Euthanasia and Psychiatric Patients – A Curse in Disguise?

By Celia Esteban Serna.

On 17th December, Spanish Lawmakers passed a bill allowing euthanasia and assisted suicide. An appeal to moral philosophy to evaluate the ethics of euthanasia is beyond the scope of this article. Instead, we do so by measuring its potential impact on psychiatric clinical practice.

Some of the requirements for individuals to request euthanasia is that they must (as translated as closely as possible from the original document):

  1. Have previously and voluntarily completed two request forms, in writing or by any other means that allow for their record, which must not be the result of any external pressure, at least fifteen calendar days apart. Shall the physician consider that the loss of the applicant’s ability to provide informed consent is imminent, they may accept a shorter period deemed sensible based on the current clinical circumstances.
  2. Have provided informed consent prior to receiving assisted death. 
  3. Suffer from a serious or incurable disease, or from a severe, chronic and debilitating illness, according to the terms established in this Law, certified by the doctor in charge.

The ‘terms established in this Law’ are the following:

«Severe and incurable disease»: a condition which, by its nature, causes constant and unbearable physical or psychological suffering, with no possibility of relief, beyond what the person considers tolerable, and with a limited life prognosis, in a context of progressive frailty.

«Severe, chronic and debilitating illness»: a condition which directly affects an individual’s physical autonomy and daily activities, in such a way that they cannot fend for themselves, as well as their expressive and relational ability, and that is associated with constant and intolerable physical or psychological suffering, and that there is confidence or high likelihood that such limitations will persist over time without the possibility of a cure or noticeable improvement. Occasionally, this can involve absolute dependence on technological support.

These terms seem to have been written with a special consideration for terminal conditions. However, are they still applicable to psychiatric patients? Should they be? These considerations are not trivial. In fact, their relevance has never been more pressing, because they no longer concern hypothetical situations, but real ones. 

In countries where euthanasia has already been legalized, this procedure is being increasingly performed on individuals affected by a major psychiatric disorder. Recent Dutch data indicate that approximately 4.5% of all deaths are due to euthanasia, with psychiatric disorders accounting for 3% of the total [1]; a similar proportion has been observed in Belgium [2].

Further elucidating these data, Kim, De Vries & Peteet (2016) [3] found that, from a sample of 66 requests to the Euthanasia Expertise Centre – Netherland’s only euthanasia clinic – forty-nine reported having depression, six involved substance abuse, and other six neurocognitive impairment. Likewise, in a review of 100 individuals who requested euthanasia in Belgium, 90% reported multiple psychiatric conditions, 58% suffered from mood disorders, 12% from Asperger’s syndrome, 10% from eating disorders, and 7% from dissociative disorders [4].

Eligibility criteria for assisted suicide seem to be blurry when it comes to psychiatric disorders. In turn, this contributes to its use in questionable cases. Indeed, several difficulties arise when attempting to determine whether a condition is ‘unbearable’. Firstly, this is not easily objectively determined. Thus, taking the applicant’s assertion at face value seems to be the only alternative. However, depression and other mental disorders are often linked with hopelessness, which intensifies the individual’s subjective distress. That is, the perceived intolerability of suffering may be a symptom of an underlying disorder, rather than a reflection of the patient’s independent judgment [5] [6] [7].

Establishing whether a person is eligible for euthanasia, then, must be done on the grounds that the psychiatric disorder is “untreatable” or that there is “no prospect of improvement”. Unfortunately, only few patients will have tried every possible treatment option – psychological, pharmacological, or other –, and it could be the case that some approach which remains untried might be effective. Nonetheless, the Law also states that only treatments acceptable to the applicant should be considered when determining treatability. Untreatability, therefore, also becomes subjectively determined by a patient whose judgement could, yet again, be biased by helplessness, and thereby concludes that no untried options are acceptable because none of them are likely to work.

In conclusion, this law has been celebrated widely, for giving individuals a right to ‘freedom of choice’ and a ‘dignified death’. However, it is worth considering if that is also the case for individuals with mental disorders, whose conditions often make them highly reactive to life stresses. That this population disproportionately seeks assisted suicide should, within a socioeconomic system which values individuals for their productivity, raise the alarm that euthanasia is not but eugenics disguised as progress.

Celia is currently studying MSc Psychology and Language Sciences at UCL. Her other written pieces include ‘How “Evidence-Based” Medicine Made Us Believe That Love was A Drug‘.

REFERENCES

[1] van der Heide, A., van Delden, J.J.M., Onwuteaka-Philipsen, B.D. (2017) End-of-Life Decisions in the Netherlands over 25 Years. The New England Journal of Medicine, 377(5), 492-494.

[2] Verhofstadt, M., Thienpont, L., & Peters, G. Y. (2017). When unbearable suffering incites psychiatric patients to request euthanasia: qualitative study. The British journal of psychiatry: the journal of mental science211(4), 238–245.

[3] Kim, S. Y., De Vries, R. G., & Peteet, J. R. (2016). Euthanasia and Assisted Suicide of Patients With Psychiatric Disorders in the Netherlands 2011 to 2014. JAMA psychiatry73(4), 362–368. 

[4] Thienpont, L., Verhofstadt, M., Van Loon, T., Distelmans, W., Audenaert, K., & De Deyn, P. P. (2015). Euthanasia requests, procedures and outcomes for 100 Belgian patients suffering from psychiatric disorders: a retrospective, descriptive study. British Medical Journal Open5(7).

[5] Deschepper R., Distelmans, W., & Bilsen, J. Requests for euthanasia/physicianassisted suicide on the basis of mental suffering. Vulnerable patients or vulnerable physicians? JAMA Psychiatry, 71, 617–618.

[6] Owen, G.S., Richardson, G., David, A.S., Szmukler, G., Hayward, P., & Hotopf, M. (2008). Mental capacity to make decisions on treatment in people admitted to psychiatric hospitals: cross sectional study. British Medical Journal, 337.

[7] Tomlinson, E., & Stott, J. (2015). Assisted dying in dementia: a systematic review of the international literature on the attitudes of health professionals, patients, carers and the public, and the factors associated with these. International Journal of Geriatric Psychiatry, 30, 10–20.

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