Psychiatric euthanasia: understand this controversial practice and where it is allowed

“I’m getting ready for my trip. Thanks for everything. I won’t be available from now on.”

In January 2018, Aurelia Brouwers, a 29-year-old Dutch woman, wrote the above sentence on her Facebook page.

Four hours later, she lay down on her bed and, surrounded by her friends, drank a toxic compound, prescribed by her doctor, to die.

Aurelia’s death in the city of Deventer, Netherlands, came a month after the state granted her the right to die under the Euthanasia and Assisted Suicide Act, which allows for death when there is “unbearable and intractable suffering”.

But Aurelia did not have a terminal illness.

The young Dutch woman was allowed to end her life due to the “terrible psychological suffering” of her mental disorders, including anxiety, depression and psychosis.

Euthanasia is allowed in seven countries and the procedure is practiced mainly in people with terminal illnesses such as cancer, where the patient has months or weeks with poor quality of life ahead.

But in four of those countries — the Netherlands, Belgium, Luxembourg and recently Spain — the procedure is allowed for people with mental illnesses such as depression, anxiety or personality disorders.

In March, Canada also had a vote to allow euthanasia for psychiatric illnesses from March 2023. As with Aurelia’s death in 2018, the issue of “psychiatric euthanasia” has sparked heated debate in the medical community in Spain and Canada.

On the one hand, there are doctors who claim that a mental illness can cause as much suffering and disability as a physical illness. On the other hand, there are those who claim that treatments exist to cure these disorders and that these people should not be helped to die.

“I believe that public efforts must be made so that people don’t want to die. But that some people want to die is something to some extent inevitable,” says David Rodríguez-Arias, professor of bioethics at the University of Granada in Spain and lead researcher of the INEDyTO project on bioethics and the end of life.

“There are circumstances so dramatic, so difficult, so irreversible and so irremediable that it is inevitable that there will continue to be some people who ask for this kind of help,” he says.

For many psychiatrists, however, euthanasia is “fundamentally incompatible” with the physician’s role in healing the sick.

“Opening the door to euthanasia facilitates the devaluation of the value of life, to which we are entitled as human beings,” Manuel Bousoño García, professor of psychiatry at the University of Oviedo, tells BBC News Mundo.

“We must fight to protect people from suffering, not to eliminate them.”

THE CRITERIA FOR EUTHANASIA

There are a number of conditions for psychiatric euthanasia to be authorized in countries where it is permitted. The problem is the difficulty in interpreting many of the established criteria.

And differentiating patients eligible for the procedure from ineligible ones is a major challenge for mental health professionals.

Is a patient with poor mental health able to make the decision to end his own life? Or is your autonomy being compromised due to the disorder?

Psychiatrist Manuel Bousoño states that one of the characteristics of psychiatric illnesses is the decrease in this ability (to make rational choices) and, therefore, these patients must be protected.

“Many psychiatric illnesses generate a tendency to commit suicide that could lead them to seek a solution to euthanasia, even if their illness is treatable or even curable with adequate means”, says Bousoño. “And people with mental illness must be protected from the risk their illness poses.”

But David Rodríguez-Arias believes that assuming that a person with a mental disorder is necessarily incapable of making decisions about their health is “a common prejudice.”

“You cannot assume that a person with a mental disorder is incapable of making decisions,” he explains. “Facing a person with depression, one must demonstrate — not assume — that he is incapable of deciding on his own death”, he says.

Furthermore, it is difficult to tell when a mental illness is incurable, chronic and disabling, conditions necessary for euthanasia to be allowed.

Bousono states that it is very rare for a disease to be truly untreatable. “Fortunately, there are treatments that are very effective in reducing the level of suffering. Over more than 40 years of professional practice, I have never encountered any cases of intractable suffering.”

“The patterns of treatment and the diagnoses themselves in the field of mental health vary greatly. Even mental health specialists themselves do not share the criteria for diagnosis or treatment,” says Professor Rodríguez-Arias.

“I think that patients with mental health problems, including those with depression, can theoretically be candidates for this type of help to die, as long as they have effective competence to make this decision and as long as they convince the doctors that their condition is chronic and disabling,” the professor tells BBC News World.

SUICIDE: PREVENT OR FACILITATES?

Euthanasia advocates claim that people have the right to autonomy and self-determination to end the intolerable suffering caused by an illness.

