Physician Aid-in-Dying: Practical Considerations

Voluntary active euthanasia is when a physician gives a medication to a mentally competent patient with the intent to end the patient's life, as requested by the patient (9). Voluntary active euthanasia is legal in the Netherlands, Belgium, Luxembourg, Colombia, Switzerland, and Canada. Similar to Oregon, in Belgium, patients with end-stage cancer comprise the majority of the population requesting and receiving physician aid-in-dying or voluntary active euthanasia, with a minority of patients with irreversible neurodegenerative diseases (10). First-year data from the Dutch End-of-Life-Clinic (which is staffed by physicians and nurses funded by the Right to Die NL, a euthanasia advocacy organization) showed that 6.8% of all patients requesting physician aid-in-dying or euthanasia were categorized as "tired of living," and another 49.1% felt isolated (11). In Belgium and the Netherlands, clinicians (psychiatrists and others) have provided physician aid-in-dying or voluntary active euthanasia to individuals with depression, personality disorders, eating disorders, psychotic disorders, and anxiety disorders (12). In 2015 in the Netherlands, 59% of all voluntary active euthanasia involving a patient with a psychiatric disorder was performed by the End-of-Life Clinic (13).

What guidelines and practices exist for evaluation of capacity and psychiatric disorders among patients requesting voluntary euthanasia in Belgium and the Netherlands? The criteria of due care (as legally noted in the Termination of Life on Request and Assisted Suicide Act) state that the physician must 1) be satisfied that the patient's request is voluntary and well-considered; 2) be satisfied that the patient's suffering is unbearable, with no prospect of improvement; 3) have informed the patient about his or her condition and prognosis; 4) have come to the conclusion, together with the patient, that there is no reasonable alternative; 5) have consulted at least one other independent physician who has evaluated the patient and provided written opinion on whether the criteria of due care have been fulfilled; and 6) exercise due medical care and attention in terminating the patient's life or assisting in his or her suicide (12).

What role do psychiatrists play in capacity evaluations concerning voluntary active euthanasia requests from patients with impaired cognition or psychiatric diagnoses? A review of 66 cases of psychiatric voluntary active euthanasia in the Netherlands showed that 41% of physicians performing voluntary active euthanasia were psychiatrists, 47% of case subjects had a second opinion provided by a psychiatrist, and 59% of the SCEN [Support and Consultation on Euthanasia in the Netherlands] consultations involved a psychiatrist as one of the consultants (12). These statistics raise questions regarding the role of psychiatrists in administering voluntary active euthanasia or physician aid-in-dying and the evaluation of capacity, because a large number of the physicians who administered voluntary active euthanasia were psychiatrists and less than half of the case subjects with a psychiatric diagnosis had a second opinion from a psychiatrist. Another review of these same 66 case subjects concluded that there was no evidence of a mandatory high threshold of patient capacity before administration of euthanasia (14). Documentation of capacity-specific criteria among these case subjects has shown that 55% demonstrated global assertion of capacity and 46% had at least one capacity-specific ability (e.g., understanding information, ability to reason, or appreciation of the consequences to self), but there is no evidence that all four Appelbaum capacity criteria were met (14, 15) (see box). This raises concern that individuals who may not have full decision-making capacity are eligible to receive voluntary active euthanasia or physician aid-in-dying.

Additionally, voluntary active euthanasia among persons with impaired cognition or psychiatric disorders raises questions pertaining to uncertain medical futility as well as treatment refusals by patients that may occur as a result of impaired judgment secondary to the disease itself (16). As long as treatable causes of distress are not adequately addressed, there will be concern surrounding the inappropriate use of physician aid-in-dying, particularly for treatment-refractory psychiatric conditions, since symptoms that may not respond to currently available treatments may be responsive to a new treatment as our understanding of the pathophysiology of many psychiatric disorders improves.

As the practice of physician aid-in-dying is legalized further in the United States and gains momentum globally, multiple practical concerns arise, particularly regarding its implementation among patients with impaired cognition or psychiatric disorders and clarification of the role of psychiatrists.

In the United States, what role should psychiatrists play regarding capacity assessments? Is the current standard for capacity (the Appelbaum criteria) sufficient? Is a new framework needed? What regulations and oversight should be in place to ensure adherence to a gold standard of capacity assessment? Would psychiatrists perform capacity evaluations for all individuals who request physician aid-in-dying or voluntary active euthanasia in an effort to not miss the influence of unrecognized psychiatric illness on an individual's decision to die? Would this place more burden upon a profession that is already overwhelmed?

What regulations should be in place, and who would monitor the practice of physician aid-in-dying to ensure maintenance of ethical integrity? In the United States, because physician aid-in-dying is approved on a state level, there is variability in the regulatory agencies overseeing the practice. Lack of strict regulations in the Netherlands has led to cases in which medically assisted suicide was done for patients with impaired cognition or psychiatric disorders (14) and to extension of the practice among vulnerable populations (9). Thus, what should the role of psychiatrists be in ensuring that depression is adequately screened among individuals requesting physician aid-in-dying?

As physician aid-in-dying becomes legalized in more states as well as internationally, it is crucial to explore this evolving practice and its current and future impact on psychiatry through education surrounding legal, ethical, and professional aspects. Exploring these issues in psychiatry training is needed.

The author thanks Drs. Marta Herschkopf and Shapir Rosenberg for their insight as well as their assistance with this article.

Publisher's Note: The September 2018 issue of the American Journal of Psychiatry will feature a commentary by Damiaan Denys, President of the Dutch Society of Psychiatrists, entitled "Is Euthanasia Psychiatric Treatment? The Struggle With Death on Request in the Netherlands."