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The Role of and Challenges for Psychologists in Physician Assisted Suicide

Shara M. Johnson, Robert J. Cramer, Mary Alice Conroy, and Brett O. Gardner Department of Psychology, Sam Houston State University, Huntsville, Texas, USA

Physician assisted suicide (PAS) poses complex legal and ethical dilemmas for practicing psychologists. Since the passage of the Oregon Death with Dignity Act in 1997, Montana and Washington have passed similar legislation. Despite the law requiring competence evaluations by medical and psychological professionals, existing psycholegal literature inadequately addresses the role of psychologists in the PAS process. This article reviews legal statutes and analyzes ethical dilemmas psychologists may face if involved. We con- sider competence both generally and in the context of PAS. Suggestions are made for psychologists completing competence assessments and future directions to improve com- petence assessments for PAS are provided.

Human beings possess greater lifespans than at any point in history due to advancements in modern medicine and technology. The average lifespan in 1900 was 47.3 years; by 1997 it was 76.5 (Kramarow, Lentzner, Rooks, Weeks, & Saydah, 1999). The trend has continued: From 1980 to 2005, life expectancy increased by nearly four years (National Center for Health Statistics, 2010). Although living longer is generally viewed as a blessing, society is witnessing increased rates of chronic disease and termi- nal illness as a result (National Center for Health Statistics, 2010). Advances in medical technology can often postpone these deaths, but many view a life pro- longed by dialysis, ventilators, and feeding tubes as unde- sirable (Sears & Stanton, 2001).

In the United States, people are increasingly express- ing an interest in controlling the way their lives end should they be diagnosed with a terminal illness or chronic con- dition that yields a poor quality of life (Cerminara & Perez, 2000). As a result, every state has legalized advance directives, which allow individuals to specify the circum- stances in which particular life sustaining treatments may be refused or withdrawn, ensuring that their wishes are respected in the event they are rendered incompetent to

make their own medical decisions (Sears & Stanton, 2001; Werth, Lewis, & Richmond, 2009).

Physician assisted suicide (PAS) and euthanasia are alternative end-of-life decisions. PAS and euthanasia both hasten the death of an individual, but the two con- cepts meaningfully differ in the role of the physician (Cerminara & Perez, 2000; Sears & Stanton, 2001). Physicians carrying out a request for PAS provide indi- viduals with the means, generally prescription medica- tion, to end their life; individuals decide if and when to use the means. Euthanasia indicates cases in which the physician administers the lethal dose of medication with the intention of killing the patient (Cerminara & Perez, 2000; Sears & Stanton, 2001).

This review examines PAS from both legal and ethical perspectives, and discusses issues related to assessment of competence in patients requesting PAS in an effort to clarify the role and duties of psychologists participating in competence evaluations. The practice of PAS is widely considered to be a criminal offense; however, the practice is currently legal in Oregon, Washington, and Montana (Oregon Death with Dignity Act [ODDA], 1995; Washington Death with Dignity Act [WDDA], 2008; Baxter v. Montana, 2009). PAS is also a highly controver- sial topic from an ethical standpoint and the duties of psychologists involved in the process remain unclear. Thus, we present arguments regarding the rationality of suicide as a framework for understanding the debate that surrounds the acceptability of PAS. We include a review

Received 29 September 2012; accepted 6 June 2013. Address correspondence to Shara M. Johnson, Department of

Psychology, Sam Houston State University, Huntsville, TX 77341. E-mail: [email protected]

THE ROLE OF AND CHALLENGES FOR PSYCHOLOGISTS 583

of the ambiguous ethical obligations of psychologists involved in PAS. In addition, guidelines for psychologists tasked with determining competence are critiqued, and we offer practical suggestions for completing the evalua- tion. Lastly, we identify areas for future research to improve PAS competence evaluations.

PHYSICIAN ASSISTED SUICIDE LEGISLATION: CRITERIA AND THE ROLE OF MENTAL HEALTH

PROFESSIONALS

In 1994, voters passed the ODDA (1995), which became available for use at the end of 1997 following a failed attempt to have the law repealed (Werth, Benjamin, & Farrenkopf, 2000). To qualify for PAS, an individual must be (a) a resident of Oregon (Oregon Revised Statute [ORS] 127.860 § 3.10), (b) at least 18 years old (ORS 127.805 § 2.01), (c) terminally ill, which two physicians agree will result in death within 6 months (ORS 127.820 § 3.02), and (d) making an informed decision (ORS 127.830 § 3.04). Furthermore, (e) the individual must make three requests to his or her attending physician, two oral and one written (ORS 127.840 § 3.06). The oral requests must be made at least 15 days apart, and an additional waiting period of 48 hr must pass between the written request and the prescrip- tion (ORS 127.850 § 3.08). Lastly, (f) the physician must offer to stop the process following the second oral request, which the individual must refuse (ORS 127.845 § 3.07).

