Quality of Life Issues (voluntary euthanasia)
In end-of-life euthanasia, there is, at least, some objective standards which we can use to determine whether a patient is truly dead. When the discussion moves to quality of life, the criteria are far more subjective. What, exactly, determines quality of life? Productivity? Mobility? Social Activity? Dignity? Any and all of these could be involved and would be given different weight by each person. This lack of objectivity is why I particularly dislike the ubiquitous measurement called Quality Adjusted Life Years or QALYs. QALYs are, of course, usually well-defined for the purpose of research. Unfortunately many people using that research to determine social policy forget that the QALY is there only to assist in comparing outcomes. It has no objective basis in reality.
It is this very lack of objective standards that makes it so hard to debate a topic like euthanasia, and almost impossible to work out ethical protocols for the practice – a fact that should warn us that we may be moving into ethically dangerous ground.
For instance, voluntary euthanasia has often been brought forward as a reasonable moral and ethical choice. After all, proponents of voluntary euthanasia propose, there is no-one better able to determine the worth of their life than the person who wishes to die. Surely, if a person of sound mind proposes to kill themselves, do they not have a perfect right to do so? And therein lies the dilemma.
These are the DSM IV criteria for diagnosing a depressive episode:
A. Five (or more) of the following symptoms have been present during the same 2-week period and represent a change from previous functioning; at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure.
Note: Do note include symptoms that are clearly due to a general medical condition, or mood-incongruent delusions or hallucinations
(1) depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad or empty) or observation made by others (e.g., appears tearful). Note: In children and adolescents, can be irritable mood.
(2) markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated by either subjective account or observation made by others)
(3) significant weight loss when not dieting or weight gain (e.g., a change of more than 5% of body weight in a month), or decrease or increase in appetite nearly every day. Note: In children, consider failure to make expected weight gains.
(4) insomnia or hypersomnia nearly every day
(5) psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down)
(6) fatigue or loss of energy nearly every day
(7) feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick)
(8) diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others)
(9) recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide
Sadly, I have yet to meet a person who wishes to kill themselves who does not meet these criteria. I have been involved with terminal care of patients for nearly three decades and every single one of them who were suicidal met all of the DSM IV criteria for depression. I can only come to the conclusion that a person who wishes to end their life is likely to be clinically depressed and in need of treatment rather than death. I am well aware that there will be many people who do not agree with this viewpoint. Many of them will be able to tell me anecdotes of people they know, often their nearest and dearest, who suffered horribly and should have been put out of their misery.
Sadly, these tales are all too common. However, they do not represent an argument for euthanasia, but an argument for the improvement of palliative care training for doctors, particularly for GPs. I am extremely happy to see that the Goodfellow Institute’s annual conference this year has palliative care as its main them, and I encourage all of my colleagues to attend. The MacDoctor will certainly be there.
My point here is that, with proper treatment of depression and any symptoms that may be precipitating depression (such as pain or shortness of breath), the person who is wishing to end his/her life usually finds that this last bit of life is actually worth living. It is very rare in my experience that patients find the additional weeks or months of reasonably good life a burden.
Things become a little more tricky when we move from the terminally ill to the severely disabled. Again, I think that people with suicidal ideation need to be treated for depression with medication and counseling. As my experience here is far more scanty, I cannot say with surety that all people who want to end their lives in this situation are depressed. Having said that, the literature suggests that all people who are disabled move through a similar process to the terminally ill and would therefore be almost certainly depressed at some point. The danger with liberal euthanasia laws is that people with eminently treatable depression are allowed to die. This seems like nothing less than discrimination against the disabled (and the elderly who often find themselves in similar straits). Any attempt at legislation for euthanasia would have to ensure that this concern is address in a far more precise way than the current way the abortion laws are interpreted.
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