BRITISH JOURNAL OF PSYCHIATRY (2006), 188, 405^409 SPECIAL ARTICLE

Euthanasia: the role of the psychiatrist applied (2.6% and 0.2% respectively; van der HeidederHeide et aletal, 2003). Specific data on assisted in patients suffering pri- KRIS NAUDTS, CAROLINE DUCATELLE, JOZSEF KOVACS, KRISTIN LAURENS, marily from mental disorder are available FREDERIQUE VAN DEN EYNDE and CORNELIS VAN HEERINGEN only from The Netherlands, where an esti- mated two to five patients a year receive assistance with suicide out of a total of 400 000 patients receiving mental health- care (Groenewoud et aletal, 1997). At the time of these studies, however, and were still prohibited in both countries. Follow-up studies are needed to Summary Belgium has become one of and to present the most relevant issues determine the change in prevalence data the few countries in the world where arising from the wider debate in the pro- after decriminalisation. fessional literature. The article is based on euthanasia is legally allowed within a a search for sources within the international specific juridical framework.Even more medical literature, Belgian and Dutch legal THE ACTACTTHE unique is the inclusion of grounds for scripts, and on public commentary on these requesting euthanasia on the basis of documents.documents. In September 2002 the new Act legalising mental suffering.Further refinement of the euthanasia in Belgium came into effect. Its conditions (Belgisch Burgerlijk Wetboek, legal, medical and psychiatric approachto DEFINITIONS AND CONCEPTS 20032003aa,,bb) are that the patient should be at the issue is required in order to clear up least 18 years old, and competent and con- scious at the time of the request; the request essentialpractical and ethicalmatters. In the Belgian Act euthanasia is defined as Psychiatrists and their professional the act of deliberately ending another per- should be voluntary, well-considered and continuous (no minimum period of time is organisations need to play a greater role in son’s life at his or her request. Euthanasia can be performed only by a physician. indicated, because the Act concerns patients this ongoing debate and contribute from a with different life expectancies), and should The law permits only voluntary euthanasia, clinical, scientific and ethical point of view. not be the result of any kind of external and tries to prevent the possible abuses that pressure; the patient should be in a medi- could occur if paternalistic non-voluntary Declaration of interest None.None. cally hopeless condition of constant and (without explicit consent) and involuntary unbearable physical or mental suffering, (done against the explicit wish to live or which cannot be cured and which is a con- In 2002 a new Act that legalised euthanasia without asking the competent patient, but sequence of a severe and incurable disorder in Belgium came into effect, with important still in the latter’s presumed interest) eutha- caused by accident or disease. The treating implications for psychiatrists (Anonymous, nasia were to be permitted. It avoids the 2002). Assessments of capacity by a psy- usual active/passive distinction by consider- doctor has to ascertain that these condi- chiatrist may be requested for patients seek- ing only the active form to be euthanasia. tions are fulfilled and has to confer with a ing euthanasia: these requests may relate to These characteristics are all contentious second, independent physician to obtain his or her advice. The treating doctor is patients with or without mental disorder. aspects within the literature (Harris, 1985; not bound by this advice. Normally, the Whether euthanasia becomes a significant Kuhse & Singer, 1985; Rachels, 1986). If treating doctor will assess the competence practice in Belgium remains to be seen; the doctor actively administers a drug to of the patient. However, when the treating however, it is clear that psychiatrists will bring about the patient’s death at the doctor thinks that the patient will not die become involved in this process because of patient’s explicit request it is called eutha- within the foreseeable future (i.e. the their role in providing assessments of capa- nasia, whereas if the doctor only prescribes patient is not terminally ill), it is mandatory city. To our knowledge, Belgium is the first or supplies the drug at the patient’s request, to consult a third doctor, namely a psy- country where mental suffering stemming it constitutes physician-assisted suicide. If from either a somatic or a mental disorder the