Patients in specialist mental healthcare services who are at risk of suicide may experience their struggles as existential in nature. Yet, research on meaning in life has been relatively scarce in suicidology. This qualitative study aimed to explore how patients at risk of suicide perceived their encounters with specialist healthcare professionals after a suicide attempt (SA), with special reference to meaning in life experiences. The study was conducted in specialised mental healthcare services in (...) Norway. Data were collected via individual interviews with eight patients aged 20–75 years. Using a four-step procedure, the interviews were analysed by systematic text condensation. The participants understood their feelings of shame, self-contempt and challenging life experiences as contributing factors to their SA. They perceived that existential themes in relation to financial difficulties, shame and trauma were resolved, while issues associated with the SA, such as death, loss and beliefs, were given less attention. The participants were either ambivalent about continuing to live or wished to rebuild a meaningful life. Overall, their experiences of meaningfulness were hampered. Assisting patients with meaning in life experiences may help them alter their life interpretations and increase their ability to rebuild their lives as meaningful. The present study should be seen as a contribution to meaning-informed approaches in specialist mental healthcare services. More research is needed to equip healthcare personnel in their overall aims of preventing suicide and supporting patients at risk in their efforts to live a meaningful life. (shrink)

The legalization of physician-assisted suicide remains a hotly debated issue throughout the United States, and continues to capture the attention of government officials at both the state and federal levels. While the practice is currently legal in Oregon, some federal lawmakers and officials from the U.S. Department of Justice have attempted to outlaw that state's practice through legislation, or through a strained interpretation of the federal Controlled Substances Act. And while several citizen groups throughout the United States have attempted (...) but failed to legalize PAS through popular initiative, several state lawmakers have succeeded in specifically outlawing the practice. Yet even though physician-assisted suicide remains unlawful in every state except Oregon, there is ample evidence that American physicians throughout the United States have participated in PAS by providing their terminally ill patients with lethal prescriptions. (shrink)

Battin et al examined data on deaths from physician-assisted suicide in Oregon and on PAS and voluntary euthanasia in The Netherlands. This paper reviews the methodology used in their examination and questions the conclusions drawn from it—namely, that there is for the most part ‘no evidence of heightened risk’ to vulnerable people from the legalisation of PAS or VE. This critique focuses on the evidence about PAS in Oregon. It suggests that vulnerability to PAS cannot be categorised simply (...) by reference to race, gender or other socioeconomic status and that the impetus to seek PAS derives from factors, including emotional state, reactions to loss, personality type and situation and possibly to PAS contagion, all factors that apply across the social spectrum. It also argues, on the basis of official reports from the Oregon Health Department on the working of the Oregon Death with Dignity Act since 2008, that, contrary to the conclusions drawn by Battin et al, the highest resort to PAS in Oregon is among the elderly and, on the basis of research published since Battin et al reported, that there is reason to believe that some terminally ill patients in Oregon are taking their own lives with lethal drugs supplied by doctors despite having had depression at the time when they were assessed and cleared for PAS. (shrink)

At the heart of the debate over assisted suicide is the recognition that not all persons can be healed and not all suffering can be relieved. This article addresses the ethical, professional and legal issues to be considered by the nurses in the United States who are facing patients’ requests for assisted suicide. Both personal and professional risks, and the consequences of an action must be evaluated. Ultimately, a decision is based on some ranking of: patient values; (...) personal values and beliefs; professional codes, standards and other guidelines; and societal laws and regulations. (shrink)

It's not unusual to hear someone say, ‘I'd rather be dead than have Alzheimer's’. In ‘Alzheimer Disease and Preemptive Suicide’,1 Dena Davis explains why this is a reasonable position. People taking this position will welcome the discovery of biomarkers permitting very early AD diagnosis, Davis suggests, for this will enable more of them to end their lives while they remain motivated and able to do so. At the same time, Davis observes, people would have less reason to resort to (...) the drastic remedy of pre-emptive suicide if they had absolute authority over the medical treatment they received as patients with dementia; but the threat of pre-emptive suicide is not, in my view, a sufficient reason to grant competent individuals that authority.If preclinical diagnosis of AD becomes possible, some pre-emptive suicides will probably occur. There would be no ethical or practical way to ban such suicides, and it would be silly to try. Clinicians will undoubtedly try to discourage people seeking biomarker information in furtherance of a suicide plan, but savvy individuals will simply conceal their true motivation for having the tests. The real problem for people intent on self-destruction is that biomarkers are unlikely to deliver a clear suicide signal.First, as Davis notes, work on biomarkers remains in the research stage. No one yet knows whether biomarker tests will prove accurate enough to warrant clinical use. Second, even clinically accepted biomarker tests will generate imperfect information about future disease. Biomarkers may produce more accurate estimates of a person's risk of developing AD, but like all predictive tests, they will also yield false positive and negative results. The …. (shrink)

Elderly persons are living longer with debilitating illnesses and are at risk for suicide. They are also more likely to have a living will with a DNR order. With the medical culture’s emphasis on patient autonomy, an ethical approach that respects the dignity of these suffering human persons is needed. Suicide must be viewed as an act against the principle of life and the intrinsic good of the human being. Beneficence outweighs autonomy in such cases. Medical providers (...) are at risk of mediate material cooperation with the evil of such an act if they fail to preserve a life that can be saved. DNR orders should be reversed in these situations until these patients receive psychological treatment and pain relief. National Catholic Bioethics Quarterly 14.4 : 661–671. (shrink)

Suicide is a public health problem which will require an integrated cross-sector approach to help reduce prevalence rates. One strategy is to include the legal system in a more integrated way with suicide prevention efforts. Caine explored a public health approach to suicide prevention, depicting risk factors across the socio-ecological model. The purpose of this paper is to examine laws that impact suicide prevention at the individual, relational, community, and societal levels. These levels are fluid, (...) and some interventions will fall between two, such as a community-level approach to training that enhances provider-patient relationships. At the individual level, we will review laws to improve screening requirements across systems. At the relational level, we note interventions with couples having conflict, such as protection orders and access to attorney consultations, which have been known to be injury prevention mechanisms. At the community level, we discuss legislation that recommends suicide prevention efforts for key individuals working as frontline providers in the medical and educational systems. At the societal level, we explore public awareness campaigns that target stigma reduction for those suffering from mental health burden and enhance linkage to care. The article closes with the discussion that laws are good, but their implementation is essential. (shrink)

