However, a legitimate state interest in preventing irrational suicides is often up for debate.
Pilpel and Amsel wrote:. Contemporary proponents of "rational suicide" or the "right to die" usually demand by "rationality" that the decision to kill oneself be both the autonomous choice of the agent i. Hinduism accepts the right to die for those who are tormented by terminal diseases or those who have no desire, no ambition or no responsibilities remaining. Death, however, is allowed by non-violent means such as fasting to the point of starvation Prayopavesa.
Other religious views on suicide vary in their tolerance and include denial of the right as well as condemnation of the act. In the Catholic faith , suicide is considered a grave sin. The preservation and value of life have led to many medical advancements when it comes to treating patients. New devices and the development of palliative care has allowed humans to live longer than before. Prior to these medical advancements and care, those who were unconscious, minimally unconscious, and in a vegetative state life span was short due to no proper way to assist them with basic needs such as breathing and feeding.
With the advancement of medical technology, it raises the question about the quality of life of a patient when they are no longer conscious. The right to self-determination and of others emerged and questions the definition of quality and sanctity of life; if one had the right to live, then the right to die must follow suit. If it is argued, the right to life is inalienable , it cannot be surrendered, and therefore may be incompatible with a right to die. It is also stated that 'right to live' is not synonymous to 'obligation to live. A court in the American state of Montana for example, has found that the right to die applies to those with life-threatening medical conditions.
Suicide advocate Ludwig Minelli , euthanasia expert Sean W. Asher, and bioethics professor Jacob M.
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Appel, in contrast, argue that all competent people have a right to end their own lives. Appel has suggested that the right to die is a test for the overall freedom of a given society. The treatment refused in an advance directive under US law, because of the PSDA, does not have to be proved to be "medically futile" under some existing due-process procedure developed under state laws, such as TADA in Texas.
As of June , some forms of voluntary euthanasia are legal in Australia , Canada ,  Colombia ,  Belgium ,  Luxembourg ,  the Netherlands ,  and Switzerland. As euthanasia is a health issue, under the Australian constitution this falls to state governments to legislate and manage. Euthanasia was legal within the Northern Territory during parts of - as a result of the territory parliament passing Rights of the Terminally Ill Act As a territory and not a state, the federal government under Prime Minister John Howard amended the Northern Territory Self-Government Act amongst others to ensure that territories of Australia are no longer able to legislate on euthanasia.
The federal government is not able to legislate restrictions on health issues for the six Australian states in the same manner. In , Belgium parliament legalized euthanasia. As of August a British Columbia Supreme Court judge had been requested to speed up a right-to die lawsuit so that Gloria Taylor could have a doctor assist her in committing suicide. She suffered from Lou Gehrig's disease. A British Columbia civil liberties lawsuit is representing six plaintiffs and challenges the laws that make it a criminal offence to assist seriously and incurably ill individuals to die with dignity.
On 6 February the Supreme Court of Canada ruled that denying the right to assisted suicide is unconstitutional. The court's ruling limits physician-assisted suicides to "a competent adult person who clearly consents to the termination of life and has a grievous and irremediable medical condition, including an illness, disease or disability, that causes enduring suffering that is intolerable to the individual in the circumstances of his or her condition.
The court decision includes a requirement that there must be stringent limits that are "scrupulously monitored. The Canadian Medical Association CMA reported that not all doctors were willing assist in patient's death due to legal complications and went against what a physician stood for. Many physicians stated that they should have a voice when it comes to helping a patient end their life. On 17 June , legislation passed both houses of the Parliament of Canada and received Royal Assent to allow euthanasia within Canada. On 20 May , the Constitutional Court of Colombia decriminalised piety homicide, for terminally ill patients, stating that "the medical author cannot be held responsible for the assisted suicide of a terminally ill patient" and urged Congress to regulate euthanasia "in the shortest time possible".
