Abstract
This 11-chapter, multiauthor text is, perhaps, the most comprehensive currently available on an issue which grows more vital (no irony intended) almost weekly. The introductory chapter by the editors summarises what is to come, explores the basic issues and examines the psychiatrist's role and, especially, how it complements the function of other members of the treatment management team.
The ensuing 10 chapters are provided mainly by a range of psychiatrists with special interests, or of the subspecialities, naturally headed by consultation— liaison and followed by child psychiatry and HIV/AIDS. They are supported by an ethicist, a lawyer and a philosopher, which provides a good, balanced, but not always harmonious, mix. Basic clinical issues involving competency, informed consent, illness and its treatment in relationship to refusal of life-saving treatment are naturally followed by psychodynamic considerations. These are adequately, if not exhaustively, covered before the next chapter which, although entitled ‘Obstacles To Doctor—Patient Communication’ is more about the dynamics of communication with and about the patient and, as such, involves our own psychological processes. All of these chapters are enhanced by vignettes and systematically presented recommendations of dimensions to be considered, interventions to follow and frameworks for discussion. Underlying is an assumption that psychiatrists will have a coordinating role, which may not necessarily be the case.
The chapter dealing with the highly charged dying child scenario is, as might be expected, the most poignant and sensitive but, nevertheless, this is not allowed to impede an objective systematic approach utilising the known principles of child development. Yet, one wonders how often child psychiatrists are involved, considering that death in childhood is comparatively rare and hospital departments of child psychiatry not numerous. The author percipiently notes that the psychiatrist's role does not always end with the child's death. The next chapter on HIV/AIDS is, one suspects, based on more extensive experience than that of other chapters. It leans heavily to euthanasia and narcissistic suicide, which some might have some problem in supporting. Unlike other chapters, it ends inconclusively, only pointing to the tasks and challenges ahead to which responses need to be formulated. Evaluation of requests and legal aspects lead into the essence of this book: the ethical underpinnings of our responses to requests to terminate suffering to the extent of physician-assisted suicide (PAS). The final chapter is a moral blast, arguing strongly that PAS and even lesser measures are a greater potential evil than suffering itself. The author compares these measures to a deadly virus that could infect and undermine the entire moral fabric of society. This is the only chapter without a list of references. Perhaps they are all in the bible.
Four threads run through all of these chapters: (i) the need for better and more extensive palliative care (including pain control); (ii) greater appreciation of the role of the psychiatrist, in particular those in consultation—liaison; (iii) an assumed perfectibility of psychiatry in this particular area; and (iv) the dangers of undermining the moral status of the profession.
Margaret Meade suggested that prior to Hippocrates, doctors and sorcerers were one and the same, possessing power both to kill and to heal. For the first time, the oaths specifically forbade the former, stipulating that physicians will not give a ‘deadly drug to anyone if asked for it, nor will (he) make a suggestion to this effect’.
All psychiatrists, even those who never go near a hospital, could, with benefit, read the first chapter. The remainder is required reading for consultation—liaison psychiatrists and psychogeriatricians. Child psychiatrists should be ready to refer to the relevant chapter when the need arises. On PAS and euthanasia, the subject of chapter 8, the reader is directed to the clinical issues so well presented and discussed by Kelly and Varghese in this Journal [1].