We're unable to sign you in at this time. Please try again in a few minutes.
We were able to sign you in, but your subscription(s) could not be found. Please try again in a few minutes.
There may be a problem with your account. Please contact the AMA Service Center to resolve this issue.
Contact the AMA Service Center:
Telephone: 1 (800) 262-2350 or 1 (312) 670-7827  *   Email: subscriptions@jamanetwork.com
Error Message ......
Original Investigation |

Euthanasia and Assisted Suicide of Patients With Psychiatric Disorders in the Netherlands 2011 to 2014

Scott Y. H. Kim, MD, PhD1; Raymond G. De Vries, PhD2,3; John R. Peteet, MD4
[+] Author Affiliations
1Department of Bioethics, National Institutes of Health, Bethesda, Maryland
2Center for Bioethics and Social Sciences in Medicine, University of Michigan Medical School, Ann Arbor
3CAPHRI School for Public Health and Primary Care, Maastricht University, Maastricht, the Netherlands
4Department of Psychiatry, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
JAMA Psychiatry. 2016;73(4):362-368. doi:10.1001/jamapsychiatry.2015.2887.
Text Size: A A A
Published online

Importance  Euthanasia or assisted suicide (EAS) of psychiatric patients is increasing in some jurisdictions such as Belgium and the Netherlands. However, little is known about the practice, and it remains controversial.

Objectives  To describe the characteristics of patients receiving EAS for psychiatric conditions and how the practice is regulated in the Netherlands.

Design, Setting, and Participants  This investigation reviewed psychiatric EAS case summaries made available online by the Dutch regional euthanasia review committees as of June 1, 2015. Two senior psychiatrists used directed content analysis to review and code the reports. In total, 66 cases from 2011 to 2014 were reviewed.

Main Outcomes and Measures  Clinical and social characteristics of patients, physician review process of the patients’ requests, and the euthanasia review committees’ assessments of the physicians’ actions.

Results  Of the 66 cases reviewed, 70% (n = 46) were women. In total, 32% (n = 21) were 70 years or older, 44% (n = 29) were 50 to 70 years old, and 24% (n = 16) were 30 to 50 years old. Most had chronic, severe conditions, with histories of attempted suicides and psychiatric hospitalizations. Most had personality disorders and were described as socially isolated or lonely. Depressive disorders were the primary psychiatric issue in 55% (n = 36) of cases. Other conditions represented were psychotic, posttraumatic stress or anxiety, somatoform, neurocognitive, and eating disorders, as well as prolonged grief and autism. Comorbidities with functional impairments were common. Forty-one percent (n = 27) of physicians performing EAS were psychiatrists. Twenty-seven percent (n = 18) of patients received the procedure from physicians new to them, 14 of whom were physicians from the End-of-Life Clinic, a mobile euthanasia clinic. Consultation with other physicians was extensive, but 11% (n = 7) of cases had no independent psychiatric input, and 24% (n = 16) of cases involved disagreement among consultants. The euthanasia review committees found that one case failed to meet legal due care criteria.

Conclusions and Relevance  Persons receiving EAS for psychiatric disorders in the Netherlands are mostly women and of diverse ages, with complex and chronic psychiatric, medical, and psychosocial histories. The granting of their EAS requests appears to involve considerable physician judgment, usually involving multiple physicians who do not always agree (sometimes without independent psychiatric input), but the euthanasia review committees generally defer to the judgments of the physicians performing the EAS.

Sign in

Purchase Options

• Buy this article
• Subscribe to the journal
• Rent this article ?





