From the Editor

Is the practice of psychiatry about to change?

We often think of change in terms of treatment developments – new drugs and therapies. But mental health services are delivered in a larger societal context, and our work is shaped by laws and court rulings. With that in mind, Carter v. Canada has the potential to reshape our work. As you know, last year, the Supreme Court of Canada struck down the provision of the Criminal Code prohibiting doctor-assisted suicide. Later today, a special joint parliamentary committee will issue its report, guiding the drafting of legislation that will legalize doctor-assisted suicide.

How will this future legislation affect those with mental illness? What will it mean for people like us who do clinical work? Obviously, it’s not possible to comment on legislation that hasn’t been drafted yet. But it is possible to look to other countries and consider their experience. In this week’s Reading, Kim et al. consider physician-assisted suicide and euthanasia in the Netherlands. In their study of a country across the ocean, there are lessons for our patients here.


The Dutch Experience

“Euthanasia and Assisted Suicide of Patients With Psychiatric Disorders in the Netherlands 2011 to 2014”

Scott Y. H. Kim et al., JAMA Psychiatry, 10 February 2016


Some form of assisted death, such as euthanasia or assisted suicide (EAS), receives legal protection in Belgium, the Netherlands, Switzerland, Luxembourg, and Canada, as well as in several American states. Although the origins of legalization of EAS centered on patients with terminal illness, many do not believe that the principles of autonomy and beneficence (relief of suffering) limit EAS to terminal conditions and argue that EAS should be extended to psychiatric conditions. Euthanasia or assisted suicide for such persons in Belgium and the Netherlands has received increasing attention. The recent Supreme Court of Canada ruling permitting physician-assisted death may not limit it to individuals with terminal illness, and no such limitation exists in Switzerland. Although the numbers remain small, psychiatric EAS is becoming more frequent. In the Netherlands, a 1997 study estimated that the annual number was between 2 and 5, and in 2013 there were 42 reported cases.

Dr. Scott Y. H. Kim

So opens a paper from JAMA Psychiatry. This isn’t an amazing paper, but it is very relevant. As the authors note, the debate over euthanasia and assisted suicide for psychiatric cases “typically focuses on persons with treatment-resistant depression” – yet little study has been made of the topic. Noting the paucity of work done in the area, Kim et al. review case summaries from the Netherlands seeking to better understand who gets euthanasia and physician-assisted suicide, and how the rules are applied.

The Kim et al. paper summarizes the legal and regulatory framework for doctor-assisted suicide in the Netherlands. Essentially, patients have a legal right in the cases where “suffering is unbearable, with no prospect of improvement” and where a physician and the patient conclude that there is “no reasonable alternative in the patient’s situation.” The practice, legal since 2002, is overseen by five regional committees who are required to review cases and also publish case reports.

Here’s what Kim et al. did:

· They reviewed the online summaries of euthanasia and physician-assisted suicide (EAS) from Dutch regional euthanasia review committees available as of June 1, 2015.

· The summaries were translated (by the NIMH’s translation services). Using content analysis, two of the authors then reviewed and coded the summaries.

Here’s what they found:

· Though there were 85 reported cases of physician assisted suicide and euthanasia, only 66 case summaries were online, and thus considered. The patients were mainly women (70%) and under 70 (68%).

· In terms of psychiatric illnesses, most had more than one condition; depressive disorders was the primary psychiatric issue (55%). Other diagnoses: psychosis (26%), PTSD and anxiety (42%). See below for a fuller explanation. Personality disorders were common (52%).

· Patients were frequently physically ill: 58% had a comorbid medical condition and 33% had two comorbid conditions.

· In terms of past psychiatric treatment, experience varied. Some patients (39%) had ECT. “On the other hand, a woman in her 70s without health problems (case 2011-120044) and her husband had decided some years before that they would not live without each other. She experienced life without her husband, who had died 1 year earlier, as a ‘living hell’ and ‘meaningless.’ A consultant reported that this woman ‘did not feel depressed at all. She ate, drank, and slept well. She followed the news and undertook activities.” Many patients had refused treatment at some point (56%).

