Suicide, Euthanasia, and the Psychiatrist
- Suicide, Euthanasia, and the Psychiatrist
In recent years attitudes towards voluntary euthanasia in certain cases such as terminal cancer appear to have become more liberal, and physicians are no longer necessarily expected to undertake all possible measures to sustain life in hopeless situations. At the same time, there has been a contrary trend in psychiatric medicine with an increasing expectation for psychiatrists to prevent suicide among their patients. This divergence in attitudes regarding voluntary death in physical and psychiatric medicine was made manifest in 1993 by the case of Dr. Chabot, a Dutch psychiatrist who openly assisted a depressed woman in committing suicide. A subsequent court case resulted in considerable publicity and opened up the debate on what has become known as “psychiatric euthanasia.”
In this paper we review briefly the historical and cross-cultural aspects of suicide and euthanasia to show how attitudes toward these practices have varied over time and place. We present the case of Dr. Chabot, and then focus on three cases from clinical practice in which a psychiatrist had to make difficult decisions when faced with a patient expressing a wish to die. Finally, we consider the bioethical literature concerning voluntary death, which has been developed mainly with regard to physical medicine, and we assess how well its guidance translates to a psychiatric context. Our conclusions are that the suicidal wishes of psychiatric patients are not always the result of an easily treatable and reversible mental illness or necessarily of any mental illness at all; that as mental illness is not always curable, there are situations in psychiatry comparable in morally relevant respects to cases of terminal illness in physical medicine; and that the bioethical literature concerning voluntary death, focusing as it does on cases of the terminally physically ill, is often not greatly helpful in psychiatry. We therefore invite comment from philosophers, lawyers, ethicists, and others concerned with mental health on our three cases, focusing on the practical issue of management. We believe our cases are not atypical, and that the dilemmas they represent will be faced with increasing frequency in years to come by psychiatrists and other mental health professionals.
suicide, assisted suicide, euthanasia, psychiatry
Introduction
Suicide, assisted suicide, and voluntary euthanasia are all practices whereby a person chooses to end his or her life. In recent years popular opinion regarding assisted suicide and voluntary euthanasia in cases of serious physical illness has become more liberal, but in the field of mental health, psychiatrists are increasingly expected to prevent their patients from ending their lives by committing suicide.
Do psychiatrists have a duty to prevent suicides? Must they always try to prevent, or are there cases where they should perhaps turn a [End Page 113] blind eye or even give assistance to a likely suicide? Is there indeed ever a justification for “psychiatric” euthanasia? In 1993 these issues were brought to worldwide attention with the case of Dr. Chabot, a Dutch psychiatrist who assisted in the suicide of a woman who was not terminally ill but suffering, and in his view suffering hopelessly, from depression.
This paper examines the “Chabot case” together with three cases from general psychiatric practice. In each of these cases, dilemmas arose for a psychiatrist regarding the treatment of a patient who wished to end their life. (Details of the cases have been altered to preserve confidentiality.) The cases will be first briefly set in their historical and cultural perspective. This highlights changes in attitudes towards voluntary death and sets the current dilemmas in context. The issues raised by the cases will then be considered and examined in the light of the bioethical literature concerning voluntary death. Our main conclusion is that the bioethical literature, which has been developed largely in reference to terminal physical illness, is often neither applicable nor particularly helpful in psychiatric practice.
Historical and Cross-Cultural Perspective
Suicide has occurred throughout the history of mankind but societies’ attitudes toward it have changed. In the classical world, suicide was seen as a noble, often heroic act, at times of adversity or to avoid dishonor, and an important freedom. Instances of suicide are common in classical literature. The prevailing...
