In rejecting active voluntary euthanasia, manymedical practitioners and their organisations con-tinue to rely upon the distinction between acts whichhasten death and omissions/withdrawals which leadto death, despite considerable challenge to the moralrelevance of the distinction over the last threedecades [1–4]. As support for euthanasia has grown,

mandatory assessment by psychiatrists of peoplerequesting active assistance to die has been urged on the grounds that protection against abuses and oversights is required [5,6]. Mandatory psychiatricassessment was written into the short-lived Rights ofthe Terminally Ill (ROTI) Act (1995) of the NorthernTerritory [7].

One’s position on mandatory psychiatric assess-ment is not fixed by that on the ethical and legislativeacceptability of euthanasia. Nevertheless, the acts–omissions distinction is often relied on, somewhatunwittingly, in advocating such assessment. In thispaper, I challenge the proposition that psychiatristsshould formally assess terminally ill patients’requests for active assistance to die through active

Medicine, psychiatry and euthanasia: anargument against mandatory psychiatricreview

Malcolm Parker

Objective: The paper critically appraises the argument that requests for activeassistance to die should be subject to mandatory psychiatric assessment.Method: The argument for mandatory psychiatric assessment is usually supportedby an appeal to the need for safeguards against errors and omissions in both thediagnosis of psychiatric conditions affecting the terminally ill and the exploration ofthe meanings of their requests. This intuitively appealing view is challenged througha broader analysis which examines connections between medicine’s traditionaladherence to the moral distinction between acts and omissions and the followingissues: the historical relationship between medical practice and dying, the recentdevelopment of research into treatment-withdrawal decisions, the scientific status ofpsychiatry, the logic of rationality and decision-making competence.Results: The analysis reveals a number of hitherto unexamined and unacknowl-edged influences which would make psychiatric review of requests for assisted deatha much less objective and impartial process than is assumed.Conclusion: Mandatory psychiatric review is an instance of the medicalisation ofdeath and dying which could abridge the freedom of certain individuals to make decisions about their deaths.Key words: acts–omissions distinction, euthanasia, medicalisation, psychiatry,rationality.

Australian and New Zealand Journal of Psychiatry 2000; 34:318–324

Malcolm Parker, Senior Lecturer in Ethics and ProfessionalDevelopment

Graduate School of Medicine, The University of Queensland,Herston Road, Herston, Queensland 4006, Australia. Email:m.parker@mailbox.uq.edu.au

Received 4 June 1999; second revision 5 January 2000; accepted 12January 2000.

y

voluntary euthanasia or physician-assisted suicide,by considering some links between the act–omissiondistinction and a number of historical, cultural andinstitutional features of medicine and psychiatry.

Acts and omissions

Killing another human being is widely regarded as morally wrong. Some people take it to be self-evidently true that killing is intrinsically and alwayswrong. Alternatively, killing might be consideredmorally wrong because it usually ends the life of aperson who desired that his life and all its experi-ences, promises, connections and hopes continue.The acts and omissions doctrine amounts to the claimthat there is a moral difference between an act and anomission even if the two events have the same conse-quence: the act of killing a person is morally worsethan the act of allowing a person to die. Opponents ofthe acts and omissions doctrine claim that, everythingelse being the same, killing a person is morallyequivalent to allowing him to die. They accept thatkilling is in most cases seriously morally wrong (forthe reasons mentioned above), but it will be morallyacceptable when a person no longer has the relevantdesires. Consider two terminally ill patients, one whois respirator-dependent. According to the acts andomissions doctrine, withdrawing ventilatory supportat the competent and informed request of the depen-dent patient, with that patient’s death as the foreseenoutcome, is morally acceptable, whereas activelybringing about the death of the second patient at herrequest is not. According to the moral equivalencethesis, there is no moral difference between the twocases: if the withdrawal is seen as acceptable, so tooshould be active assistance to die. Supporters of theacts and omissions doctrine often base the claimedmoral difference on a causal claim: in the case oftreatment withdrawal, the patient’s death is caused bythe disease, whereas in the second case, death iscaused directly by a human agent.

Those committed to the view that killing is intrin-sically wrong will have no interest in debating themoral equivalence question or investigating the con-ditions under which euthanasia might be acceptable,since for them there will be no such conditions.Conversely, anyone who advocates the importance ofassessing patients who request active assistance todie, to exclude depression or ensure the rationality oftheir requests, is thereby committed to accept that,in some circumstances at least, the moral equivalencethesis holds. This is because the assessment aims at

distinguishing those whose request is competent,rational and uncoerced from those where such factorswill cause us to refuse the request. There would be nopoint making such assessments if one viewed activeassistance to die as never acceptable (i.e. as intrinsi-cally wrong).

