Dying in dignity: The pros and cons of assisted suicide

Abstract This paper describes the historical background and the current situation regarding the practice of assisted suicide in The Netherlands. It outlines and discusses what is considered to be the 'golden standard' of conduct for doctors and other health professionals in this area, it describes experiences with the application of this standard and discusses some of the major pitfalls involved. It also describes the results of several empirical studies on the attitudes of the general public, and the nature and magnitude of the practice of assisted suicide in the country.
It is concluded that although perfect application of the 'Dutch Protocol' encourages and supports careful and responsible professional conduct regarding assisted suicide and provides satisfactory safeguards both for the patients involved, (potential) survivors and society as a whole, there are many cases where the desired perfection is far from feasible, hence assistance with suicide remains very hazardous. It is also concluded, however, that health care policy makers, as well as professionals, should confront the issue of assisted suicide, since, as the historical development in The Netherlands has shown, repression and denial implicates the worst of all possible scenarios, and does not contribute at all to the primordial goals of a humane health care system: the alleviation of suffering and the prevention of premature death.     

Suicide as a crime in the UK: legal history,international comparisons and present implications

Suicide was a crime in England and Wales until 1961. This paper compares the English legal treatment of suicide with that in other Western countries. The delayed English decriminalization of suicide is a likely result of the nature of English common law, rather than a reflection of actual public opinion and medico-legal practice. This subject remains of interest. Coronership, the cornerstone of English suicide certification, developed out of anti-suicide legislation, and important biases result from this. The Church of England may still deny ordinary burial rites to certain suicide victims. Assisted suicide, to be distinguished from euthanasia and suicide pacts, became a separate offence in 1961. Legislative reform regarding these issues, similarly to that regarding suicide, is likely to lag behind the development of public opinion and medical practice.     

Public attitudes to life-sustaining treatments and euthanasia in dementia

BACKGROUND: Issues surrounding end of life care, such as how aggressively to treat life threatening medical conditions in patients with dementia and when, if ever, to withhold or withdraw treatment require further scrutiny and debate. METHODS: We conducted a cross-sectional survey to elicit the views of the general public on euthanasia and life-sustaining treatments in the face of dementia. RESULTS: Seven hundred and twenty-five members of the general public completed this questionnaire throughout London and the South East. In the face of severe dementia, less than 40% of respondents would wish to be resuscitated after a heart attack, nearly three-quarters wanted to be allowed to die passively and almost 60% agreed with physician assisted suicide. Respondents were more likely to be in favour of life-sustaining treatments for their partner than for themselves and the opposite was true regarding euthanasia. White respondents were significantly more likely to refuse life-sustaining treatment and to agree to euthanasia compared with black and Asian respondents. CONCLUSION: Our survey suggests that a large proportion of the UK general public do not wish for life-sustaining treatments if they were to become demented and the majority agreed with various forms of euthanasia.     

Suicide and violent death among adolescent suicide attempters

A total of 422 subsequent suicide attempts commited by 362 people 15-19 years old in the Helsinki area in 1973-1982 were investigated to find risk factors for subsequent suicide or violent death. By the end of 1982, 8.7% of 115 boys and 1.2% of 247 girls had died. Eight (2.2%) had committed suicide. The mean annual mortality for suicide and violent death was 20-fold compared with the mortality for suicide and violent death among people 15-19 years old in Finland at that time. The risk ratios of the boys for suicide (2.0) and for violent death (2.4) were greater than that of the girls (0.6 and 0.3 respectively). The risk ratio of psychotic persons for suicide was 4.2 and for violent death 4.1. Seriousness of intent heightened the risk, whereas degree of lethality did not influence it. The people who expressed clear-cut difficulties as a reason for their suicide attempt seemed to have a smaller risk for suicide or violent death than people whose reasons remained unclear. Attempted suicide among boys is a serious symptom for predicting subsequent suicide that should be addressed in suicide prevention.     

Principles and concepts of brain death and organ donation: the Jewish perspective

The harvesting of organs for transplantation is dependent on a stringent definition of brain death. Different societies have had to struggle with their cultural heritage, adapting their traditional attitudes to conform to the advances in medical science and the needs of the sick. In this article, the development of the concept of brain death as it applies to organ transplantation in Judaism is outlined. The ability of traditional Jewish values to address themselves to the challenges of modern medicine can serve as a basis for cultural cross-fertilization and comparison in modern societies. Received: 4 March 1998     

Suicidal acts on metro systems: an international perspective

Suicide is a problem experienced by railway networks worldwide. The epidemiology of this method of suicide has not been described in any detail. To investigate the characteristic features of railway suicide, data were gathered from 23 metro systems around the world. The similarities in the nature of this problem across systems were striking. Universally the victims were young (aged less than 40 years); most incidents involved men; case fatality was generally less than 60%; there was no consistent seasonal variation in incidence; the peak time of day for incidents was 1000–1200; proximity to psychiatric institutions was possibly a risk factor. This method of suicide may be prevented by environmental modification of the railway system. Strategies for reducing the opportunities for suicide on railways are discussed.     

Attitudes toward Assisted Suicide: Does Family Context Matter?

Little is known about how family-related contextual variables impact attitudes toward assisted suicide. A probability sample (N = 272) responded to a multiple-segment factorial vignette designed to examine the effects of 6 variables—patient sex, age, type of illness, relationship status, parenthood status, and family support—on attitudes toward physician- and family-assisted suicide. Respondents were more likely to support physician-assisted suicide if they heard about an older patient or a patient experiencing physical pain than a younger patient or one suffering from depression, respectively. For family-assisted suicide, respondent support was higher when the patient had physical pain than depression, and when the patient's spouse or friend was supportive of the wish to die than unsupportive. Attitudes about physician and family obligation to inform others were affected by type of illness, relationship status, family support, and respondent education and religiosity. The experience of pain, motivations for family involvement, confidentiality issues, and physicians’ biases concerning assisted suicide are discussed.     

