Assisting suicide is legal in Switzerland if it is offered without selfish motive to a person with decision-making capacity. Although the ‘Swiss model’ for suicide assistance has been extensively described in the literature, the formally and informally protected liberties and claims of assistors and recipients of suicide assistance in Switzerland are incompletely captured in the literature. In this article, we describe the package of rights involved in the ‘Swiss model’ using the framework of Hohfeldian rights (...) as modified by Wenar. After outlining this framework, we dissect the rights involved in suicide assistance in Switzerland, and compare it with the situation in England and Germany. Based on this approach, we conclude that in Switzerland, claim rights exist for those requesting suicide assistance, and for those who are considering providing such assistance, even though no entitlements exist toward suicide assistance. We then describe the implementation of the ‘Swiss model’ and difficulties arising within it. Clarifying these issues is important to understand the Swiss situation, to evaluate what features of it may or may not be worth correcting or emulating, and to understand how it can impact requests for suicide assistance in other countries due to ‘suicide tourism’. It is also important to understand exactly what sets Switzerland apart from other countries with different legislations regarding suicide assistance. (shrink)

Assisting suicide is legal in Switzerland if it is offered without selfish motive to a person with decision-making capacity. Although the ‘Swiss model’ for suicide assistance has been extensively described in the literature, the formally and informally protected liberties and claims of assistors and recipients of suicide assistance in Switzerland are incompletely captured in the literature. In this article, we describe the package of rights involved in the ‘Swiss model’ using the framework of Hohfeldian rights (...) as modified by Wenar. After outlining this framework, we dissect the rights involved in suicide assistance in Switzerland, and compare it with the situation in England and Germany. Based on this approach, we conclude that in Switzerland, claim rights exist for those requesting suicide assistance, and for those who are considering providing such assistance, even though no entitlements exist toward suicide assistance. We then describe the implementation of the ‘Swiss model’ and difficulties arising within it. Clarifying these issues is important to understand the Swiss situation, to evaluate what features of it may or may not be worth correcting or emulating, and to understand how it can impact requests for suicide assistance in other countries due to ‘suicide tourism’. It is also important to understand exactly what sets Switzerland apart from other countries with different legislations regarding suicide assistance. (shrink)

In Europe the elderly population is projected to increase from 18.5% (93.9 million) in 2014 to 28.7% (149.1 million) by 2080. In the USA it is estimated that by the year 2030 more than 20% of the population will be aged 65 years or over. This specific population is at high risk of unrecognised or untreated psychiatric illnesses and suicide. It is well known that completed suicide rate increases with age in both men and women. Although elderly people (...) attempt suicide less often than other age groups, they show a higher completion rate. Generally the methods chosen by elderly are more lethal, the intent is more serious, they are more determined and they show fewer warning sign than the younger population. A recent systematic review and meta-analysis of psychosocial intervention following self-harm in adults found that cognitive behavioural therapy was the most effective in these patients. Unfortunately there have been few reported trials of other potentially effective interventions. Because the scientific literature on psychosocial suicide prevention interventions in the elderly is still scant we decided to conduct a mini-review in order to take stock of the situation. Studies were identified through electronic searches of the Cochrane library, MEDLINE, Scopus and Web of Science databases. PRISMA guidelines were followed and only 7 articles met the inclusion criteria. No firm conclusions can be drawn about this topic because there is still little data and studies used inconsistent outcome measures and designs. Nonetheless, the existing data suggests that psychosocial interventions are promising. (shrink)

Over the course of the last century, physicians have written a number of articles about suicide among their own. These articles reveal how physicians have fundamentally conceived of themselves, how they have addressed vulnerability among their own, and how their self-identification has changed over time, due, in part, to larger historical changes in the profession, psychiatry, and suicidology. The suicidal physician of the Golden Age (1900–1970), an expendable deviant, represents the antithesis of that era’s image of strength and invincibility. (...) In contrast, the suicidal physician of the modern era (1970 onwards), a vulnerable human being deserving of support, reflects that era’s frustration with bearing these unattainable ideals and its growing emphasis on physician health and well-being. Despite this key transition, specifically the acknowledgment of physicians’ limitations, more recent articles about physician suicide indicate that Golden Age values have endured. These persistent emphases on perfection and discomfort with vulnerability have hindered a comprehensive consideration of physician suicide, despite one hundred years of dialogue in the medical literature. (shrink)

The post-Holocaust suicide of a concentration camp survivor is particularly unsettling. One thinks, for instance, of Cliff Stern's devastated response to Professor Louis Levy's death in Woody Allen's movie Crimes and Misdemeanors. Loosely based on Primo Levi, Allen's professor provides in short documentary clips an astute analysis of the contradictions of a loving God in the Old Testament and stoically counsels embracing life despite the indifference and occasional cruelty of the universe. Having experienced, understood, and accepted the absurdity and (...) injustice of life, Levy, one might think, would rage to the bitter end against the dying of the light. But for no apparent reason, he kills himself. Cliff's response... (shrink)

Ever since the start of the twentieth century, a growing interest and importance of studying fatwas can be noted, with a focus on Arabic printed fatwas (Wokoeck 2009). The scholarly study of end-of-life ethics in these fatwas is a very recent feature, taking a first start in the 1980s (Anees 1984; Rispler-Chaim 1993). Since the past two decades, we have witnessed the emergence of a multitude of English fatwas that can easily be consulted through the Internet (‘e-fatwas’), providing Muslims worldwide (...) with a form of Islamic normative guidance on a huge variety of topics. Although English online fatwas do provide guidance for Muslims and Muslim minorities worldwide on a myriad of topics including end-of-life issues, they have hardly been studied. This study analyses Islamic views on (non-)voluntary euthanasia and assisted suicide as expressed in English Sunni fatwas published on independent—i.e. not created by established organisations—Islamic websites. We use Tyan’s definition of a fatwa to distinguish between fatwas and other types of texts offering Islamic guidance through the Internet. The study of e-fatwas is framed in the context of Bunt’s typology of Cyber Islamic Environments (Bunt 2009) and in the framework of Roy’s view on the virtual umma (Roy 2002). ‘(Non-)voluntary euthanasia and assisted suicide’ are defined using Broeckaert’s conceptual framework on treatment decisions at the end of life (Broeckaert 2008). We analysed 32 English Sunni e-fatwas. All of the e-fatwas discussed here firmly speak out against every form of active termination of life. They often bear the same structure, basing themselves solely on Quranic verses and prophetic traditions, leaving aside classical jurisprudential discussions on the subject. In this respect they share the characteristics central in Roy’s typology of the fatwa in the virtual umma. On the level of content, they are in line with the international literature on Islamic end-of-life ethics. English Sunni e-fatwas make up an influential and therefore important developing body of Islamic orthodox normative authority on end-of-life ethics that is still open for further research. (shrink)

