Italian psychiatrist raises doubts
about assisted suicide and mental illness
Bernardo Carpiniello reports that psychiatrists raise serious clinical concerns in approving euthanasia for mentally ill patients.
Bernardo Carpiniello of the Department of Medical Sciences and Public Health-Unit of Psychiatry at the University of Cagliari, Italy, published an article in the Journal of the Italian Society of Psychiatrywarning about the dangers of permitting euthanasia and assisted suicide for those with mental disorders.
In the article “Conceiving the unconceivable: ethical and clinical concerns over assisted suicide for people with mental disorders,” Carpiniello stated that there are typically three requirements that must be met to grant a euthanasia or assisted suicide request: the patient’s suffering must be lasting and unbearable; all therapeutic options must have been exhausted, and further treatment considered futile; the patient’s request should be voluntary, enduring, and well considered (that is, the person must be competent to make the request). Carpiniello notes, “Each of these aspects may represent an intrinsic challenge to psychiatrists, who are largely forced to base their evaluation on subjective, personal criteria, particularly given the lack of objective, reliable criteria.”
He also reported that treatment-resistant depression is difficult to diagnose, and that there is no generally accepted definition of what constitutes treatment-resistant depression.
Carpiniello examined clinical concerns among psychiatrists approving euthanasia or assisted suicide requests, pointing out, “assessments of competency, sustained wish to die prematurely, depressive disorder, demoralization and ‘unbearable suffering’ in the terminally ill are clinically uncertain and difficult tasks … As yet psychiatry does not have the expertise to ‘select’ those whose wish for hastened death is rational, humane and ‘healthy’.”
The paper also examines whether those suffering mental illness are competent to make such requests. Carpiniello reports statistics from the Netherlands and Belgium that show half of all assisted suicide requests for people with mental disorders were related to diagnoses of personality disorder. Because personality disorders are “often associated with a strong reactivity to environmental and interpersonal stresses,” there are serious questions raised about “the consistency of their desire to die” when making a request. He also highlights a Belgian study that found almost a third of people with mental health issues who requested assisted suicide later changed their mind.
These figures may help explain why surveys of Dutch doctors find that only a third of them will participate in euthanasia for mental disorders. He also noted that the number of psychiatrists opposed to euthanasia for mental illness grew from 53 per cent in 1995 to 63 per cent in 2015.
Carpiniello offers a possible explanation: “Euthanasia or assisted suicide represents a typical example of a situation in which psychiatrists are faced with the impossibility of having to reconcile two moral obligations, a duty of care and respect of patient autonomy. To put it bluntly, for many psychiatrists euthanasia is ethically unacceptable, particularly as the main aim of psychiatry is to limit patients’ suffering.”
He also notes that the American Psychiatric Association “holds that a psychiatrist should not prescribe or administer any intervention to a non-terminally ill person for the purpose of causing death.”
Still, despite such opposition, Carpiniello warns, once euthanasia is permitted in a jurisdiction, it becomes a “slippery slope, down which we have rolled to now allow something that was impossible to conceive as ever being acceptable.”
Carpiniello also addresses the issue of suicide as a public health concern, noting global statistics that show one person dies every 40 seconds from suicide and saying that suicide prevention and suicide assistance seem to be irreconcilable. He writes: “An emphasis on suicide prevention from a public health perspective seems to be somewhat hard to reconcile …for those countries simultaneously equipped with social and health policies established for the specific purpose of preventing suicide. Considering the specific role of psychiatry in preventing suicide, put in very simple terms, the question is: what is the point of psychiatrists trying in every way possible to prevent suicide if the person concerned is entitled by law to seek assistance to commit this action?”
Carpiniello worries that among the “undesirable consequences of assisted suicide,” will be psychiatrists “giving up treating some patients” if euthanasia is legalized and perhaps even lead to fewer resources being committed to mental health research as assisted-suicide becomes normalized. A vicious cycle of “a lack of progress in developing more effective therapeutic strategies” could lead to more people being diagnosed with treatment-resistant depression (or other mental health issues), which in turn leads to more demand for suicide-on-demand for those with mental illness.
Alex Schadenberg, executive director of the Euthanasia Prevention Coalition, said, Carpiniello’s study is a “significant paper dealing with the concerns related to euthanasia for psychiatric reasons.” Schadenberg explained, it “clearly indicates that the negative consequences related to euthanasia for mental disorders suggest that this should not be done.”
In February, the Liberal government introduced Bill C-7, an act to amend the Criminal Code (medical assistance in dying). Among other changes Canada’s euthanasia and assisted-suicide law, C-7 allows medicalized killing for mental illness, although it denies doing so.
Schadenberg noted that Canadian euthanasia law says a person qualifies for assisted-suicide if “the illness, disease or disability or that state of decline causes them enduring physical or psychological suffering that is intolerable to them and that cannot be relieved under conditions that they consider acceptable.” Schadenberg said psychological suffering would include mental illness as does the amendment to remove the requirement for eligibility that “natural death be reasonably foreseeable.”
Consultations by the government undertaken in January found that most respondents who left comments about expanding euthanasia to those with mental illness were opposed to the idea. Most respondents said they would prefer to see more resources for support and intensive treatment for those with mental illness.
If passed, C-7 would also allow advanced directives for euthanasia and remove the 10-day waiting period between requesting “aid in dying” and being killed.
Schadenberg said if Bill C-7 is passed without amendments, it “will make Canada’s euthanasia law the most permissive in the world.”