Medicine and death

Medicine’s association with death and its preven-tion is obvious, but is a historically recent develop-ment [8]. While death was often perceived as bad inpast eras, it was also generally seen as natural andinevitable. Medicine’s power to prevent or postponedeath has increasingly made death something whichour culture considers ought to be avoided [9]. Themodern physician’s duty to save life derives from thatpower in the context of a strong allegiance to thesanctity of human life. However, in recent years, wehave witnessed the deconstruction of the unques-tioned imperative to prolong life, underpinned by theloss of absolute allegiance to the sanctity of lifethrough the secularisation of society. This has led toa greater emphasis on patients’ rights to refuse treat-ment [10–12], a clearer distinction between thera-peutic and comfort measures elaborated within thepalliative care/hospice movements, and subsequentaccommodations within the medical profession itselftowards a ‘re-naturalisation’ of death and dying [13].The euthanasia movement, too, is motivated by thesede-medicalising imperatives, since euthanasia argu-ably would deliver certain individuals from a sociallyimposed prolongation of life, in which the institutionof medicine plays a crucial normative role. Whilesome perceive euthanasia as a pinnacle of medical-isation, the crucial issue in the balance betweenmedical power and patient autonomy is whetherpatients’ settled and competent wishes are met, notthe identity of the person who assists in their dying,whether by active assistance or a treatment with-drawal. Similarly, while palliative care is argued asreducing curative medicine’s power over the terminalphase of life, some terminally ill patients come toperceive palliative care as inappropriate, and as unac-ceptable medicalisation, the more it is normalised asthe only possible kind of ‘good death’ [14].

As terms such as ‘natural’, ‘artificial’, ‘ordinary’,‘extraordinary’, ‘medicalisation’ and ‘demedical-isation’ have increasingly been perceived to functionevaluatively as well as descriptively according tocontext, movements to weaken the grip of medicalpractice on dying have become stronger. While

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doctors often claim that the law has intruded too farinto the doctor–patient relationship, an alternate per-ception is that it has gone some way to reducingmodern medicine’s powerful, but unarticulated,dominion over death and dying.

Medicine, euthanasia and treatmentwithdrawal

‘Euthanasia is the single most serious challenge to the Hippocratic tradition that has nurtureddoctors for well over two thousand years’ [15] andorganised medicine continues to reject it, adheringto the sanctity-of-life principle and the moral distinc-tion between acts and omissions [16,17]. Medicalparticipation in active euthanasia is also seen as vio-lating the goals and ideals of a healing profession[18,19]. However, while acceptance of active eutha-nasia is lower in the medical profession than it is inthe community, the level of medical acceptance issignificant [20]. At least some practitioners considerthat ideals can sometimes blind us to the real needsof suffering patients [21]. Empirical studies demon-strate that a significant number of individual doctorsflout official ethics and the law to actively assistpatients to die [22,23].

Organised medicine has had far less difficultyaccepting the legal formalisation of the right to refuseunwanted treatment than involvement in activeeuthanasia, due largely to the perception that whentreatment is refused, it is the disease and not thephysician which causes death [9]. This intuitionmakes it easier to think that requests for active assis-tance, but not those for withdrawal of treatment,require interpretation and exploration. Recent researchhas been undertaken into factors which may influ-ence refusals of treatment, including clinical depres-sion [24–27]. That such research is now occurringarguably results, at least in part, from a new, butunstated (perhaps unconscious), recognition that theneed to explore and interpret requests for with-drawals is no different from the need in respect to requests for active assistance to die. If so, theacts–omissions distinction does not mark the moralboundary that the profession has long supported, butthe fact that the research is recent also demonstrateshow official doctrine influences both researchagendas and clinical practices, both of which haveimportant social implications.

The recognition of the need to explore requests fortreatment withdrawals also weakens the claim thatactive euthanasia should not be legalised because we

have not yet had sufficient enquiry into the manyfactors which can motivate euthanasia requests [28].There are no new calls for a moratorium on treatmentwithdrawals pending adequate enquiry into thesedecisions.

The de-medicalisation movements share concernsabout personal autonomy and quality of life in theface of the harmful possibilities of medical power.They focus on issues of decision-making competenceand voluntariness, the meaning of a person’s dying,interpretation of requests, burdensomeness and coer-cion as these influence end-of-life decision-making,and these issues must be faced in the contexts of bothactive euthanasia and treatment withdrawal. They aretherefore not factors to which we may indefinitelyappeal to reject assisted death while remainingneutral about them in situations of treatment with-drawal. They demand reasoned distinctions andjudgements now that active euthanasia is widelysocially accepted, as indicated by both public opinionpolls and academic research [20].

