From 2014 to 2015, 124 patients in Belgium were euthanized at their own request for psychiatric disorders. These patients had a wide range of psychiatric disorders: 4% had schizophrenia; 6%, bipolar; 4%, autism; 23%, dementia; 31%, depression; and 32%, personality disorders (half of which were borderline disorder). In one Belgian series that covered 2007 to 2011, diagnoses also included substance abuse, autistic spectrum disorder, OCD, ADHD, dissociative disorder, and “complicated grief.”
Supporters of these laws argue that many who were granted permission for euthanasia did not end up using it. Advocates suggest that this makes the “treatment plan” of euthanasia paradoxically lifesaving. If allowed to peer over the edge of the abyss in this sanctioned way, some choose life, knowing that an exit option is within legal reach, should they choose to use it. There is the implication —unsupported by data —that this program can reduce suicides (that are said to be characterized by much greater misadventure and shock to families).
Prominent cases profiled in the Belgian media include a pair of deaf twins euthanized on request because they were going blind, a man with gender identity disorder who was unhappy with surgical results, and another man who sought euthanasia for ego-dystonic homosexuality. Although participation by health care systems is optional, there can be consequences for not cooperating. For example, a Catholic nursing home in Belgium was fined for prohibiting a physician from entering to administer an approved lethal injection to a resident.
In the spring of 2016, at the instructions of their Supreme Court, the Canadian Parliament followed the course of these European countries. Physician-assisted suicide was legalized nationally, and terminal/non-terminal and physical/mental suffering distinctions were effaced. As in Europe, Canadian patients can refuse treatments that might forestall death —and still be eligible. However, thanks to the influence of the Prime Minister, Parliament stopped short of enacting its original intention to allow this for people with only psychiatric disorders.
Not surprisingly, several cases of psychiatric patients are working their way through the Canadian courts, demanding that there be no such discrimination for psychiatric patients. One case that received particular attention was a woman with chronic conversion disorder, who successfully fought in the courts to overrule the proscription on PAS/E for psychiatric disorders in her case. Several psychiatrists supported her pursuit of this action. So that legal precedent is now in place in Canada.
In the US, the states that permit assisted suicide by physician-prescribed medication are Oregon, Washington, California, Montana, Vermont, and Colorado. Washington, DC, just passed a law pending implementation. Unlike the European countries and Canada, eligible patients must be “terminally ill” (generally agreed as predicted death within 6 months, independent of treatment). There are advocates who are asking for the non-terminally ill to be considered eligible, including psychiatric patients. They argue from the position of parity, nondiscrimination, and other tropes embedded in mental health and disability advocacy. As documented by PBS Frontline, suicide “assistance” organizations, such as the Final Exit Network, have helped psychiatric patients to suicide, with helium-mask techniques.
Even with current laws, there are emerging regulations that directly affect psychiatric patients in those states that allow assisted suicide. The California Department of Mental Health has adopted a regulation that requires state psychiatric hospitals to provide assisted suicide services to committed patients, if terminally ill. Under this regulation, a court hearing must be held to determine whether the patient is qualified for release to obtain physician-assisted death, even over clinically based objections of the treating psychiatrist. If a patient is deemed eligible, and no outside physicians can be located, the facility must provide fatal care itself, within the hospital. Unlike refusing treatment for mental disorders, committed inpatients’ competent refusal of treatment for medical disorders (eg, diabetes) cannot be overridden, even if refusal may result in death —thus rendering their condition “terminal.”
In November 2016, a judge (who poignantly had represented Karen Ann Quinlan in 1976) ruled that a woman with chronic anorexia was competent to refuse treatment, with the likelihood that such refusal would lead quickly to her death. Arguments of experts were rejected: that her refusal was a symptom of the very illness that needed treatment, disqualifying her for this “passive voluntary euthanasia.” This opens the door in the US for other kinds of psychiatric conditions to go untreated, although they may be associated with poor insight and treatment refusal, even if the predicted outcome of non-treatment is death.
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.