Dr Marc Van Hoey with Simona de Moor shortly before she was euthanised. (SBS Dateline)
On December 8, a group of psychiatrists, psychologists, philosophers and others published a letter in De Morgen, a Flemish newspaper, asking the government to remove the option for euthanasia on the basis of psychological suffering alone. Here is an English translation from the blog of Trudo Lemmens, Professor and Scholl Chair in Health Law and Policy at the University of Toronto Faculty of Law.
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For the first time since the adoption of the law in 2002, a decision to allow euthanasia –the De Moor/Van Hoey case – has been challenged by the euthanasia evaluation committee and forwarded to the public prosecutor.
The Australian broadcaster SBS made a documentary about this case and about the conversations between the patient and doctor. Another poignant video report was recently made public by The Economist, involving a 24-year-old young woman from Bruges, who ultimately declined the execution of her euthanasia request, which had been granted, and which was based on psychological distress. (24 and Ready to Die).
In our open letter in the Artsenkrant (September 2015) we have already drawn attention to the legal uncertainty for the doctor in cases of euthanasia based on purely psychological suffering. In this opinion piece we draw attention to its particularly problematic character, in particular the impossibility of objectifying the hopelessness of psychological suffering.
One would expect that the untreatable nature of this condition is supported by, for example, indications of an organic injury, or of tissue damage — in other words, with factors independent of what is subjectively felt or thought as a result of the disease. Such objectification is problematic in mental suffering.
Let us be clear. Mental suffering is real and can be at least as severe as physical suffering.
What is unique, however, is that you can only rely on the word of the person who is suffering to evaluate it. And this is clearly a good thing, because he or she is the only one who knows how much it hurts at that precise moment. At that moment indeed … because when we suffer psychologically, we are often convinced that no other future is possible.
It is often precisely these thoughts that push a person into the abyss, since as long as there is perspective, one can usually tolerate a great deal. We see that some people who were first declared terminally ill eventually abandon euthanasia because new prospects appear. In a paradoxical way, this proves that the disease cannot be called incurable.
Today depression is the most common mental illness: according to estimates by the World Health Organization one in seven people have to deal at one point in their lives with serious depression. If we connect these figures to the fact that hopelessness is one of the central features of a depressive phase, it is clear that the feeling of hopelessness is in no way commensurate with the true hopelessness of a situation.
In contrast to diseases that are the consequence of tissue damage, mental suffering is connected to a change in functioning – and not to a deterioration of tissue. This difference is essential because such dynamic changes, by definition, can and do revert, and sometimes quite suddenly. Thus we see that some people who were first declared untreatably ill and who received on that basis permission for euthanasia decline to exercise their option because new – albeit fragile – prospects appeared.
In a paradoxical way, this proves that the disease cannot be called incurable. The subjective assessment of one’s own perspective in the context of mental suffering therefore offers no stable support to make an “incurably ill” verdict.
The conclusion is clear: the current law assumes wrongly that there are objective clinical criteria for psychological suffering that might justify euthanasia. It is for this reason that euthanasia on the grounds of mental suffering alone cannot be regulated by law.
Some also defend the thesis that the mere offering of death as an option can cause a positive change and can therefore also be considered a component of good care.
In our view, however, this inevitably entails the radical failure of the mental health sector. The use of “death as therapy”, possibly up to the point of actually even performing the requested euthanasia, implies a priori renouncing what therapy still can and should be offering: the inexhaustible opening up of new perspectives.
As representatives of the various directly-involved professional groups, from different parts of the country and from across the different ideological fault lines, we are alarmed by the increasing trivialisation of euthanasia on the grounds of mental suffering alone.
We believe that this situation is intrinsically linked to the concept of an act which is based on subjective criteria. That is why we insist that allowing euthanasia based on purely psychological suffering should be removed from the current legislation.
Ariane Bazan, a clinical psychologist at Université libre de Bruxelles; Gertrudis Van de Vijver, a philosopher at Ghent University; and Willem Lemmens, an ethicist at the University of Antwerp, wrote this open letter, which was signed by 65 professors, psychiatrists and psychologists.