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Because mental state is invariably at issue when someone chooses to die, psychiatry will become increasingly involved in the debate, said West. "This controversy is destined to continue and expand, and psychiatrists will be drawn into it," he commented.
It is not just pain and suffering, but an end to total helplessness and dependence that motivates many requests for assisted suicide, said West. Many such requests would never occur if more attention was paid to the physical and psychological comfort of the terminally ill, he contended. Hospice care and the use of better methods of pain control such as self-administered analgesia may ease suffering and enhance the sense of control.
As a clinician, said West, he has seen again and again the power of the will to live in the mentally healthy, despite their facing a terminal illness.
A physician who works with the terminally ill may gain the wisdom "to face one's own end with nobility of spirit when it comes, as it must, to us all," he added. There is an old saying, recalled West, that applies well today. "It is the physician's privilege to cure sometimes, to relieve often, to comfort always."
Refusal of medical care is a right "based on the belief in self-determination and bodily integrity," observed West. Given this right, the patient needs to be fully informed and may benefit from a psychiatric consultation to ensure that the decision is lucid and rational. In every case where a patient's competency has been established, that right has been upheld, West said.
In practice, even when a patient's wish not to receive extraordinary care is known, it is often ignored, said West. There are several legal precautions that family members may take to ensure that a patient's wishes are followed, but they are hardly foolproof, West explained. Drawing up a durable power of attorney is one method. Unlike an ordinary power of attorney, a durable power of attorney does not cease when the patient becomes incompetent.
Living wills are often helpful but are not always effective, said West. He joked that for a living will to be truly effective, the person drawing it up should be aware of all the nuances of state law and "make sure [he] is in that state when [he] becomes incompetent." He should also carry his durable power of attorney with him at all times, he added. Of course, the former is impossible and the latter is unlikely, West noted.
The issues surrounding euthanasia and assisted suicide are more complex than those surrounding refusal of care or withdrawal of life support. Euthanasia means literally "an easy or good death" or commonly "a merciful death caused by an intervention" rather than merely through withholding of a medical procedure, explained West.
Using analgesics to alleviate pain with the knowledge that they may hasten death occurs frequently but is generally viewed as an acceptable practice provided the main goal is analgesia, not euthanasia, West commented.
In Holland, the Dutch came to terms with euthanasia 25 years ago. After a case in 1972 brought the issue to a head, the Dutch courts set guidelines for euthanasia without officially legalizing the practice. Since then, doctors adhering to these strict guidelines have not been prosecuted for performing euthanasia.
In a later decision, the Dutch courts held that a patient's wish to die was justifiable only if the patient was not depressed, said West. The issue of whether a psychiatric patient who has repeatedly failed to respond to treatment for depression should be viewed as rational in wishing to die remains unresolved.
The Dutch medical system makes it likely that the physician most involved with a patient's decision to seek help in dying has sustained a long relationship with that patient and so knows the patient well, observed West. But in the U.S., such long-term doctor-patient relationships have become increasingly uncommon under managed care.
The statistics on who chooses to die have raised concern about the devaluing of the elderly. Those 65 and over are twice as likely to take their own lives as are younger people, and nursing home residents have a suicide rate eight times higher than that of the general population, said West.
APA has joined the AMA in opposing the establishment of a federal right to assistance from a physician in dying, but it is not clear exactly where the majority of APA members stand on the issue, West noted. Substantial groups of dissenters, including some prominent members of the Association, have expressed support for assisted suicide. APA should poll the membership before taking any further stance on this issue, West urged.
Recent surveys indicate that a majority of Americans (more than 60 percent) believe there should be a right to get assistance in dying from a physician, said West.
(Psychiatric News, July 4, 1997)