Suicide is a major problem in the United States, with the number of suicides annually exceeding the number of homicides by 10,000. Many studies have examined the relationship between media coverage of suicides and the suicide rate. This article reviews literature on imitative suicide and discusses implications of suicide stories on people in crisis. In addition, it explores the options for suicide coverage and gives suggestions for more ethical coverage that could save people's lives, (...) rather than reinforcing suicide as an option. (shrink)

Peña-Guzmán (2017) argues that empirical evidence and evolutionary theory compel us to treat the phenomenon of suicide as continuous in the animal kingdom. He defends a “continuist” account in which suicide is a multiply-realizable phenomenon characterized by self-injurious and self-annihilative behaviors. This view is problematic for several reasons. First, it appears to mischaracterize the Darwinian view that mind is continuous in nature. Second, by focusing only on surface-level features of behavior, it groups causally and etiologically disparate phenomena under (...) a single conceptual umbrella, thereby reducing the account’s explanatory power. Third, it obscures existing analyses of suicide in biomedical ethics and animal welfare literatures. A more promising naturalistic approach might seek a theoretical understanding of the social/ecological circumstances that drive humans and perhaps other animals to self-destruction. (shrink)

Literature reports that depressive symptoms may precede suicidal ideation. Several studies have identified social support and substance use as moderators of this relationship. However, no study has evaluated these variables together by testing how substance use can affect the moderating effect of social support in this relationship. The purpose of this article is to individually evaluate dimensions of social support (friends, family, significant others, and school) and substance use (alcohol, marijuana, and other illicit drugs), as moderators of the relationship (...) between depressive symptoms and suicidal ideation; as well as analyze the moderating role of substance use in the moderation exerted by social support in this relationship. This study, quantitative and cross-sectional, considered 775 adolescents [Average age = 15.48 (SD = 0.96), 45.9% women], from 20 randomly selected schools in Santiago de Chile. Simple moderation models were used to analyze possible moderators separately, and double moderation models were used to analyze the moderating role of substance use in the moderating effect of social support. The results show that the four dimensions of social support moderate the relationship between depressive symptomatology and suicidal ideation, showing the strongest interaction in the case of family support, followed by support of a significant person, support at school, and support of friends, in that order. On the other hand, alcohol was the only drug that moderated the relationship in question. In addition, the results show that the use of alcohol limits the moderating effect of social support in the fields of family, significant person, and school support, but not in the case of support of friends. The use of marijuana and other illicit drugs did not affect the moderating effects of social support for any of the areas evaluated. The results are discussed according to the different roles that alcohol use can play in adolescence, and how these, together with perceived social support, are related to the emergence of suicidal ideation from depressive symptoms. (shrink)

This article examines the cultural meanings of suicide, self-sacrifice, military and terrorist violence in the context of contemporary Israel, Palestine and the U.S. ‘War on Terror’. Notions of ‘sacrifice’ and ‘suicide’, employed in the anthropological and sociological literature, are evaluated with regard to these materials using a theoretical framework for interpreting violent acts as part of cultural expression and as critically linked to collective imagination and memory. This theoretical approach is then also deployed to re-examine other apparently (...) unintelligible forms of violence, such as school-shootings, serial-killing in the U.S., as well as ethnic-cleansing and community violence elsewhere. (shrink)

While euthanasia and assisted suicide have been the subject of continuing public debate, few studies have examined the attitudes of relevant patient groups. This study systematically reviews the research literature on patients’ attitudes from 1989 to 2003, to i) identify the number of studies, ii) evaluate study methods and measures, and iii) examine prevalence of favourable attitudes. A systematic search was undertaken across five databases. Methods of the 21 studies identified varied considerably. General support for euthanasia and assisted (...) suicide was substantial across patient groups, with lower support for these as a personal option. The cancer / terminally ill / palliative care patient group had the lowest median general support for euthanasia (60% [IQ1=47, IQ3=65]) and assisted suicide (50% [IQ1=38, IQ3=71]), while the general/older/younger patient group had the lowest median personal preference for these (18% [IQ1=14, IQ3=27]). The effect of question context on level of support was unclear, due to the variety and number of contexts used across questions. There is still work that needs to be done in this controversial area before any robust conclusions can be made concerning the attitudes of patients to euthanasia and assisted suicide, and the adoption of a minimum set of standard questions would enhance this work. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Crisis of Meaning in Sartor Resartus—Thomas Carlyle's Pioneering Work in Articulating and Addressing the Existential ConfrontationFrank Martelawhat i call an "existential confrontation" is the encounter with the possibility that human life is absurd: created for no purpose and devoid of any lasting value or meaning. It is "the hour of terror at the world's vast meaningless grinding" that William James (Will to Believe 173) examines, described by Todd May (...) (xi) as "the confrontation of our need for meaning with the unwillingness of the Universe to yield it to us." This confrontation with the existential void and the potential absurdity of human existence is often not just an intellectual dilemma, but felt as a deep personal crisis accompanied by melancholia, angst, nausea, or even suicidal thoughts. Young William James confessed in a letter to a friend that "all last winter" he "was on the continual verge of suicide" (quoted in Gunnarsson), writing later that "too much questioning" leads "to the edge of the slope" wherein lies "nightmare or suicidal view of life" (James, "Is Life Worth Living?" 6). Similarly, Leo Tolstoy (54) reports how his inability to identify a lasting meaning of life drove him to a "state of lunacy" where "the best I could do was to hang myself."Despite a few earlier allusions—most famously the Book of Ecclesiastes proclaiming that "all is vanity and a striving after wind," and Shakespeare's Macbeth lamenting that life is "a tale told by an idiot … signifying nothing"—the existential confrontation is predominantly a modern phenomenon (Martela, A Wonderful Life). The modern history of descriptions of existential confrontations start at the turn of the nineteenth century, and includes Søren Kierkegaard's Sickness Unto Death, Leo Tolstoy's A Confession, Fyodor Dostoevsky's Notes from Underground, Camus's Outsider, Sartre's Nausea, and T. S.Eliot's The Waste Land.There are many responses that the confrontation with the existential void has generated. Sartre embraced the lack of values imposed from outside and [End Page 80] emphasized human freedom. Human beings are "cast into this world … condemned to be free" without any "luminous realm of values" providing "justification or excuse," as Sartre famously summarized in "Existentialism Is a Humanism" (29). Other responses range from Søren Kierkegaard's leap of faith and William James's will to believe to Albert Camus's happiness from absurdity.While some of the responses end up finding a new way of connecting with God and faith, and others are explicitly atheistic, embracing the "death of God," a common thread in most responses is an acknowledgment of the situatedness of human experience and an emphasis placed on human subjectivity and the opportunity to live one's life more authentically. While existentialism, broadly conceived, is often seen as the central philosophical tradition dealing with the existential void, the confrontation was very much alive in the United States as well, visible in both literature and philosophy. As already alluded, William James had an existential confrontation in his youth, writing about the topic in "Is Life Worth Living" and other essays in Will to Believe. There has also been much back-and-forth between Europe and the United States around these themes, with the influences crossing the Atlantic on many occasions. For example, William James cites Thomas Carlyle in Will to Believe, while Sartre cites William James in Nausea, when discussing themes related to the existential confrontation. Similarly, Emerson inspired Nietzsche who inspired Josiah Royce. Typically, the histories tracing the early encounters with the existential confrontation acknowledge Friedrich Nietzsche, Søren Kierkegaard, and Fyodor Dostoevsky as key nineteenth-century predecessors to Existentialism, as all faced directly the question of the meaning of life and the dreadful possibility that life might not have any meaning or value to it.However, there is a key author usually not mentioned in these histories, despite the fact that he played a pivotal role in introducing existentialist themes to the English-speaking audience, coining the phrase "meaning of life" in the English language. Thus, in writing the prehistory of Existentialism, we need to examine Thomas Carlyle and his Sartor Resartus, which has been described by literary historians as "one of... (shrink)

