WHEN PATIENTS REQUEST ASSISTANCE WITH SUICIDE.

• Position: Brief Article

When a patient makes a request for assistance with suicide, the physician's response should not be a simple yes or no, maintains Philip R. Muskin, associate professor of clinical psychiatry, Columbia-Presbyterian Medical Center, New York. Instead, the doctor should engage the patient in a dialogue that explores the possible meanings behind the stated wish to die. Only then can the physician determine whether the request is "rational" or driven by other, possibly resolvable factors, such as depression or inadequately treated pain. To date, the medical literature on this topic has focused almost entirely on whether the patient is competent to make such a request, "which is too simplistic an approach for so complex a matter."

Physician-assisted suicide is illegal in all but one state (Oregon), and the Supreme Court ruled in 1997 that it is not a constitutional right. Nevertheless, there is substantial support for physician-assisted suicide. Studies have shown that 55% of people with HIV and 25% of those with cancer have contemplated it. How many patients actually make such a request and how often it is granted by caregivers are not known, but assisted suicide does occur. In a survey of critical-care nurses, 16% reported that they assisted in a patient's death and four percent acknowledged that they expedited a patient's death by pretending to deliver vital treatment ordered by a doctor.

Muskin advocates a "psychodynamic" approach to these patients. In modern psychodynamics, he explains, one seeks to find "important hidden meanings within emotion, thought, and behavior, rather than searching for a singularity, a core unit, or a `truth.'" Thus, the request to die may be, in fact, a communication to the physician, an appeal to be given a reason to...