The Death Treatment

Debating the ethics of euthanizing the mentally ill.

Aviv, Rachel. “The Death Treatment.” New Yorker. June 22, 2015. (accessed September 3, 2016).

Those unfamiliar with the spate of assisted suicides taking place in the Netherlands and Belgium would do well to read up on the harrowing issue in Rachel Aviv’s “The Death Treatment,” from the June 22, 2015 issue of The New Yorker. In both countries, patients can be euthanized even if they do not suffer from a terminal illness:

In the past five years, the number of euthanasia and assisted-suicide deaths in the Netherlands has doubled, and in Belgium it has increased by more than a hundred and fifty per cent. Although most Belgium patients had cancer, people have also been euthanized because they had autism, anorexia, borderline personality disorder, chronic-fatigue syndrome, partial paralysis, blindness coupled with deafness, and manic depression.

Aviv’s poignant article begins with one such case of euthanasia. Godelieva De Troyer, a Belgium woman, suffered from severe depression since she was 19. In 2010, her life spiraled out of control following a breakup. Compounded with a fractured relationship with her son and daughter, she decided that she wanted to end her life:

Godelieva felt as if her emotional progress had been an illusion. She had seen the same psychiatrist for more than ten years and had consulted him on every decision, even those involving financial investments and home renovations, but she had now lost faith in his judgment. She complained to friends, “I give him ninety euros, he gives me a prescription, and after ten minutes it’s over.” Her psychiatrist acknowledged that there was no cure for her condition; the best he could do, he said, was listen to her and prescribe antidepressants, as he had been doing for years.

In September 2011, De Troyer saw Dr. Wim Distelmans, sometimes dubbed “Dr. Death,” at his clinic. Distelmans, an oncologist and professor of palliative medicine, has devoted his career to ending people’s suffering through assisted suicide. On April 20, 2012, Tom Mortier, De Troyer’s son, received a short letter from his mother that was written in the past tense. She explained that her euthanasia had been carried out the day before at the Free University of Brussels.

The bulk of the article focuses on Mortier, whose life changed dramatically when he was informed that his mother was dead and that she had chosen her death. Mortier responded by seeking answers from the doctor who euthanized her. He was enraged that he was not informed of his mother’s choice until after she had carried it out. A week after his mother’s death, Mortier emailed a psychiatrist named Lieve Thienpoint, who, with Distelmans, founded Utleam, a clinic for patients who are considering euthanasia. Aviv reports that in the past three years, 900 patients have gone to Ulteam, half of whom complained that they were suffering psychologically, not physically.

She writes:

Since Ulteam opened, in 2011, Thienpoint said it has been “overrun by psychiatric patients”—a phenomenon that she attributes to the poor quality of psychiatric care in the country. In Belgium, it is not uncommon for patients to live in psychiatric institutions for years. Outpatient care is minimal, poorly funded, and fragmented, as it is in most countries.

Let me be clear: I am all for assisted suicide. But I find this article disturbing. Belgium’s policy for euthanasia seems to me to be very mechanistic: send in an application, have it reviewed by three specialists who determine whether your suffering is “unbearable” and your condition “untreatable” and, if they agree, you get your wish. As Aviv writes: “The laws seem to have created a new conception of suicide as a medical treatment, stripped of its tragic dimensions.”

The destigmatization of mental illness has been achieved in part by claiming that mental illness is just as debilitating as physical illness and should be treated accordingly. But if mental illness and physical illness are similarly incapacitating, should we use the same standards in deciding how to best alleviate the overwhelming suffering they cause? Part of the rationale behind allowing euthanasia for the mentally is that if we are willing to help a terminal-cancer patient to die why shouldn’t we do the same for a person suffering from an “incurable” mental illness. The problem seems to lie with the term “incurable,” which is subjective in the case of psychiatric conditions.

One study has shown that many psychiatric patients euthanized in the Netherlands may have in fact suffered from treatable conditions. 66 cases of people who received either euthanasia or assisted suicide between 2011 and 2014 for psychiatric reasons were published online by the Dutch regional euthanasia review committee. Of the patients whose case files were studied, more than half had previously refused at least one form of treatment with many of those patients citing “lack of motivation” as the reason for their refusal. In Aviv’s article, it was reported that De Troyer did not undergo electroshock therapy (ECT) prior to requesting and being approved for euthanasia despite the fact that ECT has been shown to have successful outcomes in treating severe mood disorders. The study also found that one quarter of cases involved differences of opinion between physicians and yet death hastening proceeded anyway.

Euthanasia in Belgium and the Netherlands also raises concerns over informed consent. It is debatable whether the deeply disconsolate can make truly informed decisions. Undoubtedly, some competence is lost with severe depression. Mental illness affects the way one sees reality and it would be wrong to assume that all severely depressed individuals can realistically appraise their likelihood of having a better future. It is known that many suicidally depressed people are prone to impulsivity and therefore are not going to weigh the pros and cons of being dead. They just want to not hurt right now. This raises the question of whether someone who is suffering from a severe mental illness even has the capacity to make a life-and-death decision.

Another factor to consider is the state of a society’s mental health system. Significant gaps exist in mental healthcare including lack of treatment, long waits, and insufficient training for health-care providers. Is it right to give the mentally ill access to euthanasia if we cannot give them full access to treatment and support options? Would resources be better spent investing in quality and affordable mental health services?

As a society, we do not usually encourage suicide, much less assist in it. Public health policy has focused on suicide prevention. When we come across people who are suicidal, we try to help them to live rather than kill themselves. Doctors are supposed to play a key role. If they have reason to believe that a patient is suicidal, do they not have a duty to try and protect that patient from self-harm?

The upsurge in euthanasia and assisted-suicide cases in the Netherlands and Belgium is concerning. In her book, Night Falls Fast: Understanding Suicide, Kay Redfield Jamison touches upon the reality of an effect called “suicide contagion.” Media publicity surrounding a suicide has been repeatedly and definitively linked to a subsequent increase in suicide, especially among young people. Suicide prevention advocates have even gone so far as to develop guidelines for news media coverage of suicide deaths. The idea is to avoid emphasizing or glamorizing suicide, or to make it seem like a simple or inevitable solution for people who are at risk. We should question whether in allowing the option of euthanasia for psychiatric maladies, we are not also running the risk of increasing its likelihood in young and vulnerable individuals.

These are important ethical issues that must be addressed in psychiatry and society when considering how to help patients with the complexity of prolonged suffering that many psychiatric conditions bring. The ultimate goal should be to find the best ways of helping patients with intractable and unbearable psychiatric illnesses in the most effective and ethical way possible. It may not be that prolonging life in severe psychiatric conditions is the best choice. However, it is clear that given the number of unresolved ethical quandaries involved in this issue that a serious discussion is necessary.