Abstract
Rainer Dziewas and Henning Henningsen, Department of Neurology, University of Münster, Germany:
In his article ‘Medicine, psychiatry and euthanasia: an argument against mandatory psychiatric review’ Malcolm Parker [1] deals with the question whether obligatory psychiatric examination of patients requesting active euthanasia is warranted, while psychiatric examination is usually not taken into consideration in the context of passive euthanasia. The author points out that neither an appeal to the traditional acts and omissions doctrine nor to the doctrine of the sanctity of life can help to solve the issue. Rather, the problem should be conceptualized as a conflict between the principle of respect for autonomy and the principle of nonmaleficience. The key question therefore is, whether patients who request active euthanasia tend to be more impaired in their decision-making abilities, because of depression, for example, than patients who request passive euthanasia. As this matter is not decided at present, the author concludes that the requirement of psychiatric assessment solely in the case of active euthanasia has neither empirical nor moral justification. He expresses the fear that such a procedure could impair the freedom of patients in making decisions about their deaths.
While we believe the author's arguments to be correct, they seem to be incomplete at the same time, making his conclusions questionable. In the current discussion of different aspects of euthanasia a lot of attention is paid to slippery-slope arguments. Most prominent is its so called psychological-sociological version [2], which examines the probable impact of making further exceptions to the rule against killing. It is feared, that if legal restraints against killing are taken away by moving from passive to active voluntary euthanasia, for example, a number of psychological and social forces would possibly make it more difficult to retain the relevant distinctions in practice, thereby causing a slide from voluntary to nonvoluntary or even involuntary euthanasia. Among others the following more concrete points have been put forward so far:
Physicians, who are used to disclosing to their patients not only ‘pure’ information but to recommend therapeutic procedures as well, might start seeing euthanasia as another therapeutic option and to influence patients in that direction [3].
Additionally, it is suspected, that a change of the attitude towards the seriously ill could be induced [4]. Besides a reduction of sympathy and compassion in the intimate social surrounding of the afflicted person, the danger is discerned, that changes to the disadvantage of the seriously ill – for example confinement of palliative medical measures – might take place at an institutional level [5].
Obviously, these consequences might lead to various forms of manipulation and coercion, thereby significantly reducing the voluntariness of the patients' decisions. Although comprehensive empirical evidence in support of this reasoning is lacking, we think that slippery-slope arguments constitute a morally relevant distinction between active and passive euthanasia. While it is disputable if a prohibition of active euthanasia can firmly rest on these arguments, they do justify measures to enhance and secure patient's autonomy in the context of active euthanasia [5]. Mandatory psychiatric review, which does not only serve to diagnose clinical depression but also to identify external manipulation or coercion, should be seen as such a suitable measure.