CE Corner
CE
Yet the topic arouses
strong feelings—and raises
plenty of questions. Can a
person with depression ratio-
nally choose to hasten death?
Would the option be less
appealing if people received
better care for physical symp-
toms and emotional distress?
Could aid in dying put margin-
alized groups at risk?
CONTINUING EDUCATION As physician-assisted dying
ASSISTED DYING: becomes available in more
THE MOTIVATIONS, places, research psycholo-
BENEFITS AND PITFALLS gists are finding opportunities
OF HASTENING DEATH to study people’s motivations
and the potential benefits and
BY KIRSTEN WEIR
harms of aid in dying. On the
clinical side, psychologists’
skills are helpful as people
sort through their feelings
and desires at the end of
I
t’s been two decades since Oregon enacted the life, says Elizabeth Goy, PhD,
nation’s first Death with Dignity Act, allowing people a psychologist at the Port-
with terminal illnesses to hasten their deaths by self- land VA Medical Center and
administering medications prescribed by a physician. associate professor at Oregon
Since then, California, Colorado, Vermont, Washington Health and Science University,
state and Washington, D.C., have passed similar statutes. and chair of the APA Working
In some ways, the cultural conversation about Group on End-of-Life Issues
assisted dying has evolved since Oregon paved the and Care.
way for physician-assisted death, says Barry Rosenfeld, “The very best thing we
PhD, a professor of psychology and adjunct professor can do as psychologists is to
of law at Fordham University who has studied the desire improve communication and
for hastened death. In the 1990s, the arguments for and make sure that we are attend-
against assisted dying “were more emotional than scien- ing to the needs and suffering
tific,” he says. Today, policymakers and voters have more of patients who are at the
data to draw from when considering similar legislation. end of life,” Goy says. “Dying
is ­universal, and it behooves
all of us to have some foun-
CE credits: 1 dational knowledge about
Learning objectives: After reading this article, CE candidates end-of-life issues.”
will be able to:  have grappled with the ques-
1 . Describe APA’s resolution on assisted dying. A NEW LANGUAGE
2. Discuss the ways depression can complicate a patient’s wish Goy and her colleagues on the
As physician-assisted dying for assisted dying. working group were charged
WILLOWPIX/ ISTOCKPHOTO
becomes more available, 3. Discuss research on how family and friends are affected when with updating APA’s previ-
psychologists are finding
opportunities to study a loved one chooses assisted dying. ous resolution on assisted
people’s motivations and For more information on earning CE credits for this article, suicide, adopted in 2001.
the potential benefits and go to www.apa.org/ed/ce/resources/ce-corner.aspx. In August, APA’s Council of
harms of aid in dying.
26  M O N I TO R O N P S YC H O LO G Y ● DECEMBER 2017 M O N I TO R O N P S YC H O LO G Y
Representatives voted to
approve the updated resolu-
tion. Like the previous reso-
lution, the 2017 update states
that APA neither endorses nor
opposes assisted dying at this
time.
“It was the consensus
of the working group that
this is a matter between the
psychologist and the person
considering aid in dying,” says
group member and Jonesville,
Virginia–based psychologist
James L. Werth Jr., PhD. “Psy-
chologists have to be aware
of their own biases, and if they
can’t be a part of the discus-
sion without those biases
getting in the way, they should
refer the person to someone
else. But we determined that
APA shouldn’t be a limiter of
that discussion.”
The most notable update
to the resolution was linguistic.
When the 2001 resolution was
passed, the topic was known
as “assisted suicide.” Today,
providers prefer the term
“assisted dying” to reflect the
distinction between suicide
and the process of hastening
death to alleviate pain and
suffering.
Still, the specter of depres-
sion and suicide hangs over
public opinion of assisted
dying. Since Oregon first raised
the possibility of legalized
dying in the 1990s, researchers
tion of whether it can ever be
considered a rational choice,
Rosenfeld says. “Some people
felt that almost everyone who
seeks this option is doing so
out of a rational appraisal of
their situation. Others argued
● DECEMBER 2017 27
CE Corner
this is just a form of suicide and
we should protect them from
themselves,” he says.
