Early in December 2016, the American Psychiatric Association (APA) Board of Trustees passed an historic Position Statement that originated in the Assembly and was unanimously supported by the APA Ethics Committee:
The APA, 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.
This position is now one of the strongest of any medical organization in the world regarding the practice of physician-assisted suicide by prescription medication or euthanasia by lethal injection (PAS/E) for those with non- terminal conditions. This is not just a theoretical possibility that might occur along a slippery slope following legalization of PAS/E for terminal illnesses. People with non-terminal illnesses have been legally euthanized at their own request in several countries for nearly 15 years. This has included certain eligible patients who have only psychiatric disorders.
In 2002, Belgium, the Netherlands, and Luxembourg removed any distinctions between “terminal” and “non-terminal” conditions, and between physical suffering and mental suffering, for legally permitted PAS/E. That was when patients with psychiatric disorders became eligible for this “right” in these countries. Independent consultants have to declare their condition “untreatable,” and the patient needs to declare it to be “insufferable.”
In the Netherlands, for example, for psychiatric-only cases, at least 1 consultant is required, but 3 are suggested. At least one should be a psychiatrist but does not have to be.
However, the patient can weigh in regarding the “untreatable” criterion as well. It is not based solely on what physicians have to offer, but on what the patient wishes to accept. For example, though potentially effective treatments may be offered, such as ECT, MAOIs, residential treatment, transcranial magnetic stimulation, and vagus nerve stimulation, “competent” patients may refuse these offers. That choice could make their case “untreatable.” So patients can rule on both the “untreatable” and “insufferable” axes; physicians can only opine on the former.
In the Netherlands, lethal injections are the most commonly used method to fulfill an approved patient’s death wish. This is often administered by the patient’s treating psychiatrist at home, in the office, or in specialized Levenseinde Klinieks (End of Life Clinics). Between 2008 and 2014, more than 200 psychiatric patients were euthanized by their own request in the Netherlands (1% of all euthanasia in that country): 52% had a diagnosis of personality disorder, 56% refused one or more offered treatments, and 20% had never even had an inpatient stay (one indication of previous treatment intensity). When asked the primary reason for seeking PAS/E, 66% cited “social isolation and loneliness.” Despite the legal requirement for agreement between outside consultants, for 24% of psychiatric patients euthanized, at least one outside consultant disagreed.
Some remarkable stories have been profiled in the Dutch media. For example, a woman was granted euthanasia for chronic PTSD due to childhood sexual abuse. The arguments based on personal autonomy to justify such access to PAS/E are being pushed even further in the Netherlands. Ministers of Health and Justice have proposed to their Parliament that criteria not be limited to medical conditions, but be extended to average citizens who feel they have lived “completed lives.”
Dr. Komrad is Ethicist-in-Residence for the Sheppard Pratt Health System and a Member of the APA Ethics Committee; he is also on the Faculty of Psychiatry at Johns Hopkins and the University of Maryland. Dr. Komrad’s opinions are his own, and he is not officially representing the APA in this article, nor Sheppard Pratt.
Dr. Komrad reports no conflicts of interest concerning the subject matter of this article. Dr. Komrad’s opinions are his own, and he is not officially representing the APA in this article, nor Sheppard Pratt.
For further reading
• Blake J. Man seeks euthanasia to end his sexuality struggle. June 9, 2016. http://www.bbc.com/news/world-europe-36489090. Accessed January 11, 2017.
• Emanuel E. Attitudes and practices of euthanasia and physician-assisted suicide in the United States, Canada, and Europe. JAMA. 2016;316:79-90.
• Groenewoud J, van der Heide A, Onwuteaka-Philipsen BD, et al. Clinical problems with the performance of euthanasia and physician-assisted suicide in the Netherlands. N Engl J Med. 2000;342:551-556.
• Heneghan T. Catholic nursing home fined thousands in euthanasia case. The Tablet. July 5, 2016.
• Kim S, De Vries RG, Peteet JR. Euthanasia and assisted suicide of patients with psychiatric disorders in the Netherlands 2011 to 2014. JAMA Psychiatry. 2016;73:362-368.
• Lemmens W, Lemmens T, Caplan A. The dangers of euthanasia on demand. Chicago Tribute. October 17, 2016.
• PBS. The Suicide Plan. http://www.pbs.org/wgbh/frontline/film/suicide-plan/. Frontline. Accessed January 11, 2017.
• Pies RW. Physician-assisted dying for adolescents with intractable mental illness? Psychiatric Times. May 2016;1,27-31.
• Pies RW. Physician-assisted suicide and the rise of the consumer movement. Psychiatric Times. August 2016;40-43.
• Schmidt S. Anorexic woman weighing 69 lbs has right to starve, court rules. Washington Post. November 22, 2016.
• Snijdewind M, Willems DL, Deliens L, et al. A study of the first year of the end-of-life clinic for physician-assisted dying in the Netherlands. JAMA Int Med. 2015;175:1633-1640.
• Thienpont L, Verhofstadt M, Van Loon T, et al. Euthanasia requests, procedures and outcomes for 100 Belgian patients suffering from psychiatric disorders: a retrospective, descriptive study. BMJ Open. 2015;5.
• Winter M. Deaf Belgian twins going blind choose to be euthanized. USA Today. January 14, 2013.