Four Reasons Why Assisted Dying Should Not Be Offered for Depression

Older Adults' Perspectives on Voluntary Assisted Death: An In-Depth Qualitative Investigation in Australia

Interest in voluntary assisted death (VAD) has been growing among researchers, policy makers and the public. This study aimed to explore older adults' perspectives on VAD in Australia. Using purposive sampling, 15 adults ≥65 years participated in in-depth semi-structured interviews. Interpretative phenomenological analysis identified four themes: cultural reflections; beliefs and worldviews; health aspects; and fabric of life. Participants expressed a desire to have control over end-of-life options, challenged by religious beliefs. Participants expressed concern that VAD legislation could leave people vulnerable to coercion and saw a need for safeguards. Reasons for and against supporting and utilising VAD were discussed. Physical illness was seen a more compelling reason for VAD than mental ill-health. Finally, connections to life and other were discussed, and being able to do the things one loved were named aspects of what it meant to live a good life. Implications are discussed along with future research directions.

Persons with mental disorders and assisted dying practices in Spain: In response to Ramos et al

Ramos et al. paper offers a narrative review of Spanish Organic Law 3/2021, which regulates euthanasia, focusing on its application to individuals with mental disorders. Ramos et al. examine the application of legal prerequisites from an ethical-legal perspective to ascertain the conditions under which psychiatric euthanasia might be considered legitimate and compliant with legal stipulations. Nevertheless, it is apparent that the core ethical inquiries linked to this matter have not been exhaustively investigated. The criteria laid out are, in our assessment, still open to further debate and broader deliberation. Our article emphasizes the need for a comprehensive ethical and legal debate in Spain regarding psychiatric euthanasia. Competency assessment is central to the legislation, but there are concerns about the validity of assessment tools and the subjective nature of interviews. Furthermore, defining irreversible suffering in mental health contexts poses challenges. The article advocates for a deeper understanding of the needs of individuals with mental disorders before considering euthanasia and emphasizes the importance of comprehensive care and psychosocial interventions in reducing the desire for euthanasia. Ultimately, it underscores the ethical complexities of euthanasia in mental health and the necessity of prioritizing comprehensive care in addressing these complexities.

Why the irremediability requirement is not sufficient to deny psychiatric euthanasia for patients with treatment-resistant depression

Treatment-resistant depression (TRD) holds centrality in many debates regarding psychiatric euthanasia. Among the strongest reasons cited by opponents of psychiatric euthanasia is the uncertainty behind the irremediability of psychiatric illnesses. According to this argument, conditions that cannot be considered irremediable imply that there are possible remedies that remain for the condition. If there are possible remedies that remain for the condition, then patients with that condition cannot be considered for access to euthanasia. I call this the irremediability requirement (IR). I argue that patients with TRD can, indeed, meet the operationalisation of irremediability in the IR. This is because the irremediability it asks for is not some global or absolute irremediability, but rather a present irremediability based on the current state of medical science. I show this by considering irremediability relating to (1) possible future treatments and (2) not trying presently available alternative treatments. I extend Schuklenk nd van de Vathorst's argument from parity to terminal malignancies, to show that (1) is an unreasonable expectation for all cases of euthanasia. Taking (2) as a more serious opponent to psychiatric euthanasia, I show how the IR, based on how it is presently operationalised, can be realistically applied to cases of TRD. I do this by further developing Tully's argument on broad-sense treatment resistance with the robust empirical data from the STAR*D trials. If my argument from Tully's is valid, then we have reasons to, again, seek parity between the operationalisations of irremediability in terminal malignancies and TRD.

Slowing the Slide Down the Slippery Slope of Medical Assistance in Dying: Mutual Learnings for Canada and the US

Canada and California each introduced legislation to permit medical assistance in dying in June, 2016. Each jurisdiction publishes annual reports on the number of deaths that occurred under their respective legislations in the previous years. The numbers are disturbingly different. In 2021, 486 individuals died under California's End of Life Option. In the same year 10,064 Canadians died under that country's Medical Assistance in Dying (MAiD) legislation. California has a slightly larger population than Canada, and while medically assisted deaths as a percentage of total deaths remained virtually unchanged in California from 2020-2021, Canada saw a 30% increase from 2020 to 2021. This essay examines some of the factors propelling Canada down the slippery slope of medically assisted suicide, as well as those that may be keeping California and other US jurisdictions from taking the slide. At a time of increasing pressure in many jurisdictions (both nationally and internationally) to liberalize access to medical assistance in dying, some lessons from this comparative analysis are offered.

