878645 APY Australasian PsychiatryGale and Barak

Australasian
Research Article Psychiatry
Australasian Psychiatry

Euthanasia, medically assisted 1­–4

© The Royal Australian and
New Zealand College of Psychiatrists 2019

dying or assisted suicide: time Article reuse guidelines:

sagepub.com/journals-permissions
DOI: 10.1177/1039856219878645
https://doi.org/10.1177/1039856219878645

for psychiatrists to say no journals.sagepub.com/home/apy

Chris Gale   Senior Lecturer, Department of Psychological Medicine, Otago University Medical School, Dunedin,
New Zealand
Yoram Barak  Consultant Psychogeriatrician, Department of Psychological Medicine, Otago University Medical School,
Dunedin, New Zealand

Abstract
Objective: Euthanasia has been considered unethical for most of the history of medicine. Recently it has been legal-
ised in some countries, including parts of Australasia. We describe the recent history of euthanasia, paying attention
to the extension of criteria that impact on the poor, elderly and vulnerable members of society in countries that
currently have legalised this.
In four of the five countries where euthanasia is legalised, there have been extensions of its criteria, either by revi-
sion of legislation or changes in practice.
Conclusions: We suggest that this dynamic can be halted by international agreements of medical societies to shun
involvement in euthanasia, as has been the case with other legal interventions that stigmatise. We may, as we have
in the past, need to work collectively to meet this ethical challenge.

Keywords:  euthanasia, legislation, ethics, psychiatry, stigma

C
ontemporaneous debate for legalisation of
assisted dying has led to the liberalisation of the
historical restrictions on this practice. In Victoria
the Voluntary Assisted Dying Act is now implemented.1
The End of Life Choice Bill in New Zealand has passed its
second reading, and is now in final committee stages.2
This is raising for psychiatrists issues relating to our
participation in assisted dying, defined as actively end-
ing a person’s life (euthanasia) or providing people the
means to end their life (assisted suicide).3 In consider-
ing how we should respond to this as a speciality and a
profession, a review of the modifications of the criteria
for assisted dying and how this has affected people with
psychiatric disorders may reinforce a continuation of
the current internationally agreed ethical position: that
medicine and psychiatry should promote life, relieve
suffering and approach this issue with marked caution,
particularly around coercion and exploitation.4
There is a common belief that most nations allow medi-
cally assisted dying, but this is limited. The first jurisdic-
tion in the world to legalise euthanasia was the Northern
Territory, Australia, but that law was overturned. Since
then, legalisation by various legal forms has happened
in the Netherlands, Belgium, Luxembourg, Colombia
and Canada; within the United States in Oregon, New
Jersey and Maine; and the Australian State of Victoria.
Physician-assisted suicide, excluding euthanasia, is legal
in Switzerland5 as well as several US states or territories
(Oregon, Hawaii, Washington, Montana, Vermont,
California and Washington, DC). In those countries
where euthanasia is legal, between 0.3% and 4.6% of
deaths are recorded as due to euthanasia.6
A brief review of those nations shows expansion in crite-
ria following the initially restricted scope of legal eutha-
nasia (see Table 1).
In the Netherlands, the initial decriminalisation was fol-
lowed by legislation with guidelines that appeared rea-
sonable and respectful of autonomy.7 The criteria were
that euthanasia had to proceed at the patient’s request,
without coercion, that there had to be unbearable and
hopeless suffering, adequate information provided to
the patient and an absence of reasonable alternatives. A
second opinion was required, and there were regulations
around the procedure of euthanasia.
Corresponding author:
Chris Gale, Department of Psychological Medicine, Dunedin
School of Medicine, Otago University Medical School, PO Box
56, Dunedin 9054, New Zealand.
Email: chris.gale@otago.ac.nz

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Table 1.  Nations with euthanasia legislation

Nation Legalised Criteria at first legalisation Extension of criteria

Netherlands Decriminalised 1993 At the patient’s request Suffering includes ‘tired of life’
Legislation 2001 Unbearable and hopeless suffering and ‘persistent requests for
Information provided to the patient euthanasia’
Absence of reasonable alternatives Risk of family pressure or family
advocacy
Euthanasia of psychiatric
patients
No age limits
Luxembourg Legislation 2009 As per the Netherlands  
Belgium Legislation 2002 As per the Netherlands Children
Psychiatric patients
Columbia Via courts, 1997, 2015 Terminal illness Extended to children aged six or
Repeated, informed consent over, with parental consent and
child consent
Canada Supreme court decision 2015 Grievous and irredeemable Organ donation at/after
Prohibition of euthanasia condition (not necessarily terminal euthanasia practised Proposal
violation of charter of Rights illness), death reasonably expected, to extend to ‘competent minors’,
and Freedoms (Carter v over age 18, able to give informed to psychiatric patients and to
Canada). Federal Legislation consent. Must have 10 full days other minors with parental
2014 (Bill C-14). Federal before reassessment and must consent. All physicians or nurse
regulations 2018 be lucid at time of euthanasia or practitioners must refer (Ontario)
physician-aided suicide (‘medically
assisted death’)

