Opinion
VIEWPOINT
Reginald Deschepper, MA, PhD Mental Health and Wellbeing Research Group, Vrije Universiteit Brussel, Brussel, Belgium. Wim Distelmans, MD, PhD Department of Supportive and Palliative Care, Vrije Universiteit Brussel, Brussel, Belgium. Johan Bilsen, MSc, RN, PhD Mental Health and Wellbeing Research Group, Vrije Universiteit Brussel, Brussel, Belgium.
Corresponding Author: Reginald Deschepper, MA, PhD, Mental Health and Wellbeing Research Group, Vrije Universiteit Brussel, Laarbeeklaan 103, 1090 Brussel, Belgium ([email protected]).
Requests for Euthanasia/Physician-Assisted Suicide on the Basis of Mental Suffering Vulnerable Patients or Vulnerable Physicians? In only a few countries, such as Belgium and the Netherlands, and in some states in the United States, euthanasia/physician-assisted suicide (EAS) is legally possible under some circumstances. Arguments in favor of legalization of EAS are that it might function as a safeguard to semilegal practices, that it fosters transparency, and that it enables one to verify whether criteria of due care are met. It also provides legal safety for the physicians involved. In these places, EAS has increasingly become an acceptable option for patients with serious irreversible diseases, such as cancer, that are accompanied by unbearable physical suffering and that finally lead to death. 1 Euthanasia/physician-assisted suicide in cases of mental suffering, however, is much more controversial. In Belgium, euthanasia for mental suffering is possible under certain extra due care conditions, such as the advice of 2 other physicians. In 2011, “unbearable mental suffering due to an irreversible disease” was the only motive for euthanasia in 3.5% of all the reported euthanasia cases (N = 1133) in Belgium (Figure).2 However, requests for euthanasia based on unbearable mental suffering are much more common.3 Although the patient is of course central to this debate, when physicians are confronted with such requests from well-informed, quite assertive, young, welleducated patients who are not terminally ill, they often experience a lot of stress. Dealing with such requests is also quite complex because of the specific medical and conflicting ethical questions they raise. Highly controversial cases (eg, those associated with Dr Jack Kervorkian in the United States or with the Dutch psychiatrist Dr Boudewijn Chabot, who provided lethal drugs to depressed patients) fueled the debate about whether patients who have been granted euthanasia have been adequately treated. The main concern of physicians dealing with such a request is that they might fail to detect a (treatable) depression or some other kind of mood disorder. Abuse has not been widespread, but EAS for mental suffering remains very controversial and has more often been judged as “not meeting due care requirements.”4 An additional complicating factor is that physicians who have to deal with requests for EAS based on mental suffering sometimes have to endure intense pressure from their patients. In extreme cases, when their requests are refused, these patients may threaten to commit suicide. Of 100 euthanasia requests based on mental suffering received in Belgium between 2007 and 2011 and followed up until
jamapsychiatry.com
February 2013, 33 were granted, but another 5 were not and ended in the patient committing suicide.5 The treating physicians may also experience extra pressure when their patients have already found 2 or more physicians who have approved the performance of euthanasia. Moreover, the implementation of laws on EAS is often impeded by ambivalence and by the vagueness of concepts such as “unbearable suffering” and “incurable disease.” In the case of mental suffering, physicians have to rely heavily on the patient’s own reporting, without there being any “objectively” measurable symptoms. There is thus often no other evidence than the patient’s subjective perception and complaints. Furthermore, in the case of mental suffering, the patient’s capacity of judgment may be impaired, making it difficult to differentiate between a request based on a genuine and constant form of unbearable suffering and a request as a symptom of a severe depression. On the other hand, mental suffering is not less severe than physical suffering and is often hard to treat, and it has also been argued that depression does not necessarily imply that a patient is unable to make well-considered decisions. Sometimes, after a long and time-consuming process, physicians acknowledge that all the available treatments have not resulted in any improvement and that the patient fulfills all of the criteria for euthanasia. In such cases, physicians may find it hard to refuse the euthanasia request any longer. Once performed, EAS has sometimes resulted in emotional reactions from family members. In some cases, accusations have also been made against physicians in the popular press by the patient’s family, speaking in detail about their experiences. However, the physicians could hardly respond to these accusations because of their duty to uphold medical confidentiality. In other cases, physicians have been questioned by an attorney or physically threatened by family members. The (emotional) impact of the decision-making process and the performing of EAS should not be underestimated, especially in cases at the limits of what physicians personally perceive as legally and/or ethically acceptable. In Belgium, for instance, some physicians have therefore decided to (temporarily) refrain from performing euthanasia, not necessarily because they doubt that they are justified in complying with a euthanasia request in a particular case but mainly because of the emotional and practical burdens that go with it. Other physicians complain of being overburdened or overloaded with too many euthanasia requests. These problems are JAMA Psychiatry June 2014 Volume 71, Number 6
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://archpsyc.jamanetwork.com/ by a SUNY Binghamton User on 05/16/2015
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Opinion Viewpoint
Figure. Reported Cases of Euthanasia in Belgium (2005-2011) 1200 Physical 1000
Mental and physical Mental
No. of Cases
800 600 400 200 0
2005
2006
2007
2008
2009
2010
2011
Year
accentuated further by a lack of trained physicians in this domain and insufficient official remuneration for physicians who are willing to participate in an EAS process.
