On January 26, 2018 at 2:35pm 29-year-old Aurelia Brouwers drank a lethal medication and died. The young Dutch woman was not terminally ill. Instead, she requested euthanasia at an end-of-life clinic because she had a borderline personality disorder and other mental health issues. “I suffer unbearably and hopelessly,” she said. “Every breath I take is torture." she said.
Her case was well documented: a team from a Dutch TV network, RTL Nieuws, followed her during her last two weeks.
She may be a perfect example why people with personality disorders may need treatment rather than euthanasia. In a recent article in Psychological Medicine, four bioethicists and psychiatrists study the circumstances surrounding the deaths of 74 people with personality disorders who were euthanised in the Netherlands between 2011 and 2017. They conclude that using personality disorders as a reason for euthanasia has a number of troubling features.
Euthanasia and assisted suicide (EAS) for psychiatric reasons constitutes only a tiny fraction of the total EAS deaths in the Netherlands, but it has risen from 0.6% in 2010 to 1.2% in 2017. In half of these cases, a personality disorder was involved, even though most of the discussion of psychiatric EAS has been about depression, which is involved in the other half. The authors note that the helplessness, hopelessness, and suicidal thoughts which are characteristic of personality disorders “may be difficult to distinguish from feelings of intolerable and hopeless suffering (which are eligibility criteria for EAS)”.
Dutch patients have to fulfil certain criteria to be eligible for euthanasia. The principle one is that the suffering has to be “irremediable”. But this did not seem to have been tested properly for the patients whose cases were studied.
For one thing, many doctors were not competent to evaluate patients with personality disorders. It is not easy to apply therapeutic strategies and in many cases it requires a psychiatrist’s insight and experience. Unfortunately, “In 50% [of the cases], the physician managing their EAS were new to them, a third (36%) did not have a treating psychiatrist at the time of EAS request, and most physicians performing EAS were non-psychiatrists (70%)”. Unsurprisingly, perhaps, treatment was inadequate. Over a fourth (27%) had not been hospitalized. Psychotherapy, the main treatment for personality disorders, was not tried in 28%.
Lack of experience in dealing with personality disorders can mislead inexperienced doctors. “Due to the patients’ chronic, complex histories, clinicians were inclined to accept the patients’ perspectives more readily. This would be consistent with a trend that Dutch psychiatrists note as an evolution toward accepting patients’ subjective definition of irremediability,” the authors note. In dealing with this type of patient, non-specialist doctors can lose their objectivity. They “seem uniquely emotionally affected by the suffering of patients,” the authors comment – sucked, that is, into the patient’s vision of hopelessness.
The authors note tersely that “The issues raised are worthy of further investigation and discussion, especially as some jurisdictions consider legalization of psychiatric EAS.”
Michael Cook is editor of BioEdge.
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