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| Japanese Journal of Clinical Oncology | Pages |
Letter
Desire for Early Death in Cancer Patients and Clinical Oncology
To the Editor:
In clinical oncology practice, it is not rare that physicians receive patients' requests for early death. However, many oncology staff members face a dilemma when confronting these requests because it is difficult to judge whether the requests are rational or not. How are we supposed to react? How should we deal with them? In connection with this issue, there has been much interest in euthanasia and physician-assisted suicide, especially among terminally ill cancer patients, and many arguments about these issues have been made from medical, legal and ethical discussions all over the world. Concerning legal aspects in Japan, the Nagoya High Court first established six criteria for lawful euthanasia in 1962 (1). The requirements are as follows: a patient is suffering from incurable disease and death is imminent; the patient's pain and suffering are unbearable; euthanasia must be performed only for the purpose of alleviating the patient's pain and suffering; the patient's own request or consent is required and must be obtained when the patient is conscious and competent; in principle, euthanasia is performed personally by his/her attending physician; the method for euthanasia must be ethically acceptable. Additionally, in 1993, the Yokohama District Court stated that euthanasia is legal, but only if four conditions are met (1). These conditions are that: a patient must be suffering unbearable physical distress, such as pain; death is unavoidable; there is no alternative for relieving suffering; and the patient's will is clear.
Recently, I had an opportunity to visit Australia as a visiting researcher of the Foundation for Promotion of Cancer Research. In Australia, I studied psycho-oncology in Melbourne University and also had an opportunity to discuss euthanasia and physician-assisted suicide with Dr David Kissane, who is a Professor at the Center for Palliative Care, Melbourne University, and the first author of a paper that reported actual experience of legalized euthanasia (2). In 1996, the Northern Territory in Australia became the first and only place in the world that legalized euthanasia (the Rights of the Terminally Ill Act). Under the law, seven patients had made formal use of the law and four died before this law was repealed in 1997 by the Australian Federal Parliament (2). It is reported that all of these seven patients had cancer. The report also indicated that pain was not a prominent clinical issue, but other symptoms including fatigue, depression and social isolation contributed more to the patients requesting euthanasia. The authors also suggested the problems of underdevelopment of palliative-care facilities in the Northern Territory. Although broad ranges of information were not obtained from actual practice, several psychosocial issues including depression may be strongly associated with this kind of medical intervention. When we discussed euthanasia problems, Dr Kissane emphasized the importance of establishing excellent symptom management against multi-dimensional distress such as physical, psychological and social issues, namely comprehensive palliative care for patients with a request for euthanasia before actually performing it. In this context, he also suggested that a desire for early death among most cancer patients is not rational, namely not a normal reaction. The great necessity for appropriate symptom management, especially several kinds of mental disorders, before euthanasia is supported by our experience in Japan (3).
Regarding euthanasia problems, there seem to be several differences between Western countries and Japan. For example, in Western countries, it is reported that more than half of the general public support this kind of medical intervention for terminally ill patients. On the other hand, in Japan, a similar survey revealed that less than 10% of the general public endorsed euthanasia for terminally ill patients (4). This discrepancy in the public's attitude to euthanasia may partly depend on cultural differences.
However, regarding the issues in clinical oncology in Japan, the discussion is too immature to reach any kind of conclusion because of the lack of sufficient palliative care practice to understand the physical, psychological and social aspects of a patient requesting euthanasia. The quality of the care of patients with terminally ill cancer is one of the most important dimensions in clinical oncology; however, few studies on palliative care including psycho-oncology have been conducted in Japan. To respond to cancer patients' and their families' wishes for excellent medical services, much further progress in comprehensive palliative care in Japan is needed.
References
- Hoshino K. The incidents reported as euthanasia in Japan. In: Hoshino K, editor. Whose is my life? Tokyo: Okurasyo Insatsukyoku 1996;85-99 (in Japanese).
- Kissane DW, Street A, Nitschke P. Seven deaths in Darwin: case studies under the Rights of the Terminally Ill Act, Northern Territory, Australia. Lancet 1998;352:1097-102.
- Akechi T, Kugaya A, Okamura H, Nakano T, Okuyama T, Mikami I, et al. Suicidal thoughts in cancer patients: clinical experience in psycho-oncology. Psychiatry Clin Neurosci 1999;53:569-573.
- Hashimoto S. Study of attitude toward terminal care. Research Report 1998 (in Japanese).
Tatsuo Akechi
Psycho-Oncology Division,
National Cancer Center Hospital,
Tokyo, Japan
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