Criminal Case Spurs a Rethink of Euthanasia for Mental Illness

Nancy A. Melville

February 19, 2019

The recent launch of a criminal investigation into a case of medically assisted death for psychiatric illness in Belgium, reported by multiple media sources, is shining a spotlight on growing concerns — even among supporters — about the controversial practice.

The criminal allegations, which reportedly mark the first investigation of medically assisted euthanasia in that country since it was legalized in 2002, are related to the 2010 death of a 38-year-old woman with Asperger syndrome, a mild form of autism.

As reported by the Associated Press, the investigation stems from alleged "irregularities" in the procedure, which include a doctor asking the patient's father to hold the needle in place while the lethal injection was administered.

The family has also reportedly questioned the patient's diagnosis of Asperger syndrome, suggesting instead that she was suffering from depression due to a recent breakup.

If convicted, the three doctors involved, who have been accused of "poisoning" the woman, could face a maximum penalty of life in prison.

Among them is Lieve Thienpont, MD, a prominent advocate for medically assisted death, who, according to the AP, is estimated to have been involved in about one third of assisted deaths for psychiatric reasons that have taken place in Belgium since euthanasia was legalized.  

There are also broader accusations that Thienpont and others have too easily granted requests for assisted death for mental illness, prompting calls to rethink the entire process.

One online petition, entitled "Review Euthanasia Law for Psychic Suffering (REBEL), has 476 signatures, including those of 253 clinicians. The petition calls for an "ethical reflection" of the law among all involved parties.

"We call for tightening the criteria for psychic suffering, and to allow a commission to judge the case beforehand or preferably remove from the law 'unbearable and hopeless psychic suffering' as a criterion for euthanasia. This would be a life-giving initiative," the petition states.

Unreliable Patient Evaluation

These concerns were echoed in an editorial published in 2018 in the New England Journal of Medicine by psychiatrist Joris Vandenberghe, MD, PhD, of University Hospitals and the University Psychiatric Center KU Leuven in Belgium. 

"The current systems in Belgium and the Netherlands fail in terms of reliable patient evaluation, at least in psychiatric illness," he writes.  

While supporting the idea that "rational suicidality" is conceivable even in the presence of mental illness, Vandenberghe notes that medically assisted death for mental illness can be an ethical practice "only if enough guarantees are in place that it truly is a last resort."

"Inconceivably," he notes, even the assessment required for deep brain stimulation (DBS) for mental illness is more rigorous than for medically assisted death.

"For DBS, the patient's lack of response to previous treatment is evaluated carefully by a multidisciplinary committee on the basis of diagnosis-specific criteria, including strict requirements for all specific treatments that must have been tried."

"For euthanasia-assisted suicide, by contrast, a single physician decides that the patient is eligible, after receiving the nonbinding advice of two colleagues who have also examined the patient and his or her file. There are no diagnosis-specific criteria for determining that no reasonable treatments remain to be tried," he writes.

The lack of mandatory, multidisciplinary review in assisted death for mental illness cases is unacceptable, he adds.  

Agreeing with the petition, Vandenberghe also notes that recent studies indicate that in many cases patients have not met the criteria of having tried every reasonable alternative to assisted death.

"The failure to adequately determine whether the criteria for euthanasia-assisted suicide are met implies that some patients have died despite having remaining treatment options," he writes.

Experts Disagree

A study published in 2016 in JAMA Psychiatry and reported by Medscape Medical News showed that among 66 cases of assisted death for mental illness in the Netherlands, there was disagreement among consultants judging the request in 16 (24%) of the cases; there was no independent psychiatric input in 7 (11%) of the cases.

Potential flaws in the review system are underscored by the fact that families — instead of review committees — are the ones calling out potential pitfalls.

"In [two] cases before the courts, the review committees were fine with them, and yet they have ended up in court because families have insisted. That seems to indicate that the review system itself has problems," the 2016 study's senior author, Scott Y.H. Kim, MD, PhD, of the Department of Bioethics, National Institutes of Health, Bethesda, Maryland; and Department of Psychiatry, University of Michigan in Ann Arbor.

