by Lieve Thienpont et al, ‘Euthanasia requests, procedures and outcomes for 100 Belgian patients suffering from psychiatric disorders: a retrospective, descriptive study’, BMJ Open 2015;5: e007454. doi:10.1136/ bmjopen-2014-007454
The authors of this study are involved in the euthanasia of psychiatric patients in Belgium. The study looks at the first 100 requests for euthanasia in the outpatient clinic where Dr Thienpont worked, covering the period October 2007 to December 2011.
These are their words (with emphasis added in blue):
The main argument in favour of providing life-ending assistance to psychiatric patients is that their suffering can be equally unbearable as the somatic suffering of other patients. The main argument against providing such assistance is that suicide prevention is a primary purpose of psychiatric care and a key focus of training for psychiatrists. From the psychiatrist’s perspective, if the psychiatric patient has no further prospect of improvement, continues to suffer unbearably and persists with his or her wish to die, the psychiatrist finds himself or herself in the position of having to accept the validity of this wish, if all legal requirements can be fulfilled and all possibilities of mistakes and abuses can be carefully avoided.
- Consent from the relatives is not required, and the attending physician needs the patient’s permission to inform family members of the euthanasia request. Fostering acceptance in the patient’s social environment can give the patient the opportunity to pass away in a serene atmosphere, surrounded by family and/or friends, whose mourning process can thus also be softened.
The patients included 23 men and 77 women, age ranging 21–80 years, with an average age at intake of 47; the average was 46 years for men (range 22–79 years) and 47 years for women (range 21–80 years). The majority (n=81) had been professionally inactive for an extended period of time, including 8 who were retired and 73 who were medically unfit for work (they were either receiving disability living allowances or had taken early retirement). Fourteen patients were still working or temporarily on sick leave. One patient was a student, one was imprisoned and one was receiving a subsistence income from the Public Social Welfare Agency. Fifty-nine patients were living alone while 41 were living with one or more companions.
In comparison to other studies, our patient group contains more women than men (23 men and 77 women), which is different from the male-to-female ratio in the euthanasia cases carried out for somatic and/or mental reasons as recorded by the FCEC (51:49). This is in line with other reports in the literature, which indicate that women fulfil the diagnostic criteria for mental disorders more often than men, except in the case of substance use disorders. Furthermore, demand for mental healthcare and utilisation of mental healthcare services are higher in women than in men.
Most of the patients suffered from a treatment-resistant mood disorder (n=58, including 48 with major depressive disorder and 10 with bipolar disorder) and/or a personality disorder (n=50), while 29 patients had both. Other psychiatric diagnoses included post-traumatic stress disorder (n=13), schizophrenia and other psychotic disorders (n=14), anxiety disorders (n=11), eating disorders (n=10), substance use disorders (n=10), somatoform disorders (n=9), pervasive developmental disorders (n=8; including 7 with Asperger syndrome —an autism spectrum disorder (ASD)— and 1 with attention deficit hyperactivity disorder), obsessive-compulsive disorders (n=7), dissociative disorders (n=7) and complicated grief (n=6), among others. In addition to their psychiatric disorder(s), 23 patients also had somatic illnesses, including chronic fatigue syndrome and/or fibromyalgia (n=8), or other chronic somatic suffering (n=15).
By the end of 2012, when follow-up was conducted, 43 of the 100 patients had died. Euthanasia had been performed on 35 patients (9 men and 26 women). Six patients had committed suicide (2 men and 4 women). Two other female patients had died, one after palliative sedation in a psychiatric hospital, and the other due to the terminal stage of anorexia nervosa.
In 33 of the 35 procedures, the relatives and the doctors performing euthanasia explicitly reported a calm and smooth passing. In one case, tensions rose due to emotional difficulties for some relatives in fully accepting the patient’s wish to die by means of the euthanasia procedure. In another case, the practitioner performing the procedure was inexperienced and became overwhelmed and stressed by the situation, which caused discomfort for the patient.
A literature review made clear that the concept of ‘unbearable suffering’ has not yet been defined adequately, and that views on this concept are in a state of flux. It is generally accepted that this concept is considered to be subjective, dependent on personal values, and that it must be determined in the first place by the patient. Nevertheless, a psychiatrist should carefully evaluate this in the context of each patient’s psychopathology. Unfortunately, there are no guidelines for the management of euthanasia requests on grounds of mental suffering in Belgium. Taking into account the ongoing fierce ethical debates, it is essential to develop such guidelines, and translate them into clear and detailed protocols that can be applied in practice.