In this episode of Euthanasia & Disability, Amy Hasbrouck and Christian Debray discuss:
- Evaluation for competency & depression in assisted suicide requests
Please note that this text is only a script and that our webcast contains additional commentary.
COMPETENCY AND ASSISTED SUICIDE
- The law of capacity embodies a tension between respecting a person’s autonomy and society’s desire to protect the person.
- Comes from laws made by legislatures and court cases
- In general, competency is the ability and legal qualifications to make a decision to do something.
Ability to make a decision means:
- Ability to understand relevant information
- Ability to appreciate reasonably foreseeable consequences.
- Ability to manipulate information rationally
- Legal qualifications
- Competency is usually decided by a court.
- In many cases, a doctor makes a recommendation, which is approved by a court
- The person is presumed to be competent unless there is “clear and convincing evidence” to the contrary.
- Make a decision
- Do something – it depends on what you’re trying to do: enter into a contract or buy a house, to prepare a will, to stand trial, to make medical decisions (catch-all category that have widely different consequences), agree to receive treatment or choose among different treatments (weigh benefits vs. side effects), refuse treatment (risk of death), request assisted suicide (death)
- Competency assessment questions for medical treatment: Does the person understand …
- the current medical condition?
- the natural course and outcome of the current medical condition?
- the proposed treatment intervention?
- the risks and/or benefits of the proposed treatment?
- what is likely to happen if they refuse the proposed treatment?
- the alternatives to the proposed treatment?
- the risks and benefits of the alternatives?
- Researchers Susan Block and Andrew Billings talk about a different way to evaluate if a person is competent to request assisted suicide.
- Physical suffering,
- Psychological suffering
- Decision-making ability
- Social suffering
- Existential/spiritual suffering
- Problems in the relationship with her doctor(s)
- Alternative: Assessment of demoralization — perceived incompetence, inability to cope, hopelessness, existential despair, and meaninglessness
- Gregory & Catherine Hamilton – Suicide requests in Oregon, compare clinical assessment and treatment with assisted suicide competency determination.
- Clinical treatment model
- Applies to everyone who is suicidal
- Suicidal feelings are a symptoms of a problem that can and should be treated
- Request for suicide is a cry for help to relieve suffering
- Life is valuable and should be saved
- Assisted suicide model
- Applies only to suicidal disabled people who are “suffering”
- Suicidal feelings are reasonable response to the person’s situation
- Suicide request is a cry for help to die
- Death is preferred over life with a disability or illness
- What to look for in a suicide-prevention assessment:
- onset and recurrence of psychiatric symptoms
- previous similar episodes and treatments
- recent stresses
- social and economic difficulties
- religious or spiritual concerns
- symptoms of depression and substance abuse
- medications that can cause or exacerbate psychiatric disturbance
- cancers or other illnesses known to cause depression or anxiety
- the adequacy of pain control
- whether or not the person is confident she will receive adequate pain and symptom management
- sources of hope, self-esteem, and strength
- the seriousness and urgency of suicidal intent and the availability of means, including access to firearms and potentially lethal medications
- the person’s mixed feelings about dying
- Treatment goals
- “understand and relieve the desperation that underlies the request for assisted suicide”
- resist becoming a “gatekeeper,” who would focus on issues of competence alone
- Deal with the person’s
- feelings of worthlessness, demoralization
- feelings of guilt requiring reassurance
- black-and-white thinking, rejecting possible solutions
- Complex feelings about their doctors
- Doctors have to deal with their own feelings about
- Disability
- Failure to cure
- Competency model — Capacity to make a decision
- Lack of knowledge
- Coercion
- mental disorders (doesn’t disqualify)
- Shortly after a cancer diagnosis, Michael Freeland requested assisted suicide.
- He saw no use in treating the cancer
- He had already tried to commit suicide years before after his mother killed herself.
- He was a recovering alcoholic
- He had surveillance cameras on his property, and many assault weapons in his home.
- Despite all that, he received a lethal prescription, without a psychiatric evaluation, despite his history of depression and suicide attempts.
- Lets look at the support provided by a Compassionate Care volunteer vs. assisted suicide counselling provided by Compassion & Dying doctors.
- Removing the means for suicide (weapons) vs. providing the means.
- Consideration of Freeland’s depression vs. lack of interest in mental health history
- Took Freeland’s suicidal threats seriously because of previous attempts vs. uninterested in previous suicide attempts
- Provided support and arranged for mental health treatment, vs. believed Freeland didn’t need psych evaluation, and was unaware that Freeland was hospitalized and determined incompetent by a psychiatrist.
- Arranged pain management and palliative care vs. offering to sit with Freeland while he took lethal dose.
- Encouraged him to take anti-depressants, which helped his mood and improved his quality of life.
- Reminded him she did not want him to die.
- Other doctors were put in a bind when faced with a suicidal mentally ill person, who had been given a lethal prescription by another doctor.