The American Medical Association opposes physician-assisted suicide on the grounds that it “would ultimately cause more harm than good,” because it is “fundamentally incompatible with the physician’s role as healer,” and because it “would be difficult or impossible to control and would pose serious societal risks”. It condemns the practice of euthanasia as conducted by physicians for these reasons as well, and adds, by way of clarifying the serious risks at hand, that “euthanasia could readily be extended to incompetent (...) patients and other vulnerable populations”. In this essay I will attempt to rebut these charges. I will devote most of my attention to the... (shrink)

ObjectiveHead and neck cancer treatments are known to significantly affect functionality and appearance, leading to an increased risk for body image disturbances. Yet, few longitudinal studies exist to examine body image in these patients. Based on a conceptual model, the current study aimed to determine, in patients newly diagnosed with HNC: the prevalence, level, and course of body image concerns; correlates of upon cancer diagnosis body image concerns; predictors of immediate post-treatment body image concerns; and association between (...) body image concerns and levels of anxiety, depression, suicidal ideation, support, and alcohol and drug misuse.MethodsTwo hundred and twenty-three, newly diagnosed with a primary HNC were assessed using structured clinical interviews and psychometric measures at three, and 6 months after diagnosis. Primary outcome was 3-month, as it was most salient to body image disturbance. Multiple linear regression analyses were conducted on the potential body image predictors, based on the model.ResultsSixty-eight percent of patients with HNC presented some level of body image concerns. Body image concerns at baseline and post-treatment were significantly related and significantly increased from pre- to post-treatment. Immediately post-treatment, 89% presented some level of body image concerns. Correlates of body image concerns in patients with HNC at baseline included: physical symptom burden, difficulties with communication and eating, coping with the cancer diagnosis using denial, suicidal ideation, and having had a past anxiety diagnosis. When controlling for sociodemographic and medical variables, body image concerns in patients with HNC in the immediate post-treatment were predicted by: baseline body image, physical symptom burden, and neuroticism.ConclusionThis longitudinal study helps identify patients more susceptible to experience body image disturbance following head and neck cancer. Clinicians ought to pay special attention to body image concerns upon cancer diagnosis, physical symptom burden, and neuroticism, and may want to target these factors in future preventive interventions. (shrink)

Background Clinical papers so flawed that they are eventually retracted may put patients at risk. Patient risk could arise in a retracted primary study or in any secondary study that draws ideas or inspiration from a primary study. Methods To determine how many patients were put at risk, we evaluated 788 retracted English-language papers published from 2000 to 2010, describing new research with humans or freshly derived human material. These primary papers—together with all secondary studies (...) citing them—were evaluated using ISI Web of Knowledge. Excluded from study were 468 basic science papers not studying fresh human material; 88 reviews presenting older data; 22 case reports; 7 papers retracted for journal error and 23 papers unavailable on Web of Knowledge. Overall, 180 retracted primary papers (22.8%) met the inclusion criteria. Subjects enrolled and patients treated in 180 primary studies and 851 secondary studies were combined. Results Retracted papers were cited over 5000 times, with 93% of citations being research related, suggesting that ideas promulgated in retracted papers can influence subsequent research. Over 28 000 subjects were enrolled—and 9189 patients were treated—in 180 retracted primary studies. Over 400 000 subjects were enrolled—and 70 501 patients were treated—in 851 secondary studies which cited a retracted paper. Papers retracted for fraud (n=70) treated more patients per study (p<0.01) than papers retracted for error (n=110). Conclusions Many patients are put at risk by retracted studies. These are conservative estimates, as only patients enrolled in published clinical studies were tallied. (shrink)

Mood disorder patients have greater suicide risk than members of the general population, but how suicidal behavior relates to brain functions has not been fully elucidated. This study investigated how functional connectivity (FC) values between the right/left amygdala and the whole brain relate to suicidal behavior in patients with mood disorder. The participants in this study were 100 mood disorder patients with suicidal behavior (SB group), 120 mood disorder patients with non-suicidal behavior (NSB group), (...) and 138 age- and gender-matched healthy controls (HC group). Whole-brain FC values among the three groups were compared using an analysis of covariance (ANCOVA). Compared to the NSB and HC groups, increased FC values in the right amygdala-bilateral paracentral lobule/precuneus circuit were observed in the SB group (Bonferroni-corrected,p 0.017). Moreover, there were no significant differences in FC values between mood disorder patients with suicide attempt (SA group) and mood disorder patients with suicidal ideation (SI group), while the FC values between the right amygdala and bilateral paracentral lobule/precuneus in the SA group were higher than the mean in the SI group. These findings suggest that right amygdala-paracentral lobule/precuneus dysfunction has an important role in patients with mood disorder and suicidal behavior. (shrink)

Nurses and midwives are the majority of healthcare professionals globally, including Africa, and they provide care at all levels of the health system including community levels. Nurses and midwives contribute to the care of patients with rigid or dogmatic religious beliefs or those with suicidal ideations. This review paper discusses acute and chronic diseases that have suicidal tendencies such as terminal cancer, diseases with excruciating pain, physical disability, stroke, end-stage renal failure, and diabetics who are amputated. It was reiterated (...) that nurses and midwives taking care of these patients should be alert and observant to identify their suicidal tendencies. The paper also discusses religious or spiritual inclinations that negatively affect healthcare access and adherence, especially to biomedical or western medicine. It was emphasized that some religious beliefs do not allow their followers to employ biomedical treatment and nurses and midwives should not impose their faith on patients and their families. The paper ends with a discussion on the specific roles of nurses and midwives in the care of patients with suicidal ideations such as assessment, counseling, administering medication, observation, social interaction, ensuring safety measures, and providing an enabling environment for the family to part of the care and for the observation of religious coping strategies. Nurses and midwives should enhance their knowledge and skills on suicide and increase public education on suicide prevention and identification of those at risk. (shrink)