The ‘no-suicide contract’ is a frequently utilized tool in both the assessment and dispersal of suicidal patients. However, little attention has been given to questioning whether suicidal persons are able to give informed consent to enter such a contract. This article utilizes both the existing literature on no-suicide contracts and the results of recent research into the effects of this tool, to examine whether its use is consistent with the legal and ethical doctrine of informed consent. Particular (...) attention is given to issues of competence, fullness of information, voluntariness and paternalistic intervention when no-suicide contracts are used. This analysis finds the tool to be problematic and suggests that individual patients’ ability to give informed consent about a no-suicide contract needs to be carefully considered by clinicians. (shrink)

When a terminally ill patient kills herself, using a drug prescribed by a physician for this purpose, in bioethical literature this would be described as a case of physician-assisted suicide. This would also be a case of suicide according to the standard account of suicide in the philosophical literature. However, in recent years, some authors have argued that terminally ill self-killing in fact should not be considered suicide. In this paper, we don’t try to (...) address the philosophical merits of such arguments. Instead, we ask whether these considerations align with the way non-philosophers think about suicide. We present empirical evidence from four studies that address different concerns raised about terminally ill self-killing being a suicide. We conclude that the raised concerns cannot be supported by the folk understanding of suicide. (shrink)

In “Should We Impose Quotas? Evaluating the ‘Disparate Impact’ Argument Against Legalization of Assisted Suicide,” Ronald Lindsay argues that it should make no difference to the debate over legalizing assisted suicide whether the risks associated with legalization would fall disproportionately on the poor, people with disabilities, racial minorities, or any other especially vulnerable social group. Even assuming such an inequitable distribution of risks would occur, he maintains, attempting to avoid such an outcome is not a good reason to (...) deny assisted suicide to “competent persons who truly voluntarily choose it.”Those of us who worry that legalization will differentially burden already disadvantaged segments of society have generally taken it for granted that the possibility of such disparities raises significant public policy concerns. By insisting on an explanation of this assumption — and, in so doing, making explicit the tension between autonomy and equality that underlies the assisted suicide debate — Lindsay has significantly advanced the ongoing conversation. While I disagree with his analysis, I commend him for a thoughtful, provocative, and important contribution to the literature. (shrink)

The literature on rational suicide (RS) holds that if a rational person wishes to suicide under circumstances deemed rational, there is no moral reason to prohibit a person from suiciding. There are forty years of literature dedicated to establishing what rational suicide is and demonstrating its moral permissibility. What is shocking is that in this literature, almost no attempts are made to include the perspectives of mental health users. Drawing from the work of Hilde (...) Lindemann, I argue that ignoring of the perspectives of mental health users constitutes a form of erasure and oppression that must be rectified. (shrink)

Background: This article aims to review research manuscripts in the past 5 years that focus on the effects of debt on depression, anxiety, stress, or suicide ideation in Asian countries.Methods: A search for literature based on the PRISMA guidelines was conducted on Medline, PubMed, Web of Science, Scopus, and ScienceDirect, resulting in nine manuscripts meeting inclusion criteria. The studies were conducted in Thailand, Korea, Singapore, Pakistan, India, Cambodia, and China.Results: The findings of the studies show that there is (...) evidence to support that being in debt is related to Asian participants experiencing depression, anxiety, stress, or suicide ideation. However, the studies are limited to quantitative studies only. The definition of debt is also unclear in most manuscripts. Few manuscripts also examined how other factors influence the relationship between debt and mental illness.Conclusion: There are limited studies on the psychological effects of debt on the Asian population. Future studies should focus on the relationship between debt and psychological well-being among this population. (shrink)

Suicide prevention is a National Health Service priority in the United Kingdom. People with mental illness are seen to represent one of the most vulnerable groups for suicide and recent British Government policy has focused on prevention and management of perceived risk. This approach to suicide prevention is constructed under a biomedical model of psychiatry, which maintains that suicidal persons suffer from some form of disease or irrational drive towards self-destruction. Many react to the idea of self-inflicted (...) death with instinctive revulsion, which has prevented serious discussion of the concept of rational suicide, particularly in relation to those with schizophrenia. The idea that there may be circumstances in which suicide can be viewed as rational is discussed within the biomedical approach to ethics and wider literature primarily in relation to physical disease, terminal states and chronic pain. It is not deemed a viable choice for those who are considered ‘non-autonomous’ due to the controlling forces of mental illness. I propose that suicide is not a consequence of mental illness per se, and that it may be seen as a rational response to a realistic perspective on the course and consequences of living with schizophrenia. The denial of dialogue about the validity of suicidal ideation for people with schizophrenia has led to negative consequences for people with serious mental illness in terms of justice and recognition of person-hood. (shrink)

ObjectivesThis paper aims to identify potential areas for refinement in existing theoretical models of suicide, and introduce a new integrative theoretical framework for understanding suicide, that could inform such refinements.MethodsLiterature on existing theoretical models of suicide and how they contribute to understanding psychological processes involved in suicide was evaluated in a narrative review. This involved identifying psychological processes associated with suicide. Current understanding of these processes is discussed, and suggestions for integration of the existing (...) class='Hi'>literature are offered.ResultsExisting approaches to understanding suicide have advanced the current knowledge of suicide in various ways. They have guided valuable research in the following areas: motivations for suicide and the psychological distress which influences suicide attempts; ambivalence about suicide; suicidal individuals’ focus of attention; and ways in which individuals who contemplate suicide differ from individuals who attempt suicide. We outline a new theoretical framework as a means to integrating all of these concepts into the three principles of control, conflict, and awareness. Within this framework, suicide is regarded as occurring due to a long standing conflict between an individual’s personal goals, culminating in an episode of acute loss of control. The new framework posits that the individual then strives to regain control through the means of suicide because of a narrowed awareness of consequences of their actions on other valued goals. This psychological mechanism of limited awareness is posited to be the common pathway by which individuals make a suicide attempt, regardless of which risk factors are present.ConclusionThis article introduces a theoretical framework that generates several hypotheses for future research, and focuses on psychological processes occurring during immediate crisis. One of the key hypotheses resulting from our predictions on how individuals progress from contemplating to attempting suicide will be tested in an ongoing program of research: Individuals who attempt suicide have a significantly reduced awareness of consequences of suicide, which would negatively impact on their important life goals, values, principles, or ideals, compared to individuals who contemplate suicide. Therapy guided by the new framework may be more flexible, immediate, and client-focused than other therapies for suicidal individuals. (shrink)