Medical assistance in dying for people living with mental disorders: a qualitative thematic review

BACKGROUND

Medical assistance in dying (MAiD) sparks debate in several countries, some of which allow or plan to allow MAiD where a mental disorder is the sole underlying medical condition (MAiD-MD). Since MAiD-MD is becoming permissible in a growing number of jurisdictions, there is a need to better understand the moral concerns related to this option. Gaining a better understanding of the moral concerns at stake is a first step towards identifying ways of addressing them so that MAiD-MD can be successfully introduced and implemented, where legislations allow it.

METHODS

Thus, this article aims (1) to better understand the moral concerns regarding MAiD-MD, and (2) to identify potential solutions to promote stakeholders' well-being. A qualitative thematic review was undertaken, which used systematic keyword-driven search and thematic analysis of content. Seventy-four publications met the inclusion criteria.

RESULTS

Various moral concerns and proposed solutions were identified and are related to how MAiD-MD is introduced in 5 contexts: (1) Societal context, (2) Healthcare system, (3) Continuum of care, (4) Discussions on the option of MAiD-MD, (5) MAiD-MD practices. We propose this classification of the identified moral concerns because it helps to better understand the various facets of discomfort experienced with MAiD-MD. In so doing, it also directs the various actions to be taken to alleviate these discomforts and promote the well-being of stakeholders.

CONCLUSION

The assessment of MAiD-MD applications, which is part of the context of MAiD-MD practices, emerges as the most widespread source of concern. Addressing the moral concerns arising in the five contexts identified could help ease concerns regarding the assessment of MAiD-MD.

Irremediability in psychiatric euthanasia: examining the objective standard

BACKGROUND

Irremediability is a key requirement for euthanasia and assisted suicide for psychiatric disorders (psychiatric EAS). Countries like the Netherlands and Belgium ask clinicians to assess irremediability in light of the patient's diagnosis and prognosis and 'according to current medical understanding'. Clarifying the relevance of a default objective standard for irremediability when applied to psychiatric EAS is crucial for solid policymaking. Yet so far, a thorough examination of this standard is lacking.

METHODS

Using treatment-resistant depression (TRD) as a test case, through a scoping review in PubMed, we analyzed the state-of-the-art evidence for whether clinicians can accurately predict individual long-term outcome and single out irremediable cases, by examining the following questions: (1) What is the definition of TRD; (2) What are group-level long-term outcomes of TRD; and (3) Can clinicians make accurate individual outcome predictions in TRD?

RESULTS

A uniform definition of TRD is lacking, with over 150 existing definitions, mostly focused on psychopharmacological research. Available yet limited studies about long-term outcomes indicate that a majority of patients with long-term TRD show significant improvement over time. Finally, evidence about individual predictions in TRD using precision medicine is growing, but methodological shortcomings and varying predictive accuracies pose important challenges for its implementation in clinical practice.

CONCLUSION

Our findings support the claim that, as per available evidence, clinicians cannot accurately predict long-term chances of recovery in a particular patient with TRD. This means that the objective standard for irremediability cannot be met, with implications for policy and practice of psychiatric EAS.

Externalist argument against medical assistance in dying for psychiatric illness

Medical assistance in dying, which includes voluntary euthanasia and assisted suicide, is legally permissible in a number of jurisdictions, including the Netherlands, Belgium, Switzerland and Canada. Although medical assistance in dying is most commonly provided for suffering associated with terminal somatic illness, some jurisdictions have also offered it for severe and irremediable psychiatric illness. Meanwhile, recent work in the philosophy of psychiatry has led to a renewed understanding of psychiatric illness that emphasises the role of the relation between the person and the external environment in the constitution of mental disorder. In this paper, I argue that this externalist approach to mental disorder highlights an ethical challenge to the practice of medical assistance in dying for psychiatric illness. At the level of the clinical assessment, externalism draws attention to potential social and environmental interventions that might have otherwise been overlooked by the standard approach to mental disorder, which may confound the judgement that there is no further reasonable alternative that could alleviate the person's suffering. At the level of the wider society, externalism underscores how social prejudices and structural barriers that contribute to psychiatric illness constrain the affordances available to people and result in them seeking medical assistance in dying when they otherwise might not have had under better social conditions.

