Depression and physician assisted dying
BMJ 2008; 337 doi: https://doi.org/10.1136/bmj.a1558 (Published 08 October 2008) Cite this as: BMJ 2008;337:a1558All rapid responses
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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
Competing interests: No competing interests
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
Competing interests: No competing interests
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
Competing interests: No competing interests
Depression and unnatural death
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
Competing interests: No competing interests