The Euthanasia Specific Competency Assessment and Psychiatric Examination (ESCAPE) consisted of a structured questionnaire and mental state examination. Like most medical forms, it was several pages long and had to be completed in triplicate. I had been called to see a 31-year-old woman with secondary carcinoma in the brain from breast primary carcinoma. Basically, all I had to do was certify that the patient in question was not clinically depressed and was capable of making a decision. Although the legislation had been in effect for 8 months, many physicians and psychiatrists were unwilling to get involved, and it was left to a few of us who were progressive enough to consider euthanasia a viable option to do the assessments.

Having always believed that the right to die was as important as any other right, I had no qualms about being the psychiatrist on the Hospital Euthanasia Committee. Not that there was much competition for that position, anyway. To me, it was a small step from withdrawal of life support to assisting suicide in the terminally ill-both produced the same result, and I couldn't see what the fuss was all about. The proponents of the "above all, do no harm" approach (the "Hippocratic" lobby) failed to accept that harm could just as easily be interpreted as letting someone suffer endlessly, with no relief in sight.

I reviewed the patient's case file and made a few notes. The paperwork from two independent physicians was complete. There was no doubt about the diagnosis; the condition was inoperable, and the patient's pain and distress were obvious. Progressive deterioration and increasing neurologic deficits were well documented by repeated assessments. She did not seem to have a significant psychiatric history. The nurses' reports described her as cheerful and cooperative despite her pain. She had been married for a short time, but her husband had died in a mining accident 3 years ago. She had no children. I could see that certifying this patient was going to be a mere formality.

I found her sitting up in bed, trying to change the channels on the television. She struggled to use the remote control, and the extent of her disability was apparent. Her features suggested that she was probably quite attractive once, but the wasting and hair loss made her look about two decades older than her 31 years. It was when she started to speak that I made the connection. I had known her many years ago in high school; I had even dated her a few times. We grew apart when I went away to medical school and had had no contact with each other since then. I could scarcely have imagined that I would meet her in this situation.

After the initial pleasantries and mutual expressions of surprise on both sides, we chatted for a while and caught up on all that had happened since we last met. For a few fleeting moments, we were two old friends meeting after many years. The moment passed, and we eventually got down to discussing her present condition. It wasn't easy for me to see her like this, but she was very clear about what she wanted to do, which made my job a little easier. She showed no evidence of depression. When I questioned her about her decision to die, she said, "Can you give me one good reason why I should go on living?" Quite frankly, I couldn't.

I promised to visit again the next day, and as I left, I added, "Since we know each other, I'll arrange for a second psychiatric opinion, just to be safe. After all, we don't want some hotshot lawyer from one of those radical anti-euthanasia groups holding us up on a technicality."

"I don't mind," she said. "As long as it's done quickly."

"I can see to that," I replied. "And once that's completed, I'll forward the application to the Euthanasia Review Board. They hold fortnightly hearings in hospitals where there are requests. If the Board approves, we can go ahead with the procedure 48 hours later." She nodded in agreement.

At the nursing station, I noticed a small tremor as I tried to fill in the form. I hesitated. I had struggled to keep a lid on my emotions during the interview, but now they surfaced all at once. My signature on a form was the only thing she required to leave this world. It would also be the last thing she would ever need. Until today, I had had no problems with what I was doing, but this time, the gravity of my collective actions over the past few months started to take its toll. My last two patients had been a 72-year-old man with disseminated tumors and a 55-year-old woman with multiple sclerosis. It was one thing to certify and recommend people I had never seen before (and who were, at some unconscious level, probably less "real" to me) and another thing to send someone I knew down a path of no return. A series of questions passed through my mind. How does one go about certifying one's ex-girlfriend? What gave me the power to authoritatively state that someone was sane enough to commit what increasingly seemed to be an insane act? And isn't everyone someone's ex-girlfriend, someone's daughter, mother, or sister? If what I was doing was so right, how come it suddenly started to feel so wrong? Memories of high school came flooding in, and I left the ward rapidly.

Later that evening, I wrote a letter to the dean requesting that my name be taken off the panel of physicians on the Euthanasia Committee. I gave no reason except the usual "personal circumstances." To be professional is to act in the best interests of the patient. To be professional is to be detached, but how good is detachment when one is dealing with human beings? Does detachment automatically go hand in hand with what is best for the patient? I wrestled with these issues as I made my way home that winter evening, gentle snowflakes caressing my windshield.

Mani Rajagopalan, MD, DPM, DNB

Ballarat Health Services; Ballarat, Australia