Collaborated Death: An Exploration of the Swiss Model of Assisted Suicide for Its Potential to Enhance Oversight and Demedicalize the Dying Process

Death, like many social problems, has become medicalized. In response to this medicalization, physician-assisted suicide (PAS) has emerged as one alternative among many at the end of life. And although the practice is currently legal in the states of Oregon and Washington, opponents still argue that PAS is unethical, is inconsistent with a physician's role, and cannot be effectively regulated. In comparison, Switzerland, like Oregon, permits PAS, but unlike Oregon, non-physicians and private organizations play a significant role in assisted death. Could the Swiss model be the answer? The following essay explores the Swiss model of assisted suicide for its potential to enhance the regulation of PAS, reduce physician involvement, and perhaps demedicalize the way we die.     

The way assisted suicide is legalised: balancing a medical framework against a demedicalised model

To date, in three European countries and three American states--i.e., The Netherlands, Luxemburg, Switzerland, and the states of Oregon, Washington and Montana--it is permitted by law for one person to assist in the suicide of another person. When comparing the legislations of these countries/states, it becomes apparent that The Netherlands, Luxemburg, Oregon, Washington and Montana have chosen a medical approach (the so-called medical model), whereas the Swiss legal framework for assisted suicide is clearly a non-medical one (the demedicalised model). The differences between these two models mainly concern two aspects: the requirement as to the capacity of the person providing assistance in suicide and the condition regarding the state of health of the person committing suicide. A closer view on the practice of assisted suicide in the depenalising countries shows that the differences are smaller than initially thought. Nevertheless, important distinctions still remain. When analysing which model is most preferable, it is concluded that an involvement of a physician is inevitable and necessary and that the requirement of a certain medical condition is needed to set a clear and objective limit.     

Self‐Strangulation Through A Sphygmomanometer: An Uncommon Suicide

Suicide by asphyxia is quite a common event in forensic practice and may be implemented in different ways. The authors report a unique case of a 16‐year‐old youth who committed suicide by means of a standard mercury sphygmomanometer. This manner of suicide has never been described in the literature reviewed. A complete forensic investigation led to the conclusion that the cause of death was mechanical asphyxia, ascribed to self‐strangulation by means of an atypical item. The victim suffered from attention‐deficit/hyperactivity disorder (ADHD) syndrome and was assisted by support teachers. He had a solitary and depressive personality. The exceptional nature of this case suggests that sphygmomanometers may be regarded as possible means of self‐strangulation. The case also highlights the importance of managing patients with psychiatric or cognitive disorders; indeed, particular caution is required to keep them away from objects that, although apparently harmless, can become lethal.     

Developmental trends in adolescents' psychological and legal competence to consent to abortion

United States Supreme Court has affirmed the right of states to require parental consent or notice from minors seeking abortion. We examine an underlying presumption that minors are not competent to consent to abortion. Participants (N=75 age 13–21, seeking a pregnancy test at a women's medical clinic) completed an interview that was audiotaped and scored on four cognitive and volitional criteria of legal competence. Competence was compared in three age groups (≤15; 16–17; 18–21) for participants who considered abortion and for those who did not. Adolescents age 16–17 and adolescents ≤15, who considered abortion, appeared as competent as legal adults; only≤15-year-old adolescents who did not consider abortion appeared less competent. Regression analysis was used to identify psychosocial predictors of competence. Results challenge the presumption that minors are not competent. An alternate policy based upon informed consent and empowerment of minors as decision makers is proposed.     

Medicare program; revisions to payment policies under the physician fee schedule for calendar year 2000. Health Care Financing Administration (HCFA), HHS. Final rule with comment period

This final rule makes several changes affecting Medicare Part B payment. The changes include: implementation of resource-based malpractice insurance relative value units (RVUs); refinement of resource-based practice expense RVUs; payment for physician pathology and independent laboratory services; discontinuous anesthesia time; diagnostic tests; prostate screening; use of CPT modifier -25; qualifications for nurse practitioners; an increase in the work RVUs for pediatric services; adjustments to the practice expense RVUs for physician interpretation of Pap smears; and revisions to the work RVUs for new and revised CPT codes for calendar year 1999 and a number of other changes relating to coding and payment. Furthermore, we are finalizing the 1999 interim physician work RVUs and are issuing interim RVUs for new and revised codes for 2000. This final rule solicits public comments on the second 5-year refinement of work RVUs for services furnished beginning January 1, 2002 and requests public comments on potentially misvalued work RVUs for all services in the CY 2000 physician fee schedule. This final rule also conforms the regulations to existing law and policy regarding: removal of the x-ray as a prerequisite for chiropractic manipulation; the exclusion of payment for assisted suicide; and optometrist services. This final rule also announces the calendar year 2000 Medicare physician fee schedule conversion factor under the Medicare Supplementary Insurance (Part B) program as required by section 1848(d) of the Social Security Act. The 2000 Medicare physician fee schedule conversion factor is $36.6137.     

