In 1994 the Supreme Court of the Netherlands convicted but did not punish a psychiatrist for assisting with suicide in the case of a woman whose suffering was not of somatic origin (1,2). This decision inflamed the national and international debate about whether assisted suicide for psychiatric patients is acceptable. In professional practice, there is much uncertainty in this area, mainly because patients' and physicians' lack of perspective on treatment is more ambiguous in psychiatry than in somatic medicine and because the competency of psychiatric patients must be given extra attention (3,4).
As early as 1985 the Dutch State Commission on Euthanasia suggested that hospitals and nursing homes clarify their policies on euthanasia and assisted suicide (5). Recently, the desirability of a policy on assisted suicide in psychiatric hospitals has been pointed out (6,7). Because little is known about the prevalence and content of such policies, we surveyed psychiatric institutions as part of a larger study of Dutch health care institutions requested by the Dutch Parliament (8).
The study population consisted of 52 general psychiatric hospitals and 59 general hospitals with psychiatric wards. General psychiatric hospitals treat all categories of psychiatric patients. Almost two-thirds of patients in those facilities stay a year or longer. General hospitals with psychiatric wards emphasize short-stay treatment. The total capacity of the facilities is 22,750 beds in the psychiatric hospitals and 2,084 beds in the general hospital psychiatric wards (9).
Four general psychiatric hospitals were excluded from the survey, two because they had participated in the pilot study for the survey, one because it had been two hospitals merged into a single hospital during the study period, and one because it was being established during the study period. Thus the net sample of 107 facilities consisted of 48 psychiatric hospitals and 59 general hospitals with psychiatric wards. The survey respondents were directors of patient care.
The survey used the following definitions. "Assisted suicide" was defined as deliberately helping another in a life-ending act at his or her request (8). "Policy" was defined as a written statement on assisted suicide issued by the hospital management. "Verbal policy only" designated a position on assisted suicide that had not been put in writing. A "guideline" consisted of a written protocol authorized by the management to guide physicians in decision making or planning related to requests for assisted suicide.
Data were collected from October 1994 through January 1995. The survey used a semistructured questionnaire designed by the authors that included questions about characteristics of the hospital and about policies on assisted suicide. The questionaire was mailed to the hospitals' directors of patient care, who were asked to complete the questionnaire and return it anonymously by mail.
The overall analytic approach was descriptive. Chi square or Fisher's exact tests were used to compare characteristics of the responding facilities with those of the overall study population.
Hospitals were considered to have a tolerant policy toward assisted suicide if the respondents stated that "assisted suicide is not possible, unless . . ." or "applying or not applying assisted suicide is left entirely to physicians." Hospitals were considered to have a permissive policy if respondents stated that "assisted suicide is possible, providing . . . ." A policy was identified as nonpermissive if respondents stated that "assisted suicide is never possible."
Several levels of policy making were distinguished. Hospitals could have a written policy, with or without a written guideline; a verbal policy only, with or without a note in which assisted suicide is discussed; no policy, but with a note in which assisted suicide is discussed; and no policy, but thematic discussions or lectures are organized.
Thirty-eight of the 48 general psychiatric hospitals (79 percent) and 42 of the 59 general hospitals with psychiatric wards (71 percent) responded to the survey.
Thirty-nine percent of the reponding psychiatric hospitals had a religious affiliation. Most of the psychiatric hospitals were situated in the western and central part of the Netherlands (35 percent and 29 percent, respectively). Fifty-four percent had less than 500 beds. There were no significant differences in these characteristics between the responding psychiatric hospitals and the net population of 107 hospitals.
Five general psychiatric hospitals, or 13 percent, had a written policy on assisted suicide. Of those five hospitals, two had a policy that assisted suicide was never possible. Three had a tolerant or permissive policy and had developed written guidelines.
Seventeen psychiatric hospitals, or 45 percent, had a verbal policy only. Four of those hospitals had a note in which assisted suicide was discussed. Three of the 17 hospitals had a verbal policy that assisted suicide was never possible, ten had a tolerant policy, and four had a permissive policy.