On 15 December , the Constitutional Court had given the Ministry of Health and Social Protection 30 days to publish guidelines for the healthcare sector to use in order to guarantee terminally ill patients, with the wish to undergo euthanasia, their right to a dignified death. Since , the Supreme Court of India has legalized passive euthanasia in India during a case involving Aruna Shanbaug under strict conditions, namely that the patient's consent or relatives is needed, and that the patient must be terminally ill or vegetative state.
The Netherlands legalized voluntary euthanasia in Under current Dutch law, euthanasia and assisted suicide can only be performed by doctors, and that is only legal in cases of "hopeless and unbearable" suffering. In practice this means that it is limited to those suffering from serious and incurable medical conditions including mental illness and in considerable suffering like pain, hypoxia or exhaustion. Helping somebody to commit suicide without meeting the qualifications of the current Dutch euthanasia law is illegal.
In February , citizens' initiative called Uit Vrije Wil Out of Free Will further demanded that all Dutch people over 70 who feel tired of life should have the right to professional help in ending it. The organization, initiated by Milly van Stiphout and Yvonne van Baarle, started collecting signatures in support of this proposed change in Dutch legislation. A number of prominent Dutch citizens supported the initiative, including former ministers and artists, legal scholars and physicians.
Euthanasia is illegal in New Zealand. In , lawyer and cancer sufferer Lecretia Seales brought a case Seales v Attorney-General to the High Court to challenge New Zealand law for her right to die with the assistance of her GP, asking for a declaration that her GP would not risk conviction. The term right to die has been interpreted in many ways, including issues of suicide, passive euthanasia, active euthanasia, assisted suicide, and physician-assisted suicide.
The right to die movement in the US began with the case of Karen Quinlan in and continues to raise bioethical questions of one's quality of life and the legal process of death. Karen Quinlan, 21, lost consciousness after consuming alcohol and tranquilizers at a party.
This led her to slip into a comatose state in which a respirator and a feeding tube were used to keep her alive and breathing. Karen Quinlan's parents understood that their daughter would never wake up and that prolonging her life may be more damaging and it would not be of quality life. The court, however, argued that the removal of the ventilator, which would lead to Karen's death, would be considered unlawful, unnatural, and unethical. Quinlan's lawyer's counterargument stated that the removal of the respirator would allow Karen to have a natural death which is natural and ethical.
The Quinlans won the court case and were appointed as the legal guardians of their daughter. The respirator was removed in , but Karen continued to live without the ventilator until The Quinlan case brings up many important issues which are still being addressed til this day. Cases, where the patient was rejected or withdrew treatment, were unheard of during that period and it went against medical ethics in preserving one's life. Debates about allowing patients the right to self-determination was controversial, and it would be evaluated for the next couple of decades from state to state.
It also brings up whether family members and those who are close to the patient are allowed in the decision-making process. Since Karen had no written documentation, voiced no decision, or appointed a proxy, this caused a lengthy legal battle between the Quinlan family and the state in determining Karen's best interest and determining if she would want to live or die. This had a significant influence on the use and establishment of advance directives, oral directives, proxies, and living wills.
Another major case that further propagated the right to die movement and the use of living wills, advance directives and use of a proxy were Nancy Cruzan. In , Nancy Cruzan suffered a car accident which left her permanently in a vegetative state. Her status as an adult and lack of an advance directive, living will, or proxy led to a long legal battle for Cruzan's family in petitioning for the removal of her feeding tube which was keeping her alive since the accident.
Nancy had mentioned to a friend that under no circumstances would she want to continue to live if she were ever in a vegetative state, but was not a strong enough statement to remove the feeding tube. This case brought great debate if the right to die should be approved from state to state or as a whole nation. Terry Schiavo is the most recent [ when? This case was controversial due to a disagreement between Terri's immediate family members and her husband. In the Quinlan and Cruzan cases, the family was able to make an unanimous decision on the state of their daughters. Schiavo suffered from a cardiac arrest which led to her collapse and soon after began to have trouble breathing.
