To the Editor: Thank you for publishing the articles on physician-assisted suicide by Hartmann and Meyerson and Schoevers and associates in the November 1998 issue. That psychiatrists are considering the issue is a sign of a profound shift in the underlying philosophical assumptions of our culture.
The traditional psychiatric frame of reference about the wish to die evolved at a time when people accepted the sanctity of life as a religious principle. There was no need to explicitly build it into our concept of treatment. When a patient came to the psychiatrist and said, "I want to die," the psychiatrist knew the message was, "Even though my life is valuable, I have frightening wishes to die. Please help me." Even when psychotherapy and medications didn't work, we protected our patients, expecting that after a while they would no longer be dangerous to themselves. Our expectations were fulfilled. No patient who was placed on suicide precautions remained there until he or she died from old age.
Today we can no longer count on our practitioners' or our patients' belief in the sanctity of life. This shift leaves a dangerous gap in our diagnostic manual. A patient with feelings of hopelessness and suicidal ideation who does not meet diagnostic criteria for any of the disorders can be perceived as making a rational choice for suicide. One of the cases cited by Schoevers and associates and discussed elsewhere by Hendin (
1) fell into this category.
If we are willing to consider hopelessness and suicidality as a psychiatric disorder, there is certainly no lack of good treatments. Thanks to the work of Albert Ellis (
2) and Aaron Beck (
3), we have powerful cognitive techniques that we could offer to far more patients than we currently do (
4), and we can hope for future medications to help them as well. Including hopelessness and suicidality as a psychiatric disorder will help us with bedside consultations, where physicians may take our judgment of "no psychiatric disorder" as automatic permission for physician-assisted suicide.
If we do not include hopelessness and suicidality as a psychiatric disorder, then we must make it clear that a doctor cannot offer a biological treatment for it in the form of lethal medication. To do otherwise encourages absurdity. It is ridiculous to treat the nonmedical disorder of suicidality and perceived hopelessness with a medical treatment that causes the patient to die. The medication gets rid of the symptoms, but it has death as a side effect. Since when do we consider that acceptable?
Our psychiatric wards are full of patients with more tragedy in their lives than the cases described by Schoevers and associates. If we do not educate our psychiatrists to know their professional limits, these patients' lives could be at risk.