Among the 22 psychiatric hospitals with either written or verbal policies, a total of 17 adopted a permissive or tolerant policy, and five adopted a nonpermissive policy. Directors of three of the 17 hospitals with permissive or tolerant policies mentioned the condition that assistance with suicide should take place outside the hospital.
Directors of eight of the 16 psychiatric hospitals without a policy explained that they had plans to develop a policy. Two reported having a note on assisted suicide, and five remarked that the hospital had organized lectures or thematic discussions about assisted suicide with medical staff or the medical ethics committee.
Among the 42 general hospitals with psychiatric wards that participated in the study, six, or 14 percent, had a written policy on assisted suicide. Five of the six reported having tolerant or permissive policies, and two had developed guidelines. Three general hospitals had verbal policies; all three hospitals had tolerant or permissive policies. Thirty-three of the 42 general hospitals, or 79 percent, had neither a written nor a verbal policy.
Three general hospitals, but none of the psychiatric hospitals, communicated their policy to patients on request. The nonpermissive written policy of one general hospital mentioned that clinicians could refer patients who were interested in assisted suicide to another institution. None of the psychiatric hospitals had policies that mentioned this possibility.
Hospitals were asked to give reasons why they did not have a written policy. The reason most frequently cited by general hospitals (15 of the 34 hospitals that responded to this question) was that the subject of assisted suicide had never been discussed. Only five of the 33 psychiatric hospitals without a written policy mentioned this reason. The management of 17 of the 33 psychiatric hospitals and 14 of the 36 general hospitals without written policies reported that they wanted to adopt a written policy in the future.
This study shows that only a few general psychiatric hospitals and general hospitals with psychiatric wards in the Netherlands had written policies on assisted suicide. Almost half of the psychiatric hospitals had a verbal policy only, but the majority of the general hospitals had neither a written nor a verbal policy. Most of the hospitals with policies had a tolerant or permissive policy toward assisted suicide.
A limitation of this study is that the findings are based on self-reports of the hospital management. We did not verify whether the policies and guidelines actually existed, what the details of their contents were, and how they were implemented. Thus we cannot draw conclusions about what the policies or guidelines mean in practice.
That so few hospitals had written policies on assisted suicide may be due to the fact the jurisprudence in this area has only recently developed. This explanation is supported by our finding that many hospitals said they want to adopt a policy in the future.
We found that psychiatric hospitals were more likely to have a policy about assisted suicide than were general hospitals, perhaps because of differences in the populations served by the two types of institutions. Many patients in psychiatric hospitals have a chronic, long-term illness; general hospitals are meant for short stays, which implies a selected population with better prospects for treatment outcomes.
Although the majority of the hospitals with policies adopt a permissive or tolerant policy, one must be careful in generalizing this finding, as only a few hospitals have written policies. Although the tendency toward a permissive or tolerant position is also reflected in verbal policies of psychiatric hospitals, an unwritten statement is less strong than a written one. Moreover, a permissive or tolerant policy does not tell us anything about actual practice. The annual number of explicit requests for assisted suicide made to psychiatrists was recently estimated to be 320; very few of those requests, no more than two to five per year, are carried out (10).
Because this study is the first systematic inventory of policies on assisted suicide for psychiatric patients in the Netherlands, no national reference material is available for comparison. We do not know of any international study on this matter.
The results of this study suggest that directors of psychiatric institutions in the Netherlands have made a beginning in formulating written policies on assisted suicide. In consideration of prudent caregiving, such institutions should be encouraged to adopt a policy that clarifies how to approach requests for assisted suicide.
This study was conducted by Vrije Universiteit in collaboration with the Inspectorate for Health Care and was funded by the Ministry of Health Care, Welfare, and Sports. The authors thank Professor F. A. M. Kortman, M.D., Ph.D., and A. J. Tholen, M.D., Ph.D., for their comments.
Ms. Haverkate is a psychologist and epidemiologist and Dr. van der Wal is professor of social medicine on the Faculty of Medicine of the Institute for Research in Extramural Medicine at Vrije Universiteit in Amsterdam. Address correspondence to Ms. Haverkate at Vrije Universiteit, EMGO-Institute, Van der Boechorststraat 7, 1081 BT Amsterdam, the Netherlands.