Sunday, September 18, 2005

Depression & requests for euthanasia

The current J Clinical Oncology has a fascinating article about depression and requests for euthanasia in the Netherlands (there's an accompanying editorial as well).  It is a prospective cohort study looking at a cohort of terminally ill cancer patients (estimated 3 months or less to live) who were screened for depression at enrollment (using the HADS scale--I'm not very familiar with this tool; the authors claim it's validated in terminally ill patients) and then followed to see who asked for euthanasia.  This was the authors' hypothesis:  [In] our experience, requests for euthanasia are mostly well considered and commonly not associated with depression. Terminally ill cancer patients who request euthanasia often do so from a position of acceptance of their impending death, rather than being driven by an underlying psychiatric disturbance. We therefore expected that patients requesting euthanasia might be even less depressed....  The assumption seems to be that requesting euthanasia is rational (?& good--there is somewhat of a moral flavor to the term "acceptance of their impending death") and so people asking for euthanasia must be rational, & not depressed, and in fact mentally healthier than those poor people who can't "accept their impending death."  At least based on this study they were wrong--those who screened positive for depression at the outset were 4.1 times more likely to request euthanasia (with the caveat here that there were only 140 in the cohort & 30 total requests for euthanasia).  To their credit the authors are quite up front with their assumptions, and that they proved themselves wrong, and that perhaps they need to consider treatable psychiatric illness more closely for those requesting euthanasia.  The editorial says it all quite well:

Much of the public debate during the last 15 years has suggested that euthanasia and PAS are just another type of withdrawal or withholding of life-sustaining treatments. However, the empirical data strongly suggest that requests for euthanasia or PAS are less like traditional requests for the withdrawal and withholding of life-sustaining interventions than like plain old suicide. Like terminating life-sustaining treatments, euthanasia and PAS are intended to end a patient's life when it is causing more suffering and do so at the patient's request. However, this does not appear to be what actually occurs in cases of euthanasia or PAS. Instead, requests for these interventions tend to be guided by psychological distress rather than rational choices about a good death. This conclusion should be especially worrisome given that approximately 15% to 25% of cancer patients are depressed, and approximately 80% of requests for euthanasia or PAS come from cancer patients. When the depression thesis is juxtaposed with epidemiologic data demonstrating that, in general, suicide is approximately 30% to 50% more likely among cancer patients and that depression is a primary motivation for suicide, euthanasia and PAS look more like a method of acting on suicidal ideation than a type of termination of medical treatment.

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