FULL PAPER (日本語ー抄録のみ)
JAPANESE PSYCHIATRISTS' ATTITUDES TOWARDS PATIENTS WISHING TO DIE IN THE GENERAL HOSPITAL: A CULTURAL PERSPECTIVE
(1) Tokyo Institute of Psychiatry, Tokyo Japan. (2) Department of Psychiatry and Behavioral Sciences, Tokai University School of Medicine, Kanagawa Japan. (3) Department of Psychiatry, Albert Einstein College of Medicine, Bronx New York. (4) Department of Psychiatry, Keio University School of Medicine, Tokyo Japan. (5) Department of Psychosomatic Medicine, Tokyo University Branch Hospital, Tokyo Japan.
Address reprint requests to: Dr. Isao Fukunishi, Tokyo Institute of Psychiatry, 2-1-8 Kamikitazawa, Setagayaku, Tokyo Japan 156
Acknowlegement: The authors thank Drs Masato Uno and Takashi Gomibuchi for their helpful comments and support, and Akemi Sakai, Emiko Takizawa, Yoko Sugita, Ruriko Kobayashi and Michiko Okamoto for technical assistance.
ABSTRACT
The attitudes of Japanese psychiatrists toward patients wishing to die in the general hospital were studied in light of the Japan Science Council's 1994 approval of "passive" euthanasia, recent media focus on a physician induced death in Japan, and the progressive aging of Japanese society.
Sixty-two psychiatrists working at fifteen general hospitals in Japan completed the Suicidal Attitudes Inventory which inquired about the reasonability of suicide, physician assisted suicide, and removal of life supports in various medical situations, and the relationship of distorted thinking and psychopathology to desire for death in medical and psychiatric patients.
While up to one-third of psychiatrists expressed some acceptance of suicide in non-terminal cases with functional impairment in social roles/duty to others, more than half did not agree even slightly that commiting suicide could be reasonable in terminal illness with or without major depression. Over one-third of psychiatrists had some agreement with the statement, "It is valuable to accept a medical patients decision to die even if depressed." Physician assisted suicide was approved of most often in cases of terminal illness/no depression (41%), and termination of life-support was considered as "letting the patient die naturally" by 62%. Psychiatrists with fewer years of experience felt that only rarely or sometimes was distorted thinking or psychopathology involved in medical patients wishes to die and were more likely to rate termination of life support as "letting the patient die naturally".
These results point to an influence on Japanese psychiatrists of the Japanese cultural value of duty and responsibility to others as equal to that of life itself and raise the importance of sensitizing Japanese doctors and legal systems to the relationship of psychopathology with suicidal ideation and to the effect of depression on patient's medical decisions. Other cultural factors affecting these issues and recommendations for future research are discussed.
INTRODUCTION
In 1961 in Japan, the son of a hospitalized man suffering from severe pain after a stroke mixed a cup of milk with insecticide and arranged for his unsuspecting mother to give this to the patient, who had requested that his son assist him in dying. The son could not endure his father's condition and killed him in order to show his love1.
In 1962, the Nagoya High Court outlined six conditions that must be met for a killing to be recognized as euthanasia. 1.) Terminal illness and approaching death. 2.) Unbearable
Suffering. 3.) The purpose of the euthanasia is to relieve suffering. 4.) If lucid, then the the patient must have consented to, and requested the euthanasia. If not lucid, the person's family has made a proxy request. 5.) The euthanasia must be performed by a physician or with full consent of the patient in the rare case where a physician is not able to preform the procedure. 6.) The methods used must be ethically acceptable.
In this case, because the procedure was not done by a physician, and because the method used could not be considered ethical, two of the above conditions were not met. Because the victim acted on his own free will, however, the court ruled this a case of "Requested Murder" and sentenced the defendent to a one year prison term and three years probation. This case formed the current background in Japan for the wishes of medical patients to die1,2.
The most recent case in Japan of a hospital-based killing took place in 1991 at the Tokai University Medical Center in Kanagawa2,3,4. After a terminally ill 58-year-old man with multiple myeloma, renal failure, severe pain and convulsions became unconscious, the doctor removed the IV lines at the family's request, and then gave the patient a lethal injection of potassium chloride. Although the doctor testified that the patient's family had urged him to perform euthanasia to ease the patient's suffering, the police investigation reported that the family had not meant for the patient to be killed when they requested intervention to ease his suffering.
In 1995, in a ruling that supported the self-determination of a terminally ill patient, the court decided that because the euthanasia was not the expressed wish of the patient, the act of euthanasia was not lawful. The doctor was sentenced to two years in prison, but the sentence was suspended for two years because of the family's suspected pressure to end the patient's suffering and the lack of a system to manage the terminally ill. The court also stated that a patient could request to have treatment stopped and that a family can make inferences about a patient's will if the patient is comatose.
