       FOCUS: A Guide to AIDS Research & Counseling
       Volume 9, Number 5 - April 1994
       --------------------------------------------

       Table of Contents
       
       Editorial
       Rational Suicide: Then and Now, When and How 
       Compassion in Dying
       Recent Reports
       Next Month
       ----------

       Editorial: Different Ways of Dying 
       Robert Marks, Editor

       No discussion of rational suicide begins without a recitation of the
events that have made the right to die and physician-assisted suicide
political issues of the day. Both of the articles in this issue of FOCUS
provide a perspective on these events. None of these events is more
significant to mental health practitioners and in and of itself a better
reflection of society's changing attitudes than the recent actions by the
National Association of Social Workers (NASW). 

       The NASW is the first of the counseling professions to consider it
ethical for practitioners to attend an assisted suicide of a client.
According to the guidelines, while "it is inappropriate for social workers to
deliver, supply, or personally participate in the commission of an act of
assisted suicide when acting in their professional role. . .if legally
permissible [under state law], it is not inappropriate for a social worker to
be present during an assisted suicide if the client requests the social
worker's presence." 

       The NASW guidelines also emphasize--as co-equal to the principle of
client self-determination--the responsibility of social workers to be
well-informed about options to suicide including: pain management,
counseling, hospice care, nursing home placement, and the range of legal
documents that attest to a client's wishes concerning health care and the
removal of life support. 

       The Ultimate Transition

       The oft-repeated danger of actions like that of the NASW is that
suicide will become too easy, and people who might commit suicide will be too
easily manipulated by those who would assist them. This danger is real, but
it is likely overstated. In the end, bringing suicide out of the closet and
into therapy, even up to the moment of death, enables mental health
professionals to protect against poorly considered suicides or shadowy
attempts to influence dying clients. 

       The most important aspect of the NASW decision is that people who
choose to die should not have to do so alone. If counseling is about
transitions, counselors belong with clients making the ultimate transition. 

       This issue of FOCUS aims to help practitioners define their feelings
about rational suicide and assisted suicide, and develop tools to help
clients approach decisions and, if necessary, actions. Jerome Motto--by
recounting the recent history of rational suicide and the clinical issues it
raises--outlines a therapeutic process for discussing rational suicide. Susan
Dunshee--by describing the philosophy and work of Compassion in Dying, a
group that straddles the line separating legal from illegal assistance-offers
a sense of what its like to be a frontline counselor, assisting people in
dying.

       ***********

       Rational Suicide: Then and Now, When and How
       Jerome A. Motto, MD

       The issue of rational suicide has long been familiar to individuals
caring for the seriously chronically ill, but it has clearly entered a new
era of heightened intensity and visibility. In fact, the president of the
American Association of Suicidology stated in December 1993 that assistance
with rational suicide is the single most significant issue in suicidology at
this time. Individuals involved with HIV-related clinical and social services
encounter the professional, legal, and ethical challenges of rational suicide
daily. For them, the new developments in this arena have special
significance. 

       Background: Then and Now

       Though debate on this issue dates back at least to the early Greek
philosophers, the current wave of social awareness was first stimulated in
the 1960s and 1970s by a progressively aging population insisting that
rational suicide is a "final right." This response appeared as a natural
outcome of dramatic scientific advances that changed the medical landscape
from predominantly acute and treatable disorders to increasingly chronic,
progressive, essentially untreatable conditions. Though rational suicide was
applied primarily in terms of terminal illness, it was not exclusively so. To
clarify what was "rational" in situations short of terminal illness,
practitioners were pressed to define their criteria for "rational"
decision-making and to express the determination of rationality in
operational terms. 

       In the 1980s AIDS emerged, and the experience of HIV-infected patients
gave enormous impetus to the demand for the means to bring about a
self-determined, dignified, and non-stigmatized death. The controversy
continued to escalate to the present storm of medical, ethical, and religious
debate. 

