A Suicide Right for the Mentally Ill? A Swiss Case Opens a New Debate

Jacob M. Appel

The Hastings Center Report. 2007;37(3):21-23. 

Advocates for the legalization of assisted suicide in the United States, including those who sponsored Oregon's Death with Dignity Act in 1994 and current backers of California's proposed Compassionate Choices Act, have sought to permit the practice only under highly limited circumstances—namely, when the requesting patient is terminally ill.[1] In contrast, the Netherlands allows physician-assisted suicide in nonterminal cases of "lasting and unbearable" suffering, and Belgium authorizes physician-assisted suicide for nonterminal patients when their suffering is "constant" and "cannot be alleviated."[2] Yet no country has laws on the subject as liberal as those of Switzerland, where assisted suicide has been legal since 1918. It remains the only jurisdiction that allows nonresidents to terminate their own lives.[3] It is also the only jurisdiction that does not require that a physician be involved in the process.

Now, a recent decision by the Swiss Federal Supreme Court threatens to undermine yet another longstanding taboo in the debate over assisted suicide and euthanasia. In its ruling on November 3, 2006, the high tribunal in Lausanne laid out guidelines under which, for the first time, assisted suicide will be available to psychiatric patients and others with mental illness.[4]

The case was that of an unnamed fifty-three-year-old manic depressive with two prior suicide attempts who sought a prescription for fifteen grams of sodium pentobarbital in order to end his own life.[5] He claimed a right to self-determination under Article 8 of the European Convention on Human Rights and alleged that no physician would prescribe him this lethal dose for fear of legal or professional repercussions.[6] Dignitas, a Zurich-based advocacy group, supported his suit. The Swiss high court responded with a sweeping opinion upholding the right of those suffering from "incurable, permanent, severe psychological disorders" to terminate their own lives.[7] According to the court, a distinction should be made between temporarily impaired individuals who wish to die as "an expression of treatable psychological disturbances" and those individuals with severe, long-term mental illness who have made "rational" and "well-considered" decisions to end their lives to avoid further suffering.[8] Since serious mental disorders could make life seem as unbearable to some patients as serious somatic ailments do to others, the court reasoned, those who repeatedly expressed a wish to end their lives under such circumstances should be permitted to do so. (The court also ruled that the plaintiff in this case would have to obtain a thorough psychiatric evaluation to determine whether he met these standards before he could end his life.)

Both supporters and opponents of assisted suicide have been highly critical of extending suicide rights to psychiatric patients.[9] One set of objections is directed against the practice of assisted suicide itself—for a host of reasons ranging from a belief in the inherent sanctity of human life to a fear of sliding down a slippery slope toward involuntary euthanasia; that debate has been extensively addressed elsewhere. Another set of objections are from those who support a basic right to assisted suicide in certain situations, such as those of terminal disease, but do not wish to extend it to cases of severe and incurable mental illness. This resistance may be inevitable, considering the increased emphasis that contemporary psychiatry places on suicide prevention, but the principles favoring legal assisted suicide lead logically to the extension of these rights to some mentally ill patients.[10]

At the core of the argument supporting assisted suicide are the twin goals of maximizing individual autonomy and minimizing human suffering. Patients, advocates believe, should be able to control the decision of when to end their own lives, and they should be able to avoid unwanted distress, both physical and psychological. While these two principles might explain why a victim of amyotrophic lateral sclerosis or cancer would choose assisted suicide, they apply equally well in many cases of purely psychological disease: a victim of repeated bouts of severe depression, particularly in cases where treatment has consistently proven ineffective, rationally might prefer dignified death over future suffering.

Obviously, there is a difference in kind between the terminally ill cancer patient and the acutely depressed teenager who transiently desires to end his life after a romantic setback; it seems logical to prevent patients from committing suicide until they have considered all of their options over an extended period of time, and to be certain that they are not acting in haste. But the difference between a patient who desires suicide after enduring the long-term agonies of rheumatoid arthritis or trigeminal neuralgia and the patient who wants to end his life after years of debilitating anxiety or intermittent psychotic episodes is not so clear.