administration occurs actively and chiatrist or a specialist in the disorder is explicitly acknowledged in law as a valid without explicit demand from the patient, concerned. The request has to be made in basis for euthanasia. Although questions it legally constitutes murder. writing, and all relevant data must be may arise concerning the other legal added to the medical file. If euthanasia is conditions included within the Act – for adopted, this is followed by a review of example, regarding the competence of the PREVALENCE DATA the case by a federal evaluation committee. patient and whether the suffering is un- bearable or the disease incurable – the Act Prevalence studies carried out in 2001– means that euthanasia can be carried out 2002 revealed that, in Belgium, euthanasia DUTCH LEGISLATION on grounds of mental illness. The aims represented 0.3% of all Belgian AND INTERNATIONAL of this article are to clarify the current deaths, whereas physician-assisted suicide CONTEXT relationship between euthanasia, psychiatry constituted 0.01% (van der Heide et aletal,, and ethics in Belgium; to make compari- 2003). In The Netherlands, euthanasia In The Netherlands euthanasia was de- sons specifically with the Dutch situation; and assisted suicide were more frequently criminalised in April 2001 (Groenewoud

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et aletal, 2000; Anonymous, 2001). Unlike the request (Huyse & van Thilburg, 1993; somatic illness. The main reasons cited for Belgian Act, the Dutch legislation also Grassi, 1997; Onwuteaka-Philipsen & van refusal of a request by the physician were considers physician-assisted suicide and it der Wal, 2001). the presence of other therapeutic options, considers the issue of minors separately. opposition in principle to euthanasia, and In addition, the nature of suffering is not suffering thought of as not unbearable or specified as physical or mental in The EUTHANASIA IN PATIENTS hopeless. Other factors in the decision- Netherlands Act. This means that, in both SUFFERING PRIMARILY making process not mentioned in the countries, euthanasia on grounds of mental FROM MENTAL DISORDER Belgian Act, apart from the legal require- suffering is legally possible, but only in ments, are primarily the nature of the Belgium is this stated explicitly. Further- Euthanasia provided on the grounds of mental disorder, but also include the dura- more, it is noteworthy that euthanasia mental suffering is permitted by Belgian tion and character of previous treatment, was legalised temporarily (1996–1997) in law if the patient is considered to be com- duration and burden of treatment alterna- Australia’s Northern Territory, and laws petent and the suffering is continuous, tives, the opinions of relatives, the patient’s allowing physician-assisted suicide for unbearable and untreatable, and is a conse- age and the threat of violent suicide physically ill patients have been in place quence of a severe and incurable disorder (Groenewoud et aletal, 1997).,1997). in Switzerland since 1937 and in Oregon, (Anonymous, 2002). In The Netherlands USA, since 1994. the situation is similar (Anonymous, 2001). Guidelines In most cases of euthanasia sought on Context grounds of mental suffering the psychiatrist EUTHANASIA ON GROUNDS Data on euthanasia and physician-assisted is the treating doctor. This means that he or OF PHYSICAL SUFFERING: suicide in patients who primarily have a she maintains a therapeutic relationship with ROLE OF THE PSYCHIATRIST mental disorder exist only in The Nether- the patient, but is also the one who carries lands. A representative survey among out euthanasia if the request is granted. This Major themes that emerged among patients Dutch psychiatrists by Groenewoud et aletal is clearly a highly complex situation, which asking for euthanasia are hopelessness, in 1995 demonstrated that the demand for has to be treated cautiously. depressive symptoms, fear and concern, assisted death in patients who suffered pri- marked dependence on caregiving, demora- marily from a mental disorder represented Context lisation, pain and other symptoms, lack of 3% of all requests for assisted death. In The Belgian professional bodies do not social support and absence of religious contrast to somatic medicine, where 37% provide guidelines on this matter. In com- beliefs (Cochinov et aletal, 1998; Emanuel etet of all requests are granted, in psychiatry parison, in The Netherlands guidelines have alal, 2000; Haverkate et aletal, 2000; Kelly etet this is seldom the case (with only 2% of been formulated by the Dutch Psychiatric alal, 2002; Suarez-Almazor et aletal, 2002;,2002; requests granted). At least half of these Association (Nederlandse Vereniging voor Tataryn & Chochinov, 2002). In neither patients also suffer from a severe somatic Psychiatrie, 1998; Tholen et aletal, 1999). ItIt,1999). Belgium nor The Netherlands is psychiatric disorder, often in a terminal stage (Groene- is stated explicitly that the guidelines are consultation mandatory for physically ill pa- woudwoud et aletal, 1997).,1997). meant for cases of mental disorder only, tients. Prevalence data from The Netherlands The motivations behind requests for as defined by the DSM–IV (American Psy- show thatin no more than 3% of all euthanasia among patients suffering from chiatric Association, 2000), and thus not physician-physician-assistedassisted deaths is a psychiatrist a mental disorder are broadly comparable for cases of personal or social suffering. In consulted (Groenewoud et aletal, 1997). In with those cited in somatic medicine. They addition, the nature and course of the men- these circumstances the main task of the include absence of any hope of improve- tal disorder has to be taken into account. psychiatrist is to assess the competence of ment (68%), unbearable mental suffering Extreme caution is recommended when the patient. Competence concerning treat- (58%), being a burden to others (29%), taking euthanasia decisions for patients ment decisions signifies that the patient is pain or other physical suffering (18%) with a personality disorder. The guidelines able to communicate his or her decision, and the loss of dignity (14%). With regard state, as a fundamental principle, that the factually understand the situation and its to the conditions of the new Belgian legisla- request for assisted suicide is essentially a consequences, and rationally assimilate the tion mentioned above, in 64% of the cases plea for assistance with life; assistance with information (Appelbaum & Grisso, 1988). there were still psychiatric treatment the ending of life is but a last, exceptional This is only one possible, ‘medical’, defini- options left that had been refused by the measure.measure. tion of what constitutes competence. patient, in 70% of the cases the death wish Neither the Belgian nor the Dutch Act was long-standing, in 86% the death wish defines competence. This issue is left to had arisen without external pressure and Core conditions the opinion of the doctor concerned. A in 32% of cases the patients were consid- In the Dutch guidelines five core conditions second importanttask for the psychiatrist ered competent. The most frequent psychi- are required. These conditions concur with is the detection andtreatment of any atric diagnosis among patients requesting the requirements set by Belgian law. First, psychiatric disorder.Third, the psychiatrist euthanasia was mood disorder. Personality the request for assisted suicide should have can attempt to make a thorough evaluation disorders were categorised separately and arisen independently of any external pres- of the biopsychosocialsituation of the were present in 64% of the cases, often in sure. Patients who primarily have a mental patient and of possible influences from comorbidity with other disorders. Twenty- disorder are at substantial risk of judging these different areas on the euthanasia two per cent of the patients also had a themselves to be a burden on their carers.

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The psychiatrist has to make sure that there patient (Nederlandse Vereniging voor do not have all the characteristics necessary is no external pressure towards the ending Psychiatrie, 1998; Schoevers et aletal, 1998).,1998). in order to fit into any of the typical of life, either perceived subjectively or categories of DSM, 20–50% of them in actual.actual. almost any diagnostic group are assigned RulesRules As a second condition, the request to the ‘not otherwise specified’ category, needs to be well considered. This means To help guarantee that these five intrinsic and are usually excluded from clinical that the patient should be competent. criteria are met, consultation with a second, research (Helmuth, 2003). Because of this, However, the assessment of competence in independent psychiatrist is mandatory. If it is often hard to predict what response a patient with a mental disorder is not the treating psychiatrist refuses to provide might be expected from a certain treatment straightforward, since the