Psychosomatics 41:193-194, June 2000
© 2000 The Academy of Psychosomatic Medicine
The Unexamined Death Is Not Worth Dying
Thomas S. Zaubler, M.D., M.P.H.
Accepted February 1, 2000. From the Department of Psychiatry, Georgetown University Medical Center, 3800 Reservoir Rd., NW, Washington, DC 20007.
Key Words: Death and Dying • Assisted Death
The article on page 195 by Cohen et al. discusses critical issues regarding the role of the psychiatrist in evaluating requests by medically ill patients to hasten death. The authors point out that there are different types of death-hastening requests, including refusal or withdrawal of life-sustaining treatment, treatment of pain with analgesic medication that may result in a hastened death, and requests for assistance in suicide. Cohen et al. recognize that when evaluating patients making requests to hasten death, psychiatrists should evaluate the decision-making capacity of these patients and explore the impact that major mental illness, character traits, and psychological defense mechanisms have on the competency, durability, and authenticity of these requests.
Cohen et al. define many factors that should be taken into consideration when determining the reasonableness of a patient's request to hasten death. Prioritizing the relative significance of each of these factors is critically important. Given the emphasis we, as a society, place on patient autonomy, determining a patient's decision-making capacity (i.e., competency) should supersede and subsume all other factors. Although it is vitally important to determine if the patient is suffering from depression or other psychiatric disorders, it is equally important to avoid conflating incompetency and psychiatric illness. They are never synonymous. Although the presence of depression, even psychosis, may raise concern about a patient's competency, no psychiatric diagnosis should, prima facie, be taken as an indication of incompetency.
The assessment of competency among severely medically ill patients can be extremely nuanced and difficult to make. Psychiatrists must familiarize themselves with the definitions and standards of competence that are well defined by Roth, Appelbaum, and others.1–3 These standards include a patient's ability to make a consistent choice about a death-hastening decision, an understanding and appreciation of the consequences and alternatives to this decision, and the ability to reason rationally about the decision.
Although it is important that most patients requesting a hastened death meet all of these standards, there may be situations when a patient's quality of life is so poor that it may be appropriate to set a lower threshold to establish competency where a patient need not meet all the standards.4 When assessing competency, psychiatrists must be attuned to the subtle effects that a rigid, controlling character style; psychological defenses such as undoing, avoidance, or denial; or the negativism and hopelessness associated with depression may have not only on the cognitive but also on the affective dimensions of competency in a terminally ill patient.5–7
Psychiatrists must not let their professional or personal biases unduly influence the assessment of competence. This is critically important given the ethic of life-prolongation within the field of medicine and, within psychiatry, in particular, the perception that suicidal thoughts must always be a product of mental illness and that any form of suicide must be prevented at all costs. As Cohen et al. point out, there is a dearth of information that allows us to meaningfully distinguish the subtleties of mental illness versus mental health among medically ill patients requesting a hastened death. Psychiatrists must be mindful of the fact that much of the debate surrounding death-hastening actions and physician-assisted suicide among the medically ill is based on information regarding a desire for death or suicidality among the medically well.8,9
Cohen et al. appropriately suggest that the psychiatric assessment of patients requesting a hastened death should be comprehensive and include discussion, when at all possible, with a patient's family, friends, and even community leaders. The decision to hasten death should be contextualized within a range of values encompassing the patient's own belief system as well as the belief systems of others with whom the patient is close. Such an assessment will help to ensure that the patient is making an authentic decision that is consistent with established norms for this patient.
Finally, psychiatrists must not limit their role to the assessment of competency and authenticity of patients' decisions to hasten death. We must strive to shed the light of empirical research on the debate over death-hastening actions. Further research is needed to define both treatable and untreatable risk factors for a desire for death among the terminally ill.
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Roth LH, Meisel A, Lidz CW: Tests of competency to consent to treatment. Am J Psychiatry 1977; 134:279–284[Abstract/Free Full Text]
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Appelbaum PS, Grisso T: Assessing patients' capacities to consent to treatment. N Engl J Med 1988; 319:1635–1638
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Grisso T, Appelbaum PS (eds): Assessing Competence to Consent to Treatment: A Guide for Physicians and Other Health Professionals. New York, Oxford University Press, 1998
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Drane JF: Competency to give an informed consent, a model for making clinical assessments. JAMA 1984; 252:925–927[Abstract/Free Full Text]
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Block SD, Billings JA: Patient requests for euthanasia and assisted suicide in terminal illness: the role of the psychiatrist. Psychosomatics 1995; 36:445–457[Abstract/Free Full Text]
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Muskin PR: The request to die: role for a psychodynamic perspective on physician-assisted suicide. JAMA 1998; 279:323–328[Abstract/Free Full Text]
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Bursztajn HJ, Harding HP, Gutheil TG, et al: Beyond cognition: the role of disordered affective states in impairing competence to consent to treatment. Bull Am Acad Psychiatry Law 1991; 19:383–388[Medline]
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Sullivan MD, Youngner SJ: Depression, competence and the right to refuse lifesaving medical treatment. Am J Psychiatry 1994; 151:971–978[Abstract/Free Full Text]
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Zaubler TS, Sullivan MD: Psychiatry and physician-assisted suicide. Psych Clin N America 1996; 19:413–427
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