Physician-Assisted Suicide in Psychiatry: Developments in the Netherlands
Abstract
Physician-assisted suicide can now be officially and legally carried out for psychiatric patients in the Netherlands who request it, provided that criteria are met. The authors describe two recent cases of psychiatric patients whose suicides were assisted by their psychiatrist. They critically examine the guidelines for physician-assisted suicide in psychiatry. The criteria address the decision of the patient to be assisted with suicide, which must be voluntary and well considered, and the patient's desire to die, which must endure over time. The patient's suffering must be unacceptable, and the disorder incurable. The authors conclude that important aspects of psychiatric practice are not addressed in the guidelines, which were originally developed for use in somatic medicine. The assessment of treatment prognosis in psychiatry is not accurate enough to allow a final decision about incurability. Boundaries of the psychiatric therapeutic relationship are violated in physician-assisted suicide. The therapist's inability to objectively assess the patient's wish to die is overlooked. Because the general public will continue to ask for clarity on the issue of euthanasia and physician-assisted suicide, the authors believe that an open discussion of both ethical and professional issues is the best option.
In the Netherlands, it is illegal to practice euthanasia and physician-assisted suicide. However, under special conditions a doctor can plead an "emergency defense" in a conflict of duties: the duty of protecting life against the duty of relieving unbearable suffering that shows no hope of improving in the future. Euthanasia or physician-assisted suicide may then be considered (1). A physician who follows the official regulations will generally not be prosecuted (2,3).
In 1995 euthanasia accounted for 2.3 percent and physician-assisted suicide for .4 percent of all deaths in the Netherlands. Seventy-nine percent of these patients had a malignancy in a terminal stage (4). Although the Dutch euthanasia policy remains internationally controversial, it is embedded in a system of socioeconomic and health care facilities that strongly reduces financial or other economic motives for euthanasia and physician-assisted suicide (5).
A new and also controversial development is physician-assisted suicide for mentally ill patients. Analogous to the general discussion of euthanasia, individuals have for a long time voiced a demand for the option of physician-assisted suicide for incurable patients whose tragic lives are not ameliorated by psychiatric treatment (6). Although the existing criteria were intended for terminally ill patients, the existence of a "dying phase" has never been an official condition for euthanasia. It was considered to be of less importance than the criterion of "intolerable and hopeless suffering"(3).
In 1991 the Dutch Right to Die Society published a report in favor of physician-assisted suicide. In a reaction, the Dutch Board of Psychiatrists claimed that suffering from a mental illness is not essentially different from suffering from medical diseases (7). It also stated that psychopathology in itself does not automatically make a person incapable of having an autonomous wish to die. In 1994 the Royal Dutch Medical Association (8) and the General Inspection of Mental Health (9), a government agency, proposed to extend the existing guidelines to include physician-assisted suicide for psychiatric patients; a final report was issued in 1997 (10). This extension of the guidelines implies that a patient who suffers from a nonterminal psychiatric condition can now ask a psychiatrist to assist in suicide. The psychiatrist is then expected to state clearly whether he or she would, in the end, be willing to comply with this request.
To assess what this new policy may mean for clinical practice, we present two actual cases and the very different consequences they have had. We then analyze the official criteria that have been developed to deal with such situations. Critical consideration of the guidelines leads us to a number of questions. What can be said about treatment prognosis in psychiatry? How does a psychiatrist's explicitly stated preparedness to eventually perform physician-assisted suicide influence the therapeutic relationship? Is it possible for a psychiatrist to judge his or her own treatment objectively? Is it possible to integrate physician-assisted suicide into different treatment settings? By attempting to answer these questions, we hope to shed some light on the underlying issue of whether an official policy in favor of physician-assisted suicide for psychiatric patients is a threat or a final "treatment"—a blemish on the medical profession or the last thing a psychiatrist can do for a suffering patient.
Two cases
The first case
In 1991 a 50-year-old woman with a major depression following the death of her only remaining child was assisted in suicide by her psychiatrist. She had met him through the Right to Die Society and refused both psychotherapeutic and pharmacological treatment. Apart from meetings with the patient, the psychiatrist also had informal contacts with the patient, who stayed in his private guesthouse. The psychiatrist then asked seven consultants for their expert opinion. Although none of them actually saw the patient, five of them supported the patient's request for physician-assisted suicide. Two months after the patient first met her psychiatrist, she died taking the deadly medication he prescribed (11,12).
A series of trials followed in which two courts found the psychiatrist not guilty (13,14). The Dutch Supreme Court ruled otherwise and found him guilty of deliberately assisting another person to die. The Supreme Court also stated for the first time that an appeal on emergency defense can be justifiable even when a patient is not in a terminal stage of illness (15). In March 1995 the psychiatrist faced the Medical Disciplinary Board. He was reprimanded for not having given his patient the necessary psychiatric treatment before even considering complying with her wish (16).