presence of assistance with suicide on grounds of prin- and when that response might occur mental disorder does not necessarily imply ciple, he or she has to inform the patient (Schoevers(Schoevers et aletal, 1998; Kelly & McLoughlin, incompetence (Burgess & Hawton, 1998; as soon as possible, thereby allowing the 2002). Furthermore, prognosis is often Nederlandse Vereniging voor Psychiatrie, patient to approach another psychiatrist. uncertain, with the result that it is rarely 1998; Kerkhof, 2000). Some examples are Each part of this process must be put in possible to describe a mental disorder as patients with recurrent depressive or psy- writing and has to be passed on to the incurable (Schoevers et aletal, 1998; Kelly & chotic episodes who are in symptom-free authorities (Nederlandse Vereniging voor McLoughlin, 2002; Helmuth, 2003; periods of recovery; patients suffering from Psychiatrie, 1998). SjoSjoberg¨ berg & Lindholm, 2003). Thus, relative isolated psychotic symptoms such as hallu- to somatic medicine, in psychiatric medicine cinations, who have preserved enough there is greater uncertainty regarding the awareness of the illness; and certain cases MEDICAL AND ETHICAL various aspects of the decision process and of chronic which are not charac- ISSUES whether the legal requirements concerning terised by low mood and nihilism but rather euthanasia are met. by psychomotor disabilities and sleep The acknowledgement of mental suffering difficulties (Nederlandse Vereniging voor as a valid ground for euthanasia, as estab- Ethical issues Psychiatrie, 1998). Moreover, incomp- lished explicitly in Belgian law, is unique. etence of the patient does not necessarily With respect to both medical and ethical The largest part of the discussion surrounds have to result in a refusal of the request issues, the debate about the legitimacy of ethical issues. The first counter-argument for assisted death. However, this sliding these grounds persists. against assistance with suicide in patients standard of competence poses the risk of suffering primarily from a mental disorder further paternalistic, non-voluntarynon-voluntary eutha- is that one of the psychiatrist’s basic nasia, as personal values of the psychiatrist Medical issues responsibilities is to advocate for the might contribute to the judgement. On a purely medical level, it is often argued vulnerable, disabled and infirm in our Third, the longing for death should be that mental disorders are distinct from society and, when necessary, to protect persistent. This is specified as the repeated somatic disorders, and that the reasoning them from themselves or others (Hamilton and unequivocal expression of the request, and practice adopted in somatic medicine et aletal, 1997; Kissane & Kelly, 2000). A to the physician as well as to a third party, should not therefore be simply applied in classic manifestation of this task is the over a period of at least several months. psychiatry. This argument is supported by prevention of suicide. Assistance with However, the request does not need to be the fact that the causes and psychopath- suicide provided by the psychiatrist implies in writing, because this might lead to ology of mental disorders are often poorly an attitude that is radically opposed to that patients forming an emotional attachment understood and multifactorial (Kelly & medical goal (Burgess & Hawton, 1998; to their suicidal intent (Nederlandse McLoughlin, 2002). The DSM–IV is the Kerkhof, 2000; Kissane & Kelly, 2000). Vereniging voor Psychiatrie, 1998). Fourth, most widely used system of psychiatric Another important argument concentrates the suffering must be perceived by the diagnosis. Although much better than its on the ambiguous notion of mental illness patient as unbearable. To evaluate this, predecessors, it is still in need of consider- itself. If patients suffer in their environment the establishment of a profound and sus- able improvement. In many cases its cate- and develop a mental disorder, it is difficult tained therapeutic relationship between gories seem to be artificial, in that they do to ascertain whether the mental disorder doctor and patient is essential (Nederlandse not represent valid disease entities. It is and suffering are solely a natural reaction Vereniging voor Psychiatrie, 1998). Finally, probable that mental health and disease to an intolerable and/or hostile environ- suffering has to be beyond human aid. This are dimensional in nature, rather than cate- ment, or whether genuine mental disorder signifies