Many suicidal patients come into therapy with sometimes conscious,
but often unconscious, fantasies that cast the therapist in the
role of their executioner. Netty seemed to be such a patient;
she and Chabot also experienced a closeness in her death. A commitment
on the therapist's part to become executioner if treatment fails
plays into and reinforces these fantasies. It may also play into
the therapist's illusion that if he or she cannot cure the patient
no one else can either.
Some therapists also seem to have entered into the patient's fantasy
of death as a reunion. Chabot's comment to Netty right before
her death that she should think about her boys suggests that he
too saw her death metaphorically as a return to her lost children.
By metaphorizing death as something other than death, it is made
to appear an attractive option. Not treating Netty as a patient
but as a devoted mother whose desire to join her boys in death
was not a sign of her disturbance but a legitimate and realizable
goal makes it impossible to explore her guilt toward her children
and her need for punishment.
From what Chabot was able to elicit in sessions with Netty, bereavement
counseling was likely to fail with her, but psychotherapy less
narrowly focused might have succeeded. Netty's personality problems
far anteceded her bereavement. She said she became a person only
when her first son was born and stayed alive only for the sake
of her second son. Netty's guilt over her first son's suicide
had sources that were deeper than her failure to have gotten a
divorce. Caring for her second son seems to have had something
of the quality of an atonement. One suspects that if therapy provided
her with the opportunity to understand her relationship to her
sons before deciding to join them in death, it might have engaged
her.
No one should underestimate the grief of a mother who has lost
a beloved child, but neither should one ignore the many ways life
offers to deal with the feelings of loss, guilt and pain a child's
death is likely to arouse. Certainly a decision to end life so
soon after the death of her second son should not have been assisted
or implemented. With or without treatment, time alone might well
have made a difference.
The Dutch Supreme Court, which ruled
on the case in June 1994, agreed with the lower courts in affirming
that mental suffering can be grounds for euthanasia, but found
Chabot guilty of not having had a psychiatric consultant actually
see the patient. Although the court expressed the belief that
a consultant's direct contact with a patient was particularly
necessary in the absence of physical illness, it imposed no punishment
since it felt that in all other regards Chabot had behaved responsibly.
The case was seen as a triumph by euthanasia advocates, since
it legally established mental suffering as a basis for euthanasia.
Since the consultation can easily be obtained from a sympathetic
colleague, it offers the patient little protection.
The acceptance of euthanasia for psychiatric patients who are
suicidal seems the inevitable consequence of allowing such criteria
as "competence" and "intolerable suffering"
to determine the outcome rather than sound clinical judgment.
The psychiatrist in some of the psychiatric cases is in the position
of working to prevent suicide until the patient asks for his or
her assistance in committing suicide and then the rules of the
game change and the psychiatrist negotiates with the patient as
to whose approach is best.
Seriously suicidal patients want suicide. In a society that makes
euthanasia accessible for them they will be harder to treat, not
easier. Many of them fantasize closeness in death with a person
who kills them. When psychiatrists and general practitioners have
complementary fantasies, euthanasia fulfills their needs as much
as the patient's.
Dutch practice ignores what we know of the complex dynamics of
the relation between the treatment of the suicidal and the desire
of some who are seriously ill to end their lives. Suicidal patients
are prone to make conditions of life that life cannot fulfill:
"I won't live if I can't be in control," "without
my husband," "if I lose my looks, power, prestige or
health," or "if I am going to die soon." Depression,
often precipitated by discovering a serious illness, exaggerates
the tendency toward seeing problems in black-or-white terms (Hendin
and Klerman 1993).