Therapists Behind Bars: Criminalizing Gay‐to‐Straight Conversion Therapy

Conversion therapy is a practice used to “change” an individual's sexual orientation from homosexual to heterosexual. Parents who expose their child to conversion therapy drastically increase the child's likelihood of developing anxiety, depression and self‐destructive behavior. Currently, 18 states ban mental health professionals from conducting conversion therapy. However, in those states, if a mental health professional conducts the therapy, the penalty is only a relatively small fine for unprofessional conduct. Additionally, to report their therapist, victims must file a complaint, which poses difficulties for minors. This Note proposes a criminal statute for mental health professionals who conduct conversion therapy.     

胚胎的法律属性及其处置规则刍议简

随着人工辅助生育技术的日益普及,实践中出现了一些涉及胚胎的法律问题,问题的解决需要首先厘清胚胎的法律属性,再确定胚胎的处置规则。本文在分析相应法律规范、制度、案例的基础上,结合比较法和实践研究,对以上问题进行初步探讨,提出了胚胎的法律定位应界定为＂中介＂,在处置规则上应考虑生育行为的社会属性、未成年人利益及利益均衡,以不允许单方处置为原则。     

Emotional and psychological effects of physician-assisted suicide and euthanasia on participating physicians

This is a review and evaluation of medical and public literature regarding the reported emotional and psychological effects of participation in physician-assisted suicide (PAS) and euthanasia on the involved physicians. MATERIALS AND METHODS: Articles in medical journals, legislative investigations and the public press were obtained and reviewed to determine what has been reported regarding the effects on physicians who have been personally involved in PAS and euthanasia. RESULTS AND DISCUSSION: The physician is centrally involved in PAS and euthanasia, and the emotional and psychological effects on the participating physician can be substantial. The shift away from the fundamental values of medicine to heal and promote human wholeness can have significant effects on many participating physicians. Doctors describe being profoundly adversely affected, being shocked by the suddenness of the death, being caught up in the patient's drive for assisted suicide, having a sense of powerlessness, and feeling isolated. There is evidence of pressure on and intimidation of doctors by some patients to assist in suicide. The effect of countertransference in the doctor-patient relationship may influence physician involvement in PAS and euthanasia. CONCLUSION: Many doctors who have participated in euthanasia and/or PAS are adversely affected emotionally and psychologically by their experiences.     

A Clinical Study of Competency to Consent to Hospitalization and Treatment in Geriatric Inpatients*

Abstract: This study used a Competency Questionnaire modified for medical surgical patients (CQ‐Med). Twenty‐nine patients (ages 65–94 years) admitted to a geriatric medicine unit were studied. Along with the CQ‐Med, patients were administered several WAIS‐R subtests, the Blessed Dementia Scale (BDS), and Mini Mental State Exam (MMSE). Additionally, a blind forensic evaluation for competency to consent to hospitalization and treatment was performed for the purpose of validation of the CQ‐Med. Results of the study found that, as expected, increased age was correlated with decreasing performance on the CQ‐Med and decreased findings of competence by clinical exam. However, there was great variability within each age group, demonstrating individual differences in the progress of declining competency. CQ‐Med scores also correlated well with the WAIS‐R subtest raw and scaled scores. Scores on the MMSE and BDS were less well correlated. The CQ‐Med may be a useful adjunct in assessing declining competency in geriatric patients.     