Medical Assistance in Dying in Neurology

An increasing number of jurisdictions have legalized medical assistance in dying (MAID) with significant variation in the procedures and eligibility criteria used. In the United States, MAID is available for persons with terminal illnesses but is frequently sought by persons with neurologic conditions. Persons with conditions that cause cognitive impairment, such as Alzheimer dementia, are often ineligible for MAID, as their illness is not considered terminal in its early stages, whereas in later stages, they may have impaired decision-making capacity.

Implications of psychiatric diagnosis for Voluntary Assisted Dying in Victoria

Voluntary Assisted Dying is a process whereby terminally ill patients are provided a lethal dose of medication for them to voluntarily ingest to end their life. Victoria, Australia, implemented legislation permitting Voluntary Assisted Dying for terminally ill adult patients with a life expectancy less than 6 months. Ethical dilemmas arise when terminally ill patients with a comorbid mental illness attempt to access Voluntary Assisted Dying because of the complex relationship between psychiatric conditions and suicidal ideation. This paper seeks to investigate the most ethical approach for doctors to respond to such a request by discussing objections raised in other literature to patients with a comorbid psychiatric illness aiming to access Voluntary Assisted Dying in Victoria. To answer this question, objections to terminally ill patients with a comorbid psychiatric illness accessing Voluntary Assisted Dying were found through review of literature. Discussion of these objections centred around unpacking the two historical ethical justifications for Voluntary Assisted Dying: respect for autonomy and relief of suffering. Regarding autonomy, contention focused on competency to make autonomous decisions. Not all psychiatric patients lack competency to decide about Voluntary Assisted Dying, and there are comparable competency assessments used in psychiatry today. Considering suffering, objections related to the authenticity of the intolerable nature of a patient's suffering out of concerns that it has been influenced by their condition, and that the psychiatric illness may still be treatable. However, given suffering is subjective, its perception is not lessened if the source is psychological in nature. Furthermore, it is challenging to justify a position where a patient is forced to spend the last months of their life enduring suffering that has been historically refractory to multiple, genuine treatment efforts. Not all terminally ill patients with a comorbid psychiatric disorder will lack competency to choose Voluntary Assisted Dying, and many will have genuine suffering for which they are requesting Voluntary Assisted Dying. Multidisciplinary, holistic assessments for these patients are not mandated, but would be useful to address the issues, overcome barriers to access and determine that applicants are making an authentic request.

Depression and Physician-Aid-in-Dying

In this paper, I address the question of whether it is ever permissible to grant a request for physician-aid-in-dying (PAD) from an individual suffering from treatment-resistant depression. I assume for the sake of argument that PAD is sometimes permissible. There are three requirements for PAD: suffering, prognosis, and competence. First, an individual must be suffering from an illness or injury which is sufficient to cause serious, ongoing hardship. Second, one must have exhausted effective treatment options, and one's prospects for recovery must be poor. Third, the individual must be judged competent to request PAD. I argue that many cases of treatment-resistant depression meet the first two requirements. Thus, the key question concerns the third. I consider four features of depression that might compromise a person's decision-making capacity. Ultimately, I conclude that PAD requests from depressed patients can be permissibly granted in some circumstances.

Physician Assisted Death for Psychiatric Suffering: Experiences in the Netherlands

Physician assisted death (PAD) for patients with a psychiatric disorder is a controversial topic of increasing relevance, since a growing number of countries are allowing it. General requirements for PAD include that patients possess decision-making capacity to decide on PAD and that their suffering is unbearable and irremediable. In the Netherlands PAD has been eligible for patients with psychiatric disorders since the 1990s, making it one of the few countries that can offer insights on the practice from real life experience. Much of the literature describing these experiences is only available in Dutch. This article aims to make this knowledge more widely available and provide a comprehensive overview of the experience with PAD for psychiatric suffering in the Netherlands. First, the history of PAD for patients suffering from a psychiatric disorder is described. Second, an overview of relevant rules and regulations governing the practice is given. Third, an overview is provided of the scarce epidemiological data. Finally, we will discuss two major clinical challenges; establishing irremediability and decision-making capacity.