The lack of oxygen to her brain caused irreversible brain damage, leaving her in a vegetative state and required a feeding tube and ventilator to keep her alive. Terri left no advance directive or had a discussion with her parents or husband about what she may have wanted if something were to happen to her. Soon after, her husband was appointed as her legal guardian.
Years later, her husband decided to remove Terri's feeding tube since the chances of her waking up were slim to none. Terri's family, however, argued against this decision and brought this case to court. The case was very turbulent and occurred over some years and involved the state and its legislators before a decision was made. Those who were for preserving Terri's life stated that removing the tube would be ethically immoral since they do not know what she would have wanted.
They challenged her physical and mental state and stated that she might have some consciousness; thus she deserved to continue living. Those for removing the tube argued for self-determination and that her quality of life was diminished. It also further looks into other complications that can arise, such as family disagreements, which should have been accounted for when dealing with a right to die case.
As the health of citizens is considered a police power left for individual states to regulate, it was not until that the US Supreme Court made a ruling on the issue of assisted suicide and one's right to die. That year, the Supreme Court heard two appeals arguing that New York and Washington statutes that made physician-assisted suicide a felony violated the equal protection clause of the Fourteenth Amendment.
While in New York this has maintained statutes banning physician-assisted suicide, the Court's decision also left it open for other states to decide whether they would allow physician-assisted suicide or not. Since , five states in the US have passed assisted suicide laws: Oregon, Washington, Vermont, California, and Colorado passed legislation in , , , , and , respectively, that provides a protocol for the practice of physician-assisted suicide. In , the Montana Supreme Court ruled that nothing in state law prohibits physician-assisted suicide and provides legal protection for physicians in the case that they prescribe lethal medication upon patient request.
In California, the governor signed a controversial physician-assisted-suicide bill, the California End of Life Option Act , in October that passed during a special legislative session intended to address Medi-Cal funding,  after it had been defeated during the regular legislative session. In early , New Mexico Second District Judge Nan Nash ruled that terminally ill patients have the right to aid in dying under the state constitution, i.
Organizations have been continuously pushing for the legalization of self-determination in terminally ill patients in states where the right to ending one's life is prohibited. From Wikipedia, the free encyclopedia. The SAHD has several advantages over a global clinician rating including more varied measurement of the continuum of desire for death and the fact that a self-report measure can be more easily standardized across study settings.
The development of research tools to measure desire for death will allow for more sophisticated and potentially more informative studies of this issue in the future. Not all patients who seek a hastened death request assistance from their physicians. Rates of suicide among medically ill populations have been a topic of clinical concern and empirical research for many years prior to the emergence of the PAS debate. This research has generally concluded that depression and suicide among patients with medical illnesses are not particularly common but rather occur more often than in physically healthy populations.
The role of psychiatric and psychosocial assessment and intervention has been well accepted as a critically important aspect of the care of patients with advanced cancer or AIDS. Early studies of suicide among cancer patients offered conflicting findings, with some studies indicating that the incidence was comparable to that of suicide among the general population and other studies suggesting an incidence of suicide as much as 10 times greater than in the general public.
More recently, large-scale epidemiologic studies of the incidence of suicide among cancer patients have revealed more modest but substantial differences. For example, a Finnish national study53 found that women diagnosed with cancer were 1. Fox et al54 also reported a higher rate of suicide among Connecticut men diagnosed with cancer 2. In a review of the literature on suicide and cancer,46 risk factors for suicide in patients with cancer included advanced disease or poor prognosis, pain, and depression or other mental disorders eg, delirium. Much more striking rates of suicide marked early epidemiologic research on HIV-infected individuals.
An early report of suicide among this population in New York City based on records from the Office of the Medical Examiner found that men with AIDS were 36 times more likely to commit suicide than were age-equivalent men in the general population. Similarly, Kizer et al57 found a rate of suicide among Californians with AIDS to be 17 times greater than that of the general public. Despite these alarming results, these early studies have been criticized on several statistical and methodological grounds.
