Introduction 

Voluntary euthanasia is defined as the act of a medical professional who administers drugs to a patient, with the patient’s consent, to end that patient’s life.1 This procedure is legal in Belgium, The Netherlands, and Luxembourg.

 

     Euthanasia and physician assisted suicide (E/PAS) is a controversial ethical dilemma; this is partly due to differing beliefs in different communities. The top 4 major world-wide religions “paint E/PAS in a negative light”2, whereas in a secular society it is “frequently supported”.2 In the article: ‘Perspectives of Major World Religions regarding Euthanasia and Assisted Suicide’, it is concluded that there are two main factors as to why religious societies oppose E/PAS. The first is due to judging morality in alignment with a religious figure. The second reason is the common theme of an afterlife or existence beyond death, which carries implications for one’s current life and accounts for actions such as taking another human life, which wouldn’t be viewed favorably. In this literature review, rather than looking at the ethics of euthanasia in a general sense, the dilemma of E/PAS with regard to patients with a mental illness will be covered. Somatic E/PAS is another sub-category of E/PAS which refers to euthanasia and physician-assisted suicide for those suffering with conditions affecting the body, not psychological or psychiatric conditions. In this literature review, comparisons will be drawn with somatic E/PAS, whilst the criteria surrounding the eligibility of the mentally ill for euthanasia will be discussed along with the burden placed on clinicians and families.

Criteria for E/PAS and the challenges it poses  

     For those patients with a mental illness, the prognosis is not so clear. According to Professor Geert Dom in the journal Psychiatria Polska, “Psychiatric assessments currently still perform very poorly as to the prediction of course and outcome of psychiatric disorders for an individual patient”.3 In some instances, it is hard to determine whether a mentally ill patient is incurable, especially compared to a patient suffering with a somatic illness.3 External factors such as the patient’s socio-economic situation further complicate the picture. It is also difficult to predict how medication or treatment will affect a psychiatric patient, adding to the uncertainty of a prognosis except for diseases such as Alzheimer’s disease. Studies from the Netherlands suggest there is a disagreement among psychiatrists 11-20% of the time regarding the suitability of a patient for E/PAS.4 Some patients will never recover from a psychiatric condition, but whether these patients can be identified is a different question. It could be argued that the time frame of the inevitability of death is more accurate and predictable with somatic E/PAS, (for example, cancer) than with psychiatric E/PAS, so errors with E/PAS are less likely to occur. With psychiatric disorders, the “model is said to describe syndromes and therefore offers no insight in the underlying biological, psychodynamic or social factors” 4, which creates difficulty in being able to predict the trajectory of a psychiatric disease. This brings us to the question: if a prognosis is uncertain and unclear, can E/PAS designation be granted?

 

      In Belgium, one of the criteria needed for psychiatric euthanasia is that all treatment options have to have been exhausted.5 However, it is difficult to assess whether all treatments have been explored, as there is a very individualized response to each treatment. Furthermore, the clinician must be aware of all the possible treatments available for each of their patients and of all the separate mental illnesses that their patients may have.3 In Belgium, for a mentally ill patient, there is a distinct difference between ending life early due to a likely outcome of death in the near future versus a condition where death is not foreseeable or expected.3 If a death is not foreseeable, then along with the clinician overseeing the euthanasia procedure, an independent opinion is needed from an expert in the patient’s psychiatric disorder. Prof. Dom explains that “In Belgium, a very real danger exists that patients may consult many doctors” 3 until they obtain the assessment they wish for. This means patients can shop around for doctors until they are given the prognosis they require; this highlights the need for more strict and vigorous guidelines.  

 

      Psychiatric patients requesting E/PAS may have refused available treatments, and it is therefore hard to assess whether all treatments have been exhausted. Does ‘all treatments exhausted’ mean that all of the treatments the patient is willing to undergo, or does it refer to all of the treatments likely to be effective? Under these premises, can a patient deem themselves incurable by refusing all treatment or only selecting some treatments, even when other suitable treatments are available? One of the most important factors when practicing medicine is that a patient can refuse care without justification and that their wishes should be respected; however, should it then automatically qualify them for euthanasia? In the Netherlands, the High Court ruled that if a patient refuses treatment and there is an available treatment, then E/PAS is not appropriate.4 However, Canada’s law overseeing euthanasia states that E/PAS is available “when all treatments acceptable to the patient have failed”, 4 indicating that treatments can be refused by the patient, but that they remain eligible for E/PAS.

Suicidal ideation as a symptom of mental illness 

      According to a paper by Lars Mehlum published in Biomed Central, “Suicidal behaviour is more frequently seen in people with antisocial personality disorder”.6 This would imply that people who have this disorder are more likely to have a “stronger wish for death”.6 When people with these conditions experience despair and see no solution, then they are potentially more likely to consider suicide. Such individuals, burdened with unbearable suffering that cannot be altered, can pose a challenge in their assessment for E/PAS. This requires answering difficult questions: as mentally ill patients, should they be refused E/PAS and instead be forced to continue their suffering? For people with suicidal thoughts, there is a range of treatments that can prevent such thoughts and actions in “most cases”.6 Should this mean that all of these treatments be tried first? For those who do not respond to any of the treatments, this could only prolong their suffering. However, for those where treatment is successful, this could prevent them from ending their life prematurely. The other element to consider is that if someone with a personality disorder who is suicidal is denied E/PAS and then dies by suicide outside of medical means, would it not have been better for them to do so in a more compassionate and controlled manner?7 If someone’s death is inevitable, would it not be better assisted by professionals in a more pleasant setting? However, it should be considered that someone with a psychiatric condition requesting E/PAS may just be trying to communicate or reach out to a clinician for help rather than wanting to end their life.6

 

      A study in Belgium on physician assisted death (PAD) revealed that “8 of the 48 psychiatric patients who were granted PAD in the end didn’t need it because simply it gave them enough peace of mind to continue living”.4 In that study, 17% of the people who requested and were granted E/PAS did not end up taking it. This poses an interesting perspective; if life continues to be unbearable for these patients, they have access to a final option of E/PAS to fall back on, which allows them to continue to elect to live. It also raises the question of whether easier access to euthanasia as a psychiatric patient would increase the hope and motivation of patients with mental illness and not necessarily lead to more deaths.