       The trend is apparent from articles published in this newsletter seven
years apart. In the November 1986 issue, Peter Goldblum and Jeffrey Moulton
recommend that when faced with an AIDS patient still contemplating suicide
after carefully examining the issues, "The clinician must consider taking
more active measures, such as psychotropic medication or involuntary
hospitalization."[1] By contrast, in the July 1993 issue, James Jones and
James Dilley suggest that "It is crucial for therapists to attempt to
understand patients' circumstances, and to consider a situation in which
dying with dignity is more important than prolonged life."[2] 

       The atmosphere has clearly changed. Two states vote on initiatives to
legalize assisted rational suicide-both of which narrowly failed to pass-and
Oregon prepares to vote in November. Respected physicians endorse the concept
in prestigious journals. The name Jack Kevorkian becomes a household word.
The National Association of Social Workers becomes the first of the
counseling professions to determine that it is within its ethical standards
for practitioners to attend the assisted suicides of patients. The membership
of the Hemlock Society soars, and the suicide "how to" book, Final Exit, tops
a best-seller list for weeks. The government of the Netherlands finally gives
conditional approval for physician-assisted rational suicide.[3] Organized
medicine and orthodox religions remain opposed, but there is broad societal
discussion of these concepts. 

       Paralleling these developments, numerous reports confirm what was
common knowledge anecdotally: individuals with HIV disease are at extremely
high risk for suicide. Among infected gay men in San Francisco since 1984,
suicide has been the leading cause of death after AIDS itself.[4] In New York
City in 1985, men with AIDS between the ages of 20 and 59 had a suicide rate
36 times that for the same age-sex population without AIDS. In Stockholm from
1985 to 1990, 25 percent of the deaths in the HIV-infected population were
suicides; most of these cases were among asymptomatic men. It is widely
recognized that many deaths attributed by coroners to AIDS or to accidental
narcotic overdose are actually suicides, some of which are assisted by
friends, families, physicians, or all three. The reported 60 to 100
HIV-related calls received each month by the San Francisco Suicide Prevention
Center confirm that the risk is ever-present. Current research is focusing on
the relationship of the stage of illness to suicidal ideas, plans, and
attempts, as well as to completed suicide. 

       Clinical Implications

       Given the ethical and professional conflicts inherent in an assisted
suicidal act, how can a clinician respond in a therapeutic way to a person
considering suicide? While every therapist has a unique approach-especially
when responding to such complex issues-there are common goals and principles
that all practitioners share. What follows is one, but not the only, model
for approaching this question. 

       First, "rational," as used in relation to suicide, implies that the
decision is based on a thorough and realistic assessment of all the available
and pertinent facts. The practitioner as well as the patient must, therefore,
carry out such an assessment before "rational suicide" can be considered. A
clear state of mind in and of itself is not sufficient, and the presence of
a cognitive deficit does not necessarily preclude it. Thus the first task of
the therapist is to review with the patient all aspects of his or her life,
to establish both a clear perception and a realistic interpretation of the
facts. By doing so in a meticulous and compassionate way, practitioners can
assure themselves that they are aware of all the relevant information and
assure their patients that practitioners understand and respect patient needs
and limits. The term "realistic," for want of a better criterion, is defined
by what appears realistic to the clinician. 

       The inquiry would cover issues such as: the compatibility of suicide
with the patient's philosophy and prior approaches to problems that seemed
insoluble; the possible effects of the suicide on others in their lives,
especially children; the attitudes of significant individuals, for example,
parents (even if these individuals are now deceased); the degree of
ambivalence patients feel about the suicide; the resolution of unfulfilled
obligations, projects, or goals; and conflicts with spiritual values. 

       In undertaking this assessment, it is also important to consider
possible psychological origins of the suicidal impulse in individuals facing
life-threatening diseases. For example, patients with HIV disease may
consider suicide as a way to avoid pain and suffering, to spare others from
financial and emotional hardship, to be remembered in a better state of
health, to remain independent, to maintain control over their lives, and in
response to the sense of having no one to live for and feeling socially
isolated. Acknowledging these factors may help practitioners distinguish
between rational and irrational suicide, and enhance their ability to provide
emotional support. 

