Psychological issues in euthanasia, suicide, and assisted suicide

This paper reviews various life-ending techniques such as euthanasia, suicide, and assisted suicide in order to better address the psychological issues related to these actions. Specific attention is paid to investigating when a death is deemed to be appropriate and the role that the level of appropriateness should play in the decisions of individuals to terminate a life. In addition, a number of additional psychological concepts such as locus of control and subjective norms are examined in terms of their importance for decisions regarding euthanasia and suicide.     

Euthanasia: Israeli Social Workers' Experiences, Attitudes and Meanings

Correspondence to Dr Ronit D. Leichtentritt, Bob Shapell School of Social Work, Tel Aviv University, Tel Aviv, Israel. E-mail: ronitl{at}post.tau.ac.il Summary Sixteen social workers in Israel were interviewed about theirexperiences with and attitudes towards various forms of euthanasia,as well as the meanings they ascribe to them. Using phenomenologicalanalysis, seven themes were identified, emphasizing individual,interpersonal, organizational, social and therapeutic considerations,and suggesting a holistic and integrative structure of the phenomenon.The themes were arrived at by identifying distinctions and similaritiesbetween different forms of euthanasia. Two themes suggestingsimilarities were revealed: ‘diminishing the value oflife’ and ‘a call for help’. Three themeswere found to distinguish between passive euthanasia (withholdingand withdrawing life-sustaining treatment) and active forms(active euthanasia and assisted suicide): ‘legality’,‘social acceptance’ and ‘concern for the sickand dying’. The last two themes distinguished betweenwithholding treatment and assisted suicide, on the one hand,and withdrawing treatment and active euthanasia, on the other:‘the involvement of others as executor’ and ‘thepublicity of the act’. Further research and training isrequired to better inform social workers in this ethical area.Given their unique position, social workers should activelyparticipate in legal, social and therapeutic discussions concerningend-of-life decisions, for the benefit of clients, their familiesand health-care providers.     

The Association of Suicide Rates with Individual‐Level Suicide Attitudes: A Cross‐National Analysis*

Objective. Research on the predictors of individual‐level attitudes toward suicide has neglected the possible role of contextual‐level predictors. The present study addresses this gap in the literature by assessing the association between suicide rates and the attitudes of individuals. Based on social learning theory, it is argued that persons socialized in nations with relatively high rates of suicide are more likely to be exposed to suicidal role models, which provide positive definitions of suicide. Methods. Data refer to 40,873 adults in 31 nations, and are taken from the World Health Organization and World Values Surveys. Given the bi‐level nature of the data, hierarchical linear modeling techniques (HLM) are utilized. Additional predictor variables are incorporated from previous research and include religious participation and political orientation from social learning theory, marital status and life satisfaction from control theory, and basic demographics such as age and gender. Results. The results of the HLM indicate that controlling for individual‐level predictors, as well as other Level 2 variables, persons residing in nations with relatively high suicide rates are more approving of suicide than their counterparts. The model was replicated for the prediction of support for euthanasia. A social learning perspective was further supported by results linking 1970 suicide rates with suicide acceptability among older adults in 1990. Conclusion. National suicide rates are predictive of individual‐level suicide acceptability. However, the main predictors of suicide acceptability included a measure from social learning theory, religiosity, and a neglected measure of control theory, life satisfaction.     

Euthanasia and assisted suicide: a survey of registered social workers in British Columbia

This anonymous postal survey explores the attitudes and experiences concerning voluntary euthanasia (VE) and assisted suicide (AS) held by professionally registered members of the British Columbia Association of Social Workers. Social workers determine only a minor moral distinction between VE and AS and a large majority believe both acts should be legal, in certain circumstances (VE 75.9 per cent; AS 78.2 per cent). Approximately 80.0 per cent feel that social workers should be involved in social policy development concerning VE and AS, and, if such acts were to be legal, 70.0 per cent believe social workers should be involved in the decision making process with clients. Over 21.0 per cent of all social workers and nearly 40.0 per cent of social workers with medical employers have been consulted by a patient about VE or AS. Six respondents (1.1 per cent) reported assisting the death of a patient by VE. None had involvement in AS. Further research and education is required to better inform social work practice in this ethical area. Given the unique position of social workers in health care, they should, for the benefit of patients, families, and physicians, actively participate in the discussion concerning end of life decisions.     

