability is inevitable, so which level of certainty is morally required should be the subject of moral deliberation. Whether PAD induces or resolves hopelessness is an empirical claim that deserves clarification. Treatment refusal in search of PAD raises questions about treatment efficacy in this patient group and about decision-making in the context of the physician-patient relationship. Going forward, more attention should be given to epidemiological research and to specific challenges posed by different psychiatric disorders.
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Affiliation(s)
- Sisco M. P. van Veen
- Department of Medical Humanities, University Medical Centre
Amsterdam, the Netherlands
- Department of Psychiatry, University Medical Centre Utrecht, the
Netherlands
| | - Andrea M. Ruissen
- Department of Medical Humanities, University Medical Centre
Amsterdam, the Netherlands
- Haaglanden MC, the Hague, the Netherlands
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Nicolini ME, Kim SYH, Churchill ME, Gastmans C. Should euthanasia and assisted suicide for psychiatric disorders be permitted? A systematic review of reasons. Psychol Med 2020; 50:1241-1256. [PMID: 32482180 DOI: 10.1017/s0033291720001543] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Euthanasia and assisted suicide (EAS) based on a psychiatric disorder (psychiatric EAS) continue to pose ethical and policy challenges, even in countries where the practice has been allowed for years. We conducted a systematic review of reasons, a specific type of review for bioethical questions designed to inform rational policy-making. Our aims were twofold: (1) to systematically identify all published reasons for and against the practice (2) to identify current gaps in the debate and areas for future research. METHODS Following the PRISMA guidelines, we performed a search across seven electronic databases to include publications focusing on psychiatric EAS and providing ethical reasons. Reasons were grouped into domains by qualitative content analysis. RESULTS We included 42 articles, most of which were written after 2013. Articles in favor and against were evenly distributed. Articles in favor were mostly full-length pieces written by non-clinicians, with articles against mostly reactive, commentary-type pieces written by clinicians. Reasons were categorized into eight domains: (1) mental and physical illness and suffering (2) decisional capacity (3) irremediability (4) goals of medicine and psychiatry (5) consequences for mental health care (6) psychiatric EAS and suicide (7) self-determination and authenticity (8) psychiatric EAS and refusal of life-sustaining treatment. Parity- (or discrimination-) based reasons were dominant across domains, mostly argued for by non-clinicians, while policy reasons were mostly pointed to by clinicians. CONCLUSIONS The ethical debate about psychiatric EAS is relatively young, with prominent reasons of parity. More direct engagement is needed to address ethical and policy considerations.
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Affiliation(s)
- Marie E Nicolini
- Center for Biomedical Ethics and Law, KU Leuven, Kapucijnenvoer 35 - Box 7001 3000 Leuven, Belgium
- Department of Bioethics, National Institutes of Health, 10 Center Drive, Room 1C118, Bethesda, Maryland20892, USA
| | - Scott Y H Kim
- Department of Bioethics, National Institutes of Health, 10 Center Drive, Room 1C118, Bethesda, Maryland20892, USA
| | - Madison E Churchill
- Department of Bioethics, National Institutes of Health, 10 Center Drive, Room 1C118, Bethesda, Maryland20892, USA
| | - Chris Gastmans
- Center for Biomedical Ethics and Law, KU Leuven, Kapucijnenvoer 35 - Box 7001 3000 Leuven, Belgium
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Booker R, Bruce A. Palliative sedation and medical assistance in dying: Distinctly different or simply semantics? Nurs Inq 2019; 27:e12321. [PMID: 31756038 PMCID: PMC9285680 DOI: 10.1111/nin.12321] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2019] [Revised: 07/17/2019] [Accepted: 08/03/2019] [Indexed: 11/29/2022]
Abstract
Medical assistance in dying (MAiD) and palliative sedation (PS) are both legal options in Canada that may be considered by patients experiencing intolerable and unmanageable suffering. A contentious, lively debate has been ongoing in the literature regarding the similarities and differences between MAiD and PS. The aim of this paper is to explore the propositions that MAiD and PS are essentially similar and conversely that MAiD and PS are distinctly different. The relevance of such a debate is apparent for clinicians and patients alike. Understanding the complex and multi‐faceted nuances between PS and MAiD allows patients and caregivers to make more informed decisions pertaining to end‐of‐life care. It is hoped that this paper will also serve to foster further debate and consideration of the issues associated with PS and MAiD with a view to improve patient care and the quality of both living and dying in Canada.
