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• A commentary on 'Euthanasia for psychiatric patients: ethical and legal concerns about the Belgian practice' from Claes et al.
  Lieve Thienpont
  Published on: 5 January 2016
• Euthanasia for psychiatric patients: ethical and legal concerns about the Belgian practice
  Stephan Claes
  Published on: 6 November 2015

• Published on: 5 January 2016

  A commentary on 'Euthanasia for psychiatric patients: ethical and legal concerns about the Belgian practice' from Claes et al.

  • Lieve Thienpont, psychiatrist
  • Other Contributors:
    • Monica Verhofstadt (commentary approved by the co-authors)

  In their warning call to Belgium and other countries in the world to (re)consider euthanasia legalisation, Claes et al. highlight some arguments that were also described in our descriptive study, including the key conditions 'untreatable and unbearable suffering' as subjects of controversy. However, we would like to react to some of the other statements in their commentary.

  Firstly, Claes et al. wrote "that 35%...

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  In their warning call to Belgium and other countries in the world to (re)consider euthanasia legalisation, Claes et al. highlight some arguments that were also described in our descriptive study, including the key conditions 'untreatable and unbearable suffering' as subjects of controversy. However, we would like to react to some of the other statements in their commentary.

  Firstly, Claes et al. wrote "that 35% and probably 50% of the euthanasia cases have been approved by one single psychiatrist", referring to psychiatrist Thienpont L. The Belgian Law on Euthanasia (2002) clearly states that in case of the non-terminally ill, it is a specific legal requirement of due care that - besides the treating physician - two 'additional' physicians, a psychiatrist or specialist in the disorder amidst them, have to be involved in careful evaluation of all legal requirements, including patient's mental capacity and the suffering experience in the context of patient's (psycho)pathology, before any advice regarding a euthanasia request can be given to patients' treating physician. In all cases in our study, these legal requirements were met.

  Secondly, Claes et al. focussed on the 38 euthanasia requests that were withdrawn: we want to clarify that these patients did not withdraw their request but were referred by the first author for additional diagnostic test and/or treatment, hence their request can be considered as pending, not withdrawn. Hence, at the moment of the final analysis of our study, these euthanasia procedures were still in process as patients accepted being referred to further testing- or treatment options and were giving these new perspectives a fair chance for success. Therefore, a final decision to grant their euthanasia requests could not be reached.

  Thirdly, concerning the key factor 'untreatable suffering', Claes et al. state - and rightly so - that mental disorders could be seen as a 'transient state'. We could not agree more on this. They rightly warn psychiatrist for having 'a narrow technical view on psychiatry' and 'denying patients' recovering abilities', when 'denying the fact that psychiatrists do not primarily treat diseases, but persons', by referring to scientific evidence showing that diseases tend to resolve over time, and specifically referring to borderline patients in remission 10 years after their diagnose. While these results are extremely hopeful, this doesn't mean that every patient can reach the state of being in remission. As could be read in the result section from our paper it concerned patients being treatment resistant, due to a comorbid psychiatric disorder. For example, it is noteworthy that almost every patient (90%) was diagnosed with more than one disorder at intake, which makes the effort to remission success a very complex one. Only when no alternative options are left and only if all legal requirements are complied, we face the boundaries of medical treatment. As stated in the introduction section of our paper, a patient can be considered to be in a medically futile situation, or treatment resistant, if the suffering is unbearable and untreatable and there is no prospect of any improvement. According to the Law, both physician and patient have to come to the conclusion that there is no reasonable alternative left to relieve the patient's suffering. In practice (and also stated in the introduction section of our paper), the guidelines from the Dutch Psychiatric Association (NVvP) are then followed to qualify untreatable suffering (e.g. any therapeutic option for a particular condition must meet the following three requirements: (i) a real prospect of improvement, (ii) the possibility to administer adequate treatment within a reasonable period of time, and (iii) a reasonable balance between the expected treatment results and the burden of treatment consequences for the patient, must be reached). Therefore, untreatable suffering is not vague in its essence.

