A conceptual framework for thinking about physician-assisted death for persons with a mental disorder.

Abstract

Physician-assisted death (PAD) has been enacted in a number of international jurisdictions, with several extending access to PAD for persons whose condition is not terminal, including those with a mental disorder. We argue that based on the state of the literature, it is too early to make well-defined recommendations on how relevant fields can proceed legally, ethically, and clinically, particularly with regard to PAD for persons with a mental disorder. The aim of this paper is to introduce a framework for further discussions on PAD for persons with a mental disorder to stimulate thoughtful and considered debate in our field. We provide a brief discussion of the principles that guide regulatory frameworks on PAD practices worldwide, including a discussion of jurisdictions in Europe and North America that allow PAD for those suffering from an incurable nonterminal disease, illness, or disability. Next, we present a conceptual framework as a series of questions that address legal, ethical, and clinical dilemmas arising from this trend. We conclude with a summary of guidelines on the practice of PAD from international jurisdictions to assist in the development of potential legal and professional regulations.

Irremediable Psychiatric Suffering in the Context of Physician-assisted Death: A Scoping Review of Arguments: La souffrance psychiatrique irrémédiable dans le contexte du suicide assisté : Une revue étendue des arguments

“…20,36 Canada's assisted dying law is more patient-centered, stating that suffering is irremediable when all treatments acceptable to the patient have failed, thus leaving more room for PAD after treatment refusal. 2,41 This patient-centered view on irremediability is held by right-to-die societies and is supported by several authors throughout the debate. 2,44,46,47 Opponents of PAD of PPD argue that the patient-centered view on treatment refusal will most likely lead to deaths that could have been prevented by offering treatment.…”

“…(continued) 47 Essay Argues that psychiatric suffering can be irremediable and that this can be ground for PAD under current Canadian law. Shaffer et al 2 Review Gives an overview of all jurisdictions that allow PAD at that time and investigate whether psychiatric patients have access and identifies irremediability as an important topic where legislation differs.…”

“…Many jurisdictions explicitly or implicitly ban patients with psychiatric disorders (PPD) from accessing PAD, but this is not the case in the Netherlands, Belgium, Luxemburg, and Switzerland. 2 In Belgium and the Netherlands, the prevalence of PAD due to psychiatric suffering has increased over the past years. 3,4 In the Netherlands, 1.1% of all cases of PAD in 2018 was due to psychiatric suffering (67 psychiatric cases in total).…”

The need to exercise caution in accepting addiction as a reason for performing euthanasia

“…Secondly, in assessing the person's request, we need to be assured that their addictive behaviour is chronic and persistent and that it is not amenable to treatment or other forms of assistance. This involves asking the following sorts of questions: Have the person's symptoms remitted in the past or been successfully treated in the past ? Have all acceptable treatment options been offered to the person? What treatment options have been tried, such as residential rehabilitation, psychosocial and pharmacological treatments? If the person has a psychiatric disorder that may have prolonged their addiction (such as depression or anxiety), have they received personal and psychological assistance or medical treatment for this disorder? Have harm reduction options been offered to the person if they cannot be abstinent? For example, has the patient considered drug substitution treatment that uses less harmful drugs to stabilize their condition and reduce their suffering?…”

“…For example, in the Dutch case was the man encouraged to consider using cannabis (which is quasi‐legal in the Netherlands), or was he offered a maintenance prescription of a long acting benzodiazepine as an alternative to drinking alcohol? To what extent have modifiable external and environmental factors (e.g. poverty, loneliness) contributed to the person requesting euthanasia ?…”