Countertransference and Assisted Suicide

Article excerpt

The role of a doctor in assisting a patient to commit suicide or in taking some other part in the termination of life is complex in the breadth of social, ethical, and psychological implications. There is a tendency to reduce this complexity to discussions about individual rights and legal issues. The underlying dilemma was highlighted by Annas in his comment that "[d]iscussions of assisted suicide ... are all symptoms of the problem modern medicine has with dying rather than the solution."(1) In community, legal, and medical debate on these issues, little attention has been paid to the role of the doctor-patient relationship in end-of-life decisions. Indeed, the impact and meaning of the request for assisted suicide with reference to transference and countertransference in the doctor-patient relationship have not been addressed. This lack of attention to these issues emphasizes the need for research to help us understand the motivation for patient requests for euthanasia and the context of these requests within the doctor-patient relationship. However, there has been relatively little research focusing on dying patients and their doctors regarding such critical issues.(2) Much more attention has been paid to documenting the attitudes of doctors and the community to euthanasia and end-of-life decisions, as if the issue could be laid to rest by results of opinion polls.(3)

In this chapter, we define euthanasia after Moulin and colleagues(4) as deliberate actions taken with the intention of ending the patient's life and either assisted or carried out by a health professional, actions in which the death of the patient is the goal. In our opinion, this definition includes physician-assisted suicide, since both euthanasia and physician-assisted suicide involve actions by the doctor with the intention of ending the patient's life. Whether the doctor administers the drug or the patient self-administers the drug provided by the doctor is irrelevant clinically since the intention is the same, although there may be subtle legal differences.

The wish of a patient for an assisted death or euthanasia needs to be evaluated within a broad context that includes the interpersonal, social, and cultural factors that can influence the suffering, concerns, and decision making of the patient. Central to this context is the nature of the relationship between patient and doctor, whether or not one uses the transference-countertransference model to describe the therapeutic frame that defines the medical consultation.

The public debate on euthanasia has focused narrowly on the patient's right to personal choice for death and its timing, and yet, as Miles has argued,(5) the personal choice for hastened death is formed by interpersonal and social forces shaping the patient's appraisal of his or her illness and situation. The doctor-patient relationship is only one such force but is nevertheless critical in influencing how patients perceive their situation, attribute meaning to it, and make the decision whether to seek assistance to die. The debate in both the professional medical press and the community has generally underestimated the important role of the relationship of the patient to his or her doctor and other health care staff in the issues of adaptation to illness and end-of-life decisions.(6)

Although much has been said of the "right to die," Muskin has argued that "[n]ot discussing a patient's motivation (for assisted suicide) is the real violation of his or her rights."(7) Legal and ethical debates about euthanasia concentrate on the notion of "rational" decision making, the possible exclusion of major psychiatric disorder at the time, and determination of "competency" to make decisions. These issues are less important at the clinical level than understanding the nature and degree of suffering for patients with terminal illness and the ways in which psychological and social factors influence decision making in this setting. …