To conclude, dealing with requests for euthanasia or physician-assisted suicide is emotionally, ethically, and even physically very demanding.6 The experiences of the countries where these practices are a legal option make it clear that, especially with regard to requests due to mental suffering, such deliberations may be too hard to deal with for an individual physician. Therefore, such decisions must be made in a multidisciplinary team that can weigh all the pros and cons along with the patient. Such a team can make decisions in a transparent way and can allow caregivers to share responsibility and find support in each other. It should also be stressed that training in end-of-life care should be part of the general medical education, including the way in which requests from patients asking for their life to be ended should be dealt with. We believe these training measures should not be restricted in any way to countries where these practices have been legalized or to physicians who consider these practices acceptable options because any physician might be confronted with such an incisive request7 and will have to deal with it in one way or another.
Belgian physicians regarding euthanasia practice and the euthanasia law. J Pain Symptom Manage. 2011;41(3):580-593.
ARTICLE INFORMATION Published Online: April 23, 2014. doi:10.1001/jamapsychiatry.2014.185. Conflict of Interest Disclosures: None reported. Funding/Support: This work was supported by a grant from the Research Council of the Vrije Universiteit Brussel (project HOA 27). Role of the Sponsor: The funding organization had no role in the design and conduct of the study; collection, management, analysis, or interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication. Additional Contributions: We thank Christophe Lemmens, LLM, LLD, for legal advice. REFERENCES
2. Federal Control and Evaluation Commission. Report to the Legislative Chambers (2010-2011). Document 53 2391/001. Belgian Chamber of Representatives website. http://www.senate.be /www/?MIval=dossier&LEG=5&NR=1718&LANG=nl. Published July 24, 2012. Accessed February 27, 2014. 3. Jansen-van der Weide MC, Onwuteaka-Philipsen BD, van der Wal G. Granted, undecided, withdrawn, and refused requests for euthanasia and physician-assisted suicide. Arch Intern Med. 2005; 165(15):1698-1704. 4. Brinkman-Stoppelenburg A, Vergouwe Y, van der Heide A, Onwuteaka-Philipsen BD. Obligatory consultation of an independent physician on
euthanasia requests in the Netherlands: what influences the SCEN physicians judgment of the legal requirements of due care? Health Policy. 2014; 115(1):75-81. 5. Thienpont L, Van Loon T. Stop the world, I want to get out of it [in Dutch]. Bodytalk. 2013:32-35. http://www.knack.be/bodytalk/. Accessed February 27, 2014. 6. Georges JJ, The AM, Onwuteaka-Philipsen BD, van der Wal G. Dealing with requests for euthanasia: a qualitative study investigating the experience of general practitioners. J Med Ethics. 2008;34(3):150-155. 7. van der Heide A, Deliens L, Faisst K, et al; EURELD consortium. End-of-life decision-making in six European countries: descriptive study. Lancet. 2003;362(9381):345-350.
1. Smets T, Cohen J, Bilsen J, Van Wesemael Y, Rurup ML, Deliens L. Attitudes and experiences of
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JAMA Psychiatry June 2014 Volume 71, Number 6
Copyright 2014 American Medical Association. All rights reserved.
