Breaking Point: Allostatic Overload and Self-Determined Euthanasia
Charles Love, MATL, St. Louis University, St. Louis, MO
Hopelessness and despair following a terminal diagnosis can affect the capacity for self-governance. Such feelings can contribute to the allostatic load (AL), a cumulative burden resulting from stress and anxiety, leading to a neurophysiologic decline that can impair autonomy and may influence the desire to end one’s life deliberately. Clinical evidence indicates that spirituality and hopefulness can reduce the AL and restore autonomy allowing patients to better process end-of-life decisions. Based on these data, this paper will argue that jurisdictions offering euthanasia are morally compelled to make mental and spiritual counseling available to patients seeking this course of action.
Self-determined euthanasia (SDE) implies a right for an individual or their legally authorized representative to end their life prior to a natural death. Over 200 million people have access to SDE with legislative initiatives for expansive legalization actively pursued in other jurisdictions. Introduced in 2016, Canada’s Medical Aid in Dying (MAiD) Act decriminalized voluntary euthanasia in eligible patients with a “grievous and irremediable medical condition.” More than 30,000 people have legally ended their lives in Canada since the law went into effect.
Arguments for patient autonomy are frequently employed as the primary justification for SDE. While many studies have associated depression and hopelessness with suicidal ideation, fewer studies have examined how the loss of hope and ensuing clinical depression in the context of intractable physical or mental illness may contribute to a patient’s disposition and desire for early release. Studies have shown that patients choosing SDE have higher levels of depression, hopelessness, and a lower sense of independence, self-reliance, and spirituality. The erosion of hope from the neglect of the psychospiritual problems that develop in the palliative phases of disease can increase the desire to cheat death’s ignominy. Providers and systems that intentionally or unintentionally deprive patients of hope overlook important avenues of physical and spiritual care, which can diminish a patient’s sense of autonomy and hasten unnatural desires.
High ALs are significantly correlated to increased mortality. Suicidal ideation is also correlated with allostasis, which may be associated with dysregulation of hypothalamic-pituitary-adrenal activity from increasing cortisol levels. The neurophysiologic decline, including adverse changes to the hippocampus, which regulates important emotional functions of the brain including memory recall and imagination, is associated with debilitating depression and anhedonia. The uncertainty and anxiety that accompany terminal disease can lead to an allostatic overload that can dysregulate executive control functions in the brain and compromise autonomy, specifically intentionality and voluntariness.
More than 10,000 patients ended their lives under the MAiD Act in 2021. Of these, fewer than 7% were referred to a psychiatrist, and only 5% were referred to "other consultation," which could include psychologists, speech pathologists, spiritual care, and biomedical ethicists. Canada recently removed provisions for a nominal 10-day reflection period, but its citizens can wait up to three or more months before seeing a licensed mental health professional. Healthcare teams involved with MAiD, which consist largely of primary caregivers and nurses, lack support from specialty care practitioners necessary to make appropriate physical, mental, and spiritual assessments to identify the nature of the suffering and the source of the crisis, likely overlooking the deteriorating cycle that exists between depressive disorders and increases in the AL.
Medicine reveals important psychological and physical dimensions of hopefulness that are associated with positive clinical outcomes. The management of end-stage or major life-altering disease benefits when psychosocial-spiritual care is incorporated into the treatment plan. In contrast, feelings of hopelessness, fear, and anxiety are comorbid and work against the aims of healthcare in ways that can accelerate physical and mental decline leading to abject despair and isolation. A sudden increase in AL negatively affects the neurohormonal balance and may enhance the putative desideratum offered in SDE. Access to mental health counseling and spiritual care is essential to ensuring that decisions made in extremis are not compromised by the lack of spiritual and mental care and are consistent with a patient’s values prior to the collision with death.
Self-determined euthanasia (SDE) implies a right for an individual or their legally authorized representative to end their life prior to a natural death. Over 200 million people have access to SDE with legislative initiatives for expansive legalization actively pursued in other jurisdictions. Introduced in 2016, Canada’s Medical Aid in Dying (MAiD) Act decriminalized voluntary euthanasia in eligible patients with a “grievous and irremediable medical condition.” More than 30,000 people have legally ended their lives in Canada since the law went into effect.
Arguments for patient autonomy are frequently employed as the primary justification for SDE. While many studies have associated depression and hopelessness with suicidal ideation, fewer studies have examined how the loss of hope and ensuing clinical depression in the context of intractable physical or mental illness may contribute to a patient’s disposition and desire for early release. Studies have shown that patients choosing SDE have higher levels of depression, hopelessness, and a lower sense of independence, self-reliance, and spirituality. The erosion of hope from the neglect of the psychospiritual problems that develop in the palliative phases of disease can increase the desire to cheat death’s ignominy. Providers and systems that intentionally or unintentionally deprive patients of hope overlook important avenues of physical and spiritual care, which can diminish a patient’s sense of autonomy and hasten unnatural desires.
High ALs are significantly correlated to increased mortality. Suicidal ideation is also correlated with allostasis, which may be associated with dysregulation of hypothalamic-pituitary-adrenal activity from increasing cortisol levels. The neurophysiologic decline, including adverse changes to the hippocampus, which regulates important emotional functions of the brain including memory recall and imagination, is associated with debilitating depression and anhedonia. The uncertainty and anxiety that accompany terminal disease can lead to an allostatic overload that can dysregulate executive control functions in the brain and compromise autonomy, specifically intentionality and voluntariness.
More than 10,000 patients ended their lives under the MAiD Act in 2021. Of these, fewer than 7% were referred to a psychiatrist, and only 5% were referred to "other consultation," which could include psychologists, speech pathologists, spiritual care, and biomedical ethicists. Canada recently removed provisions for a nominal 10-day reflection period, but its citizens can wait up to three or more months before seeing a licensed mental health professional. Healthcare teams involved with MAiD, which consist largely of primary caregivers and nurses, lack support from specialty care practitioners necessary to make appropriate physical, mental, and spiritual assessments to identify the nature of the suffering and the source of the crisis, likely overlooking the deteriorating cycle that exists between depressive disorders and increases in the AL.
Medicine reveals important psychological and physical dimensions of hopefulness that are associated with positive clinical outcomes. The management of end-stage or major life-altering disease benefits when psychosocial-spiritual care is incorporated into the treatment plan. In contrast, feelings of hopelessness, fear, and anxiety are comorbid and work against the aims of healthcare in ways that can accelerate physical and mental decline leading to abject despair and isolation. A sudden increase in AL negatively affects the neurohormonal balance and may enhance the putative desideratum offered in SDE. Access to mental health counseling and spiritual care is essential to ensuring that decisions made in extremis are not compromised by the lack of spiritual and mental care and are consistent with a patient’s values prior to the collision with death.