The new regulation of voluntary euthanasia and medically assisted suicide in the Netherlands

On 1 April 2002 the Dutch Bill 'Termination of Life on Request and Assisted Suicide (Review Procedures) Act' (Wet toetsing levensbeeindiging op verzoek en hulp bij zelfdoding) came into force. This article starts with an outline of the former legal position in The Netherlands regarding euthanasia and medically assisted suicide, followed by an explanation of the new Act. The main focus of this contribution lays on the requirements of due care, the obligation to notify euthanasia to the coroner and the revised legal position of the so-called Regional Review Commissions. Furthermore, the article considers the termination of life in the case of minors and the function and requirements of written statements of euthanasia by patients no longer capable of communication. Finally, the article gives an overview of the problems [that] may come in the future concerning the approach to euthanasia in The Netherlands.     

Therapeutic response to assisted suicide request

The authors review the first publicly reported case of legal assisted suicide in the United States and discuss possible clinical responses other than assistance in suicide. Psychiatric observers have noted that acceptance of assisted suicide or euthanasia as a medical option has resulted in loss of knowledge about how to respond to suicidal ideation in the seriously ill. The authors discuss specific therapeutic interventions that may be appropriate for seriously ill patients requesting suicide.     

The Double Entendre of Juvenile Prostitution: Victim versus Delinquent and the Necessity of State Uniformity

Under the federal Trafficking Victims Protection Act (TVPA), minors performing commercial sex acts are deemed victims of human trafficking; however, prosecutors and judges continue to charge and adjudicate minors as prostitution offenders rather than as sexually exploited youth. To stop the perpetuation and victimization of sexually exploited children, states must join the movement in reform to match the standards of the TVPA. The federal law presumes that minors charged with prostitution are victims rather than criminals and are in need of specialized social services. To protect victims of sex trafficking, states should pass legislation in line with the TVPA, creating a presumption of immunity for all prostituted minors.     

Developmental incompetence to stand trial in juvenile courts

Juveniles' competency to participate in delinquency proceedings has received increased attention in recent years. Developmental incompetence, whereby juveniles' incompetency is based upon their immaturity, as opposed to a mental disorder or developmental disability, is an evolving and important aspect of this area of law. The following paper reviews theories used to support the notion of developmental incompetence, as well as the extant empirical research on juveniles' competency-related abilities. Using a LexisNexis search, statutory and case laws pertaining to juvenile competency were identified across the 50 states and the District of Columbia. Only six states clearly allow developmental incompetence, whereas 17 have laws that do not include developmental immaturity as an acceptable basis of incompetence in juvenile courts. Developmental incompetence is likely to affect a relatively small proportion of juvenile cases, but has important implications for juvenile forensic practice. Recommendations are offered for forensic practitioners conducting this type of evaluation.     

论未成年人受侵害的过失相抵

与加害人的过失不同，受害人的过失并非违反不得侵害他人权益的义务，而是违反了对自己的保护义务，此种义务在法律上是一种不真正义务。对于受害人的过失的判断，应以受害人尽到与处理自己事务一样的注意义务而非善良管理人的注意义务为标准。为保持现行立法与司法的稳妥，可以规定：10周岁以上的未成年人具有过失相抵能力，10周岁以下的未成年人不具有过失相抵能力。在未成年人遭受他人侵害，其监护人未尽监护职责导致损害的发生或扩大的情况下，若监护人违反善良管理人的注意义务，未成年的受害人应该承担监护人的过失，在斟酌损害赔偿数额时，实行过失相抵。     

Juvenile Competency and Pretrial Due Process: A Call for Greater Protections in Massachusetts for Juveniles Residing in Procedural Purgatory

While juvenile courts continue to balance and reevaluate the dual goals of community safety and rehabilitation of youth, juveniles who are not competent to stand trial have been left without sufficient procedural protections. This paper examines Massachusetts’ approach to juvenile competency, due process, and pretrial procedure, within a national context. The inadequacies of the Massachusetts juvenile competency laws are not unique. Currently there are nineteen states that either entirely lack juvenile‐specific competency legislation or merely incorporate inapposite adult criminal statutes and standards into the juvenile context—making it difficult or impossible for those juvenile courts to dismiss or divert a delinquency petition following an incompetency finding. Massachusetts and states similarly situated should adopt explicit statutory language to delineate the basis for a juvenile incompetency finding and the grounds for dismissing delinquency complaints pretrial after an incompetency finding has been made. This paper proposes that Massachusetts adopt a timeline for effecting such dismissals based in part on the amount of time a juvenile could face if committed to the juvenile correctional authority following an adjudication of delinquency. The paper also recommends best practices of states that are pioneering juvenile legislative reforms like dismissal timelines and incompetency presumptions. Finally, we suggest a more stringent regulatory framework be put in place governing the pretrial detention of youths who have been found not competent to stand trial—a framework that recognizes and preserves the juvenile's substantive rights to education, mental health and rehabilitative services. Without legislation, juveniles found not competent to stand trial remain subject to the prospect of indefinite locked detention, often without access to the necessary services that contribute to future success as well as attainment of competency. This lack of due process runs counter to the foundational goals of the juvenile justice system.     

