Abstract
The article by Malcolm Parker [1] attempting to examine the place of psychiatry in active voluntary euthanasia is a disturbing and difficult piece of work. Its tone is so profoundly antimedical and specifically antipsychiatric that it is reminiscent of days now rather gone by. Nevertheless, the issue is one of such significance that it is important to overlook the tone of the writing and attempt to address the points made as far as possible.
First, the issue of medicine's association with death is described as historically recent. Parker suggests that death is now ‘something which our culture considers ought to be avoided’. Such a statement must be seen as a rather strange fantasy. The only certainty that we each individually have about life is that it will end. Death is not a right, it is an inevitable outcome. Medicine throughout its long history has engaged in attempts of varying success to lessen illness and suffering and to restore health and prolong life. It is thus intimately associated with patients who are dying; it remains ultimately powerless to render anyone immortal. It is precisely this impotence that creates the distress and helplessness of patients, physicians and family, and perhaps it is this which creates in us the need to try to pretend a control which we in reality do not have.
Second, Parker suggests that psychiatry's ‘search for acceptability’ has led to the medicalisation of suicide. He himself acknowledges that suicidality is highly correlated with mental illness, something which has been well demonstrated in numerous studies in subjects with and without cocurrent physical illness [2,3]. His further suggestion that depression may be overdiagnosed by psychiatrists is sweeping and unsubstantiated.
Third, he raises the notion that psychiatrists are somehow unable to assess suicidality because of their own rate of suicide, or because they are not ‘immune to errors of judgement’. This, as well as being gratuitously insulting, makes little sense. Personal experience of distress and despair has never been shown to lower sensitivity or specificity of assessment, and could in fact be assumed to deepen rapport and understanding when contained within a professional framework.
Finally, Parker raises the acts–omissions distinction, as if it supported his case. In fact, psychiatrists in the general hospital environment would see their role as equally important in either instance where a patient's choices seem to invite dangerous outcomes. Competence evaluation is a routine task. That treating physicians are continually involved in decisions regarding potential advantages and disadvantages of treatment in no way includes the role of actively taking steps to kill. This is the role that the acceptance of physician-assisted suicide or active voluntary euthanasia would add.
It probably goes without saying that I am opposed to such a step. I am disappointed, however, that such a serious matter should be handled in a manner which adds little to the debate.