However, the interpretation of these restrictions and
guards has been loosened over time. In one case in the
Netherlands, the second opinion noted ‘The unbearable
nature of her suffering was also apparent from the
resolve of her request for euthanasia’.8 There is no exclu-
sion of psychiatric diagnoses and a number of people
suffering with psychiatric diagnoses have received
euthanasia, generally for mood disorders,9 even though
the availability of reasonable alternative treatments is an
exclusion criteria for euthanasia. There is no age limit on
euthanasia in the Netherlands,10 and in the cases of chil-
dren aged 1 to 17 receiving euthanasia parents have ini-
tiated the process in the majority of cases reported.11
Belgium legalised euthanasia in 2002.12 In 2014 the leg-
islation was amended to allow euthanasia for children,
provided the child understands the concept of death.13
The criteria are similar to those of the Netherlands, and
reporting was mandatory. However, about half the
deaths by euthanasia were not reported.14 The rubric of
‘unbearable suffering’ has been used by psychiatric
patients to request euthanasia.15 Recently, some have
advocated an extension of the law in order to allow
euthanasia to be performed in patients with dementia.16
Luxembourg legalised euthanasia in 2009.17 They have
generally followed Belgian models and practices.
In Colombia, the constitutional court ruled in 1997 that
euthanasia in some circumstances was not illegal, but
guidelines were not formulated until 2014. The right to
die is seen as a fundamental right.18 The criteria set by
the courts were that the patient has a terminal illness,
that euthanasia is specifically requested by the patient,
repeated after informed consent. In 2018 the courts
extended this to children over the age of six with their
agreement and the consent of both their parents and at
age 14 to a child without the consent of their parents.19
Within the United States, various states have legalised
assisted suicide or euthanasia. However, decriminalised
physician-assisted suicide was associated with an
increase in suicide rates and especially a 14.5% increase
in suicides in the individuals older than 65 years.20 In
Oregon over 50% of people requesting euthanasia report
‘being a burden to their families’ as their major reason.21
Canada is the most recent country to have a national
law on euthanasia. Although euthanasia had been legal-
ised within the province of Quebec in 2014,22 the key
change was a Canadian Supreme Court decision23 that
prohibiting euthanasia violated the Canadian Charter of
Human Rights.24 This was seen by some psychiatrists in
Canada as radical and disturbing,25 as there were no
guidelines or law in place. Since that decision, there has

2
Gale and Barak
been a significant shift. The Canadian College of
Physicians and Surgeons sees euthanasia as part of medi-
cal care, and this has left the Canadian Medical
Association in conflict with the World Medical
Association.26 The current clinical criteria for euthanasia
include having a grievous and irremediable medical con-
dition. However, grievous and irremediable medical con-
dition’s definition includes ‘. . . does not require a
specific prognosis as to how long you have left to live.
You do not need to have a fatal or terminal condition to
be eligible for medical assistance in dying’.27 There are
reports of paediatricians having parents suggest eutha-
nasia for very disabled children,28 court challenges on
the practice to not consider psychiatric patients for
euthanasia29 and some quite psychiatrically unwell peo-
ple have requested euthanasia.30
The situation in Australia remains uncertain (supple-
mental Table 1). The only state with legalised assisted
dying is Victoria, and this law was designed to be
conservative. To our knowledge, only one person has
received assisted dying in that State.
The New Zealand Bill is modelled on the Victorian bill.
It is being amended extensively in its third hearing, and
the final form is unknown. However, the Attorney
General’s report notes the current bill is in contraven-
tion of the NZ Bill of Human Rights.
The Attorney-General found that the age limit was not
a justified limitation under section 5 of the Bill of Rights
Act.31
It appears that the bill could be subject to legal challenge
within a short period of implementation.
Conclusions
When euthanasia is legalised, there seems to be a pres-
sure to have equal access to active euthanasia for any
and all who are suffering or perceive that they are a bur-
den. The most vulnerable – the elderly, the poor and the
disabled – are disproportionate in their use of euthana-
sia. From the data available, the rate of suicide, particu-
larly in the most vulnerable, increases in jurisdictions
where euthanasia is legal.
Although the debate is often framed in terms of choice
and rights and dignity, the practice of euthanasia
becomes discriminatory.32 The impact on elderly, sick
and disabled Māori and Aboriginal people who are failed
by our health system is likely to be significant.
Psychiatrists, therefore, have a moral responsibility akin
to the prohibition of the use of psychiatric expertise in
execution, in the detention of dissidents or in treatment
of homosexuality.4 These are legal in some places, but
are intrinsically antithetical to the dignity and h
­ umanity
of all.
Regardless of the legal status of assisted dying, we should
not be facilitating death and oppression. Our challenge
is to provide the needed ethical leadership.
Disclosure
The authors report no conflict of interest. The authors alone are responsible for the content
and writing of the paper.
Funding
The authors received no financial support for the research, authorship and/or publication of
this article.
ORCID iD
Chris Gale https://orcid.org/0000-0001-8032-765X
Supplemental material
Supplemental material for this article is available online.
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