The documented efficacy and long-term benefit of antidepressants in patients with recurrent forms of severe anxiety or depressive disorders support their use in those individuals with these disorders, who experience suicidal thoughts or behavior. In general, it is assumed that antidepressants are beneficial for all symptoms of depression, including suicidality. However, some evidence suggests that Selective Serotonin Reuptake Inhibitors [SSRIs] may cause worsening of suicidal ideas in vulnerable patients. Systematic reviews and pooled analysis of experimental, observational, and epidemiological (...) studies have investigated the use of SSRIs and their association with suicidality. Taking account of the methodological limitations of these studies, the current evidence fails to provide a clear relationship between their use and risk of suicidality in adults. However, in children and adolescents, there appears to be a bit of increased risk of suicidal ideations and attempts, but not of completed suicides. This risk can be anticipated and managed clinically. Clinicians are, therefore, advised to maintain a close follow-up during the initial treatment periods and remain vigilant of this risk. This advisory, however, should not deter clinicians from the use of effective dosages of antidepressants for a sufficient period of time, in every age group of patients, when clinically needed, and if found suitable otherwise. (shrink)

Psychiatric nurses frequently encounter suicidal patients. Caring for such patients often raises ethical questions and dilemmas. The research question for this study was: 'What understandings are revealed in texts about consolation and psychiatric nurses' responses to suicidal patients?' A Gadamerian approach guided re-interpretation of published texts. Through synthesizing four interpretive phases, a comprehensive interpretation emerged. This revealed being 'at home' with self, or an ethical way of being, as a hermeneutic understanding of a way to become ready (...) to mediate consolation with suicidal patients. Trustworthiness was addressed by means of the qualities of auditability, credibility and confirmability. This re-interpretation adds to nursing knowledge, enhances understanding of previous research findings, provides pre-understanding for further research and reveals the value of hermeneutic inquiry in nursing. It also deepens understanding of a published model of consolation. These understandings may help to guide nurses who are struggling with suicidal patients. (shrink)

For each one of the approximately 800,000 people who die from suicide every year, an additional twenty people attempt suicide. Many of these attempts result in hospitalization or in contact with other healthcare services. However, many personal, educational, and institutional barriers make it difficult for healthcare professionals to care for suicidal individuals. We reviewed literature that discusses suicidal patients in healthcare settings in order to highlight common ethical issues and to identify knowledge gaps. A sample was generated (...) via PubMed using keywords “[(ethics OR *ethic*) AND suicid*] AND [English (Language) OR French (Language)]” (final N = 52), ethics content was extracted according to scoping review methodology, and categorized thematically. We identified three main areas posing ethical challenges for health professionals caring for suicidal individuals and their families. These were: (1) making clinical decisions for patients in acute care or when presented with specific circumstances; (2) issues arising from therapeutic relationships in chronic care, and (3) organizational factors. There is considerable uncertainty about how to resolve ethical issues when caring for someone who is suicidal. The stigma associated with suicide and mental illness, problems associated with risk–benefit assessments, and the fear of being held liable for malpractice should a patient die by suicide were overarching themes present across these three categories. Caring for suicidal patients is clinically and ethically challenging. The current literature highlights the complexity and range of decisions that need to be made. More attention should be paid to the difficulties faced by healthcare professionals and the development of solutions. (shrink)

A lively topic of debate in decision theory over recent years concerns our understanding of the different risk attitudes exhibited by decision makers. There is ample evidence that risk-averse and risk-seeking behaviours are widespread, and a growing consensus that such behaviour is rationally permissible. In the context of clinical medicine, this matter is complicated by the fact that healthcare professionals must often make choices for the benefit of their patients, but the norms of rational choice are (...) conventionally grounded in a decision maker’s own desires, beliefs and actions. The presence of both doctor and patient raises the question of whose risk attitude matters for the choice at hand and what to do when these diverge. Must doctors make risky choices when treating risk-seeking patients? Ought they to be risk averse in general when choosing on behalf of others? In this paper, I will argue that healthcare professionals ought to adopt a deferential approach, whereby it is the risk attitude of the patient that matters in medical decision making. I will show how familiar arguments for widely held anti-paternalistic views about medicine can be straightforwardly extended to include not only patients’ evaluations of possible health states, but also their attitudes to risk. However, I will also show that this deferential view needs further refinement: patients’ higher-order attitudes towards their risk attitudes must be considered in order to avoid some counterexamples and to accommodate different views about what sort of attitudes risk attitudes actually are. (shrink)

Suicide is considered a global public health issue and compulsory admission is a commonly used measure to prevent suicide. However, the practice has been criticised since several studies indicate that the measure lacks empirical support and may even increase suicide risk. This paper investigates whether the practice has enough empirical support to be considered proportionate. To that end, arguments supporting compulsory admission as a suicide-preventive measure for most suicidal patients are scrutinized. The ethical point (...) of departure is that the expected benefits of compulsory admission should outweigh the potential harms of the measure to be proportionate and defensible. It is concluded that, for most suicidal patients, suicide-preventive compulsory admission cannot be presumed to be a proportionate measure. To be so, the expected medical benefits of the measure should be greater than the potential increase in suicide risk and other harms that compulsory admission could entail. Instead of using compulsory admission as a suicide-preventive measure, extra safety measures may be needed during and after compulsory admission to prevent the risk of hospitalisation-induced suicide. (shrink)

The standard of care in the United States favors stabilizing any adult who arrives in an emergency department after a failed suicide attempt, even if he appears decisionally capacitated and refuses life-sustaining treatment. I challenge this ubiquitous practice. Emergency clinicians generally have a moral obligation to err on the side of stabilizing even suicide attempters who refuse such interventions. This obligation reflects the fact that it is typically infeasible to determine these patients’ level of decisional capacitation—among other (...) relevant information—in this unique setting. Nevertheless, I argue, stabilizing suicide attempters over their objection sometimes violates a basic yet insufficiently appreciated right of theirs—the right against bodily invasion. In such cases, it is at least prima facie wrong to stabilize a patient who wants to die even if they lack a contrary advance directive or medical order and suffer from no terminal physical illness. (shrink)

