A new study of doctor-assisted death for people with mental disorders raises questions about the practice, finding that in more than half of approved cases people declined treatment that could have helped, and that many cited loneliness as an important reason for wanting to die. The study, of cases in the Netherlands, should raise concerns for other countries debating where to draw the line when it comes to people’s right to die, experts said.
At least three countries — the Netherlands, Belgium and Switzerland — allow assisted suicides for people who suffer severe psychiatric problems and others, like Canada, are debating such measures, citing the rights of people with untreatable mental illness. Laws in the United States, passed in five states, restrict doctor-assisted suicide to mentally competent adults with terminal illnesses only, not for disorders like depression and schizophrenia.
The study, published Wednesday in the journal JAMA Psychiatry, finds that cases of doctor-assisted death for psychiatric reasons were not at all clear-cut, even in the Netherlands, the country with the longest tradition of carefully evaluating such end-of-life choices. People who got assistance to die often sought help from doctors they had not seen before, and many used what the study called a “mobile end-of-life clinic” – a mobile team with a nurse and a doctor, funded by a local euthanasia advocacy organization.
“The criteria in the Netherlands essentially require that the person’s disorder be intractable and untreatable, and this study shows that evaluating each of those elements turns out to be problematic,” said Dr. Paul Appelbaum, a professor of psychiatry, medicine and law at Columbia University.
Dr. Appelbaum added, “The idea that people are leaving their treating physician and going to a clinic that exists solely for this purpose, and being evaluated not by a psychiatrist but by someone else who has to make these very difficult decisions about levels of suffering and disease – it seems to me like the worst possible way of implementing this process.”
The study, led by Dr. Scott Y. H. Kim, a psychiatrist and bioethicist at the National Institutes of Health, looked at records of most of the cases of doctor-assisted death for psychiatric distress from 2011 to mid-2014. In 37 of those 66 cases, people had refused a recommended treatment that could have helped. The study did not evaluate the cases of people who had been denied assistance.
Depression was the most common diagnosis, but loneliness was also a frequent theme. “The patient was an utterly lonely man whose life had been a failure,” read one account. In another, a woman in her seventies said she and her husband had decided years earlier that they would not live without one another. She had no health problems, but after her husband died, she described her life as “a living hell.”
Five states in this country have laws allowing doctors to prescribe life-ending drugs to mentally competent, terminally ill adults: Oregon, Vermont, Montana, Washington, and California. The California law is expected to take effect later this year. By contrast, laws in several European countries allow such assistance for any competent person with “unbearable suffering” – regardless of the cause of that suffering.
Last year, a team of doctors in Belgium, where laws are similar to those in the Netherlands, reported that most people who sought doctor-assisted death for psychiatric problems had depression, personality disorders or both. The new study of the Netherlands fills out that picture considerably, detailing the agonizing decisions by both doctors and patients in cases that went forward, ending in voluntary death.
The researchers, who included Dr. John Peteet of Harvard Medical School and Raymond De Vries of the University of Michigan and Maastricht University in the Netherlands, found that 46 of the patients had been women, most 60 or older.
The depression was often mixed with other problems, like substance abuse, mild dementia or physical pain. More than half had received a diagnosis of a personality disorder, like avoidant or dependent personality, which are typically bound up with relationship problems. The group also included people with diagnoses of eating disorders and autism spectrum conditions. Many reported being intensely lonely.
“The Dutch system is really the idealized setting in which to try something like this,” said Dr. Kim, in an interview. “But still, you can see that there are many cases that make us question whether this is the right practice.”
In the Dutch system, consulting doctors review petititions for assistance in dying. In one quarter of the cases, the study found, the doctors disagreed.
Barbara Coombs Lee, president of Compassion & Choices, which advocates for compassionate end of life care, said the debate over people with psychiatric conditions was not relevant to laws in this country, which have been modeled on Oregon’s 1997 Death With Dignity Act.
“I have seen no parallel movement or discussion at any level in this country,” Ms. Coombs Lee said. “I don’t know of anyone ever proposing this here, or of any poll supporting anything but self-administration by mentally competent, terminally ill adults.”