Attitudes of people with disabilities toward physician-assisted suicide legislation: broadening the dialogue

Physician assisted suicide in dementia: A critical review of global evidence and considerations from India

BACKGROUND

Dementias are a group of gradually progressing neurodegenerative conditions, leading to significant impairment in cognition, functioning, decision-making, capacity and autonomy. With the rise of human rights and patient-centred perspectives in psychogeriatric management, physician-assisted suicide (PAS) has emerged as an important and integral part of end-of-life care in advanced dementias.

METHODS

With only few original studies in the area, this paper takes a narrative and critical approach to review the global legislations, treatment decisions, debates as well as perspectives from patients, families and medical professionals.

RESULTS

PAS and euthanasia are legally allowed in countries like Belgium, Netherlands, Switzerland and few states of the United States (U.S.). Germany has fewer clearer legislations in this regard. The Oregon state requirement and care criteria of the Dutch euthanasia act form the basis of most such laws. Even in the presence of these provisions, PAS is fraught with multiple medical, ethical, moral and legal dilemmas and physicians as well as caregivers are quite heterogenous in their outlook. While right to live with dignity and need to end incurable suffering form the main arguments for PAS, several arguments against it are possibility of undue influence, impaired judgement leading to biased decision-making such as depression and suicidality, inappropriate assessment of capacity, and that all deaths are not necessarily painful. These dilemmas are critically discussed in light of autonomy, decision-making and advanced directives in people living with dementia as well as the rationality of ending life and 'right to live vs right to die'. Based on the findings, certain balanced strategies are highlighted for the health professionals.

CONCLUSION

The 'slippery slope' of PAS needs to be carefully evaluated from a social justice and human rights perspective to improve dignified end-of-life care in dementia. Considerations are also discussed from India, a rapidly-ageing nation with no current provisions for PAS.

Perceptions and Experiences of Medical Assistance in Dying Among Illicit Substance Users and People Living in Poverty

Since medical assistance in dying (MAiD) became legal in Canada in 2016, there have been concerns about vulnerable people feeling pressured to end their lives. It is important to understand what people in marginalized communities know and feel about MAiD in order to help prevent any pressure to hasten death and to prevent any barriers to accessing assisted death. This qualitative study explored the perceptions and experiences of MAiD and other end-of-life care options with 46 people who were illicit substance users, living in poverty, or who worked with marginalized people in these communities. Six broad themes were identified: the importance of family, friends, and community; the effects of the opioid crisis; barriers to accessing end-of-life care services; support for MAiD; the difference between suicide and MAiD; and what constitutes a good death. Findings from this research may be used to help inform future legislation, professional guidelines, and standards of best practice.

Euthanasia and assisted suicide for people with an intellectual disability and/or autism spectrum disorder: an examination of nine relevant euthanasia cases in the Netherlands (2012-2016)

BACKGROUND

Euthanasia and assisted suicide (EAS) have been legally possible in the Netherlands since 2001, provided that statutory due care criteria are met, including: (a) voluntary and well-considered request; (b) unbearable suffering without prospect of improvement; (c) informing the patient; (d) lack of a reasonable alternative; (e) independent second physician's opinion. 'Unbearable suffering' must have a medical basis, either somatic or psychiatric, but there is no requirement of limited life expectancy. All EAS cases must be reported and are scrutinised by regional review committees (RTE). The purpose of this study was to investigate whether any particular difficulties arise when the EAS due care criteria are applied to patients with an intellectual disability and/or autism spectrum disorder.

METHODS

The 416 case summaries available on the RTE website (2012-2016) were searched for intellectual disability (6) and autism spectrum disorder (3). Direct content analysis was used on these nine cases.

RESULTS

Assessment of decisional capacity was mentioned in eight cases, but few details given; in two cases, there had been uncertainty or disagreement about capacity. Two patients had progressive somatic conditions. For most, suffering was due to an inability to cope with changing circumstances or increasing dependency; in several cases, suffering was described in terms of characteristics of living with an autism spectrum disorder, rather than an acquired medical condition. Some physicians struggled to understand the patient's perspective. Treatment refusal was a common theme, leading physicians to conclude that EAS was the only remaining option. There was a lack of detail on social circumstances and how patients were informed about their prognosis.

CONCLUSIONS

Autonomy and decisional capacity are highly complex for patients with intellectual disabilities and difficult to assess; capacity tests in these cases did not appear sufficiently stringent. Assessment of suffering is particularly difficult for patients who have experienced life-long disability. The sometimes brief time frames and limited number of physician-patient meetings may not be sufficient to make a decision as serious as EAS. The Dutch EAS due care criteria are not easily applied to people with intellectual disabilities and/or autism spectrum disorder, and do not appear to act as adequate safeguards.