Suicide is a complex act whose meanings, while sometimes tragic, vary widely. This chapter surveys the ethical landscape surrounding algorithmic methods of suicide prevention especially as it pertains to social media activity and to the moderation of online suicide communities. We begin with a typology of suicide, distinguishing between varied goals in which suicide may factor as a means. Suicides should be understood as an act with varied eliciting desires, meanings, consequences, and ethics. Further,while many (...) suicides may be grounded on irrational desire, we argue that a desire to suicide may nonetheless be rational in some cases. We then offer a survey of the attempts by social media corporations to create suicide prediction algorithms and launch interventions aimed at preventing suicide as well as an overview of the current ethical debate. We argue that the values embedded within algorithmic suicide prevention nudges are “thick” in a substantive sense and deserving of scrutiny. Given that debates about the rationality, meaning, and permissibility of suicide are common and subject to intracultural and cross-cultural differences, we maintain that the task of suicide prediction is ill-suited to algorithmic approaches. Despite an algorithm’s ability to quantify a complex phenomenon like suicide risk and its appearance of objectivity, any suicide prediction algorithm is thoroughly subjective and involves moral judgments all the way down. Any such algorithm would necessarily impose a normative stance on suicide onto its user base that is subject to reasonable intra and cross-cultural disagreement. (shrink)

As suicide rates increase worldwide, the mental health industry has reached an impasse in attempts to assess patients, predict risk, and prevent suicide. Traditional assessment tools are no more accurate than chance, prompting the need to explore new avenues in artificial intelligence (AI). Early studies into these tools show potential with higher accuracy rates than previous methods alone. Medical researchers, computer scientists, and social media companies are exploring these avenues. While Facebook leads the pack, its efforts (...) stem from scrutiny following suicides and suicide attempts broadcasted on Facebook Live. The company continues to face scrutiny for ethical, privacy, and safety concerns associated with the quick rollout of proprietary AI technology that seems more focused on the optics of the company than the protection of its billions of users. This paper explores some of these issues, including a lack of transparency, questionable data practices, escalation to law enforcement, little to no regulation, potential for bias, increased viewership of troubling content, and worsening thoughts of suicide among vulnerable Facebook users. Despite AI tools showing promise in improving the accuracy of suicide risk predictions over traditional methods, without regulation, external review, and increased protection of users and data, these tools have the potential to cause more harm than good in the hands of powerful companies like Facebook. (shrink)

In this piece I discuss when care providers should not contact suicidal patients’ families to get collateral information from them or hospitalize patients over their objections. I suggest that when these patients are chronically suicidal, overriding these wants may be best in the short run but increase their net risk in the longer run. I also discuss in this regard how contacted families may become overprotective and how hospitalization can be traumatic. I present an alternative approach (...) that can increase these patients’ safety over the longer run and relate three practical approaches care providers may find useful: explaining their decisions to patients, monitoring their own fear, and instilling hope. (shrink)

Derek Parfit’s view of ‘personal identity’ raises questions about whether advance decisions refusing life-saving treatment should be honored in cases where a patient loses psychological continuity; it implies that these advance decisions would not be self-determining at all. Part I of this paper argues that this assessment of personal identity undermines the distinction between suicide and homicide. However, rather than accept that an unknown metaphysical ‘further fact’ underpins agential unity, one can accept Parfit’s view but offer a different account (...) of what it implies morally: that the social and legal bases for ascribing a persisting ‘personal identity’ maintain the distinction between homicide and suicide. (shrink)

It is often argued by health professionals working within the field of palliative care that palliative care and euthanasia/assisted suicide are incompatible. Across the literature, this claim is grounded on the three claims that (1) palliative care and euthanasia/assisted suicide have different aims, (2) euthanasia/assisted suicide is at odds with the doctor’s fundamental role as a healer, and (3) euthanasia/assisted suicide constitutes patient abandonment. Furthermore, even if palliative care and euthanasia/assisted suicide are compatible, it is (...) often argued that the availability of palliative care renders euthanasia/assisted suicide redundant. This depends on two claims that (1) palliative care is always available and effective, and (2) palliative care is always preferable to euthanasia/assisted suicide. This article argues that all of these claims are false, ultimately aiming to establish that palliative care and euthanasia/assisted suicide are complementary rather than mutually exclusive. (shrink)

In an age of rapid advances inlife-prolonging treatment, patients and caregivers areincreasingly facing tensions in making end-of-lifedecisions. An examination of the history of healthcare in the United States reveals technological,economic, and medical factors that have contributed tothe problems of terminal care and consequently to themovement of assisted suicide. The movement has itsroots in at least two fundamental perceptions andexpectations. In the age of technological medicineenergized by the profit motive, dying comes at a highprice in suffering and in personal (...) economic loss. Thefailure to provide affordable resources for terminalcare is the result of the marketplace in health care. The medical profession has been painfully slow inresponding to the challenges of terminal care, mainlybecause of the pressures of the marketplace and lackof adequate training. This has occurred at a time ofrapid advances in life-sustaining treatment and ofexpanding public awareness of personal rights underthe law. Overly aggressive treatment in the finalstages of terminal illness has enhanced anxieties overa painfully prolonged and expensive dying. Thesefactors have promoted the movement to assistedsuicide. In the U.S. debate of the issues, ethiciststend to argue abstractly without examiningadequately the context of terminal care that is thehealth care system. It is a system in dire need of areform that will remove it from the marketplace. (shrink)

Volume 19, Issue 10, October 2019, Page 97-98.

The medical response to suicide is generally resuscitation, followed by attempts to maximise the patient's recovery. Care is generally withdrawn when it is futile and there is no hope for recovery. Suicidal patients who have completed an advance directive may complicate matters. Should medical providers not resuscitate a patient with an advance directive who has attempted to commit suicide? If stated wishes for care are ignored in the emergency setting, how should decisions be made over time in (...) the event of a successful resuscitation resulting in the need for prolonged therapy counter to the wishes of the advance directive? What are the merits of the stated the wishes of suicidal patient? What if they were depressed at the time of the advance directive? This case highlights the need for consideration of these and other concerns in the care of patients who commit suicide and have an advance directive. (shrink)