Although the penalty was one of the most minimal that the board could impose, it was harsher than expected and reflected a more critical interpretation of the violation of professional standards than that of the legal authorities. The focus in the discussion had previously been on law and ethics, but it became clear that practical application of the guidelines had not received the same amount of attention (17). It was this case that accelerated the debate.
The second case
In July 1997 another psychiatrist was investigated for participating in physician-assisted suicide and was not prosecuted. He had assisted in the suicide of a 48-year-old woman who had been suffering from anorexia nervosa and severe depressions since the age of 17. She had had several episodes of both inpatient and outpatient treatment. After both her mother and her husband died, she first expressed her death wish. The patient then went through the treatment protocol for depression, except for electroconvulsive therapy (ECT), for which her psychiatrist saw no indication.
A specialist in the treatment of depression was consulted. He concluded that all of the guidelines had been met. Physician-assisted suicide was carried out some months later by another psychiatrist working in the same hospital. The public attorney saw no further need to try the case. Unlike the first case, this case received little public attention.
In a recent study on current practice in Holland by Groenewoud and associates (18), it was estimated that 320 requests for assisted suicide are made to psychiatrists annually and that between two and five psychiatric patients are actually assisted in dying. More than half of the patients making the request had a terminal somatic condition. All of the patients had been seen by more than one psychiatrist before a decision was made. Mood disorder was the most frequent psychiatric condition.
However, most of these physician-assisted deaths took place before publication of the guidelines. Because psychiatrists who follow the guidelines are unlikely to be prosecuted, recent data are unavailable. It is therefore difficult to evaluate the impact of the criteria on current psychiatric practice. We now describe the criteria and their possible consequences for psychiatric practice.
The criteria
The guidelines, which were issued in 1995 by the Royal Dutch Medical Association (19), deal with the request itself, with the patient's prognosis, and with consultation and administrative matters. They are adapted from those used in somatic medicine (3). Table 1 summarizes the criteria.
Criteria related to the decision
A voluntary decision.
The patient must come to the decision independently. The guidelines state that special attention has to be given to this criterion because of possible influences from others and institution policy. In a broader sense, opponents argued that terms like "autonomy" and "self-determination" are no more than ethical constructs used by an ideology to serve a higher ideal. Death wishes, no matter how genuine and private they may seem, cannot be separated from the society in which they arise. Loneliness and lack of warmth and care are social problems, and doctors cannot be asked to solve them (20). Although the criterion is valid, its execution confronts us with questions that are difficult to answer.
A well-considered decision.
Analogous to the criteria developed by Appelbaum and Roth for the assessment of competency (21), the patient must be capable of understanding all relevant information and come to a conclusion on the basis of rational thought. But to what extent can psychiatric patients be considered capable of decision making? In a stable interval, a bipolar patient can make rational decisions. But other patients may have chronic psychiatric symptoms.
The commission of the Royal Dutch Medical Association argued that a suicidal wish by a chronic psychiatric patient cannot just be ignored because of presumed incapacity (8). Little study has been done on the interaction of rationality and psychopathology (22,23). How severe must a depression be before it precludes rational decision making? Opponents of physician-assisted suicide in Holland stated that a decision about life and death can never be made rationally in the case of a psychiatric disorder, personality disorder, or even neurosis (24). The criterion that the decision be well considered thus leads to very different viewpoints.
An enduring wish to die.
The patient's wish to die must be consistent over time. However, the guidelines state that if suffering is "unbearable," time limits are relatively less important (8). In the Netherlands, the initial number of people who at some stage in their illness consider requesting euthanasia or physician-assisted suicide is much larger than the number of people who actually die from it (4). In about two-thirds of cases, the death wish is temporary, and two-thirds of those with a persistent wish finally choose another alternative.
Some have argued that the possibility of controlling life's termination can be a coping strategy when a patient is faced with uncertainty and fear of the future because of serious illness. The relief a patient feels at the prospect of a self-chosen death is therefore not necessarily a sign that the decision is appropriate (25). Research among terminally ill patients supports the idea that serious and pervasive desire for death is both rare and closely associated with clinical depression (26). The fact that a request is enduring could therefore be interpreted in many ways.
Criteria related to treatment prognosis
The degree of suffering or illness considered "unacceptable" is primarily a personal estimation of the patient. We therefore focus here on the treatment perspective. The guidelines state that treatment is imperative when "to current medical knowledge there is reasonable chance of recovery, within a surveyable period of time, whereby the suffering caused by the treatment is not disproportionate to the expected outcome"(10). Although this criterion may be applicable in somatic medicine—for example, in a disseminated malignancy—it is uncertain whether the same is true for psychiatry.