Psychiatrists are clinically involved in assessingcompetence and interpreting mental symptoms, andwith suicide. Because active euthanasia, but notrefusal of life-sustaining treatment, is conventionallyconceptualised as suicide, there is a strong assump-tion in favour of mandatory psychiatric assessment of euthanasia requests. If such assessments are sup-ported, however, there appears to be as much reasonto require mandatory psychiatric review of treatmentwithdrawal decisions.

Suicide, society and psychiatry

Suicide has been variously conceptualised acrosshistorical periods and cultural groups as heroic,sinful, criminal or rational [29]. Suicidal thoughts arenow conceived as symptoms of mental illness, as aresuicide attempts, which were, until recently, punish-able choices. There are strong correlations betweensuicide and mental illness [30]. Psychiatrists occupya frontline position in the fight against the problem of suicide, and the perceived culpability for failure to prevent it adds strength to the generalisation of amedical, preventable conception [31]. The medical-isation of suicide and the consequent relief frommoral responsibility for the act [30] may also havebeen strengthened by the relatively high rate ofsuicide among psychiatrists themselves [32].

Psychiatry still searches for acceptability within themedical, and (to a lesser extent), the wider communities[8,33]. Its subject matter includes phenomena

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accepted as causally determined and actions whichmost people would describe as the exercise of freewill. This distinction has forensic implications:psychiatric advice determines offender status. Diag-nostic systems such as the DSMs of the AmericanPsychiatric Association have been analysed asinevitably evaluative as well as descriptive classifica-tions [34]. Despite its enormous influence, Freud’sproject purportedly failed to provide a true science ofpersons [35], partly because it failed Popper’s claimthat a scientific theory must in principle be falsifiable[36], and there was no method of refuting psycho-analysis. Because it deals necessarily with illnesses ofthe mind, because the mind–body distinction remainsthe enigma that it does, and because our recalcitrantconcepts concerning freedom cannot be accommo-dated within reductionist science, psychiatry remainsat the fringe of scientific respectability.

Thus conceived, psychiatry could be expected totry to earn the respect of its sister disciplines by beingas scientific as it can. Science aims to discover objec-tive truth; this requires causal explanations whichshow why a particular event could not but occur,given just those conditions existing at the time. Asa seeker of causes and explanations (e.g. of newlynoted epidemiological patterns, such as increases insuicide rates among young men), scientific medicinetends to reduce reasons for action to causes, narrow-ing the possibilities of conceiving various actions asrationally free. The psychiatrisation of suicide hasarguably narrowed the conceptual possibilities of thephenomenon, including that of rational suicide andits entailed notion of free choice.

One of the ways in which psychiatry has attemptedto establish a respectable scientific basis is by pre-senting a ‘biopsychosocial’ model of disease [37].However, while this approach importantly extendsthe purely biomedical treatment of illness, it is not anadequate explanatory model [38]. An adequate modelfor psychiatry would provide a satisfactory unitaryconception of the mind: no small thing. But theassumption of the biopsychosocial approach as acomplete, descriptive model encourages exhaustiveexploration of each of the three dimensions to reveala cause of the phenomenon being studied. Finding acause promises a remedy, since a consequence ofexplaining something is the possibility of better con-trolling it. Requests for assistance to die invite thesearch for such remediable causes. The duty of caredemands a therapeutic response, by tending to ruleout the possibility of a rational judgement that a lifehas ceased to be worth living.

This would have an interesting and paradoxicalresult. In Nazi Germany, doctors and others definedcertain lives as not worth living on the basis ofmorally irrelevant criteria, including race. If moderndoctors disallow the possibility that some people’sjudgements that their lives are not worth continuingcan be rational, they will be formally repeating thisgate-keeper function. While we might agree thathaving your life prolonged against your will wouldusually be preferable to having your life terminatedagainst your will, defining the value of others’ lives isthe same paternalistic process in both cases.

