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Late to bed, early to rise?

The problem with skipping sleep—and how to get enough of it

King David promised to “awaken the dawn” and offered elsewhere in the Psalms that he would “both lie down in peace, and sleep.” Plenty of us are doing the former, but many of us aren’t doing enough of the latter: According to a 2012 report in the journal Sleep, “approximately 1 in 3 adult Americans are sleeping less than 7 hours per night.”

The report describes the medical risks of accumulating a sleep debt, from heart attacks and obesity to cancer. The most immediate risk is obvious: We drive and operate machinery poorly when we’re tired. One study found that “drowsy driving” played a role in up to 20 percent of traffic accidents. Another likened the effect of sleep deprivation to driving drunk.

So how much sleep do we need? As parents with young children know, it varies with age: The National Sleep Foundation advises an average of 14 to 17 hours per day for a newborn, with as few as five being appropriate for certain older adults. For the average adult, the foundation recommends seven to nine hours.

All hours of sleep are not the same. Everything from city noise to stress can interrupt sleep, leaving a person groggy the next day. One common medical cause is sleep apnea, where a sleeper’s airway temporarily closes—forcing him to wake up, sometimes hundreds of times per night, to take a breath. It’s most common in heavy snorers, especially those who punctuate their snoring with gasps or pauses, and the most obvious result is frequent sleepiness during the day without any other obvious cause. Treatments include weight loss and continuous positive airway pressure (CPAP) machines; for patients who can’t tolerate CPAP, experimental treatments include a specially fitted mouthpiece designed to pull the lower jaw slightly forward.

Sleep apnea deserves professional evaluation, but not all sleep troubles need such measures: Sleep hygiene—the term refers to ways people can protect their sleep, not to showering and putting on clean pajamas—is a series of commonsense recommendations that help many people sleep more soundly. They include not drinking caffeine in the afternoon or evening, avoiding food and TV in bed, and establishing a dark, quiet environment in the bedroom.

Research also appears to establish a link between bright lights—think TVs, computer screens, and smartphones—in the hour before bedtime and dips in the body’s level of melatonin, a hormone that regulates sleep. Between online activity and the stimulation of the screen itself, a 2014 study by the National Sleep Foundation found that children with tablets or smartphones in their bedrooms averaged almost an hour per day less sleep than those without. Mom was right: We sleep best when we turn our toys off at bedtime.

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Suicidal tendencies

Some now advocate physician-assisted suicide for those without terminal illnesses? 

Mrs. Calvin’s bladder wouldn’t stop burning. Every few minutes she felt a strong urge to urinate that she could never fully relieve. When she finally received a diagnosis of interstitial cystitis, she hoped an effective treatment would soon follow. But after years of visiting several specialists and trying many medications and procedures, nothing worked. Her once expansive existence, filled with dreams and plans, now centered on her bladder.

Mrs. Calvin (a composite person based on some of my patients) decided to make an appointment with her long-time internist to have a difficult conversation. At 76 years old, she had lived a full life. But now she couldn’t see anything that provided enough pleasure or purpose to justify continuing to live with her constant pelvic pain. Would he as her doctor help her end her life?

At the annual meeting for the American Association for Geriatric Psychiatry (AAGP), New York University (NYU) psychiatry professor Robert McCue reported that cases like Mrs. Calvin’s are becoming more common. One educational session focused on how physicians should respond to patients who ask about “rational suicide.” McCue noted that the term “rational suicide” is used to describe a person with free choice and decision-making capacity who decides to end his or her life.

The physician-assisted suicide (PAS) laws in Oregon, Washington, and Vermont permit doctors to prescribe a life-ending medication to adults who are found to have decision-making capacity and a terminal illness that will lead to death within six months. But now groups such as the Society for Old Age Rational Suicide (SOARS) are advocating that people without terminal conditions also be granted means for committing suicide. At the AAGP meeting, NYU psychiatry professor Meera Balasubramaniam said “more and more individuals are expressing the wish to end their lives when they’re doing well.”

Switzerland’s permissive suicide laws may reflect what’s in store if legal efforts to make suicide more acceptable and accessible are successful. A study published in the Journal of Medical Ethics on Switzerland’s so-called suicide tourism found that foreigners are increasingly traveling there to end their lives. The country’s statute allows nonphysicians to help people kill themselves and does not require the presence of a terminal illness. The organization Dignitas is Switzerland’s largest provider of assisted suicides for foreigners. A 2014 survey by the University of Bern found that of the 1,301 suicides orchestrated at Dignitas between 2003 and 2008, 16 percent had been for people who were physically healthy.

The debate about the moral acceptability of suicide is not new. The ancient Stoics held that when one was no longer capable of living a flourishing life, suicide is justified. The Roman Stoic Seneca, who himself committed suicide, claimed that “mere living is not a good, but living well,” and therefore a wise person “lives as long as he ought, not as long as he can.”

The Stanford Encyclopedia of Philosophy notes “the advent of institutional Christianity was perhaps the most important event in the philosophical history of suicide.” The early church fathers opposed suicide, and the influential theologian Augustine wrote that “God’s command, ‘Thou shalt not kill,’ is to be taken to be forbidding self-destruction.”

A study of people who committed suicide using the Oregon law found that among their most common reasons for doing so were worries about loss of dignity. This suggests one way Christians can counter the growing movement to legalize suicide is confidently affirming that even the frail, aged, and least productive among us are deeply loved and valued by God.

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