Introduction

Webcast archive: Evaluation for competency

Today, we discuss the link between suffering and competency in assisted suicide requests, including the story of Michael Freeland.

Webcast archive: Evaluation for competency

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.