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jamapsychiatry.com
VIEWPOINT
Reginald Deschepper, MA, PhD Mental Health and Wellbeing Research Group, Vrije Universiteit Brussel, Brussel, Belgium. Wim Distelmans, MD, PhD Department of Supportive and Palliative Care, Vrije Universiteit Brussel, Brussel, Belgium. Johan Bilsen, MSc, RN, PhD Mental Health and Wellbeing Research Group, Vrije Universiteit Brussel, Brussel, Belgium.
Corresponding Author: Reginald Deschepper, MA, PhD, Mental Health and Wellbeing Research Group, Vrije Universiteit Brussel, Laarbeeklaan 103, 1090 Brussel, Belgium ([email protected]).
Requests for Euthanasia/Physician-Assisted Suicide on the Basis of Mental Suffering Vulnerable Patients or Vulnerable Physicians? In only a few countries, such as Belgium and the Netherlands, and in some states in the United States, euthanasia/physician-assisted suicide (EAS) is legally possible under some circumstances. Arguments in favor of legalization of EAS are that it might function as a safeguard to semilegal practices, that it fosters transparency, and that it enables one to verify whether criteria of due care are met. It also provides legal safety for the physicians involved. In these places, EAS has increasingly become an acceptable option for patients with serious irreversible diseases, such as cancer, that are accompanied by unbearable physical suffering and that finally lead to death. 1 Euthanasia/physician-assisted suicide in cases of mental suffering, however, is much more controversial. In Belgium, euthanasia for mental suffering is possible under certain extra due care conditions, such as the advice of 2 other physicians. In 2011, “unbearable mental suffering due to an irreversible disease” was the only motive for euthanasia in 3.5% of all the reported euthanasia cases (N = 1133) in Belgium (Figure).2 However, requests for euthanasia based on unbearable mental suffering are much more common.3 Although the patient is of course central to this debate, when physicians are confronted with such requests from well-informed, quite assertive, young, welleducated patients who are not terminally ill, they often experience a lot of stress. Dealing with such requests is also quite complex because of the specific medical and conflicting ethical questions they raise. Highly controversial cases (eg, those associated with Dr Jack Kervorkian in the United States or with the Dutch psychiatrist Dr Boudewijn Chabot, who provided lethal drugs to depressed patients) fueled the debate about whether patients who have been granted euthanasia have been adequately treated. The main concern of physicians dealing with such a request is that they might fail to detect a (treatable) depression or some other kind of mood disorder. Abuse has not been widespread, but EAS for mental suffering remains very controversial and has more often been judged as “not meeting due care requirements.”4 An additional complicating factor is that physicians who have to deal with requests for EAS based on mental suffering sometimes have to endure intense pressure from their patients. In extreme cases, when their requests are refused, these patients may threaten to commit suicide. Of 100 euthanasia requests based on mental suffering received in Belgium between 2007 and 2011 and followed up until
jamapsychiatry.com
February 2013, 33 were granted, but another 5 were not and ended in the patient committing suicide.5 The treating physicians may also experience extra pressure when their patients have already found 2 or more physicians who have approved the performance of euthanasia. Moreover, the implementation of laws on EAS is often impeded by ambivalence and by the vagueness of concepts such as “unbearable suffering” and “incurable disease.” In the case of mental suffering, physicians have to rely heavily on the patient’s own reporting, without there being any “objectively” measurable symptoms. There is thus often no other evidence than the patient’s subjective perception and complaints. Furthermore, in the case of mental suffering, the patient’s capacity of judgment may be impaired, making it difficult to differentiate between a request based on a genuine and constant form of unbearable suffering and a request as a symptom of a severe depression. On the other hand, mental suffering is not less severe than physical suffering and is often hard to treat, and it has also been argued that depression does not necessarily imply that a patient is unable to make well-considered decisions. Sometimes, after a long and time-consuming process, physicians acknowledge that all the available treatments have not resulted in any improvement and that the patient fulfills all of the criteria for euthanasia. In such cases, physicians may find it hard to refuse the euthanasia request any longer. Once performed, EAS has sometimes resulted in emotional reactions from family members. In some cases, accusations have also been made against physicians in the popular press by the patient’s family, speaking in detail about their experiences. However, the physicians could hardly respond to these accusations because of their duty to uphold medical confidentiality. In other cases, physicians have been questioned by an attorney or physically threatened by family members. The (emotional) impact of the decision-making process and the performing of EAS should not be underestimated, especially in cases at the limits of what physicians personally perceive as legally and/or ethically acceptable. In Belgium, for instance, some physicians have therefore decided to (temporarily) refrain from performing euthanasia, not necessarily because they doubt that they are justified in complying with a euthanasia request in a particular case but mainly because of the emotional and practical burdens that go with it. Other physicians complain of being overburdened or overloaded with too many euthanasia requests. These problems are JAMA Psychiatry June 2014 Volume 71, Number 6
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://archpsyc.jamanetwork.com/ by a SUNY Binghamton User on 05/16/2015
617
Opinion Viewpoint
Figure. Reported Cases of Euthanasia in Belgium (2005-2011) 1200 Physical 1000
Mental and physical Mental
No. of Cases
800 600 400 200 0
2005
2006
2007
2008
2009
2010
2011
Year
accentuated further by a lack of trained physicians in this domain and insufficient official remuneration for physicians who are willing to participate in an EAS process.
