Will Assisted Dying in Europe Impact Living With Dignity?

BUDAPEST — Only a handful of European countries have legislation in place that decriminalizes the act of physician-assisted dying for certain patients, such as those who are terminally ill. But in recent months, public debates on the topic have been on the rise. Most notably, perhaps, were comments made by French President Emmanuel Macron to the press in March 2024 saying he was in favor of assisted dying under strict conditions. A new bill on the subject is likely to be submitted to France's National Assembly (l'Assemblée) for discussion this summer. 

But what do Europe's psychiatrists think?

This was a topic of discussion at the annual meeting of the 32nd European Congress of Psychiatry (EPA 2024) in a session titled "Psychiatry and Physician-Assisted Dying: Europe — Is Diversity Needed?"

British Organizations Already Undergoing Debate

Currently in the United Kingdom, it is illegal to intentionally help someone end their life. 

Scotland has recently introduced a bill that calls for mentally competent, terminally ill adults to be able to "lawfully request, and be provided with, assistance by health professionals to end their own life." This bill is set to be debated by the Scottish Parliament later this year. 

Historically, professional medical organizations, such as the British Medical Association (BMA) and the Royal College of Physicians, have been opposed to the concept of physician-assisted dying. But both have recently changed their stance to a neutral position that is neither for nor against physicians aiding those who wish to voluntarily end their life owing to unbearable circumstances. The Royal College of General Practitioners remains opposed, but it too will be setting up a working group to ensure that they are prepared for any changes in the law that might allow assisted dying across the UK.

The overall view, explained Dr Jan Wise, a consultant psychiatrist based in London and the current chair of the BMA's medical ethics committee, is that physician-assisted dying needs to be legalized first, and then the details of how and who should do it can be worked out. He noted that neutrality did not mean that the BMA or others would stay silent, however, and that the BMA position on physician-assisted dying carefully considers what the organization would do to protect and represent its members if the law were to change.

"People have got to choose to provide it. It cannot be a general duty of doctors or any other healthcare professional," said Wise. If it is opt-in, he added, there must be a right to refuse without needing to explain why that refusal was made.

Whatever the stance, doctors must be protected from discrimination and abuse, he said. There should also be a safe way for people to access the assisted-dying service, with a clear and transparent oversight system that monitors it and very carefully and routinely logs and assesses all legally assisted deaths. 

France: What About People With Psychiatric Conditions?

Phillipe Courtet, MD, professor of psychiatry at the University of Montpellier and head of the department of emergency psychiatry and acute care at CHU Montpellier, France, is concerned. "There is danger in opening up the Pandora's box, at least for psychiatric patients," he said.

He explained that some of the wording in the draft French bill, which aims to make it possible for some people to request aid in dying under strict conditions, could imply that people with psychiatric conditions may be about to be included. 

Although the wording is not that different from that used in other countries, he observed, it talks about the person's medium-term prognosis, mental capacity, psychological suffering, and awareness of the scope and consequences of their choice. "How can we be sure that people have the capacity to consent, the capacity of discernment when requesting assisted dying?" he asked. 

He referred to an editorial published in JAMA Internal Medicine that explained that countries that have legalized assisted dying have since revised their original laws to remove prognostic requirements, eliminate psychiatric exclusions, broadly define unbearable suffering to include geriatric syndromes and existential distress, and reduce reporting requirements.

The editorial asks whether legal access to assisted dying would mean a quick, easy, and inexpensive way to handle the needs of an increasingly aging population around the globe. 

A concern is that people with psychiatric conditions may be deemed to have a life less worthy than others. 

Courtet asked: Has the person tried all the available therapies, refused treatment, or been diagnosed with treatment-resistant illness? Even for those with the latter, there is some hope, he said. In addition, how do you define something so subjective as unbearable suffering, and what if people change their mind?

Certainly, the role of psychiatrists will be even more important if assisted dying is legalized in France and other countries, he said. 

