About
the practice of psychiatric
euthanasia:
a commentary
Jorge
Lopez-Castroman1,2,3
Abstract
Euthanasia
motivated by mental disorders is legal in only a few countries and has a short
history. In a recent report of all psychiatric euthanasia cases in Belgium
between 2002 and 2013, Dierickx and colleagues suggest that the number of these
cases is increasing, and provide a profile of the applicants. To date,
knowledge of the practice of psychiatric euthanasia is limited, but rising
public awareness might increase the number of requests. The authors reveal
several shortcomings in cases of psychiatric euthanasia and open avenues for
future research. Please see related article: https://bmcpsychiatry.biomedcentral.com/articles/10.1186/s12888-017-1369-0
Keywords:
Physician-assisted suicide, Palliative
care, Psychiatry, Assisted death, Terminal care
Background
The medical definition of euthanasia
is “the act or practice of causing or permitting the death of hopelessly sick
or injured individuals in a relatively painless way for reasons of mercy” [1].
Physician-assisted suicide is a modality of euthanasia that involves giving
medical assistance to a person requesting to end his or her own life by the
self-administration of a lethal mean. Assisted dying, a closely related term,
is generally restricted to the prescription
of life-ending drugs for terminally ill patients.The legal regulation of
these practices is recent, and definitions remain controversial [2] – probably
because debates have focused on the majority of cases involving physical
illnesses with short life expectancies. However, in some countries euthanasia
is not restricted to the terminally ill, and mental suffering caused by mental
disorders can be alleged to request assistance in dying. Of course, strict
regulations are followed to ensure that these assisted suicide requests are
made voluntarily in the face of untreatable and unrelenting conditions. There
are five other considerations for euthanasia requests:
1)
the medical condition conveys unbearable pain; 2) there is no prospect of
improvement; 3) available treatments are futile; 4) the person is mentally
competent to make a conscious and reasonable choice;and 5) the person is fully
informed about the prognosis.
For
psychiatric cases, assessing fulfillment of these five requirements is
problematic. Not surprisingly, although the medical community
largely
accepts euthanasia in terminal illness, debate continues on the adequacy of
assisted suicide as applied to mental disorders, particularly in
treatment-resistant depression [3]. To date, this debate is mostly based on
moral or ethical grounds. Objective information about how psychiatric
euthanasia takes place might be illuminating. A 2016 report on publicly
available cases in the Netherlands [4]revealed that applicants completing a
psychiatric assisted suicide were generally affected by chronic mental
conditions, often with comorbidities. Prior hospitalizations in psychiatry
wards, suicide attempts (often multiple), and personality issues were common,
as well as a personal history of traumatic events. For those who work with
suicidal patients, or who study suicidal behavior, these features are well
known [5].
New
data
The recently published paper
by Dierickx et al. [6] describes 179 psychiatric and dementia patients, with no
comorbid physical illnesses motivating their request, who were accepted for
euthanasia in Belgium between 2002 and 2013. In general, the profile of
psychiatric patients in this cohort was similar to those in the study by Kim et al. [4], who found that most
psychiatric patients were depressed, middle-aged women, with or without
comorbidity. Additionally, approximately one-third of the patients in Dierickx
et al.’s cohort were elderly dementia cases. Some interesting points can be
raised from Dierickx et al.’s report. First, consultations by palliative care
specialists were not uncommon, and not limited to dementia cases. This is
timely, since a distinct field of palliative psychiatry has recently been
outlined as a reasonable approach for treating severe persistent mental illness
[7]. Second, approximately 1 in 4 patients said that they suffered physical
pain, together with psychic pain, despite the absence of reported physical
illnesses. It is noteworthy that psychic pain is associated with the modulation
of physical pain, and may facilitate suicidal behaviors through increased pain
tolerance [8]. Third,although the numbers remain low, Belgium has recently
experienced an increase in psychiatric euthanasia cases (0.5% up to 2008, 3% in
2013). A similar trend is observed in the Netherlands up to 2013 [4]. This rise
may be associated with increasing public awareness of psychiatric euthanasia.
In cases of mental disorders, physician-assisted death might be justifiable,
but only when applicants are fully informed, and have access to adequate
treatment options and support in (psychic) suffering [9]. Indeed, psychiatrists
should be involved in evaluating euthanasia requests motivated by a mental
disorder. This is the case in Belgium, but not in other countries such as the
Netherlands or Switzerland. For a given patient, psychiatric assessment may
help to ensure that available means are indeed futile to reduce their mental
pain and suicidal ideation (which are core symptoms in the suicidal process),
and that the person requesting euthanasia is competent and fully informed [10].
The report by Dierickx et al. raises a sensible question about the need for
specific criteria and guidelines in assisted suicide for mental conditions. It
also reveals some unexplained shortcomings in the practice of psychiatric
euthanasia, such as the association of a foreseeable death with mental
disorders, or the lack of specialized assessment in some cases. More generally,
absence of standardization in the evaluation of psychopathology and mental
capacities is problematic. In the Netherlands, a study on psychiatric
euthanasia showed that the assessment of decision-making capacity is flawed by
the lack of a systematic procedure and disagreements between physicians, which
are not uncommon [11].
CONCLUSIONS
Beyond its practical
implementation, the debate on euthanasia motivated by mental disorders must be informed
by more accurate and detailed records, including standardized methods for
diagnosis and capacity assessment, and specific research protocols. For
instance, we need to understand how applicants with mental disorders progress
through the euthanasia process (e.g., are their therapeutic options reviewed?),
and for those whose euthanasia request is denied, how we might attenuate their
suffering [12].
References
1.
Merriam-Webster. Euthanasia. 2017. https://www.merriam-webster.com/
dictionary/euthanasia.
Accessed 02 June 2017.
2.
Dyer O, White C, García Rada A. Assisted dying: law and practice around the world.
BMJ. 2015;351:h4481.
3.
MIller FG. Treatment-resistant depression and physician-assisted death. JMed
Ethics. 2015;41:885–6.
4.
Kim SYH, De Vries RG, Peteet JR. Euthanasia and assisted suicide of patients with
psychiatric disorders in the Netherlands 2011 to 2014. JAMA Psychiatry. 2016;73:362–7.
5.
López-Castromán J, Nogue E, Guillaume S, Picot MC, Courtet P. Clustering suicide
attempters: impulsive-ambivalent, well-planned, or frequent. J Clin Psychiatry.
2016;77:e711–8.
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disorders or dementia in Belgium: analysis of officially reported cases. BMC Psychiatry. 2017.
doi:10.1186/s12888-017-1369-0.
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severe persistent mental illness as a new approach to psychiatry? Definition,
scope, benefits, and risks. BMC Psychiatry. 2016;16:260
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Olie E, Courtet P. The controversial issue of euthanasia in patients with
psychiatric
illness. JAMA. 2016;316:656–7.
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assisted death in the Netherlands. Psychosomatics. 2016;57:556–65.
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Thienpont L, Verhofstadt M, Van Loon T, Distelmans W, Audenaert K, De Deyn PP.
Euthanasia requests, procedures and outcomes for 100 Belgian patients suffering
from psychiatric disorders: a retrospective, descriptive study. BMJ Open.
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