Paul Russell 

The Flemish Newspaper, De Morgen published an open letter by a distinguished and long list of 65 Belgian Psychiatrists, Psychologists, Philosophers and others calling for the 2002 law on euthanasia to exclude euthanasia for psychological suffering.

Triggered on this occasion by two contemporary situations, it follows an earlier letter in September 2015 published in the medical magazine Artsenkrant where the group warned doctors about the uncertainty of legal protection for euthanasia for these same reasons. That letter responded an academic paper published in the British Medical Journal in July 2015 by Dr Lieve Thienpont reviewing euthanasia requests from 100 Belgian patients. Thienpont, notably, was involved in the approval of all 48 successful requests (and also that of 'Laura' - see below).

In October this year the Belgian Euthanasia Commission referred its first ever case to the Belgian judiciary for review. Simona de Moor was an otherwise healthy 85 year old woman who received assisted suicide with the assistance of Dr Marc van Hoey. De Moor was grieving the death of her favourite daughter only months earlier as was demonstrated in an SBS documentary featuring her story and chronicling her death.

This new letter also refers to the case of 'Laura' - a 24 year old woman who sought euthanasia for psychological distress. Not her real name, Emily featured in a short documentary by The Economist magazine. Emily thankfully, did not go ahead with her planned death. However, as the documentary notes, the plan was formally approved and her decision endorsed by medical personnel.

Under the sub-heading, Death as Therapy, the signatories call into question the nature of psychological suffering - including the reality that it is suffering that is entirely subjective and, therefore, the criteria for acceptance for euthanasia is, likewise entirely subjective.

It is certainly true that the entire concept of euthanasia as a personal decision is framed in terms of subjective suffering. Terms like 'hopelessly ill' or 'suffering unbearably' can only ever have meaning within a subjective, personal experience. However, the authors of this letter draw a critical distinction between the subjective nature of euthanasia, generally understood in the context of a prognosis, and euthanasia where there is no physical deterioration. They argue that the situation with psychological suffering is, therefore, unique.

They also stress that, even though psychological suffering is very real and may be 'at least as severe as physical suffering', that it is not the same as for those who are dying. "We see that some who were first declared terminally ill eventually abandon euthanasia because new prospects appeared. In a paradoxical way, this proves that the disease cannot be called incurable." (Another example is that of the Belgian prisoner, Frank van den Bleeken, who requested euthanasia because his interment without treatment was intolerable, but who was finally offered better treatment services.)

'In contrast to diseases that are the consequence of tissue damage, mental suffering is connected to a change in functioning - and not a deterioration of tissue. This difference is essential because such dynamic changes, by definition, can and do revert, and sometimes quite suddenly. Thus we see that some people who were first declared untreatably ill and who received on that basis permission for euthanasia decline to exercise their option because new - albeit fragile - prospects appeared.

'In a paradoxical way, this proves that the disease cannot be called incurable. The subjective assessment of one's own perspective in the context of mental suffering therefore offers no stable support to make an 'incurably ill' verdict.

'The conclusion is clear: the current law assumes wrongly that there are objective clinical criteria for psychological suffering that might justify euthanasia. It is for this reason that euthanasia on the grounds of mental suffering alone cannot be regulated by law.'

So, even though, as was seen in The Economist video, the medical professionals involved in cases of approving euthanasia for psychological reasons may well be exceedingly 'careful' in their work, diligence does not displace ethics nor good medical decision making.

The argument that Belgian and Dutch doctors are 'careful' and even diligent in their approach to euthanasia does not hold much weight against what the 65 signatories call a 'trivialization' of euthanasia. Just because someone is good at what they do does not make what they do ethical or desirable.

Indeed they also consider the oft-heard idea that providing a lethal dose or approval for euthanasia on the premise that doing so is therapeutic (and therefore a form of palliative care) as using 'death as therapy' and wrong-headed:

'Some also defend the thesis that the mere offering of death as an option can cause a positive change and can therefore also be considered a component of good care. In our view, however, this inevitably entails the radical failure of the mental health sector. The use of 'death as therapy,' possibly up to the point of actually even performing the requested euthanasia, implies a priori renouncing what therapy still can and should be offering: the inexhaustible opening up of new perspectives.'

While these 65 professionals are only arguing that the Belgian law should remove the possibility of euthanasia for psychological reasons, the arguments they make, in many ways, extend naturally to the entire murky project.

If, as many wrongly assume to be the case already, approvals for euthanasia were withheld until everything else had been tried, it might be a different kind of argument. As the authors point out, even then, new therapies and perspectives may be just around the corner. But we realise that the 'palliative filter' as it is known, can never be applied because it would be contrary to human rights to force therapies upon people, denying them their rights to refuse. Because we have made the matter of state-sanctioned killing a 'right' then even the most sensible of suggestions by a doctor may be rightfully ignored in favour of an early death.

If the Belgian parliament ignores this call of the letter writers to remove access to euthanasia for psychiatric reasons, it will be re-affirming the reality that Belgian euthanasia is not about assistance for people who are dying but, rather, solely about the elimination of suffering. That being the case, what boundaries can be set? Can anyone gainsay any claim to 'unbearable suffering'?

Not convinced? Imagine what it would be like if the Belgian parliament changed the law so that, prior to approving a euthanasia request, a doctor would need to list every possible reasonably available treatment for the disease and insist that the patient try every one. 'What! And put them through all that suffering!' Precisely!

This is a basis for a carte blanche approach to killing. The subjectivity is not only now expressed by the sufferer only but also by the doctor. He or she is therefore not duty bound to seek remedy, to question why, to seek alternatives, to talk the patient 'down from the ledge'. He or she may do so, but clearly now will have a defence if they choose not to.

Some will consider the Dr van Hoey case and this call from eminent persons as evidence of a 'push back'. That may well be the case. However, as one cynic recently observed and as I note above, it may well also be the beginning of the removal of the last barriers to euthanasia on demand. For most living outside the Low Countries who read these developments, euthanasia for psychiatric reasons will not sit well. For those at home in Belgium and The Netherlands, the distinction may be virtually meaningless.

Thanks to Trudo Lemmens for the English translation of the De Morgen letter.