Overview of Euthanasia and Physician-Assisted Suicide Practices and Challenges

Euthanasia and physician-assisted suicide

Overview of practices and current challenges

Marie Nicolini MD MSc

Postdoctoral fellow

Department of Bioethics

NIH

Disclaimer

The views expressed in this talk are my own.

They do not represent the position or policy

of the NIH, DHHS, or US government

About me

•

2005-2012: Medical school (KU Leuven, Belgium)

•

2012-2017: Residency in adult psychiatry (KU Leuven)

•

2012-2014: Erasmus Mundus Master in Bioethics

•

2015-2016: fMRI research in patients with dementia

•

2017-2018: Visiting

scholar, Georgetown

University

•

2018-Present: NIH

Postdoctoral fellow,

Department of bioethics

Why this topic?

•

Timely, global issue

•

Remains controversial

•

Rapidly changing laws

Some terms and definitions

Often used terms

–

Euthanasia and/or assisted suicide (EAS

)

–

Physician-assisted suicide (PAS)

–

Physician-assisted death (PAD)

–

Physician aid-in-dying

–

Death with dignity

–

Hastened death

–

Medical assistance/aid-in-dying (MAID)

Some terms and definitions

But all have detractors because

–

Not all places require physicians

–

‘Suicide’ has descriptive as well as negative meaning

–

Palliative care can be ‘aid in dying’

–

PAD does not distinguish between euthanasia and PAS

–

Etc. etc.

Overview for today

•

Part 1: Introduction

–

Different end-of-life options

–

EAS around the world

•

Part 2: The practice in the Netherlands

–

EAS for psychiatric disorders

–

EAS for dementia

•

Part 3: Implications for the US

–

Debate about EAS in the non-terminally ill

–

Conclusion & future directions

Overview for today

•

Part 1: Introduction

–

Different end-of-life options

–

EAS around the world

•

Part 2: The practice in the Netherlands

–

EAS for psychiatric disorders

–

EAS for dementia

•

Part 3: Implications for the US

–

Debate about EAS in the non-terminally ill

–

Conclusion & future directions

Part 1: Introduction

•

Different end-of-life options

–

Refusal of treatment

–

Withdrawal or withholding life-sustaining treatment

–

Pain relief with potential life-shortening effect

–

Terminal/palliative sedation

–

Voluntarily stopping eating and drinking (VSED)

–

Physician-assisted suicide

–

Voluntary active euthanasia

–

[Involuntary and non-voluntary euthanasia]

Griffith, 2008

Different end-of-life options

Griffith, 2008

Different end-of-life options

EAS

Euthanasia in 96% of Dutch EAS cases

RTE,2018

Overview for today

•

Part 1: Introduction

–

Different end-of-life options

–

EAS around the world

•

Part 2: The practice in the Netherlands

–

EAS for psychiatric disorders

–

EAS for dementia

•

Part 3: Implications for the US

–

D

ebate about EAS in the non-terminally ill

–

Conclusion & future directions

Historical context in the US

•

Vacco v Quill (1997

) US Supreme court ruling 

1) drew sharp distinction between withdrawal of life-

sustaining treatment and PAS

2) no need 

for PAS, since there is terminal sedation

3) 

no constitutional right 

to PAS, hence no

constitutional protection

•

Leaving it up to the states to regulate

•

Oregon first US state to legalize PAS in 1997

United States: 9 states + DC

United States: 9 states + DC

Legal criteria

•

For 

terminal illness 

only: 6 months of expected

life or less

–

End of life boundary

–

Medical boundary

–

No requirement of assessment of suffering

•

Medically 

assisted

 death: prescription for

medication

•

Similar in past proposed UK bills

Top 3 reasons for request in Oregon

(As reported by doctors; DWDA report 2018)

California End of Life Option Act

2017 data, N=374 deaths

Different rationales for PAD/EAS

•

As an end of life issue

•

As an issue of relief of suffering

•

As a matter of right to self-determination

Why is it important to know about the

different rationales?