What I call medically enabled suicides have four distinctive features: 1. They are instigated by actions of a suicidal individual, actions she intends to result in a physiological condition that, absent lifesaving medical interventions, would be otherwise fatal to that individual. 2. These suicides are ‘completed’ due to medical personnel acting in accordance with recognized legal or ethical protocols requiring the withholding or withdrawal of care from patients (e.g., following an approved advance directive). 3. The suicidal individual acts purposefully (...) to ensure that medical personnel will act on these protocols. 4. These suicides do not involve medical personnel providing aid in dying in the standard sense, either through (a) active voluntary euthanasia, or (b) assistance by means of prescriptions, etc. -/- Regardless of how common medically enabled suicides are, they raise compelling questions at the interface of medicine and individual choice. After first clarifying the concept of medically enabled suicide and exploring some of the reasons why it might be attractive to suicidal individuals, I then investigate two apparent dilemmas that medically enabled suicides raise for medical care providers. The first alleges that medical care providers may not contribute to harming their patients, and so they may not contribute to their patients’ suicides. The second alleges that if care providers, as a matter of personal conscience, believe that suicide is wrong, then they may not be compelled to contribute to their patient’s acting wrongly by assenting to the wishes of a patient pursuing medically enabled suicide. Both dilemmas arise from the fact that while medical personnel are bound by widely accepted precepts of medical ethics to honor the competent wishes of their patients, medically enabled suicides entangle them in their patients’ suicidal plans in ways that result in their contributing to those suicides. I conclude that neither dilemma should be resolved in the direction of medical personnel having the right to refrain from involvement in medically enabled suicides. Thus, while we may find medically enabled suicide distasteful or exploitative, a strong case cannot be made that medical personnel refusing to involve themselves in such suicides is ethically permissible. (shrink)

There are widely held premises that suicide is almost exclusively the result of mental illness and there is “strong evidence for successfully detecting and managing suicidality in healthcare”. In this context, ‘zero-suicide’ policies have emerged, and suicide risk assessment tools have become a normative component of psychiatric practice. This essay discusses how suicide evolved from a moral to a medical problem and how, in an effort to reduce suicide, a paternalistic healthcare response emerged to (...) predict those at high risk. The evidence for the premises is critiqued and shown to be problematic; and it is found that strong paternalistic interventions are being used more often than acknowledged. Using a Principles approach, the ethics of overriding autonomy in suicide prevention is considered. Ethical concerns are identified with the current approach which are potentially amplified by the use of these risk assessments. Furthermore, it is identified that the widespread use of risk assessments in health settings is equivalent to screening without regard to the ethical principles of screening. The essay concludes that this is unethical; that we should abandon the use of standardized suicide risk assessments and ‘zero-suicide’ policy; and that this may improve outcomes. (shrink)

This study reviews the existing literature on psychiatric interventions for individuals affected by the COVID-19 epidemic. My article cumulates previous research on how extreme stressors associated with COVID-19 may aggravate or cause psychiatric problems. The unpredictability of the COVID-19 epidemic progression may result in significant psychological pressure on vulnerable populations. Persons with psychiatric illnesses may experience worsening symptoms or may develop an altered mental state related to an increased suicide risk. The inspected findings prove that psychological intervention measures (...) for patients affected by the epidemic should be designed and personalized adequately. Preventive measures seek to decrease infection rates and cut down the risk of the public healthcare system to eventually be overburdened. Throughout the COVID-19 crisis, people with psychiatric illnesses may confront a decrease in mental health services. As limitations in the current review, by focusing only on articles published in journals indexed in Web of Science, Scopus, and ProQuest, I inevitably disregarded other valuable sources. Subsequent research directions should clarify the effectiveness of online mental health services in providing remote psychiatric interventions to individuals affected by the COVID-19 epidemic. (shrink)

Total knee arthroplasty (TKA) is a commonly implemented elective surgical treatment for end-stage osteoarthritis of the knee, demonstrating high success rates when assessed by objective medical outcomes. However, a considerable proportion of TKA patients report significant dissatisfaction postoperatively, related to enduring pain, functional limitations, and diminished quality of life. In this conceptual analysis, we highlight the importance of assessing patient-centred outcomes routinely in clinical practice, as these measures provide important information regarding whether surgery and postoperative rehabilitation interventions have effectively (...) remediated patients’ real-world “quality of life” experiences. We propose a novel precision medicine approach to improving patient-centred TKA outcomes through the development of a multivariate machine-learning model. The primary aim of this model is to predict individual postoperative recovery trajectories. Uniquely, this model will be developed using an interdisciplinary methodology involving non-linear analysis of the unique contributions of a range of preoperative risk and resilience factors to patient-centred TKA outcomes. Of particular importance to the model’s predictive power is the inclusion of a comprehensive assessment of modifiable psychological risk and resilience factors that have demonstrated relationships with TKA and other conditions in some studies. Despite the potential for patient psychological factors to limit recovery, they are typically not routinely assessed preoperatively in this patient group, and thus can be overlooked in rehabilitative referral and intervention decision-making. This represents a research-to-practice gap that may contribute to adverse patient-centred outcomes. Incorporating psychological risk and resilience factors into a multivariate prediction model could improve the detection of patients at risk of sub-optimal outcomes following TKA. This could provide surgeons and rehabilitation providers with a simplified tool to inform postoperative referral and intervention decision-making related to a range of interdisciplinary domains outside their usual purview. The proposed approach could facilitate the development and provision of more targeted rehabilitative interventions on the basis of identified individual needs. The roles of several modifiable psychological risk and resilience factors in recovery are summarised, and intervention options are briefly presented. While focusing on rehabilitation following TKA, we advocate for the broader utilisation of multivariate prediction models to inform individually-tailored interventions targeting a range of health conditions. (shrink)

Wish to die statements are becoming a frequent phenomenon in terminally ill patients. Those confronted by these statments need to understand the complexity of such wishes, so they can respond competently and compassionately to the requests. If misunderstood, the statements can be taken at face-value and the practitioner may not recognise that a patient is in fact experiencing ambivalent feelings at the end of life, or they may misinterpret the expressed wish to die as a sign of clinical depression. (...) Public debate about the morality and ethics of various end-of-life care options has exploded in recent years. However, it has never been sensitive to the finer aspects of clinical reality or the experiences of patients. The Patient's Wish to Die: Research, Ethics, and Palliative Care brings together that reality and the patient's voice, combining them with different research approaches. It presents the best available knowledge and research methodologies about patients' wishes at the end-of-life, together with a series of ethical views and a discussion about the clinical implications for palliative care. The book presents material in an open and unbiased manner whilst remaining sensitive to the spiritual and existential dimensions of dying, and to the different cultural views that provide meaning to the individual. Written by the best specialists and ethics scholars from around the world, including palliative care practitioners and end-of-life scholars from countries where assisted dying practices are legalized and from those where it isn't, The The Patient's Wish to Die: Research, Ethics, and Palliative Care will prove essential reading for all those working or studying in the field of palliative care. (shrink)

