The Conundrum of Euthanasia for Psychological Suffering

At times you hear of things that stir fear in the present and for the direction in which the world is likely heading. I recently learned that several countries have legalised euthanasia for people with psychological disorders who are otherwise healthy. The chief requirement that must be satisfied for approval of a request for euthanasia or physician assisted suicide (EAS) for a psychological condition, is mental suffering that is ‘unbearable’ and ‘without reasonable prospect of improvement’ using ‘available treatment options.’ What could be worse than considering your life not worth living on account of feeling depressed than to have health professionals or society at large agree that yours indeed is a hopeless situation?

I present what is reported publicly about two Dutch citizens who died by EAS. I am concerned that mental healthcare system inefficiencies might give rise to seeing EAS as a preferred treatment option in some instances (not only in the Netherlands but wherever EAS for psychological reasons has been legislated), where other options are not considered.

Iatrogenic effects are unintended adverse effects due to treatments received. After reading several published reports of completed EAS, I can’t dismiss the possibility that a lack of trauma-informed care contributes to the profound hopelessness that precipitates some requests for EAS. Ultimately, I question whether poorly recognised trauma potentially contributes to a degree of re-traumatisation making EAS seem tolerable or desirable compared to undergoing further ‘treatment.’ Trauma-informed care services refrain from implicitly blaming victims for their inability to successfully manage their traumatic reactions and thereby aim to embrace messages of hope and optimism. This sentiment isn’t reflected entirely in the published EAS reports I summarise below.

Regional Euthanasia Review Committees (RERC) oversee the procedural integrity of EAS deaths by reviewing whether ‘due care’ criteria have been satisfied in the conduct of EAS. Problematically, they do so retrospectively, meaning they review cases after-the-fact, and without evaluating whether EAS was ultimately the ‘right’ course of action given the specific circumstances of each case.

This essentially means EAS is deemed appropriate or permissible so long as a RERC confirms that: i) requests for EAS are voluntary, ii) suffering is unbearable, without prospect of improvement, iii) information is provided about the likely prognosis of a person, iv) there are no foreseeable reasonable alternatives to EAS, v) physicians consult at least one independent physician who ensures in writing that due care criteria are observed, and vi) the termination of life or assistance of suicide is performed with proper attention and medical care.

A Case Study

Consider the case of a man aged 20 who died by EAS in 2019. From what is reported of his history, he first displayed anger and behavioural difficulties at age 12. This led to placement in foster homes and youth care institutions at age 15. He attempted suicide three times in the years between the emergence of his mental health problems and his placements in out-of-home care. Records indicate a diagnosis of borderline personality disorder with antisocial features was given in 2011 at which time he was presumably in his early teens. The fact that personality disorder diagnoses are typically avoided during adolescence because personality is formative in this developmental period, raises questions about the appropriateness of the diagnosis.

Subsequently, other diagnoses were given including attention deficit disorder with features of autism, obsessive compulsive disorder, pyromania, and problematic substance use. He self-harmed constantly and had acquired a brain injury. Therapy comprised medications and psychotherapy amid long stays in forensic and psychiatric wards. Schema therapy was said to have had no effect in a way that is suggestive of the futility of continuing treatment. If the earlier diagnosis of autism was correct, it could be expected that therapy involving self-reflection on longstanding patterns of behaviour would have suboptimal effect.

Had his diagnostic banquet included ‘trauma’ as an overarching term, this might have informed more viable treatment approaches, however trauma is not mentioned anywhere in reference to his plight. Two months before his death, it was determined “there was no way of starting psychotherapy” because he had “no desire whatsoever to receive treatment.” If treatments weren’t working or made him worse and he was offered more of the same, why would express desire for ongoing treatment? Over five years of institutionalised care he reportedly deteriorated relative to his state at admission. Change was deemed unfeasible because of his “long treatment history with limited results.”

A Second Case Study

In the case of a woman in her seventies, her past trauma was offered to justify a physician’s failure to obtain independent opinion to comply with EAS due care criteria. The woman sought EAS for a lifetime of unbearable mental suffering relating to traumatic experiences she suffered at a young age. It is stated that she felt “worn out and powerless,” “experienced poor quality of life,” and “wanted to die with dignity.” When the RERC found the physician had not complied with due care criteria on account of failing to consult an independent physician, he argued that he had not done so because the woman had “developed an aversion to psychiatrists as a result of many failed treatments.”

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Can we assume she felt the way she did having received unhelpful aid, or intervention that was sub-optimally responsive to her trauma? Arguably, the woman saw EAS as the best solution to end what appears to be a degree of treatment-induced hopelessness. This seems an iatrogenic effect of the worst kind where unbearable mental suffering that is not remediable is attributable to failed encounters with the mental health system and its apparent failure to incorporate trauma-informed care. To rub salt in the wounds, the system agrees that EAS is the answer to the problems to which it contributes.

EAS for psychological reasons has been available in Belgium, Luxembourg, and the Netherlands since 2002. Switzerland also permits it. One hundred and fifteen Dutch citizens died by EAS for psychological reasons in 2021. This is more than six times the number (14) who died by the same means in 2012. Recently, Canada passed legislation to make Medical Aid in Dying (MAID) available to people with unbearable suffering that is entirely of a mental nature. This is anticipated to come into effect this year.

I do not write this post to condemn EAS. It’s not my job as a clinical psychologist to assess or determine the ethical position of someone’s choice. My intention is to raise awareness to the increasing availability of EAS to people with psychological conditions, and to prompt debate and dialogue over a practice that seems positioned as an alternative to mental health treatment where ‘other options’ are considered untenable. More should be done to ensure ‘other options’ are effective, offered, and tenable. Treatment options should be expanded if the unsuitability of extant psychological treatments contribute to EAS appearing a suitable answer to intense and protracted psychological suffering. Mental health services must operate in a trauma-informed manner and aim to treat people first before considering EAS, as it is questionable whether the myriad diagnoses often attached to people who die by EAS help to inform ways out of suffering and towards lives worth living.