       Having examined all the facts, the practitioner's criterion for
determining rationality is the intuitive judgment, faulty as it may be, as to
whether the patient's awareness and interpretation of those facts is
realistic. The practitioner might not agree with the decision, but it
deserves respect if it is the best the patient can make while in control of
his or her ability to reason. 

       If the patient seems to see all the facts clearly and still opts for
suicide, the next step is to assure that he or she has thoroughly explored
all alternatives to suicide, including simply temporizing. A suicidal
person's outlook can be shifted by time alone, and delaying the act does not
require relinquishing the option. The tone of this inquiry is profound
respect for the utter finality of suicide, so if other alternatives might be
bearable, even temporarily, a patient might reasonably consider them first. 

       The therapist should refer the patient for a consultation with another
experienced clinician-if such resources are available-both on the chance that
the patient may benefit from another approach and for the therapist to obtain
some confirmation of his or her own view of the situation. With the patient's
consent, the therapist should bring into the process appropriate family
members or trusted friends, or other significant individuals in the patient's
life, for example, a minister or life partner. This will allow for further
discussion of other alternatives and for psychological preparation, leave
taking, and mutual support, and will avoid surreptitiousness or isolation. 

       If the family is resistant to a suicide plan, the therapist and
patient should consider taking time to try to resolve the issue with them. If
the patient does not want the family to know of suicide plans, the therapist
may be under an ethical obligation to inform them nonetheless. Whether this
obligation overrides the patient's right to confidentiality can be decided
only in terms of the specific circumstances, including the emotional
relationship between the patient and family members, the physical proximity
of family members, the potential harm to the counseling relationship, and the
clinician's personal philosophy about the issue. In any case, the therapist
should inform the patient of any intended communication with family members
or others. 

       What Would You Do? 

       When a patient challenges a clinician with the question "What would
you do in this situation?" clinicians should candidly acknowledge that they
cannot know what alternative they would choose if roles were reversed. If
questioned about the lethal doses of medications or over-the-counter drugs,
clinicians should respond to such questions openly and freely, including, in
particular, information about the unpredictability of individual differences
in drug metabolism. While there is no "standard practice" prescribed in such
a situation, complete openness remains one of the most important attributes
of the counseling relationship. Being open with patients ensures that they
will be open with their therapists, an especially important quality when
dealing with life and death issues. 

       If a patient requests the clinician's active collaboration--that is,
assistance with the lethal act--it would be moral to comply if this were
consistent with the clinician's own philosophy, but is currently considered
professionally unethical and a violation of the law. A clinician can base an
ethical justification for passive collaboration--for example, providing a
lethal amount of medication with information about the risks of overdose--on
the principle of giving the patient a choice in the time, place and manner of
his or her own death. Passive collaboration now occurs frequently, but it is
not openly acknowledged. 

       How does a clinician decide to passively assist? Again, there is no
standard of practice for this decision. There are points in clinical
practice, and this is one of them, when clinicians have no better guidelines
than their own intuition. They must base their judgments on all the
circumstances of an individual's case--ensuring, for example, that the
patient is lucid, that he or she has considered all the alternatives that he
or she is not influenced by panic or depression--and applying their own
clinical, ethical, and philosophical beliefs to this assessment. 

       The factors affecting the choice between passively assisting and
actively assisting go beyond legal and ethical concerns. Last-second
reversals of suicidal intent are not infrequent. For some individuals it is
not until that final moment that the full implication of the act is clear.
Only if suicide is under the patient's continuous control can clinicians be
completely confident of the non-coercive nature of the outcome. 

       The Future: When and How

       The fact that passive collaboration now involves respected clinicians,
loving families, and grateful patients suggests that socially sanctioned
suicide in some form is an inevitable development. While there is an
understandable fear that the option could be abused, for some individuals,
the assurance of the choice of a quick, sure, painless, and dignified demise
can dramatically reduce the suicidal impulse. A distinguished oncologist
quotes one such patient: "The great thing was, once I knew I could do it,
life became valuable again. I was back in charge." 