•

To understand

–

the different laws across jurisdictions

–

why different jurisdictions allow PAD/EAS in

different populations

–

the current debates in Europe and Canada

–

the impact these debates may have for the US

1997

Oregon

2002

The Netherlands

Belgium

2009

Montana

Washington

2016

California

Colorado

D.C

2013 

Vermont

2016

Canada

2017

Australia 

(Victoria)

United States

Countries outside the US

2018

Hawaii

2019

New Jersey

2020

Maine

2015

Columbia

Legalization of PAD/EAS

1942 

Switzerland

//

2019 

Western 

Australia

Countries outside the US

•

Columbia

•

Canada

•

Australia

•

Switzerland

•

The Netherlands & Belgium

Columbia (2015)

•

In response to 2 court rulings in 2015

•

Euthanasia only

•

Terminal illness 

required

•

Prospective permission required from review

board

Canada (2016)

•

Voluntary request without external pressure

•

Grievous and irremediable

 medical condition

a. having a serious and incurable illness, disease or disability; and,

b. being in an advanced state of irreversible decline in capability; and,

c. experiencing enduring physical or psychological 

suffering 

[…]

that is 

intolerable

 to the

person and 

cannot be relieved 

in a manner that 

they consider acceptable

; and,

d. where the person’s 

natural death has become reasonably foreseeable

Victoria, Australia (2017)

•

Law allows both PAS and euthanasia

•

Terminal illness 

(6months)

–

with exception of neurodegenerative disorder (12mo

prognosis)

•

Suffering 

that 

cannot be relieved 

in a manner 

tolerable

to person

Switzerland (1942)

•

Assisted suicide decriminalized in Penal Code

•

Requirements

–

Person has a consistent wish to die

–

Person has decisional capacity

–

Assistance is 

not selfishly motivated



No

 unbearable suffering

 requirement 

BUT

 in practice yes

–

Guidelines specify there should be unbearable suffering

The Netherlands & Belgium (2002)

•

Both countries have very similar key legal criteria

-

Voluntary, well-considered request

-

Unbearable suffering

-

Medically futile

/no reasonable alternative

•

Suffering-based

 jurisdictions

Eligibility Criteria for EAS: Variability Across Jurisdictions

*Deemed unconstitutional by Quebec Superior Court in September, 2019

The Netherlands & Belgium

•

EAS are similar…

•

But have different legal history and justification

–

Dutch EAS law derived from case law over 25y

•

Along with professional organizations, advisory bodies

–

Belgian EAS law consequence of a political process

•

Was primarily intended to modify physicians’ behavior

The Netherlands & Belgium (2002)

•

Both make no distinction between type of medical

condition

•

Hence, allow for EAS for nonterminal illness, e.g.

•

EAS on the 

sole basis of a psychiatric disorder

(psychiatric euthanasia)

•

EAS on the 

sole

basis of dementia

•

But these two applications remain 

controversial

…

2019-2020: First legal prosecutions

•

First prosecutions since law was enacted in 2002 relate to

psychiatric and dementia EAS

•

Netherlands: advance directive case (dementia EAS)

–

85y old woman: current Dutch criminal court trial (August, 2019)

•

Belgium: 2 psychiatric EAS cases

–

G. De Troyer (64) currently investigated by European Court for Human Rights

–

Tine Nys (38): currently investigated by Belgian criminal court (2020)

Godelieve De Troyer (64)

Tine Nys (38)

Overview for today

•

Part 1: Introduction

–

Different end-of-life options

–

EAS around the world

•

Part 2: The practice in the Netherlands

–

EAS for psychiatric disorders

–

EAS for dementia

•

Part 3: Implications for the US

–

Debate about EAS in the non-terminally ill

–

Conclusion & future directions

A closer look…EAS in the Netherlands

•

Why focus on the Netherlands?