Research has demonstrated that policing is a stressful occupation and has a negative impact on police officers’ mental and physical health, performance, and interactions with citizens. Mental health at the workplace has become a concern due to the costs of depression, anxiety, burnout, and even suicide, which is high among police officers.To ameliorate occupational health, it is crucial therefore to identify stress and burnout levels on a regular basis. However, the instruments frequently used to measure stress have not valorized (...) the specificity of policing tasks. This study aims: i) conducting a literature review, to identify questionnaires used to assess occupational stress and burnout among police officers; ii) to analyze the psychometric characteristics of a Portuguese version of Operational Police Stress Questionnaire (PSQ-Op); and, using the PSQ-op and other questionnaires, iii) to identify operational stress, burnout, and distress levels among Portuguese police officers. The literature review identified 108 studies, which use a multiplicity of questionnaires to measure burnout or occupational stress among police officers, but few studies use specific police stress questionnaires. Sample sizes were mostly below 500 participants and studies were mainly developed in the last decade in the USA and Brazil, but also in another 24 countries, showing the extent of the interest in this topic. This study applied to 2057 police officers from National Portuguese Police, a force policing urban centers, the PSQ-Op, as well the Spanish Burnout Inventory and the Kessler Psychological Distress Scale.The results show that the psychometric properties of the Portuguese version of PSQ-Op are adequate. Factorial analysis revealed two dimensions defined as social and work issues, which were associated with measures of distress and burnout.Fit indices suggested a second-order solution called operational police stress. Overall, and considering the scale range of each questionnaire, the results showed moderate values of operational stress, distress, and burnout. However, considering their cut-off points, 85% of the sample presented high operational stress levels, 11% critical values for burnout, and 28% high distress levels, with 55% of the sample at risk of psychological disorder. These results reinforce the need to prevent stress and to invest in police officers’ occupational health. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Euthanasia in Utopian LiteratureLyman Tower Sargent (bio)The word euthanasia, meaning a peaceful, gentle, or easy death, has been traced back to Roman times. But the "good" in a good death is obviously open to interpretation. Good for whom? The individual? The family of the individual? The society? And, who decides? The individual? The doctor? The family of the individual? The legal system? These questions are constantly raised throughout the (...) literature with diametrically opposed answers given from the earliest times to the present. And, unfortunately, one word is used for all the positions, with two subcategories, voluntary and involuntary, both of which are perceived as good for someone.Death is universal but whether or not a person should have a choice about when to die or voluntary euthanasia is deeply controversial.1 Inducing such a death, primarily in cases of a painful terminal disease, appears to be largely a nineteenth-century invention while, of course, existing as a concept well before that.2 Also, discussions of voluntary euthanasia raise related issues, suicide, involuntary euthanasia, and how eugenics has determined the criteria for involuntary euthanasia. Also, the fear of someone [End Page 238] being putting to death for the convenience or advantage of the living has been the most prominent issue, and one must wonder if involuntary euthanasia, at least when consent was possible but not given, ever constitutes a "good" death. As simply a peaceful and painless death, the earliest use of the word was by Suetonius in the early first century, where in his life of Augustus he reports Augustus's position on death as that "on hearing that anyone had died swiftly and painlessly, he prayed that he and his might have a like euthanasia, for that was the term he was wont to use."3 In his De Augmentis Scientiarum [Advancement of Learning], Francis Bacon refers to this statement, commenting, "For it is no small fidelity which Augustus Caesar was wont so earnestly to pray for, that same Euthanasia … was not so much like death as like falling into a deep and pleasant sleep." And Bacon continued: "In our times the physicians make a kind of scruple and religion to stay with the patient after he is given up, whereas in my judgment, if they would be wanting in their office, and indeed to humanity, they ought to acquire the skill and to bestow the attention whereby the dying may pass more easily out of life. This part I call the inquiry concerning outward Euthanasia, or the easy dying of the body (to distinguish from that Euthanasia which regards the preparation of the soul)."4The most explicit statement, generally ignored for sixty years, was that made in an 1870 speech to the Birmingham Speculative Club by Samuel D. Williams Jr., about whom little is known. Williams proposed:That in all cases of hopeless and painful illness, it should be the recognized duty of the medical attendant, whenever so desired by the patient, to administer chloroform or such other anæsthetic as may by-and-bye supersede chloroform—as to destroy consciousness at once, and put the sufferer to a quick and painless death; all needful precautions being adopted to prevent any possible abuse of such duty; and means being taken to establish, beyond the possibility of doubt or question, that the remedy was applied at the express wish of the patient.5This was not, though, the usual practice and many doctors saw no need to act. In an 1887 book one doctor contended that "as long as there was proper medical care, there was no need to speed up death to relieve suffering."6 Still, Williams's position is in almost all respects the position taken by advocates [End Page 239] of voluntary euthanasia since then, although it did not get much of an airing again until C. Killick Millard, the Medical Officer of Health of Leicester, gave the Presidential address to the Society of Medical Officers of Health in late 1931. There he said, referring to Bacon, thatthe proposition merely is that individuals, who have attained to years of discretion, and who are suffering from an incurable and fatal disease which usually... (shrink)

In “Should We Impose Quotas? Evaluating the ‘Disparate Impact’ Argument Against Legalization of Assisted Suicide,” Ronald Lindsay argues that it should make no difference to the debate over legalizing assisted suicide whether the risks associated with legalization would fall disproportionately on the poor, people with disabilities, racial minorities, or any other especially vulnerable social group. Even assuming such an inequitable distribution of risks would occur, he maintains, attempting to avoid such an outcome is not a good reason to (...) deny assisted suicide to “competent persons who truly voluntarily choose it.”Those of us who worry that legalization will differentially burden already disadvantaged segments of society have generally taken it for granted that the possibility of such disparities raises significant public policy concerns. By insisting on an explanation of this assumption — and, in so doing, making explicit the tension between autonomy and equality that underlies the assisted suicide debate — Lindsay has significantly advanced the ongoing conversation. While I disagree with his analysis, I commend him for a thoughtful, provocative, and important contribution to the literature. (shrink)

