The Other Side of the Slippery Slope

By Ganzini, Linda; Prigerson, Holly | The Hastings Center Report, July-August 2004 | Go to article overview

The Other Side of the Slippery Slope


Ganzini, Linda, Prigerson, Holly, The Hastings Center Report


Much of the suffering in the dying and their families does not fit into the usual categories of mental disease, and palliative care mental health researchers are now examining formulations that integrate psychological, spiritual, and relational domains. For example, William Breitbart is examining the essential role of finding "meaning" at the end of life, and Harvey Chochinov and colleagues have proposed that a fractured sense of "dignity" can be diagnosed, quantified, associated with decreased quality of life, and treated with dignity-conserving therapies. (1) In a similar vein, David Kissane and others have hypothesized that "demoralization" is a diagnostic entity characterized by hopelessness, loss of meaning, and existential distress. Such research holds great promise for improving the lives of the dying.

A promise is a future possibility, however. Dr. Kissane's claims in this issue of the Hastings Center Report should be read cautiously. There are no published, empirically validated studies to confirm that demoralization is a distinct psychiatric diagnosis. Dr. Kissane asserts that demoralization seems to meet the criteria for a diagnosis, but the paper he cites contains almost no data about distinctive symptoms, etiology, course, or treatment outcomes.(2) The research evidence provided barely represents a beginning on the work necessary for official acceptance in the International Classification of Disease (ICD) or the Diagnostic and Statistical Manual of the American Psychiatric Association (DSM).

Even if there were studies to support demoralization as a diagnostic entity, its presence might not render a person unable to make decisions, including decisions that may hasten death. Patients are determined to lack capacity to make medical decisions if they are unable to understand or to appreciate the nature of their illness and the risks, benefits, or alternatives of different courses of action to address the illness. But patients lack appreciation when they are irrational, unrealistic or distorting reality to a severe degree, and denying a patient choice because she lacks appreciation poses a serious risk of error, resulting in an unwarranted deprivation of patient autonomy. Just as the legalization of physician-assisted suicide may become a slippery slope to reckless killing, the politically motivated use of psychiatric labels to prevent euthanasia may become a slippery slope to unwarranted paternalism.

The most important consequence of Kissane's proposal would not be the rare case of rendering a choice for assisted suicide incompetent. …

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