–

Long 

history

: prior to the EAS law in 2002, the

practice was decriminalized in 1987

–

Law based on relevant 

series of cases

–

More 

transparent

 oversight system which allow

for empirical research

Legal criteria under the Dutch EAS

Law of 2002

•

Voluntary and well-considered request

•

Unbearable suffering 

with 

no prospect of improvement

•

Informing the patient about prospects

•

No reasonable alternative

•

Physician consulted at least one independent physician

•

Physician provided assistance with due medical care

Legal precedents in the Netherlands

•

1984 Schoonheim case ruling

–

Principle of necessity can justify physician-assisted

suicide

•

1994 Chabot case ruling

–

The source of patient suffering is not relevant

–

Psychiatric patients can make a competent request



 Case lead to EAS on the sole basis of a psychiatric

disorder to become effectively legal in 1997

Legal precedents in the Netherlands

•

2002 Brongersma case ruling

–

Principle of necessity does not apply to “tired of

life” case

–

Suffering must be based on a medical condition

EAS for non-terminal disorders

Documentary

24 & ready to die 

| The Economist (2015)

https://www.youtube.com/watch?v=SWWkUzkfJ4M

Psychiatric EAS: Overview

•

General background

•

Patient characteristics

•

Main issues in psychiatric EAS evaluations

•

The challenge of personality disorders

About 1% of all EAS cases in the NL

RTE, 2018

Note: About 2.4% in Belgium (2018)

1994

Chabot

 case

2002

Dutch and Belgian 

EAS Laws

2010 

First cases 

published by RTE

*

2018 Council 

of Canadian 

Academies 

Report

2016 

Canada

legalized

MAID

#

* 

RTE: Dutch Euthanasia Review Committees

# 

Medical Assistance in Dying

Psychiatric EAS timeline

2015-2016

First empirical papers

Belgium& the

Netherlands

2012

Dutch 

End of life 

Clinic

Some background on the Dutch system

•

Regional Euthanasia 

Review Committees 

(RTE)

–

Founded in 1999

–

All cases must be 

reported

 to the RTE

–

Publish a 

selection of cases 

on website since 2010

–

5 RTEs with the goal of providing uniform guidance

–

Cases important for the development of standards

and provide transparency and auditability

–

Published a first 

Code of Practice 

in 2015

Some background on the Dutch system

•

End of Life Clinic

–

Organization founded in 2012

–

Provides EAS evaluation for persons whose

physician refuses to perform EAS

–

Most patients who receive EAS at the End of Life

clinic are non-terminally ill

–

Sept 2019 renamed ExpertiseCenter Euthanasia

Estimated numbers of Dutch

psychiatric EAS cases

•

About 50% of psychiatrists ever received explicit requests.

•

Majority (60-75%) of psychiatric EAS cases are performed

at the 

End of Life Clinic

(Onwuteaka et al 2017; RTE, 2016)

Annual Reported Dutch EAS cases

 2016-2018

NB: Occasional cases until 2010, with steady rise since 2011.

RTE, 2018

Reported Psychiatric EAS cases

in Belgium 2014-2018

FCEC, Belgium 

Psychiatric EAS remains controversial even in the

Netherlands…

•

Large majorities of Dutch public and physicians support

EAS in physical, terminal disease (>80%)

•

Yet only a minority of public and doctors approve of

psychiatric EAS (28-35%)

•

37% of psychiatrists 

can conceive performing EAS

–

decrease from 47% in 1995

Bolt, 2015; Onwuteaka et al 2017

Psychiatric EAS: Overview

•

General background

•

Patient characteristics

•

Main issues in psychiatric EAS evaluations

•

The challenge of personality disorders

Patient characteristics in the NL

•

First empirical study of 66 cases (2011-2014)

•

Psychiatric diagnosis

•

Depression

 the most common diagnosis (in 73%)

•

Personality disorders 

in 52%

•

Psychosis of some form in 17 of 66 (26%)

•

Note the variety of disorders

•

Autism

•

Prolonged grief

•

Neurocognitive impairment

Kim et al. 2016 JAMA Psych

•

Women request and receive

psychiatric EAS 2X more than

men.