Views of euthanasia from an east Texas university

Euthanasia has become a subject of public debate and concern. Here we examine the views of euthanasia among students at an east Texas university. Roughly three-fourths are in favor of euthanasia -similar to the general public. Because the university is located in a conservative geographical area, this result suggests growing approval of the various forms of euthanasia and doctor assisted death. While no significant differences were found between the three student major groups -Liberal Arts, Science and Business, some demographic differences were found within the groups. Mainly, African American female Science majors are the most opposed to euthanasia whereas Caucasian male Science majors are the most in favor and the most likely to use a scientific definition of death. The views of the latter group contrast notably with practicing doctors who lag behind the public in their approval of euthanasia. Student views might reflect a cohort difference, a lack of professional experience, or a growing trend among medical practitioners. Liberal Arts majors are the most conservative of the three groups, indicating nonscientific reasons for opposition. Resistance to euthanasia is apparently associated with demographics and nonscientific reasoning.     

Euthanasia: an introduction

It has been argued that euthanasia is one of the most pressing social concerns of our times. A review of current scientific and legal materials, however, indicates that this issue is a complex and contentious one that crosses numerous perspectives and theoretical orientations. In order to provide background for the other articles in this collection, we present a brief history of attitudes toward euthanasia. In addition, various terms that are associated with the concept of euthanasia are defined. Finally, this paper provides a framework for the articles that follow by suggesting that three central issues must be addressed in order to resolve the controversies surrounding euthanasia. These are (1) the establishment of standardized criteria of euthanasia eligibility, (2) the investigation of public attitudes regarding acceptable means for engaging in euthanasia, and (3) the evaluation of the roles of professionals who are directly involved in euthanasia decisions. We hope that the following articles will provide insight into these issues.     

Practical reasons and reasonable practice: the case of euthanasia in The Netherlands

Since the early 1970s the issue of euthanasia has been intensely debated in The Netherlands. Through these debates knowledge about medical practices involving the end of life was no longer confined to medical or legal quarters, but became public to a large extent. Following public opinion changes, the legal reaction to euthanasia changed. By prosecuting test cases the public prosecutors allowed the Dutch Supreme Court to formulate specific conditions in which euthanasia would go unpunished. The political debate about changing the criminal law, which still holds that euthanasia is a serious crime, developed at a much slower pace. Several extensive empirical studies were undertaken to gain valid knowledge about the medical practices. This article is concerned with a presentation of the various debates and the changes that took place in the fields of criminal law, politics, and medicine. The main conclusion is the hypothesis that a more open climate for medical practices concerning the end of life allows society to better control these practices.     

On gender role violations and judgments made about euthanasia: a research note

The impact of perceived gender role violations on the willingness of evaluators to label a deadly act to "end suffering" as euthanasia was explored in two studies. It was predicted that "killing" (even mercy killing) would be perceived as more role contradictory for a female actor than for a male actor. Therefore, it was expected that the deadly actions of a female actor would be judged as less justified (i.e., less likely to be labeled as euthanasia) than the same action committed by a male actor. A total of 486 undergraduates participated in one of two studies. It was found that although perceptions of justification for a deadly act were clearly influenced by whether or not the method of action taken was direct and proactive (commission) vs. indirect and passive (omission), the gender of the actor did not impact differently on the judgments of the participants. Possible explanations and future research directions are discussed.     

Rebellion and revenge: the meaning of suicide of women in rural China

The current literature on suicide in China shows that the female suicide rate is extraordinarily higher than the rate for males. Many studies have been conducted on the prevalence and perpetrating factors for suicidal incidents. Few have attempted to understand women's suicide acts. In this article, the ethnographic data are used to explore the special meaning of the suicide act in a Chinese family and its impact on the other family members. Research has shown that suicide may have a different meaning in the Chinese context, especially for women with an inferior status within the family. Suicide is taken as an act of revenge in a moral and spiritual sense. The act of suicide is very powerful; it grants the woman so much power that she may achieve what she could not during her lifetime. The suicide event remains in the collective memory of the relatives and other people who knew the person. Its powerful meaning is related to the memory of the transgressive event of taking one's own life as well as to the collective and personal guilt connected with the event.     