Feeling Seen, Being Heard: Perspectives of Patients Suffering from Mental Illness on the Possibility of Physician-Assisted Death in the Netherlands

Physician-assisted death (PAD) for patients suffering from a mental illness is allowed in the Netherlands under certain conditions but is a very controversial topic, mainly discussed by ethicists and physicians. The voice of the patient is rarely included in the debate, so we know little about what their views on the topic are. We aim to understand the views of patients with mental illness and wish to die with regard to the possibility of PAD in the Netherlands. The data for this qualitative study were collected through 21 in-depth interviews with Dutch patients who have a wish for PAD as a result of suffering from a mental illness. We identified four themes in relation to the meaning of PAD for the patients suffering from mental illness and wish to die. These themes are (1) Autonomy and self-determination, (2) ending the suffering, (3) recognition, and (4) a dignified end-of-life. The option of PAD for patients suffering from mental illnesses was considered of great importance to the patients who have a wish to die. We highlight the importance of 'recognition' for the situation of the patient, as this could lead to new perspective. We argue that psychiatrists need to reflect on providing this recognition in earlier phases of treatment, taking seriously and discussing a wish for PAD in treatment is beneficial to patients. It provides space for the patient to discuss their wishes and could cause them not wanting to die anymore.

Establishing irremediable psychiatric suffering in the context of medical assistance in dying in the Netherlands: a qualitative study

Background:

Establishing irremediability of suffering is a central challenge in determining the appropriateness of medical assistance in dying (MAiD) for patients with a psychiatric disorder. We sought to evaluate how experienced psychiatrists define irremediable psychiatric suffering in the context of MAiD and what challenges they face while establishing irremediable psychiatric suffering.

Methods:

We conducted a qualitative study of psychiatrists in the Netherlands with experience assessing irremediable psychiatric suffering in the context of MAiD. We collected data from in-depth, semistructured interviews focused on the definition of irremediable psychiatric suffering and on the challenges in establishing irremediability. We analyzed themes using a modified grounded theory approach.

Results:

The study included 11 psychiatrists. Although irremediable psychiatric suffering is a prospective concept, most participants relied on retrospective dimensions to define it, such as a history of failed treatments, and expressed that uncertainty was inevitable in this process. When establishing irremediable psychiatric suffering, participants identified challenges related to diagnosis and treatment. The main diagnostic challenge identified was the frequent co-occurrence of more than 1 psychiatric diagnosis. Important challenges related to treatment included assessing the quality of past treatments, establishing when limits of treatment had been reached and managing “treatment fatigue.”

Interpretation:

Challenges regarding the definition, diagnosis and treatment of irremediable psychiatric suffering complicate the process of establishing it in the context of MAiD. Development of consensus clinical criteria for irremediable psychiatric suffering in this context and further research to understand “treatment fatigue” among patients with psychiatric disorders may help address these challenges. Registration: This study was preregistered under osf.io/2jrnd.

Experiences and views of Dutch general practitioners regarding physician-assisted death for patients suffering from severe mental illness: a mixed methods approach

BACKGROUND

In the Netherlands, physician-assisted death (PAD) is allowed under certain conditions. Patients who suffer from mental illnesses are not excluded from this practice. In 2018, general practitioners (GPs) performed 20 out of a total of 67 cases of EAS for psychiatric suffering.

OBJECTIVE

More insight into GPs' experiences and views with regard to PAD in psychiatry.

DESIGN

The data for this study were obtained through a survey amongst 500 randomly selected Dutch GPs and by in-depth interviews with 20 Dutch GPs.

SETTING

A survey study and in-depth interviews.

SUBJECTS

Dutch GPs.

RESULTS

86 out of 101 GPs found it conceivable to perform EAS in case of somatic disease, and 51 out of 104 GPs found it conceivable in the case a patient suffered from a mental illness only. The main reason given for refusing an PAD request was that the criteria of due care were not met. Reasons for supporting psychiatric PAD related to responsibility, self-determination, compassion, fairness, and preventing suicide. Reasons for not supporting psychiatric PAD were related to the scope of medicine, a perceived lack of experience, uncertainties regarding the criteria of due care and life-expectancy.

CONCLUSION

GPs are less likely to perform PAD for suffering from a mental illness, compared to somatic suffering. Some GPs apply an extra criterion of 'life-expectancy' in case of PAD for suffering from a mental illness. Refusing PAD based on a long life expectancy keeps open the possibility of recovery, but may also just prolong the suffering and add to the unbearableness of it.KEY POINTSCurrently, there is no qualitative research on what the views are of general practitioners regarding the subject of physician-assisted death (PAD) for patients suffering from severe mental disorders.General practitioners are less likely to consider a request for physician-assisted death by a patient suffering from a psychiatric disorder, compared to somatic suffering. Reasons for supporting psychiatric PAD related to responsibility, self-determination, compassion, fairness, and preventing suicide.Reasons for not supporting psychiatric PAD were related to the scope of medicine, a perceived lack of experience, uncertainties regarding the criteria of due care and life-expectancy.Significance for the reader: Although allowed in the Netherlands, PAD in case of severe mental suffering remains a controversial topic. We need in-depth information about the actual practice of it to have an informed debate with regard to this subject.