Current UK legislation is impacting upon the feasibility and cost-effectiveness of medical record-based research aimed at benefiting the NHS and the public heath. Whereas previous commentators have focused on the Data Protection Act 1998, the Health and Social Care Act 2001 is the key legislation for public health researchers wishing to access medical records without written consent. The Act requires researchers to apply to the Patient Information Advisory Group for permission to access medical records without written permission. We present a (...) case study of the work required to obtain the necessary permissions from PIAG in order to conduct a large scale public health research project. In our experience it took eight months to receive permission to access basic identifying information on individuals registered at general practices, and a decision on whether we could access clinical information in medical records without consent took 18 months. Such delays pose near insurmountable difficulties to grant funded research, and in our case £560 000 of public and charitable money was spent on research staff while a large part of their work was prohibited until the third year of a three year grant. We conclude by arguing that many of the current problems could be avoided by returning PIAG’s responsibilities to research ethics committees, and by allowing “opt-out” consent for many public health research projects. (shrink)

The legal treatment of physician-assisted suicide is in flux. Reform has been impelled by several forces, including the recent success of novel constitutional arguments in the Ninth and Second Circuit Courts of Appeals. I will review and discuss Compassion in Dying v. State of Washington and Quill v. Vacco, addressing the constitutional arguments, and then briefly considering the attractions and difficulties of these new constitutional theories.Before 1990, state criminal laws dealing with assisted suicide had reached a remarkably stable (...) consensus: suicide was not illegal, but assisting suicide was a criminal action with no distinction typically made between physicians and others who assisted. The details of the relevant criminal law varied from state to state. Some states had criminal statutes specifically addressing assisted suicide, while others treated the practice under more general homicide statutes. But in no state was it clearly legal for a physician to prescribe a lethal medication at the request of a dying patient. While remarkable legal developments took place during the 1970s and 1980s regarding other aspects of the rights of dying patients, there was relative quiescence regarding the law of PAS. (shrink)

Current UK legislation is impacting upon the feasibility and cost-effectiveness of medical record-based research aimed at benefiting the NHS and the public heath. Whereas previous commentators have focused on the Data Protection Act 1998, the Health and Social Care Act 2001 is the key legislation for public health researchers wishing to access medical records without written consent. The Act requires researchers to apply to the Patient Information Advisory Group for permission to access medical records without written permission. We present a (...) case study of the work required to obtain the necessary permissions from PIAG in order to conduct a large scale public health research project. In our experience it took eight months to receive permission to access basic identifying information on individuals registered at general practices, and a decision on whether we could access clinical information in medical records without consent took 18 months. Such delays pose near insurmountable difficulties to grant funded research, and in our case £560 000 of public and charitable money was spent on research staff while a large part of their work was prohibited until the third year of a three year grant. We conclude by arguing that many of the current problems could be avoided by returning PIAG’s responsibilities to research ethics committees, and by allowing “opt-out” consent for many public health research projects. (shrink)

The standard of care in the United States favors stabilizing any adult who arrives in an emergency department after a failed suicide attempt, even if he appears decisionally capacitated and refuses life‐sustaining treatment. I challenge this ubiquitous practice. Emergency clinicians generally have a moral obligation to err on the side of stabilizing even suicide attempters who refuse such interventions. This obligation reflects the fact that it is typically infeasible to determine these patients’ level of decisional capacitation—among other (...) relevant information—in this unique setting. Nevertheless, I argue, stabilizing suicide attempters over their objection sometimes violates a basic yet insufficiently appreciated right of theirs—the right against bodily invasion. In such cases, it is at least prima facie wrong to stabilize a patient who wants to die even if they lack a contrary advance directive or medical order and suffer from no terminal physical illness. (shrink)

In the past few decades, increased awareness of environmental pollution has led to the exploitation of microbial metabolic potential in the construction of several genetically engineered microorganisms (GEMs) for bioremediation purposes. At the same time, environmental concerns and regulatory constraints have limited the in situ application of GEMs, the ultimate objective behind their development. In order to address the anticipated risks due to the uncontrolled survival/dispersal of GEMs or recombinant plasmids into the environment, some attempts have been made to construct (...) systems that would contain the released organisms. This article discusses the designing of safer genetically engineered organisms for environmental release with specific emphasis on the use of bacterial plasmid addiction systems to limit their survival thus minimizing the anticipated risk. We also conceptualize a novel strategy to construct “Suicidal Genetically Engineered Microorganisms (SGEMs)” by exploring/combining the knowledge of different plasmid addiction systems (such as antisense RNA‐regulated plasmid addiction, proteic plasmid addiction etc.) and inducible degradative operons of bacteria. BioEssays 27:563–573, 2005. © 2005 Wiley Periodicals, Inc. (shrink)

There is a need to understand more of the risk factors involved in the process from suicide ideation to suicide attempt. Cognitive control processes may be important factors in assessing vulnerability to suicide. A version of the Stroop procedure, Delis–Kaplan Executive Function System Color–Word Interference Test and Behavior Rating Inventory of Executive Function were used in this study to test attention control and cognitive shift, as well as to assess everyday executive function of 98 acute suicidal (...) psychiatric patients. The Columbia Suicide History Form was used to identify a group of suicide ideators and suicide attempters. Results showed that suicide attempters scored lower on attention control than suicide ideators who had no history of attempted suicide. The self-report in the BRIEF-A inventory did not reflect any cognitive differences between suicide ideators and suicide attempters. A logistic regression analysis showed that a poorer attention control score was associated with the suicide attempt group, whereas a poorer cognitive shift score was associated with the suicide ideation group. The results found in this study suggest that suicide attempters may struggle with control of attention or inhibiting competing responses but not with cognitive flexibility. (shrink)