that there is no realistic therapeutic gorical as is presumed in DSM–IV. This is has ensued. Historical examples are the option left; that is, there is no remaining particularly true for the categories of per- high numbers of suicide in unmarried treatment option that gives a prospect of sonality disorders, which are among the mothers and gay men (once considered to improvement within a reasonable period least valid and reliable of DSM categories be mentally ill) in social environments of time and that imposes no unreasonable (Helmuth, 2003). All these reasons contri- where they were not accepted. Thus, the burden on the patient. Essentially, this bute to a scientifically weak basis upon term ‘mental suffering stemming from implies that all applicable biological, which to rest such an important decision mental disorder’ is vague and hard to psychotherapeutic and social interventions as euthanasia. Moreover, there are still define, and the potential for abuse is should have taken place, according to too few long-term follow-up studies in serious. A final but recurring theme in the medical understanding and to the personal psychiatry to predict the natural course of literature is a fear of gradual social values, standards and life aims of the a psychiatric disorder. Since many patients acceptance of the practice of euthanasia,

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which might lead to a less careful decision- DISCUSSION Psychiatrists should, however, participate making process and to dealing less ade- more and contribute from a scientific, quately with and behav- Reactions from the medical world ethical and clinical point of view. iour (van der Maas et aletal, 1996; Hamilton Reaction to the Belgian Act came, & Hamilton, 2000; Onwuteaka-Philipsen among others, from the World Medical REFERENCES et aletal, 2003).,2003). Association (WMA), a federation of medical unions who stated that ethics should always American Psychiatric Association (2000) Diagnostic prevail over the law, and that Belgian and Statistical Manual of Mental Disorders (4th edn,Text physicians refusing to cooperate with the Revision) (DSM^IV^TR).Washington, DC: APA. Potentially positive implications new Act on euthanasia would be supported Anonymous (2001) Wet euthanasie Nederland [The by the WMA (de Pape & Selleslagh, 2003). Netherlands euthanasia law] KB12/04/2001.‘Wet The main argument in favour of assistance toetsing levensbeeindiging op verzoek en hulp bij with suicide for patients who primarily zelfdoding’, Nederlands Staatsblad,26April,Artikel194. have a mental disorder arises from the area Social responses Anonymous (2002) Wet betreffende de euthanasie of . The demand for From the Association of Care Institutions, [Law concerning euthanasia]. Belgisch Staatsblad,22,22 June,28515^28520. euthanasia by a patient means that life at the umbrella organisation of Catholic that particular moment is unbearable to hospitals in Belgium, a disapproving and Appelbaum, P. S. & Grisso,T.Grisso, T. (1988) AssessingAssessing the patient and that something has to patients’capacities to consent to treatment. NewNew discouraging attitude towards euthanasia in England Journal of Medicine,, 319,,1635^1638. 1635^1638. change. Thus, in the Dutch guidelines, the its institutions was adopted: euthanasia of demand for assisted suicide is considered Belgisch Burgerlijk Wetboek (2003aa)) VerlengdeVerlengde patients who were not terminally ill, patients minderjarigheid. Inleidende titel en boek I: Personen, to be a demand for good, effective treat- in a coma who had supplied advance direc- Titel X,Chapter IV. http://www.staatsblad.be ment. From this point of view, it is import- tives and patients experiencing mental suffer- Belgisch Burgerlijk Wetboek (2003bb)) ant to take this request seriously and open it ing were all considered to be unacceptable Onbekwaamverklaring. Inleidende titel en boek I: up for discussion. In these circumstances a (Vereniging van Verzorgingsinstellingen, Personen,Titel XI,Chapter II. http:/www.staatsblad.be therapeutic relationship can be established 2002). Criticism also arose in the Catholic Burgess, S. & Hawton, K. (1998) Suicide, euthanasia in which space can be found to restore hope Church. Belgium’s leading cleric con- and the psychiatrist. Philosophy,PsychiatryPhilosophy, Psychiatry and Psychology,, 55,113^176. in the patient. When this has been suffi- demned the euthanasia Act, calling it a ciently achieved, alternative treatment token of the negation of the worth and Chochinov, H. M.,Wilson, K. G., Enns, M., et aletal (19 9 8) options may be considered by the patient Depression, hopelessness, and suicidal ideation in the dignity of man (Wouters, 2002). Since the terminally ill. Psychosomatics,, 3939,,366^370. 