Euthanasia still a taboo for mental patients - even in the Netherlands

People suffering from an incurable mental disease have the same legal right to euthanasia as physically terminally ill patients in the Netherlands, but they almost never get it.

A 66-year old woman suffering from depression told her psychiatrist, Cornelis van Houwelingen, she intended to throw herself in front of a train. She had tried to kill herself before. Van Houwelingen had treated the woman for 15 years and tried every possible treatment, to no avail. The woman was suffering intolerably, he said, and could not be helped. So he finally gave her a lethal drug.

Van Houwelingen's decision is rare among psychiatrists. The Dutch law that legalized euthanasia in 2002 also applies to the mentally ill, but psychiatrists have so far been extremely reluctant to resort to assisted suicide.

Two cases in 2008

Of the 2,331 cases reviewed by the regional euthanasia review committees in 2008 only two involved psychiatric patients. All doctors are obligated to report assisted suicides to the committees, who then investigate if all the legal requirements were met.

"Psychiatrists have a holier-than-thou attitude," Hans van Dam, a nurse and a teacher, said at a symposium organised by the Right to Die-NL foundation in the Dutch town of Ede on Monday. The taboo on assisted suicide for mental patients needs to be broken, Van Dam argued. "To put it bluntly: cancer will kill you in a matter of years, but schizophrenia is forever."

"The suffering of psychiatric patients can be just as intolerable as many forms of physical suffering," said Eugène Sutorius, a professor of criminal law and a former president of the foundation.

At Monday's symposium many attendees had horror stories about people who ended up killing themselves in the most atrocious ways after their treating psychiatrist refused to help them. "At some clinics they will say right away: we don't do that here," according to Van Houwelingen. And suicide attempts are not always successful, said Sutorius, "leaving people to go through life even more damaged than before."

"If euthanasia wasn't such a delicate subject I would be tempted to bring it before the disciplinary tribunal," added Sutorius. "Doctors have a duty to discuss this if patients have a death wish and there is no treatment available."

Guidelines

Sutorius estimates 200 to 300 patients each year ask their psychiatrists for assisted suicide. He stressed that patients always have to be encouraged to pick up their lives again, "but we're talking about a small group of people for whom this no longer makes sense. Most psychiatrists will readily acknowledge that a solution needs to be found for these people, but they're afraid to do anything about it."

According to Van Dam, many doctors are afraid that assisting some patients with suicide will create a precedent for other patients. And many psychiatrists are also unaware of the Dutch Psychiatry Association's guidelines on the subject, added Sutorius.

The guideline says "any request for assisted suicide by a psychiatric patient should first be interpreted as a request for life help. Accordingly the treatment should be directed towards finding a new life perspective." But it also says assisted suicide can be "ethically and medically responsible behaviour" in extreme cases where the patient is suffering "hopelessly and intolerably" and there is no other "reasonable solution".

But most of the time, said Sutorius, "psychiatrists just don't want to do it. They're afraid of the paperwork, they're afraid of being prosecuted and they're afraid of death. Sometimes they're afraid their own treatment of the patient was wrong, and in case of assisted suicide that treatment would become part of the report."

Ferdi Keppels, a lay counsellor, asked the symposium to show some understanding for the position of the psychiatrists. "It is all too easy to leave it to the psychiatrist. I personally know a psychiatrist who was all in favour of euthanasia, but who found it terribly difficult when he asked to do it."

Sutorius is hoping for a change of culture at the psychiatric clinics will change. He suggest making it obligatory for psychiatrists to report and motivate why they declined a patient's request for assisted suicide."I don't want to see psychiatrists dragged into court," he said, "but I do want them to make their case."