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.

If you're going to commit suicide, you should have the guts to do it yourself. Asking someone else to help you kill yourself is just... rude. And in the most technical sense of the word, you're asking someone to murder you. (Beyond any legal definition, you are asking someone else to perform an action which will immediately result in your death.)

http://en.wikipedia.org/wiki/Euthanasia_in_Switzerland

Switzerland has legislatively permitted assisted suicide since 1942. For example, lethal drugs may be prescribed as long as the recipient takes an active role in the drug administration. Euthanasia (such as administering a lethal injection) is not legal.[1] The law does require a physician to be involved. It does not require the recipient to be a Swiss national. This latter aspect of the law is unique in the world, and the nation has come to be known for the phenomenon of "suicide tourism".[1]


The legality of assisted suicide is a result of article 115 of the Swiss Criminal Code, in effect since 1942, which provides:

"Inciting and assisting suicide: Any person who for selfish motives incites or assists another to commit or attempt to commit suicide shall, if that other person thereafter commits or attempts to commit suicide, be liable to a custodial sentence not exceeding five years or to a monetary penalty."

Consequently, assisting suicide is a crime only if the motive for doing so is selfish,[1] such as personal gain.

When an assisted suicide is declared, a police inquiry may be started. Since no crime has been committed in the absence of a selfish motive, these are mostly open and shut cases. Prosecution can occur if doubts are raised about the patient's competence to make an autonomous choice, or about the motivation of anyone involved in assisting the suicide.

Article 115 was interpreted as legal permission to set up organizations administering life-ending medicine only in the 1980s, 40 years after its coming into effect.


Role of physicians in assisted suicide

Article 115 does not give physicians a special status in assisting suicide, although they are most likely to have access to suitable drugs. Ethical guidelines have cautioned physicians against prescribing lethal drugs. However, the guidelines also recognize that, in exceptional and clearly defined cases, physicians may justifiably assist suicide.[citation needed] Based on more recent ethical, juridical and medical statements, a prescription of Sodium-Pentobarbital is not necessarily contra-indicated, and thus is no longer generally a violation of medical duty of care.
Assisted suicide and mental illness

Evaluating a wish for assisted suicide requires distinguishing between a wish to die that reflects a curable psychic distortion, which calls for treatment, and a wish that is based on a self-determined, carefully considered and lasting decision made by a lucid person, which possibly needs to be respected. In the latter case, under certain circumstances even a mentally ill person may be granted help to commit suicide.[citation needed] Whether the prerequisites for this are satisfied cannot be evaluated separately from medical – especially psychiatric – special knowledge and proves to be difficult in practice. Therefore, the appropriate assessment requires the presentation of a special in-depth psychiatric opinion.[citation needed] In an essay in the Hastings Center Report, bioethicist Jacob M. Appel advocated adopting similar rules in the United States.[2]


Active euthanasia

All forms of active euthanasia like administering lethal injection remain prohibited in Switzerland. Swiss law only allows providing means to commit suicide, and reasons for doing so must be altruistic.[3]


Recent debate in Switzerland has focused on assisted suicide rights for the mentally ill. A decision by the Swiss Federal Supreme Court on November 3, 2006, laid out standards under which psychiatric patients might terminate their lives: “It cannot be denied that an incurable, long-lasting, severe mental impairment similar to a somatic one can create a suffering out of which a patient would find his/her life in the long run not worth living anymore."[citation needed]

Euthanasia organisations have been widely used by foreigners,[4] most notably Germans, in what critics have termed suicide tourism. Around half of the people helped to die by the organisation Dignitas[5] have been Germans.

In July 2009, British conductor Sir Edward Downes and his wife Joan died together at a suicide clinic outside Zürich "under circumstances of their own choosing." Sir Edward was not terminally ill, but his wife was diagnosed with rapidly developing cancer.[4]
Referendum

In a referendum on 15 May 2011, voters in the Canton of Zurich have overwhelmingly rejected calls to ban assisted suicide or to outlaw the practice for non-residents. Out of more than 278,000 ballots cast, the initiative to ban assisted suicide was rejected by 85 per cent of voters and the initiative to outlaw it for foreigners was turned down by 78 per cent.[6][7][8][9]

Mentally ill people can get better with therapy and meds and learn coping skills. I think it is dangerous grounds to allow a mentally ill person to choose.

