I struggled to decide where to begin this week’s column in the wake of news that a Belgian inmate had been granted his request for physician-assisted suicide. Beyond stifling an instinctive “oh my god” response, I felt an immediate regret that I predicted something like this would happen eventually when I wrote about state laws regarding assisted suicide for a previous column. I just didn’t expect it to happen quite so soon, or to involve a prison inmate.
According to an Associated Press story published in the Washington Post, inmate Frank Van Den Bleeken had served almost 30 years for the rape and murder of an unspecified number of women, and had requested euthanasia on the basis of having a mental condition deemed incurable by the Belgian courts. The story didn’t specify exactly what that condition was, or why it was untreatable, but the inmate alleged that he couldn’t live with the knowledge that he would be a danger to society again upon release. I’m surprised at this newly developed sense of conscience, since it apparently wasn’t enough to prevent him from committing the crimes in the first place. If his incurable condition was sociopathy, then some intervention must have worked to lead to this remarkable development of empathy. Setting skepticism aside, the case does raise serious concerns for psychiatrists working in jails and prisons.
Adopted in 2002, the Belgian law defines euthanasia as “intentionally terminating life by someone other than the person concerned, at the latter’s request.” The individual making the request must do so competently and without external pressure if his condition is “constant and medically futile,” leading to “unbearable physical or mental suffering that cannot be alleviated.” A physician cannot be compelled to perform the killing but must notify the patient of the refusal and must forward the patient’s medical record to another physician of the patient’s choosing.
It seems we’ve arrived at a strange mirror-inverse world of medicine in correctional health care now. Given that the World Health Organization has proscribed the force feeding of prisoners, a correctional physician may not only be forbidden from intervening to save a life, he may also be called upon to intentionally end one. If there were ever a situation that calls for scrupulous medical integrity, this is it.
I’m not shocked by the thought that an inmate might request suicide. Most prisoners are young, are male, and have active substance use disorders – three commonly accepted risk factors for suicide – even before walking into the facility. What concerns me more is the thought that in all likelihood, requests for assisted suicide by prisoners are going to be considered less carefully than those by noncriminals. Given the horrific nature of some offenses, it would be easy to imagine a court turning a semiblind eye to other factors influencing a request to die. It would be easy to view suicide as a rational choice for someone serving a life term, rather than as a product of a treatable psychiatric condition. Courts might also be unwilling to examine the underlying conditions of confinement or an institutional culture that would lead one to accept death as a viable alternative to life in a threatening or inhumane environment. Prisoners are also less likely to have outside supports or involved family members to provide more factual context to the decision to seek physician-assisted suicide, or to challenge the competence of the petitioner. The institution itself might be unwilling to acknowledge inadequate health care services, or lack of palliative care, for terminally ill prisoners.
Belgium and the Netherlands have expanded physician-assisted suicide processes far beyond anything presently contemplated here in the United States, but petitions for assisted suicide have been increasing there year after year, and an increasing number of American states have been considering this legislation. As the Van Den Bleeken case illustrates, only the professional integrity of physicians may stand between poorly considered laws and a select group of vulnerable human beings.
Dr. Hanson is a forensic psychiatrist and coauthor of Shrink Rap: Three Psychiatrists Explain Their Work. The opinions expressed are those of the author only, and do not represent those of any of Dr. Hanson’s employers or consultees, including the Maryland Department of Health and Mental Hygiene or the Maryland Division of Correction.