•

Dutch psychiatric EAS cases

are older than Belgian cases.

•

Social isolation/loneliness:

“

[t]he patient was an utterly

lonely man whose life had

been a failure.

”

Kim et al 2016 JAMA Psych

Belgian study: 100 

consecutive requestors

 of

psychiatric EAS

Thienpont et al. 2015 BMJ Open

Reasons for requesting psychiatric EAS

Verhofstadt et al . 2017 BrJ Psyc

Case descriptions: brief examples

Some definitions

•

EAS physician

: the physician who evaluates and

performs EAS

•

Official EAS 

consultant

: the independent physician

consultant as required by law

•

Second opinion 

consultant: consulted by EAS physician

regarding case

•

SCEN

 (Support and Consultation on Euthanasia in the

Netherlands): specially trained physicians, usually

function as official EAS consultant

Case: Woman with prolonged grief (2011)

•

70-80y old

•

Lost her husband in 2009

•

Previously made a decision with husband

that neither would live alone if one died

•

After husband’s cancer diagnosis, asked for

dual EAS, but only husband was given EAS

about a year prior

Case: Woman with prolonged grief (2011)

•

Consultant: “The patient said that the love between her

and her husband had been 

very special

. They had

always been together...  They believed it was a waste of

time to spend time with others at parties, receptions,

etc. The patient and her husband were fully focused on

each other…”

•

Treatment 

ineffective

–

“two different antidepressants… adverse effects,

and the lack of any effect on the patient’s feelings”

–

“mourning and grief counseling… had no results.”

Case: Woman with prolonged grief (2011)

•

1

st

 consultant

–

“The patient wanted to die in a controlled,

humane manner. If that was not possible she

would commit suicide. This was 

not a threat but

a fact

.”

–

“The patient 

did not feel depressed at all

. She

ate, drank and slept well. She followed the news

and undertook activities.”

Case: Woman with prolonged grief (2011)

•

2

nd

 consultant

–

“It is never possible to be absolutely certain if

pathological grief will disappear when time

passes, but due to the 

intensity of the grief 

a

year after the loved one died, the 

limited social

network

, and the persisting wish of the patient

to no longer live without her husband, recovery

seemed less likely.”

Case: man in his 30s (2016)

•

Schizoaffective disorder, personality disorder

(mixed cluster B and C) and OCD-traits

•

Received “almost the entire treatment

protocol for schizoaffective depression”

•

“hospitalized multiple times, had tried many

types of medication and undergone ECT”

Case: man in his 30s (2016)

•

Suffering consisted of “an empty feeling in

his head” and “not being able to think”.

•

The patient, who had been an intelligent,

sociable man and suffered from his loss of

abilities, described “a feeling of painful

emptiness and intense pain in the soul,

which he couldn’t bear and which was

overwhelming”.

Case: man in his 30s (2016)

•

Evaluation process

–

Treating physicians refused to perform EAS

–

Patient requested EAS to EAS physician (non-

psychiatrist), who consulted an independent

psychiatrist

•

Independent psychiatrist found there were remaining

pharmacological and psychotherapeutic options

Case: man in his 30s (2016)

•

EAS physician

–

“acknowledged that these were possible in theory,

but that with the patient’s 

lack of motivation 

these

couldn’t be forced on the patient”

–

and that “psychotherapeutic treatments would have

little chance of success because of the patient’s low

coping capacity”.