Background People who are at elevated risk of suicide stand to benefit from internet-based interventions; however, research in this area is likely impacted by a range of ethical and practical challenges. The aim of this study was to examine the ethical issues and practical barriers associated with clinical studies of internet-based interventions for suicide prevention. Method This was a mixed-methods study involving two phases. First, a systematic search was conducted to identify studies evaluating internet-based interventions for people at (...) risk of suicide, and information pertaining to safety protocols and exclusion criteria was extracted. Second, investigators on the included studies were invited to complete an online survey comprising open-ended and forced-choice responses. Quantitative and qualitative methods were used to analyse the data. Results The literature search identified 18 eligible studies, of which three excluded participants based on severity of suicide risk. Half of the 15 suicide researchers who participated in the survey had experienced problems obtaining ethics approval, and none had encountered adverse events attributed to their intervention. Survey respondents noted the difficulty of managing risk in online environments and the limitations associated with implementing safety protocols, although some also reported increased confidence resulting from the ethical review process. Respondents recommended researchers pursue a collaborative relationship with their research ethics committees. Conclusion There is a balance to be achieved between the need to minimise the risk of adverse events whilst also ensuring interventions are being validated on populations who may be most likely to use and benefit from them. Further research is required to obtain the views of research ethics committees and research participants on these issues. Dialogue between researchers and ethics committees is necessary to address the need to ensure safety while also advancing the timely development of effective interventions in this critical area. (shrink)

``What Does a Right to Physician-Assisted Suicide (PAS) Legallyentail?''''Much of the bioethics literature focuses on the morality ofPAS but ignores the legal implications of the conclusions thereby wrought. Specifically, what does a legal right toPAS entail both on the part of the physician and the patient? Iargue that we must begin by distinguishing a right to PAS qua``external'''' to a particular physician-patient relationship from a right to PAS qua ``internal'''' to a particular physician-patientrelationship. The former constitutes a negative (...) claim right inrem that prohibits outside interference with the exercise of aright to PAS while the latter can provide the patient witha positive claim right in personam to obligatory assistancefrom his physician. Importantly, I argue that the creation of sucha patient right, however, originates with the physician who may exercise an unqualified right of first refusal prior to promisingto help her patient commit suicide. In doing so, I hope to establishthat explicit physician promises of assistance in dying shouldbecome legally binding. As such, current PAS law in both theNetherlands and Oregon is in need of substantive modification. (shrink)

In theological discourse of sexuality, queer theory has often been regarded as an extension of the project of gay and lesbian liberation, when it actually challenges an organizing value of the entire discourse, because it challenges any ascription of ultimate value to "sex," an imaginative formation of power relations. Rather than appeal to God to authorize the privileged status of sex, queer commentary suggests that theological writers should refuse assertions of the absolute importance of any particular formation of human imagination (...) as a basis of relation between self and God. The goal is to recognize the violence—symbolized and real—that enforces the worth of certain imaginations of intelligibly sexed personal identity and stunts the formation of alternative imaginations of intelligible personal identity. Critical account of this violence as sentimental-homicidal-suicidal opens space to confess a theological discourse of personal identities that is entirely beyond sex. (shrink)

One of the common domains in health care in which the concept of vulnerability is used is end-of-life care, including euthanasia and assisted suicide (EAS). Since different uses and implications of the notion have been recognised in the literature on EAS, this paper aims to analyse them and reflect on who is the most vulnerable in the context of EAS. A prior exploratory review of the literature has served as a starting point for the discussion. We concluded (...) that vulnerability is a complex, multi-perspective and multi-layered concept, which implies the vulnerability of different stakeholders involved in EAS practices and vulnerability in different aspects of being human (i.e., physical, mental, moral, social and spiritual). A comprehensive understanding of the notion of vulnerability, which balances as well as complements the concept of autonomy, seems to be an indispensable element of the discourse on EAS. (shrink)

Schopenhauer’s argument against suicide is typically received negatively in the scholarly literature, insofar that it appears to be one of the numerous inconsistencies that haunt his philosophical system. Thus, after elaborating upon the unique characteristics of Schopenhauer’s argument against suicide, I will discuss the well-known objection to it. By offering a fresh outlook on Schopenhauer’s ethics, I will suggest a new way of appreciating Schopenhauer’s argument so as to rehabilitate his understanding of suicide within the framework (...) of his pessimistic philosophy. Central to developing this new outlook is to acknowledge structural similarities between Schopenhauer’s ethics and Protestant soteriology. (shrink)

The idea of commercial‐assisted suicide lives a marginal existence in the bioethical literature, despite its significant presence in popular culture. The practice of commercial‐assisted suicide (CAS) is defined as suicide assistance performed for a financial reward through a contractual agreement between a customer and a service‐provider, who does not necessarily need to be a medical professional. While CAS does indeed offer some potential solutions regarding the moral controversies surrounding physician‐assisted suicide (PAS), I defend the idea (...) that adopting it as policy ultimately proves morally indefensible and practically inefficient. This is due to the fact that the commodification of a given good necessarily implies the creation of a market of said good; as such, what I propose in this paper is a moral and practical evaluation of a market of CAS. In order to do so, I first examine the arguments in favor of CAS as put forward by Roland Kipke, who argues that any liberal defense of PAS necessarily implies a defense of CAS. In the first section, I argue against this idea using the liberal values of autonomy and equality of opportunity. In the second section of the paper, I argue that a market of CAS would be gravely dysfunctional due to one particular characteristic of death, namely, that is not compensable ex post. I conclude by arguing that while the practice of CAS may not prove morally problematic, the inevitable market that it will create should it be legalized most certainly will. (shrink)

