The Euthanasia Debate: How do the Mentally Ill Factor In?

A couple of months ago, I came across an article claiming that Belgium psych wards euthanize the mentally ill. As someone with a mental illness myself, I was shocked by the article, and possibly even more by some of the comments below it:

Well of course they do. How could they possibly afford to pay for medication, housing, and treatment for all those unproductive members of society? Next week they’ll be euthanizing the homeless and the handicapped. -PW

The article was an oversimplification of the legal process and obviously click-bait, but it had me wondering about euthanasia practices when it comes to those with mental illnesses. In some US states and Canada, assisted dying legislation is only for those with a terminal illness and a limited life expectancy. In contrast, in the Netherlands, Belgium, and Luxembourg, assisted dying is also for people who are not terminally ill, such as those with psychiatric illness or early stage dementia. Belgium legalized euthanasia in 2002 for patients suffering “unbearably” from “untreatable” medical condition(s), including psychiatric conditions.

Despite this being legal under very strict conditions, it remains a very controversial practice. Some newspaper articles and documentaries have highlighted cases in which psychiatrists offered to euthanize people with mental illnesses, some in their 20s or 30s, “under dubious circumstances“. One such case was a 24 year old woman known as Laura, who was suffering from depression but what otherwise healthy. Under the Belgian law, she qualifies for euthanasia, despite lack of a terminal or life-threatening illness. Laura was approved for a lethal injection after spending her childhood and adult life suffering from suicidal thoughts.

The Belgian Act of Euthanasia

This law specifies that substantive and procedural requirements must be met for euthanasia to be legally performed. To meet the substantive criteria, the request for euthanasia must be “voluntary, well considered, repeated and not the result of any external pressure”. The person should be legally competent at the time of the request. The person must also have a condition causing constant and unbearable physical or physiological suffering resulting from a serious disorder with no reasonable treatment alternatives or therapeutic perspective. The euthanasia request is considered voluntary and well-considered only if the person has sufficient insight into their illness and prognosis and has the capacity to make treatment decisions.

The procedural requirements include the consultation of a second independent physician and sometimes a third (if patient is not expected to die in foreseeable future). The third physician should be an expert in the disease (i.e. a psychiatrist), given that many with psychiatric conditions or dementia have a longer life expectancy. Also, a one-month waiting period is required between the written request and the euthanasia.

The Results

Reported euthanasia cases with a diagnosis of psychiatric disorder or dementia, 2002-2013 (Dierickx et. al)

The proportion of euthanasia cases with a psychiatric disorder or dementia diagnosis has risen from 0.5% of all cases in 2002-2007 to 3.0% in 2013. The increase in number of cases is most evident in the mood disorder category. The majority of cases were women (58.1% in dementia cases, 77.1% in mood disorder cases). A 2017 study of the Belgium euthanasia cases (from implementation of euthanasia law in 2002 to end of 2013) identified 179 cases. Most of the cases were of mood disorders (46.4%) or dementia (34.6%), followed by other psychiatric disorders (12.3%) and mood disorders with a comorbid psychiatric disorder (6.7%). According to a report, over 2 years, lethal injections were administered upon the request of five non-terminally ill people with schizophrenia, five with autism, eight with bipolar disorder, 39 with depression, and 29 with dementia.

Debate

Not everyone is on board with this euthanasia law. In fact, 65 Belgian mental-health professionals, ethicists, and physicians published a call to ban the euthanasia of the mentally ill. There are numerous concerns regarding the law, including the vulnerability of the mentally ill patient population. A wish to die could be a symptom of a mood disorder, so it raises the question of whether euthanasia is really respecting patient autonomy, reducing self-harm or suicide, or simply giving in to wishes due to the nature of the illness itself (symptom featuring suicidal ideation).

A main objection is that, by definition, the mentally ill may be less capable of forming “true will”, making it difficult to establish especially in the context of a life-or-death decision. Opponents of the practice stated:

“We see that some who were first declared incurable, eventually abandon euthanasia because new prospects showed up. In a paradoxical way, this proves that the disease can not be called incurable.”

Clearly, the irreversibility of psychiatric disorders is questionable at best, given that many of the disorders are hard to predict and the prognosis is uncertain. If this is the case, psychiatric conditions would not meet the criteria for the euthanasia law, making the euthanasia of mentally ill not only unethical but illegal. Also, the law brings up the question of whether this law is really in place for sake of patient autonomy or due to the possible economic burden these patients may be placing on the system.

Looking Ahead

Euthanasia of people with autism, depression, schizophrenia and dementia in the Low Countries represents a global moral crisis for psychiatry, and all of medicine, that can no longer be ignored. -Charles Lanes, Washington Post

Despite the controversial nature of the euthanasia on ground of “unbearable suffering” stemming from a psychiatric disorder or dementia, its prevalence has risen since 2008. The rate of euthanasia for such conditions is significantly lower than for other conditions, but the debate about whether it should be happening at all continues to take place. People with psychiatric conditions or dementia are increasingly seeking access to euthanasia. The practice guidelines for physicians who may be asked to address these requests must be carefully reevaluated. Given the increase in euthanasia cases, especially in patients with mood disorders or dementia, there should be research done into the underlying reasons and significance of this notable increase.

As someone with bipolar disorder myself, I find it rather alarming that people with my condition can request lethal injection. I don’t wish to downplay the severity of other cases. Clearly mental illnesses can severely limit one’s ability to function and cause suffering, despite years of trying different pharmaceutical and therapeutic treatment approaches. I think that during the low points of depression, many people, if offered the euthanasia option, would take it. The wish for death is a symptom of the illness, so euthanasia may be letting the illness win rather than really serving in the best interest of the patient. Even with a grim prognosis, I hope that patients can hold out hope for a better tomorrow rather than seeking an end to their lives.

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