Is suicide an option?: The impact of disability on suicide acceptability in the context of depression, suicidality, and demographic factors

BACKGROUND

Suicide is a major clinical and public health issue, especially in people with disabilities. However, research on the acceptability of suicide in people with disabilities has not directly compared the relative acceptability of suicidality in people with and without disabilities.

METHOD

An online sample of five hundred American adults read five pairs of vignettes about individuals who were experiencing suicidal ideation following a life stressor. Each pair contained a disability and no-disability condition; a sixth pair of vignettes discussed suicidal ideation in an elderly individual and contained physical and cognitive disability conditions. Participants completed questions regarding the relative acceptability of suicidality for each vignette as well as demographic items and measures of suicidality, depressive symptoms, and attitude towards disability.

RESULTS

In all vignette five pairs, suicidality was seen as significantly more acceptable in the disability condition; this was true even when the participants themselves had disabilities or friends or family members with disabilities. Suicidality, depressive symptomology, and more negative attitudes towards disability predicted greater acceptability in both conditions; no factors predicted greater differences between the two conditions.

LIMITATIONS

The vignettes in this study focused primarily on individuals in their 20s and most did not compare two disabling conditions.

CONCLUSIONS

The greater social acceptability of suicidality in people with disabilities may be taken by individuals with disabilities who are suicidal as implicit permission to end their lives. The potential impact of such social influences should be assessed and addressed by clinicians and suicide prevention advocates.

Successful strategies to engage research partners for translating evidence into action in community health: a critical review

Objectives. To undertake a critical review describing key strategies supporting development of participatory research (PR) teams to engage partners for creation and translation of action-oriented knowledge. Methods. Sources are four leading PR practitioners identified via bibliometric analysis. Authors' publications were identified in January 1995–October 2009 in PubMed, Embase, ISI Web of Science and CAB databases, and books. Works were limited to those with a process description describing a research project and practitioners were first, second, third, or last author. Results. Adapting and applying the “Reliability Tested Guidelines for Assessing Participatory Research Projects” to retained records identified five key strategies: developing advisory committees of researchers and intended research users; developing research agreements; using formal and informal group facilitation techniques; hiring co-researchers/partners from community; and ensuring frequent communication. Other less frequently mentioned strategies were also identified. Conclusion. This review is the first time these guidelines were used to identify key strategies supporting PR projects. They proved effective at identifying and evaluating engagement strategies as reported by completed research projects. Adapting these guidelines identified gaps where the tool was unable to assess fundamental PR elements of power dynamics, equity of resources, and member turnover. Our resulting template serves as a new tool to measure partnerships.

Why do older people oppose physician-assisted dying? A qualitative study

BACKGROUND

Physician-assisted dying at the end of life has become a significant issue of public discussion. While legally available in a number of countries and jurisdictions, it remains controversial and illegal in New Zealand.

AIM

The study aimed to explore the reasons some healthy older New Zealanders oppose physician-assisted dying in order to inform current debate.

DESIGN

Recorded interviews were transcribed and analysed by the authors after some edits had been made by respondents.

SETTING/PARTICIPANTS

In all, 11 older participants (over 65 years) who responded to advertisements placed in Grey Power magazines and a University of Auckland email list were interviewed for around 1 h and asked a number of open-ended questions.

RESULTS

Four central themes opposing physician-assisted dying were identified from the interviews: one's personal experience with health care and dying and death, religious reasoning and beliefs, slippery slope worries and concern about potential abuses if physician-assisted dying were legalised.

CONCLUSIONS

An important finding of the study suggests that how some older individuals think about physician-assisted dying is strongly influenced by their past experiences of dying and death. While some participants had witnessed good, well-managed dying and death experiences which confirmed for them the view that physician-assisted dying was unnecessary, those who had witnessed poor dying and death experiences opposed physician-assisted dying on the grounds that such practices could come to be abused by others.

Advance directives, control, and quality of life for persons with disabilities

BACKGROUND

Personal control over end-of-life (EOL) care via advance care planning is a key component of high-quality care. Although this desire for control has been well documented in some populations, EOL care issues are not well understood within the disabilities community.

OBJECTIVE

The objective for this study was to describe the relationships between individual demographic characteristics, health-related quality of life, health locus of control, and attitudes toward advance directives (ADs) in individuals who are disabilities activists.

