Genetic testing for suicide risk assessment: Theoretical premises, research challenges and ethical concerns.

We explore ethical premises and practical implications of using genetic testing to predict suicide risk. Twin studies indicate heritable components of suicide risk, intertwined with the heritability of mental disorders, and possibly other traits. Current genetics research has abandoned searching for single gene Mendelian determinants, in favour of complex probabilistic epigenetic models. Genome-Wide Association Studies (GWAS) might identify thousands of single nucleotide polymorphisms (SNPs), each contributing very little to the variance associated with behavioral phenotypes. However, suicide is a behavioral outcome rather than a phenotype, with so many different causal aetiologies, that it is impossible to predict the behaviors of individuals. We analyse practical and ethical issues that would arise if future research were to identify genetic information that will accurately predict suicide. Applying ACCE guidelines that specify when genetic tests should and should not be used, we examine the Analytic Validity, Clinical Validity, Clinical Utility and Ethical, Legal, and Social Implications. Low sensitivity and specificity for predicting suicide diminish potential advantages and exacerbate risks. Key considerations include the likelihood that testing will result in effective preventive interventions, which are not currently available, and unreliable positive results increasing hopelessness, stigma, and psychosocial risks. If the unregulated direct-to-consumer genetic testing services include suicide risk assessments, their use risks negative impacts. In the future, if genetic testing could accurately identify suicide risk in individuals, its use would be contraindicated if we cannot provide effective preventive interventions and mitigate the negative impacts of informing people about their risk level.

The unconscious, myth, and the rule of law: Reflections on the persistence of gender inequality.

Social order, to remain stable, needs the voluntary compliance of the majority of the population. Such consent requires normative justification. The rational foundation of the rule of law and the democratic state rests on the presumption of the equality of every citizen. Male domination of females nevertheless remains universal even in the most advanced democratic nation states because it is legitimized by the shared assumption that patriarchy reflects the will of God or is dictated by nature. Freud's diagnosis of patriarchy as a collective neurosis of the group mind negates every possible normative justification that can be made for gender hierarchy. Freud made extensive references to myth in developing his analysis of the neurotic foundations of social order. An analysis of the structure of myth suggests that ideological seduction rather than God, nature or biology determines male dominance.

The legal status of suicide: A global review.

Copies were obtained of the criminal codes from 192 countries and states; in 25 suicide is currently illegal, and an additional 20 countries follow Islamic or Sharia law where suicide attempters may be punished with jail sentences. The vast majority of countries have laws making it illegal to abet, aid or encourage suicide, but the nature and punishment of the actions that are illegal varies. Laws in places with Civil, Common Law, Islamic Law and Traditional Law systems are compared. Great variances in application were noted, sometimes within countries. It is impossible to estimate the number of persons currently in jail for having attempted suicide, but jail sentences are still given to suicide attempters. Some countries do not prosecute suicide attempters despite the laws, while others consistently jail suicide attempters. In countries where suicide attempts have been decriminalized, attempters may still face prosecution when another person is injured or dies as a result of their suicide attempt or where the attempter is a member of the military. We discuss the roots of laws making suicide, aiding, and encouraging suicide illegal and examine prospects for future changes. The recent Supreme Court Decision in Canada, invalidating the law making it illegal to assist in the suicide of physically ill people who are suffering (abeit with restrictive conditions) illustrates current trends towards "liberalization" of assisted suicide.

Premises and evidence in the rhetoric of assisted suicide and euthanasia.

In debates about euthanasia and assisted suicide, it is rare to find an article that begins with an expression of neutral interest and then proceeds to examine the various arguments and data before drawing conclusions based upon the results of a scholarly investigation. Although authors frequently give the impression of being impartial in their introduction, they invariably reach their prior conclusions. Positions tend to be clearly dichotomized: either one believes that the practice of euthanasia or assisted suicide is totally acceptable or completely unacceptable in a just and moral society. Where there is some admission of a gray zone of incertitude, authors attempt to persuade us that their beliefs (preferences) are the only sensible way to resolve outstanding dilemmas. The practice of vehemently promoting a "pro" or "con" position may be useful when societies must decide to either legalize certain practices or not. Although only a handful of countries have thus far accepted the legal practice of euthanasia or assisted suicide (Belgium, Luxembourg, The Netherlands, the U.S. states of Montana, Oregon, Vermont and Washington, and Switzerland), scholarly articles in recent trends mainly promote legalization, to the point of recommending expansion of the current practices. Is this a case of the philosophers being ahead of their time in promoting and rationalizing the wave of the future? Alternatively, does the small number of countries that have legalized these practices indicate a substantial gap between the beliefs and desires of common citizens and the universe of the 'abstracted realm'? For the time being, what we do know is that more countries and states are debating legalization of euthanasia or assisted suicide, the nature of laws and legal practices vary greatly and both ethical and empirical assessments of current practices are the subject of much controversy. This article presents an examination of the premises and evidence in the rhetoric of assisted suicide and euthanasia. Inasmuch as any analysis cannot be totally impartial, we do not contend that our analysis is without influence from our experiences and philosophical affinities. Notwithstanding this caveat, we venture to propose that our scrutiny of the arguments and empirical data may offer some guidance to individuals who are attempting to reach practical conclusions based upon the available evidence, whether empirical or rationalized.

Resolving ethical dilemmas in suicide prevention: the case of telephone helpline rescue policies.