366^370. (Nederlandse Vereniging voor Psychiatrie, vast majority of Belgian hospitals call them- de Pape, N. & Selleslagh, P. (2003) WMA: Ethiek heeft 1998; Werth, 1998; Kerkhof, 2000). selves Catholic, the importance of these voorrang op wet. Artsenkrant,, 15161516,2. Further arguments in favour are mainly opinions should not be underestimated..underestimated Emanuel, E. J., Fairclough, D. L. & Emanuel, L. L. based on compassion. Essentially, most Such responses are by no means atypical. (2000)(2000) Attitudes and desires related to euthanasia and patients suffering primarily from a mental In England and Wales, consultation by the physician assisted suicide among terminally ill patients disorder are physically capable of suicide, joint committee examining the draft and their caregivers. JAMAJAMA,, 284284, 2460^2468. hence – some may argue – it is not really Mental Incapacity Bill resulted in a welter Grassi, L. (1997) Psychiatric implications of euthanasia necessary to provide assistance. If no assis- of critical responses from those who feared and assisted suicide in terminally ill patients. NewTrends in Experimental and Clinical Psychiatry,, 13,127^132.,127^132. tance is provided, however, the patient may that it would permit euthanasia to proceed Groenewoud, J. H., van der Maas, P.P.J., J., van der Wal, be more likely to attempt suicide in lonely, via the ‘backdoor’ (House of Lords & G.,G., et aletal (19 9 7)7)(19 Physician-assisted death in psychiatric difficult circumstances and in a risky and House of Commons, 2003). practice in the Netherlands. New England Journal of violent way. Moreover, such patients may MedicineMedicine,, 336336,1795^1801. run the risk of failing in their suicide Guidelines Groenwoud, J. H., van der Heide, A., Onwuteaka- attempt, and instead harm themselves Philipsen, B. D., et aletal (2000) Clinical problems with the The Belgian professional bodies of psychia- seriously and permanently. Once the legal performance of euthanasia and physician-assisted suicide trists have formulated no guidelines for the inThe Netherlands. New England Journal of Medicine,, requirements have been met, assistance particular situation of a request for eutha- 342,551^556. with suicide may create the opportunity nasia on grounds of mental suffering. The Hamilton, N. G. & Hamilton, C. A. (20(2000) 00) for a more humane method of suicide law provides a framework for the approach Therapeutic response to assisted suicide request. IssuesIssues (Burgess & Hawton, 1998; Nederlandse in Law and Medicine,, 1616,167^176. to this situation, but a reply on the part of Vereniging voor Psychiatrie, 1998; Kerkhof, the professional world is lacking. We think Hamilton,N.G.,Edwards,P.J.,Crawshaw,R.S.,Hamilton, N. G., Edwards, P.J., Crawshaw, R. S., et aletal 2000). Furthermore, prevention of violent (19 9 7) Physician-assisted suicide in Oregon. AmericanAmerican it is essential that such guidelines are devel- suicide can be seen as a measure to protect Journal of Psychiatry,, 154,,1326^1327. 1326^1327. oped, in keeping with the state of affairs in people who might become accidentally Harris, J. (1985) The Value of Life. London: Routledge & The Netherlands. Moreover, consensus involved in, and traumatised by, the Kega n Paul.Paul.Kega documents and protocols are needed con- patient’s suicide (Nederlandse Vereniging Haverkate, I., Onwuteaka-Philipsen, B. D., van der cerning which therapies should be applied voor Psychiatrie, 1998). However, the Heiden, A., et aletal (2000)(2000) Refused and granted requests in specific disorders before euthanasia or for euthanasia and assisted suicide in the Netherlands: psychiatrist should rule out the possibility assistance with suicide can be considered. interview study with structured questionnaire. BMJBMJ,, 321,, that the threat of a violent suicide is a 865^866.

manipulative gesture; to this end, the Helmuth, L. (2003)(20 03) In sickness or in health. Science,, psychiatrist should rely predominantly Civil debate 302302,,808^810. 808^810.

on his or her own clinical experience There has been ongoing, albeit little, House of Lords & House of Commons (2003) JointJoint (Kerkhof, 2000). debate about this controversial legislation. Committee on the Draft Mental Incapacity Bill ^ First

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