In their editorial, Shaw et al argue that current medical practice is overly paternalistic towards patients who are mentally competent and who have a terminal illness (including those with psychiatric illness) who request assisted suicide.Reference Shaw, Trachsel and Elger¹ They base their general argument on the four principles of bioethics with a special emphasis on patient autonomy and end by asserting that, ‘any doctor who attempts to prevent a patient who is mentally competent from accessing assisted suicide is adopting an over-paternalistic stance’.Reference Shaw, Trachsel and Elger¹

The authors’ implicit argument against dissuading a patient from assisted suicide appears to rest on the premise that death is a lesser evil (or a lesser suffering) compared with being alive and suffering. We would hold that this premise merits a closer examination.

Life has always been regarded as the basic right and fundamental good for any human person. Aristotle's distillation of popular wisdom is unequivocal: ‘death is the most terrible of all things; for it is the end, and nothing is thought to be any longer either good or bad for the dead’.Reference Aristotle and Barnes² The person who has lost the desire to live represents the ultimate instance of suffering – existential suffering; and in seeking medical attention, the existential sufferer accepts de facto that the physician is the last instance of help. Ultimately a request for suicide is a request for help to relieve existential suffering. It is not a request to annihilate existence.

We would argue that any doctor who unconditionally accedes to assisting his or her patient to die by suicide is abdicating his or her role as a beneficent protector of the sick and suffering and is instead championing absolute patient autonomy.

The Hippocratic dawn of medical practice with its paternalistic physician–patient relationship is thankfully behind us but the beneficent physician is still the necessary companion for the autonomous patient. Indeed, a total abdication of physician beneficence in favour of patient autonomy is neither called for nor is it in the best interests of patients.Reference Savulescu³ As Brett & McCullough put it ‘if the aim of medicine should be seen as a form of beneficence, then doing harm in the service of autonomy is illogical’.Reference Brett and McCullough⁴

The authors rightly conclude that ‘to impose [one's] values on one's patients is deeply unethical and unprofessional’.Reference Barry and Edgman-Levitan¹ Certainly patients must always be free to decide about their own life; but again there is something deeply unethical and unprofessional for a doctor who is traditionally committed to saving life to be instrumental in taking away that very life. The ideal physician–patient relationship should be characterised by the equally important contribution of physician beneficence and patient autonomy operating in a shared environment of justice and non-maleficence. In this regard, an open and sincere shared decision-making process is probably the best context within which a constructive discussion of the meaningful alternatives to suicide for the management of existential suffering can take place.Reference Barry and Edgman-Levitan⁵ Such alternatives include, but are not necessarily limited to: meaning-centred therapy, hope-centred therapy, dignity therapy and supportive-expressive therapy.