       The conflicts of socially sanctioned suicide with the traditions of
medicine and religion to prolong and revere life appear to be irreconcilable
in the foreseeable future. Probably the only way this can be effectively
addressed in the United States is to follow the steps the Dutch government
took in 1990 to address the issue of physician-assisted suicide. In the
Netherlands, assisting a suicide remains illegal, but if the act is reported
to the coroner and prosecutor with specified details assuring non-abuse, the
government will not bring charges. How long it will take for society to
develop such a process can only be guessed at, but one thing can be said with
confidence: the pressure to provide a non-stigmatized means for rational
suicide will continue to grow. 

       The moral challenge to clinicians is to be non-moralizing. In
considering with patients the issue of rational suicide, our conduct is best
determined not only by professional and legal codes, but by the dictates of
a humane and caring spirit. It is part of our task as clinicians to nurture
that spirit and trust its influence on our judgment. 

       Authors

       Jerome A. Motto MD is Professor Emeritus of Psychiatry and an
       attending psychiatrist on the Psychiatric Consultation Service at
       University or California San Francisco. He is also Past President of
       the American Association of Suicidology. Past Secretary General of the
       International Association for Suicide Prevention and a member of the
       Ethics Committee or the American Association of Suicidology. 

       References

            1. Goldblum P. Moulton J. AIDS-related suicide: A dilemma for
       health care providers. FOCUS: A Guide to AIDS Research and Counseling.
       1986; 2(1): 1-2. 

            2. Jones J. Dilley J. Rational suicide and HIV disease. FOCUS: A
       Guide to AIDS Research and Counseling. 1993,8(8):5-6. 

            3. Huyse FJ, van Tilburg W Euthanasia policy in the Netherlands:
       The role of consultation-liaison psychiatrists. Hospital and Community
       Psychiatry. 1993; 44(8).733-738. 

            4. Harvard Mental Health Letter. AIDS and mental health. Harvard
       Mental Health Letter. 1994;10(7):1-4. 

       **********

       Compassion in Dying
       Susan J. Dunshee

       People with HIV disease seem to come to one of three decisions in the
later stages of their illness. Some fight to their last breath, trying every
form of treatment. Others fight long and hard, up to a point, drawing the
line around issues of independence or quality of life, choosing to succumb to
the disease rather than receive institutional care. A third and smaller group
chooses another option: actively ending their lives before being entirely
consumed by the disease. Whether by prescription medication, illegal drugs,
or violent means, whether with loved ones or alone, these people, determined
to hasten their inevitable deaths, usually find a way to do so. 

       Compassion in Dying, a Seattle organization founded in 1993, seeks to
support and honor the choices of people in this third group.  So far, the 
majority of inquiries to Compassion have come from people with HIV disease,
who, being knowledgeable health care consumers, have given serious thought to
rational suicide even if they decide not to proceed. The experience of
Compassion staff and volunteers provides a glimpse into the world of
counseling people considering rational suicide. 

       Compassion in Dying

       Compassion in Dying was formed to validate the concept of rational
suicide for the terminally ill and to provide support for people requesting
assistance. Operating within a framework of strict guidelines, Compassion
accepts only terminally ill people of sound mind whose private physicians
confirm that death is expected within a "reasonable" period of time, usually
six months. This prognosis must be confirmed by at least one other physician
who is affiliated with Compassion. Medical conditions must cause severe,
unrelenting suffering that patients find unacceptable and intolerable.
Patients must have explored alternatives to suicide, including better pain
management, hospice services, and spiritual counseling if requested. 

       Patients must make requests to Compassion--in writing or on videotape,
by themselves and not via health care directives or any other person--on
three separate occasions with an interval of at least 48 hours between the
second and third requests. Finally, to minimize legal complications at a time
when assisting suicide represents a gray area of the law, Compassion will not
assist if any close, involved family member, partner, or friend of the
patient expresses disapproval about this choice. 