While the majority of public responses reported in the media expressed admiration and respect for the physician's actions, some have pointed out how this case illuminates the tendency in Japanese society for families to make serious medical decisions on behalf of a sick family member sometimes even without discusssion with the patient, without informing the patient of their diagnosis, and even overriding the patient's own decisions2,5. One Japanese neurologist wrote, "...we should reconsider our current policy of everyone from the patients' friends to their boss feeling they have the right to inquire about a patient's condition "6.
These issues may come more to the fore since the Japan Science Council approved a report in 1994 advocating voluntary euthanasia for patients in a deep, irreversible coma, provided the patient has previously stated opposition to life-prolonging measures4,7. Because suicide is culturally more acceptable in Japan than in western countries8 (Japanese society usually feels sympathy for a mother who commits "oyako shinju", murder-suicide of herself and her children9), there is the concern that a loose interpretation of the law might put too much decision making power into the hands of physicians. There are also concerns that if 'dignified death' is overvalued in Japan, rescue efforts that can save some patients may be overlooked6. In addition to the problems of an aging society that are now becoming more acute in Japan7,10, these legal changes might lead to a situation where what should be an individual question could be extended to a kind of "social euthanasia". In 1993, while those 65 and over accounted for 13% of the total Japanese population, this group made up 26% of all suicides, and is expected to comprise 24% of the total population by the Year 202010. Intervention for Japanese elderly suicidal patients may be particularly difficult because of the strong sense of shame about seeking help from a mental health professional, and primary care physicians often do not correctly diagnose a mental disorder10.
Consultation/Liaison (C/L) psychiatry in Japan is not a well established subspecialty as it is in other countries like the United States and psychiatric problems encountered on medical units are often handled by the primary physician, with little experience in this area11. The population of Japan is about 120,000,000 and there are about 10,000 psychiatrists. About 50% of general hospitals have departments of psychiatry which provide some consultation service, however there are very few full-time C/L psychiatrists largely because this service is not reimbursed by the National Heatlth Insurance (11, Personal communication-Japanese General Hospital Psychiatry Association).
While medically ill patients' refusal of lifesaving treatment is more and more viewed as "allowing to die", in psychiatric settings, a patient's desire to die is generally considered evidence of a mental disorder and disturbed decision making capacity12. Studies of suicide victims in both the west and in Japan have consistently found high rates of pre-existing mental disorders13,14. While court rulings in the West that have legitimized patients' decisions to limit treatment have labeled these refusals not as suicide but as allowing the patient to die naturally, there is a minority of the public who construe this as suicide or killing. If suicide is a behavior that intentionally leads to death, some treatment refusals may represent suicide15. Recent studies support the view that suicidal ideas among the terminally ill are linked to psychiatric disorder, and psychiatrists will need to determine when depression in the terminally ill may affect one's decision to forgo life-sustaining medical treatment16-18.
The burden of proof the desire to die psychiatry is on the patient who desires to die; in internal medicine, the burden is to prove that the patient lacks competence to refuse life-sustaining treatment on the physician who wishes to override the refusal. Because psychiatrists are in the pivot seat on these decisions in the clinical setting, it is imperitive to clarify their attitudes on this. With this as a backdrop, psychiatrists consulting in general hospitals in Japan will likely be called on more and more to evaluate patients' their family's requests for euthanasia, assisted suicide, suicidal ideation and treatment refusal.
Education and professional guidlines on these issues for psychiatrists in Japan are lacking6, and Japanese psychiatrists attitudes on these issues have not been studied. Issues of whether patients in general medical hospitals who have a desire to die should be allowed to or assisted in this regard, and whether they require psychiatric evaluation and intervention are important areas for Japanese psychiatrists to take the lead in guiding their medical colleagues. The present study was an attempt to begin to systematically investigate these issues.
METHODS
The investigators initially planned a direct study of medical patients' suicidal ideation in the general hospital, but because questions such as "Do you ever feel like you would rather die?" were seen as being too direct for Japanese patients, this approach had to be abandoned. Japanese are in general reluctant to discuss personal matters openly19 and this may necessitate changes in research design, ie.-anonymous self-report in place of interview20,21.