A review of the literature was conducted to better understand the (potential) role of mental health professionals in physician-assisted suicide. Numerous studies indicate that depression is one of the most commonly encountered psychiatric illnesses in primary care settings. Yet, depression consistently goes undetected and undiagnosed by nonpsychiatrically trained primary care physicians. Noting the well-studied link between depression and suicide, it is necessary to question giving sole responsibility of assisting patients in making end-of-life treatment decisions to these physicians. (...) Unfortunately, the use of mental health consultation by these physicians is not a common occurrence. Greater involvement of mental health professionals in this emerging and debated area is advocated. Beyond describing mental health professionals' role in the assessment of patient competency or decision making capacity, other areas of potential involvement are described. A discussion of ethical principles relevant to this area follows, along with comments on the training necessary to adequately serve patient needs. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Active Euthanasia and Assisted SuicidePat Milmoe McCarrick (bio)Although the President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research in its 1983 report, Deciding to Forego Life-Sustaining Treatment, described the words and terms "euthanasia," "right to die," and "death with dignity" as slogans or code words—"empty rhetoric," (I, p. 24), the literature reviewed for this Scope Note continues to use these terms. Therefore, (...) to discuss the termination of a patient's life by a physician at the patient's request, the phrase active euthanasia is used, and the supplying of a means by a physician whereby a patient can end his or her life is referred to as assisted suicide.Euthanasia, either as the "good death" from classical Greek or "mercy killing" to end unbearable suffering in the dying, has long been a topic of interest in western civilization (III, Brody 1989). In recent years, public awareness of this discussion about control over the time of one's death has been informed by a series of well-publicized events. They include the November 1991 rejection by a vote of 54 percent to 46 percent of the Washington state Initiative 119, which would have allowed the option of requesting one's physician to "aid-in-dying" for adult patients in a "medically terminal condition" (V, Gross 1991); two medical journal articles describing physician's actions in helping bring death to two patients (V, Anonymous 1988; V, Quill 1991); Dr. Jack Kevorkian's assistance in the suicide of three women (V, Belkin 1990; V, Wilkerson 1991); and the best seller status of a how-to book on committing suicide with opiates obtained from a physician (III, Humphry 1991).For the most part, material included in the annotated bibliography in Scope Note 18 has been chosen from works published in the four years since "It's Over, Debbie" (V, Anonymous 1988) appeared in early January 1988 in the Journal of the American Medical Association.Dr. Edmund D. Pellegrino (V, 1991, pp. 3118-19) presented opposing views about active voluntary euthanasia as follows:Those who favor voluntary euthanasia argue that it is a beneficent and compassionate act; it respects autonomy by preserving the patient's control of the manner, method, [End Page 79] and timing of death; it takes the matter outside the reach of "medical power" (accessed in this Scope Note's bibliography at V, Fletcher 1973; V, Nowell-Smith 1989) and scrupulosity; and it prevents the injustice that allows some patients to choose death by refusal of life-support measures, while denying others the right to do so by active euthanasia....The opponents of active euthanasia argue that it undermines the value of, and respect for, all human life (V, Kass 1989; V, Coyle 1990; V, Singer 1990). They fear that guidelines cannot avoid sliding down the "slippery slope" to involuntary euthanasia and selective devaluation of the lives of the most vulnerable among us.... If euthanasia is legal, it is predicted that patients will feel subtle pressure to conform so as to relieve the economic and emotional burdens they impose on family and friends.Euthanasia, its opponents further argue, is socially destructive: it undermines trust in physicians, desensitizes society to killing, and imperils the ground already gained in legitimating passive euthanasia(IV, Wolf 1989).Physicians were not particularly involved with a patient's death until after World War II when participation grew in proportion to the growth of technology. Since the complex, life-sustaining equipment that could forestall death was located in a hospital, death itself became almost completely medicalized (V, Dagi 1991). For terminally ill persons who would like to die a painless death, either by their own hand or with assistance, physicians have almost a monopoly on obtaining strong drugs for distribution to patients (V, Abrams 1990).Active euthanasia for human beings is not legalized anywhere in the world (V, VonDrehle 1991). It is classified as homicide or murder in all fifty states and in Great Britain, Canada, Australia, and the Phillippines (V, Nerland 1989). Twentysix states in the United States prohibit assisted suicide by statute (V, Rosenblum 1990).In 1969 in the Netherlands, a physician named Jan Hendrik van... (shrink)

The relationship between traumatic life events and increased suicide risk has been well reported in literature. However, the complex nature of suicidality phenomena still hinders our ability to comprehend the mediation mechanism underlying this association. In this study, we examined the mediating role of adult attachment and reflective functioning in the relationship between traumatic life events and suicidal ideation. Nine hundred and fifty Italian adults completed an online survey evaluating traumatic life events, adult attachment, reflective functioning and suicidal (...) ideation. The path analysis showed that the positive relationship between traumatic life events and suicidal ideation was partially mediated by attachment anxiety and reflective functioning. From a clinical point of view, these results support the relevance of evaluating and improving patients’ ability to mentalize as a part of psychotherapeutic intervention aimed at reducing suicidality in people with a history of traumatic experiences and attachment anxiety. (shrink)

A literature search was conducted on studies of new drugs used with patients with schizophrenia reported by U.S. and non-U.S. researchers from 1966–1993, yielding 41 U.S., and a total of 24 other non-U.S. studies, among them 11 British studies. Results of the U.S. and non-U.S. studies were pooled separately and compared. Among several comparable conditions discussed, the lack of any data on suicides in the U.S. studies was observed. For a second statistical analysis of suicide rates ‘person-years’ were (...) calculated to adjust for differing washout durations. The results obtained include findings that the percentage of patients relapsing in U.S. studies was slightly lower than in non-U.S. studies ; the percentage of patients dropping out in U.S. studies was higher than in non-U.S. studies ; known location of dropout patients in U.S. studies was 1.7%, compared to 2.6% in non-U.S. studies. The most interesting finding was that no suicides were reported in U.S. studies, compared to 0.6% of patients reported in British studies. Some U.S. studies used ‘challenge doses’, such as amphetamines or L-dopa; no non-U.S. studies reported their use. Compared to U.S. studies, those by non-U.S., and particularly British, researchers appeared to report adverse events in their studies. ‘Challenge’ drugs were not used; suicides were reported. It is estimated that the probability that no patients suicided who participated in the U.S. is small—one in 500. (shrink)

Kant’s conception of remorse has not received focused discussion in the literature. I argue that he thinks we ought to experience remorse for both retributivist and consequentialist reasons. This account casts helpful light on his ideas of conversion and the descent into the hell of self-cognition. But while he prescribes a heartbreakingly painful experience of remorse, he acknowledges that excess remorse can threaten rational agency through distraction and suicide, and this raises questions about whether actual human beings ought (...) to cultivate their consciences in such a way as to experience remorse on his model. (shrink)

It is plausible that what possible courses of action patients may legitimately expect their physicians to take is ultimately determined by what medicine as a profession is supposed to do and, consequently, that we can determine the moral acceptability of voluntary euthanasia and physician-assisted suicide on the basis of identifying the proper goals of medicine. This article examines the main ways of defining the proper goals of medicine found in the recent bioethics literature and argues that they cannot (...) provide a clear answer to the question of whether or not voluntary euthanasia and physician-assisted suicide are morally acceptable. It is suggested that to find a plausible answer to this question and to complete the task of defining the proper goals of medicine, we must determine what is the best philosophical theory about the nature of prudential value. (shrink)