Death with dignity in the Japanese culture

Abstract In Japanese culture, the concept of death with dignity focuses on enhancing the relationship with significant others (especially with family members) and is expected to continue even after death, unlike the autonomous decision making in Western cultures. Deaths in such relationships are self-worthy, majestic and wished for. The author depicts these traits by describing the worship of sudden death aspiration in a special temple, the death ceremonies repeated even after death which involve even distantly related people, a suicide allusively asking for something, and a joint suicide.     

When jurors’ moral judgments result in jury nullification: moral outrage at the law as a mediator of euthanasia attitudes on verdicts

In a mock-trial study, jurors read evidence about a doctor who had killed a terminally ill patient at the patient’s request. We tested whether instructing jurors about jury nullification (ie jurors’ power to return a not-guilty verdict even when legal guilt is beyond doubt, often because the law would result in unjust convictions) would exacerbate the effect of pre-trial euthanasia attitudes on their verdicts – compared to standard, pattern jury instructions. We also hypothesized that anti-euthanasia pre-trial attitudes would result in moral outrage at the defendant and higher conviction rates, but pro-euthanasia attitudes would prompt feelings of moral outrage at the law and lower conviction rates. Moderated mediation analyses revealed that nullification instructions bolstered the effect of attitudes on verdicts by encouraging jurors to rely on their feelings of moral outrage toward the defendant. Jurors’ moral outrage toward the law mediated the effect of attitudes on verdicts regardless of nullification instructions.     

Passive euthanasia in response to attempted suicide: one form of aggressiveness by relatives

A total of 88 interviews were conducted with 40 people attempting suicide who were receiving care in an intensive-care unit, and 129 interviews were carried out with their relatives and friends. The subjects were divided into 3 diagnostic groups: neurosis (n = 14), abuse (n = 19) and psychosis (n = 7). The incidence of relatives' failure to provide care after the suicide attempt--turning-away reactions as well as do not resuscitate orders, a form of passive euthanasia--was investigated. In 8 cases, partners of patients in the abuse and neurosis groups showed turning-away reactions. In 2 cases, relatives of elderly patients in the neurosis group said to the doctor that life-preserving measures should not be taken. Relatives explained their behaviour by saying that they had the best interests of the suicidal individual at heart. In-depth interviews, however, revealed that these reactions were a manifestation of the relatives own psychic conflicts, brought forth by the confrontation with the depressed and suicidal patient. Turning-away reactions and do not resuscitate orders might be interpreted as expressing the relatives' aggressiveness towards the suicidal individual and attempts to escape from a difficult situation. It is important that doctors stand up for the interests of suicidal people, which at times may conflict with relatives' interests, and help the relatives to sort out their problems and wishes with respect to the problem areas of passive euthanasia.     

Is sudden unexplained nocturnal death a breathing disorder?

Abstract Sudden unexplained nocturnal death syndrome (SUNDS), or 'Lai Tai' in northeastern Thai dialects usually occurs during sleep in healthy young adults, mostly male. The characteristics of Lai Tai are similar to SUNDS which has been reported in several southeast Asian countries and in Japan by the name of 'Bangungut' in Tagalog or 'Pokkuri' in Japanese. The condition has been recognized by the people in the northeastern part of Thailand for many years. Elderly people in the region have described 'Lai Tai' victims as making loud groans and showing signs of difficulty in breathing or labored respiration, who become rigid and die. Data, from relatives or those who had witnessed the episodes of deaths, revealed that the deaths usually occurred in the same manner as described by the elderly. The data also reported that the patients were unresponsive and difficult to arouse. From these reports it is likely that the instability of the physiological systems, especially respiration, in particular during the REM phase, may play some roles in precipitating the sudden death.     

Correlates of suicide attempt history in bipolar disorder: a stress-diathesis perspective

Objectives:  Distinguishing clinical characteristics of bipolar patients who have made a suicide attempt may help to identify at-risk individuals. We sought to identify such factors and to consider them within a stress-diathesis model of suicidal behavior.
Methods:  Patients with bipolar disorder (N = 96) were compared with respect to the presence or absence at baseline evaluation of a history of suicide attempt. We used multiple logistic regression analysis to assess the unique associations of independent variables to history of a past suicide attempt.
Results:  The regression analysis showed that a history of suicide attempt in bipolar disorder was associated with greater recent suicidal ideation, more psychiatric hospitalizations, lifetime aggressive traits and an earlier age at onset of a first mood episode.
Conclusions:  Aggressive traits and early treatment of mood disorders, especially major depressive episodes, are potential targets for suicide prevention in bipolar disorder.     

Life after death: grief therapy after the sudden traumatic death of a family member

TOPIC: Survivors of the sudden traumatic death of a family member are at increased risk for complicated grief and bereavement. PURPOSES: To present the complicating factors inherent to sudden traumatic death in order to promote adaptive grieving in the survivors. SOURCES: A comprehensive review of the existing bereavement literature, clinical anecdotes, and therapeutic experiences. CONCLUSIONS: Grief is a process and not an endpoint. The goal of grief is not to forget about the loss, a commonly stated goal of survivors; rather, the goal is to remember the decedent, understand the changes created by the loss, and determine how to reinvest in life.