Should Psychiatrists Serve as Gatekeepers for Physician-Assisted Suicide?

Article excerpt

As our society debates the legalization of physician-assisted suicide for terminally ill persons, mandatory psychiatric evaluation has been suggested as a safeguard against abuse. This is to guarantee that the patient choosing physician-assisted death is mentally competent to do so. As psychiatrists who have provided both psychiatric and ethics consultation for dying patients, we believe there are serious unacknowledged problems with this "safeguard."

Our arguments do not depend on a moral position for or against physician-assisted suicide. Nor do we deny that psychiatry has a great deal to offer in the evaluation and treatment of patients who request assistance in dying. Rather, we argue that due to the lack of applicable objective standards of decisionmaking capacity and the inevitable distortion of the mental health professional's role as a clinician, we should think carefully before requiring psychiatric certification of competence in every case. We are concerned that this "safeguard" inappropriately uses a technical clinical procedure to disguise our society's ambivalence about suicide itself. By making every patient who requests physician-assisted suicide jump the hurdle of psychiatric evaluation, we shift responsibility for a troubling moral decision from the therapeutically directed and socially embedded context of shared decisionmaking of patient, family, and primary physician to an outside specialist. As this specialist, the consultant psychiatrist becomes a secular priest dressed in the clothes of a medical expert.

The Question of Safeguards

Health professionals who believe assisted suicide may sometimes be appropriate have called for safeguards to ensure that suffering patients who are assisted to die are choosing suicide freely and autonomously. To address these concerns, recent initiatives for the legalization of assisted suicide have incorporated specific restrictions to assure autonomous decisionmaking. Some initiatives have included the requirement that the request be expressed consistently over a specified period of time

in order to prevent impulsive decisions and allow time for ambivalence to be manifested. A delay of fifteen days in Oregon and nine days in Northern Australia (the only other region in which physician-assisted suicide was legal, until overturned by the Australian Parliament in March 1997) is required between a request for assisted suicide and its implementation.[1]

The most important safeguard of autonomous choice is the restriction of access to physician-assisted suicide to those whose decisionmaking capacity is above a threshold that qualifies them as "competent" to make the choice of suicide. Expert discussion of safeguards in the implementation of physician-assisted suicide frequently includes a call for mandatory psychiatric consultation.[2] The Oregon initiative requires that a psychiatric consultation be completed in just those cases where the primary physician believes that the patient has a mental disorder affecting his or her judgment, but the injunction mentioned this safeguard as inadequate.[3] The Northern Australia statute required psychiatric consultation in all cases, and a "Model State Act to Authorize and Regulate Physician-Assisted Suicide" recently published in the United States mandates that "a professional mental health provider (psychiatrist, psychologist, or psychiatric social worker) evaluate the patient to determine that his or her decision is fully informed, free of undue influence, and not distorted by depression or any other form of mental illness."[4] There is thus widespread support for mandatory psychiatric evaluation to verify the competence of all those who request physician-assisted suicide.

How Our Society Understands and Copes with Suicide

Psychiatrists who have cared for suicidal patients can describe how deeply ambivalent these patients can be about suicide. What is not as apparent from the clinical perspective is the ambivalence of psychiatrists and our culture about the morality of suicide. …