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APA Position on Medical Euthanasia

APA Position on Medical Euthanasia

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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.”

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