About the practice of psychiatric euthanasia: a commentary

The recently published paper by Dierickx et al. [6] describes 179 psychiatric and dementia patients, with no comorbid physical illnesses motivating their request, who were accepted for euthanasia in Belgium between 2002 and 2013. In general, the profile of psychiatric patients in this cohort was similar to those in the study by Kim et al. [4], who found that most psychiatric patients were depressed, middle-aged women, with or without comorbidity. Additionally, approximately one-third of the patients in Dierickx et al.’s cohort were elderly dementia cases.

Some interesting points can be raised from Dierickx et al.’s report. First, consultations by palliative care specialists were not uncommon, and not limited to dementia cases. This is timely, since a distinct field of palliative psychiatry has recently been outlined as a reasonable approach for treating severe persistent mental illness [7]. Second, approximately 1 in 4 patients said that they suffered physical pain, together with psychic pain, despite the absence of reported physical illnesses. It is noteworthy that psychic pain is associated with the modulation of physical pain, and may facilitate suicidal behaviors through increased pain tolerance [8]. Third, although the numbers remain low, Belgium has recently experienced an increase in psychiatric euthanasia cases (0.5% up to 2008, 3% in 2013). A similar trend is observed in the Netherlands up to 2013 [4]. This rise may be associated with increasing public awareness of psychiatric euthanasia.

In cases of mental disorders, physician-assisted death might be justifiable, but only when applicants are fully informed, and have access to adequate treatment options and support in (psychic) suffering [9]. Indeed, psychiatrists should be involved in evaluating euthanasia requests motivated by a mental disorder. This is the case in Belgium, but not in other countries such as the Netherlands or Switzerland. For a given patient, psychiatric assessment may help to ensure that available means are indeed futile to reduce their mental pain and suicidal ideation (which are core symptoms in the suicidal process), and that the person requesting euthanasia is competent and fully informed [10].

The report by Dierickx et al. raises a sensible question about the need for specific criteria and guidelines in assisted suicide for mental conditions. It also reveals some unexplained shortcomings in the practice of psychiatric euthanasia, such as the association of a foreseeable death with mental disorders, or the lack of specialized assessment in some cases. More generally, absence of standardization in the evaluation of psychopathology and mental capacities is problematic. In the Netherlands, a study on psychiatric euthanasia showed that the assessment of decision-making capacity is flawed by the lack of a systematic procedure and disagreements between physicians, which are not uncommon [11].