According to ODDA, to receive the life ending pre- scription, the patient must be considered to be making an “informed decision,” which is

based on appreciation of the relevant facts and after being fully informed by the attending physician of: a) his or her medical diagnosis; b) his or her prognosis; c) the potential risks associated with taking the medication to be prescribed; d) the probable result of taking the medi- cation to be prescribed; and e) the feasible alternatives, including, but not limited to, comfort care, hospice care, and pain control. (ORS 127.800 § 1.01.7)

As the law is written, a mental health professional should only become involved in requests for PAS when either the attending or consulting physician believes the patient is “suffering from a psychiatric or psychological disorder or depression causing impaired judgment” and makes a “counseling referral” (ORS 127.825 § 3.03). It is up to “the person performing the counseling” to deter- mine that the patient is no longer suffering from the psy- chological disorder causing impaired judgment and capable of continuing with PAS. However, the definition of capable provided by the ODDA, “the ability to make and communicate health care decisions to health care providers” is too vague to serve as a guide for psycholo- gists asked to make such a determination (ORS 127.800 § 1.01; Werth et al., 2000). Guidelines do not exist and no

recent court cases have clarified what constitutes decisional competency in PAS (Werth et al., 2000).

Two other states have followed Oregon. In 2008, Washington voted to adopt an assisted suicide law (WDDA, 2008). In 2009, the District Court of Montana held that state residents’ constitutional rights of individ- ual privacy and human dignity grant the right of a “com- petent, terminally ill patient to die with dignity” (Montana Death with Dignity Act [MDDA], 2009). The Montana Court went on to permit patients to use the assistance of their physician in obtaining a prescription for a lethal dose of medication, but specified that the patient is responsible for deciding to self-administer the medication and induce death (Baxter v. Montana, 2009).

ARGUMENTS FOR AND AGAINST PAS

Understanding variant perspectives on suicide itself is necessary to fully evaluate the ethical issues involved in PAS. From a medical model, suicidal ideation is com- monly considered symptomatic of mental illness and irra- tionality (Sullivan, Ganzini, & Younger, 1998). As proof, thoughts of death are listed among diagnostic criteria for depression in the Diagnostic and Statistical Manual (4th ed., text rev.; American Psychiatric Association, 2000), much clinical literature is devoted to assessing and pre- venting suicide (e.g., Bryan, Corso, Neal-Walden, & Rudd, 2009; Cukrowicz, Wingate, Driscoll, & Joiner, 2004; Kleespies & Dettmer, 2000; Wingate, Joiner, Walker, Rudd, & Jobes, 2004), and numerous organizations (i.e., American Association of Suicidology, American Foundation for Suicide Prevention, and International Association for Suicide Prevention) are committed to pre- venting suicide (Silverman, 2000). Furthermore, the implication that suicidal ideation indicates incapacitating pathology extends into the legal arena and is used to jus- tify involuntary commitment and mental health treatment (Sullivan et al., 1998).

Although a wide body of research on suicide exists, it focuses primarily on prediction and prevention; very little conceptualizes suicide as a rational alternative (Werth, 1998; Widiger & Rinaldi, 1983). This emphasis likely reflects a denial of circumstances that may render a life no longer worth living and common fears about death. Two arguments support suicide prevention. The first is the link between suicidal ideation and psychopathology (Widiger & Rinaldi, 1983). Indeed, presence of suicidal ideation results in a lower Global Assessment of Functioning score, which is a rating of psychological dys- function. Suicidal behavior also mimics four features common among mental disorders: the low base rate for suicide represents a deviation from normal behavior, it is viewed as undesirable by society, it is indicative of high levels of distress, and it impairs functioning in one or more domains (Widiger & Rinaldi, 1983). The second is

584 S. M. JOHNSON ET AL.

the ambivalence of the individual toward death. Individuals who are in, or seek, treatment during their suicidal crisis are perceived to be ambivalently committed to ending their own life and receptive toward intervention (Widiger & Rinaldi, 1983).