•

EAS physician then consulted a SCEN-physician

(non-psychiatrist) 2 weeks prior to death, who

concluded due care were met

Psychiatric EAS: Overview

•

General background

•

Patient characteristics

•

Main issues in psychiatric EAS evaluations

•

The challenge of personality disorders

Main issues related to the evaluation

of psychiatric EAS requests

•

Treatment history and refusals

•

Assessment of irremediability

•

EAS evaluation process

•

Decision-making capacity

•

Disagreements among consultants

Kim et al. 2016 JAMA Psych

Treatment history and refusals

•

2/3 of patients had extensive treatment

histories (>10y)

•

But not always the case

–

56% (37 of 66) 

refused

 at least some treatment

–

In 73% patients with depression: half had tried

electroconvulsive treatment

–

20% no history of psychiatric hospitalization

Kim et al 2016 JAMA Psych

Assessment of Irremediability

•

Dutch Psychiatric Association Guidelines state that all

evidence-based treatments should be tried (Nvvp, 2009)

•

Patients need not to go through ‘every conceivable form of

treatment’ but they do not meet the requirement if they

refuse ‘a reasonable alternative’ (Code of Practice, 2015)



 How to interpret “irremediability”? 

Kim et al. 2016 JAMA Psych

 EAS evaluation process

•

In 41% the EAS physician was a psychiatrist

•

In 59% psychiatrist was one of the consultants

•

24% had disagreement among consultants

Decision-making capacity discussions

•

Functional model of decision-making capacity defines 4

abilities 

(Grisso &Appelbaum)

–

Understand

–

Reason

–

Appreciate

–

Communicate

•

34 (51%)— 

global

assertions

 of capacity

•

11 (17%)— simple assertion that a criterion met

•

21 (32%)— 

some

 direct evidence given for capacity ability

•

Only 5 of 66 cases (

8%) mention all 4 relevant abilities

.

Doernberg et al. Psychosomatics, 2016

Disagreement among consultants

•

24% (16 of 66 cases) had disagreement

among consultants

•

In half of these cases, GP consultants’

opinion taken over psychiatric consultants’

opinion.

Psychiatric EAS: Overview

•

General background

•

Patient characteristics

•

Main issues in psychiatric EAS evaluations

•

The challenge of personality disorders

The challenge of personality disorders

•

Why personality disorders?

–

Common (>50%) among psychiatric EAS cases

–

Sometimes difficult patient-physician interactions

–

Sometimes not considered a “true” diagnosis by

clinicians

–

Suicidal behavior is common

Nicolini et al. 2019. Psychol Med

Media coverage of anecdotal cases

Case: woman with PTSD, borderline

personality disorder & depression

•

A woman in her 30s, multiple suicide attempts

•

She underwent “various forms of drug treatments and electroconvulsive

therapy, all with mediocre results”.

•

The patient’s suffering consisted of very low self-esteem, “continuous

negative thoughts and 

negative judgments about herself

” and

omnipresent “thoughts that she was not worthy to live, could not handle

life, and wanted to die”. She “experienced nightmares and relived her

childhood traumas”.

•

A year before her death, after she had made a euthanasia request to

her previous therapist, the EAS physician (psychiatrist) took over the

treatment with regard to the euthanasia process.

Case: woman with PTSD, borderline

personality disorder & depression

•

A second opinion psychiatrist was consulted. Other therapeutic

options were discussed, including mentalization based therapy

(MBT), but the patient refused further treatment.

•

The physician “agreed with her as her 

personality structure 

was

deemed 

not strong enough 

to endure such a drastic treatment

(MBT) without her suicidal tendencies or depression getting out

of control”.

•

The physician then consulted an independent (primary care)

SCEN-consultant, who visited the patient twice within a month

prior to her death. The consultant found that the alternatives

mentioned were no longer realistic and concluded that due care

criteria were met.