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Affiliation(s)
- Reanne Booker
- Palliative and End-of-Life Care Services, Calgary, AB, Canada.,Tom Baker Cancer Centre, Calgary, AB, Canada
| | - Anne Bruce
- School of Nursing, University of Victoria, Victoria, BC, Canada
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Nicolini ME, Gastmans C, Kim SYH. Parity Arguments for 'Physician Aid-in-Dying' (PAD) for Psychiatric Disorders: Their Structure and Limits. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2019; 19:3-7. [PMID: 31557116 DOI: 10.1080/15265161.2019.1659606] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
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15
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Wang ZH, Zhou GH, Sun LP, Gang J. Challenges in the ethics review process of clinical scientific research projects in China. J Int Med Res 2019; 47:4636-4643. [PMID: 31537141 PMCID: PMC6833390 DOI: 10.1177/0300060519863539] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Purpose Ethics review processes have become increasingly complex. The objective of this study was to explore the challenges currently faced in ethics reviews of clinical scientific research projects in China, with the goal of standardizing the structure of medical ethics committees and better protecting the rights and interests of research participants. Methods We reviewed and comprehensively analyzed the available literature discussing standardized ethics reviews of clinical scientific research projects. Results We identified the following problems: incomplete legislation, absence of supervision, vague review criteria, limitations of ethics committee competence, inadequate ethics consciousness, and poor tracking of reviews. In this paper, we suggest strategies for the development of future ethical reviews of clinical scientific research projects. Conclusion To standardize the ethics review process of clinical scientific research projects in China, it is necessary to establish relevant laws and regulations and implement supervisory responsibilities. Professional training of medical ethics committees is suggested as an effective way to improve the quality of ethics reviews.
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Affiliation(s)
- Zhu-Heng Wang
- Department of Critical Care Medicine, Daxing Teaching Hospital, Capital Medical University, Beijing, China
| | - Guan-Hua Zhou
- Department of Critical Care Medicine, Daxing Teaching Hospital, Capital Medical University, Beijing, China
| | - Li-Ping Sun
- Department of Critical Care Medicine, Daxing Teaching Hospital, Capital Medical University, Beijing, China
| | - Jun Gang
- Department of Critical Care Medicine, Daxing Teaching Hospital, Capital Medical University, Beijing, China
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16
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Simpson AIF. Response to Comment Regarding: Medical Assistance in Dying and Mental Health: A Legal, Ethical, and Clinical Analysis. CANADIAN JOURNAL OF PSYCHIATRY. REVUE CANADIENNE DE PSYCHIATRIE 2018; 63:572. [PMID: 30097001 PMCID: PMC6099751 DOI: 10.1177/0706743718775945] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Alexander I F Simpson
- Complex Care and Recovery Program, Forensic Division, Centre for Addiction and Mental Health Head, Division of Forensic Psychiatry, University of Toronto, Toronto, Ontario
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17
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Dembo J, Schuklenk U, Reggler J. "For Their Own Good": A Response to Popular Arguments Against Permitting Medical Assistance in Dying (MAID) where Mental Illness Is the Sole Underlying Condition. CANADIAN JOURNAL OF PSYCHIATRY. REVUE CANADIENNE DE PSYCHIATRIE 2018; 63:451-456. [PMID: 29635929 PMCID: PMC6099778 DOI: 10.1177/0706743718766055] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Canada is approaching its federal government's review of whether patients should be eligible for medical assistance in dying (MAID) where mental illness is the sole underlying medical condition, and when "natural death" is not "reasonably foreseeable". For those opposed, arguments involve the following themes: capacity, value of life, vulnerability, stigma, irremediability, and the role of physicians. It has also been suggested that those who are able-bodied should have to kill themselves, even though suicide may be painful, lonely, and violent. Opponents of MAID for severe, refractory suffering due to mental illness imply that it is acceptable to remove agency from such patients on paternalistic grounds. After years of efforts to destigmatise mental illness, these kinds of arguments effectively declare all patients with mental illness, regardless of capacity, unable to make considered choices for themselves. The current paper argues that decisions about capacity must be made on an individual-patient basis. Given the rightful importance granted to respect for patient autonomy in liberal democracies, the wholesale removal of agency advocated by opponents of a permissive MAID regime is difficult to reconcile with Canadian constitutional values.
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Affiliation(s)
- Justine Dembo
- 1 University of Toronto, Toronto, ON, Canada.,2 Thompson Anxiety Disorders Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Udo Schuklenk
- 3 Department of Philosophy, Watson Hall 309, Queen's University, Kingston, ON, Canada
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18
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Jones RM, Simpson AIF. Medical Assistance in Dying: Challenges for Psychiatry. Front Psychiatry 2018; 9:678. [PMID: 30618860 PMCID: PMC6295549 DOI: 10.3389/fpsyt.2018.00678] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2018] [Accepted: 11/23/2018] [Indexed: 11/13/2022] Open
Affiliation(s)
- Roland M Jones
- Complex Care and Recovery Program, Forensic Division, Division of Forensic Psychiatry, Centre for Addiction and Mental Health, University of Toronto, Toronto, ON, Canada
| | - Alexander I F Simpson
- Complex Care and Recovery Program, Forensic Division, Division of Forensic Psychiatry, Centre for Addiction and Mental Health, University of Toronto, Toronto, ON, Canada
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