After having granted euthanasia in April, Zoraya Ter Beek He died on May 22 with 29 years of age after submitting, without success, to different medical treatments to address his various mental health pathologies such as depression, autism and personality borderline disorder.

But the case of the young Dutch, despite the debate she has generated, is not unique in the Netherlands, one of the few countries in the world, together with Belgium, Luxembourg or Switzerland, which contemplates the euthanasia/suicide assisted by doctors (ESAM) motivated by a psychiatric disease as a primary cause.

In 2021, of the 7,666 notifications of euthanasia received by the Regional Commission for Verification of the Netherlands, in 115 “suffering was based on one or more mental illnesses”, being 77 the number of total notifications by euthanasia in children under 40 years, including cases of mental illness as a primary cause.

So, Zoraya’s case is not uniquebut unusual, which leads us to expose the situation of euthanasia due to mental illness in Spain from a legal, medical and ethical point of view.

Euthanasia due to mental illness: What does the law say in Spain?

Soledad – Source: Pexels

On March 25, 2021, the Organic Law of Euthanasia regulation was published in the BOE with the objective of giving “a legal, systematic, balanced and guarantee response, to a sustained demand of today’s society such as euthanasia”.

This law does not make an explicit mention to mental disorders, although it does specify that sufferings can be physical or psychic. In this sense, the requirements that the requesting patient must meet to receive the aid provision to die do not differ in both cases, indicating that “a serious and incurable illness or a serious, chronic and impossible suffering, certified by the responsible doctor/doctor, should suffer.

The law defines this severe, chronic and unable Like that “whose limitations directly affect physical autonomy and activities of daily life, so that it does not allow to use itself, as well as the capacity for expression and relationship, and that have associated physical suffering associated or psychic Constant and intolerable for those who suffer from it, existing security or great probability that such limitations will persist over time without the possibility of healing or appreciable improvement. ”

Likewise, define the serious and incurable disease as “that by its nature causes constant and unbearable physical or psychological sufferings without relief that the person considers tolerable, with a limited life forecast, in a context of progressive fragility.”

In this sense, the other fundamental requirements to receive ESAM are to have made two requests voluntarily and in writing, or by another means that allows to record, and that it is not the result of any external pressure, leaving a separation of at least fifteen calendar days between the two

Also lend Informed consent Previously to receive the provision of help to die about your medical process, the different alternatives and possibilities of action, access to comprehensive palliative care included in the common portfolio of services and access to the benefits that were entitled in accordance with the regulations of attention to the agency.

Throughout this process, of course, the medical professional has a great responsibility (for which a manual of good practices was published), which, in the case of mental disorders, falls to the Psychiatrists that offered this position in 2021 after the first proposition for the law of euthanasia regulation, which we break down.

What does the Spanish Psychiatry Society say about euthanasia due to mental illness?

Mental Disorder – Source: Pexels

Although euthanasia applied to people with mental disorders affects a limited amount of cases (between 1% and 3%) relative growth is very important, the SEP points out in its statement, remembering, likewise, that the suicide Associated with mental disorders is one of the main causes of death in people between 15 and 34 years.

Inequality, will and freedom before euthanasia

In this sense, the SEP also highlights vulnerability and inequality that abounds among people with serious mental disorders in life expectancy, access to housing, employment, health care specialized in a social context of stigma towards mental disorders: “It is important to ensure that these remediable deficiencies do not contribute to the desire to die“, In addition to these deficiencies do not affect the” principle of autonomy “that should be guaranteed in the patient requesting the ESAM to be accepted.

In this sense, the SEP points out that, if “will and freedom” are the fundamental axes to make the decision to end one’s life, in the case of mental disorders, “internal freedom is generally the most committed element, being able to get to cancel transitory or definitively the ability to decide. ”

And, although not all mental disorders study in the same way, “it is evident that some, and at certain times, can compromise the essential psychic functions for making relevant decisions, such as consciousness, thought, sensory perception, the experience of the self or affectivity.”

Therefore, and taking into account that the integrity of these functions is condition sine qua non To assume that a decision is freely taken according to the law, it is fundamental, according to the SEP, to ensure that this decision fits the true will of the person and not to the will pathologically determined.

In this sense, the SEP recalls that it is “well known that the desire to die is part of the usual symptomatology of several mental disorders, especially depressive, but also schizophrenia, addictions and serious personality disorders. ”

How to assess the ability to consent?

One of the essential requirements to request euthanasia, as we have indicated, is to provide consent previously informed to receive the provision of help to die. The SEP points out in this regard the “conflict” derived from whether mental illness is affecting or not The patient’s ability to choose freely when his decision to die is manifested.

Thus, the SEP points out that “despite the fact that the mere presence of a psychiatric disorder does not distort the presumption of capacity, in some cases psychiatric disorders are accompanied by cognitive and emotional distortions, inherent in their psychopathology.”

Likewise, “there is no accepted standard for the assessment of decision -making capacity and, although there are various instruments and evaluation methods, the final decision has a high degree of subjectivity.”

For all these reasons, in the legislation on euthanasia in some countries it is pointed out that the two doctors consulted (to grant the ESAM) must be psychiatrists outside the case, be affiliated with the department of psychiatry of a series of centers of renowned prestige and the ESAM can only be done in case of unanimity between them in the evaluation.

Are incurable mental disorders?

The SEP points out in this regard that “there is a general agreement to consider that psychiatric disorders, unlike other diseases, do not lead to death”, nor can they be qualified together as “incurable” or “chronic and invalidating”, in addition to “there are no universal standards that define incurability In most cases of mental disorder. ”

However, the SEP points out that within serious mental disorders among which are certain cases of schizophrenia, bipolar disorder, and some especially serious ways of depression and personality disorder may exist a Great resistance To treatments, in addition to having a chronic course or generating a great need for support.

The suffering of mental disorders

The SEP points out that the enormous suffering and the degree of affectation that generate the most serious mental disorders, indicating that “the defenders of euthanasia, the differentiation between physical and psychic suffering is artificial and discriminatory” is undoubtedly.

However, it also indicates what is in his opinion an “incongruity” that would be derived from the law: “propose the help to die to people who suffer disorders that have among their symptoms, forming part of the pathology, suicidal ideation and the desire to die”, assuming that “in societies in which suicide prevention is considered a global responsibility, and the decrease in annual figures a common objective.”

An ‘extremely rigorous’ evaluation of euthanasia due to mental illness

Of all the above, the Spanish Society of Psychiatry concludes the extreme complexity of the approach to the aid to die in psychiatric patients who cannot be resolved if in the process “not enough safeguards are stipulated and the guarantee of an extremely rigorous evaluation”.

Thus, the SEP points out four essential issues that they must be resolved before accepting the request for euthanasia due to mental illness:

1. The manifest will to die, is obeying only to the presence of a mental disorder that can improve after treatment? 2. Is the will to die influenced by the presence of a mental disorder that can improve after treatment, although it is not the fundamental cause of the euthanasia application? 3. Regarding the “incurable” or “chronic and invalidant” character of mental illness, have the therapeutic resources of biological, psychological and social types been exhausted, according to the Lex Artis? 4. Does the person have the capacity to give informed consent with all guarantees?

Only if you answer unanimously and reasoned “no” to the first two issues and “yes” to the third and fourth you can keep ahead in the process Of euthanasia in which the psychiatric assessment must be, of course, essential, the SEP points out to end.