Psychiatrie, soins palliatifs et de fin de vie : des univers (ir)réconciliables? Le cas de madame Sanchez

Contexte : En psychiatrie, la question d’offrir des soins palliatifs et de fin de vie pour ce qui serait une « condition psychiatrique terminale » ou, plus globalement, de considérer adopter une approche palliative pour des problèmes de santé mentale sévères et persistants constitue encore un tabou. Méthodologie : Cette question est abordée par l’analyse d’un cas effectuée lors d’une consultation en éthique clinique à l’aide de la méthode des scénarios d’Hubert Doucet. Il s’agit de madame Sanchez, une patiente âgée de plus de 90 ans, présentant des troubles psychiatriques, exprimant le désir de mourir par des gestes suicidaires, refusant les traitements proposés, ainsi que refusant de boire et manger. Son histoire clinique est racontée par le filtre de l’accompagnement réflexif offert en éthique clinique aux diverses parties prenantes. Résultats : L’analyse de cas, loin de répondre aux défis posés par le concept des soins palliatifs et de fin de vie en contexte psychiatrique, présente néanmoins une occasion d’en nommer les enjeux éthiques principaux : la souffrance psychique, le refus de manger et de boire ainsi que le refus de traitement, la sédation palliative et l’aide médicale à mourir, les volontés et directives médicales anticipées, ainsi que les défis clinico-organisationnels suscités par la clientèle gérontopsychiatrique. Conclusion : Les défis cliniques et éthiques demeurent nombreux pour les professionnels et les décideurs afin de répondre aux besoins de la clientèle de santé mentale très âgée. Nous appelons à un plus grand développement des connaissances sur ce thème précis.

The influence of cognitive distortions on decision-making capacity for physician aid in dying

As international laws on physician aid in dying (PAD) evolve, the question of permitting PAD in non-terminal illness, and in sole psychiatric illness, is under intense debate. In jurisdictions where PAD is permissible, certain safeguards and eligibility requirements must be met for all patients making a PAD request, and one of these requirements is that the patient have sound decision-making capacity with respect to the request. Legal criteria already exist for the determination of capacity, and they are quite similar between different jurisdictions. In current debates about the question of psychiatric PAD, one concern that has been raised is that cognitive distortions in mental disorders may affect a patient's decision-making capacity. At the same time, it has been established that all persons, with or without a mental disorder, experience cognitive distortions. If cognitive distortions are ubiquitous, it is likely that the severity and frequency of cognitive distortions is dimensional rather than categorical, between samples with and without mental illness. Furthermore, currently, there is no requirement for a formalized evaluation of cognitive distortions as part of capacity assessment for any type of medical decision, including PAD decisions. The current paper examines the literature related to cognitive distortions in mental disorders and in healthy populations. It proposes that the existence of cognitive distortions, alone, cannot be used as an argument for a blanket exclusion of psychiatric PAD. It therefore concludes that further research and ethical analysis should be undertaken to examine the impact of cognitive distortions on decision-making for consequential medical decisions, including PAD, in patients with and without mental disorders.

Irremediable Psychiatric Suffering in the Context of Physician-assisted Death: A Scoping Review of Arguments: La souffrance psychiatrique irrémédiable dans le contexte du suicide assisté : Une revue étendue des arguments

OBJECTIVES

Physician-assisted death (PAD), also known as medical assistance in dying, of patients with a psychiatric disorder (PPD) is a global issue of debate. In most jurisdictions that allow PAD, irremediable suffering is a legal requirement, how to apply the concept of irremediability to PPD remains challenging. The aim of this article is to identify the main arguments concerning irremediability in the debate about PAD of PPD and give directions for further moral deliberation and empirical research.