EAS and Personality disorders

•

Challenges in EAS evaluations

–

Frequent feelings of 

helplessness, hopelessness

and suicidal thoughts, difficult to distinguish from

EAS requirement of “unbearable suffering”

–

Complex 

interpersonal dynamics

•

(Counter)transference

EAS and Personality disorders

•

Results

–

28%

 had not tried psychotherapy

–

30% of physicians performing EAS were

psychiatrists

–

Physicians used their 

own feelings 

to determine

whether the patient’s suffering meets the legal

requirements (use of the word “palpable” almost

exclusively with personality disorder patients)

Overview for today

•

Part 1: Introduction

–

Different end-of-life options

–

EAS around the world

•

Part 2: The practice in the Netherlands

–

EAS for psychiatric disorders

–

EAS for dementia

•

Part 3: Implications for the US

–

Debate about EAS in the non-terminally ill  

–

Conclusion & future directions

EAS in patients with dementia

•

Relatively little is known about the practice

–

Cases started slowly increasing since 2011

–

First empirical study looking at Dutch cases

published in 2019

•

First Dutch 

criminal

 investigation since 2002

law involves a dementia EAS case

Why study dementia EAS?

•

Poses unique challenges

–

Assessing competence

–

Assessment of unbearable suffering

•

Frequently debated

–

Scholarly literature

–

Media

–

Professional organizations

Assessing competence

•

According to RTE guidance, a person should

–

Be 

able to communicate 

intelligibly about his request for

euthanasia

–

Understand

 the relevant medical and other information

–

Have 

insight into his condition 

(can assess his situation

and the implications of euthanasia or alternative

treatment)

–

Able to 

make it clear why he wants euthanasia 

to be

performed

Functional model of capacity

•

Abilities

 focused 

(Appelbaum&Grisso)

•

Threshold sensitive to consequences

•

Decision-specific

Dementia EAS in the Netherlands

•

One of few jurisdictions allowing dementia EAS

–

Only one that allows EAS in 

late-stage

 dementia

•

Experience

–

2011-2018: 834 reported cases

–

US equivalent of 16 000 cases

Advance requests in Dutch EAS law

•

Article 2.2. Advance requests possible if

–

Age 16 or over

–

Was previously deemed capable of making a

reasonable appraisal of his own interests

–

Has made a written declaration requesting that his

life be terminated

•

Advance euthanasia directives (AED)

–

Can satisfy informed consent requirement for

incompetent patients

Two types of requests

•

Concurrent request

–

Patient deemed competent to request EAS

–

Presumably in ‘early stage dementia’

•

Advance request

–

Patient deemed incompetent to request EAS

–

AED used for informed consent

–

Presumably ‘late stage dementia’

Dementia disease stage

•

The RTE divides cases in early and late stage

•

Early-stage dementia

–

‘Phase in which the patient generally still has

insight into the disease and symptoms’

•

Late-stage dementia

–

‘Phase where it is uncertain whether they are

still decisionally competent regarding their

request’

Analysis of 75 cases

•

Concurrent requests (n=59)

•

Advance requests (n=16)

•

Most public discussions are about advance

requests, little is known about challenges

associated with concurrent requests

Case: man in his 70s (2018)

•

Diagnosis of mild cognitive impairment in

2013 and of Alzheimer’s disease in 2015

•

Steep decline 6mo prior to death

•

Had talked about EAS for family and his GP

•

1week prior to death: patient asked to

implement EAS

Case: man in his 70s (2018)

•

Used the terms “last bus ride” and “end time”

•

SCEN consultant

–

“A real 

conversation

 with the patient was 

no longer

possible

 and patient could no longer clearly state his

euthanasia wish. In a way, the patient realized that it

was about dying. Patient made an 

incomprehensible,

deplorable, searching impression

.”

–

Patient “no longer competent”

Case: man in his 70s (2018)

•

SCEN consultant: due care met

–

“

the patient’s situation fully corresponded with his

euthanasia wish” 

expressed in previous statements

and “documented conversations with his family

doctor and wife”

–

“it is reasonable to assume” that the “euthanasia

wish of the patient has not changed.”

Case: man in his 70s (2018)

•

RTE asked the EAS physician and SCEN consultant

why a specialist was not consulted

•

Reply EAS physician

–

“patient was not yet incapacitated. Life did not

pass him by, 

he did not vegetate

”

•

Reply SCEN consultant

–

“felt that the patient was still 

sufficiently aware 

of

his situation.”