Belief in an inherent right to autonomy and acknowl- edgement of the possibility that death can be a desirable alternative to life are arguments used by those who lobby for an acceptance of suicide (Silverman, 2000; Widiger & Rinaldi, 1983). Autonomy proponents believe that indi- viduals have the right to oversee their own goals and des- tinies, which includes the manner and timing of their death. They argue psychologists’ duty to commit or refer a patient who is experiencing suicidal ideation fully removes the autonomy from the patient so that the psy- chologist assumes control over the suicidal patient (Abeles & Barlev, 1999). They also point out that circum- stances may arise in which the individual experiences unbearable suffering or permanent impairment, and death would be a merciful relief (Silverman, 2000; Widiger & Rinaldi, 1983). From this perspective, there is little perceived difference between PAS and acceptable end-of-life alternatives, such as refusal or withdrawal of life sustaining treatment (Jamison, 2000).

Opponents of PAS cite numerous concerns. One com- mon argument is that PAS would be unnecessary if termi- nally ill patients had adequate palliative care (Cerminara & Perez, 2000; Jamison, 2000; Rosenfeld, 2000). It is argued that more effective pain management for termi- nally ill patients and additional social support for the patient and family should be developed. Another fre- quently cited argument against PAS is monetary; PAS is less expensive than extensive palliative treatment and might be more frequently used when medical resources are scarce (Rosenfeld, 2000). Furthermore, it has been theorized that should such a scarcity arise, PAS may be used more frequently with members of vulnerable soci- etal groups, such as minorities, individuals with disabili- ties, and those of low socioeconomic status (Rosenfeld, 2000). Lastly, there is fear that legalizing PAS will lead to a slippery slope in which euthanasia and assisted death for patients not suffering from a terminal illness also become legal (Rosenfeld, 2000). In fact, White and Callahan (2000) proposed that “the most disastrous long- term effect of legal PAS would be to legitimate suicide as a socially acceptable way of dealing with pain and suffer- ing of life and the end of life” (p. 333).

THE ROLE OF PSYCHOLOGISTS

The legal statutes recommend that a psychologist become involved in PAS when there are concerns regarding the patient’s decisional capacity due to the presence of psy- chopathology, such as depression (ODDA, 1995; WDDA, 2008; MDDA, 2009). There appears to be a consensus

that the training psychologists receive in assessment, psychopathology, and cognitive impairment qualifies them to assist in determining whether a patient is capable to consent to PAS (Farberman, 1997; Farrenkopf & Bryan, 1999; Werth et al., 2000; Werth et al., 2009). It has been proposed that psychologists with forensic training may be uniquely qualified to evaluate competence requests in PAS, given their training and experience with issues related to competence and capacity (Ganzini, Leong, Fenn, Silva, & Weinstock, 2000). Indeed, a survey of forensic psychiatrists revealed that the majority had professional experience with competence evaluations and end-of-life decisions, with 74% having conducted compe- tence evaluations for individuals refusing life sustaining treatment, 54% having personally cared for a family member or close friend who was suffering from a termi- nal illness, and 67% having witnessed the suffering of a dying family member or friend (Ganzini et al., 2000).

There is no consensus regarding the extent to which the psychologist should be involved in the process and the statutes provide no guidance aside from allowing for the assessment. According to Farrenkopf and Bryan (1999), when consulting on a case of PAS, the psychologist should first clarify the reason for the referral, which may be an evaluation of competence, but may also include treatment of a disorder and treatment designed to improve competence. In addition to performing the assessment, Farberman (1997) proposed that psycholo- gists serve as protectors of the patient’s rights and pro- vide support for the patient’s family.

In a survey of Oregonian psychologists, further dis- agreement regarding the psychologist’s role was revealed. Sixty-two percent of those willing to perform the evalua- tion indicated they would take no further action after providing the referring physician with a report (Fenn & Ganzini, 1999). However, 28% reported they would sup- port the patient in completing the request, whereas 10% reported they would actively work to prevent the suicide (Fenn & Ganzini, 1999).

ETHICAL CONSIDERATIONS FOR PSYCHOLOGISTS

Individual psychologists possess considerable freedom of choice in regard to duties and involvement in PAS. Werth and colleagues (2009) suggested there are no unique pro- fessional or ethical considerations for a psychologist working with a patient making end-of-life decisions beyond the ethical concerns present with any client, but our position is that the ambiguously defined and poten- tially dynamic role could give rise to complex ethical dilemmas.