The systematic application of ethical codes in the counseling of persons who are considering euthanasia

As health psychology develops, psychologists and counseling professionals are becoming progressively more involved with patients who have chronic terminal illnesses such as AIDS, Alzheimer's disease, and cancer. Consequently, they will be consulted increasingly by patients, caregivers, and lawyers in cases where euthanasia is being considered. There are numerous ethical dilemmas that could arise when counseling persons who are contemplating euthanasia. Professionals must consider carefully issues such as informed consent, bodily autonomy, respect for a person's dignity, patient welfare, as well as responsibility to society. The national psychological, social work, and medical associations of North America have each adopted a code of ethics. These codes may be used by counseling professionals to assist in the resolution of ethical dilemmas that may arise as a result of working with persons considering euthanasia. This paper discusses the relevance of these codes to the counseling of terminally ill patients.     

Assessing right to die attitudes: a conceptually guided measurement model

This article discusses the current status of research regarding the assessment of attitudes toward euthanasia and other right to die constructs with a focus on conceptual and methodological issues hindering advancement in this area. Two models are presented: a conceptual model for differentiating the various right to die constructs, and a measurement model to guide scale development and refinement. The conceptual model defines the right to die constructs as a function of locus of decision and locus of action. Health status and age are hypothesized as important factors that in some instances are defining attributes in right to die constructs and in other instances are factors influencing people's attitudes toward the right to die. The measurement model considers the importance of construct specificity, individual characteristics, and conviction in the assessment of right to die attributes. An extant euthanasia attitude scale is presented and evaluated in terms of the models to demonstrate how they may be useful for advancing attitude research in this important area.     

The Bereavement of Parents and Their Search for Meaning

Summary The emotional relief of bereavement is generally recognizedas being the primary task of mourner and caregiver, but lessattention has been given to the ways in which the bereaved understandtheir experience and reconstitute family life. Recent studiesof parents whose children have died in traumatic circumstances,from murder, suicide and operation, suggest that it is an essentialpart of griefwork to resolve the meaninglessness of the crises.Those whose children die from chronic disease, handicaps, oraccidents, also need to find a meaning in their tragedies. Bereavementis thus a total psychophysical experience of suffering, andthe renewal of family life depends on the acceptance of separationand the regenerative use of its pain. Insights from psychiatrists and sociologists are acknowledgedand related to those of bereaved parents, and to the developmentof their self-help association, The Compassionate Friends. Theseprovide models of mourning and a collective response to familyloss which offer hope, support and varieties of meaning to thenewly bereaved. The roles of health and social workers involved in pre- andpost-bereavement care are explored, and ideas are offered formaking the social network more supportive. It is suggested thatthis will not be costly in material resources, but in thoseneeded for the more therapeutic involvement of the caregiver.     

The Politics of Hope and Despair: The Effect of Presidential Election Outcomes on Suicide Rates*

Objectives. This article examines the effect of election outcomes on suicide rates by combining the theory of social integration developed by Durkheim with the models of rational choice used in economics. Methods. Theory predicts that states with a greater percentage of residents who supported the losing candidate would tend to exhibit a relative increase in suicide rates. However, being around others who also supported the losing candidate may indicate a greater degree of social integration at the local level, thereby lowering relative suicide rates. We therefore use fixed‐effects regression of state suicide rates from 1981 to 2005 on state election outcomes during presidential elections to determine which effect is stronger. Results. We find that the local effect of social integration is dominant. The suicide rate when a state supports the losing candidate will tend to be lower than if the state had supported the winning candidate—4.6 percent lower for males and 5.3 percent lower for females. Conclusion. Social integration works at many levels; it not only affects suicide risk directly, but can mediate other shocks that influence suicide risk.     

Management of Pressure Sores in the Inpatient Hospice Setting

ABSTRACT

Hospice care is a valuable approach to persons with progressive, fatal illness, that emphasizes the relief of symptoms -making what time they have left the best possible -rather than a futile attempt at cure when cure is not possible. Pressure sores are a common problem in the hospice setting that may contribute to the suffering of the patient. Risk factors for pressure sores include immobility, poor nutrition and the catabolic state, moisture, and sheer forces. In managing pressure sores in the hospice, it is important to remember that the primary goal is to relieve symptoms and not necessarily to cure disease. The most important factor is having a dedicated nursing staff, while specific approaches are secondary. Beyond this, important factors are good positioning, optimizing nutrition and adequate analgesia. Once these are achieved, the general principal is “clean it up, cover it up and leave it alone.” Surgical procedures and cultures and systemic antibiotics are to be avoided in this setting. The specific technique for fairly superficial ulcers, after cleansing, is to cover them with a semiperiable membrane, such as OpsiteT or DuodermT. Deeper ulcers and those with copious drainage are often managed better by cleansing daily with saline, filling the crater with a mixture of SilvadeenT and sugar (in the high concentration used, the sugar provides osmotic cleansing while not promoting bacterial growth), and covering with sterile gauze.     