METHODS

Systematic searches in MEDLINE, Embase, and PsycINFO were combined with 4 additional search strategies. All conceptual-ethical articles, quantitative and qualitative empirical studies, guidelines, case reports, and commentaries that met the inclusion criteria were included, and a qualitative data synthesis was used to identify recurring themes within the literature. The study protocol was preregistered at the Open Science Framework under registration code: thjg8.

RESULTS

A total of 50 articles met the inclusion criteria. Three main arguments concerning irremediability were found in the debate about PAD of PPD: uncertainty, hope, and treatment refusal.

CONCLUSIONS

Uncertainty about irremediability is inevitable, so which level of certainty is morally required should be the subject of moral deliberation. Whether PAD induces or resolves hopelessness is an empirical claim that deserves clarification. Treatment refusal in search of PAD raises questions about treatment efficacy in this patient group and about decision-making in the context of the physician-patient relationship. Going forward, more attention should be given to epidemiological research and to specific challenges posed by different psychiatric disorders.

Should euthanasia and assisted suicide for psychiatric disorders be permitted? A systematic review of reasons

BACKGROUND

Euthanasia and assisted suicide (EAS) based on a psychiatric disorder (psychiatric EAS) continue to pose ethical and policy challenges, even in countries where the practice has been allowed for years. We conducted a systematic review of reasons, a specific type of review for bioethical questions designed to inform rational policy-making. Our aims were twofold: (1) to systematically identify all published reasons for and against the practice (2) to identify current gaps in the debate and areas for future research.

METHODS

Following the PRISMA guidelines, we performed a search across seven electronic databases to include publications focusing on psychiatric EAS and providing ethical reasons. Reasons were grouped into domains by qualitative content analysis.

RESULTS

We included 42 articles, most of which were written after 2013. Articles in favor and against were evenly distributed. Articles in favor were mostly full-length pieces written by non-clinicians, with articles against mostly reactive, commentary-type pieces written by clinicians. Reasons were categorized into eight domains: (1) mental and physical illness and suffering (2) decisional capacity (3) irremediability (4) goals of medicine and psychiatry (5) consequences for mental health care (6) psychiatric EAS and suicide (7) self-determination and authenticity (8) psychiatric EAS and refusal of life-sustaining treatment. Parity- (or discrimination-) based reasons were dominant across domains, mostly argued for by non-clinicians, while policy reasons were mostly pointed to by clinicians.

CONCLUSIONS

The ethical debate about psychiatric EAS is relatively young, with prominent reasons of parity. More direct engagement is needed to address ethical and policy considerations.

Survey of Mental Health Care Providers’ Perspectives on the Everyday Ethics of Medical-Aid-in-Dying for People with a Mental Illness

Context: In most jurisdictions where medical-aid-in-dying (MAiD) is available, this option is reserved for individuals suffering from incurable physical conditions. Currently, in Canada, people who have a mental illness are legally excluded from accessing MAiD. Methods: We developed a questionnaire for mental health care providers to better understand their perspectives related to ethical issues in relation to MAiD in the context of severe and persistent suffering caused by mental illness. We used a mixed-methods survey approach, using a concurrent embedded model with both closed and open-ended questions. Findings: 477 healthcare providers from the province of Québec (Canada) completed the questionnaire. One third of the sample (34.4%) were nurses, one quarter psychologists (24.3%) and one quarter psycho-educators (24%). Nearly half of the respondents (48.4%) considered that people with a severe mental illness should be granted the right to opt for MAiD as a way to end their suffering. Respondents were more likely to feel comfortable listening to the person and participating in discussions related to MAiD for a mental illness than offering care or the means for the person to access MAiD. Most (86.2%) reported that they had not received adequate/sufficient training, education or preparation in order to address ethical questions surrounding MAiD. Conclusions: The findings highlight how extending MAiD to people with a mental illness would affect daily practices for mental healthcare providers who work directly with people who may request MAiD. The survey results also reinforce the need for adequate training and professional education in this complex area of care.

Euthanasia and assisted suicide of persons with psychiatric disorders: the challenge of personality disorders

BACKGROUND

Euthanasia or assisted suicide (EAS) for psychiatric disorders, legal in some countries, remains controversial. Personality disorders are common in psychiatric EAS. They often cause a sense of irremediable suffering and engender complex patient-clinician interactions, both of which could complicate EAS evaluations.

METHODS

We conducted a directed-content analysis of all psychiatric EAS cases involving personality and related disorders published by the Dutch regional euthanasia review committees (N = 74, from 2011 to October 2017).