Concurrent request evaluations

•

Challenges assessing capacity

–

15% (9/59) were deemed incompetent at some

point

–

12% had ambiguous requests requiring

interpretation

–

15% AEDs were used to help assess the voluntary

and well-considered criterion

–

12% involved using body language to assess

competence

Concurrent request evaluations

•

Challenges with assessing capacity

–

One or more of these were present in about a third

(

31%

,

18/59) of concurrent request cases

•

Inconsistent

 with functional model of capacity

•

Discrepancy between existing guidance and practice

Possible explanations

•

Physicians use a lower threshold for capacity

while using a functional model

•

Physicians use another standard/model for

assessing capacity

–

Primarily based on authenticity

–

But at odds with RTE’s guidance

Concurrent requests

•

Practice appears inconsistent with guidance

•

Concurrent cases 

not always “early-stage”

•

Implications: RTE requires consulting an

expert only for late-stage dementia

Advance request evaluations

•

Challenges

–

Difficulties interpreting the advance directive

•

Triggers often lack specificity

–

Unbearable suffering?

•

Difficult to assess in late stage dementia

•

25% did not meet due care criteria

–

Implementation

•

Patients often unaware of implementation

Dementia EAS case: first criminal

prosecution?

Dementia EAS case: first criminal

prosecution?

•

74-y old with Alzheimer’s disease received euthanasia in 2016

•

Had symptoms for past 9 years, diagnosed 4y earlier

•

Wrote an advance directive (AD) shortly after diagnosis

–

“I want to be able to decide (when to die) while still in my senses

and 

when I think the time is right

”

•

Revised AD 1y later adding

–

“when the 

quality of my life 

has become so 

poor

, I would like my

request for euthanasia to be honored”

Problems with interpreting the

advance directive

•

Did the patient have capacity when she drafted the AED?

•

Ambiguous AED

–

What does “when the time is right” mean?

•

Little evidence that she weighed pros and cons of

request

Issues at the moment of EAS

implementation

Dutch legal and disciplinary review system

What happened next?

•

Central 

Disciplinary College 

for Healthcare

–

 turned reprimand issued previously into a warning

•

Main question the 

Criminal Court 

assessed

–

To what extent should a doctor (try to) talk to her

incapacitated patient prior to performing EAS?

Other relevant ethical questions

•

Can premedication be used? If so, when?

•

What constitutes a meaningful refusal of an

incapacitated patient?

Ruling Dutch Criminal Court

(September 2019)

•

To what extent should a doctor (try to) talk to her

incapacitated patient prior to performing EAS?

–

“The court does not see why the accused should

have had a discussion with this incompetent and

deeply demented patient about how the euthanasia

was going to be implemented. Such a conversation

would not only be useless […] but it could have

provoked even greater agitation and unrest”

Ruling Dutch Criminal Court

(September 2019)

•

With regard to the patient’s reaction at the moment of

EAS implementation

–

“The patient’s physical and verbal reactions were

according to expert [X] reflexes that were not

conscious”

•

Conclusion

–

“The court relieves the accused of all legal proceedings”

Overview for today

•

Part 1: Introduction

–

Different end-of-life options

–

EAS around the world

•

Part 2: The practice in the Netherlands

–

EAS for psychiatric disorders

–

EAS for dementia

•

Part 3: Implications for the US

–

Debate about EAS in the non-terminally ill

–

Conclusion & future directions

Implications for the US

•

Dementia and end-of-life

–

Debates about advance directives in dementia

care e.g. stopping spoon-feeding

•

Debates about where to draw the line in EAS

are relevant for the US

–

Currently restricted to the terminally ill in the US

–

Should the terminal disease requirement be

upheld?

EAS for nonterminal illness in Canada?

