Commentary on "Suicide, Euthanasia, and the Psychiatrist"

Although challenging, Burgess and Hawton’s cases are, as they say, far from unusual clinically. In this commentary I would like to set their cases in context by describing some further cases with rather different outcomes, and by briefly reviewing some of the relevant epidemiological and clinical research in this area.

Epidemiologically, euthanasia and physician-assisted suicide are no longer statistically unusual. While hard evidence is difficult to come by, claims have been made that the practice is widespread in many countries. For example, the International Association of Suicide Prevention (IASP) undertook a survey of its fifty-one members in which forty-nine participated (Kelleher et al. 1998b). The following occurrences of euthanasia were reported: active euthanasia in twelve member countries; non-voluntary active euthanasia in eight countries; passive euthanasia in twenty-three countries; and non-voluntary passive euthanasia in thirty countries. Physician-assisted euthanasia was not examined, but this is now the subject of a further inquiry. The implications of the work is that euthanasia is common, if not commonplace, worldwide. It therefore behooves us to look at the law and the morality of the practice.

Figure 1.

Death from external causes: The relationship between suicide and euthanasia

As Burgess and Hawton indicated, matters of definition are important. Part of the problem is that there is an overlap between suicide, physician-assisted suicide, and euthanasia. Some aspects of their relationship are shown in Figure 1.

The place of intention is crucial to any debate on the subject; this is particularly so when large doses of pain-relieving medication are given to relieve suffering in the terminally ill. There is a clear-cut legal distinction between foreknowledge that death may be brought forward in time, and intending to bring death forward in time. Lawyers in the House of Lords Report (1994) and the Report of the American Supreme Court (Burt 1997), for example, recognize the distinction as valid. Moral philosophers like Rachels (1986) may see such a distinction as disingenuous hair-splitting. The common formula of words given for such matters is the law of double effect. It has no particular relevance to psychiatry in the practice of euthanasia or assisted suicide.

Moralists may also question distinctions made between active and passive euthanasia as being meaningless because death is the outcome in both. Death, however, is always the outcome no matter what we do. Doctors have always drawn a distinction between interventions that have a direct fatal outcome—such as giving potassium chloride, which immediately stops the heart as when Dr. Nigel Cox ended the life of his long-term patient Lillian Boyes, and withdrawal of treatment as in the case of Tony Bland—or failure to start treatment, like giving antibiotics for an attack of bronchopneumonia in the terminally ill. In the case of Tony Bland, the distinction hinged on whether artificial feeding was to be regarded as a treatment or a natural right to food and drink. The court decided that it was a treatment and as such could be withdrawn, and a similar anonymous case has occurred more recently in Ireland. Neither High Court judgment used the word euthanasia. In practice they condoned what doctors regard as passive euthanasia while virtually ignoring active euthanasia or direct killing. The House of Lords Report (1994) states that “the prohibition of intentional killing” is “the cornerstone of law and social relationships.”

Further sets of important relationships hinge on the words voluntary, involuntary, and non-voluntary (House of Lords Report 1994; New York State Task Force on Life and the Law 1994). The Dutch would have us restrict the word euthanasia to voluntary (freely chosen) euthanasia only. However, as shown by the IASP Study mentioned above, the most common form of euthanasia is non-voluntary, where the individual is incapable of making a free choice. This ought to be a cause for concern.

Involuntary euthanasia, although presumably rare, does occur. In 1996, a Japanese surgeon killed his friend who was dying from cancer and suffering enormously because he felt he could no longer relieve his...