I believe in assisted suicide for terminally sick people who have the mental capacity to make that decision.. for themselves.

Mentally ill people do not have that capacity, that is why they are mentally ill.

Many mentally ill people love life one day, then hate it the next.

What do you do.. wait until they string a full week of one emotion together then allow them to kill themselves.

JMO

some people choose euthanasia not because they want to die, but because they feel they are a burden to family and they feel everyone else would be better with them gone.

I wholeheartedly agree. I have witnessed suicidal wishes due to mental illness and had their death wish been allowed, they would not be here to realize growth and learning new thinking strategies is possible.

Depends on the mental illness. I don't think you can ask a schizophrenic if he wants to take his own life. Their medical status is completely different than people suffering from depression. I think depressed people without taking their meds and have no psychological support at all tend to end their life in a very dramatic way. Pretty sad, unfortunately.

I wonder how many people Today benefit from that?
Financial support
Therapy
Medication
Religious support
Family support.

Personally I disagree with having a person euthanized. Especially under these conditions . No one deserves to die like this.

if someone wants to die, let them... to many people anyway...

i have never been a supporter of euthanasia, not for any reason...it not only involves the conscious capacity to decide on suicide, but also a conscious decision to decide on murder...

you don't euthanize someone without the intent of killing them beforehand...

i was moreso surprised to find out that the mentally ill can actually be given the choice to end their lives thru euthanasia...

seems like a legally-justfied form of an "easy way out"...

Euthanasia: 10 Myths
Richard DW Hain

Over the two decades that have elapsed since I first became interested in the ethics of euthanasia and physician-assisted suicide, I have changed my mind. Not about whether or not I think it should be made legally permissible, but about why I think it should not.

My early objections were merely matters of morality. Actively killing patients (ie, euthanasia in the sense in which I am using it here) seemed self-evidently wrong in principle. But at the same time, it seemed quite a good idea in practice. As the years have passed, some of the myths presented by proselytes have made me less sure of both propositions. In a bid to dispel some of those myths, let's start by applauding the Belgian government for recognising that children can participate in decisions in respect of their own lives. Myth number one is that euthanasia in children is wrong because children cannot have meaningful autonomy in medical care.

Let's also remind ourselves that those who favour euthanasia for children are not child-haters. They are not recommending that children be killed because they consider children unimportant or because they value life insufficiently highly. That is myth number two. Most are well-intentioned, caring people who support euthanasia because they genuinely believe it is the most compassionate way to treat suffering patients when there is no prospect of a cure. Supporters often appeal to the compassion of the owner who asks the vet to put his dog out of its misery.

Myth number three, then, is that euthanasia and physician-assisted suicide do not ameliorate suffering. They certainly do. Loving families and compassionate professionals faced with the day-to-day agony of caring for a dying child will certainly feel the same sort of relief as the child dies that a loving dog-owner experiences as he watches his pet slip into sleep for the last time. But myth number four is that it is the suffering of the patient that is relieved. That can't be true. We must be clear that the suffering that euthanasia would ameliorate is that of the family, not of the child. Euthanasia obliterates the child's ��illness, suffering and all. We would never equate killing the child with curing her illness, and it is no less nonsense to equate it with abolishing her suffering. To suggest that one way to relieve a child's suffering is to kill her is like saying that that one way to restore a painting is to wash it back to white with bleach and turpentine.

So this is not about whether children should be allowed to choose whether or not to die. It is about how society should best care for its vulnerable members. Which leads us to myth number five: euthanasia is a legitimate part of good palliative care. The term 'euthanasia' originally meant 'a good death', and some proponents have taken that to mean that euthanasia in its modern sense can be regarded as a form of palliative care. That conclusion is a logical fallacy. The fact that palliative care can (by using an archaic definition) be thought of as a form of euthanasia cannot rationally lead to the conclusion that euthanasia (in its modern sense) can be thought of as a form of palliative care. The success of euthanasia legislation in Belgium has partly been the result of enshrining in the same laws statutory provisions ensuring access to adequate palliative care. That was great strategy. Opposition from palliative care doctors is persuasive; after all, it is physicians who, if it were made legal, might be called upon to do the actual killing. And, to be fair, it is more than just strategy. There is some truth in the claim that voluntary euthanasia potentially serves some of the same ends as palliative care. Good palliative care can usually ameliorate a patient's suffering, but it would be wrong to claim that it can always abolish suffering completely. A benefit that euthanasia can plausibly offer is restitution of a sense of personal autonomy. One of the losses faced by adults and children with terminal illness is the loss of a sense of control over their own lives. There is no doubt that giving choice of a death date is one way of helping restore that sense of control.