But research in the interven-
ing years has suggested the truth
lies in the gray area between, he
adds. “Of the people who pursue
this option, a sizable portion are
rationally appraising their situa-
tion. And a sizable proportion are
appraising it through a lens of
depression.”
In a study of terminally ill
patients, for instance, Rosenfeld
and his colleagues found that
desire for death was associ-
ated with depression, and that
desire decreased in patients who
responded to antidepressants
(Psychosomatics, Vol. 51, No. 2,
2010). Other research, however,
suggests that depression is not
a major driver for most people
who request aid in dying. When
Oregon’s law was passed, Goy
teamed up with psychiatrist Linda
Ganzini, MD, MPH, at Oregon
Health and Science University, to
study the moods, values, needs,
concerns and symptom burdens
of 58 Oregon residents with
terminal illnesses who pursued
assisted death. They found that
most of those people did not
have depressive disorders.
However, they also concluded
that the Death with Dignity Act,
as written, might fail to protect
some patients with depression
from making the choice to hasten
death (BMJ, Vol. 337, 2008).
Still, some advocates note that
depression shouldn’t ­necessarily
make a person ineligible for
physician-assisted death. “In the
normal world of decision-mak-
ing, we wouldn’t say people lose
autonomy to make decisions
because they’re moderately
28  M O N I TO R O N P S YC H O LO G Y
depressed,” Rosenfeld says.
Indeed, he adds, there’s too
little research to indicate how a
person should feel or act as they
approach their final days. “How
cheerful should you be when you
have a terminal illness?” he asks.
Some proponents of legal-
ized aid in dying suggest that the
option may be unfairly singled out
ABOUT CE because of cultural beliefs about
“CE Corner” is the morality of suicide. “Assisted
a continuing
dying gets a lot of attention
education article
offered by APA’s
because of the values and emo-
Office of CE in tions that get brought into it,” says
Psychology. Werth. Yet many more people
with serious illness end their lives
To earn CE credit,
through some other negotiated
after you read this
article, purchase the
means, he says, such as ceasing
online exam at  medications, withholding food
www.apa.org/ed/ or drink, refusing life-­sustaining
ce/resources/ce-
corner.aspx. 
treatment or signing “do not
Upon successful
resuscitate” orders. “Most people
completion of will die those ways,” he says.
the test—a score
of 75 percent or REGAINING CONTROL
higher—you can After two decades of evidence
immediately print
from Oregon, research is answer-
your CE certificate. 
ing many questions about aid in
The test fee is dying. That evidence suggests
$25 for members that the desire to hasten death
and $35 for often comes from wanting to main-
nonmembers.
tain some power over one’s own
The APA
Office of CE in
life, Goy says. “In our research,
Psychology retains the main reason people voiced
responsibility for for wanting the option was that
the program. For they really wanted to have control
more information,
over the circumstances of dying.”
call (800) 374-2721.
The wish for control can be
for a variety of reasons, they
found, including loss of autonomy
and function or worries about
future pain (JAMA Internal Med-
icine, Vol. 169, No. 5, 2009). But
reassuringly, when Goy and her
colleagues compared people who
expressed a desire for aid in dying
with others with terminal illness
who did not seek that option,
● DECEMBER 2017
they found no indication that the human development at the Uni-
former group was motivated by versity of Illinois at Chicago. “This
financial concerns or being a bur- sector of the population generally
den to their loved ones, Goy says. has access to options and seeks
A need for control may also control of their life circumstances
be behind another finding related up to the end of life,” she points
to assisted dying: Many people out. “In contrast, there are
who go through the steps to underrepresented communities
receive a prescription for lethal who have very different views of
medication don’t ultimately move assisted dying.”
forward with taking it, points out The biggest concern to Gill
Veronica L. Shead, PhD, a clinical and others is that people from
psychologist who specializes in disadvantaged groups might
palliative care at the VA St. Louis consider hastened death because
Health Care System and a mem- their health-care needs are
ber of the APA working group. In not being met. There are well-­
Oregon, for example, 204 people documented disparities in access
received prescriptions through to health-care services, with
the Death with Dignity Act in people from lower socioeconomic
2016, but only 133 of them died backgrounds, those with lower
through that means—a proportion Families of people who chose aid in dying health literacy, and members of
similar to that of previous years. reported that they felt more prepared for and accepting ethnic or racial minorities being
More research is needed to of their loved one’s death, research found. less likely to receive adequate
fully understand why and when care, including palliative care
some people ultimately make services.
