Psychiatric euthanasia: salvos across the Atlantic

The development of the idea and then the availability of euthanasia for psychiatric reasons is something that few people, if any, could have foreseen when Belgium and Holland passed their laws in 2001 and 2002 or when the short-lived law existed in the Northern Territory of Australia in the mid 1990s.

Certainly, commentary existed regarding concerns of competency (capacity) and the presence of depression etc. in people requesting euthanasia - where psychiatry had a legitimate role; but this was always in the context of assessment of a person who 'qualified' or was eligible for euthanasia by virtue of other criteria (such as a terminal illness or the presence of 'untreatable' or 'incurable and irreversible' suffering due to illness or injury). It was never that the 'illness' was itself psychological in nature.

The Belgian act of 2002 states that:

"The patient is in a medically futile condition of constant and unbearable physical or mental suffering that can not be alleviated, resulting from a serious and incurable disorder caused by illness or accident."

Mental suffering, or what we would call psychological suffering is clearly included here, but the 'serious and incurable disorder' that is the underlying cause of the 'physical or mental suffering' is listed as being 'caused by illness or accident'. The reference is, therefore, to the presence of psychological suffering as a result of illness or accident.

In recent years, the approval of euthanasia for psychiatric reasons has been noted in both Belgium and Holland to the point where the Euthanasia Evaluation Commission in Belgium has created a separate category in its summary reports to reflect this development. In December 2015, 65 Belgian professors, psychologists and psychiatrists published an open letter entitled: Death as therapy? raising their concerns about these developments and arguing that the Belgian law should be changed to exclude euthanasia for psychiatric reasons.

The letter outlines the very real difference between an illness that results in psychological suffering and psychological illness as the prime reason for euthanasia:

"(W)e want to draw attention to its specific problematic character, and in particular the fact that it's impossible to objectify the hopelessness of psychological suffering.

"One would expect that this incurability is founded on indications of for example, organic injury or tissue damage - in other words, factors that are independent of what is subjectively felt and thought about the illness. Such objectification is problematic in relation to psychological suffering.

"Let's be clear: psychological suffering is real and can be at least as severe as physical suffering. However, specific to mental suffering is the fact that you can rely only on the word of the sufferer to estimate it. And this is a good thing, because he or she is the only one who knows how much it hurts at that moment. At that moment… because when we suffer psychologically, we are often convinced that no other future is possible anymore. It is often precisely this thought that pushes a person into an abyss, because as long as there is perspective, a person can usually tolerate much."

Belgian psychiatrist, Dr Lieve Thienpont & Prof Wim Distelmans et al published a research paper in May 2015 looking into 100 applications for euthanasia for psychiatric reasons; cases that Thienpont she was intrinsically involved in.

As Alex Schadenberg observed at the time: 'This may be the first study to examine the experience with euthanasia for psychological pain, but it is also a study that appears to have been done to create more acceptance of euthanasia for psychiatric reasons.'

Thienpont, commenting in The Knack last week in defence of her work, is now claiming that 'Just to have the ability (to be approved for euthanasia), adds quality to life...perhaps even adds a little life too." She later talks in the same article about organising a group whereby people making such a request can be 'inspire(d)...towards life'. A noble and proper pursuit. However, she provides the rider that 'we must first take seriously their demand for euthanasia.'

What is she really saying here? It seems to me that she is creating a series of false binary options. She is implicity suggesting that psychiatrists don't take seriously their patients' death wishes and that, secondly, only by entertaining the possibility (read: possibly approving euthanasia) can the patient come to a place where other options become possible. This is not the first reference in discussions on euthanasia where the idea of access being considered as therapeutic has been raised and it will likely not be the last; but it is nevertheless a false dichotomy. It is a slight upon her colleagues and her profession.

But, internationally, psychiatrists have not been silent on this matter. Earlier this month the American Psychiatric Association made waves across the Atlantic by declaring an official policy position:

The American Psychiatric Association, in concert with the American Medical Association's position on Medical Euthanasia, holds that a psychiatrist should not prescribe or administer any intervention to a non-terminally ill person for the purpose of causing death.

The timing of the statement will hopefully provide a caution to the Canadian Government who have just announced a study into the possible inclusion of euthanasia for psychiatric reasons - a decision that was codified in their assisted suicide laws passed there barely six months ago as a compromise position.

It is also seen as setting the ground for 'possible direct organisational protest by American psychiatrists to their Belgian and Dutch colleagues', according to Charles Lane of the Washington Post. 'The logical next step in the APA's welcome assertion of what should be a global ethical principle'.

Logical and welcome as it certainly is, the news has not been received well in Belgium. Health Minister, Maggie De Block told The Knack quite simply that, 'I do not see what this debate has to do with Americans.'

Also returning fire, President of the Flemish Association of Psychiatry, Prof. Frieda Matthys said that, 'Americans have nothing to do with the debate with us. Maybe they should but first sweep for its own door.' (Ouch!)

It's not the first time that the Low Countries have reacted that way when the international focus has drawn down on problems with their euthanasia laws. The Dutch and Belgians pride themselves on 'serene debate', doing things 'carefully' and 'diligently' and seem genuinely perplexed when criticism arises.

The question is: Is this criticism valid? Put aside the centuries of divergent cultural and social development and consider if it is appropriate for psychiatrists to kill or at least process the killing option for their patients who have no physical deterioration and for whom the very notion of hopelessness is changable?

Mark Komrad, a member of the ethics committee of the APA sees psychiatric euthanasia as 'a fundamental inversion of our mission and duty as psychiatrist'. "We must help people deal with their suffering and treat that suffering. Moreover, this goes right against what public health requires is to do, namely, reduce the number of suicides. We can not use suicide as a treatment anyway."

Will this debate develop beyond this 'serve - return' game across the Atlantic? Belgian academics Ariane Bazan, Professor of Clinical Psychology (ULB), Willem Lemmens, Professor of Ethics and Modern Philosophy (UA) and Gertrudis Van de Vijver professor of Modern and Contemporary Philosophy (University of Ghent) urged policy makers to take these concerns seriously in a letter published in De Morgen in November:

"Euthanasia in purely psychological suffering introduced in mental health care a medical-cultural revolution without precedent. We urge policymakers to take our concerns seriously and to reflect thoroughly on the current practice of euthanasia for purely psychological suffering."

Senior physician and fellow psychiatrist at the Psychiatric Clinic Alexianen in Tienen, An Haekens, is somewhat sceptical:

"The debate is very spoiled. Who dares to criticize the legislation is quickly dismissed as a conservative, Catholic or extremely disrespectful to the suffering of patients. Also, people who have nothing in principle against euthanasia, to criticize them for questioning."

The Knack editorial gives Haekens an important last word:

The inevitable point remains that euthanasia is irreversible. Therefore Haekens finds it problematic that (the cases) are now only evaluated after the euthanasia was performed. "There is obviously a check: the patient must find a second and third doctor to give permission. But this is not so difficult: the doctors who are sympathetic are known.

See also:

Euthanasia for purely psychological suffering: reflections on the Belgian report.
Belgian professionals speak out against euthanasia for psychological suffering
Belgium: Experts call for the removal of euthanasia on the grounds of psychological suffering
The 'end of the therapeutic path': supporting suicide in disguise
Study: 100 requests for euthanasia for psychiatric reasons in Belgium.
Euthanasia's open season on the mentally ill
Canada: Euthanasia for minors, for mental health reasons and via directives may now be on the table. 

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