For this study we developed the Suicidal Attitudes Inventory (SAI) data base. The questions were designed to tap the issues discussed in the introduction and were based on prior surveys and literature on these topics12,16,22. The SAI given to the psychiatrists was in Japanese, the English translation in the table was checked by three bilingual psychiatrists (D.B, T.H, and Y.T.). To avoid bias, we did not use the term "euthanasia" in the data base. Anonymity was optional. The SAI is as follows:
SUICIDAL ATTITUDES INVENTORY
This questionnaire is aimed at understanding the attitudes of psychiatrists working in general hospitals toward medical/surgical inpatients who exhibit suicidal ideation or behaviors while in the hospital for a medical/surgical illness. Your answers should be directed towards patients with medical or surgical illnesses who exhibit suicidal ideation or behaviors to staff or family. Do not include those patients brought to or admitted for the medical consequences of a suicidal attempt. Please circle the choice or fill in the circle that best fits your answer, or fill in the blank where appropriate.
Your name:________________________ Age________ Sex________
Hospital name:__________ Number of years experience as a psychiatrist_______
Suicidal Attitudes Inventory (SAI)
1.) Do you feel there may be times when suicidal ideation is logical or reasonable?
yes no If yes, what percent of the time do you think this occurs at your hospital?
<10 10-20 20-30 30-40 40-50 50-60 60-70 70-80 80-90 90-100
2.) Do you feel there may be times when commiting suicide is logical or reasonable?
yes no If yes, what percent of the time do you think this occurs at your hospital?
<10 10-20 20-30 30-40 40-50 50-60 60-70 70-80 80-90 90-100
3.) In the list below, in what cases do you feel that commiting suicide is logical or reasonable? Put an "x" next to those cases that apply. Use one x for "feel slightly" two x's for "feel, moderately", and three x's for "feel strongly".
4.) In the list below, in what cases do you feel that a physician assisting the suicide (assuming legal restrictions and safeguards are in place) is logical or reasonable? Put an "○" next to those cases that apply. Use one ○ for "feel slightly" two ○'s for "feel, moderately", and three ○'s for "feel strongly".
(Assuming the patient is competent and knows their diagnosis and prognosis.)
________Terminal illness with poor quality of life no major depression.
________Terminal illness with poor quality of life has major depression.
________Terminal illness with fair to good quality of life, no major depression .
________Terminal illness with fair to good quality of life, has major depression.
________Patient is not terminal but will be a burden on family for care.
________Patient is not terminal but has been unable to fulfill responsibilities at work.
________Patient is not terminal but has been unable to fulfill responsibilities with
family.
________Patient is not terminal but feels they should take responsibility for a superiors' failure.
________Patient is not terminal but they cannot care for their children.
________Patient is not terminal but they cannot care for their children, and it would also be logical or reasonable to commit suicide along with their children ("Shinju" suicide).
5.) A competent non-depressed patient with an incurable though non-terminal illness (ie.-quadreplegia due to an accident) who requires life support (ie.-ventilator or tube feeding) requests termination of this support because of poor quality of life. You would describe termination of the medical care by the physician as (circle one) A: suicide,
B: killing, C: allowing the patient to die naturally.
6.) Suicidal ideas among the terminally ill are linked to psychiatric disorder.
rarely sometimes usually always
7.) Medically ill patients who desire death have distorted thinking.
rarely sometimes usually always
8.) Before acceding to a medical patients wish to refuse life saving treatment it is important to give optimal medical and psychiatric treatment (ie. treat pain and depression)
rarely sometimes usually always
9.) It is valuable to accept a medical patients decision to die even if they are depressed.
rarely sometimes usually always
10.) Psychiatric patients wishes to die are rooted in psychopathology.
rarely sometimes usually always
11.) Medical patients wishes to die are rooted in psychopathology.
rarely sometimes usually always
12.) Withholding a patients' diagnoses can cause suicidal
ideation.
rarely sometimes usually always
13.) Informing patients of a diagnosis of cancer or other
terminal illness can cause suicidal ideation.
rarely sometimes usually always
Five data base sets with return-address stamped envelopes were sent to eighteen psychiatrists working at eighteen different university hospitals chosen from a list of members of the Japanese Society of General Hospital Psychiatry. These psychiatrists were then requested to have up to five members of their departments who do C/L work fill out the questionnaires. These psychiatrists were known by one of the authors (T.H.) to be active in seeing patients on medical services but otherwise there was no knowledge of their attitudes toward medical patients with suicidal ideation, physician assisted suicide or euthanasia.
Data was analyzed as described in the results section. P values of less than 0.05 were considered as statistically significant. N's in the results section that do not add up to the total N of 62 respondents indicates no response on that item for the missing subjects.
RESULTS
Fifty-nine data bases were returned from fifteen of the hospitals within a month and on re-mailing after two months one more hospital responded for a total of sixty-two data bases (56 male and 6 female, average age of 36.3+9 years, age range 25 to 55 years. The mean number of years of exprience of the psychiatrists was 10.2+6.52 years (range 1 to 29 years). Number of years of experience was found to correlate with age (r=.92, t=18.3, p=.0001). Demographic variables were otherwise not examined in this study, nor was breakdown by sex or hospital due to the small number of respondents from each hospital and the low ratio (10.7%) of female psychiatrists.