RESULTS

Most patients were women (76%, n = 52), often with long, complex clinical histories: 62% had physical comorbidities, 97% had at least one, and 70% had two or more psychiatric comorbidities. They often had a history of suicide attempts (47%), self-harming behavior (27%), and trauma (36%). In 46%, a previous EAS request had been refused. Past psychiatric treatments varied: e.g. hospitalization and psychotherapy were not tried in 27% and 28%, respectively. In 50%, the physician managing their EAS were new to them, a third (36%) did not have a treating psychiatrist at the time of EAS request, and most physicians performing EAS were non-psychiatrists (70%) relying on cross-sectional psychiatric evaluations focusing on EAS eligibility, not treatment. Physicians evaluating such patients appear to be especially emotionally affected compared with when personality disorders are not present.

CONCLUSIONS

The EAS evaluation of persons with personality disorders may be challenging and emotionally complex for their evaluators who are often non-psychiatrists. These factors could influence the interpretation of EAS requirements of irremediability, raising issues that merit further discussion and research.

Is the exclusion of psychiatric patients from access to physician-assisted suicide discriminatory?

Advocates of physician-assisted suicide (PAS) often argue that, although the provision of PAS is morally permissible for persons with terminal, somatic illnesses, it is impermissible for patients suffering from psychiatric conditions. This claim is justified on the basis that psychiatric illnesses have certain morally relevant characteristics and/or implications that distinguish them from their somatic counterparts. In this paper, I address three arguments of this sort. First, that psychiatric conditions compromise a person's decision-making capacity. Second, that we cannot have sufficient certainty that a person's psychiatric condition is untreatable. Third, that the institutionalisation of PAS for mental illnesses presents morally unacceptable risks. I argue that, if we accept that PAS is permissible for patients with somatic conditions, then none of these three arguments are strong enough to demonstrate that the exclusion of psychiatric patients from access to PAS is justifiable.

Research on the pathophysiology, treatment, and prevention of suicide: practical and ethical issues

BACKGROUND

Despite decades of research, the rate of death from suicide is rising in the United States. Suicide is a complex and multifactorial phenomenon and, to date, no validated biomarkers that predict suicidal behavior have been identified. Only one FDA-approved drug to prevent suicide exists, and it is approved only for patients with schizophrenia. Although anti-suicide psychotherapeutic techniques exist, treatment takes time, and only preliminary data exist for rapid-acting therapies.

DISCUSSION

While more research into suicidal ideation and acute suicidal behavior is clearly needed, this research is fraught with both practical and ethical concerns. As a result, many investigators and bioethicists have called for restrictions on the types of research that individuals with suicidal behavior can participate in, despite the fact that the available empirical evidence suggests that this research can be done safely. This manuscript presents background information on the phenomenology of suicide, discusses the current state of treatment and prevention strategies, and reviews the practical and ethical issues surrounding suicide research in the context of available empirical data. Currently, the causes of suicide are poorly understood, in part due to the fact that very few studies have investigated the acute suicidal crisis. Although some biomarkers for predicting risk have been developed, none have been sufficiently validated. The most successful current interventions involve means restriction. However, while numerous hurdles face researchers, these are not insurmountable. The available evidence suggests that research into suicide can be conducted both safely and ethically.

Public and physicians' support for euthanasia in people suffering from psychiatric disorders: a cross-sectional survey study

Background

Although euthanasia and assisted suicide (EAS) in people with psychiatric disorders is relatively rare, the increasing incidence of EAS requests has given rise to public and political debate. This study aimed to explore support of the public and physicians for euthanasia and assisted suicide in people with psychiatric disorders and examine factors associated with acceptance and conceivability of performing EAS in these patients.

Methods

A survey was distributed amongst a random sample of Dutch 2641 citizens (response 75%) and 3000 physicians (response 52%). Acceptance and conceivability of performing EAS, demographics, health status and professional characteristics were measured. Multivariable logistic regression analyses were performed.

Results

Of the general public 53% were of the opinion that people with psychiatric disorders should be eligible for EAS, 15% was opposed to this, and 32% remained neutral. Higher educational level, Dutch ethnicity, and higher urbanization level were associated with higher acceptability of EAS whilst a religious life stance and good health were associated with lower acceptability. The percentage of physicians who considered performing EAS in people with psychiatric disorders conceivable ranged between 20% amongst medical specialists and 47% amongst general practitioners. Having received EAS requests from psychiatric patients before was associated with considering performing EAS conceivable. Being female, religious, medical specialist, or psychiatrist were associated with lower conceivability. The majority (> 65%) of the psychiatrists were of the opinion that it is possible to establish whether a psychiatric patient’s suffering is unbearable and without prospect and whether the request is well-considered.