It can also have the reverse effect, of course. Technical consent is no guarantee of a decision freely taken. If it becomes the norm in society for a terminally ill patient to consider euthanasia or suicide, it is inevitable that some children will feel pressure to conform, even where there is no actual coercion. And sometimes, there will be actual coercion, ranging from explicit abuse to an exhausted parent's desperate wish that it would all be over.

In any case, knowing when you are going to die is not the only way to feel more in control. The skill of palliative care is working to identify and influence what can be influenced; to find in exploration with families and children things they can still change, like pain relief, place of care and place of death. It is not necessary to promise death on a due date in order to restore a realistic sense of autonomy. Good palliative care will do it without the need to extinguish the patient.

To some, that may seem a tiny victory; a trivial battle in a campaign against indignity that will inevitably be lost, as faculties are taken over time by a child's progressive illness. Myth number six, however, is that there is an important link between what someone can do and the quality of their life. Humans are astonishingly able to enjoy their lives despite severely limited function. There is a great temptation for us, as physicians caring for a dying child, to assume we know something about the quality of her life simply on the basis of what we observe that she can no longer do. That is implausible, and it is also irrelevant. Good palliative care means helping people (whatever their function) to live lives whose quality is maximised. The quality of a life does not exist separately from life itself, and removing life must in the same fact remove life's quality. However compassionate the motives, killing children must always be antithetical to palliative care because euthanasia aims to remove precisely what palliative care aims to preserve: a life that has quality.

So far, all I've done is suggest that killing children who are dying is usually unnecessary. Rationalists might argue that that is enough. The onus is on those who want to change our law to prove that such a change is the only reasonable way to achieve the desired objective. Myth number seven, however, is surely that there is no child whose suffering cannot be relieved by good palliative care. Unless we want to leave ourselves open to a charge of monstrous arrogance, those of us working with dying children must acknowledge the reality ��or, at the very least, the conceptual possibility of a child whose suffering cannot be relieved and who begs for easeful death. I have yet to meet such a child. But surely it could happen. Effective palliative care is plan A. But if that fails, however remote the possibility, surely a child has a right to plan B?

Myth number eight is that euthanasia legislation provides a right to die. It is not clear what a 'right to die' is but it seems unlikely that a change in the law will influence it one way or another. Euthanasia legislation gives a right to kill. The issue here is not whether it is morally permissible for an individual to take her own life, but whether it is wise for the state to give to some people legal permission to kill other people. That distinction matters, because while the number of patients with unrelievable suffering is extremely small, the number and influence of those on whom legislation would confer a right to kill other people is rather larger, perhaps extending to all physicians. Time to address myth number nine: that the ethical issues raised by euthanasia are no different from those of physician-assisted suicide. If there are persuasive arguments for physician-assisted suicide, they are based on ideas of justice. As a rule, a fair society is generally conceived to be one in which people who are less able to do something are enabled to do it (providing it is something, like suicide, that is permitted by society). The ethical justification for euthanasia, on the other hand, comes from a broadly utilitarian idea that there is a life that can be taken by, or at the request of, those who judge it to be in some way not worth living.

The key ethical impact of legalised killing, then, is not that it allows people to die, but that it allows people to kill. Furthermore, it allows a group of healthy, strong, autonomous, tax-paying individuals to kill sickly, weak, vulnerable, benefit-claiming ones; individuals whose care is expensive in a way that is ultimately unjustified by any measurable outcome, and whose voice is thereby extinguished.

Which brings us to our tenth, final and most misleading myth: a slippery slope is not inevitable. There is ��there must be ��momentum towards ever more frequent killing of vulnerable individuals without their permission. Its force is the relative cheapness of killing compared with long-term or palliative care, occurring in the context of constrained financial resources. Of course, the mere fact of such a slope does not mean we inevitably have to slide down it into social Darwinism. But it would take an unwise observer of human nature to deny that there is a slope, that it is slippery and that there needs to be some kind of 'grit' capable of halting a slide. Sadly, even careful legislation is inadequate because it must rely on phrases that have no objectively true meaning (such as the claim that someone has 'unbearable suffering') or else are meaningless in practice (such as the shamanic pronouncement that someone is 'within 6 months of death'). That lack of meaning is not a weakness of the words. It is inherent in the nature of what is being expressed. Parliamentary draftsmen, however patient and painstaking, cannot fix it because it is not fixable. No language not even legal language can ever give enough grip because it is the meanings themselves that fail to provide friction.