Among those countries monitoring the situation in Europe is Canada, which has been debating expansion of its new medical assistance in dying (MAID) law that passed in 2016 and currently excludes patients who are not terminally ill.

A 2017 survey shows that of 528 Canadian psychiatrists, 72% supported medically-assisted death, but only 29.4% supported the practice for mental illness.

"Many Canadians appreciate, I believe, the need for extreme caution in this area," Trudo Lemmens, a professor in health law and policy at the University of Toronto, who has been active in the debate in Canada, told Medscape Medical News.

He noted that many in Canada support euthanasia for terminal illness, but that the issues in Europe underscore the greater complexities when mental illness is a reason requesting medically assisted death.

"The controversies in Belgium and the Netherlands should receive more attention in Canada where there is a tendency to emphasize only positive stories about MAID," he said.

"Many Canadians, and certainly most mental health care providers are, in my view, aware that offering MAID as some form of therapy risks undermining our societal obligations to those who struggle with mental health issues and could have an impact on suicide prevention."

Ill-Advised Approach

The very prospect of placing a psychiatrist in the position of determining whether a patient is beyond the reach of treatment is ill-advised, said Lemmens.

"Psychiatrists, and even more so other physicians, who say that they can easily determine who will never get better or will never manage to cope better with their chronic mental health condition lack humility," he said.

While rates of medically assisted death have risen steadily since the legalization of the practice in Belgium and the Netherlands, cases with a cause of mental health illness still represent only a very small proportion.

Of the 6585 reports of medically assisted death in the Netherlands in 2017, only 83 (1.3%) were for psychiatric disorders.

Belgium reports that its numbers of medically assisted euthanasia cases for mental illness have declined from 124 in 2014–2015 to 77 in 2016 and 2017.

Of the 83 cases in the Netherlands, the notifying physician was a psychiatrist in 36 cases; 22 cases involved a general practitioner and six cases a geriatric care specialist.

Meanwhile, experts predict it will likely be just a matter of time before similar efforts to include mental illness as a basis for medically assisted death are launched in the seven US states (plus District of Columbia) where the practice is legal.

"I have no doubt that will be the case," Kim said. "The terminal illness criterion that exists is already under criticism; it was initially not part of physician-assisted death advocates' plan…and there is no shortage of legal experts who will make anti-discrimination arguments to include mental illness cases," he said.

No Justification

Among the most vocal critics of such efforts in the US is Paul Appelbaum, MD, who agrees that the reports of the Belgian/Dutch experience are troubling.

"Many people with mental illness are susceptible to undue influence and impulsive actions, leaving them vulnerable to advocates for physician-assisted death who take an 'ask no questions' approach," he told Medscape Medical News.

"Unfortunately, based on the reports from the Netherlands and Belgium, that seems to be happening there today," said Appelbaum, who is director of Division of Law, Ethics, and Psychiatry and also director of the Center for Research on Ethical, Legal & Social Implications of Psychiatric, Neurologic & Behavioral Genetics at the Columbia University College of Physicians & Surgeons in New York City.

Appelbaum, who coauthored a separate editorial published in the same New England Journal of Medicine edition as Vandenberghe's, counters the suggestion that stricter criteria is needed.

Instead, he said, it is difficult to imagine any level of rigid policies or assessment that could justify the role of a psychiatrist bringing about the death of a patient based on mental illness.

"Even if the standards and procedures were adhered to, the application of physician-assisted death to people with mental illness remains problematic. The desire for death can be a symptom of the illness itself, compounded by social isolation and demoralization," Appelbaum said.

"The proper response is more comprehensive treatment and programs aimed at increasing socialization of people with mental illness — not helping them end their lives," he added.

Editor’s note: An earlier version of this story incorrectly stated that Dr Thienpont had been involved in "10,000 assisted deaths that have taken place in Belgium since euthanasia was legalized." The article has been corrected. 

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