Abandoning hope: Euthanasia for mental disorders.

This article was published by the Australian Care Alliance on July 24, 2019.

Guidelines issued for assessing and executing requests for euthanasia and assisted suicide from people with mental disorders, including addictions such as alcoholism, by the Netherlands Federation of Medical Specialists and the National Council of the Order of Physicians of Belgium essentially authorise doctors to agree with a patient that abandoning all hope - as if they were at the gates of hell in Dante's Divine Comedy - is the only proper response to their mental illness or addiction.

This plaque could appropriately be put on the office door of Dutch and Belgian doctors who give effect to the guidelines.

The Belgian "Guidelines for the application of euthanasia to patients suffering from mental illness as a result of a psychiatric disorder" were issued by the National Council of the Order of Physicians on 27 April 2019.

While these new guidelines show some recognition that there is a problem with the normalisation of euthanasia as a response to persons with psychiatric disorders at the heart of the guidelines there is an abandonment of the patient by formalising a process in which a doctor agrees that his or her life is hopeless, not worth living and that suicide by doctor is the only appropriate response.

The guidelines state that "A determination that the psychiatric condition is incurable and hopeless should not be made unless all 'all possible evidence-based treatment' has been tried. If a patient refuses 'certain evidence-based treatments, the doctor cannot apply euthanasia'. However, 'the doctor must show a certain reasonableness. He must not fall into a therapeutic obstinacy. The reasonable number of treatments to be followed is limited'.

In other words the doctor is authorised to, along with the person struggling with a mental illness or addiction to agree with the person's sense of despair and hopelessness.

Read further on the Belgian guidelines here.

The directive "Termination of life on request in patients with a mental disorder" was issued by the Netherlands Federation of Medical Specialists on 28 September 2018.

The directive states that:

The granting of life termination on request for patients with mental illness is an ultimate and extraordinary medical treatment to eliminate suffering, or an ultimate refuge.

Interestingly the 73 page directive includes information on a survey of psychiatrists in the Netherlands which summarises the views of those opposed to euthanasia for mental illness:

• Considering a euthanasia request conflicts with the goal of ongoing treatment; 
• There is a real danger of counter-transference which makes objective assessment of a request for the termination of life doubtful; 
• There is no ultimate distinction between a desire for euthanasia or assisted suicide and chronic suicidal ideation; 
• Hopelessness and unbearable suffering for persons with a mental disorder are elastic, subjective concepts; 
• There is a contradiction between “hopelessness” and the relatively long life expectancy of persons with mental disorders; and 
• There are many uncertainties in the accurate diagnosis of mental disorders and the assessment of reasonable treatment options.

The directive dismisses this perspective and attempts to maintain that there is a real distinction between "a lonely suicide” and a “dignified” termination of life arranged by the doctor.

However, this distinction unravels as the directive goes on to observe:

the distinction between suicidality and a request for termination of life can fade over time or completely disappear. This situation can occur if:

• suicidality is chronically present against the background of a long-standing mental disorder; 

• the patient can form a reasoned opinion about his disorder; and 

• seeks professional help with the execution of his death wish.

Suicidality can then be the expression of a long-standing and autonomous desire not to live anymore, after many episodes of severe suffering. It can be a rational reflection on the lack of future prospects, lack of treatable suicidality and mental disorder and an inability to endure suffering.

Patients can suffer greatly from their own suicidality, for example when there are endless images imposed of their own future suicide on them. Suffering from one's own suicidality can also be a component form of a considered request for termination of life.

Thus in the Netherlands suicidality can in itself be seen as a reason for a doctor to collaborate with the patient’s mentally disordered desire to commit suicide by providing “professional help with the execution of the patient’s death wish”.

The directive even notes that “suicidal behavior is increasingly expressed by the patient as a request for euthanasia or assistance with suicide. After all, the term ‘euthanasia’ is becoming more and more common in the media and patients are increasingly adopting this language in a completely different context.” This observation is consonant with the danger of suicide contagion – in this case from the context of societal approval of euthanasia and assisted suicide to the thinking of persons with a metal disorder.

Read further on the Netherlands directive here.