Lit+Review

Lit Review
**Suicide the dilemma of the right to die… AIDS & HIV Infection Update: Kenneth S. Pope Stephen F. Morin http://kspope.com/ethics/aids-hiv.php** This chapter ("AIDS and HIV Infection Update: New Research, Ethical Responsibilities, Evolving Legal Frameworks, and Published Resources") appeared in Keller, Heyman, et al. (Eds.), Innovations in Clinical Practice: A Source Book, vol. 10, pages 443-457. It is important for people in the mental health profession to be conscious of the suicidal risk when working with those infected with HIV. A study of men in New York City found that “the relative risk of suicide in men with AIDS ages 20-59 years was 36.30 times that of men aged 20-59 without the diagnosis, and 66.10 times that of the general population”. This study did not focus on the sexual orientation of the males, but the diagnosis alone shows a dramatic increase in the likelihood of suicide. In Miami, seven people took their lives during a six week period after testing positive for the virus, even though they were asymptomatic (Pierce, 1987). A controversial question the profession has not adequately addressed is whether a psychotherapy patient suffering from AIDS has the right to commit suicide without interventions from the therapist. State statutes may require oppositional intervention from the therapists to prevent a patient’s suicide. Criminal statutes may declare any help, advice or encouragement rendered by a therapist a felony. Regardless, a national study of psychologists found that 1 out of 5 had accepted a client’s decision to commit suicide. 45.2% of respondents believed to do so was always unethical, while 48% believed doing so was always poor practice (Pope, Tabachnick, & Keith-Spiegel, 1987-88). “An adequate sensitive and ethical response to people with AIDS wishing to die will take willingness by the counselor to discuss these issues more openly and to inform ourselves about the complex clinical and ethical aspects. It is important to identify factors within ourselves that extinguish, block, or distort our respect and empathy toward fellow humans” (Pope). **Werth Jr., J. L. (1995). Rational suicide reconsidered: AIDS as an impetus for change. Death Studies, 19(1), 65.** It is necessary to reconsider the traditional idea that the only legal, ethically, and morally appropriate response is intervention, forcibly if necessary. The ethical codes make preventing a suicide required. It is the idea that anyone with suicidal ideation is suffering from a metal health problem. The article argues that as the AIDS epidemic continues the profession is going to come into contact with more people diagnosed with the disease, planning suicide and some of them may be making rational decisions. The connection between AIDS and suicide was so explicit in 1987, the American Association of Suicidology developed a Task Force. Since 90% of the people with AIDS are between 20-49, they struggle with redefining their quality of life. Quality of life can be measured by a sense of security, love, family, friends, achievement, pleasurable activity, the ability to control reinforcements, freedom from pain and suffering, and freedom from deliberating (Werth, 1995). Social integration, physical and mental health, love and affection were noted as making life meaningful. Several variables should be assessed when determining if a suicide is rational. In 1986, Siegel outlined 3 components of rational suicide: Werth added two components in 1992: Determining if the person has a realistic assessment of the situation depends on how informed the person is about the topic. //If they have seen friends or family members die of the disease, attended conferences, or attended support groups.// If the professional does not believe the person has a realistic view of the situation, they are responsible for educating them or referring them to someone that can. The second criteria is the most difficult to assess. It is important to determine if the HIV infection has affected the brain to a point that the person is not thinking clearly. Neurological testing can be completed to see if the thought process is affected, and a mental health professional can administer a mental status exam that checks for cognitive impairment. In 1991, The American Psychological Association stated that infection with HIV is not enough to assume impairment, and tests must be done to prove there has been an effect on the brain. If the tests reveal nothing, assuming impairment would be a mistake. Depression is another area that presents difficulty. Overt depression can cause very negative thinking that may impair rational thinking. It can be assumed, however, that the presence of some depression is understandable given the circumstances. The third factor can be studied by looking at literature on how society accepts suicide, or the right to die, of people with terminal illnesses. Terminal cancer is usually what comes to mind when thinking about cases of rational suicide. In 1990, Lawrence, Kelly, Owen, Hogan, and Wilson found that psychologists rated suicide as a drastically more applicable option for AIDS patients as opposed to leukemia patients. Werth believes for a decision to be rational, it must be deliberated and reiterated over a period of time. Although there is no hard evidence to determine what that period of time should be, he recommends 3 months. He suggests that gives time to make sure the decision is not rash and also to determine there is not impairment from overt depression. The final criteria is including significant others in the decision making process. It is noted that the wish to involve other people should be up to the person considering suicide, and the wishes of the others should never override that of the client. Werth also included the 5th criterion because of a study that concerned psychotherapists’ attitudes toward suicide. 81% of 146 respondents believed in the concept of rational suicide. They included making that decision should be in conjunction with family and friends so the suicide doesn’t lead to a “legacy of guilt” (Werth and Cobia, 1994). For the person with AIDS, as for all people, the approach of death is an existential issue that must be faced (Yalom, 1980). It is important that the professional working with an HIV/AIDS client does not force their own values about life and death upon them. Allowing an open discussion restores autonomy to the client. While the client may feel empowered, it does put pressure on the clinician to determine if the suicide is rational or irrational. Generally speaking, there is currently no painstaking thought process necessary when a client is suicidal. The directive is to change their mind or prevent it from happening by mandated reporting. The current standard is opposition to autonomy in the area of life or death decisions which implies that suicide is never an appropriate option. Choron (1972) summarized the situation “In any event, for