  Fourthly, in response to the vagueness of the key factor 'unbearable suffering', we have stated in the introduction section of our paper that the unbearability of suffering cannot easily be defined, as it is a subjective term by its nature and qualitative research in the context of death wishes is paid cursory attention to (Dees et al, 2010). Delbeke (2013) described that the evaluation whether suffering is continuous and unbearable, is up to the patient. The physician has no solid psychophysical or psychological instruments to measure the irrefutable degree of physical or mental suffering, but has to come to a level of mutual and empathic understanding with the patient about the extend of his or her intolerable, unendurable suffering. However, the consulted physician can have patient's consent in having access to patient's medical file that contains information about patients' suffering history. Moreover, it belongs to the expertise of the advising specialist (psychiatrist) involved to judge patient's mental competency and whether there are any opportunities left to alleviate that type, extend or intensity of patients' suffering (Naudts et al., 2006). Psychiatrists are expected and supposed to have the knowledge and skills to decide whether and to estimate the extent to which the mental disorder is curable or not and whether or not there's a prospect of improvement. However, the dependence of the actual state of medicine and treatment options does include a subjective element.

  The aim of our paper was to open the discussion about the realised practice of euthanasia because of psychiatric illness within the Belgian legal framework. We take note of the considerations of Claes et al. and fully acknowledge that more research needs to be done in order to improve the quality of healthcare for this patient group. Therefore, we are already working on qualitative and quantitative research in order to gain more insight in this topic and to offer human and legal protection of patients, friends and relatives involved.

  References

  Delbeke E. Legal aspects of care at the end of life. Antwerp: Intersentia; 2012 (in Dutch).

  Dees, M, Vernooij-Dassen, M, Dekkers, W, & van Weel, C. (2010). Unbearable suffering of patients with a request for euthanasia or physician-assisted suicide: an integrative review. Psycho-Oncology, 19(4), 339-352.

  Federal Control and Evaluation Committee on Euthanasia. Fourth report to the Parliament (2008-2009). Brussels: Federal Control and Evaluation Committee on Euthanasia; 2010. Available from: http://www.ieb- eib.org/nl/pdf/rapport-euthanasie-2010-belgique-nl.pdf (in Dutch).

  Federal Control and Evaluation Committee on Euthanasia. Fifth report to the Parliament (2010-2011). Brussels: Federal Control and Evaluation Committee on Euthanasia; 2012. Available from: http://www.senate.be/www/webdriver-MItabObj=pdf&MIcolObj=pdf&MInamObj=pdfid&MItypeObj=application/pdf&MIvalObj=83889004 (in Dutch and French).

  Ministry of Justice. Law on euthanasia of May 28, 2002. Belgian Official Gazette: Brussels, 2002. Available from: http://www.npzl.be/files/107a_B3_Wet_euthanasie.pdf (in Dutch and French).

  Naudts, K, Ducatelle, C, Kovacs, J, Laurens, K, Van den Eynde, F, Van Heeringen, C. (2006). Euthanasia: the role of the psychiatrist. The British Journal of Psychiatry, 188(5), 405-409.

  Tholen AJ, Berghmans RLP, Huisman J, Scherders MJ. Guideline dealing with the request for assisted suicide by patients with a psychiatric disorder. Utrecht: Dutch Psychiatric Association. De Tijdsstroom; 2009. Available from: http://steungroeppsychiaters.nl/wp-content/uploads/Richtlijn-hulp- bij-zelfdoding_NVvP-2009.pdf (in Dutch)

  Conflict of Interest:

  Authors of the original article 'Euthanasia Requests, Procedures and Outcomes for 100 Belgian Patients Suffering from Psychiatric Disorders: A Retrospective, Descriptive Study'

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  Conflict of Interest:
  None declared.

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• Published on: 6 November 2015

  Euthanasia for psychiatric patients: ethical and legal concerns about the Belgian practice

  • Stephan Claes, Professor of Psychiatry
  • Other Contributors:
    • Ludi Vanbouwel, An Haekens, Marc Eneman, Georges Otte, Jan De Lepeleire, Marc Calmeyn, Ariane Bazane and Willem Lemmens

  As Belgian professionals in mental health care and medical ethics, we felt the need to comments on the paper published in BMJ Open by Thienpont et al., entitled "Euthanasia requests, procedures and outcomes for 100 Belgian patients suffering from psychiatric disorders: a retrospective, descriptive study" (Thienpont et al., BMJ Open. 2015 Jul 7;5(7):e007454.) We argue that this study denies several important and unresolved iss...

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  As Belgian professionals in mental health care and medical ethics, we felt the need to comments on the paper published in BMJ Open by Thienpont et al., entitled "Euthanasia requests, procedures and outcomes for 100 Belgian patients suffering from psychiatric disorders: a retrospective, descriptive study" (Thienpont et al., BMJ Open. 2015 Jul 7;5(7):e007454.) We argue that this study denies several important and unresolved issues in this ethically very delicate field.