This book demonstrates that law can be newly interrogated when examined through the lens of literature. Like its forerunner, Empty Justice, the book creates simple pathways which energise and illustrate the links between legal theory and legal science and doctrine, through the wider visions of history, literature and culture. This broadening approach is integral to understanding law in the context of wider debates and media in the community. The book provides a collection of essays, with additional commentary which (...) reflects upon very recent scholarship and debate on a range of ethico-legal topics; it also illustrates how conventional legal matters may be rendered lively and palatable, as an adjunct to approaching doctrine and cases 'cold' in the conventional textbook manner. The chapters range from examination of current thought on cohabitation and marriage laws (via Jude the Obscure), 19th century medico-legal cases relevant to current narratives of insanity in women and the nature and status of expert evidence generally; assisted suicide and autonomy (via a poem by Jon Stallworthy) to an essay on the nature of race and ethnicity (via a poem by R S Thomas), a discussion of obscenity and moral philosophy (via an essay on Crash by J G Ballard and the philosophy of Bernard Williams) and a history of ideas discussion of positivism, natural law and political crisis, war and terrorism through legal and political theory texts and a poem by Auden. The materials refer to case law where appropriate. The chapters range from examination of current thought on cohabitation and marriage laws (via Jude the Obscure), 19th century medico-legal cases relevant to current narratives of insanity in women and the nature and status of expert evidence generally; assisted suicide and autonomy (via a poem by Jon Stallworthy) to an essay on the nature of race and ethnicity (via a poem by R S Thomas), a discussion of obscenity and moral philosophy (via an essay on Crash by J G Ballard and the philosophy of Bernard Williams) and a history of ideas discussion of positivism, natural law and political crisis, war and terrorism through legal and political theory texts and a poem by Auden. The materials refer to case law where appropriate. (shrink)

It has been argued that voluntary euthanasia (VE) and physician-assisted suicide (PAS) are morally wrong. Yet, a gravely suffering patient might insist that he has a moral right to the procedures even if they were morally wrong. There are also philosophers who maintain that an agent can have a moral right to do something that is morally wrong. In this article, I assess the view that a suffering patient can have a moral right to VE and PAS despite the (...) moral wrongness of the procedures in light of the main argument for a moral right to do wrong found in recent philosophical literature. I maintain that the argument does not provide adequate support for such a right to VE and PAS. (shrink)

The Gift of Death, Jacques Derrida’s most sustained consideration of religion, explores questions first introduced in his book Given Time about the limits of the rational and responsible that one reaches in granting or accepting death, whether by sacrifice, murder, execution, or suicide. Derrida analyzes Czech philosopher Jan Patocka’s Heretical Essays in the Philosophy of History and develops and compares his ideas to the works of Heidegger, Lévinas, and Kierkegaard. One of Derrida’s major works, The Gift of Death resonates (...) with much of his earlier writing, and this highly anticipated second edition is greatly enhanced by David Wills’s updated translation. This new edition also features the first-ever English translation of Derrida’s Literature in Secret. In it, Derrida continues his discussion of the sacrifice of Isaac, which leads to bracing meditations on secrecy, forgiveness, literature, and democracy. He also offers a reading of Kafka’s Letter to His Father and uses the story of the flood in Genesis as an embarkation point for a consideration of divine sovereignty. “An important contribution to the critical study of ethics that commends itself to philosophers, social scientists, scholars of religion... [and those] made curious by the controversy that so often attends Derrida.”—Booklist, on the first edition. (shrink)

This paper deals with the subject of self-sacrifice from an interdisciplinary perspective. Using various examples from different cultures and periods of history it will present aspects of the phenomenon of violent self-sacrifice in combat or with the occasion of suicide terrorist attacks, currents and movements familiar with these techniques through history; its psychological, moral and social background and above all, their impact and perception on the suicide terrorist's own society. It also includes, from a general, theoretical point of (...) view, a few methods and practices beneficial for fighting this phenomenon. (shrink)

Objective—Consultation of another physician is an important method of review of the practice of euthanasia. For the project “support and consultation in euthanasia in Amsterdam” which is aimed at professionalising consultation, a protocol for consultation was developed to support the general practitioners who were going to work as consultants and to ensure uniformity. Participants—Ten experts (including general practitioners who were experienced in euthanasia and consultation, a psychiatrist, a social geriatrician, a professor in health law and a public prosecutor) and the (...) general practitioners who were going to use the protocol. Evidence—There is limited literature on consultation: discursive articles and empirical studies describing the practice of euthanasia. Consensus—An initial draft on the basis of the literature was commented on by the experts and general practitioners in two rounds. Finally, the protocol was amended after it had been used during the training of consultants. Conclusions—The protocol differentiates between steps that are necessary in a consultation and steps that are recommended. Guidelines about four important aspects of consultation were given: independence, expertise, tasks and judgment of the consultant. In 97% of 109 consultations in which the protocol was used the consultant considered the protocol to be useful to a greater or lesser extent. Although this protocol was developed locally, it also employs universal principles. Therefore it can be of use in the development of consultation elsewhere. (shrink)

The main causes of suicide and how suicide could and should be prevented are ongoing controversies in the scientific literature as well as in public media. In the bill on public health from 2008, the Swedish Parliament adopted an overarching “Vision Zero for Suicide” and nine strategies for suicide prevention. However, how the VZ should be interpreted in healthcare is unclear. The VZ has been criticized both from a philosophical perspective and against the background of (...) clinical experience and alleged empirical claims regarding the consequences of regulating suicide prevention. This study is part of a larger research project in medical ethics with the overarching aim to explore whether the VZ is ethically justifiable. The aim is to enrich the normative discussion by investigating empirically how the VZ is perceived in healthcare. Interviews based on a semi-structured interview guide were performed with 12 Swedish psychiatrists. The interviews were analysed with descriptive qualitative content analysis aiming for identifying perceptions of the Vision Zero for Suicide as well as arguments for and against it. Though most of the participants mentioned at least some potential benefit of the Vision Zero for Suicide, the overall impression was a predominant skepticism. Some participants focused on why they consider the VZ to be unachievable, while others focused more on its potential consequences and normative implications. The VZ was perceived to be impossible to realize, nonconstructive or potentially counterproductive, and undesirable because of potential conflicts with other values and interests of patients as well as the general public. There were also important notions of the VZ having negative consequences for the working conditions of psychiatrists in Sweden, in increasing their work-related anxiety and thwarting the patient-physician relationship. (shrink)

Kant’s argument against suicide is widely dismissed by scholars and often avoided by teachers because it is deemed inconsistent with Kant’s moral philosophy. This paper attempts to show a way to make sense of Kant’s injunction against suicide that is consistent with his moral system. One of the strategies adopted in order to accomplish my goal is a de-secularization of Kant’s ethics. I argue that all actions of self-killing are morally impermissible because they are inconsistent with God’s established (...) nature and order. It is argued that the existence of God as the locus of moral value and duty in Kant’s moral system, and not belief in God, can explain the consistency of Kant’s injunction against suicide. A synergistic view is offered, which rests on three arguments: First, suicide goes against God’s authority. Second, suicide is inconsistent with our self-perpetuating nature. Third, suicide goes against the rational will. (shrink)

