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Rapid Responses: Rapid Responses published:
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Euthanasia and Medical Establishment
- Kazem Zarrabi (24 October 2008)
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Requests for assisted dying ;psychiatric assessment should not be mandatory
- Simon Kenwright (26 October 2008)
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Life, death and depression
- Piotr Szawarski (26 October 2008)
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Depression and unnatural death
- Eugene G Breen (29 October 2008)
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Kazem Zarrabi, Researcher Biomedical and Cultural Study and Research Center (BMCSRC), 2200 Copenhagen N., Denmark.
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Discussions on Euthanasia have been negatively affecting the public attitudes towards the medical establishment and harming the physician- patient relationship. It is true that the concepts of disease and its cure or treatment are culturally perceived. But in fact its meanings, actual mechanisms, and treatments are constantly shifting with the advances made in science and technology. The essential philosophical merits of biomedical establishment and its ethics are based on biophilia i.e. love of life (Wilson 1984). Darwinian evolutionary concept of survival is comprised of two main complementary components of individual and reproductive survival in a way that one without the other is incomplete. Darwinian evolution, after its successful attempt in binding natural sciences together, is now gradually being accommodated with cultural disciplines. The concept of culture essentially as an “extended” biology has its roots in the fact that culture is ultimately an evolutionary product of the brain to enhance survival (Wilson 1980, Dawkins 1989). In Darwinian sense, individual and reproductive survivals of organisms are the interlocked and complementary events. Individuals not only should survive to the reproductive age but in fact in order to protect their children and grandchildren they should survive to an older age. This is why natural selection, through its other components known as sexual and kin selections, has enabled us to enjoy the companionship of our grandparents. The behaviour of our species of "Homo sapiens" is constrained by both our biology and culture. In other words, we are a “biocultural” species. And our language-based culture, as an extension of our biology, is a powerful and useful tool created by our brains in order to enhance our survival in a hostile and changing environment. Both our biology and culture change within a coevolutionary relationship wherein culture is ultimately constrained by biology (Lumsden and Wilson 1983). In other words, the key biophilic words of health and survival are synonymous for the continuity of human civilization on this planet with the assumption that we change our wasteful life styles to ensure that there will a planet left after all. We can improve our biology by means of our cultural undertakings to provide the networks of health systems that can improve our physical and mental health. This actually means to have access to an advanced and constantly improving biomedical establishment. Such an establishment is an interacting social (biocultural) complex comprised of biomedical and science schools with high standards of training, well-equipped hospitals and labs, biomedical technology, pharmaceuticals, committees of biomedical ethics, essential funding, and the managerial aspects of organization. Therefore, in order to offer a better health care system for all, these mentioned units should mutually interact and constantly improve their functions. However, we should be reminded that medical establishment is part of an overall social system. This means that socio-economic policy formulations especially in terms of setting the priorities will directly and indirectly affect the medical establishment. In any given country biomedical establishment has one main survival strategy of keeping the public "healthy." Disregarding the cultural variations in defining the concepts of disease in human populations, being healthy in a sense of not being severely ill with a crippling psycho- somatic disorder is synonymous with being able to conduct individual daily routines while enjoying a reasonable quality of life. This is why, in societal organization of human populations, biomedical establishment righteously occupies a very special place of importance with clinical staff enjoying morally privileged status. In public's-eye view, and especially for those who get sick and are called “patients,” a medical doctor or a nurse is synonymous with delaying death and reducing pain and suffering especially if no cure is available. This is the central logic against physician or nurse assisted death, suicide or euthanasia in the so-called terminally ill patients. The clinical definitions for being terminally ill and/or suffering from a severe pain are not universally agreed. Furthermore, what is defined as a terminally ill patient today may not be so with the advances of tomorrow. Nevertheless, in very special cases, termination of a patient's life with an incurable and very painful disease, i.e. on his/her or family request, should be decided by the courts of law, and not by the physicians or nurses. Indeed, scientists such as human biologists, pharmacologists, geneticists, microbiologists, biophysicists, and chemists may possess much wider and deeper knowledge of natural world and human conditions. If so, then what makes physicians, nurses, and other health professionals rather unique by putting them at the centre of our attention? These are the special and systematic life-saving knowledge, procedural performance, practical training, devotion to patients, and the oath taken to save human lives, which makes medical staff so unique. In other words, health professionals and especially physicians and nurses have the vital biological knowledge and training to save life and delay death. We can call this a “survival programme,” which is likened to a computer programme. According to Henry Plotkin (1994) biological knowledge is adaptation