Euthanasia, defined as the painless killing of a patient who is suffering from an incurable and painful ailment/in a coma, is a practice that’s taken shape in differing forms throughout centuries. Originating in Ancient Greece, differing forms of euthanasia exist. Typically, medical euthanasia is thought of as “pulling the plug:'' ending the suffering of a terminally ill patient. Medical euthanasia, however, also exists as a way to end the lives of mentally ill patients. Mentally ill patients in legal countries, like Belgium, can choose to seek out physician assisted death if they feel as though no treatment aids their recovery. Though these countries often have strict regulations for who qualifies for euthanasia on the basis of mental health, the idea that a mentally ill patient can consent to their own death is controversial itself. Mental health also spans far and wide, with patients who suffer from personality disorders, schizophrenia, or major depressive disorder (MDD) all being potential candidates for medical assistance in death (MAiD.) These disorders can be immensely debilitating, often preventing patients from having a family, working an average job, or even leaving their own home. It’s understandable why mentally ill patients seek out relief in the form of euthanasia, as mental illness can feel as painful as terminal illness. However, the idea of MAiD is almost entirely unethical in its current form. Medically assisted death for mentally ill patients is, more often than not, unethical due to the patient’s inability to truly consent, the lack of mental health systems in place during a patients’ life, and the larger implications the program may have for mental health treatment.
Informed consent for mentally ill patients is confusing at the best of times. Often, most patients with conditions like mild generalized anxiety are considered to be capable of informed consent, while some patients suffering with more debilitating conditions, like severe schizophrenia, often have to give consent through a surrogate decision maker. Some patients with generalized anxiety are still incapable of informed consent, as mental health is judged on a purely individual basis. Considering that mental illness must be severe and debilitating in order to qualify for MAiD, the ability for these patients to truly consent is often brought into question. Countries with the practice legalized often specify some sort of informed consent as a necessary criteria, including the Netherlands, which was the first European country to decriminalize MAiD. One criteria to qualify for MAiD in the Netherlands is that, when the patient makes their request, “the…request must be voluntary and well-considered. The consent of a patient who is no longer able to express himself may be taken into account if he has previously made a written declaration to that effect , and is at least 16 years old” (Law for the Termination of Life on Request and Assissted Suicide). Whether the patient’s request is “voluntary and well-considered” is proven on an individual basis, but larger issues still remain. Even if an individual seems as though they are giving informed consent, many mentally ill patients experience suicidal thoughts as a symptoms to their illnesses. If a patient who is suffering suicidal thoughts as a side effect to their medication pursues MAiD, they may slip through the cracks of the system and be eligible for euthanasia.
An important example of the complexities of informed consent comes in the form of patients with personality disorders. For example, borderline personality disorder is a somewhat well known disorder with an extremely complex description. Simplistically, a patient with BPD may have unstable relationships, be unable to keep a job, indulge in reckless activities (ie: reckless sexual activity, driving under the influence, and shoplifting), and may have recurrent suicidal behavior (Diagnostic and Statiscal Manual of Mental Disorders, Fifth Edition). Specifically focusing on recurrent suicidal behavior, up to 10% of BPD patients will die by suicide. Most of this percentage comes from suicide attempts in younger people, under the age of 30, with BPD. (Suicidality in Borderline Personality Disorder). Though BPD is an extreme disorder that often decreases quality of life, the condition itself is extremely treatable. Instability due to the disorder has been proven to decrease with age (Diminished Impulsivity in Older Patients With Borderline Personality Disorder) and retainment of the BPD diagnosis for long periods is somewhat rare (Prospective Follow-up Study of Borderline Personality Disorder: Prognosis, Prediction of Outcome, and Axis II Comorbidity). Despite the treatable nature of this condition, BPD patients often seek out MAiD for relief. Personality disorders are often trademarked by their ability to make patients’ impulsively suicidal and unsure of who they are/ what they want. Allowing MAiD for this extremely treatable condition is controversial in of itself without also considering the fact that patients with BPD may not truly be able to voluntary consent to euthanasia. Especially when these patients are young, such as 29 year-old Aurelia Brouwers, who went through with medically assisted death. She was diagnosed with BPD at the age of 12, and didn’t even get to live long enough to experience the symptoms tapering off with age (Psychiatric Euthanasia and the Ontology of Mental Disorder). Though this is just following one disorder, this case can be made for a variety of different disorders. Allowing young patients with impulsive mental disorders to pursue MAiD is just part of its failures. As a whole, mentally ill patients pursuing MAiD are typically unable to give 100% guaranteed voluntary and informed consent as it’s impossible to truly know what’s the patients’ choice and not the symptoms of mental illness. Without certain informed consent, MAiD is almost always unethical, as it may be euthanizing those who truly do have the potential to improve their lives.
Furthermore, mental illness is incredibly unpredictable in nature. This isn’t to say that mentally ill patients are unpredictable, but that their moods and improvements often may be.
How can it be ethical to euthanize patients with mental illness without supporting mental health programs for the living? To go deeper into mental health support, countries must be examined on an individual basis. The Netherlands, Switzerland, Belgium, and Canada are the only countries with clear laws on allowing euthanasia for mentally ill patients. However, some countries, like Chile, are on the edge, and may allow MAiD for the mentally ill soon. In each of the countries that allow MAiD for mentally ill patients, there are clear issues in their mental health system. Mental Health Problems and Barriers to Service Use in Young Dutch Adults may have been published in 2008, but considering the Netherlands legalized euthanasia in 2001, is still extremely relevant. The book notes that “patients who had received prior mental health treatment perceived their depressive symptoms as being more chronic and as having more negative consequences than the patients with no prior mental health treatment.” (Vanheusden 50) Youth in the Netherlands often don’t even have a grasp on the severity of their own mental illness, and when treatment may only make them view their illness even more negatively, many young people may turn to MAiD. Those 12 and over can be euthanized in the Netherlands (12-16 year old's require parental consent), and it’s important to note that it’s unclear if anyone under the age of 18 has actually been euthanized due to mental illness. However, it’s been reported that an 18 year old has. When youth in the Netherlands have a limited grasp on their own mental illness, and institutions potentially making them believe their cases are more severe, it’s irrational to allow someone who’s only just become an adult to be euthanized.
Similarly, in Switzerland (along with a multitude of other countries that haven’t legalized euthanasia), the inpatient hospitalization experience was described as “devoid of warm therapeutic relationships, respectful interactions, information or choice about treatment…instead such care experiences are personified by: coercion [and] inhumane practices” (Raiders of the Lost Art: A review of published evaluations of inpatient mental health care experiences emanating from the United Kingdom, Portugal, Canada, Switzerland, Germany and Australia) Inpatient, being treatments like wellness centers and psychiatric hospitals, are both essential and traumatizing for the mentally ill. Being away from their home for an extended period of time, it’s essential that the psychiatric professionals at their facility are kind, welcoming, and professional. However, the fact that Swiss facilities fit into being completely empty of warmth and even having coercive practices is absurd. Instituting MAiD while not having a decent inpatient program, which is often used consistently by the severely mentally ill who may consider euthanizing, is clearly unethical.
Lastly, Canada has its own severe issues in their mental health system. Canada has been experiencing an uptick in mental health related issues in their youth, with an increase from 32.5% hospitalizations related to mental health to a shocking
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