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Euthanasia for ‘untreatable’ mental illness raises ethical concerns

Posted on 04-10-16 in Mental Health

Euthanasia for ‘untreatable’ mental illness raises ethical concerns

Euthanasia is becoming acceptable in countries around the world for the terminally ill to spare them unbearable suffering. Lately, even people with excruciating emotional pain due to psychiatric conditions have the option of physician-assisted suicide in the Netherlands. The topic is controversial for obvious reasons, but an exploration of the research data helps illuminate an otherwise dark subject.

Euthanasia or assisted suicide in the Netherlands

Euthanasia or assisted suicide (EAS) has been in practice in the Netherlands for decades, though formal legislation was not established until the Termination of Life on Request and Assisted Suicide Act was enacted in 2002. In 2012, a mobile end-of-life clinic was established by a Dutch euthanasia advocacy program to bring EAS to patients whose own physicians refused to perform the procedure.

The Dutch euthanasia and physician-assisted suicide due care criteria apply to either physical or psychological conditions. Physicians in the Netherlands performing EAS must ensure the following:

  1. The patient’s request is voluntary and certain
  2. The suffering is unbearable and untreatable
  3. The patient is informed of prognosis
  4. The physician and patient agree there is no reasonable alternative
  5. Another physician who has seen and written a report on the patient agrees
  6. Due medical care and attention is given during the procedure

Understanding the research

In a study published in the April 2016 issue of JAMA Psychiatry, investigators reviewed the case summaries of 66 patients who requested and were granted EAS for psychiatric indications. Most patients were women (70 percent), age 30 years and older, who had histories of psychiatric hospitalizations and suicide attempts. Most were described as isolated or lonely and had physical disabilities as well. Most had personality disorders and 55 percent had depression. Other conditions included psychosis, post-traumatic stress disorder, anxiety, eating disorders, prolonged grief and autism.

Physicians performed the life-ending procedures, 41 percent of whom were psychiatrists. Fourteen were physicians from the End-of-Life Clinic, a mobile euthanasia unit. Consultations among physicians were extensive and 24 percent of them involved disagreement among consultants. The ultimate decision was deferred to the physician performing the procedure. One case failed to meet legal criteria under retrospective review. Conclusions were difficult to draw from this study.

An editorial by Paul Applebaum, M.D., in the same issue of JAMA Psychiatry highlighted a few areas of concern, based on details from the Dutch study. First, some patients had diagnoses that were transient in nature, like depression and substance abuse, or reflected cognitive impairment that could affect decision-making, like neurocognitive problems and autism. Next, having many patients with social isolation and loneliness raised the concern that EAS was being used as a substitute for psychosocial intervention and support. Also, physician evaluators, who did not know the patients, were making decisions on whether or not they were treatable. Applebaum specifically expressed concern over the 12 percent of cases in which the patients’ psychiatrists did not believe euthanasia criteria were met, but these deaths took place anyway.

Medically assisted suicide in the United States

Today, five U.S. states allow EAS and many have proposed bills to legalize it. But U.S. laws regarding EAS differ from the Netherlands in several fundamental ways. First, mental illness is not considered a terminal illness and cannot be used as grounds for EAS. Even those who qualify due to a terminal physical illness cannot get EAS if they also have a mental illness, because impaired judgment is assumed, which is a whole separate controversy. Also, in the Netherlands, physicians perform the EAS procedure but, in the U.S., physicians only provide the prescription for the medication to the patient and/or his or her family. Only in Oregon are physicians required to attend the procedure but, in other states, health care providers must not have any involvement other than providing the prescription. In the U.S., patients must be terminal with an expectation of less than six months to live.

Protecting the future

Current legislative efforts that aim to transfer medical decision-making rights from families to states on other issues raise even greater concern with the legalization of medically assisted euthanasia in this country. As with any new piece of legislation, citizens must be extremely vigilant to possible changes to their rights regarding health care policies before such changes become the rule of law.

“Experience in The Netherlands, where there has been relatively little effort to improve pain and symptom treatment, suggests that legalization of physician-assisted suicide might weaken society’s resolve to expand services and resources aimed at caring for the dying patient.”

— “Treatment of Pain at the End of Life, A Position Statement from the American Pain Society

Finding hope

At Sovereign Health, we believe that all psychiatric disorders are treatable and that all human beings have the capacity to recover with proper care. We tirelessly strive to bring the newest, most effective treatments to clients struggling with mental illness, substance use disorders and dual diagnosis. Our multimodal diagnostic assessment and treatment approaches have been successful with the most challenging cases. After treatment, our continuing care program provides the long-term support clients need to fully recover from addiction and all of its consequences. To find out more about specialized programs at Sovereign Health, please call us at our 24/7 helpline.

About the author

Dana Connolly, Ph.D., is a senior staff writer for the Sovereign Health Group, where she translates current research into practical information. She earned her Ph.D. in research and theory development from New York University and has decades of experience in clinical care, medical research and health education. The Sovereign Health Group is a health information resource and Dr. Connolly helps to ensure excellence in our model. For more information and other inquiries about this article, contact the author at