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A further major difficulty with the discernment of genuine autonomy in those who are dying concerns the close association between the sincere wish to be dead and mental illness, present in up to 95% of those who wish to commit suicide or who request euthanasia. Numerous articles in the literature of psychiatry reveal that the great majority of patients who desire death during a terminal illness are suffering from a treatable mental illness, most commonly a depressive condition. This is not a diagnosis which can easily be made by the average doctor unless he or she has had extensive experience with depression and suicide, and it is frequently missed even in those already under medical care. It has been suggested, therefore, that patients will be protected by having a psychiatrist see every person who requests euthanasia. But it is not so simple, since only those psychiatrists with extensive experience of terminal illness and suicide will be sufficiently qualified in this area. Frank Varghese, Professor of Psychiatry in Brisbane, believes that if these patients were always seen by someone with the appropriate experience, ‘it is unlikely euthanasia would ever go ahead’. Hendin and Klerman, American psychiatrists with extensive experience with suicide, comment that ‘there is still too much we do not know about such patients, too much study yet to be done before we could mandate psychiatric evaluation for such patients and define conditions under which assisted suicide would be legal’. Depressive illnesses can be associated with a number of cognitive changes, including a significant and measurable decrease in intellectual functioning, diminished concentration, indecision, mild memory loss and sometimes confusion. In fact, serious debilitating illness of any kind can cause degrees of confusion and depression. When to these factors is added the lack of any objective criteria for assessing the degree of mental competence required for different kinds of decision-making, simple assumptions about the presence of genuine self-determination evaporate.
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