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December 6,1994
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"Dr. Kevorkian doesn't seem to be required to prove his point that it is the function of doctors to help people die--which is a point that flies in the face of the nature of medicine as it has been practiced since the Hippocratic oath." --Paul R. McHugh, M.D.
A study conducted by two researchers from the University of Southampton in
England concludes that patients who suffer from a variety of chronic,
debilitating, painful or even terminal medical conditions are no more likely to
commit suicide than are members of the general population. However, mental
disorders associated with other major diseases do lead to a heightened risk of
suicide, they say.
The findings, based on an analysis of 235 studies of suicide published in the
medical literature between 1966 and 1992, show that suicide rates are about the
same as in the population as a whole for patients suffering from two dozen
diseases or conditions. These include ALS (Lou Gehrig's disease), prostate or
cervical cancer, non-Hodgkins lymphoma, diabetes, obesity, heart pacemakers,
rheumatic diseases including rheumatoid arthritis, and viral hepatitis.
Suicide rates are significantly elevated, however, for persons suffering from
AIDS (where the risk is nearly seven times that of the general population),
Huntington disease (where the risk triples), systemic lupus erythematosus, many
types of cancer, multiple sclerosis, spinal cord injury, peptic ulcers, and
kidney problems requiring dialysis, report E. Clare Harris, M.Sc., and Brian
M.Barraclough, M.D., in the November 1994 issue of the journal
Medicine.
In an accompanying commentary, the director of psychiatry at The Johns Hopkins
Medical Institutions questions whether the current interest in assisted
suicide" may not lead seriously ill patients to leap to "dangerous and
despairing assumptions that, if directly and traditionally combated, would
wither."
The difference in suicide rates that is documented in the Harris and
Barraclough study can be accounted for by the presence of major depression,
which is a known consequence of many illnesses and which can be treated
successfully, Paul R. McHugh, M.D., writes in his commentary.
"Major depression encourages suicide in patients not only by lowering mood but
also by promoting in the patient the view that his life is hopeless; that he,
himself, is worthless; and that his
future is appalling," he writes. "These attitudes, like the depressed mood
itself, are symptoms of disease and are reversed by pharmacologic and physical
treatments."
In an interview, he added: "Rather than help their patients commit suicide,
doctors should be alert for signs of major depression and should treat their
patients aggressively. People want to live. They want to be treated by doctors
who fight their fear and suffering, not by doctors who say their life is
over."
He continued, referring to the current controversy over Dr. Jack Kevorkian and
the suicides of seriously ill patients that he has aided in Michigan: "Dr.
Kevorkian doesn't seem to be required to prove his point that it is the
function of doctors to help people die--which is a point that flies in the
face of the nature of medicine as it has been practiced since the Hippocratic
oath."
On the bright side, the literature survey found that suicide rates fall
significantly for women during pregnancy and the first year following delivery.
A study in England and Wales found an eightfold decreased risk of suicide for
women in this category, while an American study found a threefold
decrease.
In his commentary, McHugh asks whether patients will not become more likely to
take their own lives when doctors become more willing to help them do
so.
"'Assisting' suicidal people will alter the links between suicide and medical
afflictions," writes McHugh. "The practice should eventually be appraised with
that in mind. For example, will conditions that never increased a patient's
suicide risk begin to do so in Utrecht [The Netherlands] and Grand Rapids
[Michigan]? Will more women choose a premature death through suicide when their
doctors are ready, indeed eager, to provide it? Such appraisals will test
whether 'assisted' patients are being helped or spurred to relinquish their
lives."
Harris and Barraclough conclude that their examination of 63 medical disorders
shows that those illnesses with a heightened risk of suicide are also those
that have known associations with mental disorders or substance abuse. "This
finding strengthens the evidence that mental disorders are the most important
disease element in suicide," they write.
Medicine is edited by Victor McKusick, M.D., of Johns Hopkins and published by
Williams & Wilkins in Baltimore.
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