Seduced by death: doctors, patients, and the Dutch cure.

In the Dutch city of Assen in the spring of 1993, a court of three judges acquitted a psychiatrist who had assisted in the suicide of his patient, a physically healthy fifty year old woman who had lost her two sons and who had been recently divorced from her husband. The court ruled that the psychiatrist, Dr. Boudewijn Chabot, was justified in his actions because his patient was competent to make the decision to die freely, her suffering was irremediable, and the doctor met the Dutch criterion for force majeure, meaning that he found it necessary to put the welfare of his patient above the law, which formally prohibits assisted suicide and euthanasia.(1) The Assen case is joining the handful of internationally known Dutch cases of assisted suicide and euthanasia, each referred to by the name of the city where it was tried. The court's decision established a milestone extending Dutch toleration for assisted suicide and euthanasia into the treatment of suicidal patients who are not physically ill. I have been involved with research into the problem of suicide and the treatment of suicidal patients all of my professional life. My studies have been psychosocial and psychodynamic in nature and have focused on the meaning and motivation for suicide in cultures and subcultures ranging from Scandinavia to Harlem and on particular groups such as college students, Vietnam veterans, and older persons.(2) I have become more directly involved with the question of assisted suicide and euthanasia since I began serving as executive director of the American Suicide Foundation, an organization that funds research and education designed to prevent suicide. Founded six years ago by scientists and lay people who were primarily occupied with the problem of suicide in general and the rise in youth suicide in particular, the foundation did not perceive euthanasia as an initial concern. In the past few years public activism for assisted suicide and euthanasia--spurred by Jack Kevorkian, Timothy Quill, and Derek Humphry--has aroused our attention. While acknowledging that there are cases where helping a terminally ill patient to die in the final weeks of his or her illness may be humane and a physician would be justified in providing such help, the only consensus we have had is that the hasty and unreflective efforts that were being undertaken in several states to legalize assisted suicide and euthanasia were the worst possible answers to a problem that needs to be addressed. Although both assisted suicide and euthanasia have been put forward as an expression of the individual's "right to die," some advocates have drawn a distinction between assisted suicide, where, as in the Assen case, the doctor prescribes or provides medication and informs the patient how much is needed to end life, and euthanasia, in which the doctor induces death, usually by injection with drugs. Assisted suicide has been seen as protecting against medical abuse by giving the patient control over his death. Advocates also see it as a first step, more likely to be accepted than euthanasia. Opponents see little protection in assisted suicide because by use of their influence or powers of coercion physicians or relatives can achieve the same result without direct action. In the past ten years in this country the argument for medically assisted suicide has centered on the personal suffering of the terminally ill and has been seen as an extension of the right to refuse to be sustained on life support systems or to request not to be resuscitated. Advocates of euthanasia see no essential difference between a doctor's withdrawing futile treatment and his becoming a more direct participant in inducing death. Assisted suicide and euthanasia are not yet advocated in this country for patients regarded as purely psychiatric. But the Assen case seemed to justify the concerns here as in the Netherlands of a "slippery slope" that moves society inexorably from assisted suicide to euthanasia, from euthanasia for the terminally ill to patients who are chronically ill, from physical suffering to mental suffering, from voluntary requests for euthanasia to killing at the discretion of the physician. …