Suicide prevention in Bangladesh: The current state and the way forward

Despite the World Health Organization's (WHO) call to adopt a national action plan on suicide, Bangladesh is yet to respond proactively to prevent this serious public health problem. The existing government and non‐government prevention interventions are very limited, segmented and almost invisible. Suicide (including attempted suicide) is currently a criminal offense under the Bangladeshi legal framework. The aim of this paper is to propose a framing toward a national suicide prevention action plan in Bangladesh based on a situational analysis of local existing suicide prevention interventions. International policy documents, empirical and review works, and legal documents that speak to suicide interventions were reviewed. Critical analysis of these interventions suggests that Bangladesh should prioritize the adoption of a multi‐sectoral suicide prevention action plan. The issue of decriminalization suicide should be carefully considered and policies harmonized before adopting the plan. Obtaining commitment from the policymakers to launch such intervention may be challenging. Considering the seriousness of the problem, Bangladeshi policymakers should be proactive in adopting a suicide prevention action plan. Neighboring countries provide useful lessons of the implementation measures that may assist with developing a suicide prevention action plan.     

Fifty family deserters: An inquiry into the reasons for their desertion 1

Human papillomavirus (HPV) is the most common sexually transmitted infection and the leading cause of cervical cancer. Consistent disparities in the incidence and mortality rates of cervical cancer for racial minorities and low-income women have been found. To date, there have been no articles written in a social work journal about HPV. This article presents an argument for including HPV under social work's purview and presents research findings that suggest access to the HPV vaccine, Gardasil®, may be difficult for financially vulnerable consumers. Recommendations for future interventions and research are offered.     

Perceptions of preparedness to assist elders with end-of-life care preferences

Using a systematic sample of Florida licensed clinical social workers (N = 272), this study found that respondents perceived themselves capable of assisting elders with end-of-life care decisions and considered themselves moderately knowledgeable of resources available to elder clients. Respondents indicated slightly positive attitudes for work with elders and elders with Alzheimer's disease, and most respondents believed that elders should have the right of physician-assisted suicide. Using multivariate analysis, four predictor variables were identified that account for 61.3% of the adjusted variance of the dependent variable of preparedness to assist elders with end-of-life care preferences. These predictor variables were (a) knowledge of resources available to elders, (b) desirability of working with elders, (c) desirability of working with elders with Alzheimer's disease, and (d) attitude toward assisted suicide.     

Perceptions of Preparedness to Assist Elders with End-of-Life Care Preferences

Abstract

Using a systematic sample of Florida licensed clinical social workers (N = 272), this study found that respondents perceived themselves capable of assisting elders with end-of-life care decisions and considered themselves moderately knowledgeable of resources available to elder clients. Respondents indicated slightly positive attitudes for work with elders and elders with Alzheimer's disease, and most respondents believed that elders should have the right of physician-assisted suicide. Using multivariate analysis, four predictor variables were identified that account for 61.3% of the adjusted variance of the dependent variable of preparedness to assist elders with end-of-life care preferences. These predictor variables were (a) knowledge of resources available to elders, (b) desirability of working with elders, (c) desirability of working with elders with Alzheimer's disease, and (d) attitude toward assisted suicide.     

Rethinking Suffering: Allowing for Suffering that is Intrinsic at End of Life

The dilemma so central to the work of providers of palliative and end-of-life care is the paradox of their professional and ethical duty to try to relieve suffering and the limitations of so doing. While the capacity to sit with suffering at the end of life is critical to clinical work, the idea that some intrinsic suffering cannot necessarily always be relieved may model for patients and families that suffering can be borne. Clinicians who encounter unrelievable suffering may feel a sense of failure, helplessness, moral distress, and compassion fatigue. While tolerating suffering runs counter to the aims of palliative care, acknowledging it, bearing it, and validating it may actually help patients and families to do the same. “Sitting with suffering” signals a paradigm shift within the discipline of palliative care, as it asks clinicians to rethink their role in being able to relieve some forms of psychosocial suffering intrinsic to dying.