Perhaps another reason we have not, until recently,questioned the rationality of treatment refusals, is thatwe perceive such refusals as motivationally removedfrom death, in contrast to requests for active assis-tance to die. The directness of death from euthanasiaencourages us to think that the patient’s core motiva-tion is a desire to be dead. What we conventionallyassociate with treatment refusal is a desire to be freeof unwanted treatment, and this desire is more easilyconstrued as prima facie rational than a desire to bedead. But, as for those who seek withdrawal of life-sustaining treatment, there is as little reason tosuppose that those who request assistance to die wishprimarily to be dead. Rather, they too have reached apoint where their lives are of no further benefit tothem, and desire release from burdens which are nolonger acceptable. This leaves both kinds of decisionswhich can lead to death as presumptively rational. But it also leaves intact the general medical obliga-tion to ensure that treatment refusals and requests forassistance to die do not emanate from remediablecauses.

Psychiatry, psychiatrists and rational suicide

I submit that a request for assistance to die wouldbe rational if there is good reason to believe that thequality of one’s life renders it not worth living, andthat this situation will not improve [32]. Now, whilesuch a belief is a subjective state, its rationalitydepends on a person’s being justified in losing hope,and this justification is obtained through the deliber-ations of members of a community [39]. The concernthat subjective rationality, unconstrained by commu-nity consensus, would underwrite unreasonable casesof assisted dying, should also be applied to cases oftreatment withdrawal. But laws which now providefor treatment refusal do not attempt to define suffer-ing, nor do they specifically attempt to exclude undueinfluence on refusal decisions [40]. The safeguards

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contained in the Rights of the Terminally Ill Act weresignificantly more protective of a consensus on hope-lessness and suffering than any Australian death withdignity guidelines or treatment refusal legislation[40]. Laws pertaining to all types of end-of-life deci-sions should ensure that decisions are free, rationaland proceed from states of suffering which, while allreasonable people might not deem them hopelessfrom their own point of view, all could view as hope-less in the light of the individual’s particular situationand values.

That psychiatrists are not required to evaluate treat-ment refusals reflects a presumption in these cases infavour of patient competence, a cornerstone of law in western jurisdictions, whereas the requirement forpsychiatric assessment of requests for assistance todie reflects a presumption of incompetence for whichthere is neither empirical evidence nor moral justifi-cation. Sometimes hopelessness will be a psychiatricsymptom, and sometimes a request for assistance todie will represent a psychodynamic process callingfor exploration [41]. But if rational suicide is possible[42], the need to explore requests should be tied to thepossibility that rational responses to objectively hope-less situations may sometimes mimic depressive orother symptoms which in other circumstances woulddemand treatment. Although some studies show thattreatment of depression can sometimes influencetreatment refusals, treatment does not always havethis effect [25,27] and there is no obvious reason tothink that the same would not apply to requests forassistance to die. There is a conceptual and a practicaldistinction between the diagnosis of depression andthe assessment of decision-making competence [26].The failure to recognise and respect this distinctioncan lead to the overriding of autonomous decisions ofsome people who happen to be depressed.

The connections between assessments of decision-making competence, seriousness of decisions and thevalues of the physicians who assess competence arealso relevant. There has been recent debate over theappropriateness of risk-related standards as againstfixed thresholds in defining decision-making compe-tence [43–45]. Risk-related models require higherlevels of competence for decisions with more seriousconsequences. Fixed threshold models apply thesame level to all decisions. If a request for assistanceto die is perceived to be motivationally closer to adesire for death than a request for withdrawal of life-sustaining treatment, there will be a greater tendencyto utilise risk-related assessment. But tying compe-tency to seriousness of outcome in this way trivi-

alises the notion of self-determination, if we acceptthat adult autonomy does not require that all ourdecisions will be in our objective interest [45].Employing the risk-related model increases the like-lihood that others’ values concerning the seriousnessof outcome will infiltrate the decision-makingprocess [45,46]. While such biases are clearly notrestricted to psychiatrists, their very alertness to thepossibilities of depression and other motivationalstates in the setting of patients’ assertions of suffer-ing, together with their own motivation towards treat-ing depression and preventing suicide, may movesome to utilise a risk-related model and discount thevalidity of patients’ assertions. The veto power givento psychiatrists under a mandatory assessmentregime may tend to both discount the rational valid-ity of some patients’ requests for assistance to die,and illegitimately medicalise the solution of a diffi-cult social issue which instead requires decisions byindividuals, communities and polities [46].