_The Gift of Death_, Jacques Derrida’s most sustained consideration of religion, explores questions first introduced in his book _Given Time_ about the limits of the rational and responsible that one reaches in granting or accepting death, whether by sacrifice, murder, execution, or suicide. Derrida analyzes Czech philosopher Jan Patocka’s _Heretical Essays in the Philosophy of History _and develops and compares his ideas to the works of Heidegger, Lévinas, and Kierkegaard. One of Derrida’s major works, _The Gift of Death_ resonates (...) with much of his earlier writing, and this highly anticipated second edition is greatly enhanced by David Wills’s updated translation. This new edition also features the first-ever English translation of Derrida’s _Literature in Secret_. In it, Derrida continues his discussion of the sacrifice of Isaac, which leads to bracing meditations on secrecy, forgiveness, literature, and democracy. He also offers a reading of Kafka’s _Letter to His Father_ and uses the story of the flood in Genesis as an embarkation point for a consideration of divine sovereignty. “An important contribution to the critical study of ethics that commends itself to philosophers, social scientists, scholars of religion... [and those] made curious by the controversy that so often attends Derrida.”—_Booklist_, on the first edition. (shrink)

The euthanasia literature typically discusses the difference between “active” and “passive” means of ending a patient’s life. Physician-assisted suicide differs from both active and passive forms of euthanasia insofar as the physician does not administer the means of suicide to the patient. Instead, she merely prescribes and dispenses them to the patient and lets the patient “do the rest” – if and when the patient chooses. One supposed advantage of this process is that it maximizes the patient’s (...) autonomy with respect to both her decision to die and the dying process itself. Still, despite this supposed advantage, Oregon is the only state to have legalized physician-assisted suicide. After summarizing the most important Supreme Court opinions on euthanasia (namely, Cruzan v. Director, Missouri Dep’t of Health; Vacco v. Quill; Washington v. Glucksberg; and Gonzales v. Oregon), this paper argues that while there are no strong ethical reasons against legalizing physician-assisted suicide, there are some very strong policy reasons for keeping it criminal in the other forty-nine states. (shrink)

IntroductionDementia diseases, especially Alzheimer’s disease (AD), are of considerable importance in terms of social policy and health economics. Moreover, against the background of the current Karlsruhe judgement on the legalisation of assisted suicide, there are also questions to be asked about medical humanities in AD.MethodologyRelevant literature on complementary forms of therapy and prognosis was included and discussed.ResultsCreative sociotherapeutic approaches (art, music, dance) and validating psychotherapeutic approaches show promise for suitability and efficiency in the treatment of dementia, but in (...) some cases still need to be scientifically tested. Biomarker-based early diagnosis of dementia diseases is increasingly becoming a subject of debate against the background of the Karlsruhe ruling.DiscussionNeeds-oriented and resource-enhancing approaches can make a significant contribution to improving the quality of life of people with dementia. The discussion on the issue of “assisted suicide” should include questions of the dignity and value of a life with dementia.OutlookThe integrative dementia therapy model can be complemented by a religion- and spirituality-based approach. Appropriate forms of psychotherapy should be scientifically evaluated. (shrink)

End-of-life decision making is fraught with ethical challenges. Withholding or withdrawing life support therapy is widely considered ethical in patients with high treatment burden, poor premorbid status, or significant projected disability even when such treatment is not “futile.” Whether such withdrawal of therapy in the aftermath of attempted suicide is ethical is not well established in the literature. We provide a clinical vignette and propose criteria under which such withdrawal would be ethical. We suggest that it is appropriate (...) to withdraw life support, regardless of the cause of the critical illness or disability, when the following criteria are met: (1) Surrogates request withdrawal of care and the adequacy of surrogates is confirmed, (2) an external reasonability standard is met, (3) passage of time, perhaps 72 hours, to allow certainty regarding the patient's wishes, and (4) psychiatric morbidity should be considered as grounds for withdrawal only in truly treatment-refractory cases. Fundamentally, we believe the question to ask is, “If this were not an attempted suicide, would a request to withdraw care be reasonable?” We believe that under these circumstances, such withdrawal of life support, even in an individual who has attempted suicide, does not constitute physician assistance with suicide and is distinct from physician aid-in-dying in several important respects. (shrink)

For each one of the approximately 800,000 people who die from suicide every year, an additional twenty people attempt suicide. Many of these attempts result in hospitalization or in contact with other healthcare services. However, many personal, educational, and institutional barriers make it difficult for healthcare professionals to care for suicidal individuals. We reviewed literature that discusses suicidal patients in healthcare settings in order to highlight common ethical issues and to identify knowledge gaps. A sample was generated (...) via PubMed using keywords “[(ethics OR *ethic*) AND suicid*] AND [English (Language) OR French (Language)]” (final N = 52), ethics content was extracted according to scoping review methodology, and categorized thematically. We identified three main areas posing ethical challenges for health professionals caring for suicidal individuals and their families. These were: (1) making clinical decisions for patients in acute care or when presented with specific circumstances; (2) issues arising from therapeutic relationships in chronic care, and (3) organizational factors. There is considerable uncertainty about how to resolve ethical issues when caring for someone who is suicidal. The stigma associated with suicide and mental illness, problems associated with risk–benefit assessments, and the fear of being held liable for malpractice should a patient die by suicide were overarching themes present across these three categories. Caring for suicidal patients is clinically and ethically challenging. The current literature highlights the complexity and range of decisions that need to be made. More attention should be paid to the difficulties faced by healthcare professionals and the development of solutions. (shrink)

End-of-life decision making is fraught with ethical challenges. Withholding or withdrawing life support therapy is widely considered ethical in patients with high treatment burden, poor premorbid status, or significant projected disability even when such treatment is not ?futile.? Whether such withdrawal of therapy in the aftermath of attempted suicide is ethical is not well established in the literature. We provide a clinical vignette and propose criteria under which such withdrawal would be ethical. We suggest that it is appropriate (...) to withdraw life support, regardless of the cause of the critical illness or disability, when the following criteria are met: (1) Surrogates request withdrawal of care and the adequacy of surrogates is confirmed, (2) an external reasonability standard is met, (3) passage of time, perhaps 72 hours, to allow certainty regarding the patient's wishes, and (4) psychiatric morbidity should be considered as grounds for withdrawal only in truly treatment-refractory cases. Fundamentally, we believe the question to ask is, ?If this were not an attempted suicide, would a request to withdraw care be reasonable?? We believe that under these circumstances, such withdrawal of life support, even in an individual who has attempted suicide, does not constitute physician assistance with suicide and is distinct from physician aid-in-dying in several important respects. (shrink)