The ethical basis of suicide prevention is illustrated by contrasting helpline emergency rescue policies of the Samaritans and the AAS and the U.S. National Suicide Prevention Lifeline network. We contrast moralist, relativist, and libertarian ethical premises and question whether suicide can be rational. Samaritans respect a caller's right to decide to die by suicide; U.S. helplines oblige emergency intervention during an attempt even against the caller's will. We analyze the effect of emergency rescue when there is high suicide risk but an attempt has not been initiated. We examine links between values and actions, needs for empirical evidence to guide practice, and propose vigorous dialogue about values in the gray zone of moral practice.

Ethical, legal, and practical issues in the control and regulation of suicide promotion and assistance over the Internet.

The promotion of suicide and description of suicide methods on the Internet have led to widespread concern that legal control is mandated. Apart from value concerns pertaining to attitudes about suicide, the guarantee of freedom of expression presents a serious challenge to the introduction of restrictive laws. Recent developments in Australia and Europe are presented, noting jurisdictional complexity as an obstacle to effective application. Finally, scientific data of an epidemiological nature are revealed to be insufficient to warrant making causal assertions about the Internet and its relation to suicidal acts, including those of vulnerable populations. Recommendations are made with respect to public education, suicide prevention, and future research.

Forensic mental health law reform in Japan: from criminal warehousing to broad-spectrum specialist services?

Since the 1980s Japan has undergone a number of mental health law reforms culminating in the 2005 forensic law. This added to its enactments on involuntary commitment, long-term aged care and substitute decision making, bringing Japan into focus as an industrialized state now possessed of a full package of civil and forensic provisions. This article seeks to demonstrate that the new forensic law cannot achieve its own stated goals without seeking to put into place financial and administrative supports aimed to integrate the myriad of patient populations that will be inevitably affected by the new forensic system. In order to avoid the widespread syndrome that has already been experienced internationally of warehousing mentally ill offenders in jails, it is critical that the Japanese government develop effective and culturally sensitive techniques for dealing with low risk populations through a diversionary process. Furthermore, although the legislation addresses serious crimes, it is imperative that policies be put into place to avoid directing young offenders, violent patients from the general hospital system, the developmentally handicapped, already convicted persons found in hospital settings and problematic cases in the correctional system, to the new forensic units established by the legislation. It is only though contemplating unintended outcomes of the legislation that the Japanese government will be able to avoid the ongoing stigmatization and prolonged institutionalization of mentally ill populations. Despite apparent cultural differences internationally vetted human rights requirements must be properly protected, not only in the forensic context, but throughout the mental health system at large. The coordination of services and the development of specialty training are necessary conditions for the realization of improved and humane conditions for mentally ill persons in Japan.

[The scope of forensic psychiatry: ethical responsibilities and conflicts of values]. / Psychiatrie médico-légale. Envergure, responsabilités éthiques et conflits de valeurs.

To write about ethics in specialties that straddle the lines of multiple systems cannot be done without discussing values and decisional rules that underlie each one of those systems. By virtue of its multiple associations, forensic psychiatry is an archetype of such specialties ; it works within a set of values that might be viewed as antithetical, even irreconcilable, with other aspects of psychiatry. The extensive scope of action of forensic psychiatry compels its practitioners to hold alternate world views and to apply decisional rules that may clash with the classical values and ethical considerations of medicine (Weisstub, 1980). In this article, following an historical précis, the authors review the scope of action of forensic psychiatry as the basis for the definition of this subspecialty. The concepts, themes and controversies pertaining to the ethical practice of this specialty will be reflected upon in the light of issues encountered in actual practice.

Ethical and legal issues in suicide research.

Moralist, libertarian and relativist ethical positions concerning suicide and its prevention are presented in order to clarify premises upon which ethical issues in suicide research may be resolved. Ethical concerns are differentiated from legal considerations and the implications of the vulnerability of suicidology research participants are discussed. Specific issues that arise in design, choice of participants, interpretation, diffusion of results and evaluative research are treated. These include: experimental methodologies, obtaining informed consent, deception and disclosure, studying innovative and unproven interventions, unknown consequences of participation, rescue criteria, disclosure of information to third parties, research with special populations, risks in publicizing results and measuring the value of human life. When specific legal obligations are lacking, ethical premises concerning the acceptability of suicide and obligations to intervene may influence research protocols.

An international perspective on Japanese mental health law: ethics and policy.

The challenge remains in international mental health legislation trends to find appropriate balances between specific cultural norms and appropriate international mental health standards for assessment, treatment, and release of persons suffering from mental disorders. It is important that cultural norms not be used as an excuse for inaction or substandard delivery of services. Furthermore, the international community of experts must agree upon a course of action to produce a set of guidelines which can become the point of reference for accelerating a timely delivery of improved services both in and outside hospital. Criteria for admission and release should not be compromised by short-term economic considerations nor by the local limitations imposed by the accepted corporate structures in place. It may be necessary for major re-thinking to occur, in order to link the hospital and the community in an interchange of services that will be to the benefit of patients and their families. To this end community treatment orders, intensive community treatment teams, and special follow-up procedures of care have to be applied and then monitored by responsible government agencies. After years of questionable applications of law reform in Japan it is imperative that critical self-assessment be done to give proper meaning to both the spirit and rule of mental health law in Japan.