He added that de pression is widespread among people with chronic terminal illnesses, which is strongly correlated with despair and a desire for an accelerated death. Courtet is concerned that most patients seeking assisted dying will be cared for by doctors who are poorly equipped to diagnose and treat depression in such complex scenarios.

A Swiss Perspective

Since moving to Switzerland and founding MentAge in 2013, Gabriela Stoppe, MD, PhD, has witnessed firsthand how physician-assisted dying, or "assisted suicide," works in real life. 

It is only in the past 6-7 years that official statistics on the number of deaths due to assisted dying in the country have been separated out from suicides in general, Stoppe said. So it has only recently been possible to see that the number of assisted suicides has increased as the number of suicides has decreased. 

In 2003, she said, the number of assisted suicides recorded in Switzerland was 187. In 2022, it was 1594. Most of these assisted suicides involved women or older adults. 

"Most assisted suicides are organized and performed by [nonhealthcare, nongovernmental] organizations," Stoppe said. These organizations, such as Dignitas and EXIT, offer to help with assisted suicide, promoting it as a sign of autonomy and dignity.

"An idea that we must think about is that medicine has done very much at the beginning of life…but there is such a resistance to do any change at the end of life," said Stoppe.

In 2015, data were published from a survey of Swiss physicians showing that more than half of the 1318 respondents had not been confronted by a request for help with dying from a patient. The results showed that 77% considered physician-assisted dying to be justifiable in principle, but 22% were fundamentally opposed to it.

The Swiss Academy of Medical Sciences has issued specific guidelines on physician-assisted dying, although these are not legally enforceable. 

Stoppe said that discussions are necessary to decide if civil law should regulate the process and quality of assisted suicide in Switzerland.

No Magic Money Tree

"There are many reasons that people might choose to want to end their life. The concern is whether there are different populations who seek it for different reasons, and in particular, marginalized populations," K. Sonu Gaind, professor of psychiatry at the University of Toronto, Canada, told Medscape Medical News.

"As we expand [physician-assisted dying] further from end-of-life, it changes potentially from something to relieve end-of-life suffering to relieving the suffering of living," Gaind cautioned. 

"We've seen some of that in Canada, where people have said that they cannot afford a place to live because of their social situation. So, are we providing people the chance to live with dignity before opening the door to easier access to dying?" he asked.

Wise said that palliative care services are still being used and may even be improved by governments that give the go-ahead to physician-assisted dying for specific patient populations.

Citing data in a recent UK House of Commons Committee report, Wise noted that most (> 80%) people who had pursued physician-assisted dying in Canada between 2019 and 2021 had received palliative care. Just more than half (∼53%) of those had received palliative care for at least a month or more. In Australia, Belgium, and six of the US states where assisted dying has been sanctioned, funding for palliative care had been increased.

"So, whether it is in the United States, Canada, Australia, or Belgium, it is simply not true that legalizing assisted dying leads to decreased funding and decreased quality of care and palliative medicine," said Wise.

In the UK, the position of the BMA is: "If parliaments across the UK decided to change the law on assisted dying, the relevant governments must ensure that additional funds are made available to ensure that the service is properly resourced, and that funding and workforce are not diverted from other, already overstretched, healthcare services."

And therein lies a potential problem, said Wise. "There is, to use an old phrase, no magic money tree that I can shake, and pounds pour out to give my patients what I think they deserve. So every penny that is spent in giving people the exit they wish for in life is something that cannot be spent on people who will still be living," he said.

As Gaind observed, "In reality, assisted dying is much cheaper than providing other needed medical care, especially for the chronically ill or elderly. This is actually another reason many are concerned since, in addition to other concerns raised, the system risks having perverse disincentives to provide care-vs-cost savings accrued through assisted dying of the disabled."

Wise, Courtet, Stoppe, and Gaind expressed that they have no conflicts to report and stated that they were giving their personal opinions, independent of any institutions or organizations they work for. 

Sara Freeman is a freelance medical journalist based in London, England.