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The Dutch government passed a law legalizing PAS three years ago, and the U.S. Supreme Court is expected to issue a ruling in the next few months that will determine whether it will be an option in this country.
Two issues related to assisted suicide are especially troubling for many Dutch psychiatrists. The first is the violation of treatment boundaries that may occur when a psychiatrist evaluates a patient's wish to die after treating that person for a mental illness, said Robert Schoevers, M.D., a psychiatry professor at Amsterdam Vrije Universiteit. The other is the notion--endorsed by the Dutch Board of Psychiatrists--that suffering from a mental rather than physical illness "does not automatically make a person incapable of having an autonomous wish to die."
The guidelines that Dutch physicians must follow in assisting someone to die were originally crafted to apply to patients suffering from somatic illnesses, but after a court case in which a psychiatrist was found guilty of advising a depressed patient who refused further treatment on how to take her life--suggestions she successfully followed--the guidelines were modified to permit physicians to assist psychiatrically ill patients commit suicide.
Schoevers described several controversial aspects of the guidelines and their impact on psychiatrists and the people they treat. Rules governing a person's request for help in dying was the first of these. The regulation requires three conditions--the request must be "voluntary, well considered, and durable," he said.
But the "well-considered" criterion, which mandates that a decision must be based a rational thought process, leads to very different viewpoints, and Schoevers questioned to what extent psychiatrically ill people can really meet this standard.
"Little study has been done on the interaction of rationality and psychopathology. How severe must a depression be," he wondered, "before it precludes rational decision making," especially when life and death are at stake?
The guidelines also insist that patients must have an incurable condition before they can legitimately take advantage of a physician's help in dying. Schoevers and other PAS opponents in the Netherlands question, however, at what point this determination is made when the person who wants to die has a diagnosable psychiatric illness.
"How much of either interpersonal, cognitive behavioral, systemic, or long-term dynamic therapy is needed before a patient can be considered incurable? And furthermore, how do we account for crucial, nonspecific therapeutic factors such as the therapeutic relationship?" he asked. For patients who don't respond to therapy, "a change of physician or treatment setting could make a major difference," he noted.
He also warned his American colleagues that if they choose to participate in PAS, they should expect to wrestle with serious boundary violation issues.
In the Netherlands, patients can ask their treating psychiatrist about willingness to assist in suicide. If the psychiatrist agrees to help, he or she then takes on the additional role of "evaluator of the [PAS] criteria and eventually that of the doctor who prescribes the deadly medication," Schoevers said. "Drawing a line and stating that PAS is not part of one's profession" is the only way to ensure a "fruitful therapeutic alliance" and avoid boundary violations, he insisted.
In addition, he maintained that a troublesome dilemma for psychiatrists who participate in PAS is how to explain to other patients with disorders similar to the one with which the suicidal patient is suffering why there is hope for recovery in that person's case.
Issues of transference and countertransference in the PAS process also cannot be ignored, he stated. "Advocates of PAS fear that irrational therapeutic rescue fantasies and grandiosity will serve as motives to refuse even considering PAS, since it would be experienced as a personal failure by the therapist," Schoevers said. "Opponents claim that the contact with chronically ill or chronically suicidal patients can be so exhausting that countertransference reactions may make the physician more likely to agree that it is 'reasonable' or 'rational' for a patient to choose death."
He concluded that while guidelines controlling the PAS process may appear workable in theory, the Dutch experience clearly reveals the perils that await psychiatrists and other physicians who agree to help patients take their own lives, particularly how the "combination of roles makes it impossible to arrive at a sound judgment about the perspective and best interests of one's patients."
In the Netherlands, where a recent survey found that of the approximately 320 requests for assisted suicide that psychiatrists have received annually since the law went into effect, between two and five patients, several of whom also had somatic illnesses, received a psychiatrist's help in ending their lives. The issues have remained troubling enough for many Dutch physicians, however, that the Royal Dutch Medical Association and the Dutch Board of Psychiatrists are working on guideline revisions that would reflect some of the concerns described by Schoevers.
(Psychiatric News, July 4, 1997)