Also Meets CME requirements for:
Browse CME for all U.S. States
Accreditation Information
The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.
Note: You must get at least of the answers correct to pass this quiz.
Please click the checkbox indicating that you have read the full article in order to submit your answers.
Your answers have been saved for later.
You have not filled in all the answers to complete this quiz
The following questions were not answered:
Sorry, you have unsuccessfully completed this CME quiz with a score of
The following questions were not answered correctly:
Commitment to Change (optional):
Indicate what change(s) you will implement in your practice, if any, based on this CME course.
Your quiz results:
The filled radio buttons indicate your responses. The preferred responses are highlighted
For CME Course: A Proposed Model for Initial Assessment and Management of Acute Heart Failure Syndromes
Indicate what changes(s) you will implement in your practice, if any, based on this CME course.
Submit a Comment
The controversial issue of euthanasia in psychiatric patients
Posted on March 17, 2016
Emilie Olié, Philippe Courtet
Department of Psychiatric Emergency & Acute Care, Lapeyronie Hospital, CHU Montpellier - Inserm U1061 - University of Montpellier, Montpellier, France.
Conflict of Interest: None Declared

By describing characteristics of patients receiving euthanasia or assisted suicide (EAS) for psychiatric conditions, Kim and colleagues (1) raised serious concerns about EAS implementation in patients with unbearable suffering, whatever the cause.

Euthanasia may be differentiated from suicide in such terms: the suicidal intent is present, and results in death without self-inflicted behavior. The management of most patients requesting EAS might thus be a matter of suicide prevention. As a matter of fact, Kim and colleagues (1) reported high rates of history of suicide attempt and social isolation, both main factors of completed suicide. Indeed, having a past history of suicide attempt is the main predictor of death by suicide. Low social integration is inversely associated with incidence of death by suicide (2).

On the one hand, a main objective of legalization of EAS is to ease suffering when a terminally ill patient's pain is overwhelming despite palliative care. But physical pain is a consistent risk factor for suicidal thoughts, suicide attempts and completed suicide (3). If “severe pain” criterion is expanded to “severe suffering”, could we consider use of analgesics to get relief from suffering beyond pain? On the other hand, patients seek death through suicide to get relief from a painful internal state. Psychological pain is reported to be one of the most frequent themes of suicide notes. Moreover, higher perception of psychological pain is associated with history of suicide attempt and with intensity of suicidal ideation in depressed patients (4).

To conclude, three main points would deserve more attention when considering EAS, particularly in psychiatric patients. First, a systematic assessment of suicidal ideation intensity is needed to propose specific pharmacological treatments. Recent data are encouraging use of rapid-acting anti-suicidal treatments, such as time-limited, short-term use of very low dosages of ketamine or buprenorphine (5). Second, considering social history is essential to organize psychosocial interventions to restore social ties, and consequently reduce suffering. Third targeting specifically psychological pain appears to be an independent and specific therapeutic target.

1. Kim SY, De Vries RG, Peteet JR. Euthanasia and Assisted Suicide of Patients With Psychiatric Disorders in the Netherlands 2011 to 2014. JAMA psychiatry (Chicago, Ill.). 2016.
2. Tsai AC, Lucas M, Kawachi I. Association Between Social Integration and Suicide Among Women in the United States. JAMA psychiatry (Chicago, Ill.). 2015.
3. Calati R, Laglaoui Bakhiyi C, Artero S, Ilgen M, Courtet P. The impact of physical pain on suicidal thoughts and behaviors: Meta-analyses. J Psychiatr Res. 2015;71:16-32.
4. Olie E, Guillaume S, Jaussent I, Courtet P, Jollant F. Higher psychological pain during a major depressive episode may be a factor of vulnerability to suicidal ideation and act. J Affect Disord. 2010;120(1-3):226-230.
5. Yovell Y, Bar G, Mashiah M, et al. Ultra-Low-Dose Buprenorphine as a Time-Limited Treatment for Severe Suicidal Ideation: A Randomized Controlled Trial. Am J Psychiatry. 2015:appiajp201515040535.
Submit a Comment


Some tools below are only available to our subscribers or users with an online account.

4 Citations

Sign in

Purchase Options

• Buy this article
• Subscribe to the journal
• Rent this article ?

Related Content

Customize your page view by dragging & repositioning the boxes below.

See Also...
Articles Related By Topic
Related Collections
PubMed Articles
Stressful ethical issues in uremia therapy. Kidney Int Suppl 2010;(117):S22-32.