To conclude, dealing with requests for euthanasia or physician-assisted suicide is emotionally, ethically, and even physically very demanding.6 The experiences of the countries where these practices are a legal option make it clear that, especially with regard to requests due to mental suffering, such deliberations may be too hard to deal with for an individual physician. Therefore, such decisions must be made in a multidisciplinary team that can weigh all the pros and cons along with the patient. Such a team can make decisions in a transparent way and can allow caregivers to share responsibility and find support in each other. It should also be stressed that training in end-of-life care should be part of the general medical education, including the way in which requests from patients asking for their life to be ended should be dealt with. We believe these training measures should not be restricted in any way to countries where these practices have been legalized or to physicians who consider these practices acceptable options because any physician might be confronted with such an incisive request7 and will have to deal with it in one way or another.
Belgian physicians regarding euthanasia practice and the euthanasia law. J Pain Symptom Manage. 2011;41(3):580-593.
ARTICLE INFORMATION Published Online: April 23, 2014. doi:10.1001/jamapsychiatry.2014.185. Conflict of Interest Disclosures: None reported. Funding/Support: This work was supported by a grant from the Research Council of the Vrije Universiteit Brussel (project HOA 27). Role of the Sponsor: The funding organization had no role in the design and conduct of the study; collection, management, analysis, or interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication. Additional Contributions: We thank Christophe Lemmens, LLM, LLD, for legal advice. REFERENCES
2. Federal Control and Evaluation Commission. Report to the Legislative Chambers (2010-2011). Document 53 2391/001. Belgian Chamber of Representatives website. http://www.senate.be /www/?MIval=dossier&LEG=5&NR=1718&LANG=nl. Published July 24, 2012. Accessed February 27, 2014. 3. Jansen-van der Weide MC, Onwuteaka-Philipsen BD, van der Wal G. Granted, undecided, withdrawn, and refused requests for euthanasia and physician-assisted suicide. Arch Intern Med. 2005; 165(15):1698-1704. 4. Brinkman-Stoppelenburg A, Vergouwe Y, van der Heide A, Onwuteaka-Philipsen BD. Obligatory consultation of an independent physician on
euthanasia requests in the Netherlands: what influences the SCEN physicians judgment of the legal requirements of due care? Health Policy. 2014; 115(1):75-81. 5. Thienpont L, Van Loon T. Stop the world, I want to get out of it [in Dutch]. Bodytalk. 2013:32-35. http://www.knack.be/bodytalk/. Accessed February 27, 2014. 6. Georges JJ, The AM, Onwuteaka-Philipsen BD, van der Wal G. Dealing with requests for euthanasia: a qualitative study investigating the experience of general practitioners. J Med Ethics. 2008;34(3):150-155. 7. van der Heide A, Deliens L, Faisst K, et al; EURELD consortium. End-of-life decision-making in six European countries: descriptive study. Lancet. 2003;362(9381):345-350.
1. Smets T, Cohen J, Bilsen J, Van Wesemael Y, Rurup ML, Deliens L. Attitudes and experiences of
618
JAMA Psychiatry June 2014 Volume 71, Number 6
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://archpsyc.jamanetwork.com/ by a SUNY Binghamton User on 05/16/2015
jamapsychiatry.com