to survive and vice versa. Plotkin implies that in order to survive, all organisms somehow to a varying degree have the ability to extract the essential biological knowledge from their environments in order to adapt and survive accordingly. Therefore, biological knowledge is essentially related to the survival programme. It is a kind of knowledge that can negate or delay death for the organisms. Thus, physicians, nurses, and other health professionals are specially trained people with the survival programmes in their brains so that they can keep the rest of us alive. In other words, using the proposed computer programme metaphor, euthanasia would behave like a computer virus leading to deletion or crippling of the survival programme i.e. the same programme, which has made the medical professionals so unique among us. Those who advocate euthanasia do not intend to delete some aspects of this survival programme. They want to change the whole programme so that physicians are authorized to kill as well as to save lives. This is the inherent contradiction with euthanasia. Dr. Kazem Zarrabi, Biomedical and Cultural Study and Research Centre (BMCSRC), Copenhagen, Denmark. References: Dawkins R. The Selfish Gene. Oxford: New York: Oxford University Press, 1989. Lumsden CJ and EO Wilson. Promethean Fire: Reflections on the Origin of Mind. Cambridge, MA: London: Harvard University Press, 1983. Plotkin H. The Nature of Knowledge. Allen Lane: The Penguin Press, 1994. Wilson EO. Biophilia. Cambridge, MA: London: Harvard University Press, 1984. Wilson EO. Sociobiology. Cambridge, MA: London: The Belknap Press of Harvard University Press, 1980. Competing interests: None declared |
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Simon Kenwright, physician (retd 2007) Ashford Kent TN25 6BD
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At the time of the Joffe Bill debate , opponents of law change made much of the need to exclude depression in those terminally ill patients who requested assisted dying. It was as though it was this request which triggers concern about depression , rather than that this should be considered a possibility during earlier care by the palliative care teams concerned. (In Oregon the position is different , as interest in assisted dying would often seem to precede hospice referral). Mandatory psychiatric opinion at this late stage seems inappropriate – it might be much more appropriate for those refusing potentially life prolonging treatments at an earlier stage of illness. Apart from the limited value of a one-off psychiatric opinion - and the often limited time available for a trial of treatment other than ECT at this late stage - in the UK there might well be problems of access for an appropriate psychiatric opinion in the short time available. The numbers of terminally patients who wish to explore the option of assisted dying seems to greatly exceed the numbers choosing it. A mandatory psychiatric opinion could also have a negative effect on some patients , even being seen primarily as a delaying tactic and there is a risk of over diagnosis in this group of patients.We need better evidence that this assessment influences outcome. Less than one-third of the invited patients in the Oregon study reported this week agreed to take part and those declining could have been the more (or less) depressed group. In time , Society might demand that all these patients have a formal psychiatric assessment , but this is a separate issue from the clinical indications. Competing interests: Member of Dignity in Dying |
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Piotr Szawarski, SpR Anaesthetics King's College Hospital, SE5 9RS, UK
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Prospect of death is hardly cheerful and terminally ill patients are likely to be depressed. Depression is also prevalent among chronically ill. While treatment and diagnosis of depression is certainly an important issue I can’t help but notice another problem raised in the editorial by Marije L van der Lee (1). Does depression impair judgement and if so to what degree? How to determine patient’s “level of competency” when discussing life saving treatments? Patients with severe respiratory or neurological disease, who are not terminal, may well refuse life saving intensive care during acute illness or exacerbation of their primary condition. They may appear to be competent and able to assert their autonomy and the physician will not force the treatment upon them. This may of course lead to their death. Should we therefore question their competency if they are on antidepressants or have symptoms suggestive of a major depressive disorder? The time frame in the acute setting may not be sufficient for a formal psychiatric assessment. 1. van der Lee Marije L Depression and physician assisted dying BMJ 2008;337:a1558 Competing interests: None declared |
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Eugene G Breen, Consultant Psychiatrist 62/63 Eccles St Dublin 7 Ireland
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The article by van der Lee brings up some important features. Suicide is a worst case scenario event in depression. The person is probably seriously impaired, from a cognitive and capacity point of view, and with appropriate treatment would not make the same decision. Some evidence for this comes from recovered parasuicides, who go on to live changed lives. This prevalence of suicide in depression, is escalated in people with chronic physical illnesses by the fact that these patients have a higher prevalence of depression. Getting someone else to cooperate in euthanasia or assisted suicide is spreading the problem...one now has two people involved in the demise and one glamourises or sanitises the act of suicide. This is not a salutary message to send out to anyone, not to mind terminally or chronically ill people and their carers. People do make free decisions, but that does not equate with correct or good decisions, and the public perception of self harm should be well informed and health promoting, and not ambivalent or conducive to person damaging attitudes and behaviour. Competing interests: None declared |
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