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05/12/2016

Euthanasia for Reasons of Mental Health

by Craig Klugman, Ph.D.

An article in the (UK) Daily Mail this week focused on a Dutch woman who chose euthanasia “after doctors decided her post-traumatic stress and other conditions were incurable.” Under Dutch euthanasia laws, a physician can end a patient’s life with a lethal injection for mental suffering. Her life was ended last year.

Euthanasia is when a physician delivers the substance that ends a patient’s life. This is distinct from physician/doctor/provider-assisted suicide (often called aid-in-dying) where a physician makes the means to end life available (often through a prescription) but the patient must ingest the life-ending medication. Such laws began as ways for people facing terminal illnesses to end their lives in order to avoid physical pain and suffering. In all 5 U.S. states that allow some form of aid-in-dying it is only available to adults who are mentally competent and terminally ill. No U.S. state permits euthanasia.

In other countries such as Belgium and the Netherlands, aid-in-dying has been broadened to euthanasia for those who cannot take their own lives (they make be unable to swallow or lack the mobility to ingest medication or flip a switch on a “suicide machine.”). In some cases euthanasia has been done to those who lack competency such as “children [who] are occasionally born with such serious disorders that termination of life is regarded as the best option.” In that case, both the physician and the parent must agree on the prognosis and lack of “reasonable alternative solution,” as part of the Groningen Protocol. In 2014, the Dutch law was amended to include emancipated children with terminal illnesses.

In the case cited in The Daily Mail, the reason for the woman’s request was unbearable mental suffering that had failed to respond to treatment. The woman had been sexually abused as a child and for the last two years had been treated with “intense therapy.” As reported by the Daily Mail, she suffered from a host of mental illnesses including anorexia, depression, suicidal thinking, hallucinations, and obsessions. According to the law, “Requests for euthanasia often come from patients experiencing unbearable suffering with no prospect of improvement.”

Euthanasia in the Netherlands has been legal since 2002. In 2015, Dutch doctors helped 5,561 people die (5,306 in 2014; 4,829 in 2013). Technically, euthanasia, when carried out under the law, provides the physician immunity from prosecution, but any irregularity in following the law could lead to criminal charges. The physician

  1. must be convinced that it concerns a voluntary and well considered request
  2. must be convinced that it concerns unbearable and hopeless suffering of a patient
  3. has informed the patient about the medical condition and the options
  4. has concluded with the patient that there are no reasonable alternatives for the situation of the patient
  5. has consulted with at least one other physician independent of the case, who has seen the patient and has given his conclusions in writing with respect to the above conditions and has carried out the life ending intervention or assisted suicide in a medically correct way

Critics of euthanasia and the law have expressed concern that the inclusion of those suffering from mental illness or dementia (as well as newborns with serious conditions) is a slippery slope that avoids trying to help people. For example, in 2013, a physician euthanized a 44-year-old trans-man who had a “botched sex change operation” that left him a “monster.” According to conservative bioethicist Wesley Smith, “A morally sane country would strip [the physician]of his license to practice medicine and prosecute him for murder.” For Smith, the possibility of ending the life of someone for mental suffering (or for any reason) is unacceptable. Ending another person’s life, from this perspective, is simply murder.

In a 2015 Belgian study, researchers examined the cases of 100 psychiatric patients who requested euthanasia for their suffering. They found that the most common reasons to request euthanasia were depression and personality disorders. Testing found that 38% had autism spectrum disorders. “In total, 48 of the euthanasia requests were accepted and 35 were carried out.” Eight cancelled their procedure (knowing it was available provided a piece of mind). An additional 8 people died through suicide, palliative sedation and anorexia nervosa.

A more recent article looked at the Netherlands and found 66 cases of patients receiving euthanasia for psychiatric illness. Most were women with complicated and long health histories including suicide attempts and hospitalizations for mental illness. Like the Belgian study, depression was the major disease through posttraumatic stress was another disease of some patients. Psychiatrists, other physicians, and even a mobile euthanasia clinic carried out most of the deaths. In most cases (but not all), there was consultation with other physicians but not all physicians on any given case were in agreement that the legal criteria for euthanasia were met.

Without knowing about the Dutch woman’s history in the first article, or her relationship to her care providers, certain answers can’t be known, such as “why” and “were all possible courses of action exhausted.” If one of the requirements for euthanasia is being competent and capacitated, one could ask if there was an assessment of these qualities in requesting patients with a psychiatric illness (or a physical illness). Can anyone truly understand the notion of their own non-existence, nevermind consent for it? And what about the social pressures that push people to this point—lack of resources and assistance for those with mental illness, not wanting to be a burden to a family, and a society that is set up in such a way that people with such diseases see no other way forward.

On the proponent side, the Dutch law recognizes that mental suffering can be as harmful and damaging as physical pain. Thus, unlike most health care systems, mental and physical health have equal standing. Some view these laws as expansions of patient’s right to autonomy. Others have suggested that this is an overreach of physician authority and are not in line with the role of physician as healer.

While some sensational headlines have tried to stir up fear that euthanasia was expanding everywhere, that it would apply to more people, and that it would be required by government death panels, expansion has been slow. While aid-in-dying may be gaining ground in the U.S. (and that could change with a new presidential administration that cracks down on rogue states in this matter), euthanasia is still illegal in all of North America. Whether an exercise in autonomy or a call for help in a broken system that can’t help those with mental illness, one question has not been asked: What is the state’s interest in preventing consenting people from having help in ending their lives? In legal history, there is an acknowledged state interest in protecting human life—this is the justification for laws against child and elder abuse. This has also been supported in the philosophy of Locke, Hegel, and Hobbes.

If there is a decision that euthanasia is sometimes acceptable, then there is also the question of who would and should carry out these deaths. Physicians? Some new health care profession? Certainly the European experiment in euthanasia will be telling as well assisted suicide programs in the U.S. Wherever the sand my settle, looking at the data and having the debate is important, more important than being swayed by fancy and inflammatory headlines written to increase clicks.

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