The moral issues involved in doctors assisting patients to die with dignity are of absolutely central concern to the medical profession, ethicists, and the public at large. The debate is fuelled by cases that extend far beyond passive euthanasia to the active consideration of killing by physicians. The need for a sophisticated but lucid exposition of the two sides of the argument is now urgent. This book supplies that need. Two prominent philosophers, Gerald Dworkin and R. G. Frey present (...) the case for legalization of physician-assisted suicide. One of the best-known ethicists in the US, Sissela Bok, argues the case against. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Active Euthanasia and Assisted SuicidePat Milmoe McCarrick (bio)Although the President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research in its 1983 report, Deciding to Forego Life-Sustaining Treatment, described the words and terms "euthanasia," "right to die," and "death with dignity" as slogans or code words—"empty rhetoric," (I, p. 24), the literature reviewed for this Scope Note continues to use these terms. Therefore, to (...) discuss the termination of a patient's life by a physician at the patient's request, the phrase active euthanasia is used, and the supplying of a means by a physician whereby a patient can end his or her life is referred to as assisted suicide.Euthanasia, either as the "good death" from classical Greek or "mercy killing" to end unbearable suffering in the dying, has long been a topic of interest in western civilization (III, Brody 1989). In recent years, public awareness of this discussion about control over the time of one's death has been informed by a series of well-publicized events. They include the November 1991 rejection by a vote of 54 percent to 46 percent of the Washington state Initiative 119, which would have allowed the option of requesting one's physician to "aid-in-dying" for adult patients in a "medically terminal condition" (V, Gross 1991); two medical journal articles describing physician's actions in helping bring death to two patients (V, Anonymous 1988; V, Quill 1991); Dr. Jack Kevorkian's assistance in the suicide of three women (V, Belkin 1990; V, Wilkerson 1991); and the best seller status of a how-to book on committing suicide with opiates obtained from a physician (III, Humphry 1991).For the most part, material included in the annotated bibliography in Scope Note 18 has been chosen from works published in the four years since "It's Over, Debbie" (V, Anonymous 1988) appeared in early January 1988 in the Journal of the American Medical Association.Dr. Edmund D. Pellegrino (V, 1991, pp. 3118-19) presented opposing views about active voluntary euthanasia as follows:Those who favor voluntary euthanasia argue that it is a beneficent and compassionate act; it respects autonomy by preserving the patient's control of the manner, method, [End Page 79] and timing of death; it takes the matter outside the reach of "medical power" (accessed in this Scope Note's bibliography at V, Fletcher 1973; V, Nowell-Smith 1989) and scrupulosity; and it prevents the injustice that allows some patients to choose death by refusal of life-support measures, while denying others the right to do so by active euthanasia....The opponents of active euthanasia argue that it undermines the value of, and respect for, all human life (V, Kass 1989; V, Coyle 1990; V, Singer 1990). They fear that guidelines cannot avoid sliding down the "slippery slope" to involuntary euthanasia and selective devaluation of the lives of the most vulnerable among us.... If euthanasia is legal, it is predicted that patients will feel subtle pressure to conform so as to relieve the economic and emotional burdens they impose on family and friends.Euthanasia, its opponents further argue, is socially destructive: it undermines trust in physicians, desensitizes society to killing, and imperils the ground already gained in legitimating passive euthanasia(IV, Wolf 1989).Physicians were not particularly involved with a patient's death until after World War II when participation grew in proportion to the growth of technology. Since the complex, life-sustaining equipment that could forestall death was located in a hospital, death itself became almost completely medicalized (V, Dagi 1991). For terminally ill persons who would like to die a painless death, either by their own hand or with assistance, physicians have almost a monopoly on obtaining strong drugs for distribution to patients (V, Abrams 1990).Active euthanasia for human beings is not legalized anywhere in the world (V, VonDrehle 1991). It is classified as homicide or murder in all fifty states and in Great Britain, Canada, Australia, and the Phillippines (V, Nerland 1989). Twentysix states in the United States prohibit assisted suicide by statute (V, Rosenblum 1990).In 1969 in the Netherlands, a physician named Jan Hendrik van... (shrink)

Nursing prides itself on a commitment to caring for patients and their families. Daily, nurses support patients and their families as they face life-threatening disease and injury and help them through the painful decisions to initiate or remove ventilators, artificial nutrition and hydration, and other life-sustaining technology.The opinions of the Second and Ninth Circuit Courts of Appeals, in Compassion in Dying v. State of Washington and Quill v. Vauo, strike at the heart of the nursing value system. If (...) the United States Supreme Court upholds either opinion, physicians will be legally allowed to help patients die, and nurses will be called on to assist with this process, just as nurses have assisted with electroconvulsive treatment, abortion, and other controversial procedures. Advanced practice nurses, who are licensed to prescribe drugs, may also be allowed by law to assist patients to end their own lives. (shrink)

Studies have consistently shown that LGBTQ individuals are at increased risk for several mental and physical health challenges including suicidality. The relationship between religion and LGBTQ well-being in general and LGBTQ suicidality specifically has increasingly been the subject of scholarly investigation. This systematic review examines all peer-reviewed articles included in the EBSCO PsycInfo database since 2000 that examined the relationship between religiosity and LGBTQ suicide (50 studies in all). These studies reveal a complex relationship that is nuanced and, (...) at times, contradictory. Overall, 65% identified at least one religiosity-related predictor as a risk factor for LGBTQ suicidality, 41% identified at least one religiosity-related predictor as a protective factor against suicidality, while 53% found no associations between religiosity-related predictors and suicide risk. However, when specifically examining religious affiliation/denomination, salience, or beliefs and behaviors, typically, religiosity was either protective or unassociated with LGBTQ suicidality. This held particularly true for studies that had population-based samples, employed control variables and included comparison groups, thus enhancing their generalizability. The one religiosity-related predictor that was almost universally identified as a risk factor was when an individual felt conflicted between their religious and sexual-gender identities. (shrink)

In this essay, we present three case studies which suggest that sometimes we are better off supporting a so–called irrational suicide, and that emotional or psychological distress – even if medically controllable – might justify a suicide. We underscore how complicated these decisions are and how murky a physician's moral role can be. We advocate a more individualized route to end–of–life care, eschewing well–meaning, principled, generalizations in favor of a highly contextualized, patient–centered, approach. We conclude that our Western (...) traditions of promoting reasoned behavior and life themselves may at times be counter–productive. (shrink)