Incurable.
Looking at specific psychotherapeutic techniques, it is hard to establish with sufficient certainty how much interpersonal, cognitive-behavioral, or long-term dynamic therapy is needed before a patient can be considered incurable. Research suggests that the influence of specific factors on therapeutic techniques is relatively limited. Nonspecific factors, such as the patient's ability to form a productive therapeutic working relationship with the therapist, the therapeutic relationship itself, the patient's motivation and expectations, the patient's perfectionism, and spontaneous recovery seem to be more important for treatment outcome (27,28,29). It is unclear how these factors should be weighed in attempting to evaluate the result of psychotherapeutic treatment in individual cases.
Similar questions can be asked when looking at biological interventions. Which serotonin reuptake inhibitors, which tricyclics, which monoamine oxidase inhibitors should be used in what dosage before pharmacological treatment can be considered sufficient? Should we add thyroid, lithium, bupropion, or methylphenidate, or combine certain drugs? After how many ECT treatments can a patient be considered incurable?
Although the biopsychosocial model (31) is seen as a gold standard, depression protocols seldom mention nonbiological factors, and there is reason to. Interactional factors, such as expressed emotion, as well as social factors can have an important influence on the course of schizophrenia and major depression with suicidality (32,33,34). Pharmacotherapy can also be seen as an interpersonal transaction, with the interaction occurring between the pharmacotherapy and the process of psychotherapy in which the psychiatrist and patient are engaged (35). Both the dynamic psychiatrist who neglects the biological dimension of experience and the biologically oriented psychiatrist who neglects the psychological realm are guilty of narrow-minded reductionism (36).
Predictions of outcome for individual patients are not very reliable. Current diagnostic classification systems have limited usefulness in predicting the longitudinal course of people who meet criteria for schizophrenia (37). Psychiatrists also do poorly in predicting suicide (38,39).
What should the implications be if a patient has not responded successfully to treatment? A change of strategy on both the psychotherapeutic and the pharmacological levels could make a major difference, as could a change of physician or treatment setting. A judgment on treatment perspective is more complicated for a psychiatrist than it is for a medical colleague. In the context of a discussion on physician-assisted suicide, this reality cannot be ignored. A comparison with the death penalty may not be as far-fetched as it seems; the death of an innocent person is always one death too many.
Physician-assisted suicide and the therapeutic relationship
The new regulations suggest that a psychiatrist can be asked before treatment begins to state whether he or she is willing to assist a patient in dying should treatment fail. This suggestion means that the psychiatrist can assume different roles toward the patient—that of the treating physician, that of evaluator of the criteria, and eventually that of the doctor prescribing deadly medication. A substantial part of the discussion in the Netherlands has been dedicated to the question of how this combination of roles would affect the therapeutic relationship.
Trust
One Dutch physician stated that "the commitment to eventually help the patient end his life can make the physician more credible, and thus lead to a willingness on the side of the patient to follow treatment" (40). Supporters of physician-assisted suicide point out that such discussions between psychiatrist and patient would initiate a constructive therapeutic alliance.
Others have stated that a willingness to help a patient end his or her life "can just as well be a sign of negligence as one of closeness and understanding" (41). They claim that the decision to commit suicide has to remain an exclusive and necessarily lonely evaluation by the person concerned, although the associated thoughts and feelings have to be thoroughly discussed with the psychiatrist. In this view, drawing the line and stating to the patient that physician-assisted suicide is not an option can establish a fruitful therapeutic alliance (24). The boundaries of the professional relationship are at stake.
Therapeutic boundaries
The openly declared willingness of the psychiatrist to eventually perform physician-assisted suicide if treatment fails appears to contradict a basic principle. It implies that a therapist and a patient can at some stage leave the fundament on which their relationship is based and start working on a practical solution to the patient's death wish. In psychoanalytic psychotherapy, wishes and fantasies are the subject of thought and discussion, not of enactment. In relation to a patient's erotic feelings for the therapist, Freud (42) stated very clearly how acting out and repeating in real life what only ought to be remembered and reproduced as psychical material destroys the patient's susceptibility to influence from analytic treatment.
Today, having sexual contact with a patient is considered clinically, ethically, and professionally unacceptable, regardless of the theoretical basis of the therapy. As Gabbard and Pope (43) have demonstrated, phenomena such as transference, internalization of the therapist, power inequalities, and professional responsibilities make such deeds unacceptable even long after therapy has ended.