Thus, the increased rate of suicide among patients with AIDS may in part reflect the presence of other risk factors for suicide aside from HIV infection itself. In addition, the studies of suicide in HIV-infected individuals have included very few actual cases of suicide. Thus, the standard error for these estimates of suicide rates would likely be quite large, leading to inaccurate estimates of the risk of suicide. In addition, the issue of relative risk rations has been criticized in these analyses as resulting in exaggerated estimates of the risk of suicide.
Several issues emerge in clinical settings when patients express a desire for hastened death, either with or without the assistance of the physician. These issues, and appropriate clinical responses, are discussed along with a synopsis of legal and ethical issues that exist in such situations. Perhaps the single most important response that clinicians can offer to their patients is a willingness to engage in this discussion. Moreover, by expressing a willingness to discuss these issues in a nonjudgmental manner, the clinician conveys a willingness to keep such topics open, often providing a significant relief to the patient.
Many experienced clinicians, however, are uncomfortable discussing suicide or death with their patients, and several fears often arise from these situations. Among these fears is the thought that by allowing a patient to discuss his or her desire for a hastened death, the physician is conveying approval or agreement with this decision. Rather, terminally ill patients often avoid discussing these thoughts with their physicians because of a perception that such discussions are "off-limits" or inappropriate, or they are awaiting a cue from the clinician that the topic is acceptable because they are tormented by dealing with the thoughts in isolation.
Many patients also find discussions of suicidal thoughts therapeutic, at times even relieving some of the urge to act on such thoughts. Even physicians who are opposed to suicide or PAS on moral, ethical, or religious grounds should be capable of engaging in a discussion of these thoughts or feelings without conveying either a willingness to carry out such actions or a judgment of the appropriateness of such feelings. The disclosure of untreated or undertreated physical and psychologic symptoms can facilitate more effective treatment to address symptoms that may be resolvable with improved palliative care.
The vulnerability factors influencing suicide, the desire for death, and PAS Tables should be used to guide evaluation and management. Once the setting has been made secure, assessment of the relevant mental status and adequacy of pain control can begin. Analgesics, neuroleptics, or antidepressant drugs should be used when appropriate to treat agitation, psychosis, major depression, or pain. Underlying causes of delirium or pain should be addressed specifically when possible. A close family member or friend should be involved in order to support the patient, provide information, and assist in treatment planning.
Psychiatric hospitalization can sometimes be helpful but usually is not desirable in the terminally ill patient. Thus, the medical hospital or home is the setting in which management most often takes place. While it is appropriate to intervene when medical or psychiatric factors are clearly the driving force in a patient who expresses suicidal plans or requests PAS, there are circumstances when usurping control from the patient and family with overly aggressive intervention may be less helpful.
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This is most evident in those with advanced illness where comfort and symptom control are the primary concerns. Another aspect of patient decision making that can be addressed once an open dialogue has been established is the extent of depression present in the patient.
Not all terminally ill patients become severely depressed, nor are all terminally ill patients who desire a hastened death suffering from a major depression. On the other hand, many terminally ill patients are likely to be experiencing a depression that may be both treatable as well as temporary. Identifying when severe symptoms of depression exist and providing a referral to a trained psychologist or psychiatrist, preferably one with experience treating patients with terminal illnesses, can be crucial in optimizing the quality of life of these patients.
Therefore, clinicians should assure their patient that treatment does not imply a lack of willingness to continue to discuss other options eg, PAS but rather merely fulfills a desire to exhaust all possible options to improve their existing quality of life. These dilemmas are lessened somewhat by the determination that theoretically resolvable symptoms exist that may be resolved or substantially reduced by available interventions.
