Improving control over euthanasia of persons with psychiatric illness: Lessons from the first Belgian criminal court case concerning euthanasia

Understanding the Experiences and Support Needs of Close Relatives in Psychiatric Euthanasia Trajectories: A Qualitative Exploration

In Belgium, adults with psychiatric disorders can opt for euthanasia under strict conditions. The impact of these euthanasia trajectories on close relatives remains insufficiently studied. This research is the first in Belgium to explore the concrete experiences and support needs of relatives involved in psychiatric-based euthanasia trajectories by means of an in-depth interview study. The interviews with 18 relatives were conducted from March to May 2023 and analyzed using inductive thematic coding. The results reveal the complex and ambivalent emotional and cognitive experiences among relatives. Experiences with euthanasia trajectories varied from positive to negative, marked by shared feelings of surrealism and unreality. This included the farewell process that relatives go through, regardless of whether euthanasia was carried out. While the desired level of involvement varied, everyone sought some degree of recognition and understanding for their complex position during the euthanasia procedure, aiding in a better comprehension and contextualization of the request. The level of actual involvement and support depended on the stage of the euthanasia request, their social network, and the reasons behind the request. There was a demand for transparent communication, more emotional and practical support, and assistance in coping with the emotionally charged process. Specific attention is needed for the emotional and cognitive rollercoaster, even if euthanasia is not ultimately pursued. Future research should employ a longitudinal design to gain deeper insights into relatives' fluctuating experiences and support needs throughout euthanasia trajectories. Seeking greater context diversity and combining perspectives in cluster research can improve understanding of interconnected needs.

Medical assistance in dying for mental illness: a complex intervention requiring a correspondingly complex evaluation approach

Medical assistance in dying for mental illness as a sole underlying medical condition (MAiD MI-SUMC) is a controversial and complex policy in terms of psychosocial and ethical medical practice implications. We discuss the status of MAiD MI-SUMC in Canada and argue for the use of the UK Medical Research Council's framework on complex interventions in programme evaluations of MAiD MI-SUMC. It is imperative to carefully and rigorously evaluate the implementation of MAiD MI-SUMC to ensure an understanding of the multiple facets of implementation in contexts permeated by unique social, economic, cultural and historical influences, with a correspondingly diverse array of outcomes. This requires a complexity-informed programme evaluation focused on context-dependent mechanisms and stakeholder experiences, including patients, service providers and other people affected by the policy. It is also important to consider the economic impact on health and social welfare systems. Such evaluations can provide the data needed to guide evidence-informed decision-making that can contribute to safer implementation and refinement of MAiD MI-SUMC.

A rebuttal on externalism

In a recent paper, I argued that an externalist understanding of mental disorder from the philosophy of psychiatry presents an ethical challenge to the practice of medical assistance in dying (MAiD) for psychiatric illness, because it highlights the ways in which the suffering associated with psychiatric illness is sustained by features of the external environment wherein the person is embedded, including social barriers and injustices. In a response to my paper, Harry Hudson argues that addressing social inequality lacks relevance to the immediate permissibility of psychiatric MAiD and that the issue of psychiatric MAiD should be informed by 'pragmatic politics' rather than by 'obfuscatory philosophy'. Herein, I contend that Hudson's response misconstrues my position and ascribes to me views I neither express nor endorse. My paper does not claim that psychiatric MAiD should be denied to people who are presently in intolerable distress. Rather, it suggests that the provision of psychiatric MAiD comes along with social responsibilities of the state to attend to the barriers and injustices that sustain and exacerbate psychiatric illness, as well as ethical responsibilities of clinicians to consider a wider range of presently available psychological and social interventions which may have been neglected under a traditional internalist approach.

Neurodiversity and disability: what is at stake?

Neurodiversity has come hugely to the fore in recent years in a variety of contexts, and is now subject to academic debate, activist discussion, and increasingly embedded in a range of institutional and corporate settings in the Global North, from workplaces to early years education, from psychotherapy to mainstream political discourses. The term has gained traction in Medical Humanities, as well as debate within bioethics, philosophy of psychology, and of law. Institutionally, it is now relied on in therapeutic practice, autism service provision, as well as in higher education, in particular. In this conceptual article we examine what is at stake in these usages and the implications in need of scrutiny. We resituate neurodiversity in relation to questions of disability by examining the deployment of neurology as the basis for identity, rights and benefits. The emergence of the term and the understandings to which it gives rise, we argue, leave out urgent questions of what is at stake for disabled people in a political climate of increasing harshness and ableism.

