Is Euthanasia for Mental Suffering Ethical?

In the Netherlands, the practice is stirring controversy among medical ethicists

In the United States, medical aid in dying is legal in only a handful of states (California, Colorado, Oregon, Washington, Vermont and Montana). What’s more, the criteria for allowing patients to participate in aid in dying are very rigid and clear cut. For example, two physicians must determine that the person has six months or less to live. The doctors must also determine that the person is “mentally competent” to make the decision to end his or her life. This excludes patients suffering from dementia, depression or a mental illness of any kind.

Additionally, euthanasia, in which a physician actively participates in taking a patient’s life, is illegal in all 50 states.

Person with mental illness contemplating euthanasia

Can mental illness cause unbearable suffering?

Not so in the Netherlands, where euthanasia to “end unbearable suffering with no prospect of improvement” has been legal since 2002. What’s more, between 2010 and 2015, the number of people who chose euthanasia to end unbearable mental suffering jumped from two to 56, according to the Telegraph.

The increase has caused alarm among medical ethicists, particularly since none of these people were terminally ill. Nevertheless, psychiatrist Paulan Stärcke, who has performed euthanasia on several patients with psychiatric disorders, says the practice is both ethical and compassionate. “Euthanasia is a good death by the wish of the person who dies and no-one else,” she says.

What Is Suffering?

The idea of unbearable mental suffering is difficult to grasp. For most of us, the word “suffering” implies unrelieved physical pain. Yet we know from data out of Oregon, where medical aid in dying has been legal for nearly 20 years, that patients rarely choose physician-assisted death because they are in physical pain. In fact, when patients were asked why they sought aid in dying, they cited loss of enjoyment, dignity and autonomy far more often than concerns about physical pain.  

How, then, can doctors quantify suffering?  Is it even possible for one person to comprehend the suffering of someone else? Can we appreciate the depth of another person’s anguish or measure their emotional pain? According to Eric Cassel’s seminal 1991 essay “The Nature of Suffering and the Goals of Medicine, the answer, for the most part, is no.

“….Someone devoid of physical pain, perhaps even devoid of ‘symptoms,’ can suffer,” Cassel writes. “People can suffer from what they have lost of themselves in relation to the world of objects, events, and relationships. Such suffering occurs because our intactness as persons, our coherence and integrity, come not only from intactness of the body but from the wholeness of the web of relationships with self and others.”

In other words, people, not bodies, suffer. And in that context, helping someone die because they are in unbearable emotional pain may make sense.

Preventing Suicide?

Stärcke, who presented her work at the Euthanasia 2016 Conference in Amsterdam last year, also says that euthanasia can spare families of mentally ill patients pain. At the conference, she showed videos of interviews with two families whose loved ones she had helped end their lives. One was a 34-year-old divorced woman with chronic depression, post-traumatic stress and a personality disorder. She left a 3-year-old daughter, who was living with her father, behind.

“[The family was] sure, and I was as well, that her mother would die by suicide if I didn’t help her die,” Stärcke explains.

“You can prepare for [euthanasia]; you can say goodbye. You are present with someone, and it can be a loving memory — not only hurt, as suicide is only hurt,” she adds.

doctor preparing euthanasia drugs

A doctor prepares intravenous medicines she will use to perform euthanasia in a patient’s home
Credit: Selina Pfrüner/

Euthanasia Deaths Up Overall

While the practice of euthanizing patients suffering from a mental illness has stirred a great deal of controversy, statistics from the Netherlands show that the actual number of patients who choose euthanasia for psychiatric reasons is very small. The vast majority (72 percent) of those who chose physician-assisted death in that country in 2015 had cancer, which is similar to the number in Oregon (77 percent). Diseases of the nervous system accounted for another 5 percent, followed by diseases of the heart and lungs. These numbers also echo the results from Oregon for that year.

What is concerning, some experts believe, is the dramatic increase in the number of people in the Netherlands who have sought medical assistance in dying in recent years. Between 2010 and 2015, the number jumped from 3,136 to 5,516, an increase of 75 percent. However, in a country of nearly 17 million people, the per-capita rate is still quite small.

Euthanasia for Dementia

Another area where the Netherlands differs from the United States is in allowing people with dementia to choose euthanasia if they state their wishes in an advance directive while they are still mentally intact. This leaves the decision as to when to end the patient’s life to the family and medical providers, which some ethicists believe is morally wrong. For example, Dr. Erwin Kompanje, assistant professor of clinical ethics at Erasmus MC University Medical Centre, says:

“Unbearable suffering can no longer be measured in a patient with dementia. Anyone can prepare a living will with a dementia clause…but the question is whether this individual, now demented, experiences life as unbearable suffering.”

It is usually the family who is suffering,  Kompanje claims. And that is not a reason to end a life.

Controversy Continues

Dr. Kligler wants physician assisted death

Dr. Roger Kligler is fighting for the right to die on his own terms
Credit: Compassion&Choices

And so it seems that both in Europe and the United States, the controversy over physician-assisted death will continue for some time to come. Despite overwhelming popular support for medical aid in dying, Britain’s Parliament soundly defeated “right to die” legislation there in 2015. But then in April of this year, the British Court of Appeal ruled that Noel Conway, a 67-year-old man with motor neuron disease, could challenge the decision in court.

Other cases are moving forward in the United States. These include a lawsuit by Dr. Richard Kligler and his physician, Alan Steinbach, M.D. Kligler, who suffers from metastatic prostate cancer, is suing the state of Massachusetts for the right to die on his own terms. Steinbach is suing for the right to help him die. 

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