those engaged in suicide prevention, there seems to be no alternative to trying to prevent even a rational suicide, no matter how irrational such a position may be, especially when painful death is inevitably near.” **Marsha, W. F., Uphold, C. R., Shehan, C. L., & Reid, K. J. (2005). Effects of spirituality on health-related quality of life in men with HIV/AIDS: Implications for counseling. Counseling and Values, 50(1), 5-19. http://search.proquest.com/docview/207569890?accountid=12774** Counselors working with males with HIV/AIDS should consider the positive benefits of spirituality. It is associated with better physical, mental, and emotional health outcomes. A spiritual orientation of believing in a higher power, or a force greater than one’s self, were significant factors in overall well-being and mental health. Including this in counseling can help the client face their mortality and come to a more peaceful place. Clarifying the client’s values in light of a chronic, terminal illness could result in them making important life choices that allow them to live a future that has a sense of purpose and connection. That support could help the client achieve an overall better quality of life. There were 3 instruments used in compiling data to support the idea of spirituality in counseling, specifically for this demographic. 1. Metal health related quality of life was assessed by the scales from the HIV Cost and Services Utilization Study. It is a 31 item measure covering 10 areas. The scales were summarized into three scores: a physical health summary, mental health summary and overall quality of life summary. This instrument was used thoroughly in previous HIV/AIDS research and has established validity and reliability (Revicki, Sorenson, & Wu, 1998). 2. The Health Promoting Lifestyle Profile II measures behaviors that are actions directed at increasing well-being, self actualization, and personal fulfillment (Pender, 1996). It is a 52 item measurement with six subscales that measure components of a healthy lifestyle. The instrument has established reliability and validity (Walker et al., 1987). 3. Spiritual coping was measured using an adaptation of the Coping with HIV Questionnaire (Moneyham, Demi, Mizuno, Sowell, & Guillory, 1998). It is a 24 item instrument which asks respondents to indicate on a scale, how frequently in the past 3 months they have used various strategies to deal with being HIV positive.
 * Has a realistic assessment of the situation
 * Mental processes are unimpaired by psychological illness or severe emotional distress.
 * The person has a motivation that would be understood to a majority of uninvolved community members
 * The decision is deliberated and reiterated over a period of time
 * If at all possible the decision involve the person’s significant others

**Plans to hasten death among gay men with HIV/AIDS: Relationship to psychological adjustment Goggin, K; Sewell, M; Ferrando, S; Evans, S; et al. AIDS Care 12. 2 (Apr 2000): 125-36.** The debate continues on whether suicidal ideation always reflects underlying psychopathology or whether it can be an adaptation to manage a perceived threat (Beckett & Shenson, 1993, Werth, 1992). One study of 164 HIV positive men found higher levels of suicidal ideation associated with increased hopelessness and higher levels of neuroticism (Kelly et al., 1998). Other researchers, however, suggest that suicidal thoughts are a means of coping with the threat of death anyway. An area that is lacking in literature is the timing of the intended plan. Usually suicidal ideation is an immediate intention rather than one that is future oriented. Few studies focus on future plans. Most of them concentrate on reported rates of plans. In 1995, Green interviewed 57 HIV- positive men and 67 HIV- negative men in Scotland. The goal was to find out how many men had considered taking their lives in the future. 28% of the HIV-positive sample had those thoughts over the 4% of HIV-negative men. Van den Boom (1995) interviewed survivors of 52 deceased AIDS patients in the Netherlands and discovered that 25 of the 52 had made arrangements for euthanasia prior to their deaths. Previous studies that attempted to address whether future plans of suicide were associated with psychopathology faced limitations. This study was done to address those limitations using a longitudinal design. The goals of the study were to The study included 167 HIV-positive gay men. 102 of the 167 had an AIDS diagnosis. After receiving a complete description of the study, the participants were given informed consent. There were many psychiatric measures used including The Beck Hopelessness Scale and Beck Depression Inventory. At the first check in 11% of the 167 men reported they had made arrangements to end their lives at some point in the future, while 6% indicated they had serious thoughts about doing so. Among those 29 men, the most common reason for the plans to end their life was to maintain a sense of control. At the second check in (18 months later) 2 more men had developed thoughts of ending their lives. The most frequent reason cited was the desire to maintain control, make one’s own decisions, and prevent suffering. The most common circumstances were intolerable pain, loss of independence, and no hope of improvement. It reiterates the importance that this client needs to feel a sense of control, and the counselor should address the client’s fear of losing it. The idea that plans for suicide may reflect adaptive coping is supported by this study. There was no difference in current psychiatric diagnoses in men with or without plans, nor did they differ in terms of distress, hopelessness, or medical status. Findings in this sample reveal that depression or psychological issues were not factors in the plans to end their lives. The study acknowledges that while these thoughts may help individuals maintain some sense of control and autonomy, they should be encouraged to look for other controllable areas in their lives with HIV disease. These clients will also benefit from a supportive environment to discuss their thoughts about controlling the end of their lives and finding comforting measures to reduce pain and suffering.
 * They relied on retrospective assessments of plans for euthanasia which were reported by significant others.
 * They also limited their focus to plans of physician assisted suicide rather than general plans to end life.
 * They were cross sectional and did not follow across time the stability of plans and levels associated with psychological distress.
 * 1) Determine the prevalence of thoughts and future plans to end one’s life in a sample of HIV/AIDS positive gay men over an 18 month period.
 * 2) Identify (when plans did exist) reasons for them and circumstances anticipated to be intolerable
 * 3) Determine whether the psychiatric and medical status of men who have thoughts/plans about ending their life differ from those who do not.