       Throughout the process, a case review team meets regularly with the
patient and his or her family to explore alternatives, to further evaluate
the level of family support for the decision, and to guarantee that the
Compassion protocol is followed to the letter. Currently, Compassion's work--
including case review--is carried out only by the group's executive director
and the 10 founding members of its board of directors, with consultation from
Compassion's Advisory Committee of physicians and, if there is any doubt
about a patient's mental competence or state of mind, referral to a mental
health professional. 

       The team informs the patient of the medications to be obtained from
his or her doctor, and provides careful instructions about the proper and
effective use of these medications. The patient must be able to
self-administer the drugs. The patient decides when to take the medications,
who will be present at the suicide, and whether to request the attendance of
two members of Compassion in Dying. 

       The Compassion protocol ensures that patients and their loved ones
have reviewed alternatives to suicide and have consciously and rationally
accepted suicide as the preferred choice. It ensures that in preparation,
patients take care of unfinished life business, and plan carefully and
creatively as they approach their final hours. It deters violent suicides by
offering a method that results in a deep sleep within a few minutes and a
quiet death within a few hours. It facilitates the presence of a patient's
loved ones, and if desired, of Compassion members, so that patients need not
die alone. It relieves the pressure on loved ones to actively assist and
eliminates the potential of guilt feelings should they assist alone and the
suicide fail or lead to a difficult death. Compassion has found that all of
this facilitates the grieving process of loved ones. 

       Supporting Rational Suicide

       The process of rational suicide raises many challenges for counselors
facilitating or observing it, three of which are particularly important.
First is determining that a suicide is indeed rational. "Irrational" suicide
may be the result of severe depression or overwhelming life situations. While
Compassion does not presume that everyone requesting assistance should be
subjected to intensive psychological testing, members watch for "red flags"
that may indicate irrational motivation: for example, an obsessive focus on
suicide with no willingness to discuss options, a history of non-medically
related suicide attempts, a history of clinical depression, and signs of
mental incompetence. In such cases, Compassion members refer patients for
psychiatric evaluation and do not proceed unless all doubts about mental
state are satisfied. Compassion disqualified one patient-a 60-year-old man
with emphysema-because he was obsessed with suicide, refusing to discuss or
consider any alternative course of action. 

       Second is helping patients deal with the ambivalence their decision
may raise. This occurs more often when suffering is not yet acute and when
patients have time to weigh again and again the pros and cons of their
choice. The process of repeatedly putting the wish to die into writing or on
tape helps patients clarify their feelings and may move them to consider anew
how they might cope if they were not to choose suicide. Over the course of
several meetings with a patient, Compassion staff cover the patient's
spiritual and philosophical beliefs, family traditions, views about suicide,
and alternatives to suicide, such as hospice care and allowing the disease to
run its course without further treatment. Third is helping families,
partners, and close friends come to terms with the client's decision and
supporting them through the process. Compassion staff facilitate discussions
to air everyone's concerns and to gauge the probability that loved ones will
fully support the patient's wishes. To prepare family and friends who plan to
be present at the suicide, staff describe the suicide process and the
physical symptoms that can accompany dying. Compassion staff also seek to
support others who decide not to attend the death. 

       Conclusion

       For Compassion staff, observing the enormous relief of the patient
gently escaping from further suffering makes the experience of participating
in an assisted death rewarding as well as moving. The gratitude of loved ones
for ending the patient's agony, without violence and not in isolation,
bolsters this feeling. This sort of death is not frightening, certainly not
as frightening as it would be if the disease proceeded. For those for whom
this is an issue of individual choice, these deaths are celebrated as
victories, not mourned as defeats. 

       **********

       Recent Reports

       Counseling about Rational Suicide
       Werth JL. Rational Suicide and AIDS: Considerations for the
       psychotherapist. Counseling Psychologist. 1992; 20(4): 645-659.
       (Auburn University, Alabama.) 

       Rogers JR, Britton PJ. AIDS and rational suicide: A counseling
       psychology perspective or a slide on the slippery slope. Counseling
       Psychologist. 1994; 22(1): 171 -178. (Youngstown State University
       Ohio, and John Carroll University, Ohio.) 

