Abstract
Vamos suggests that the impotence of medicine to render us immortal has induced in us the need to ‘pretend a control’ which in reality we do not have. Just so and my argument [1] aimed to demonstrate the possibilities and risks that psychiatry may play a part in distorting the balance between legitimate and illegitimate control.
It is well recognised, and supported in the paper, that medicine's increasing power to postpone death, coupled with strong allegiance to the sanctity of life principle deriving from an essentially Christian Anglo-European cultural heritage, have resulted in problems concerning the prolongation of life. A range of responses including guidelines, charters, legislation and common law judgements have been made to these concerns, in order to restore patients' decision-making rights at the end of life.
Vamos implies that the medicalisation of suicide follows from the high correlation between suicide and mental illness. It is precisely this correlation which poses risk from the conflation of ordinary suicide and physician-assisted suicide. Against society's historical/cultural background of opposition to active assistance to die, it is not surprising that mental illness, a cry for help, or other potentially remediable motivations will be sought by doctors much more relentlessly in the group of patients seeking active assistance, than in the group who request the withdrawal of life-sustaining treatment. In this latter group, who are not perceived to be requesting help to commit suicide and not perceived to desire death, the ever-present possibility that the request proceeds from pathology or irrationality has not been exploited to prevent the practice occurring.
Apart from difficulties resulting from clinical conditions and variations, and apart from the influence of coercive factors, competence evaluation can be subject to the seriousness of the outcome of the decision and the values of the person making the assessment, and the relationship between them. When we then place these against the backgrounds of personal beliefs and the forces of medical culture, competence evaluation becomes anything but routine.
In the paper I suggested that there is only one way by which one could oppose active assistance to die, and that is by claiming that it is intrinsically wrong, because if one argues strongly for the painstaking scrutiny of requests (including psychiatric examination), one is logically committed to the rationality/ acceptability of at least some of those requests (i.e. active assistance is NOT intrinsically wrong). But some supporters of psychiatric review argue for both painstaking scrutiny and that active assistance is never acceptable. This is a crucial point which Vamos does not address, but which suggests that the call for mandatory psychiatric review can serve unstated agendas.
My arguments focus on broad cultural and historical developments in science and medicine and exemplify how cultural forces might work through individual practitioners and disciplines in unconscious ways. More than others, psychiatrists should be aware of such possibilities. To point to them does not constitute an antimedical or antipsychiatric stance. It is to raise considered arguments against what many take to be a self-evident truth.