What about basic human morality? Some moral theories that have their roots in religious teachings might slow up slipping down the slope, for example, by an axiomatic insistence on a special value for persons, or a duty to care for, rather than to eradicate, the vulnerable. But those are rather metaphysical bases for modern medical ethics that are neither agreed nor empirically based. As the call for cost-effective practice becomes increasingly urgent, doctors feel pressure to turn instead to utilitarian moral theories whose outcomes can be measured. Since the demonstrable result of legalising euthanasia is that incurably ill patients are removed, making more resources available to people who can be restored to full health, utilitarian medical ethics must logically hasten progress down the slope, rather than retarding it. The Belgian experience was that, once legal, there was an increase in involuntary euthanasia that was particularly evident among those with slowly progressive conditions occupying hospital beds.

Making it legal to kill people is a terrible idea. An idea that will result in the unnecessary deaths of individuals capable of leading good quality lives. An idea that will forever impoverish the community of persons by codifying that it can be better to kill a person than to continue to care for her; better to help her to die than to help her to live. An idea, moreover, that we will never be able to recall because what is particularly terrible about this idea is that, for the people who are not killed by it, it is, in practice, such a bleakly, starkly, relentlessly great idea.

I find this disturbing on many levels. What specifically makes their lives so unbearable that they seek to end them? I noticed the larger percentage of people seeking assisted suicide was over 40. If we are talking about people who are hooked up to life support machines and they are vegetables or brain dead, that is one thing. If it is someone who has severe mental problems like hearing voices or multiple personality disorders, that could be another issue. I'm not clear on what condition exactly these people had to compel them to end their lives.

It is the will of every living organism, no matter how poor their quality of life, to choose to live. It is the natural will of every living organism, the fight to live, the fight for life. I cannot fathom the severity of someone's condition, either mentally or physically, that would make them chose death, UNLESS THEY ARE MENTALLY IMPAIRED. At this point, assisted suicide is the last thing they should be allowed. I just would like a detailed description of the extreme cases and their condition, which is not mentioned in the article.

How many people at one time or another in their lives have not contemplated suicide when they were low or hit a rough patch or after a painful breakup or devastating experience? I am sure this article refers to persistent thoughts of suicide but a lot of very depressed people are in this category. What criteria exactly is used to assess competent to die????

This is frightening. Who's to say that a vengeful spouse or relative may choose to end the life of someone with impunity, under the guise of mercy killing?

Committing suicide is neither "gutsy" nor courageous. It an act of despair, like the person is in so much mental and/or physical anguish, their quality of life is diminished and they see no reason to carry on living. It is too painful to carry on. People ask for assisted suicide as a quick and effective means of ending their miserable existence. Suicide attempts can be painful, botched or unsuccessful. The assisted suicide guarantees a clear exit.

In the film "Million Dollar Baby" (2004), the protagonist in the film asked for assisted suicide after she became a quadriplegic (paralysis of the body from the neck down) when suffering injuries in the boxing ring. Her quality of life had become severely diminished and it was too painful for her both mentally and physically to carry on living.

There is a difference between euthanasia and the withholding of extraordinary means of prolonging life.

People with terminal illnesses can always have the option to stop treatment or have life support withdrawn. This is very very different from assisted suicide.

Active euthanasia

All forms of active euthanasia like administering lethal injection remain prohibited in Switzerland. Swiss law only allows providing means to commit suicide, and reasons for doing so must be altruistic.[3]

its not that simple. someone mentally ill isn't in the right frame of mind to make that decision.

some people hit so low, make serious suicide attempts and desperately want to die, but they get better and think thank god im alive.

the post I made, was in regards to especially elderly sick people who feel a burden to there family choose euthanasia over guilt and not because they really want to die. and that I find so sad.

Oregon's 'Death With Dignity' Act:
http://public.health.oregon.gov/ProviderPartnerResources/EvaluationResearch/DeathwithDignityAct/Pages/faqs.aspx

I do like living in a state where I can
access this if I choose.