       Two review articles examine the appropriate role of therapists in
counseling about rational suicide. The first outlines the legitimate and
rational reasons HIV-infected clients may have for committing suicide and
advocates for their rights to proceed. It states that the process of life
review, often used by therapists to covertly convince clients to choose life,
may, in the face of HIV-related issues, favor suicide, especially if the
therapist is prepared to accept this choice. 

       If asked, practitioners should help clients explore suicide as a
viable option. It then outlines the defining characteristics of rational
suicide: First, individuals must possess a realistic assessment of their
situation. To confirm this, therapists must determine whether or not clients
understand their prognosis (both physical and psychosocial) and whether
clients are aware of potential resources and alternatives. Realistic
assessment requires the passage of a period of time during which clients
consider and reconsider suicide. Second, the mental processes leading to a
decision to commit suicide must be unimpaired by psychological illness or
severe emotional distress, a factor that is particularly relevant to people
with AIDS, 20 percent to 70 percent of whom may have some degree of
clinically evident cognitive impairment. Finally, the motivation for the
person's decision should fit the conceptions of a "reasonable person." 

       In response to this approach, the second article suggests that with
the large number of HIV-infected people presenting with dementia, it is
difficult to accurately identify psychological, emotional, or cognitive
impairment and rule out irrational suicide. Research addressing the
prevalence of central nervous system disturbances suggests that as many as 80
percent of people with AIDS have neuropathological changes at autopsy.
Moreover, as many as 25 percent of HIV-infected people experience
neurological changes before the development of opportunistic infections, and
mental status exams lack sensitivity to detect the mild neurocognitive
impairment that might occur early in the course of HIV infection. 

       Suicidal ideation in clients with a debilitating illness may not
represent a wish to die, but rather, a blocked wish to live. AIDS clearly
represents a substantial deviation from the expected developmental process of
many people 20 to 49 years old. It is more appropriate to work through these
developmental issues than to collude with suicidal clients. 

       Finally, while a client's decision may make sense to the client, that
very rationality may cloud the client's ability to express or be aware of
ambivalence. In response, therapists must explore the proportion of
ambivalence to certainty of a client's decision. Therapists must also
consider whether or not a decision to commit suicide can be rational yet
transient in light of the roller-coaster effects of HIV disease. 


       Epidemiology of AIDS and Suicide

       Cote TR, Biggar RJ, Dannenberg AL. Risk of suicide among persons with
       AIDS. Journal of the American Medical Association. 1992; 268(15):
       2066-2068. (National Cancer Institute.) 

       A large national study of death certificates confirmed that people
with AIDS have elevated rates of suicide, although this rate may be
decreasing. Suicide occurred among people with AIDS of all ages, throughout
most regions of the United States, and the rate of suicide for men with AIDS
was 7.4 times higher than for men in the general population. 

       Reviewing National Center for Health Statistics records from 1987
through 1989, researchers identified 165 reports of AIDS and suicide on the
same death certificate. Of these, 99 percent were men; 87 percent were White,
12 percent were Black, and 1 percent were other races. Drug poisoning,
firearms, and suffocation were the most common methods of suicide. 

       The rate of suicide among people with AIDS declined from 10.5 times
the general population to 7.4 times in 1988, and 6.0 times in 1989. This may
have been the result of renewed hope in the wave of advances in medical care,
diminished social stigma toward people with AIDS, and increased availability
of psychiatric support for people with AIDS. 

       Suicidal Ideation in Long-Term Survivors

       Rabkin JG, Remien R. Katoff L, et al. Suicidality in AIDS long-term
       survivors: What is the evidence? AIDS Care. 1993; 5(4): 401-411 .
       (Columbia university and Gay Men's Health Crisis.) 

       A small New York study found a surprisingly low level of psychiatric
distress among long-term survivors. In particular, wishes to die were
context-specific, occurring almost exclusively during serious illness, often
accompanied by severe pain or at times of bereavement. One out of four men
spontaneously referred to rational suicide, saying that they considered
suicide an option if circumstances became intolerable. 


