Assisted Suicide for Mental Illness Gaining Ground

Nancy A. Melville

July 31, 2015

A first-of-its-kind report offers insights into the characteristics and outcomes of requests for euthanasia on the grounds of suffering related to psychiatric illness in Belgium, where it is legal in that country.

"This retrospective study draws attention to and deepens our understanding of the circumstances of a rather small but severely afflicted subgroup of psychiatric patients," the study authors, led by Lieve Thienpont, PhD, of University Hospital, in Brussels, Belgium, write.

Euthanasia (referred to as assisted suicide in the Netherlands and Luxembourg, where it is also legal in cases involving suffering due to medical and psychiatric illness) has been legal since 2002 in Belgium, and the law was extended in 2014 to include emancipated children with suffering due to terminal illness.

Through a required process, patients must show their illness to cause "unbearable or untreatable suffering"; however, the definition is acknowledged to be subjective, Dr Thienpont told Medscape Medical News.

"By its nature, the extent to which the suffering is unbearable must be determined from the perspective of the patient him- or herself and may depend on his or her physical and mental strength and personality," said Dr Thienpont.

The study was published online July 27 in BMJ Open.

"Unbearable" Suffering

To better understand the characteristics of euthanasia requests due to mental illness, Dr Thienpont and colleagues evaluated 100 consecutive requests that were based on suffering associated with psychiatric disorders between October 2007 and December 2011.

The patients included 77 women and 23 men (mean age, 47 years; range, 21 - 80 years).

About half (48) of the requests were accepted, and 35 were carried out. Among the remaining 13 requests that were approved, eight patients either postponed or canceled the procedure on the grounds that "simply having this option gave them enough peace of mind to continue living," the authors report.

As of a follow-up in December 2012, six patients whose requests had not been approved died as the result of suicide, one of palliative sedation and one of anorexia nervosa.

Most of the 100 patients (91) had been referred to either psychiatric counseling or counseling in a program called the Life End Information Forum.

Ninety of the 100 patients had more than one disorder; the most common diagnoses were depression (n = 58) and personality disorder (n = 50). Thirteen of the patients were tested for autistic spectrum disorders, and 12 were diagnosed with Asperger's syndrome.

Seventy-three of the patients had been deemed medically unfit to work, and 59 were living alone.

The analysis is the first report of a relatively large series of requests for euthanasia on the grounds of mental health suffering, Dr Thienpont said.

"We found that when considering patients' demands seriously, most do find a way to continue with their life," Dr Thienpont said.

"We also found that some patients postpone or cancel their euthanasia request or procedure themselves, saying that knowing they have the option to proceed with euthanasia gave them sufficient peace of mind to continue living."

"For those who do not find a solution for their suffering, and there are no further (reasonable) treatment options available, we do proceed with the euthanasia process with maximum care for dying in dignity."

Under the Belgian euthanasia law, 2086 patients died between 2010 and 2011 after their euthanasia requests were granted; the deaths represent 1% of all deaths in Belgium during the 2-year period. Among the euthanasia deaths, 58 (2.8%) were related to neuropsychiatric disorders.

The rates reflect a steady increase from just 742 in 2004-2005, which included only 9 (1.2%) for neuropsychiatric disorders.

The authors note that "this rise over a 6-year period may reflect a true increase or better reporting of cases of euthanasia."

There were no proportionate differences in terms of sex, age, diagnoses, or the nature of the patients' suffering during the period.

The male-female ratio between 2008 and 2011 was 51:49. Two percent of these deaths involved patients aged 20 to 39 years; 21.5% were aged 40 to 59 years: 51.5% were aged 60 to 79 years; and 25% were aged 80 years or older.

Sodium thiopental, a barbiturate, was the life-ending drug used in the vast majority of cases, the authors reported.

Under the law, a request for euthanasia must be made in writing by an adult or emancipated minor who is legally competent and conscious and who is in untreatable and unbearable suffering with no prospect of improvement.

The request must be confirmed by two physicians. If the patient is not expected to die in the near future, advice is required from a third physician who is a psychiatrist or medical specialist in the patient's disorder. The physicians and patient must all conclude that there is no reasonable alternative remaining to relieve the patient's suffering.

Opponents of the law argued during its deliberation that the primary purpose of psychiatric care should be the prevention of suicide, but the opposing argument that the suffering of psychiatric patients is as "unbearable" as the suffering of patients with other medical conditions prevailed.

"A Bridge Too Far"

According to medical ethicist Kenneth W. Goodman, PhD, professor and director of the Institute for Bioethics and Health Policy at the University of Miami Miller School of Medicine, in Florida, the findings underscore some of the troubling aspects of including psychiatric illness as a reason for euthanasia.

"What this study makes clear is the need for more research on the question whether a terminal illness should be a precondition for euthanasia or, as in Oregon, physician-assisted suicide," he told Medscape Medical News.

"Although psychological pain can hurt just as much as physical pain, my fear is that the planned death of psychiatric patients represents a failure of treatment; perhaps more or better treatment would work."

The suggestion of patients being deemed to have "no further prospect of improvement" runs the serious risk of drawing a conclusion too quickly, he said.

"When the stakes are this high, this is not something you get to be wrong about."

Although Dr Goodman says Belgian physicians are correct in recognizing the debilitating severity of mental suffering, the idea of mental health issues as a reason for physician-assisted suicide is "a bridge too far for the United States."

"The main reason for this is likely that we still have not recognized either the scope of mental pain or, for that matter, many other needs of psychiatric patients."

"Look ― we still have to fight for adequate coverage of behavioral conditions in ordinary health plans. Until we sort that out, we will not get it right about mental pain and suffering."

Dr Thienpont is cofounder of Ulteam, a clinic established to assist patients who are considering euthanasia. Dr Goodman has disclosed no relevant financial relationships.

BMJ Open. Published online July 27, 2015. Full text

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