Those against it say that society must do more to help the mentally ill and that the role of psychiatrists is to prevent suicide and not offer it as a treatment.

“The possibility of access to assisted suicide goes against what psychiatry promotes as a science, which is the cure or alleviation of mental illnesses and their consequences”, says Manuel Bousoño.

“The fight for improvement must be towards better and more complete assistance, even if this implies higher costs than euthanasia, which only serves to eliminate the weakest members of a society”, he adds.

But what happens when a patient’s suffering is truly irremediable?

“I think the task of psychiatrists is to know when to prevent suicides and when to support them,” says Asunción Álvarez del Río, a professor and researcher at the Department of Psychiatry and Mental Health at the National Autonomous University of Mexico, tells BBC Mundo.

“The problem is that, by definition, many psychiatrists consider that if someone wants to commit suicide or take their own life, that’s an expression of disturbance, a symptom of the illness, and that’s wrong. In many cases, it can be the expression of a deep depression or something that can be treated. But not always.”

The specialist believes that there is a problem with psychiatric training which states that if someone thinks about ending his life, it is because he is disturbed. “There are people who are very sure they want to end their lives because their lives will not get better and they want to use their freedom to stop living,” adds she, author of the books Euthanasia and Euthanasia Practice and Ethics.

The fact is that many psychiatric patients, even in the most developed countries, do not find adequate treatment for their illness (or do not seek it) and end up committing suicide. In countries like Belgium or the Netherlands, there were testimonies of parents whose children committed suicide violently after being denied euthanasia.

“It is very difficult to have to listen to a child ask for euthanasia. But it is also very difficult for him to commit suicide,” says bioethics professor David Rodríguez-Arias. “The law will only allow those deaths that are very well argued, justified and reviewed by various experts.”

“I believe that the law would not allow young people to end up committing suicide when they still had alternatives for a quality life,” adds the expert.

The responsibility of doctors who are faced with the challenge of diagnosing a person in this situation and knowing if he/she meets the criteria ends up being gigantic.

It is the doctors who will have to say when a person is making a decision with autonomy or when their ability to decide is affected. They are also the ones who need to ensure that all options to try to better the person’s suffering have been tested. “It is the responsibility of the doctor responsible for this patient and he must consult other doctors who will also have to evaluate the patient”, explains Asunción Álvarez del Río.

“There have been interesting cases where psychiatric patients talk about the relief they feel when euthanasia is authorized and how it allows them to continue living, because they know that when they decide to die, they already have that help. And it’s also a fact that patients who do have it. denied euthanasia often find another, more violent way of committing suicide,” he adds.

OPEN OR DEBATE

The number of people who are authorized to carry out assisted suicide in cases of psychological distress is very small: it represents between 1% and 3% of all euthanasia cases in countries where procedures are legal.

In the Netherlands, of the 6,938 euthanasia procedures performed in 2020, 60 were assisted deaths where the cause was suffering due to mental disorders.

Even so, there are still many fears around the world to open the debate about the legalization of euthanasia and assisted suicide.

Bioethics professor David Rodríguez-Arias says there are still many taboos in society about death. “There is the idea that giving up life is a kind of failure and perhaps this also generates a feeling of guilt on the part of other people, of society”, he says. “And that may partly explain this taboo and this silencing of death.”

“But this trend contrasts with a whole cultural, philosophical and literary tradition. From Seneca to Hume, there are several philosophers who speak of suicide as an honorable way to end a life with some meaning”, he says.

“And societies are increasingly understanding that biotechnologies applied to the maintenance of life sometimes only manage to prolong life, without preserving its quality”, adds the specialist.

Del Río also believes that it is necessary to debate the issue and accept that there will always be opposing positions.

“It’s not about getting people to agree, but about respecting the different positions. That’s what must be considered,” he says.

Doctor Manuel Bousoño, however, believes that Spain “was better off without this law”. “My opinion is that the legislation on euthanasia opens a door that is difficult to close, which will generate more suffering than correcting.”

“It would have been much better to have a Palliative Care law, which in our country is still insufficient”, says the expert.

WHERE TO FIND HELP?

CAPS and Basic Health Units (family health, health posts and centers)

UPA 24h

Samu 192

hospitals

Emergency Room

CVV – Life Enhancement Center (emotional support and suicide prevention)

188 (toll free from any landline or cell phone)

www.cvv.org.br (Chat, Skype or e-mail)