Impact on families and clinicians 

      One of the key distinctions with E/PAS for the mentally ill is that psychiatric illness is not always a terminal disease, although “it can be immensely difficult and painful”.8 Some believe that if there is any possibility of recovery for a patient then they should be kept alive, but at what point does the chance of recovery become so slim that it would be deemed improbable?4 This risks the patient having to carry the burden of unbearable suffering for longer than necessary. A clinician administering E/PAS can be seen as having given up hope, and with this option available to a patient, motivation for treatment and hope can be removed. Clinicians losing hope for patients can be particularly dangerous; instead, they should continue providing support and trying a range of treatments and/or medications to help relieve suffering. Allowing E/PAS for psychiatric patients risks the values of “protecting and upholding life”.8 This may conflict with the Hippocratic oath and the ethical principle of ‘doing no harm’, as psychiatrists have traditionally focused on the diagnosis, treatment, and prevention of mental health conditions.9 

 

      For many psychiatrists, E/PAS can be challenging as physicians may feel that they are no longer treating or preventing their patients' conditions. Expecting clinicians to determine whether a patient lives or dies places extra pressure on them to decide “which lives are worth living”.8 This is true in somatic euthanasia as well, but due to the unknown response to treatments and unpredictability of the diseases, this is especially true in euthanasia for psychiatric conditions. Clinicians are asked to grant E/PAS, but it can harm their mental health in doing so.

 

      In the past, several clinicians have been put on trial for murder. In 1981, in the UK, Dr. Leonard Arthur was put on trial for murdering a child with Down's syndrome (trisomy 21). In this case, Dr. Arthur decided not to prescribe nursing and give prolonged life care to his patient.10 Dr. Arthur was initially charged with murder as he purposely gave treatment which accelerated the life of the child. The doctor was eventually acquitted after extensive deliberation, and new guidelines were put in place for the care of children, especially those lacking mental capacity. More recently, in Belgium, 3 clinicians were “put on trial for murder by poisoning”3 following the euthanasia of a psychiatric patient. The clinicians were found not guilty in January 2020. The euthanized patient had recently been given a diagnosis of autism and borderline personality disorder.3 These cases demonstrate the controversial nature of these issues and the toll it can take on clinicians. It also highlights an ongoing issue of establishing medical laws and guidelines only after a serious event occurs due to a lack of preexisting regulations or support. While it is necessary to reflect on serious events and prevent them from occurring again, establishing robust guidelines before these events would have prevented any doubt or questioning of medical professionalism. 

 

     Previously, there had been little research conducted into how families have been affected by psychiatric E/PAS. A qualitative study based in the Netherlands showed that the family and friends of those undergoing psychiatric E/PAS remained respectful of the decisions made.11 This was for many reasons, including “compassion, respect for autonomy, fear that the patient will commit a gruesome suicide”.11 However, the families had still hoped for a different decision. A Swiss study of family members and close friends of the euthanized found that 13% of them met the criteria for PTSD.11 In comparison, a mental health report by the UK government found the prevalence in the general population of PTSD to be 4.4%.12 Among widows whose the spouses died from “unnatural causes (suicide or accident)”13, 36% met the criteria for PTSD. Although the statistic of 36% is not exclusive to suicide, it suggests what while PTSD rates are higher among the bereaved families and friends of those who underwent euthanasia compared to the general population, they are lower than among those grieving a loved one who died by suicide. These statistics are not specific to psychiatric patients, though they could still indicate what might be expected amongst families of euthanized mentally ill patients.   
 

Euthanasia of people deemed to be without capacity 

      Another possible scenario is the case of non-voluntary euthanasia, where the patient is unable to communicate but has attempted to end their life multiple times. Autonomy allows us to make our own medical decisions, provided that we have the capacity. However, for some psychiatric patients, their “concept of reality is severely distorted”14, and they therefore cannot justify their decisions and lack the capacity to make them. In this case, is the decision to die by suicide truly their own beliefs, or is it a warped perception? Even if it is a distorted version of reality, should clinicians prevent them if this is their reality? It has been suggested that patients could be sedated until a cure is discovered.14 However, it’s unlikely that psychiatric patients in this case are able to process the information and make an informed decision. Could it be assumed that for the psychiatric condition they are suffering from, a potential cure would no longer entail euthanasia? It could be widely agreed that E/PAS can’t be carried out under the influence of a misconception or misunderstanding. However, in the case of non-autonomous patients who don’t necessarily have the correct understanding of reality, should they be granted E/PAS? These considerations further emphasize the difficulty physicians have to determine the eligibility for euthanasia with the consequences of making the wrong decision enormous. 

 

Conclusion

     To summarize, it is difficult to accurately determine the extent of a psychiatric patient's unbearable suffering and whether it is ‘incurable’. This creates an issue when deciding to grant E/PAS in the countries where it is legal. The patient's ability to refuse treatments poses a challenge for clinicians in their attempt to exhaust all the possible treatment plans. Can a patient refuse all treatments and then gain access to E/PAS? For those who can’t communicate their feelings and aren't able to act on them, how will they be treated, and will it be equitable? It is also important to consider the burden placed upon psychiatrists and clinicians, who are tasked with making one of the most profound decisions possible - the termination of a patient’s life.