Editor’s Note: Jason Spiegelman’s interview with Dr. James Werth (“Graduate Student Spotlight”) in the Fall 2000 issue of Behavioral Emergencies Update inspired a lively debate about end-of-life issues. Following are comments from Dr. Bob Yufit, a response from Dr. Werth, and concluding comments from Dr. Phil Kleespies.

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I want to respond to the interview conducted by Student Representative Jason Spiegelman with James Werth, PhD, in the previous (Fall 2000) issue of Behavioral Emergencies Update.

In response to a question, Dr. Werth indicates that a psychologist’s role should be a "duty to assess" (the situation) as opposed to a "duty to prevent" the suicide.

I do strongly agree that there is a duty to assess, and the psychologist is in the most unique position to provide such an assessment, even though our assessment tools need to be more refined and focused. (In the same Newsletter issue, our Past President, Dr. Phil Kleespies, bemoans the absence of psychologists in such situations, and this should be corrected, as we do have much to offer in terms of both assessment and treatment.)

However, I strongly disagree with Dr. Werth's opinion that if the stress of the situation cannot be improved, it "would be inappropriate for me to intervene to prevent the person from following through with his or her well-reasoned decision to hasten death..." I have devoted over 30 years of my professional life to the diagnosis and treatment of suicidal persons and have yet to find a "well-reasoned" decision by a suicidal person. Suicide is not a rational act, which is why the term "rational suicide" is an oxymoron. The suicidal person typically suffers from highly constricted thinking. Alternative options are almost always available, and certainly should be presented by the therapist. To passively allow a suicide to occur is simply wrong, in my considered opinion. We should not allow a depressed, pessimistic, hopeless person make an irrational, irreversible decision.

Ending the pain and suffering of a terminally ill patient is often offered as a compassionate reason for assisted suicide. I do feel that physicians need to apply better pain management to ease suffering, and that hospice should be better utilized to offer comfort to the dying patient and their family. However, passive allowance of assisted suicide is not an acceptable professional role for any mental health provider. In the case of a suffering patient with an irreversible terminal illness, I would not interfere with a family making this decision on their own; however, I could not be a party to this decision, and if asked for my professional judgment, I would indicate that I could not approve.

Worse yet, in my opinion, would be the attempts to legalize assisted suicide. The “slippery slope” clearly applies here, as was crudely exemplified by the work of Kevorkian under the guise of “compassionate care.” Legalization of assisted suicide would give the wrong message to suicide-prone persons that we approve of such behavior, and many younger suicidal patients in treatment have raised this issue. I believe any such laws to legalize assisted suicide would create confusion for suicidal persons, as we try to expand their constricted horizons of the present and the future (we are expanders and not shrinks!) Assisted suicide is against the law in 49 of 50 states.

Some of my greatest professional satisfaction has been derived from calls and letters from suicidal persons, after therapeutic treatment, expressing their gratitude for being helped to decide to live. Once the patient comes to see us, there is usually enough ambivalence about their decision to die that we can show them a reason to live, and in fact, have the professional duty to do so. Once a future time perspective is developed (it usually does not exist, or exists only in a negative framework for most suicidal persons), options are developed, and life can be viewed in a broader perspective. Building some realistic hope and trust can do wonders for many patients. I have seen this happen many times. So, I would say "yes" to assess, but to assist, we should desist.

According to an article in the March/April 2001 The National Psychologist, the American Psychological Association Council of Representatives, after intensive discussion, narrowly approved a policy in February that states that it “neither endorses nor opposes assisted suicide at this time.” One representative, Dr. James Bray, reportedly termed the language “wishy-washy.” Some council members feared that a position of neutrality could be interpreted as an endorsement of the issue. I would hope that both the APA and the American Association of Suicidology would give up their neutral positions and take a stronger stand on prevention of all suicide, including assisted suicide. The AAS mission, which I helped formulate in 1990, is “to understand and prevent suicide...” I look forward to further considering these issues on the APA Advisory Panel.

Reactions to this issue are most welcome. I would especially like to hear other contrary viewpoints (as well as support) on this important matter. Robert I. Yufit, Ph.D. President, Section VII Past President, American Association of Suicidology, Illinois Association of Suicidology

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