Euthanasia for 'Untreatable' Mental Illness: New Data

Nancy A. Melville

February 10, 2016

Patients granted assisted suicide for psychiatric suffering in the Netherlands, where the practice is legal, often have complex histories of psychiatric illness involving much more than treatment-resistant depression, new research shows.

The data also reveal that euthanasia is often granted despite disagreement by treating physicians and psychiatrists over whether cases meet criteria for unbearable suffering.

The study was published online February 10 in JAMA Psychiatry.

Detailed Picture

"Our study provides for the first time a more fine-grained picture than mere quantitative data of what is happening when patients suffering from psychiatric disorders are euthanized or given lethal doses of medications for ingestion under the Dutch system," lead author Scott Y. H. Kim, PhD, Department of Bioethics, National Institutes of Health (NIH), Bethesda, Maryland, told Medscape Medical News.

"It could be argued that we need more studies like this to give us a better idea of what is happening at the individual patient level," said Dr Kim.

Although euthanasia or assisted suicide (EAS) for terminal illness has gained legal protection in several states in the United States and in other countries, assisted suicide for psychiatric disorders is more controversial and is legal only in a few countries, including Belgium and the Netherlands.

The criteria in those countries generally require that patients have unbearable suffering and untreatable mental illness, but data profiling the details of cases in which assisted suicide has been granted have been limited.

As reported by Medscape Medical News, one recent study included 100 consecutive patients in Belgium who had made requests for euthanasia because of psychiatric reasons; 35 requests were granted.

To better understand the characteristics of a larger number of psychiatric assisted suicide cases that were fulfilled, Dr Kim and colleagues evaluated 66 case summaries of patients who were granted and received assisted suicide from 2011 to 2014. The summaries were made available by Dutch authorities.

Of the patients included in the study, 70% (n = 46) were women; 32% (n = 21) were aged 70 years or older, and 44% (n = 29) were aged 50 to 70 years.

Most of the patients had chronic, severe mental illness with histories of suicide attempts and psychiatric hospitalizations; about 52% had personality-related disorders; 56% described social isolation and loneliness.

Although depressive disorders were the primary psychiatric diagnoses in 55% of cases, other conditions were also diagnosed, including post-traumatic stress or anxiety, neurocognitive and eating disorders, and prolonged grief and autism.

"Unbearable Suffering" Subjective

Among 29 patients whose primary psychiatric condition was nonbipolar depression, most (25) had one of the other conditions; 26% had some form of psychosis, including life-long schizophrenia, a fact that underscores the complex nature of the cases, Dr Kim said.

"The debates over psychiatric EAS tend to focus on a particular picture: a patient with long history of severe treatment-resistant depression who, after insightful assessment of her situation, exercises her autonomy to choose EAS," he said.

"But the biggest surprise was that people who received EAS and the usual picture of what that person should look like didn't quite match."

Importantly, the ratio of women to men was notable in that it is the reverse of the ratio of women to men who commit suicide without assistance in the Netherlands (43% women vs 57% men), yet it matches the ratio of women to men in terms of suicide attempts.

"It is possible that the availability of EAS renders the desire to die in women psychiatric patients more effective," the authors write.

The study further found concerning patterns in the regulatory structure of how assisted suicide requests are granted. Although euthanasia review committees typically defer decisions to the judgement of physicians, that judgement often appears inconclusive. In 24% (n = 16) of cases, there was disagreement among consultants; 11% (n = 7) of cases were found to have had no independent psychiatric input at all; and one case was found by a review committee to have failed to meet legal due-care criteria.

Only 41% (n = 27) of physicians administering the assisted suicide were psychiatrists, and among 32% (n = 21) of patients, previous assisted suicide requests had been refused.

Three of those patients had physicians who later changed their mind, and the remaining 18 were granted the assisted suicide from physicians who were new to them. Among those, 14 of the physicians were affiliated with a mobile euthanasia clinic called the End-of-Life Clinic.

In 12% of cases (n = 8), the researchers found evidence that the psychiatrist involved believed that the criteria for granting a request were not met, but the assisted death took place anyway.

Dr Kim noted, however, that such disagreements are not grounds for denying assisted suicide requests in the Netherlands, largely owing to the fact that, unlike with terminal illness, the key criterion of "unbearable suffering" is much more subjective with psychiatric illness.

"There is no evidence base to operationalize 'unbearable suffering,' " he said. "There are no prospective studies of decision-making capacity in persons seeking EAS for psychiatric reasons."

The prognoses for patients with treatment-resistant depression vary considerably, according to the population and treatments, he added.

"I think that may explain why physicians disagree even in these completed EAS cases," Dr Kim said. "It is fair to say that the Dutch system is based on a lot of trust. As we note in the paper, whether such a system is sufficient is probably an open question."

Key Concerns

The findings highlight some of the key concerns about assisted suicide for psychiatric illness, perhaps exemplified by the fact that the ratio of women to men differs from that for nonassisted suicides but matches that for suicide attempts, Paul S. Applebaum, MD, told Medscape Medical News.

"Most people who consider or attempt suicide never die by suicide, [and] the conviction that there is no alternative but to end their lives often passes with the resolution of an acute crisis," said Dr Applebaum, Dollard Professor of psychiatry, medicine, and law and director of the Division of Law, Ethics, and Psychiatry at Columbia University College of Physicians and Surgeons, in New York City.

"By making the option of suicide easier, ie, a painless, certain death with medical assistance, the Dutch, Belgian, and similar laws may encourage many people ― especially women ― who would not have ended their lives to do so."

Dr Applebaum, who is author of an accompanying editorial, added that on a broader level, the study highlights the challenges in determining truly untreatable mental illness and unbearable suffering.

"Untreatability is impossible to determine in many cases when more than half the patients seeking death have refused some recommended treatment," he said.

"And unbearable suffering is problematic to ascertain in patients with psychiatric disorders because so many of them are responsive to changes in the environment, especially in the large number of patients with coexisting personality disorders. The high rate of social isolation underscores this problem."

Too "Trigger Happy"?

Barron H. Lerner, MD, PhD, who is coauthor of an editorial on the subject of euthanasia in Belgium and the Netherlands, said one reassuring finding from the study was "that many of the people had longstanding psychiatric disease that had not responded to multiple treatments," he told Medscape Medical News.

He expressed concern about various findings, including the fact that so many patients were assisted by physicians at the mobile End-of-Life Clinic.

"There is the concern that the mobile euthanasia people may be too trigger happy, as they are offering a service they believe in as a political right," said Dr Lerner, of the Division of Medical Ethics, Department of Medicine and Population Health, at New York University's Langone Medical Center, in New York City.

He seconded concerns regarding the challenge of determining psychiatric illness that is truly "untreatable," particularly in light of evidence of patients commonly regretting previous suicide attempts.

"A high percentage of people with unsuccessful suicides regret having tried to take their lives. To the degree that this process is facilitating people making mistakes, it needs to be revisited," he said.

Dr Kim's comments reflect his own views and not the views or policies of the NIH, the Department of Health and Human Services, or the US government. Dr Kim, Dr Applebaum, and Dr Lerner have disclosed no relevant financial relationships.

JAMA Psychiatry. Published online February 10, 2016. Full text, Editorial

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