One could construe the participation of psychologists as a violation of Standard 3.04 Avoid Harm in the American Psychological Association Ethics Code (APA, 2010); after

THE ROLE OF AND CHALLENGES FOR PSYCHOLOGISTS 585

required by using relevant research, training, consulta- tion, or study” (APA, 2010, p. 5). Unfortunately, the lit- erature offers few and often impractical suggestions for psychologists conducting an evaluation for PAS.

PAS COMPETENCE EVALUATIONS

The concepts of capacity and informed consent are focal points of a patient being competent to request PAS. In an attempt to elucidate the potential roles and responsibilities of psychologists who receive a counseling referral for a cli- ent requesting PAS, we believe it beneficial to look to stan- dards of competence in related domains (e.g., competence to stand trial or consent to treatment). In addition, because the state statutes specifically name depression as a psycho- logical disorder believed to impair capacity, we address dif- ficulties assessing depression in terminally ill patients. We also provide a critique of protocols for assessment that have been proposed in the literature.

Standards of Competence

A successful PAS requires an “informed decision” (ORS 127.800 § 1.01.7). Similarly, when mental health profes- sionals assist in competence evaluations for purposes other than PAS, such as competence to stand trial and compe- tence to withdraw treatment, four elements are commonly assessed: (a) the ability to communicate choice, (b) factual understanding of information related to the decision, (c) appreciation of the situation and possible consequences, and (d) a rational understanding of information (Ganzini et al., 2000; Werth et al., 2000). In addition, the psycholo- gist is responsible for ensuring that patients are making the request of their own volition (Werth, 1999).

Competence evaluations in other domains have estab- lished precedents to be considered in PAS competence evaluations. For example, assessments should begin with the assumption that the individual is competent; therefore the patient will only be rendered incapable of making deci- sions should sufficient evidence exist (Werth et al., 2000). Mere presence of a mental illness or history of mental health treatment is insufficient to determine incompetence (Werth et al., 2000). However, the profession of psychol- ogy has long viewed suicidal ideation as not only a symp- tom of mental illness, but also as justification for involuntary hospitalization. Thus, psychologists may be unprepared to perform the type of evaluation specified by statutes legalizing PAS without better defined standards for evaluations (Ganzini et al., 2000; Sullivan et al., 1998).

Although these precedents provide some basis for what to consider in an assessment, the legal definition of capacity remains vague and evaluators are responsible for determining how to conduct an assessment and how stringent of a standard to use in making a determination (Werth et al., 2000). Unfortunately, forensic psychiatrists,

all, psychologists are typically required to intervene in cases of suicidal crises. As APA has no official opinion regarding the involvement of psychologists in PAS, psychologists should carefully consider whether participation would vio- late their professional responsibility to avoid harm. If upon self-reflection the psychologist feels that participation would violate personal or professional ethics and impair objectivity, he or she must decline the task according to Standard 3.06 Conflict of Interest (APA, 2010).

As the laws are written, it is unclear whether the client being served is the patient making the request or the phy- sician making the referral (Fenn & Ganzini, 1999). According to Standard 3.07 Third-Party Requests for Services, psychologists must clarify the nature and bounds of relationships with everyone involved (APA, 2010). Properly defining the relationships will help the psychologist adhere to Standard 3.05 Avoid Multiple Relationships and Standard 4.01 Maintain Confidentiality (APA, 2010).

Limits of confidentiality will vary depending on who the client is. Should the physician be identified as the cli- ent being served, the patient and patient’s family should not receive direct communication from the evaluator regarding the findings and any report generated should be delivered directly to the physician (Fenn & Ganzini, 1999). Furthermore, identifying the client will also deter- mine whether services in addition to the evaluation should be rendered. Specifically, if the physician is the client, then the patient and patient’s family will be ineli- gible for treatment or intervention from the evaluator and would need to seek their own service provider. Similarly, it would be inappropriate for psychologists serving the referring physician to then either become advocates for the patient’s wishes or actively intervene in the patient’s request, as they were hired as an objective evaluator (Fenn & Ganzini, 1999).

