DISCUSSION

Diagnosing psychopathology in medical patients even in the face of "the reality of the situation" is an important task of the general hospital psychiatrist16,18. A surprising finding in this study was that while the vast majority of psychiatrists agreed that there may be times when suicidal ideation (91.5%), or completed suicide (78%) in med-surg patients is logical or reasonable, the majority of psychiatrists did not agree even slightly that commiting suicide could be logical or reasonable in terminal illness with major depression irrespective of the quality of life, or in terminal illness with good quality of life and no major depression. This was despite the fact that 18-32% of psychiatrists had some degree of acceptance of suicide in non-terminal cases with inability to function in various social roles (26% agreeing at least slightly that a murder-suicide could be reasonable), and despite the significant positive relationship of degree of acceptance of suicide as reasonable in non-terminal cases unable to fulfill family duties with rating termination of life support in an incurable non-terminal patient with poor quality of life as a "suicide".

These results point to an influence on a number of Japanese psychiatrists of the Japanese cultural value of duty and responsibility to others at a level equal to that of life itself, a value seen in the medical setting that can be seen in in other aspects of Japanese culture including intense devotion to one's company even at the expense of one's health (karoshi), suicide in order to take responsibility for something by persons who feel loyal to superiors involved in a scandal (inseki jisatsu), and others9,23,24. Maintenance of the value of duty and responsibility to others in a manner that does not have to call for unnecessary loss of life could be promoted through psychosocial interventions and education of both the general public as well as the medical profession on issues of death and dying.

These findings also raise the importance of sensitizing Japanese doctors to the need to determine when depression in the terminally ill may affect the decision to forgo life-sustaining medical treatment16-18. While 92% of psychiatrists responded that it is usually or always important to give optimal medical and psychiatric treatment to medical patients who refuse life saving treatment, 25% responded that it may be sometimes, and 10% usually or always, valuable to accept a medical patient's decision to die even if they are depressed. Interestingly, the small group, N=5 who responded that it was only "sometimes" important to give optimal treatment on this item, had significantly greater degrees of agreement on physician assisted suicide in cases of failure in duty to others. A view of depression in the face of serious illness as reasonable may be a form of "pseudo-empathy" against which psychiatrists should be warned, especially as physicians have been shown to underestimate seriously ill patients' quality of life and their desire for life-sustaining treatmen 2,28.

Ganzini et al.16 found that remission of major depression with hopelessness in psychiatric patients increased the preferences of these patients for life-saving treatment, while Chochinov et al.18 and Berger25,26 found that desire for death in med-surg or terminal patients is associated with clinical depression, that this desire for death is often transient, and that improvement in family support and treatment of pain can diminish desire for death. Because of these findings some authors have even recommended a trial of ECT before accepting a do-not-resuscitate order in patients with affective disorder27. Such findings need to be communicated to the Japanese psychiatric community.

Interventions that could enhance social support and address high stress levels (family meetings, therapist support); diminish physical distress (medical or surgical interventions); treat depression (psychotherapy/pharmacotherapy); and improve physical and role functioning (physical therapy, interpersonal therapy) are important avenues that psychiatric consultants should explore when faced with med-surg patients with suicidal ideation. Attention to patients' reaction to acute changes in their medical condition is also important 25,26.

Although physician assisted suicide was approved of less often than individual suicide, and most often for the terminally ill no-major depression cases (41%), almost two-thirds agreed that termination of life-support at the request of a non-terminal patient was allowing the patient to die naturally. These psychiatrists may have been influenced by the wide media coverage of the recent Tokai case described in the introduction in which the court frowned on active intervention on the part of the doctor.

In addition, while the relationship of suicidal ideas among the terminally ill to psychiatric disorder, and the assumption of distorted thinking in medically ill patients who desire death were thought to be at least sometimes the case in the opinion of 92% and 95% of psychiatrists respectively, there was a stronger trend for these psychiatrists to feel "usually" or "always" that psychiatric patients are more likely to have their wishes for death rooted in psychopathology (93%) when compared with this response for medical patients' psychopathology (39%).

