杏吧原创

LIKE many psychiatrists, Paulan St盲rcke sometimes sees patients in such mental torment that they have tried to kill themselves. Where St盲rcke differs is that occasionally, after much discussion with the patient, their family and other doctors, she helps them to do it.

St盲rcke prepares a lethal dose of barbiturate sedatives, either in the form of an injection or a medicine that can be drunk. She sits with her patient as they die and, at the end, certifies their death. She considers this her final professional duty to them.

St盲rcke practises in the Netherlands, one of three countries 鈥� along with Belgium and Switzerland 鈥� that permit assisted suicide for non-terminal illnesses that are causing unbearable suffering, which has been taken to include mental suffering. For many, this is a step too far.

鈥淭his is not compassion 鈥� it鈥檚 abandonment,鈥� says Stephen Drake of the US group Not Dead Yet, which opposes assisted suicide.

So how do doctors navigate this ethical minefield? Is mental illness any less justifiable as a reason for assisted suicide? Or is it a slippery slope?

Switzerland was the first country to permit assisted suicide, in 1942, and since then has been joined by several other countries, most recently Canada. In the UK there is a long-standing movement to legalise assisted dying, although a high-profile bill was rejected by MPs last September. In the US, such legislation is being considered by individual states, with five currently allowing it and a campaign to expand it to the rest.

鈥淭he mind is a black box. We still don鈥檛 know enough to be able to say how a condition will progress鈥�

In the main, the UK and US campaigners steer clear of any suggestion they want assisted suicide approved for people who are not terminally ill. 鈥淭his is where the public draws the line,鈥� says Sarah Wootton of the UK campaign group Dignity in Dying.

Wootton points out that a 2007 independent survey found that 80 per cent of people supported assisted dying for the terminally ill, but only 43 per cent did for those who are not terminally ill.

鈥淚f we see depression as an OK reason to help someone kill themselves, then why bother to put rails on bridges for suicide prevention?鈥� says Drake.

Not taken lightly

St盲rcke says that accepting assisted suicide for psychiatric reasons in principle does not mean that logically we should cease all suicide prevention efforts, because only a minority of requests are granted. For instance, in 2012 to 2013, only six out of 121 requests from people with a psychological condition were granted at the clinic where St盲rcke works. At a Belgian psychiatric hospital, they granted 48 out of 100 requests, although .

The decision is never taken lightly. Psychiatrists must believe the person is mentally competent, has had a long-standing wish to die and that there is no prospect of treatment. Typically they have more than one psychiatric diagnosis, which may include depression and a personality disorder.

鈥淭he suffering from a psychiatric illness can be as unbearable as the suffering from a physical illness,鈥� says St盲rcke.

But even so, and despite growing campaigns for mental illnesses to be taken as seriously as physical ones, there remain some important differences between psychiatry and other areas of medicine that colour the debate.

Unlike with most physical illnesses, there are no blood tests or brain scans that can give someone a definitive diagnosis of a psychiatric problem. Also, people with mental illnesses are frequently given different diagnoses at different points in their life, and no one knows if that means their first diagnosis was wrong or their condition has genuinely changed.

If someone is dying from cancer or heart failure, their doctor can make a reasonable prediction about the course their illness will take and roughly how long they will live. Many people who go to Dignitas, the Swiss organisation for assisted dying, do so because they have a degenerative condition that they know will leave them physically helpless. By comparison, the mind is a black box. We still don鈥檛 know enough to be able to say how a condition will progress.

The US government-funded National Institutes of Health has said that the whole system of classifying mental illness is flawed and needs to be based more on neuroscience. It has launched a major research effort to base diagnosis and treatments on the underlying problems at the levels of genes, neurotransmitters and brain circuits.

This project might lead to more insights about who is likely to recover from mental illness and who isn鈥檛, but it is many years from bearing fruit. For now, psychiatrists can only grant requests of assisted suicide for patients who have been at rock bottom for years, or more usually decades, and have exhausted all potential remedies, such as antidepressants and electroconvulsive therapy.

St盲rcke argues that the fact someone is not terminally ill means their situation could be seen as even worse than if they had just weeks to live. 鈥淭he unendingness can be unbearable,鈥� she says.

Dignitas says that for some people, just having the option of assisted suicide can help, even to the extent that they may choose not to take it. 鈥淚t may sound paradoxical: in order to prevent suicide attempts, one needs to say 鈥榶es鈥� to suicide,鈥� the organisation said last year in evidence to an Australian inquiry into end-of-life choices.

If the patient does go ahead, this is still preferable to most methods of suicide, says St盲rcke. 鈥淭here鈥檚 a huge difference between this and a violent, lonely, unplanned death,鈥� she says.

But Drake dismisses that argument as society being selfish. 鈥淭hey鈥檙e talking about the mess. If we鈥檙e going to have suicide, let鈥檚 have it neat and tidy,鈥� he says.

鈥淲e are many years away from better understanding who is likely to recover from mental illness鈥�

Along with religious groups, disability rights activists are the main campaigners against euthanasia and assisted suicide, whether for those with mental or physical suffering. They believe that legalising assisted dying sends a message to people who are disabled, sick or elderly that their lives are worthless, and they see people with psychiatric illnesses as another such group whose rights they must protect. 鈥淚f help is helping someone to die, I don鈥檛 see that as help,鈥� says Dennis Queen of the UK branch of Not Dead Yet. 鈥淔or us, this is about human rights.鈥�

Even in the Netherlands, a country with broadly liberal attitudes, two-thirds of doctors have difficulty accepting assisted suicide for psychiatric reasons. St盲rcke works for a clinic called End of Life, in The Hague, that provides second opinions for people whose request has been denied by their doctor or psychiatrist.

St盲rcke understands that some of her colleagues do not feel comfortable agreeing to requests of assisted suicide for psychiatric reasons, but calls for them to make their views clear to patients. If doctors aren鈥檛 transparent then patients may make a request and submit to a lengthy assessment process, only to be turned down at the end because their doctor objects on moral grounds.

鈥淪ome psychiatrists would rather not think about this because they鈥檙e only human after all,鈥� she says. 鈥淲hat I do scares people.鈥�

鈥� Need a listening ear? UK Samaritans: 08457 90 90 90 (). Visit for hotlines and websites for other countries.

This article appeared in print under the headline 鈥淧sychiatry鈥檚 last taboo鈥