that choice, Shead notes. But it “There are a number of
may be that just having the option of Pain and Symptom Manage- talk to their families about their ­marginalized populations that
provides a sense of control over ment, Vol. 38, No. 6, 2009). decision. “One of the gifts when are legitimately concerned about
the circumstances of one’s death, That could be because family someone makes this choice is whether they are getting all of the
allowing the person to focus on discussions of hastened death that it brings the discussion to the best options in care at the end
the quality of life that remains often force families to discuss table. The whole family or support of life,” Goy says. “We want to be
rather than fear of future suffering. difficult topics they might other­ group talks not just about this sure we are attentive to treating
Research also shows that the wise not have spoken about, particular way of dying, but about pain adequately and addressing
choice to hasten death doesn’t suggests Judith Gordon, PhD, a all the issues related to how they emotional experiences such as
negatively impact surviving family Seattle-based psychologist and feel about the death and what hopelessness, depression and
members. Months or years after clinical professor of psychology they will do later. It’s an enormous despair, so that assisted dying
the death of the patients in their at the University of Washing- benefit,” Gordon says. does not seem like the only
study, Goy and Ganzini inter- ton who has studied end-of-life option.”
viewed their family­­caregivers. decision-making since 1996. “In END-OF-LIFE INEQUITY Gill says that many in the
When they compared family this culture, there’s still a lot of Despite those potential benefits, disability-rights community have
members of those who requested resistance to talking about dying, critics express concerns about the expressed unease with aid in dying
aid in dying with those who did even if someone is diagnosed possible harms of assisted death. because of concerns that people
not, the researchers found no with a terminal disease,” she says. One worry surrounds access. won’t receive the resources they
differences in depression, grief or “When people want to use this So far, most of the people who need to live meaningful lives
PEOPLEIMAGES/ ISTOCKPHOTO
use of mental health services. In option, they need the support of have requested aid in dying are despite physical limitations. “There
fact, families of people who chose their doctors and typically also white, middle-class and typically are no assisted-dying laws that
aid in dying reported that they felt want the support of their families.” well-educated, notes Carol Gill, guarantee those resources, and
more prepared and accepting of Most people who receive a PhD, APA working group member that feels discriminatory to a lot of
their loved one’s death (Journal prescription for lethal medication and professor of disability and people with disabilities,” she says.
M O N I TO R O N P S YC H O LO G Y ● DECEMBER 2017 29
CE Corner
Indeed, the very idea of “death
with dignity” is an affront to many
people who have physical limita-
tions that require daily assistance,
Gill says. “Some right-to-die activ-
ists have written about assisted
dying as an antidote for indignity
that occurs at the end of life, such
as needing help to dress or use
the bathroom. If you’re a person
with functional limitations, that’s a
real slap in the face,” she says.
For most people, including
those with disabilities and those
facing functional loss at the
end of life, social connection is
what makes life worth living, she
adds. “Having a meaningful life
doesn’t necessarily mean that life
needs to be pain-free or without
physical impairment or functional
limitations. What it means is to
remain engaged humanly, and
get enough support from others
or technology to engage in the
activities that matter, that make
life meaningful.”
UNANSWERED QUESTIONS
Even advocates of physician-­
assisted death say it’s crucial that
researchers continue to explore
Evidence suggests that the desire to hasten death often comes from
wanting to maintain some power over one’s own life.
30  M O N I TO R O N P S YC H O LO G Y
the process to ensure it’s used
responsibly. More work is needed
to understand how terminally ill
people make treatment decisions,
Rosenfeld says, including the
decision to end one’s life. “The
fact that assisted-dying laws aren’t
used that often has made people
more confident that the law isn’t
being misused. But could that
number go down a notch further
by having more services available?
That’s where more research could
be really informative,” he says.
