Wednesday, June 5, 2019

New Belgian guidelines for psychiatric euthanasia.

Dr Mark Komrad
Dr Mark S. Komrad M.D., DFAPA, DACP Faculty of Psychiatry, Johns Hopkins and University of Maryland sent a summary of The Belgium National Council of Physicians new “guidelines” for the voluntary euthanasia of psychiatric patients
(Link to the guidelines). Mark wrote:

The guidelines include some positive changes even though the eligibility of certain psychiatric patients with “unbearable” and “untreatable” mental illness remains, there have been some changes in the recommend procedures that slightly reign in the practice. I provided a Google Translation. 

The highlights of these changes are:
• Now there must be THREE doctors involved: the one who will administer the euthanasia, and two who are not administering the euthanasia, but are involved in determining a patient's eligibility. Both consultants MUST be psychiatrists. That is new. [Again, this pertains only to psych patients]. Previously, a psychiatrist as a consultant was recommended but not required. So, it had previously been possible for psychiatric patients seeking euthanasia to not have a second opinion from a single psychiatrist prior to being euthanized.

• The three doctors now MUST MEET IN PERSON to confer about the case. Previously, such a conference was not required. However, “they are not required to agree on everything.” In fact, it is recommended (not required) that other professionals involved in the case, such as nurses, therapists, and psychologists, attend this potentially “interdisciplinary" meeting.

• Heretofore, the established right of patients to refuse certain treatments was also extended to psychiatric patients. So, the concept of an “untreatable” condition was confined to the list of treatments that a patient would accept. Now, to be eligible for psychiatric euthanasia, the patient must have tried “all evidence-based treatments” for that condition. Refusal of one of those treatment options would disqualify a patient for euthanasia. This is a significant step.

• The established “one month” waiting period between requesting and receiving euthanasia, is now deemed insufficient for psychiatric patients. These new guidelines say that one-month is insufficent. Unfortunately, they do not stipulate how long is appropriate for psychiatric patients. Psychiatric patients should have “a treatment process spread over a long-term period.” Unfortunately, no specific time frames are specified. So, this feature may have little value without that clarity.

• Though patients have a right to exclude family members for the euthanasia evaluation and decision process, physicians are urged to include family members unless there is no substantial reason to include them. This only re-iterates suggestions for common sense practice that is largely the status quo anyway. There are no mandates to include family either for corroborative history, or co-consent. But psychiatrists are urged to encourage their patients to include their family. I do not see this as a substantive change.

• Though not a change, there is more emphatic reiteration that a conscientiously objecting physician MUST REFER to an alternative doctor who might be willing to approve euthanasia (no guarantees). In this regard, the Belgian law is similar to the recently litigated and court-supported rules for conscientious objection to euthanasia in Ontario.
A few notes. This is not a new law, but a set of “guidelines” issued by the national organization that regulates physicians, not a legislature. It’s like a “practice guideline” in the U.S. The legal consequences of failing to following these guidelines with its “musts” and its “shoulds,” is not clear. The new disqualification for euthanasia if a patient refuses an “evidenced based” treatment, pertains strictly to psychiatric patients seeking euthanasia for their psychiatric conditions, not those with other kinds of illnesses. In that sense, it is a step away from parity, and interestingly, applies only to those with psychiatric conditions, not other conditions. So, for example, a patient with chronic renal failure, may still refuse dialysis. But, a psychiatric patient who refuses, say ECT for treatment resistant depression, would not be eligible for euthanasia.

Though somewhat tighter, these regulations continue to sustain the eligibility of some psychiatric patients to have euthanasia, helping them to commit suicide, sometimes administered by the same psychiatrists who previously had been trying to prevent their suicides.

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