· Some patients had long-standing issues, but others (8%) had psychiatric conditions for under five years.

· Social circumstances were unevenly reported but many patients struggled with social isolation and loneliness (56%).

· In terms of the procedure, physicians often disagreed with each other about patient capacity (24%). The review committees only disagreed with criteria being met in one case.

The authors conclude:

Perhaps reflecting the complexity of such situations, the physicians performing EAS generally sought multiple consultations (but not always), and disagreement among physicians—especially regarding competence and futility—was not unusual. Despite these complexities, a significant number of physicians performing EAS were new to the patients. We conclude that the practice of EAS for psychiatric disorders involves complicated, suffering patients whose requests for EAS often require considerable physician judgment.

In an accompanying editorial, Columbia’s Paul Appelbaum seeks to put the Dutch experience in a larger context.

You can find his editorial here:

Dr. Paul S. Appelbaum

His piece is short and doesn’t require much of a summary from me. That said, he makes good points. First and foremost, he notes the challenges to clinicians of euthanasia and physician-assisted suicide when it involves mental health disorders:

For psychiatric patients… for whom a desire to die is often part of the disorder and whose response to additional treatment is less certain, the competence of their decision and the intractability of their suffering are much more difficult to assess.

He then draws from European examples, noting the complexities of these issues:

The argument for allowing physicians to help end the lives of people with psychiatric disorders is usually based on the assumption that most cases will involve treatment-resistant depression. However, at most, 49 of the 66 cases in the Dutch database experienced depression, either as a primary or secondary diagnosis, and 6 of 66 cases were complicated by substance abuse, 4 by neurocognitive impairment, and 2 by autism spectrum disorder. Similar puzzling findings regarding autism spectrum disorder appear in a study of 100 consecutive cases of psychiatric patients evaluated for physician-assisted death in Belgium, where 12% had Asperger syndrome. Moreover, 52% (34 of 66) of the Dutch cases and 50% of the Belgian cases carried diagnoses of personality disorders, conditions often associated with strong reactivity to environmental and interpersonal stresses, raising questions about the stability of the expressed desires to die. Indeed, 38% of the Belgian patients who asked for physician assistance withdrew their requests to die before the evaluation could be completed.

A few thoughts:

1. This is a very relevant paper, as is the editorial. Literally, as you are reading this, Ottawa is drafting legislation on exactly this topic.

2. Of course, our legal framework is different than that of the Netherlands. In the Carter v. Canada decision, the Justices wrote of: “Grievous and irremediable medical condition… that causes enduring suffering that is intolerable to the individual.” Still, like in the Netherlands, such language allowing physician-assisted suicide would almost surely apply to people with physical conditions and mental health conditions.

3. Are there lessons to draw from the Netherlands and Belgium? Dr. Appelbaum – who clearly has hesitation with the whole concept – does raise a reasonable point about the need for procedures to be carefully crafted and meaningfully implemented. It’s difficult to draw full conclusions, of course, about the Netherlands. Because the Dutch data is from people who had physician-assisted suicide or euthanasia, we can’t understand the effectiveness (or ineffectiveness) of screening and counselling; we know who received the lethal treatment but nothing about those who didn’t. Still, the data does suggest the complexities of these issues, with doctors often disagreeing with each other on the capacity of some psychiatric patients who are requesting physician-assisted suicide or euthanasia.

4. Thus, regardless of your opinion of Carter v. Canada, the Dutch experience offers a cautionary tale.

Further Reading

Much has been written on this topic here in Canada, including from regulatory and professional bodies. The College and Physicians of Ontario has weighed in with “Interim Guidance” which is thoughtful and thus worthy of mention. The paper can be found here:

Reading of the Week. Every week I pick articles and papers from the world of Psychiatry.