The remaining three hospitals had still not responded after six months. It was decided not to contact these hospitals in order to inquire as to why they did not respond as in the Japanese context of relationships this might put unnecessary pressure on them and they would not likely answer directly if there was a sensitive reason to not responding.
Comparison testing among the questions on the SAI was carried out in order to study those factors that had significant relationships. Unpaired student t-test (two-tailed) used for two-group comparisons, and analysis of variance (ANOVA) testing used for three-group or more testing revealed the following significant relationships.
Question 2: Those subjects who agreed that there may be times when commiting suicide is logical or reasonable had significantly greater degrees of agreement on items a,b,c, and d on question 3 (that commiting suicide is logical or reasonable in terminal patients with or without major depression regardless of quality of life) compared with subjects who responded "no"; association with 3a, p=.003, 3b, p=.002; 3c, p=.02; 3d, p=.02. Subjects who responded "yes" on question 2 also had a significantly greater degree of agreement on item a on question 4 item a (physician assisted suicide is logical or reasonable in terminal illness with poor quality of life and no major depression, p=.02).
Question 5: Subjects responding that termination of life support in an incurable non-terminal patient with poor quality of life who requests termination is a "suicide" had significantly greater degrees of agreement on question 3 item g (that commiting suicide is logical or reasonable in cases where a non-terminal patient cannot fulfill family duties) compared with those who labeled termination of life support as a "killing" or "letting the patient die naturally". (ANOVA P=.03). Post hoc t-testing revealed that on item g, the "suicide" group, m (mean analog response)=0.8+1.2, was significantly different from the "Killing" group m=0.2+.4 (Fisher PLSD=.52, p=.02); and from the "letting the patient die naturally" group m=0.2+.4 (Fisher PLSD=.47, p=.008).
Also on question 5, subjects responding that termination of life support in an incurable non-terminal patient who requests termination is a "suicide" had significantly greater number of years experience as a psychiatrist (20+4.8) compared with those who labeled termination of life support as a "killing" (11.7+5.1, Fisher PLSD=5.4, p=0.003), or those labeling this as "letting the patient die naturally" (8.1+5.7, Fisher PLSD=4.9, p=0.0001). Years of experience was also significantly different between the "killing" and "letting the patient die naturally" groups (Fisher PLSD= 3.5, p=0.04). Three-group ANOVA testing: P=.0001. This was also true for age with the "suicide" group's average age of 46.2+5.0 significantly different from the "killing" group (avg. age=36.9+5.0, Fisher PLSD 6.0, t=3.1, p=.003) and "letting the patient die naturally" group (avg. age= 34.3+6.6 years, Fisher PLSD=5.4, t=4.4, p=.0001) groups. Three-group ANOVA testing: P=.0006.
Question 8: Subjects responding that it is "sometimes" important to give optimal medical and psychiatric treatment before acceding to a medical patients wish to refuse life saving treatment had significantly greater degrees of agreement on question 4 items f,g,h,i (situations related to failure in duty to others where physician assisted suicide is logical or reasonable) than those subjects who responded "usually" or "always" on this item. After three-group ANOVA testing, P=.03, post hoc t-testing revealed that for items f,g,h,i the "sometimes" group, m (mean analog response on table 1)=0.4+0.9, was significantly different from the "usually" group m=0.0 (Fisher PLSD=.3, p=.01); and also from the "always" group m=0.06+.2 (Fisher PLSD=.29, p=.19) (exact same statistics for f,g,h,i items).
Question 11: Subjects responding that medical patients wishes to die are "rarely" rooted in psychopathology had significantly greater degrees of agreement on question 4 item e (that physician assisted suicide is logical or reasonable in cases where a non-terminal patient is a burden on family for care) than those subjects who responded "sometimes" or "usually" on this item. After three-group ANOVA testing, p=.047, post hoc t-testing revealed that for item e, the "rarely" group, m (mean analog response on table 1)=0.7+1.2, was significantly different from the "sometimes" group m=.06+.2 (Fisher PLSD=.48, p=.01; and from the "usually" group m=0.1+.4 (Fisher PLSD=.49, p=.03).
Also on question 11, subjects responding that medical patients wishes to die are "rarely" or "sometimes" rooted in psychopathology had a significantly lower number of years of experience (8.7+5.8) than those subjects who responded "usually" on this item (12.8+6.8), t=2.54, p=.014.
DISCUSSION
