Three years of the euthanasia law with new debate on mental illness as a reason to request benefits

The Organic Law for the Regulation of Euthanasia (LORE) turns three and blows out its candles in the midst of a crucial debate about how mental illness fits into the euthanasia context. The provisional data Regarding the execution in 2023, in the absence of the final report, there are 323 euthanasia services carried out and 727 requests. According to him Annual Evaluation Report 2022576 requests were made that year and 173 in 2021, and 288 benefits were executed throughout the territory, 50% of those requested and 75, respectively.

Was mental illness outside the LORE? There is no exclusion of these pathologies, but the dilemma or doubt was planted by the Constitutional Court in the two sentences with which it responded to the appeals against the law presented by the Popular Party and Vox. The Constitutional Court endorsed the LORE, but making an interpretation of the norm that left mental illnesses out of euthanasia requests.

The lawyer and vice president of the Euthanasia Guarantee and Evaluation Commission of Catalonia, Francesc José María Sánchez, has written and argued a lot in relation to this issue. And not only him, The decision of the Constitutional Court outraged and surprised other members of these autonomous guarantee commissions in equal measure. They are the ones who decide on the requests and know, better than anyone, the strengths and weaknesses of a standard that is young, three years old, and in need of adjustments.

On the other hand, the TC in the aforementioned rulings, where it endorsed the LORE, gave normative character to the Manual of Good Euthanasia Practices, a document prepared by the Ministry of Health together with the autonomous communities and that includes in detail the practical aspects for the application of the LORE.

Why does mental illness spark a debate in the provision of euthanasia?

Well, these weeks, as this newspaper has learned, the Ministry of Health is reviewing the Manual to include, clearly, that mental illness may motivate the request for euthanasiabecause it can give rise to the two assumptions established by the LORE as requirements to request the benefit: “Serious, chronic and disabling illness” and “serious and incurable illness.”

This step forward taken by the Ministry of Health is preceded by statements from the Euthanasia Guarantee and Evaluation Commissions of Catalonia and Andalusia, pointing in the same direction: mental illness is not excluded from the euthanasia context.

At this point, both the Ministry of Health and the autonomies that have expressed themselves on this issue, give a predominant role to the psychiatrist in requests for euthanasia motivated by a mental illness as the main pathology. They consider it necessary that, in these cases, the responsible doctor or consulting doctor be a psychiatrist.

But what do psychiatrists think of this controversy? Manuel Martín, president of the Spanish Society of Psychiatry and Mental Health (SEPSM), begins by highlighting that he could not “agree more” with the psychiatrist intervening in requests for euthanasia due to mental illness, “logical.”

Furthermore, he goes further, and remembers that, when the LORE was being processed, the Society he presides requested that within the composition of the euthanasia guarantee and evaluation committees there would always be a psychiatrist, “in order to have an assessment of the emotional situation of the patient in response to his request to die from oncological diseases or any other type” and now reiterates this demand.

Are there psychiatrists on euthanasia commissions? Martín affirms that “each community has decided at its own will.” He explains that “in the commissions for the Guarantee and Evaluation of Euthanasia of Madrid, Basque Country, Catalonia or Aragon yes there is a psychiatrist; while, in Navarra, for example, there is no“.

Regarding whether mental illness can motivate the request for euthanasia, the president of the SEPSM puts on the table that we are facing a “complex issue”, full of nuances and grays. The application of euthanasia in mental illness has several complexities. On the one hand, “There is the difficulty of establishing the terminal nature of a disease that will not lead to the death of the patient.“. Martín recalls that the LORE requires that the patient exhaust the therapeutic alternatives that exist before making the request.

While remembering that “There are patients who do not have access to the treatments they need, taking into account that, as scientific evidence shows, these treatments must be comprehensive and address aspects such as the patient’s social environment or psychotherapy. It would be necessary to guarantee that the patient has had access to these comprehensive treatments before processing any request for euthanasia, because this is required by the LORE.”

Along with this, Martín points out the obvious difficulty of establishing the patient’s capacity to act, “the autonomy of your decision“. That is, knowing with certainty whether the illness is speaking in the request to die of these patients. Because, “the reality is that there is no articulated assessment of the patient’s capacity to act, nor are there professionals trained to carry out this assessment in the field of mental illnesses”.

Have euthanasia requests been requested due to mental illness?

It should be noted that among the underlying diseases of the people requesting euthanasia that appear in the report, 576 in total, 205 (35.5%) were due to neurological diseases, followed by oncological diseases, with 192, which are a 33.33%. As “other unspecified diseases“, which would be outside the established qualification and could be susceptible to collecting cases of mental illness, 68 applications appear and, in addition, there are 48 applications for which “there is no data.”

In these years with the law in force, there have been requests for euthanasia motivated by mental illness, as confessed by members of the Euthanasia Guarantee and Evaluation commissions of several autonomous communities, without wanting to appear or give more details. There have even been euthanasias performed in those cases.

Now, based on the aforementioned report from the Ministry of Health, There have been no psychiatrists who have participated in the evaluation of euthanasia requests, neither as responsible physicians nor as consulting physicians. Víctor Expósito Duque, family doctor in the Canary Islands and member of the national mental health group of the Spanish Society of Family and Community Medicine (SemFYC), highlights that, if the situation “has generated and generates many doubts in the population and among professionals”, therefore, “I consider that, indeed, it is necessary to modify the Manual of Good Practices of Euthanasia to unify and clarify the processes in these cases”.

In any case, Expósito Duque admits that he has always been “of the opinion that mental illness was not excluded from the LORE.” He also understands the role of the psychiatrist in these processes, but warns that The family doctor is the professional who “has the privilege” to better understand the patient’s environment and, therefore, “to understand, in a global way, the patient’s situation that motivates the request for euthanasia.”

“What if the psychiatrist should intervene in these requests? Of course, but the role of the family doctor in these cases is also fundamental,” he concludes.