METHODS

We surveyed 55 participants attending a disability conference. Instruments included a demographic data sheet, the Advance Directive Attitude Survey (ADAS), the Multidimensional Health Locus of Control scale, and the Functional Assessment of Non-Life Threatening Conditions quality of life (QOL) scale.

RESULTS

Most participants were Hispanic females with some college education. About 46% had a disability. Group means revealed a high level of QOL (M=75.72, SD=19.09) and a positive attitude about ADs (M=66.49, SD=8.03). On the Opportunities for Treatment Choices subscale of the ADAS, activists without disabilities (M=14.23) were more positive about their control over EOL decisions than were the activists with disabilities (M=12.97) [t(2,52)=2.116, p<0.05].

CONCLUSIONS

Although participants were positive about ADs, differences in attitudes about control over opportunities for treatment choices between the nondisabled and disabled groups support previous findings that people with disabilities may have concerns regarding undertreatment for serious health conditions. Further study of EOL care issues for persons with disabilities is warranted.

What makes or breaks provider-researcher collaborations in HIV research? A mixed method analysis of providers' willingness to partner

Research is lacking about what makes or breaks collaboration between researchers and HIV services providers. This study identified factors that influence providers' levels of willingness to collaborate in HIV prevention scientific research. Survey measures were grounded in in-depth interview data and included providers' "willingness to collaborate," and providers' attitudes toward researchers' availability, benefits of research, and agency preparedness. This survey was administered to 141 providers in New York City. A hierarchical regression model showed that providers' perceptions of researchers' availability (p < .05), research benefits (p < .001), and agency preparedness (p < .05) were associated with providers' willingness to engage with researchers to purse HIV prevention research. Findings indicate that researchers need to be socially and professionally available, future HIV research should benefit providers and consumers, and policy makers should help agency settings develop human and financial resources in preparation for research.

Why do we want the right to die? A systematic review of the international literature on the views of patients, carers and the public on assisted dying

BACKGROUND

Assisted dying is legal in four European countries and three American states. Elsewhere, particularly in more affluent or mainly Protestant countries, it remains controversial. Dominant headlines feature professional (medical, legal, religious) arguments versus celebrity campaigners; ordinary people are less clearly represented.

AIM

To synthesise the international evidence of people's views and attitudes towards assisted dying in order to inform current debate about this controversial issue.

DESIGN

Systematic review and mixed method synthesis of qualitative and survey data.

DATA SOURCES

Eleven electronic databases from inception to October 2011; bibliographies of included studies.

REVIEW METHODS

Two reviewers independently screened papers and appraised quality. Qualitative results were extracted verbatim; survey results were summarised in a table. Qualitative data were synthesised using framework methods and survey results integrated where they supported, contrasted or added to the themes identified.

RESULTS

Sixteen qualitative studies and 94 surveys were included; many participants considered the immediate relevance of assisted dying for them. Themes related to poor quality of life, a good quality of death, potential abuse of assisted dying and the importance of individual stance. People valued autonomy in death as much as in life. Attitudes were diverse, complex and related to definitions of unbearable suffering including physical, psycho-social and existential factors and were consistent regardless of social, economic, legal and health-care contexts.

CONCLUSION

Our review sheds light on ordinary people's perspectives about assisted dying, when they are ill or disabled. Unbearable suffering is a key construct, and common factors are revealed that lead people to ask for help to die. The consistency of international views indicates a mandate for legislative and medical systems worldwide to listen and understand this.

Death with "dignity": the wedge that divides the disability rights movement from the right to die movement

Much of the American debate over physician assisted death (PAD) is framed as an ideological split between conservatives and liberals, pro life and pro choice advocates, and those who emphasize morality versus personal autonomy. Less examined, but no less relevant, is a split within the ranks of progressives--one that divides those supporting a right to die in the name of human rights from disability rights activists who invoke human rights to vehemently oppose euthanasia. This paper reviews how "dignity" serves both as a divisive wedge in this debate but also as a value that can span the divide between groups and open the way to productive discourse. Supporters of legalized euthanasia use "dignity" to express their position that some deaths might indeed be accelerated. At the same time, opponents adopt the concept to argue that physician assisted suicide stigmatizes life with a disability. To bridge this divide, the worldviews of two groups, Compassion & Choices and Not Dead Yet, are studied. The analysis concludes that the two organizations are more parallel than contrary--a finding that offers opportunities for dialogue and perhaps even advances in public policy.