A Suicide Right for the Mentally Ill? A Swiss Case Opens a New Debate

Advocates for the legalization of assisted suicide in the United States, including those who sponsored Oregon's Death with Dignity Act in 1994 and current backers of California's proposed Compassionate Choices Act, have sought to permit the practice only under highly limited circumstances-namely, when the requesting patient is terminally ill.¹ In contrast, the Netherlands allows physician-assisted suicide in nonterminal cases of "lasting and unbearable" suffering, and Belgium authorizes physician-assisted suicide for nonterminal patients when their suffering is "constant" and "cannot be alleviated."² Yet no country has laws on the subject as liberal as those of Switzerland, where assisted suicide has been legal since 1918. It remains the only jurisdiction that allows nonresidents to terminate their own lives.³ It is also the only jurisdiction that does not require that a physician be involved in the process.

Now, a recent decision by the Swiss Federal Supreme Court threatens to undermine yet another longstanding taboo in the debate over assisted suicide and euthanasia. In its ruling on November 3, 2006, the high tribunal in Lausanne laid out guidelines under which, for the first time, assisted suicide will be available to psychiatric patients and others with mental illness.⁴

The case was that of an unnamed fifty-three-year-old manic depressive with two prior suicide attempts who sought a prescription for fifteen grams of sodium pentobarbital in order to end his own life.⁵ He claimed a right to self-determination under Article 8 of the European Convention on Human Rights and alleged that no physician would prescribe him this lethal dose for fear of legal or professional repercussions.⁶ Dignitas, a Zurich-based advocacy group, supported his suit. The Swiss high court responded with a sweeping opinion upholding the right of those suffering from "incurable, permanent, severe psychological disorders" to terminate their own lives.⁷ According to the court, a distinction should be made between temporarily impaired individuals who wish to die as "an expression of treatable psychological disturbances" and those individuals with severe, long-term mental illness who have made "rational" and "well-considered" decisions to end their lives to avoid further suffering.⁸ Since serious mental disorders could make life seem as unbearable to some patients as serious somatic ailments do to others, the court reasoned, those who repeatedly expressed a wish to end their lives under such circumstances should be permitted to do so. (The court also ruled that the plaintiff in this case would have to obtain a thorough psychiatric evaluation to determine whether he met these standards before he could end his life.)

Both supporters and opponents of assisted suicide have been highly critical of extending suicide rights to psychiatric patients.⁹ One set of objections is directed against the practice of assisted suicide itself-for a host of reasons ranging from a belief in the inherent sanctity of human life to a fear of sliding down a slippery slope toward involuntary euthanasia; that debate has been extensively addressed elsewhere. Another set of objections are from those who support a basic right to assisted suicide in certain situations, such as those of terminal disease, but do not wish to extend it to cases of severe and incurable mental illness. This resistance may be inevitable, considering the increased emphasis that contemporary psychiatry places on suicide prevention, but the principles favoring legal assisted suicide lead logically to the extension of these rights to some mentally ill patients.¹⁰

At the core of the argument supporting assisted suicide are the twin goals of maximizing individual autonomy and minimizing human suffering. Patients, advocates believe, should be able to control the decision of when to end their own lives, and they should be able to avoid unwanted distress, both physical and psychological. While these two principles might explain why a victim of amyotrophic lateral sclerosis or cancer would choose assisted suicide, they apply equally well in many cases of purely psychological disease: a victim of repeated bouts of severe depression, particularly in cases where treatment has consistently proven ineffective, rationally might prefer dignified death over future suffering...