“At some point they have the right to say, I’ve tried enough,” says doctor pioneering euthanasia for psychiatric patients

13-03-2017

One of the most thought-provoking films at this year’s One World festival of human rights documentaries in Prague has been I’m Not Afraid. It follows the assisted suicide of Eli, a Dutch woman who has been suffering from extreme anxiety for most of her life. To discuss the ethics of euthanasia involving people in mental rather than physical pain, I spoke to another protagonist in the documentary, Eli’s psychiatrist – and the man who approved and assisted her voluntary death – Dr. Frederick Polak.

Frederick Polak, photo: Ian WilloughbyFrederick Polak, photo: Ian Willoughby “She suffered from anxiety attacks from when she was 18 or 19 years old. And treatment hadn’t really helped her.”

Were there no drugs that could help her?

“I don’t know exactly how she was treated when she was 20 or 21, because we don’t have the data about that.

“But I suppose she had the normal anti-depressant drugs. Anti-anxiety and anti-depressant drugs.

“Many anti-depressant drugs also have an anti-anxiety function, so you can name a whole list of medicines that she had been using – with some success, but not sufficiently.”

In the film we learn that she has been your patient for 15 years and you say that it took some time for you to come to the decision or the realisation that she should undergo euthanasia. What was the point at which you reached that conclusion?

“It was not a specific point. There were a number of aspects.

“One important aspect was that I already had her in treatment when I was invited by the Netherlands psychiatric association to take part in a working group that had to draw up the rules for assisted suicide to psychiatric patients.

“Because there already was the possibility for normal people, or for non-psychiatric patients. That had been regulated.

“But at that time psychiatric problems were still more a reason to exclude somebody.

“There was no question about the strength of her wish. That was the easier part of it. The other part was, If I do this, will I get into trouble?”

“But I was on the board of the psychiatric association in the Netherlands and people thought I was a good choice to do this, because I was interested for so long in drugs – illegal drugs [he is a campaigner for marijuana liberalization], but also legal drugs.

“And I accepted that. So I was aware of the rules better than most people, because of that job that I took on.

“It took a few years to make the guidelines for physician-assisted suicide to psychiatric patients.

“Then very small steps; things happened that I heard or read about or there was information from other countries, and so on.

“So gradually I was ready to do it.”

When did it become legal in Holland to provide assisted suicide to somebody with psychiatric problems?

“I’m not sure: 2014 or 2015.

“But it’s not that the law changed to make it possible for psychiatric patients. It’s more that there was clarity for how the thinking was about it in the medical world.

“Because you can do it as a doctor, but when it’s ready you have to have a whole pile of papers with all the earlier examinations and all the diagnoses, treatments, reports, and how you came to that conclusion.

'I’m Not Afraid', photo: archive of One World festival'I’m Not Afraid', photo: archive of One World festival “On top of that, two other doctors have to agree. For non-psychiatric patients it is a little bit easier: Only one extra doctor is necessary.

“Also, it is quite obvious in non-psychiatric diseases. Like with people with cancer who are suffering pain and the medication is not working and they want to be helped to quit life.

“That had already developed into a quite, well not normal… but doctors were used to it and were aware of the rules. And then this, for psychiatric patients, was added.

“One thing that I did not want was to get into legal problems after it had been done.”

Is this a common procedure in Holland? Have there been many cases of assisted suicide for psychiatric patients?

“No, it’s still only 40 or 50 per year in the whole country. So around one a week – but that’s the whole country.”

In the case of this patient of yours, this woman Eli, was there anything that gave you pause for thought and made you think, Is this the right thing to do for her?

“Yes. It took a long time. There was not a specific point. When I knew exactly what the rules were, and I was clear to myself that was possible to it with her…

“Because there was no question about the strength of her wish. That was the easier part of it.

“The other part was, If I do this, will I get into trouble because of it?

“Because there was still in the media a lot of debate. People were really angry and said it was sort of murder.

“It’s still only 40 or 50 per year in the whole country. So around one a week – but that’s the whole country.”

“When we talked about it, my patient and I, she could laugh about things that she found funny.

“But when she left my office and went home she knew she would have a depressive state when she was alone at home.”

One of the common arguments against legal euthanasia is a slippery slope to possible involuntary euthanasia. Isn’t an even more slippy slope when it comes to people suffering from mental distress, when it’s even more complicated than in the case of physical distress or physical pain?

“That’s difficult to say. I’ve never compared it in the way you ask.

“But in general this argument of the slippery slope is a very strange argument.

“Because the normal way is that when some people think that the law has to be widened, or things have to become possible that were not allowed before, or the other way around, then the decision is not made by a single person but when it’s to do with law the decision is made by the parliament.

“When there is agreement that it was not a good thing to do, then you can take it back. You can change it again in a parliamentary vote.

“Now there is a new draft law and it was accepted in the second chamber of our parliament, but not yet in the first, for what they call ‘ready with life’ [he later clarifies this as ‘life is complete’], where people say, I’ve had a wonderful life, but the last three or four years have been terrible and it won’t get any better.

“This is without that person having any specific disease. So the disease element is not there.

'I’m Not Afraid', photo: archive of One World festival'I’m Not Afraid', photo: archive of One World festival “And that’s now a big political question, whether that can be allowed.

“That is what many people want. They don’t want to first have to become terminally ill or to suffer unbearably from a disease.

“Now in this new law it’s that the person should suffer unbearably simply from having to continue to live.”

There’s a very powerful moment in the film when your patient actually dies. You were there for this and you took part in this. What was your feeling in that moment?

“Mixed. I felt with her. At least I tried to, as far as that is possible.

“But also for me it was important to know that things simply went well. That no mistakes were made. And whether the filmmaker did not interfere too much or disturb the situation.

“But there I was quite clear that it was working well for her, that it was not a problem for her. She was happy that the film was made. She wanted it to become known.”

But how did you feel watching her life slip away like that?

“I was not her best friend. I was paying attention to what was happening and if I saw the right development or something that disturbed me.

“That’s a different situation, if you’re there as the medical person responsible for it.”

Before hearing about and watching this film, I didn’t even know that there was such a thing as assisted suicide for people suffering from mental distress or anxiety. Do you think in the future it’s something that’s likely to spread beyond the Netherlands? Or that will catch on more widely?

“In general this argument of the slippery slope is a very strange argument.”

“I think it will, yes. In Canada and the US there is interest. In a number of European countries there is interest.

“Switzerland has been advanced in this and as far as I know they don’t even have psychiatric patients as a separate category.

“That is only in Holland. And there is something to say for it, because it is more difficult to gauge the situation.

“It is also more difficult to know whether there may be some sort of treatment that offers a way out.

“If you are sitting around with three psychiatrists, there will be two or three or four options for possible therapies. And that’s a problem then: Do they all have to be tried?

“But there what we said in these guidelines was that new medication, or medication that has been tried and according to some specialist not well enough – that those things had to be judged in the context of her whole illness history and in the history of her treatment.

“There it could only be asked when it still was reasonable any more to ask the patient to just try this one sort of medication.

“I think it was a good thing that we had that. Because in psychiatry this whole procedure takes time and there would be a new anti-depressant on the market – so you will never be able to do this.

“And the patient at some point has the right to say, Now I have done enough, tried enough, on the advice of my doctor or my specialist and I think it has been enough.

“That is accepted in the rule that was drawn up by the profession itself. And it was taken over by the general medical association and also the government.

“So you could say that was a sort of success for us.”

13-03-2017