Gill adds that too little is
known about how people make
the decision to take lethal med-
ication after they request the
prescription. “We don’t follow
these individuals and hear what
they’re thinking day to day in the
period before they ingest the
drugs, and we don’t know what
happens to people who express
interest but don’t end up going
through with it,” she says.
Gill also hopes that research-
ers will further explore how the
availability of aid in dying will
affect medical practice. “Will it
seem more and more reasonable
for people to want their death
● DECEMBER 2017
hastened? Will we remember The Ethical Practice
that life, even when it includes
suffering, can still be consid-
of Consulting Psychology
ered meaningful given adequate Rodney L. Lowman and Stewart E. Cooper
support and resources? What will
This book reviews the unique ethical issues that psychologists
happen to the balance of those
encounter when working as consultants in business and other
resources when assisted dying
organizational settings. It provides guidelines based on the APA Ethics
FURTHER becomes more common?”
Code to help consulting psychologists make ethical decisions when
READING There’s an open opportunity
conducting assessments and interventions with individual employees,
for psychology researchers to
APA End of Life teams and work groups, and entire organizations. Case examples
answer such questions, Rosen-
Issues and Care illustrate complex ethical dilemmas, such as how to confront corrupt
feld says. “I think we are uniquely
www.apa.org/pi/ business practices. Emerging issues like telepsychology, multinational
aging/programs/eol poised to do the kind of research
and multicultural consulting, and coaching are given special consideration.
that would inform these issues.”
2018. 168 pages. Paperback.
Physician-Assisted Psychologists can also fill an
Dying: important role by evaluating and
A Turning Point? counseling people who have Series: Fundamentals of Consulting Psychology
Gostin, L.O., &
expressed a wish to pursue aid List: $44.95 | APA Member/Affiliate: $34.95
Roberts, A.E., To view the full Table of Contents,
in dying. Though it’s not a topic ISBN 978-1-4338-2809-6 | Item # 4312026
JAMA, 2016 visit www.apa.org/h4312026
taught in graduate school, some
Mental Disorders state psychological associations
and the Desire have prepared guidelines for
for Death in IN THE SERIES:
Patients Receiving mental health professionals who
Palliative Care do such evaluations, Gordon says.
for Cancer (For example, the Washington An Introduction to Consulting Psychology
Wilson, K.G., et al., Working With Individuals, Groups, and Organizations
State Psychological Association
BMJ Supportive & Rodney L. Lowman
issued the Washington Death 2016. 192 pages. Paperback.
Palliative Care,
2016 with Dignity Act WSPA Guidelines
ISBN 978-1-4338-2178-3 | Item # 4317403
for Mental Health Professionals,
The Relief of and the California Psychological Transcultural Competence
Existential Association recently published Navigating Cultural Differences in the Global Community
Suffering Jerry Glover and Harris L. Friedman
its guidelines, California’s End of
Kissane, D.W., 2015. 164 pages. Paperback.
JAMA Internal Life Option Act: CPA Guidance for
Psychologists.) ISBN 978-1-4338-1945-2 | Item # 4317366
Medicine, 2012
Although it’s not an easy job Using Feedback in Organizational Consulting
The Oregon Death to work with people facing their Jane Brodie Gregory and Paul E. Levy
with Dignity Act: final days, it is often a gratifying 2015. 152 pages. Paperback.
A Guidebook
for Health Care one, says Goy. “All of psychol- ISBN 978-1-4338-1951-3 | Item # 4317367
Professionals ogy comes to bear when you are
The Center for working with people at the end of
Ethics in Health life. It calls for skills in every area
Care, Oregon
Health and Science
that psychologists are trained TO ORDER: 800-374-2721 § www.apa.org/h4312026
University, in,” she says. “There are a lot of
In Washington, DC, call: 202-336-5510 § TDD/TTY: 202-336-6123 § Fax: 202-336-5502
2008 emotions around this topic and
it’s ethically sensitive. The best In Europe, Africa, or the Middle East, call: +44 (0) 1767 604972
JRYANC10/ ISTOCKPHOTO
we can do is be open to the
concerns, continually be looking
for data and challenge our own
biases as best we can.” ■
AD3192
M O N I TO R O N P S YC H O LO G Y ● DECEMBER 2017 31