Why would death wishes be an exception to this rule against enactment? When in the process of therapy would the moment arrive to consider practically assisting a patient with real suicide? An objective evaluation cannot be expected from the therapist, who is himself or herself engaged in the interpersonal process. The psychiatrist in the first case described above seems to illustrate this point. It can hardly be considered coincidental that the exceptions he made for his patient have been identified as warning signs of future boundary violations (44).
Transference and countertransference
Advocates of physician-assisted suicide in psychiatry fear that irrational therapeutic rescue fantasies and grandiosity may cause therapists to refrain from exploring death wishes and considering physician-assisted suicide, because they would experience it as a personal failure (45). Opponents claim that contact with chronically ill or chronically suicidal patients can be so exhausting that countertransference reactions may make the therapist more likely to agree that it is reasonable or rational for a patient to choose death (46,47). Similarly, a therapist's own fear of "deterioration, dependence, loneliness, and illness" (48) could lead to a heightened understanding of a patient's death wish and a willingness to assist in suicide.
Apart from the question of whether transference and countertransference can be objectively evaluated, it is doubtful whether a therapeutic relationship can be fully understood by these processes. Psychoanalytic literature stresses the concept of a two-person relationship in which "the reality in a relationship is not something that can be exclusively determined by one party"(49). Because of the psychiatrist's irreducible subjectivity, it is not possible to prevent unconscious feelings from interfering with an objective view of the patient (50). A "collusion of death" between therapist and patient is not at all unthinkable.
In the final report on medical practice concerning the end of life of mentally incapacitated patients, the Royal Dutch Medical Association's special committee on the acceptability of termination of life advised physicians to make sure that their own countertransference feelings do not interfere with the decision process (10). This task appears to be tremendously difficult for the individual therapist. Mere consultation of a colleague would be equally insufficient in creating a complete picture of the process in which the patient and psychiatrist are involved.
Setting
A decision to perform physician-assisted suicide for a hospitalized patient would have a severe impact on other patients and staff. Advocates have suggested that in this case, contact with the responsible psychiatrist should take place through the outpatient department (51). Still, one can only wonder about the impact on other patients. It seems unlikely that staff could conceal the fact that a certain patient is leaving the ward to go home and be assisted with suicide. It may be difficult to explain to other patients with a similar disorder that hope for recovery exists in their case.
Discussion and conclusions
We have considered the official criteria on physician-assisted suicide, asking ourselves how they could be applied in psychiatric clinical practice. We encountered a number of complexities that are not sufficiently addressed by the guidelines. However, recent developments in the Netherlands seem to indicate that a more critical approach is under way. The Medical Disciplinary Board's verdict in the first case described above illustrates a discrepancy between the juridical and ethical developments that has been building for many years and the practicalities of physician-assisted suicide in psychiatry. The Dutch Board of Psychiatrists is currently working on more detailed guidelines for a careful evaluation of requests. Many Dutch psychiatric hospitals, patient organizations, and individual practitioners are evaluating whether it is better to have an official standpoint on physician-assisted suicide in psychiatry or first to develop more clarity and consensus on the subject.
We hope we have illustrated why we are critical of the actual situation with regard to physician-assisted suicide in psychiatry in the Netherlands. We also believe that the procedure is at present primarily in the discussion stage and does not constitute the enormous threat that some believe it to be, or a final treatment, or the "Dutch cure." Even though physicians both in the Netherlands and abroad may consider any policy to regulate physician-assisted suicide a threat to our patients and profession, others will continue to question whether that is in every case the preferred humane attitude of modern medicine.
As many authors have concluded, even medicine has its limits. The Hippocratic oath to relieve suffering does not always seem to be reflected in endless medical procedures, nor in fruitless psychiatric treatment for an infinite period of time. Alongside the professional considerations, international public discussion on the issue is also developing rapidly. Its demand for a careful evaluation of viewpoints by physicians cannot be ignored. Recent research in the Netherlands shows that introduction in 1991 of an official notification procedure, in which physicians are required to report each case to the coroner who then notifies the public prosecutor, has led to substantial progress in the oversight of physician-assisted death (52,53). It is in line with these developments that we believe only an open and ongoing debate based on a combination of research and pragmatism can be the way to advance towards what some consider to be "the social issue of the next decade" (54).
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Acknowledgment
The authors thank Glen O. Gabbard, M.D., for his careful reading and comments.
Footnote
Dr. Schoevers and Dr. Van Tilburg are affiliated with the department of psychiatry at Vrije Universiteit Amsterdam, Valeriusplein 9, 1075 BG Amsterdam, the Netherlands (e-mail, [email protected]). Dr. Asmus is with the department of psychiatry at the University Hospital Dijkzigt in Rotterdam, the Netherlands.
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