Abstract
Hopelessness and demoralization following a terminal diagnosis can affect the capacity for self-governance. Such dispositions can increase the allostatic load-the cumulative burden of stress and anxiety-resulting in a neurophysiologic decline that can impair autonomy and influence the desire to end one's life deliberately. An allostatic overload is characterized by the inability to autoregulate stress and is associated with pathological changes to the hypothalamic-pituitary-adrenal axis and hippocampus. These changes raise concerns about the reliability of concepts of autonomy in extremis, potentially undermining arguments that are used to justify voluntary euthanasia and medically assisted death. Studies have associated depression and hopelessness with suicidal ideation in the general population. However, fewer studies have examined how patients without a history of depression or suicidal ideation may suddenly contemplate the act when facing a terminal prognosis. This paper will argue that an allostatic overload can help explain how the spectrum of physical and psychological comorbidities associated with the onset of a terminal illness can influence a decision to hasten death. Data show that patients with a terminal disease wishing to hasten death typically exhibit lower rates of clinical depression, higher rates of demoralization, and a greater likelihood of rational suicide. These differences indicate that suicidal ideation in the terminal disease patient population is different. Changes in autonomous decision-making secondary to pathological alterations in the brain may offer an explanation. Such changes have been shown to dysregulate executive control functions, specifically intentionality and voluntariness. Clinical evidence also indicates that spirituality and hopefulness can help manage the allostatic load during the palliative stages of a disease so that patients can better process end-of-life decisions. Based on these data, this paper will further argue that jurisdictions offering euthanasia are morally compelled to make mental and spiritual counseling available to patients seeking this course of action.