Psychiatric Euthanasia: Too Few To Matter? Not so fast

Since the publication of our study on 66 cases of psychiatric euthanasia or assisted suicide (EAS) in the Netherlands, I have heard comments from people that the issue is of minor consequence given how few cases there are.  The relative numbers are indeed low. In the Netherlands in 2014, there were a total of about 5300 EAS cases, of which psychiatric cases were 41.

Bracketing for now arguments about the importance of each individual life regardless of number, it may be useful to consider this issue from a purely quantitative standpoint. This will require some speculations about numbers but I will try to stay with what is known as much as possible, focusing on the U.S.

Using per capita rates (rather than mortality rates) as a rough guide, there would be about 950 psychiatric EAS cases per year in the US using the current Dutch rates (US is 19x more populous; reporting rate in the Netherlands is about 80% or lower).  For a large country like US, that is a small number but it does not seem inconsequential that nearly a 1000 persons per year would receive EAS for psychiatric reasons in the US.

But the problem with dismissing psychiatric EAS based on current low numbers in the Netherlands is that it ignores three things: one, the tremendous potential for growth in numbers over the years; two, the large significance–quantitatively–of each false positive in terms of person-years lost; and three, the high likelihood of false positives given the broad and vague set of criteria for eligibility that are usually used (criteria which may be much less likely to be problematic in the terminal illness setting but extremely problematic to operationalize for psychiatric disorders–that is an issue for another discussion; here I focus on the numbers only).

In the US, there are almost 43,000 completed suicides per year.  For each completed suicide, there are about 25 suicide attempts.  So there are about 1 million suicide attempts per year. Over 90% of completed suicides are in persons with some serious psychiatric disorder. Most people who request psychiatric EAS have attempted suicide in the past (often multiple times)–this does not directly  help us in estimating how many people who attempt suicide might seek EAS, but we can make a rough, conservative assumption that about 1 in 10 persons who attempt suicide  would attempt to make use of legalized EAS.

I want to make clear that I do NOT mean that in fact there will immediately be that many people asking for EAS if it is legalized.  Because both the medical culture (physicians feeling uncomfortable with the practice–as in the Netherlands where 2/3 of MDs cannot conceive of aiding in psychiatric EAS) and lay culture (only 28% of the Dutch public approve of psychiatric EAS even in the paradigmatic case of refractory depression) are opposed to psychiatric EAS, even legalization will not immediately lead to high numbers. But in a country with a broken mental health care system such as ours, we probably should not underestimate the potential for the system to flow toward the path of least resistance.

Once the practice becomes established and accepted, there could be an increasing number of persons who apply, as is happening in Belgium and the Netherlands now. This number, even conservatively measured, could reach at least 100,000 persons per year in the U.S. based on above assumptions (i.e., 10% of all suicide attempts per year).

In addition, there will be people who desire to die who would not have attempted suicide. This number is impossible to guess but if you speak with any experienced psychiatrist, suicidal ideation (without attempts) in persons with serious psychiatric conditions is common.  I would imagine that given the large number of such patients, even if a tiny fraction sought EAS, the absolute numbers would be quite sizable.  But to be conservative, we will ignore this group since it is very difficult to estimate.

Thus, it is not unreasonable to assume that eventually the number of person who may ask for psychiatric EAS in the US, were it legalized, would over the years reach into six figures per year.

Only a minority of such patients would likely meet criteria for EAS, even under a liberal regime.  A longer discussion is necessary to argue this point but there are a variety of reasons to think this:  many patients change their minds, some may not be competent to make decisions, and most commonly many will, with support and treatment over time, be able to cope better which may in turn lead to improvements in their symptoms.  Still, a sizable minority might qualify for EAS.  Suppose 20% would truly meet criteria, and 80% would not–assuming perfect application of eligibility criteria.

The application of the criteria, if similar to the ones in the Netherlands, Belgium, and the ones proposed by the recent Canadian Parliament special committee, will not be easy in the psychiatric setting (‘grievous and irremediable’ condition, competent as measured by current medical practice, etc).  The criteria from the Netherlands are:

1. The attending physician has come to the conviction that the
request from the patient is voluntary and well considered.
2. The attending physician has come to the conviction that the
suffering of the patient is unbearable and without prospect of
3. The physician has informed the patient about his or her
situation and prospects.
4. There are no more reasonable alternatives for the patient.
5. The physician has consulted at least one other, independent
6. The physician has terminated the patient’s life or provided
assistance with suicide with due medical care and attention.

I have bolded the key substantive criteria having to do with competent decision-making, assessment of ‘unbearable suffering,’ and medical futility.  In case you are wondering if these broad criteria are further specified or operationalized to guide the physicians, the answer is no.  This is why there are disagreements in judgment.

We can explore what would happen if physicians’ judgments are 90% sensitive (pick of 9 of 10 cases of truly eligible persons) and 90% specific (eliminate 9 of 10 persons who are truly not eligible) in identifying persons who are eligible for EAS. Based on my experience conducting capacity evaluations and conducting several studies on how physicians make capacity determinations, this is a fairly optimistic estimate of physician accuracy.  Also, we already know that even in completed psychiatric EAS cases in the Netherlands, 90% reliability (i.e., agreement among physicians) is not achieved. Thus, the idea that the overall accuracy (sensitivity and specificity) can be 90% is probably too optimistic. Without reliability, we can’t have validity.  But let’s press on.

Under these assumptions, there will be about a 31% false positive rate.  As applied to our sample of 100,000 requestors, there will be 26,000 persons found to be eligible by physician judgment. But of those, 8000 will be false positives and would be incorrectly provided with EAS.

If we use instead a more realistic estimate of physician judgment accuracy–say, 80% for both, or even lower–we get the following results: if a physician says a request for psychiatric EAS meets all criteria, the chances that the person does not meet all criteria will be about 50%, i.e., a false positive rate of 50%.  For our sample of 100,000 requestors, this will result in 32,000 persons being judged to be eligible, of whom 16,000 per year would not be in fact eligible (false positives).  This would translate into about 320,000 person-years lost, using a conservative mean of 20 years lost per false positive.

For those who are skeptical of my 100,000 estimate of potential requestors of psychiatric EAS, you can instead use a lower estimate, say, of 1% of suicide attempters requesting EAS. Using that assumption, we have:

  • 3200 persons per year who would receive psychiatric EAS in US
  • 1600 of whom are false positives
  • Loss of 32,000 person-years due to false positives

Not an insignificant public health impact.