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精神科诊断对维多利亚州自愿协助死亡的影响。

Implications of psychiatric diagnosis for Voluntary Assisted Dying in Victoria.

机构信息

The Centre of Health Equity, School of Population and Global Health, The University of Melbourne, Melbourne, VIC, Australia.

出版信息

Aust N Z J Psychiatry. 2023 May;57(5):629-635. doi: 10.1177/00048674231154200. Epub 2023 Feb 8.

Abstract

Voluntary Assisted Dying is a process whereby terminally ill patients are provided a lethal dose of medication for them to voluntarily ingest to end their life. Victoria, Australia, implemented legislation permitting Voluntary Assisted Dying for terminally ill adult patients with a life expectancy less than 6 months. Ethical dilemmas arise when terminally ill patients with a comorbid mental illness attempt to access Voluntary Assisted Dying because of the complex relationship between psychiatric conditions and suicidal ideation. This paper seeks to investigate the most ethical approach for doctors to respond to such a request by discussing objections raised in other literature to patients with a comorbid psychiatric illness aiming to access Voluntary Assisted Dying in Victoria. To answer this question, objections to terminally ill patients with a comorbid psychiatric illness accessing Voluntary Assisted Dying were found through review of literature. Discussion of these objections centred around unpacking the two historical ethical justifications for Voluntary Assisted Dying: respect for autonomy and relief of suffering. Regarding autonomy, contention focused on competency to make autonomous decisions. Not all psychiatric patients lack competency to decide about Voluntary Assisted Dying, and there are comparable competency assessments used in psychiatry today. Considering suffering, objections related to the authenticity of the intolerable nature of a patient's suffering out of concerns that it has been influenced by their condition, and that the psychiatric illness may still be treatable. However, given suffering is subjective, its perception is not lessened if the source is psychological in nature. Furthermore, it is challenging to justify a position where a patient is forced to spend the last months of their life enduring suffering that has been historically refractory to multiple, genuine treatment efforts. Not all terminally ill patients with a comorbid psychiatric disorder will lack competency to choose Voluntary Assisted Dying, and many will have genuine suffering for which they are requesting Voluntary Assisted Dying. Multidisciplinary, holistic assessments for these patients are not mandated, but would be useful to address the issues, overcome barriers to access and determine that applicants are making an authentic request.

摘要

自愿协助死亡是一个过程,通过这个过程,绝症患者会被提供致命剂量的药物,让他们自愿服用以结束生命。澳大利亚维多利亚州实施了立法,允许预期寿命不足 6 个月的绝症成年患者自愿协助死亡。当患有合并精神疾病的绝症患者试图通过自愿协助死亡来结束生命时,就会出现伦理困境,因为精神疾病和自杀意念之间存在复杂的关系。本文旨在通过讨论维多利亚州患有合并精神疾病的患者在寻求自愿协助死亡时提出的其他文献中的反对意见,探讨医生对此类请求做出回应的最合乎伦理的方法。为了回答这个问题,通过文献回顾找到了反对患有合并精神疾病的绝症患者通过自愿协助死亡的意见。对这些反对意见的讨论集中在对自愿协助死亡的历史伦理依据进行剖析:尊重自主权和缓解痛苦。关于自主权,争议集中在做出自主决策的能力上。并非所有精神病患者都缺乏决定自愿协助死亡的能力,并且今天在精神病学中也有可比的能力评估。考虑到痛苦,反对意见与患者所遭受的无法忍受的痛苦的真实性有关,这些痛苦源于对其病情的担忧,并且这种精神疾病仍可能得到治疗。然而,鉴于痛苦是主观的,如果痛苦的根源是心理上的,那么对其的感知并不会减少。此外,如果一个患者被迫在最后几个月的生命中忍受历史上对多种真正治疗方法都没有反应的痛苦,那么很难为这种情况辩护。并非所有患有合并精神疾病的绝症患者都会缺乏选择自愿协助死亡的能力,而且许多患者会有真正的痛苦,他们正在请求自愿协助死亡。对这些患者进行多学科、全面的评估并非强制性的,但这将有助于解决问题,克服获取服务的障碍,并确定申请人正在提出真实的请求。

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