PSYCHIATRY AND EUTHANASIA
Is there a world to be gained from Euthanasia in psychiatry?
Nowadays people want quality of life and to die with dignity. Protection of their “holy” life by all means possible is not what they want. That is why in 2019, 83% of Dutch citizens were in favor of their own end-of-life management. Patients with serious psychiatric disorders also sometimes ask their psychiatrist for end-of-life assistance. Unfortunately, Dutch psychiatrists are becoming more reluctant when it comes to active end-of-life care. In 1995, 47% of psychiatrists appeared willing to provide euthanasia, in 2016 this was 37%1. Why these hesitations?
A first and important issue is respecting individual autonomy in addition to the duty to protect life. Many psychiatrists who experience this dilemma hesitate to provide euthanasia.
A second problem is that, according to current Dutch Euthanasia legislation, the psychiatrist who is considering euthanasia must be certain that his patient is suffering from medically hopeless, persistent and unbearable psychological suffering. Factors are the current situation, the physical and psychological capacity and burden, the future perspective, and the personality of the patient. However, only the patient can assess his suffering, capacity, burden and non-medical hopelessness. Psychiatrists who realize this hesitate to provide euthanasia.
A third problem is distinguishing from divergent (“abnormal”; sick) to normal (not sick) on a sliding scale of accountability and liability without hard criteria. Expressing an euthanasia request, which stands alone without any psychological or psychiatric disorder, is not in itself an accepted psychiatric disorder. Serious psychopathologies are divergent, that is clear. There is a good chance that the psychiatrist defines his patient’s euthanasia request with often invalid assumptions: a person involved is “mentally ill”, has no insight into his situation, his euthanasia request is involuntary and a symptom of a treatable psychiatric disorder. However, based on these assumptions, treatment is a violation of a person’s self-determination and morally impermissible. Psychiatrists who realize this hesitate to provide euthanasia.
A fourth problem is that psychiatrists often want to use their entire arsenal of therapy before they believe that the patient has finished treatment and they look forward to new treatment options. Hoping: “Maybe there is something or something will come soon that can help the patient,” they hesitate to provide euthanasia.
A fifth problem is the threat of possible prosecution by the Public Prosecution Service, which makes the psychiatrist hesitant to provide euthanasia.
The actual psychiatric practice of euthanasia appears to be rather difficult.
Suffering from an incurable disorder, anxiety, depression, fatigue, loneliness, being unable to take care of oneself or losing meaning in life, can lead to an undesirable life. For example: a patient suffered from “ghosts and noise” in her head even in her childhood. She noticed that as her body became lighter, her mind became lighter. She was admitted at the age of sixteen with anorexia. She was in hospitals, mental health care and the psychiatric ward of a general hospital. What she never wanted happened to her there and she became very depressed. She wanted to die. In 2022 she was admitted again with a court order. She had to gain weight from 23 kilograms to 36 kilograms, then she would be mentally competent (is that scientifically justified?). Her own views and her euthanasia request were ignored. An agony. Her suffering from various psychiatric disorders was severe and unbearable, long lasting and her work, relationships, etc. were problematic. That should be sufficient for euthanasia. Psychiatric patients like her need to be helped, when they have an euthanasia request.
What does the future bring?
It is clear that in 20161 only 37% of psychiatrists were prepared to provide end-of-life care, while psychiatrists in training are much more positive: 89% accept end-of-life care for psychiatric patients; 73% consider it conceivable to one day provide euthanasia; 54% somewhat or strongly agreed with leaving end-of-life care to specifically trained psychiatrists; 73% felt that the doctor’s personal frame of reference largely determines the assessment of unbearable and hopeless suffering; 81% thought that psychiatric suffering is sometimes difficult to imagine, but should not hinder euthanasia; 67% felt that psychiatrist training pays insufficient attention to existential issues and the topic of end-of-life care.
It would be good to improve the End of Life Management component in their training. A dialogue between practicing psychiatrists and newly trained psychiatrists can lead to the improvement of psychiatric end-of-life care.
Psychiatrist Huub van Oosterom: “Offering euthanasia to a psychiatric patient with no future prospects who wants to end his or her life is… liberating. It is murderous to deprive this patient of the means to fall asleep softly and painlessly in a dignified manner.”
Wim van Dijk, psychologist.
- Euthanasia and assisted suicide in psychiatric patients; what do psychiatry residents think? – Journal of Psychiatry Issue 2019, 4, 50-11905
G.E.M. Penders, A. van Nispen tot Pannerden, G. van Loenen, S. van de Vathorst, F.M.M.A. Van der Heijden