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Recently, the discussion on physician aid-in-dying (PAD) extended to the context of mental disorders. Supporters of that view mainly argue based on patient autonomy. In Switzerland the Swiss Academy of Medical Sciences (SAMW) updated their recommendation, replacing the requirement of terminality with the criteria of unbearable suffering. This would allow people suffering from mental illness to access PAD. However, the Swiss Medical Association (FMH) decided not to adopt this recommendation and to restrict PAD to cases of terminal illness. In Germany, in 2020 the Federal Constitutional Court ruled that the right to self-determined death, including the freedom to seek assistance for suicide, if available, is a civil right. The implications of these decisions for legislation and practice on PAD in general and mental disorders in particular are not fully conceivable yet. The discourse about defining severe suffering and terminal illness in psychiatry is complex and challenges legal, ethical and professional positions on both an individual and a collective level. Suffering is a necessary but insufficient condition for PAD in psychiatry, the other criteria being decision-making capacity and refractoriness of the suffering. Additionally it has to be taken into account that suffering is a subjective experience that can only be quantified by the patient. The symposium aims to focus on the discussion of conditions under which severe mental illness might lead to such a pronounced and unbearable state of suffering, with no prospect of therapeutic improvement that - after a conscientious assessment - PAD can be considered.
S0105 - PAD in Psychiatry: A Review on History and Current Developments
S0106 - PAD, Psychiatry and Stigma
In 2018, the Swiss Academy of Medical Sciences (SAMW) published a new guideline on physician-assisted dying (PAD). In line with the SAMW guideline published in 2004, the patients' ability to judge, their self-determination, careful consideration and permanence of their wish to die as well as the lack of therapeutic options were set as necessary conditions. However, while the previous wording considered assisted suicide to be ethically justifiable if the patient's condition is terminal, the new guideline requires that it is unbearable. This difference has been the subject of intense discussion in Swiss healthcare professionals and the population alike.
This controversy is particularly important for those affected by mental illness who have a persistent desire to die. This is because mental disorders cannot usually be classified as terminal illnesses, but they can certainly lead to suffering that is perceived as unbearable. Furthermore, it is known that persons with mental illness are subject to stigmatization. It is therefore likely that there is a connection between the stigmatization of mentally ill people and the position on PAD for this group.
This talk provides theoretical background on this discusion and proposes a study protocol to investigate the acceptance of PAD in relation to the type of illness as well as the factors of unbearable suffering and terminality. It will furthermore look into the criteria of the 2004 and 2018 guidelines and will explore if there is a connection between stigmatization and the assessment of whether a person should be granted access to assisted suicide.
S0107 - PAD in Forensic Psychiatry
Introduction: A recent court decision in Germany defined assisted suicide as a basic human right. Consequently, the discussion regarding PAD needs to be extended to people who are in forensic/secure psychiatric hospitals or prisons, sometimes without any prospects of release. Several studies have shown that long-term hospitalization and detention are associated with feelings of hopelessness, depression and suicidal ideations. Moreover, the resources for adequate therapy are often rare. This results in complex moral challenges for mental health care.
Objectives: To review current practices in countries that allow PAD and to discuss ethical conflicts.
Methods: Literature review; international comparison of current regulations.
Results: A majority of the literature on PAD in detention refers to prisoners with terminal medical conditions. Single case reports of PAD-requests of mentally disordered offenders aroused great public interest. The resulting ethical conflicts are similar to those issues regarding PAD and mental disorder in general. However, in secure treatment settings and detention additional aspects such as adverse living conditions and inadequate access to mental health care need to be taken into account.
Conclusions: If unbearable pain is not a precondition for assisted suicide, then mentally disordered and healthy offenders have a right to request PAD, provided they have medical decision-making capacity. Considering the common insufficient mental health care for people in detention, policy and law makers need to ensure that access to PAD will not replace therapy. Professionals involved in PAD evaluations need support by specific guidelines.
S0108 - Ethics of PAD in Mental Disorders
Involuntary psychiatric hospitalization for suicide prevention and physician assistance in dying (PAD) for patients with severe and persistent mental illness (SPMI) combine to create a moral tension. Switzerland has the longest history of non-medicalized assistance in dying, considered as a civil right even beyond pathological situations. The debate in Switzerland centers on the notion of suffering in the context of PAD. In 2018, the Swiss Academy of Medical Sciences revised their end-of-life policy stipulating intolerable suffering due to severe illness or functional limitations and acknowledged as such by the physician as a core criterion for PAD. However, we argue that suffering is a necessary but insufficient condition for PAD, the other criteria being decision-making capacity (DMC) and refractoriness of the suffering. Moreover, we hold that suffering is a subjective experience that can only be quantified by the patient and cannot be compared between two persons in an objective way. According to this concept, however, some patients with SPMI, refractory suffering, and preserved DMC will meet the criteria for PAD. Therefore, we call for palliative care approaches in psychiatry which includes relief of suffering as much as possible, but also accepting PAD after a conscientious assessment of the criteria.