Belgium’s debate over euthanasia for psychological suffering is heating up. Last week 42 psychiatrists, psychologists and academics published an open letter calling for a national debate on euthanasia and mental illness.
Euthanasia because of unbearable and futile psychological suffering is very problematic. It is about people who are not terminal and, in principle, could live for many years. Therefore, extreme caution is appropriate both clinically and legally. The essence of the case seems to us that in estimating the hopelessness of one's suffering, the subjective factor cannot be eliminated …
The current law, the signatories say, is far too vague and flexible:
“The law does not indicate the exact criteria for unbearable and psychological suffering. Any complaint about any carelessness in this area will only end in a legal ‘no man's land’.
“More and more, no matter how many criteria there are, it depends simply on how an individual psychiatrist interprets or tests them, aided by the doctor's own assumptions and the patient's account of his symptoms.”
Some people are dying unnecessarily, the signatories claim. To stand silently on the sidelines is a crime of neglect.
The danger inherent in euthanasia for psychological suffering is a topic which seems to bore the Belgian media. But it was jolted out of its slumber by an exclusive article (in English) from Associated Press which also appeared in the Washington Post. This prompted a number of articles in the local press.
The article in the Washington Post highlighted a conflict between Lieve Thienpont, a psychiatrist who has processed a number of patients who wanted euthanasia on the basis of psychological suffering, and Wim Distelmans, the head of the federal euthanasia commission. Distelmans is by no means a conservative; apart from his regulatory role, he is one of Belgium's most prominent euthanasia doctors and the chief national cheerleader for euthanasia. But according to the AP’s report, even Distelmans was shocked. He thought that Thienpont had allowed patients to die who did not fulfil the criteria set down by Belgium’s euthanasia legislation.
Thienpont denied this and blamed some of her patients for misrepresenting her. “These patients are very desperate, stressed,” she said. “They say things that are not always correct.”
These words prompted Ignaas Devisch, a bioethicist at Ghent University, to question her reasoning.
Talk about paternalism! Suddenly, people who were previously able to achieve full self-determination and who just requested euthanasia, were no longer able to articulate their thoughts in an appropriate way.
This argument reveals a gigantic problem: if a psychiatrist who deals with requests for euthanasia due to a psychiatric disorder doubts at the same time whether those same people can make a clear judgment about themselves, that is so much as saying that their euthanasia request is a highly problematic case.
A long feature in the magazine Knack last week illustrates some of the difficulties that Belgian psychiatrists now find themselves in. One experienced psychiatrist complained that it had changed her relationship with her patients, even though she supports the idea of euthanasia.
“Strangely enough, people with less severe and readily treatable mental disorders – such as borderline personality disorders – request euthanasia more often than seriously ill patients. The offer really creates the question. Euthanasia has become a new symptom. Often it's a cry for help: 'Am I still worth living, or are you giving up on me?' But it is a symptom with particularly dangerous consequences…
“If you refuse to take the euthanasia question seriously, you put the relationship with the patient at risk and lose your trust…
“Since the euthanasia law there has been some kind of madness in our work. After the threat of suicide, for which you must be constantly on guard as a psychiatrist, there is now the threat of euthanasia. ”
This wrangle within Belgium's euthanasia club comes as a time when international observers are becoming more and more alarmed by developments there. An excellent recent book from Cambridge University Press takes a critical look at euthanasia in Belgium. Euthanasia and Assisted Suicide: Lessons from Belgium features essays on legal, philosophical and medical issues, as well as how euthanasia affects vulnerable populations, with a number of authors from Belgium and the UK.
The editors, David Albert Jones, of the Anscombe Bioethics Centre, Oxford; Chris Gastmans, of the Faculty of Medicine at KU Leuven in Belgium; and Calum MacKellar, of the Scottish Council on Human Bioethics, say that the volume is the first interdisciplinary study of Belgian euthanasia. The authors point out that
- The system is not transparent. Just 16 members of a euthanasia commission are supposed to oversee thousands of euthanasia cases.
- The system relies on self-reporting. Of the thousands of reported cases, only one has been referrrd to a public prosecutor and it is estimated that only half of all cases are even reported.
- Since legalisation in 2002, euthanasia has been “normalised”, with more and more cases of life-ending without request.
- A leading palliative care doctor who is sympathetic to euthanasia warned in 2013 that “once the barrier of legalistation is passed, [euthanasia] tends to develop a dynamic of its own and extend beyond agreed restrictions”.
- “Continuous deep sedation” is increasingly being used as a means of euthanasia.
“Death by euthanasia in Belgium is, generally, no longer regarded as an exception requiring special justification. Instead, it is often regarded as a normal death and a benefit not to be restricted to without special justification.”
It's clear now that euthanasia for psychological suffering is out of control. Only about 40 of of Belgium's 2,000 euthanasia deaths each year are psychiatric patients. But it appears that the controls which are supposed to limit this to the most extreme cases are no longer working. Wim Distelmans is a euthanasia radical. If he is worried, the rest of Belgium should be terrified.
Michael Cook is editor of MercatorNet and of BioEdge (also published by New Media Foundation) from which this article has been republished.