Countertransference and assisted suicide.

• Author: Varghese, Francis T.
• Position: Physician-assisted suicide

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.(8)

An empathic gap can exist between doctors and some of their patients on the basis of gender, class, culture, and age, among other things. Because in most societies the large majority of doctors come from particular socioeconomic groups, some disadvantaged groups are rendered particularly vulnerable. The cultural context of the dominant ethical and legal debate (including the assumption of the overriding ethical status of individual autonomy), along with the cultural context and meaning of the care of the dying, of illness, and of suffering, also needs to be acknowledged.(9) Holland points out that "the current emotional debate about the appropriate role of physician-assisted suicide for cancer patients who wish to die has been based far too long on personal beliefs and personal bias and far too little on objective observations."(10)

In this chapter we discuss evidence emerging from a range of research in clinical populations concerning terminally ill patients, end-of-life and other treatment decisions by medically ill patients, and the impact of care of the dying patient on the treating doctor. The research provides an empirical basis for the discussion that follows, addressing the broader psychodynamic issues, including the role of countertransference and projective identification, in order to highlight important clinical factors that have been relatively neglected to date in this area.(11) Indeed, empirically based research demonstrates the complexity of the situation faced by terminally ill patients and contradicts many popular misconceptions.

Suicide and "Rational" Suicide in the Terminally Ill

It is frequently assumed that patients who have been diagnosed with cancer and other severe physical illness will consider suicide and, moreover, that suicide is "rational" in cases of severe illness in which no treatment is available. In fact, the available evidence indicates that even though suicide risk may be increased in cancer patients, suicide accounts for only a small minority of deaths in this population.(12) When suicide and attempted suicide do occur in cancer patients, they are closely associated with major psychiatric disorders, particularly depression.(13) The association with psychiatric disorder also applies to the wish to die in other terminally ill patients.(14) Furthermore, depression and psychological symptoms are difficult to detect and frequently underdiagnosed and undertreated, particularly in patients with chronic physical illness or in the terminally ill,(15) casting further doubt on the assessment of "rational" suicide in the terminally ill. Such underdiagnosis and undertreatment of psychiatric illness may reflect particular emotional reactions in doctors to the terminally ill, representing a countertransference issue rather than a question of diagnostic acumen alone. Doctors treating terminally ill patients tend to consider the patient's mood state as "normal" on the assumption that they would feel the same if they were in a similar situation,(16) a situation of pseudoempathy. Significant doubt must be cast on the concept of rational suicide in patients with terminal illness and on efforts to normalize suicide and suicidal ideation in this group.(17)

The severity of physical illness may be of less significance in the patient's decision to end life, or indeed in making other treatment decisions, than the basic adaptive pattern of the individual and the impact of this on the patient's response and the responses of those around him or her.(18) The importance of the basic adaptive pattern of the individual and of its impact is borne out in studies of correlates of the wish to die and suicidal ideation in patients with medical illness.(19) It also emerges in studies of "medically assisted death" among individuals with AIDS,(20) studies of patients' evaluations of quality of life and disability,(21) and studies of patients with end-stage renal failure who elect to die by withdrawal of dialysis.(22)

Suicidal ideation is not predicted by the severity of disease or objective indices of quality of life in medically ill patients;(23) nor does it seem to be the normal reaction of a dying individual.(24) This highlights the need for physicians to fully understand the clinical correlates of the wish to hasten the death in the terminally ill so as to fully appreciate the factors that promote understanding of the total context of the request for assisted suicide from terminally ill patients.

In a study involving more than three hundred men with AIDS, having an "interest" in physician-assisted suicide was predicted by high levels of psychological distress and the experience of terminal illness of a friend or relative and by a perception of lower levels of social support. There was no significant association between interest in assisted suicide and severity of the disease.(25) Chochinov and colleagues examined the desire for death in a group of more than 100 terminally ill cancer patients.(26) The authors found that only 8.5% had an enduring and clinically significant desire for death, and of these the diagnostic criteria for major depression were fulfilled in 59%, compared with 8% of those without a stated desire for death. Pain, lower levels of family support, and depression were significantly associated with the desire for death. An important finding here is that the desire for death was temporally unstable, thus raising concern about assisting in a patient's requested suicide at any particular point in the disease. This also emphasizes the dangers in evaluating a request for assisted suicide in the absence of a relationship with the patient over a significant period of time and highlights particularly the difficulties in assessments in which "competence" is the only issue considered. In one survey, whereas only 6% of 321 Oregon psychiatrists were "very confident" in conducting a psychiatric assessment with respect to physician-assisted suicide, 66% supported physician-assisted...