Conclusion

The general public shows more support than opposition as to whether patients suffering from a psychiatric disorder should be eligible for EAS, even though one third of the respondents remained neutral. Physicians’ support depends on their specialization; 39% of psychiatrists considered performing EAS in psychiatric patients conceivable. The relatively low conceivability is possibly explained by psychiatric patients often not meeting the eligibility criteria.

Supplementary information

Supplementary information accompanies this paper at 10.1186/s12910-019-0404-8.

Euthanasia and physician-assisted suicide in patients suffering from psychiatric disorders: a cross-sectional study exploring the experiences of Dutch psychiatrists

BACKGROUND

The medical-ethical dilemmas related to euthanasia and physician-assisted suicide (EAS) in psychiatric patients are highly relevant in an international context. EAS in psychiatric patients appears to become more frequent in the Netherlands. However, little is known about the experiences of psychiatrists with this practice. This study aims to estimate the incidence of EAS (requests) in psychiatric practice in The Netherlands and to describe the characteristics of psychiatric patients requesting EAS, the decision-making process and outcomes of these requests.

METHODS

In the context of the third evaluation of the Dutch Euthanasia Act, a cross-sectional study was performed between May and September 2016. A questionnaire was sent to a random sample of 500 Dutch psychiatrists. Of the 425 eligible psychiatrists 49% responded. Frequencies of EAS and EAS requests were estimated. Detailed information was asked about the most recent case in which psychiatrists granted and/or refused an EAS request, if any.

RESULTS

The total number of psychiatric patients explicitly requesting for EAS was estimated to be between 1100 and 1150 for all psychiatrists in a one year period from 2015 to 2016. An estimated 60 to 70 patients received EAS in this period. Nine psychiatrists described a case in which they granted an EAS request from a psychiatric patient. Five of these nine patients had a mood disorder. Three patients had somatic comorbidity. Main reasons to request EAS were 'depressive feelings' and 'suffering without prospect of improvement'. Sixty-six psychiatrists described a case in which they refused an EAS request. 59% of these patients had a personality disorder and 19% had somatic comorbidity. Main reasons to request EAS were 'depressive feelings' and 'desperate situations in several areas of life'. Most requests were refused because the due care criteria were not met.

CONCLUSIONS

Although the incidence of EAS in psychiatric patients increased over the past two decades, this practice remains relatively rare. This is probably due to the complexity of assessing the due care criteria in case of psychiatric suffering. Training and support may enable psychiatrists to address this sensitive issue in their work better.

"For Their Own Good": A Response to Popular Arguments Against Permitting Medical Assistance in Dying (MAID) where Mental Illness Is the Sole Underlying Condition

Canada is approaching its federal government's review of whether patients should be eligible for medical assistance in dying (MAID) where mental illness is the sole underlying medical condition, and when "natural death" is not "reasonably foreseeable". For those opposed, arguments involve the following themes: capacity, value of life, vulnerability, stigma, irremediability, and the role of physicians. It has also been suggested that those who are able-bodied should have to kill themselves, even though suicide may be painful, lonely, and violent. Opponents of MAID for severe, refractory suffering due to mental illness imply that it is acceptable to remove agency from such patients on paternalistic grounds. After years of efforts to destigmatise mental illness, these kinds of arguments effectively declare all patients with mental illness, regardless of capacity, unable to make considered choices for themselves. The current paper argues that decisions about capacity must be made on an individual-patient basis. Given the rightful importance granted to respect for patient autonomy in liberal democracies, the wholesale removal of agency advocated by opponents of a permissive MAID regime is difficult to reconcile with Canadian constitutional values.

Medical Assistance in Dying and Mental Health: A Legal, Ethical, and Clinical Analysis

Medical assistance in dying (MAiD) legislation is now over a year old in Canada, and consideration is turning to whether MAiD should be extended to include serious mental illness as the sole qualifying condition for being eligible for MAiD. This article considers this question from ethical and clinical perspectives. It argues that extending the eligibility for MAiD to include those with a serious mental illness as the sole eligibility criterion is not ethical, necessary, or supported current psychiatric practice or opinion.