The de-medicalisation of assisted dying: is a less medicalised model the way forward?

Although assisted dying has been most commonly presented within a medicalised framework, the notion of de-medicalisation is employed in this paper to suggest that there are emerging models of assisted dying in which some medical aspects assumed to be an integral part of the phenomenon are both challenged and diminished. The paper considers cases where relatives have facilitated a loved one's assisted suicide abroad, cases of assisted death in which the assistor in the actual suicide act is a non-medic, and the growing debate surrounding non-medical grounds for desiring death. In evaluating the potential impact of partial de-medicalisation on the assisted dying debate, the argument presented is that whilst a de-medicalised model could well contribute to a richer understanding of assisted dying and a better death for the person who is assisted, there are cogent reasons to retain some aspects of the medicalised model and that a completely de-medicalised model of assisted dying is unrealistic.     

In the laboratory of the states: the progress of Glucksberg's invitation to states to address end-of-life choice

It has now been ten years since the Supreme Court handed down Glucksberg and Quill, rulings on laws that forbid "assisted suicide." In that time, normative and legal developments in the fields of law, medicine, and psychology have changed the landscape of the discourse on the choice of a mentally competent, terminally ill individual to choose to self-administer medications to bring about a peaceful death. Although the Court rejected petitioners' claims that state laws denying them the ability to end their terminal illnesses through self-administered medication violated the Constitution, it left states with the opportunity to experiment with legislation that would allow terminally ill individuals the choices they had previously sought through litigation. Oregon's experience with its Death with Dignity Act, which grants terminally ill, mentally competent individuals the choice to end their lives through self-administered medication, has proven that such laws provide comfort not only to those who, faced with the prospect of a horrible death from a terminal illness, choose to end their lives in a peaceful and dignified manner, but also to those to ultimately choose not to. Additionally, Oregon's experience shows that the fears that originally attended the "assisted suicide" debate are unfounded so long as proper procedures are in place. Because Oregon's Death with Dignity Act has proven both useful and harmless, this Article concludes that it is time for other states to follow Oregon's lead and enact their own legislation to allow their citizens an alternative to what otherwise could be a prolonged and painful death from terminal illness.     

Attitudes toward physician-assisted suicide: Effects of physician background,patient prognosis and patient mental health status

Abstract

The purpose of this study was to investigate views toward physician-assisted suicide (PAS) as patient illness (terminal, not terminal), patient mental health (depressed, not depressed) and physician background (preoccupied, not preoccupied with death) are varied. Participants (N = 211) read a newspaper article and trial summary involving a PAS then gave their impressions of the patient, physician and PAS. Patient mental health did not affect decisions, but the preoccupied physician's testimony was seen as less believable (intent was seen as patient death, not an end of pain and suffering), and he was more likely to be seen as guilty than the non-preoccupied physician (reflected by both verdict and guilt level ratings). The terminal patient was seen as suffering more, wanting suicide more, and making a more rational decision to die than the non-terminal patient. Results are discussed in light of recent legal activity involving PAS.     

Asphyxial suicide with helium and a plastic bag

Suicide by helium inhalation inside a plastic bag has recently been publicized by right-to-die proponents in "how to" print and videotape materials. This article reports a suicide performed according to this new and highly lethal technique, which is also a potentially undetectable cause of death. Toxicology information could not determine helium inhalation, and drug screening did not reveal data of significance. The cause of death could be determined only by the physical evidence at the scene of death. Helium inhalation can easily be concealed when interested parties remove or alter evidence. To ensure that their deaths are not documented as suicide, some individuals considering assisted suicide may choose helium methods and assistance from helpers. Recent challenges to Oregon's physician-assisted suicide law may increase interest in helium instead of barbiturates for assisted suicide.