On January 26 last year, 29-year-old Aurelia Brouwers drank a lethal medication and died. The young Dutch woman was not terminally ill. Instead, she had a psychiatric illness which, she said, made her suffer unbearably. “Every breath I take is torture.” she said. Finally she requested euthanasia at Levenseindekliniek, a group of Dutch doctors specialising in people who want to be euthanised.
The case was well documented: a team from a Dutch TV network, RTL Nieuws, ghoulishly followed her as Aurelia counted down the minutes to her death. She was not going to die in the foreseeable future. Instead, she had a “borderline personality disorder” and other mental health issues. According to Dutch law, only patients who are suffering unbearably with no prospect of improvement are eligible for euthanasia, but this can include mental suffering.
Euthanasia and assisted suicide (EAS) for psychiatric reasons constitute only a tiny fraction of the total EAS deaths in the Netherlands, although it doubled between 2010 and 2017, from 0.6 percent to 1.2 percent.
Most studies of such cases – which are nearly as controversial in the Netherlands as they are elsewhere – have focused on the “relentless despair” of treatment-resistant depression. But these constitute less than half of the EAS cases for psychiatric reasons.
The other half, as with Aurelia Brouwers, involve a personality disorder. The authors note that the helplessness, hopelessness, and suicidal thoughts which are characteristic of personality disorders “may be difficult to distinguish from feelings of intolerable and hopeless suffering (which are eligibility criteria for EAS)”.
Aurelia may be a perfect example why people with personality disorders should have been treated rather than euthanised. In a recent article in Psychological Medicine, four bioethicists and psychiatrists study the circumstances surrounding the deaths of 74 people with personality disorders who were euthanised in the Netherlands between 2011 and 2017. They conclude that using a personality disorder as a reason for euthanasia has a number of troubling features.
Dutch patients have to fulfil certain criteria to be eligible for euthanasia. The principle one is that the suffering has to be “irremediable”. But this did not seem to have been tested properly for patients suffering from personality disorders whose cases were studied.
There is no doubt that these are challenging patients. But, claim the authors of the study, “There is substantial evidence for the effectiveness of several psychotherapeutic treatment options on outcome measures such as depressive symptoms or suicidal behavior. Furthermore, although the number of studies are limited, long-term follow-up shows that the majority of persons with personality disorders achieve sustained remission.”
The implication of this is that these patients were granted euthanasia even though their situation was not “irremediable”.
Unfortunately, many Dutch doctors, even those at the Levenseindekliniek, are not competent to evaluate patients with personality disorders. It is not easy to apply therapeutic strategies and in many cases it requires a psychiatrist’s insight and experience. Unfortunately, “In 50 percent [of the cases], the physician managing their EAS were new to them, a third (36 percent) did not have a treating psychiatrist at the time of EAS request, and most physicians performing EAS were non-psychiatrists (70 percent)”. Unsurprisingly, treatment was inadequate. Over a fourth (27 percent) had not been hospitalized. Psychotherapy, the main treatment for personality disorders, was not tried in 28 percent.
Another problem is that patients with personality disorders suck doctors into their own vision of a hopeless future. “Due to the patients’ chronic, complex histories, clinicians were inclined to accept the patients’ perspectives more readily,” the authors point out. “This would be consistent with a trend that Dutch psychiatrists note as an evolution toward accepting patients’ subjective definition of irremediability”. In dealing with this type of patient, non-specialist doctors can lose their objectivity. They “seem uniquely emotionally affected by the suffering of patients”.
Michael Cook is editor of MercatorNet.