Psychiatric gate-keeping for euthanasia

Despite these possibilities, we might think that, inview of the strong connections between suicide andmental illness, and since psychiatrists are involvedmore frequently than other practitioners in assess-ments of competence, psychiatrists are still betterable to gauge this element. Further, given that psy-chiatrists presumably have greater insight than otherpractitioners into the mechanisms of introjection andprojection which occur in relationships with theirpatients, they should be better equipped to deal withthe possible distortions which may arise in emotion-ally charged situations and which may influenceassessments of competence and interpretations ofrequests. However, these strengths of theoreticalinsight have not rendered psychiatrists any moreimmune to errors of judgement than other practition-ers, for example, those who rationalise harmfulsexual relations with patients [47]. If there have beenfailures to translate theoretical abilities to discernone’s own and one’s patient’s motivations, needs,projections and introjections into practices whichprotect patients’ interests by significant numbers ofthe very group which could be expected to do so,there is no reason to suppose that in other areaswhere practitioners’ motivations are so strong theywill be less prone to exploiting patients under coverof what they perceive to be the provision of bene-ficent care.

Kelly and Varghese have argued the reverse of this

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point: through the provision of assisted death, doctorsmay disguise their own feelings of futility and failureand regain feelings of control, and these countertrans-ference responses may influence patients’ perceptionsand decisions [48]. Kelly and Varghese regardrequests for assisted death as analogous to requests bya psychiatric patient for a sexual relationship; suchrequests cannot be autonomous but must be examinedin the context of the relationship; such examinationrequires the framework provided by the prohibition.But, again, this is to mandate that requests for assis-tance in dying are always reducible to some thera-peutic explanation that will enable the reversal of the initial request. To make the prohibition of assisteddeath a necessary condition of the therapeutic endeav-our is surely to codify beneficence according to a par-ticular moral view of the acts–omissions distinction.

Responding to requests for assistance to die or fortreatment withdrawal which will lead to deathinvolves the conflict between the duties to preservelife and those to relieve suffering. The Dutch haveallowed this conflict to be resolved in certain casesthrough the concept of euthanasia as a lawful excep-tion to a retained prohibition on active killing [49].The less satisfactory way of resolving the conflict isthrough a process of moral splitting, whereby thechoices involved in the conflict are attributed asexclusively good or bad according to the acts–omis-sions distinction, so that the duty to relieve sufferingis rendered impossible to fulfil through its associa-tion with killing. Such splits avoid the complexitiesof these situations, but can impose on the patient anundesired prolongation of life.

It is also claimed that depression is under-diagnosed by non-psychiatrists [6], and that thesepractitioners may prematurely acquiesce to requestsfor assistance to die which may otherwise have beenretracted. While the under-diagnosis of depressionby non-psychiatrists should certainly be of concern,this should not rule out the possibility that (espe-cially in a field where diagnostic categories are oftenproblematic due to their syndromal nature and evalu-ative components), depression may actually be over-diagnosed by psychiatrists and other practitionersinfluenced by psychiatry as part of the more generalprocess of medicalisation of some adjustment prob-lems and other vicissitudes of life [50].

The model of gate-keeping followed in the ROTIAct mandated only one psychiatric assessment. Bothopponents and supporters of euthanasia agree thatthis is not sufficient to make an adequate assessmentof competence and to interpret requests for assistance

to die, although their motivations for rejecting themodel will be different. Supporters of euthanasiawho oppose mandatory psychiatric review will claimthat this shifts responsibility and accountability awayfrom where that very process of exploration andsupport has occurred and should continue: betweenpatient, family and usual caregivers, including thepatient’s doctor. On this view, psychiatrists should beinvolved optionally as part of a healing team lookingto augment autonomy, not merely to check that it ispresent. The Oregon Physician-assisted Suicide Actadopts this ‘encouragement’ model, in contrast tomandated psychiatric assessment [51]. Opponents ofeuthanasia may raise the same objection, but if this ison the basis that one mandated assessment woulddisplace a more exploratory and therapeutic relation-ship with the patient, with different goals from that of euthanasia [52], this again rules out, a priori,euthanasia as a possibly reasonable choice.

Conclusions

I have explored the question of mandating psychi-atric assessment of patients who request assistance todie in terms of historical trends in the relationshipbetween the institution of medicine and the society itserves, and in terms of the influences of and upon thediscipline of psychiatry. Mandatory assessment is aninappropriate medicalisation of decisions which,while they must be informed by medical expertise, areessentially non-medical. Psychiatrists particularlyshould be aware of the relationships between beliefs,politics, power and individual freedom [53], and ofthe historical abuses of their discipline in pursuit of anumber of political goals. They should consider theimplications of the institutional and cultural forceswhich they may unwittingly instantiate. Such forcescan threaten the freedom of those facing the end oflife, surely a time when freedom ought to be protectedand promoted.

Acknowledgement

The author acknowledges review of earlier draftsof this paper by Colleen Cartwright.

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