  First, we would like to emphasize that the paper represents the practice of a small minority of the Belgian psychiatric professionals. The 100 cases described in this study stem from one single psychiatrist, the first author. These 100 cases led to the actual performance of euthanasia in 35 patients between 2007 and 2011. The Federal Control and Evaluation Commission for Euthanasia (FCEC) does not provide specific data on euthanasia in psychiatric patients in the whole of Belgium during this period. However, the number of euthanasia cases linked to "neuropsychiatric disorders" (also including neurodegenerative disorders such as Alzheimer's and Huntington's disease) does not exceed 100 for the entire period 2007-2011 (see reports at http://www.health.fgov.be/eportal/Healthcare/Consultativebodies/Commissions/Euthanasia/Publications/). Hence, in Belgium a substantial proportion of euthanasia cases for psychiatric disorders - certainly more than 35% and probably close to 50% - has been approved by one single psychiatrist. The abstract suggests that out of 100 euthanasia requests submitted to this single psychiatrist, 48 got a positive advice, and 35 lead to the actual application of the euthanasia procedure. This is misleading. In fact, the paper states that 38 patients withdrew their request before any advice was formulated. This implies that the actual number of euthanasia requests approved in this study was 48 out of 62, or 77.4 %.

  Second, we believe that the qualification of a patient's suffering being "unbearable" and "untreatable", a necessary condition for the approval of an euthanasia request according to the Belgian law, has not been sufficiently clarified in a psychiatric context. The author correctly states "...that the concept of 'unbearable suffering' has not yet been defined adequately, and that views on this concept are in a state of flux". But also the notion of a psychiatric disease being "untreatable" poses major problems. The most common psychiatric disorders diagnosed in the 100 cases described in the paper were major depression and (borderline) personality disorder. It is possible that in both disorders, the suffering is often perceived as unbearable by the patient, but that this state is transient in many cases. Depression is self-limiting in its natural course. Regarding borderline personality disorder (BPD), scientific evidence shows that this disease tends to resolve over time. A DSM diagnosis of BPD remits in 56% of patients after 2 years (Grilo e.a. 2004; Skodol e.a. 2005). According to Zanarini et al. (2011), 85% of BPD patients were in remission 10 years after the diagnosis was formulated.

  Further, the application of the term "untreatable" in a psychiatric context poses fundamental problems. The act of diagnosing a psychiatric patient, then calling the disease "untreatable" and proceeding to a life- ending procedure, implies a narrow technical view on psychiatry. While a given disease might be resistant to classical treatments, the psychiatric patient as a person is never beyond the possibility of recovery. To consider a patient a "hopeless case" when evidence-based therapies do not lead to remission of the diagnosis, denies the fact that psychiatrists do not primarily treat diseases, but persons, who can always surprise by their capabilities to recover, with or without evidence-based therapies. This is demonstrated by the following paragraph in the paper "In the remaining 57 cases (12 men and 45 women), the patients or their practitioners were contacted and it was confirmed that these patients were still alive. In nine cases their requests were still in process and no decision had been reached. In 48 cases, their requests were on hold because they were managing with regular, occasional or no therapy."

  The paper by Thienpont et al. also states that "all patients were legally competent under the Law" and that "the patient's capacity for discernment was evaluated during the process (...) according to explicit criteria described in the Belgian Legal Doctrine." Both from a clinical and ethical point of view this way of determining the accountability and moral autonomy of psychiatric patients by a merely legal procedure is questionable. In particular the determination of the capacity of discernment of psychiatric patients requires more clinical, therapeutic and ethical caution than a legal procedure can offer.

  Summarizing, we believe that this paper reveals some alarming features of the Belgian law regarding euthanasia. The Law has been stretched out to psychiatry with insufficient consideration for the specificity of the field. We think that mental health care workers in Belgium should urgently start a fundamental debate on this matter. We also think that the current dangerous evolution in Belgium should be a warning for other countries considering to implement euthanasia legislation.

  References

  Grilo CM, Sanislow CA, Gunderson JG, e.a. Two-year stability and change of schizotypal, borderline, avoidant, and obsessive- compulsive personality disorders. J Consult Clin Psychol 2004; 72: 767-75.

  Skodol AE, Gunderson JG, Shea MT, e.a. The collaborative longitudinal personality disorders study (CLPS): overview and implications. J Pers Disord 2005a; 19: 487-504.

  Zanarini MC, Frankenburg FR, Hennen J, e.a. Prediction of the 10-year course of borderline personality disorder. Am J Psychiatry 2006; 163: 827- 32.

  Conflict of Interest:

  None declared

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  Conflict of Interest:
  None declared.

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