Last-Minute Recovery of a Psychiatric Patient Requesting Physician-Assisted Death

Because of the variety of explanatory models and the unclear biological basis of psychiatric disorders, there is always room for uncertainty. Some authors argue that this uncertainty makes physician-assisted death morally inadmissible for psychiatric patients (8, 9). Others argue that absolute certainty about a prognosis is epistemologically impossible and therefore unreasonable (10). Schuklenk and van de Vathorst (11) mention that uncertainty should be discussed with the patient. If he or she understands this uncertainty after adequate counseling and still requests physician-assisted death, why should the right to self-determination be restricted? The case presented here illustrates the high level of uncertainty common in psychiatric clinical practice. Meanwhile, it shows that discussing the need for a specialized second opinion before a request for physician-assisted death can be met, and actually obtaining this second opinion, can be regarded as a justifiable way of dealing with this uncertainty.

If physician-assisted death is made possible for psychiatric patients, a thorough due-diligence procedure should be implemented. In 2018, the Dutch Psychiatric Association reformulated the guideline concerning physician-assisted death among patients with a psychiatric disorder, aiming “to provide a contemporary, thorough procedural framework that is both applicable to everyday practice and complies with ethical standards” (12). The guideline offers a comprehensive framework for the entire procedure, specifically tailored to psychiatric patients.

The procedure is composed of four phases and involves at least three physicians, two of whom must be psychiatrists. The first phase, the request phase, starts when a patient requests physician-assisted death. In this phase, the crucial goals are to create an open and safe environment to discuss the patient’s death wish, to assess whether there is an acute risk of suicide, to ascertain whether those close to the patient have been informed and their views on the matter, and to give clear information about the (extensive) procedure that will follow. In the second phase, the assessment phase, the physician investigates whether all clinical and legal requirements have been met. Above all, the physician ascertains whether the request is voluntary and well considered, whether the patient’s suffering is unbearable and without prospect for improvement, whether the patient is informed about the prognosis, and whether there are other reasonable alternatives. This phase often takes several months and entails at least one obligatory second opinion performed by an independent psychiatrist (preferably one who works in an academic setting) who is specialized in the patient’s disorder. In the third phase, the consultation phase, a physician trained as a physician-assisted death consultant must assess whether all due-diligence requirements have been met. If the primary physician is not a psychiatrist, this consultant must be a psychiatrist. In the fourth phase, the executive phase, the physician assists the patient with dying by either lethal injection or by ingestion of a lethal liquid. After the death of the patient, a public coroner examines the body, and a regional review board consisting of a physician, a lawyer, and an ethicist investigates the case.

In our view, the case presented here shows the importance of an obligatory second opinion by a psychiatrist specialized in the patient’s disorder during the second phase. Psychiatry is a broad specialty, and subtle nuances can be easily missed if a clinician does not have extensive experience with a specific disorder. Utmost care and expert evaluation are required, especially in matters of life or death. Although the Dutch Psychiatric Association’s new guideline further clarifies and sharpens the due-diligence process, several challenges remain. For instance, when patients suffer from multiple disorders, it is unclear which specialist should be consulted. Furthermore, the attitudes of Dutch specialized psychiatrists concerning the obligation to seek a second opinion have not yet been investigated.