       Participants were Gay Men's Health Crisis (GMHC) clients who had had
an AIDS-defining illness for at least three years prior to the 1990 study.
Researchers administered a 25-page, 90-minute interview, including several
self-rating scales. Assessment covered physical functioning, psychological
functioning, thoughts about living and dying, and past and current suicidal
ideation and behavior. 

       Of the 54 participants: all were self-identified gay men; 24 percent
were African American or Latino; 56 percent had been raised as Catholics, 29
percent as Protestants, and 10 percent as Jews; and 90 percent had attended
college. Their average age was 39. Eighty-eight percent said they had
excellent medical care and trusted their doctors, and 96 percent had
insurance and benefits. 

       When feeling rested, alert, and energetic, no man reported thoughts
about wanting to die. Of those who had thought about ending their lives, most
said that these thoughts had occurred during specific instances of either
personal illness or bereavement rather than as recurrent ruminations. Only
two participants had attempted suicide after knowing they had AIDS and both
had a prior history of suicide attempts. Furthermore, neither suicide attempt
was related to AIDS. 

       The rate of depressive disorders among participants was 6 percent, not
significantly different from the general population rate of 5 percent.
Measures of positive mental health for the group were largely equivalent to
nonpsychiatric samples. 

       Physician-Assisted Suicide

       Slome L, Moulton J, Huffine C, et al. Physicians' attitudes toward
       assisted suicide in AIDS. Journal of Acquired Immune Deficiency
       Syndromes. 1992; 5(7): 712-718. (California School of Professional
       Psychology, San Francisco General Hospital, and University of
       California San Francisco.) 

       In a small study of physicians, 24 percent of participants said they
would likely prescribe a lethal dose of medication to an HIV-infected patient
who requested it. More than 50 percent said they would refer the requesting
patient to a mental health professional, and 41 percent said they would refer
him to the Hemlock Society. 

       Two groups of San Francisco physicians responded to a
self-administered questionnaire, including a hypothetical case study, about
their beliefs and intentions concerning physician-assisted suicide:
specifically, providing medications to a patient who requested them in order
to commit suicide. Sixty-nine worked primarily with people with HIV disease,
and 86 were randomly selected from the mailing list of the California Medical
Association (CMA). 

       Variables that predicted the intention to assist included: believing
that assisted suicide is ethical; favoring pain control and reduction of
suffering over other treatments; identifying with patients in terms of age
and background. Variables that did not predict the intention to assist
included: personal or professional experience with HIV disease or other
life-threatening illnesses; and feelings of helplessness about AIDS
treatment. 

       **********

       Next Month

       The controversy surrounding services for seronegative people in high-
incidence communities has been fueled by a general scarcity of AIDS funding
and an historical belief that psychosocial support is unnecessary. Over the
past three years, however, with data showing a relationship between
psychosocial support and HIV prevention, policy planners have accepted these
services as a responsible use of resources. In the May issue of FOCUS, James
W. Dilley, MD, Associate Clinical Professor of Psychiatry at the University
of California San Francisco and Executive Director of the UCSF AIDS Health
Project, and Thomas Moon, MS, a therapist doing doctoral research on
seronegative gay men, report on a survey of seronegative gay and bisexual and
their attitudes towards relationships and safer sex practices. 

       Also in this issue, Shirley Hansell, EdD, RN, Wendy C. Budin, MSN, RN,
and Phyllis Russo, EdD, RN, all at Seton Hall University in New Jersey,
examine the psychosocial and developmental challenges faced by the youngest
seronegatives: uninfected siblings and children of HIV-infected people. 

       **********

       Comments and Submissions 

       We invite readers to send letters responding to articles published in
FOCUS or dealing with current AIDS research and counseling issues. We also
encourage readers to submit article proposals, including a summary of the
idea and a detailed outline of the article. Send correspondence to: 

       Editor, FOCUS 
       UCSF AIDS Health Project
       Box 0884 
       San Francisco, CA 94143-0884 

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