This decision will no doubt rest on a number of factors, including the physicians personal beliefs regarding the appropriateness of suicide and PAS. Consultation with a peer, even if done in a confidential and discreet manner, not only reassures the clinician that his or her perception of the situation and condition of the patient is accurate, but also provides a second opinion regarding the potential for, and availability of, possible interventions. Unfortunately, we have no easy answer for facilitating clinical decision making in these difficult situations other than to suggest that with adequate interventions and clinical response, such requests will hopefully be relatively infrequent.
The Figure illustrates a proposed model for understanding the influences on suicide, the desire for death, and the interest in PAS as developed by the work of Chochinov et al22 and Breitbart et al. Prevalence rates for major depressive syndromes in cancer patients are estimated to range from 4. Depression in cancer patients with advanced disease is optimally managed using a combination of supportive psychotherapy, cognitive-behavioral techniques, and antidepressant medications.
Psychotherapeutic interventions, either in the form of individual or group counseling, can effectively reduce psychologic distress and depressive symptoms in cancer patients. Any treatment for major depression in the terminally ill will be less effective if given in a context devoid of psychotherapeutic support. Although both psychotherapy and cognitive behavioral therapy are effective in reducing psychologic distressive and mild to moderate depressive symptomatology in the cancer setting, pharmacotherapy is the mainstay for treating terminally ill patients who meet diagnosis criteria for major depression.
A depressed patient with several months of life expectancy can afford to wait the two to four weeks that may be required to respond to a tricyclic antidepressant. The depressed dying patient with less than three weeks to live may do best with a rapid acting psychostimulant.
Right to die
There are a number of controlled studies of antidepressant drug treatment for depressive disorders in cancer patients in general, but fewer that focus on the terminally ill. All of these studies treated cancer patients with depressive symptoms of a certain threshold of severity based on observer-rated or self-report measures of depression, distress, or anxiety. Of the two controlled trials of traditional antidepressants in terminally ill cancer populations, one study72 of nortriptyline was not completed because of high attrition rates due to drug side effects and disease progression, and another study of alprazolam87 contained a sample of only 20 patients.
Traditional antidepressants such as the tricyclic and tetracyclic drugs have apparently limited roles in the treatment of depression in terminally ill cancer patients because of their unfavorable side effect profiles and the long duration of time required prior to onset of antidepressant effects. However, psychostimulants ie, methylphenidate, dextroamphetamine, pemoline, and mazindol are rapidly effective antidepressants in not only cancer patients with advanced disease, but also other medically ill populations. Pemoline was also shown to be an effective antidepressant that is particularly useful for terminally ill patients who have no available oral route for drug administration but could utilize the chewable tablets for buccal absorption.
A number of psychotherapy intervention trials for the treatment of psychologic distress and depression have been conducted with cancer patients, but few if any have included patients with far advanced disease. Supportive psychotherapy is a useful treatment approach to depression in the terminally ill patient. Psychotherapy with the dying patient consists of active listening with supportive verbal interventions and the occasional interpretation. The dying patient who wishes to talk or ask questions about death should be allowed to do so freely, with the therapist maintaining an interested, interactive stance.
It is not uncommon for the dying patient to benefit from pastoral counseling. If a chaplaincy service is available, it should be offered to the patient and family. Oxford Textbook of Palliative Medicine. Neuropsychiatric syndromes and psychiatric symptoms in patients with advanced cancer. J Pain Symptom Manage.
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A Patients Right To Die - With A Free Essay Review - EssayJudge
Efficacy and safety of mianserin in the treatment of depression of women with cancer. Acta Psychiatr Scand Suppl. Psychiatric complications of cancer. Current Therapy in Hematology Oncology. Mermelstein HT, Lesko L. Depression in patients with cancer. Psychooncology ; Treatment of depression in cancer patients. Acta Psychaitr Scand Suppl.
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Carroll B. Alprazolam, promising in treatment of depression in cancer patients. Psychiatr Times. Breitbart W, Mermelstein H. Pemoline, an alternative psychostimulant for the management of depressive disorders in cancer patients.