Respondents who felt that only rarely or sometimes (N=37) was distorted thinking or psychopathology involved in medical patients' wishes to die had a significantly lower mean number year of experience. This younger and less experienced group, which was also more likely to rate termination of life support in an incurable non-terminal patient with poor quality of life as "letting the patient die naturally" rather than a"suicide" or a "killing", may not be as sensitive to the relationship of psychopathology to suicidal ideation in this group of patients as their more experienced colleagues.

Our study has several strengths and several limitations. First, we choose psychiatrists known to be actively involved in general hospital work who were likely to have actually encountered the proposed situations. The recent media coverage may have informed the psychiatrists further about these issues, although it may have also colored their opinions in the wake of the court's ruling. Limitations include the relatively small sample size. The high degree of cooperation by the respondents and the manner of their selection may have carried with it some inherrent bias. The fixed-response format of the questionnaire could have limited the respondents' ability to evaluate the whole picture as in a real-life situation, although this may also have elicited their uncensored responses.

The findings of this study have important implications for medical personnel, patients, and for policy makers. Courts should actively consider the role of affective impairment in determination of decision making capacity16. Even if there is a living will that coincides with the patient's request, the patient could have been affectively disturbed at the time of making the will, and this might be verified by history. Legislation permitting assisted suicide or euthanasia that guides a psychiatric evaluation would need to specify the need for evaluation of depression, unrecoverable poor quality of life, and, in Japan, degree of distortion in the estimation of failure in duty to others. Development of a competence standard that assesses the patient's appreciation of their clinical situation (how the risks and benefits of treatment affect their life) in addition to whether they understand their situation is one way to evaluate a depressed patient's refusal of life-saving treatment12. The Japanese Society of General Hospital Psychiatry could develop guidelines that go beyond the legal prerequisites and also help to initiate educational programs in medical school and residencies in order to sensitize young physicians to these issues. The evaluation of psychopathology in the terminally ill and the relationship of that psychopathology to wishes for death are pressing issues for research. The items used in the SAI data base may be helpful in clarifying health care workers' attitudes toward these issues.

Psychiatrists must also be aware that there are times when psychiatric treatment is not appropriate. The value of treatment of depression should not be over or underestimated; in some instances it may be best to accept a patient's decision to die12. Some depressions in the seriously ill may be absolutely treatment resistant, or the burden of serial trials of antidepressants or ECT may be too great in view of the physical quality of life. These patients should not necessarily loose their right to refuse treatment.

Consciousness raising on the issue of self-determination will be a large task in Japan. The concept of individuality has not taken root well in Japan where relationships are fostered to be, mutually dependent29,30. The cultural attitudes, funerals and other death ceremonies reflect minimal seperation between the dead and the living. Suicide is not strictly forbidden as it is in western cultures; the death of Buddha was a peaceful transition into Nirvana while that of Christ was suffering31.

CONCLUSION

The major results and conclusions are as follows:

1.) 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.

2.) 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."

3.) Physician assisted suicide was approved of most often in cases of terminal illness/no depression (41%).

4.) Termination of life-support was considered as "letting the patient die naturally" by 62%.

5.) 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.

Exactly how and if there will be a role for assisted suicide or euthanasia in Japan is an open issue. There is some consensus that these acts go on more often than openly discussed here, usually in the context of a long-standing relationship between physician and a patient and their family. What is "allowed" legally and in public and what is "allowed" in private is often seperated in Japanese culture. Both the legal and medical communities need to consider at what point should decision making be relegated to the patient and how much of this can be entrusted to the family? Even before issues of self-determination can be considered in medical patients wishing to die, we should note that because only a minority of cancer patients are actually told of their diagnosis, very few of these seriously ill patients can make an informed decision.5 Further study is still needed on the attitudes of psychiatrists from other cultures, physicians in other subspecialties, the general population, as well as terminal patients and their families both before and after the death of their loved one.

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希死念慮を持つ総合病院入院患者に対する日本人の精神科医の考え方：文化的な立場から