To the Editor: The November 1998 debate on physician-assisted suicide between Drs. Hartmann and Meyerson (1), followed by the paper from the Netherlands by Dr. Shoevers and associates (2), raises significant issues about how psychiatrists ought to conduct themselves if asked to assist in suicide.
Unfortunately, the debate between Hartmann and Meyerson ignores the clinical context and concentrates instead on ethical, moral, and philosophical issues. While consideration of these issues is important, we believe the narrow focus on them will not resolve the question of whether legislation should allow physician-assisted suicide. What we are left with is disagreement as to what is ethical and what is not, and a choice between different philosophical versions of the notion of autonomy of the individual. Such questions need to be placed in the clinical context, specifically the way decisions of life and death can be affected by the vicissitudes of the doctor-patient relationship (3).
Whether a physician should assist in a patient's suicide remains fundamentally a question about the framework and boundaries of clinical practice. To draw a parallel, we suggest that whether a physician should engage in a sexual relationship with a patient is less a moral or philosophical issue than one of therapeutic boundaries. The therapeutic framework that implicitly and explicitly forbids a sexual relationship allows the doctor to examine the patient's feelings with the patient. Whether a patient who seeks a sexual relationship with the doctor is "competent" is not the issue. The very presence of the prohibition against a sexual relationship makes it possible for the patient's wishes to be dealt with in a therapeutic manner.
We contend that the same therapeutic framework applies to requests for physician-assisted suicide. Without a framework that prohibits the action, a doctor is not able to carefully examine the possible meanings of such a request in the total context of the patient's life, and indeed in the context of the relationship with the doctor. Such a process of therapeutic engagement is not possible within a legislative framework in which assisting suicide is a potential outcome.
Much of the debate about euthanasia and physician-assisted suicide has as its underlying assumption that doctors will always act in the interests of their patients. This assumption fails to take into account the doctor's unconscious and indeed sometimes conscious wishes for the patient to die and thereby to relieve everyone, including the doctor, of distress. The Dutch authors rightly point to the question of the violation of therapeutic boundaries and the role of countertransference in influencing how doctors behave toward suicidal patients. We suggest that countertransference is also an issue with terminally ill patients, where disgust with disease and decay may operate (4).
Legislation to enable assisted suicide has been designed to provide a safeguard, through psychiatric assessment, that protects patients from themselves (5). What these laws do not do and cannot do is protect the patient against unconscious factors in the doctor.
Dr. Varghese and Dr. Kelly are associate professors in the department of psychiatry at the University of Queensland in Brisbane, Australia. Dr. Varghese is chair of the division of mental health and Dr. Kelly is director of consultation-liaison psychiatry at the Princess Alexandra Hospital and District Health Service in Brisbane.