Externalist argument against medical assistance in dying for psychiatric illness

Medical assistance in dying, which includes voluntary euthanasia and assisted suicide, is legally permissible in a number of jurisdictions, including the Netherlands, Belgium, Switzerland and Canada. Although medical assistance in dying is most commonly provided for suffering associated with terminal somatic illness, some jurisdictions have also offered it for severe and irremediable psychiatric illness. Meanwhile, recent work in the philosophy of psychiatry has led to a renewed understanding of psychiatric illness that emphasises the role of the relation between the person and the external environment in the constitution of mental disorder. In this paper, I argue that this externalist approach to mental disorder highlights an ethical challenge to the practice of medical assistance in dying for psychiatric illness. At the level of the clinical assessment, externalism draws attention to potential social and environmental interventions that might have otherwise been overlooked by the standard approach to mental disorder, which may confound the judgement that there is no further reasonable alternative that could alleviate the person's suffering. At the level of the wider society, externalism underscores how social prejudices and structural barriers that contribute to psychiatric illness constrain the affordances available to people and result in them seeking medical assistance in dying when they otherwise might not have had under better social conditions.

Characteristics and outcomes of peer consultations for assisted dying request assessments: Cross-sectional survey study among attending physicians

Background

In most jurisdictions where assisted dying practices are legal, attending physicians must consult another practitioner to assess the patient's eligibility. Consequently, in some jurisdictions, they can rely on the expertise of trained assisted dying consultants (trained consultants). However, these peer consultations remain under-researched. We examined the characteristics and outcomes of peer consultations to assess an assisted dying request with trained consultants, and explored how these characteristics influence the performance of assisted dying.

Methods

We conducted a cross-sectional survey in 2019–2020 in Belgium among attending physicians who had consulted a trained consultant for an assisted dying request assessment (N = 904).

Results

The valid response rate was 56% (502/903). The vast majority of attending physicians (92%) who had consulted a trained consultant were general practitioners. In more than half of the consultations (57%), the patient was diagnosed with cancer. In 66%, the patient was aged 70 or older. Reported as the patients' most important reasons to request assisted dying: suffering without prospect of improving in 49% of the consultations, loss of dignity in 11%, pain in 9%, and tiredness of life in 9%. In the vast majority of consultations (85%), the attending physician consulted the trained consultant because of the expertise, and in nearly half of the consultations (46%) because of the independence. In more than nine out of ten consultations (91%), the consultant gave a positive advice: i.e., substantive requirements for assisted dying were met. Eight out of ten consultations were followed by assisted dying. The likelihood of assisted dying was higher in consultations in which loss of dignity, loss of independence in daily living, or general weakness or tiredness were reasons for the request.

Conclusion

Our findings indicate that the peer consultation practice with trained consultants is most often embedded in a primary care setting. Moreover, our study corroborates previous research in that assisted dying is performed relatively less frequently in patients with cancer and more often in patients with general deterioration. Our findings suggest that attending physicians hold peer consultations with trained consultants to endorse their own decision-making and to request additional support.

Media coverage of Belgium's first criminal case concerning euthanasia for psychiatric patients: A content analysis of Flemish newspapers and magazines

BACKGROUND

Belgium is one of the few countries worldwide where euthanasia on the grounds of unbearable suffering caused by a psychiatric disorder is legally possible. In April 2010 euthanasia was carried out on a 38-year-old Belgian woman with borderline personality disorder and/or autism. After a complaint by the family, three physicians were referred to the Court of Assizes on the charge of "murder by poisoning".

METHODS

A content analysis of print and online news coverage of the euthanasia case in a selected sample of Flemish newspapers and magazines, published between December 1, 2019 and March 1, 2020, was conducted to analyze the prominence and framing of the euthanasia case, as well as the portrayal of key figures in this case. A quantitative analysis, as well as an in-depth qualitative analysis (with the aid of NVivo 1.0 software) was performed.

RESULTS

One thousand two hundred fifteen news articles were identified through database searching. Of these, 789 articles were included after screening for relevance and eligibility. Mean prominence scores were moderate and did not statistically significantly differ between newspapers with a different historical ideological background or form (elite versus popular). The most frequent headline topics featured legal aspects (relating to the Belgian Euthanasia Law or the course of the trial). Headlines and content of most articles (90 and 89%, respectively) did not contain an essential standpoint on the euthanasia case itself or, if they did, were neutral. Historical ideological background, nor form of newspaper (elite versus popular) significantly influenced headline tone or article direction toward the euthanasia case. Despite this, our qualitative analysis showed some subtle differences in selection, statement or tonality of reports between certain newspapers with a different historical ideological background.

CONCLUSION

Although major Flemish newspapers and magazines generally were neutral in their coverage of the judicial case, major points of contention discussed were: the need for an evaluation and possible amendments to the existing Euthanasia Law, including a revision of the Belgian Control Commission and the system of penalties for physicians, and the absence of any consensus or guidance on how to define psychological suffering.