The question of legalizing physician-assisted suicide has become a serious public debate. Growing interest in assisted suicide reflects a public increasingly fearful of the process of dying, particularly the prospect of dying a painful, protracted, or undignified death. PAS has been proposed as a compassionate response to unrelievable suffering, designed to give terminally or incurably ill individuals direct control over the timing, manner, and circumstances of their death. Although the American Medical Association remains firmly opposed to legalizing PAS, (...) many physicians have begun to express support for the practice, and some have acknowledged that they have helped patients commit suicide despite the existing legal ban.As support for PAS grows, it becomes increasingly likely that the practice will be legalized in at least some states in the not-too-distant future. In 1994, Oregon voters approved a referendum legalizing PAS for competent, terminally ill patients; a federal court injunction preventing the referendum from going into effect is currently on appeal, and it is widely expected that the injunction will be lifted. (shrink)

In my career as a primary care physician and as a palliative care consultant, I have assisted many patients to die with their full consent. None of them wanted to die, and all would have chosen other paths had their disease not been so severe and irreversible. To a person, none of these patients thought of themselves as “suicidal,” and they would have found that label preposterous and demeaning. In fact, the kind of personal disintegration that the label (...) implies is just what is trying to be prevented by those choosing this possibility. So on behalf of patients who have chosen this option, I reject the title of this debate as it unnecessarily tars the discussion with the suggestion of mental illness. In my primary care practice, I have also met many patients who were “suicidal” in the mental health sense of the word, and rest assured I have assisted none of them to die. In fact, I have at times had them involuntarily hospitalized to prevent them from carrying out their wishes. (shrink)

Discussions in Germany regarding appropriate end-of-life decision-making have been heavily influenced by the liberalization of access to physician-assisted suicide and voluntary active euthanasia in the Netherlands and Belgium. These discussions disclose conflicting moral views regarding the propriety of physician-assisted suicide and euthanasia, threatening conflicts within not only the medical profession, but also the mainline churches in Germany, whose membership now entertains views regarding end-of-life decision-making at odds with traditional Christian doctrine. On the surface, there appears to be a (...) broad consensus supporting the hospice movement and condemning physician-assisted suicide and euthanasia. The German Supreme Court has held that treatment decisions should, in absence of known patients’ wishes, be made in light of commonly shared values, unless these violate the principle of “in dubio pro vita”. The Roman Catholic church and the Evangelical Lutheran church in Germany have developed an advance directive for treatment choices at the end of life, while condemning physician-assisted suicide and euthanasia. This stance is in tension with the strong emerging support for physician-assisted suicide and euthanasia, a development that promises to open up foundational disagreements within mainline German Christianity regarding the appropriate approach to intentionally terminating human life. (shrink)

There is a death by suicide in the world every 40 seconds, and suicide is the second leading cause of death for 15–29-year-olds. Experts say that one of the best ways to prevent suicide is for those in distress to hear from people who care about them. Facebook is in a unique position—through its support for networks and friendships on the site—to help connect a person in these difficult situations with people who can support them. Connecting people (...) with the resources they need is part of Facebook’s ongoing efforts to help build a safe community inside and outside of Facebook. This article provides a brief overview of how Facebook’s work to develop suicide prevention tools started and evolved, and the ethical considerations which surfaced during the process in the form of concrete product decisions around the implementation of these tools. This article is structured into three sections. Section 1 reviews what has been done in this space and lists and briefly describes other suicide prevention apps and tools. Section 2 describes Facebook’s overall approach to suicide prevention. Here, we’ll delve first into how that approach originated and how it was influenced by the external community’s proactive interactions with Facebook, highlighting our unique position to help address the problem. Afterwards, we’ll explain how that approach evolved, describing its various stages and iterations: understanding, reactive reporting, queue prioritization, and proactive reporting. This section describes the tools and resources Facebook has developed for people who may be at risk. Particular attention is devoted to the use of ArtificiaI Intelligence and Machine Learning to detect posts or live videos where someone might be expressing thoughts of suicide. Section 3 will elaborate on the ethical questions addressed when developing our approach and when making concrete product decisions to implement our suicide prevention tools. In this last section, we’ll expound the competing values and interests that were at stake during the product development process, and how we reached ethical balances between them. (shrink)

To many in India and elsewhere, the life and thoughts of Mohandas Karamchand Gandhi are a source of inspiration. The idea of non-violence was pivotal in his thinking. In this context, Gandhi reflected upon the possibility of what is now called ‘euthanasia’ and ‘assisted suicide’. So far, his views on these practices have not been properly studied. In his reflections on euthanasia and assisted suicide, Gandhi shows himself to be a contextually flexible thinker. In spite of being a (...) staunch defender of non-violence, Gandhi was aware that violence may sometimes be unavoidable. Under certain conditions, killing a living being could even be an expression of non-violence. He argued that in a few rare cases it may be better to kill people who are suffering unbearably at the end of life. In this way, he seems to support euthanasia and assisted suicide. Yet, Gandhi also thought that as long as care can be extended to a dying patient, his or her suffering could be relieved. Since in most cases relief was thus possible, euthanasia and assisted suicide were in fact redundant. By stressing the importance of care and nursing as an alternative to euthanasia and assisted suicide, Gandhi unconsciously made himself an early advocate of palliative care in India. This observation could be used to strengthen and promote the further development of palliative care in India. (shrink)

A virtually infinite array of new discoveries are bringing increasingly evident transformations to all that we do, how we live, how all of us relate to each other, ourselves and the world. To think about this new time, it is necessary to experience the vertigo of placing our mind at risk. We are immersed in a comparatively new context of existence. A new humanity is being built, and it will thus represent a new society and a unique conception of (...) what a person is. We have established ourselves as the cities we pass through daily, as sets of flows, relations of power and strengths. Like a city, we are also information networks; power fields constantly brought into play, as we connect with spaces in an imbricated and interdependent way. We are a kind of species that, in face of its desire, is capable of putting this very existence at risk; of suicidal artists, kamikazes, who risk themselves and the planet. What is the specificity of this species? What is the possible (psycho)analysis? The aim of this article is to present and articulate the current changes and the absolute artificialism of our species in the transformation of its corporeity that devours and appropriates whatever presents itself, and which produces means and prostheses for the compulsive realization of our fantasies; new realities that increasingly appear on the horizon and affect our daily lives. The mind at risk is the state that enables the craziness of any act of creation. (shrink)