An additional ethical concern pertains to Standard 2.01 Bounds of Competence, which indicates that psychol- ogists should only provide services within their compe- tence, “based on their education, training, supervised experience, consultation, study or professional experi- ence” (APA, 2010, p. 4). Some (33%) of Oregonian psy- chologists surveyed felt that a competence evaluation for PAS would fall outside of their area of practice; however, 60% reported that they would perform the evaluation (Fenn & Ganzini, 1999). Although the general training psychologists receive seems to qualify them for such an evaluation, it is unlikely that they have enough training in or exposure to geriatrics, end-of-life issues, the intersec- tion of health and psychology, and the concept of capac- ity to be truly competence in this domain. Standard 2.01 makes allowances for psychologists to work outside of their area of competence to ensure individuals who require mental health services are not denied, but only if the psychologist has had related prior experiences and “makes a reasonable effort to obtain the competence

586 S. M. JOHNSON ET AL.

that it is the loss of autonomy, as opposed to the physical illness itself, which creates the desire for death.

An additional concern is that the methods commonly used to identify depressive disorders may have less utility when implemented with individuals suffering from grave physical illnesses (Forkmann et al., 2009). Specifically, the presentation of depressive symptoms may be due to a genuine depressive disorder; however, effects of the illness itself and even the palliative treatments can mimic symp- toms of depression, particularly neurovegetative symp- toms (Christensen & Ehlers, 2002). For example, patients with end-stage renal disease often receive diagnoses of depression; however, a number of the somatic symptoms of depression (i.e., sleep disturbance, loss of appetite, and cognitive deficits) are identical to the physical symptoms of renal failure and effects of treatment (Christensen & Ehlers, 2002).

Suggested Protocols for Assessment

Several authors have published suggestions for assessing competence in patients requesting PAS, including neces- sary qualifications for an evaluator, the number of inde- pendent evaluators needed, and topics to review during the assessment. In addition to the necessary training and experience, Werth (1999) recommended that the psychol- ogist should have general training in assessment, diagno- sis, theories of individual and family therapy, death and dying, hospice/palliative care, ethics, and medical/mental health law. Ideally, the psychologist would also have prior experience with individuals considering end-of-life alter- natives (Werth, 1999).

In regard to general procedural guidelines for con- ducting a competence evaluation for PAS, psychologists should first ensure that the patient meets the require- ments of the statute (Werth, 1999). The evaluator should then review the patient’s record to become familiar with the condition, prognosis, and treatment alternatives (Farrenkopf & Bryan, 1999; Jamison, 2000). Suggested topics to review in the interview with the patient, and family if possible, include psychosocial history, patient’s values, motivation for making the request, perceived quality of life, patient’s description of physical condition and treatment options, and certainty of decision (Farrenkopf & Bryan, 1999; Jamison, 2000).

In 2000, Werth and colleagues published guidelines to follow when conducting a competence evaluation for a patient requesting PAS. They recommend exhaustively reviewing medical records from past and current care providers, using relevant objective assessment instru- ments (i.e., depression and hopelessness inventories, intelligence tests), conducting an extensive clinical inter- view, and interviewing family and friends. Furthermore, within each of these domains are long lists of specific probes and rule out disorders. These guidelines intended to synthesize components of competence evaluations

reported high standards for competence (Ganzini et al., 2000). Specifically, 78% reported that a stringent stan- dard should be set, even if some competent patients are disqualified as a result. This directly contradicts the prec- edent of basing the evaluation on assumed competence. Also, psychiatrists who believed PAS to be unethical favored stricter standards than those who believed PAS to be acceptable in some or all circumstances, which sug- gests personal bias may interfere with the assessment (Ganzini, 2000).

Assessment of Depression

Although legal statutes allowing for PAS specifically cite depression as a mental illness that could interfere with a patient’s decisional capacity, the importance placed on this diagnosis may be overemphasized (ODDA, 1995; WDDA, 2008; MDDA, 2009). Although a mental illness does not necessarily render an individual incompetent, 58% of forensic psychiatrists reported that major depres- sion, in their opinion, would automatically classify a patient as incompetent to make a request for PAS and approximately 38% felt that less severe mood disorders (i.e., dysthymic or adjustment disorders) were enough to render a patient automatically incompetent (Ganzini et al., 2000). Furthermore, personal values influenced clinical decision making; psychiatrists who believed that PAS was never acceptable were more likely to automati- cally determine a patient with a mood disorder incompe- tent (Ganzini et al., 2000).

