A 42-year-old married woman with three children was referred to our department for treatment of treatment-resistant depression. Pharmacotherapy, psychotherapy, and ECT were unsuccessful. We applied deep brain stimulation, which was partially effective and reduced depressive symptoms by 30%, but the patient still suffered. During our struggle to find optimal deep brain stimulation parameters in the course of treatment, the patient requested that her general physician provide euthanasia. Following guidelines in the Netherlands, our team was consulted, but we disapproved because her suffering was not prospectless and there still were treatment options with deep brain stimulation. Although we had treated her intensively for 2 years, our advice was disregarded. Eight weeks later we received the obituary of the patient.
Denys D. Is Euthanasia Psychiatric Treatment? The Struggle With Death on Request in the Netherlands. Am J Psychiatry. 2018 Sep 1;175(9):822-823. doi: 10.1176/appi.ajp.2018.18060725.
By way of a case story, two common presuppositions in the academic debate on conscientious objection in healthcare are challenged. First, the debate typically presupposes a sharp division between conscience-based refusals based on personal core moral beliefs and refusals based on professional (eg, medical) reasons. Only the former might involve the moral gravity to warrant accommodation. The case story challenges this division, and it is argued that just as much might sometimes be at stake morally in refusals based on professional reasons. The objector’s moral integrity might be equally threatened in objections based on professional reasons as in objections based on personal beliefs. Second, the literature on conscientious objection typically presupposes that conflicts of conscience pertain to well-circumscribed and typical situations which can be identified as controversial without attention to individualising features of the concrete situation. However, the case shows that conflicts of conscience can sometimes be more particular, born from concrete features of the actual situation, and difficult, if not impossible, to predict before they arise. Guidelines should be updated to address such ‘situation-based’ conscientious refusals explicitly.
Magelssen M. Professional and conscience-based refusals: the case of the psychiatrist’s harmful prescription. Journal of Medical Ethics Published Online First: 24 April 2017. doi: 10.1136/medethics-2017-104162
Mariana Cuceu, Theodote Pontikes
Abstract: This article presents the case of a Romanian Orthodox Christian patient in the United States suffering from bipolar disorder. The patient had no family in the United States, and a community of parishioners from the Romanian Orthodox Church, including one of the authors, Mariana Cuceu (MC), cared for him after he was discharged from a psychiatric ward. The case serves as a starting point for exploring the duty of physicians not only to avoid harm but to do good, the importance of coordinating care for such patients and attending to their religious and spiritual needs, as well as the role of the community of Orthodox Christian faithful in responding to the command that we love one another.
Cuceu M, PontikesT. The Physician and Community of Faithful in the Integrated Care of the Mentally Ill: An Orthodox Christian Discussion of the Physician’s Moral and Professional Obligations. Christ Bioeth (2016) 22 (3): 301-314 doi:10.1093/cb/cbw010
Eva Elizabeth Bolt, Marianne C Snijdewind, Dick L Willems, Agnes van der Heide, Bregje D Onwuteaka-Philipsen
Background Euthanasia and physician-assisted suicide (EAS) in patients with psychiatric disease, dementia or patients who are tired of living (without severe morbidity) is highly controversial. Although such cases can fall under the Dutch Euthanasia Act, Dutch physicians seem reluctant to perform EAS, and it is not clear whether or not physicians reject the possibility of EAS in these cases.
Aim To determine whether physicians can conceive of granting requests for EAS in patients with cancer, another physical disease, psychiatric disease, dementia or patients who are tired of living, and to evaluate whether physician characteristics are associated with conceivability. A cross-sectional study (survey) was conducted among 2269 Dutch general practitioners, elderly care physicians and clinical specialists.
Results The response rate was 64% (n=1456). Most physicians found it conceivable that they would grant a request for EAS in a patient with cancer or another physical disease (85% and 82%). Less than half of the physicians found this conceivable in patients with psychiatric disease (34%), early-stage dementia (40%), advanced dementia (29–33%) or tired of living (27%). General practitioners were most likely to find it conceivable that they would perform EAS.
Conclusions This study shows that a minority of Dutch physicians find it conceivable that they would grant a request for EAS from a patient with psychiatric disease, dementia or a patient who is tired of living. For physicians who find EAS inconceivable in these cases, legal arguments and personal moral objections both probably play a role.
Bolt EE, Snijdewind MC, Willems DL, van der Heide A, Onwuteaka-Philipsen BD. Can physicians conceive of performing euthanasia in case of psychiatric disease, dementia or being tired of living? J Med Ethics doi:10.1136/medethics-2014-102150