•

2106 Medical assistance in dying law in

–

Unbearable suffering

–

Proximity to death requirement

•

2018 Canadian Council issues report on

psychiatric EAS – no consensus

•

2019 Truchon case in Quebec (September)

Canada: the Truchon court case

Truchon case & Implications

•

Judge ruled the proximity to death

requirement unconstitutional

•

EAS becomes effectively legal for

nonterminal illness in Quebec

•

Parliament will most likely enact a new or

expanded law that applies to all of Canada

1994

Chabot

 case

2002

Dutch and Belgian 

EAS Laws

2010 

First cases 

published by RTE

*

2018 Council 

of Canadian 

Academies 

Report

2016 

Canada

legalized

MAID

#

* 

RTE: Dutch Euthanasia Review Committees

# 

Medical Assistance in Dying

Psychiatric EAS in whole of Canada as of 2020?

2015-2016

First empirical papers

Belgium& the

Netherlands

2019 

Truchon

 case

2020?

What does this mean for the US

•

Developments in Canada are important for all

other jurisdictions where EAS is limited to the

terminally, physically ill

–

US states

–

Australia

–

Columbia

–

Other jurisdictions debating legalization of EAS

What does this mean for the US?

•

Unlike the European countries, Canada is an

example of a jurisdiction that had some form

of limitation to terminal disease

•

Relevant ethical/policy question for

jurisdictions that allow for physician-assisted

suicide

–

 What are arguments pro/con allowing EAS in

the non-terminally ill?

Overview for today

•

Part 1: Introduction

–

Different end-of-life options

–

EAS around the world

•

Part 2: The practice in the Netherlands

–

EAS for psychiatric disorders

–

EAS for dementia

•

Part 3: Implications for the US

–

Debate about EAS in the non-terminally ill

–

Conclusion & future directions

Conclusions and future directions

•

Legal landscape is rapidly evolving

•

EAS for nonterminal illness, especially

psychiatric disorders and dementia, poses

specific challenges

•

The US have an opportunity to learn and make

own conclusions from the practice in Europe as

more data emerge

Acknowledgments

•

Scott Y.H. Kim, MD, PhD (NIH)

*

•

Chris Gastmans, PhD (KU Leuven)

•

Dominic Mangino, MS, RRT (NIH)

*

•

Madison Churchill, BA

•

NIH Bioethics Department

•

KU Leuven Center for Biomedical Ethics and Law

*Some slides were a kind courtesy of Scott Kim and Dominic

Mangino and were adapted for the purpose of this talk

Thank you!

 Questions?

marie.nicolini@nih.gov

References

Quill et al. 

(1997) Palliative options of last resort: a comparison of voluntarily stopping eating and drinking,

terminal sedation, physician-assisted suicide, and voluntary active euthanasia. 

JAMA

Griffith et al

. (2008) Euthanasia and Law in Europe. Hart Publishing.

Kim et al. 

(2016) Euthanasia and assisted suicide of patients with psychiatric disorders in the Netherlands

2011 to 2014. 

JAMA Psychiatry

Verhofstadt et  al. 

(2017) When unbearable suffering incites psychiatric patients to request euthanasia:

qualitative study. 

British Journal of Psychiatry

Thienpont et al. 

(2015) Euthanasia requests, procedures and outcomes for 100 Belgian patients suffering

from psychiatric disorders: a retrospective, descriptive study. 

BMJ Open

Doernberg et al

. (2016) Capacity evaluations of psychiatric patients requesting assisted death in the

Netherlands. 

Psychosomatics

Nicolini et al. 

(2019) Euthanasia and assisted suicide of persons with psychiatric disorders: the challenge of

personality disorders. 

Psychological Medicine

RTE 

Regional Euthanasia Review Committees Annual Report. Available at

https://english.euthanasiecommissie.nl/the-committees/annual-reports

Onwuteaka-Philipsen et al. 

(2017) Third review of the Dutch Termination of Life on Request and Assisted

Suicide Act. DenHaag:ZonMw.

Mangino et al. (2019) 

Euthanasia and Assisted Suicide of Persons With Dementia in the Netherlands. 

Am J

Geriatric Psychiatry