There appears to be an assumption that terminally ill patients are more disposed to symptoms of depression and suicidal ideation than other patients due to the pain and physical limitations inflicted by their medical diagno- sis (Farberman, 1997). Indeed a positive association exists between physical illness, symptoms of depression, and a desire for death, creating complex cases for the consulting psychologist (Breibart et al., 2000; Conwell et al., 2010; Duberstein, Conwell, Connor, Eberly, & Caine, 2004). However, it is likely that the patient’s personal values and current behaviors are better indicators of suicide risk (Farberman, 1997). Support for this hypothesis can be found in public surveys regarding attitudes toward PAS. Most people could envision circumstances in which PAS would be acceptable, but those with higher religious con- viction and abhorrence of suicide were consistently less accepting and less likely to have considered PAS as a per- sonal option (Achille & Ogloff, 1997; Wilson et al., 2007).

Autonomy is another personal value that likely con- tributes to requests for PAS among terminally ill patients. In one study, when functional impairments were added to the regression model of physical illness and suicide, phys- ical health no longer predicted suicide (Conwell et al., 2010). In addition, severe physical illness, particularly those necessitating in-home assistance, predict suicide (Duberstein et al., 2004). Both of these results suggest

THE ROLE OF AND CHALLENGES FOR PSYCHOLOGISTS 587

shape their perspectives may increase the objectivity of the evaluator and perhaps help correct for their biases. In addition, psychologists may want to consult with col- leagues following the evaluation. Discussing the data gathered during the assessment with a party who is removed from the immediate process may also help to reduce potential bias.

FUTURE RESEARCH

The extent to which personal values of psychologists appear to influence their decision making in competence evaluations for PAS is concerning. In Oregon, six personal values predicted opposition to PAS: no personal consider- ation of PAS as an end-of-life alternative, belief that sui- cide is an immoral act, belief in a physician’s duty to preserve life, viewing patient autonomy and self-determi- nation as less important than maintaining life, concern about abuse, and younger age. Future research should sur- vey psychologists about their personal values, professional obligations in competence assessments, how they conduct competence assessments for PAS, and any perceived ethi- cal concerns, in addition to having participants make a competence decision. Doing so would allow for analyses to determine whether particular personal characteristics of psychologists actually impact their decision making.

Also, developing a standard of practice for PAS is crit- ical. These standards should be practical for use with debilitated, terminal patients. The MacCAT-T should be researched in the context of PAS as a possible structured interview that would perhaps reduce some bias while elic- iting information from the patient that relates to the four prongs of competence. An additional instrument that may have utility in PAS evaluations is the Mini Mental State Examination, which was originally designed as a brief, objective assessment of cognitive function (Tombaugh, McDowell, Kristjansson, & Hubley, 1996). Since its inception, it has been extensively used in clinical settings to assess changes in cognitive status and screen for dementia (Muniz-Terrera, van den Hout, Piccinin, & Matthews, 2012; Tombaugh et al., 1996). Given its his- tory, it may prove to be a useful starting point in assessing the cognitive capacity of patients with diminished physi- cal abilities and stamina.

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from across disciplines and thus create a systematic method for evaluation that minimizes evaluator bias (Werth et al., 2000). However, this set of guidelines has come under harsh criticism for the threshold for compe- tency being so high that it is unlikely an evaluator could finish the assessment and make a determination within the time limit (minimum of 15 days) imposed by the ODDA, thus rendering the patient unable to continue through the process (Burt, 2000). Werth et al. (2000) acknowledged the high threshold as a motive, stating that a benefit of an extensive process is that it may deter patients from making the request. The burden placed on the dying patient is an additional criticism of any assess- ment protocol as convoluted as the Werth guidelines (Ganzini et al., 2000).

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Existing research suggests that personal characteris- tics of psychologists may influence their attitudes toward PAS. Psychologists’ attitudes toward suicide, their desire for PAS to be a legal option for personal use, religiosity, experience with someone who suffered from a mental ill- ness, ethnicity, and orientation toward personal auton- omy or preservation of life have been found to differentiate those that support PAS from opponents (DiPasquale & Gluck, 2001; Fenn & Ganzini, 1999; Ganzini et al., 2000). Prior to completing a competence evaluation for PAS, it may be helpful for psychologists to reflect on their per- sonal opinions of suicide and PAS, with special consider- ation as to how their religious/spiritual beliefs, culture, and personal experience with end-of-life issues have shaped their perspectives. Awareness of how these factors

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