One crucial distinction between chronic mental illness and terminal disease is that death is inevitable in the latter cases. Yet "inevitable" is really not quite right. From today's vantage point, a rapid cure for ALS or certain cancers appears highly unlikely, yet the history of modern medicine is replete with examples of illnesses (type I diabetes, acute lymphoblastic leukaemia, choriocarcinoma) that have rapidly gone from universally fatal to highly manageable. What we really mean when we speak of inevitability is that we believe the patient should be able to weigh the unlikely possibility of a cure against her other interests. While the window of opportunity for discovering effective treatment may be longer in cases of chronic mental illness, it seems reasonable to afford the patient the same choice in balancing likelihoods against other values. And if the offer is that an effective treatment may eventually be found, but a person will have to suffer for some decades more until that happens, then it might still be rational to prefer suicide.

A second concern in cases of mental illness is that of the competence of the decision-maker. For example, a severely depressed patient might substantially underestimate her long-term prognosis. But rather than arguing against assisted suicide, this might indicate even further the depth of the patient's present suffering. Clearly, patients who experience psychosis or are incapable of making general medical decisions should not be able to take their own lives until they can think rationally. Morever, the finality of a life-terminating decision indicates that a higher threshold of competence should be required in suicide cases than in more run-of-the-mill health care choices. But one can be both deeply depressed and capable of making rational decisions. If the values championed by assisted suicide advocates are maximization of autonomy and minimization of suffering—even when they conflict with the extension of life—then it follows that chronically depressed, competent individuals would be ideal candidates for the procedure. At the very least, a patient with a history of mental illness who is currently experiencing a temporary remission of symptoms will certainly be competent enough to make such a choice before the return of the disease. (An additional concern might be the increased suffering endured by families of assisted suicide victims—but why this suffering should trump that of the patient is not clear.)

The most compelling argument against extending assisted suicide rights to the mentally ill relates to the role of physicians. The nature of psychiatric therapy differs from that of other medical treatment in the degree of attachment between caregiver and patient. This distinction is recognized in various regulatory codes, and most glaringly in the rules banning romantic relations between psychiatrists and former patients, even many years after care has ceased. Moreover, psychiatrists are trained to prevent suicide—an outcome widely regarded by the profession as a failure. This conflict of interest places the psychiatrist in the unpleasant bind of choosing between a patient's wish and the standard of care in the field. Psychiatrists might even attempt to avoid treating such rational but chronically suicidal patients in an effort to avoid this choice. Any meaningful discussion of the subject of assisted suicide for the mentally ill should include an exploration of alternative mechanisms by which such patients might obtain help in ending their lives, possibly including the use of full-time thanatologists specially trained for the act.

Most likely, the taboo against assisted suicide for the mentally ill is a well-meaning yet misplaced response to the long history of mistreatment that those with psychiatric illness have endured in western societies. Psychiatrists and mental health advocates may fear that their patients will be coerced to "choose death" against their wishes, or that, once suicide is an acceptable option, the care for those who reject assisted suicide will be diminished. But as the plaintiff argued before the Swiss high court, in challenging "medical paternalism," we are entering an era during which psychiatric patients do not need to be protected, but empowered.[11] Our goal should be to maximize the options available to the mentally ill.

The Swiss case is not the first in which a nation's high court has suggested a right to suicide for those with mood disorders. In 1993, the Dutch Supreme Court refused to impose a penalty on psychiatrist Boudewijn Chabot for assisting in the suicide of his patient, Hilly Bosscher, a chronically depressed fifty-year-old woman who insisted she did not wish to continue living after the death of both of her adult sons.[12] Boudewijn nevertheless received a reprimand from his local medical disciplinary tribunal, creating a strong civil deterrent for others to follow his lead.[13] The Bosscher case arose when the euthanasia movement was still in its infancy, however. Since assisted suicide for the terminally ill was itself taboo fifteen years ago, it was unrealistic to expect that a mainstream debate would arise over the issue of suicide rights for psychiatric patients. But now that several Western nations and one U.S. state have liberalized their laws, it seems reasonable to question the policies that universally deny such a basic opportunity to the mentally ill.

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