Legal requirements for EAS

According to the Dutch Termination of Life on Request and Assisted Suicide Act (2002), the substantive requirements are that the attending physician must be satisfied that the patient's request is voluntary and well-considered, and that the patient's suffering is unbearable and without prospect of improvement, and must have come to the conclusion, together with the patient, that there is no reasonable alternative in the patient's situation.^{Reference Onwuteaka-Philipsen, Legemaate, van Der Heide, van Delden, Evenblij and El Hammoud8,9} The Belgian Act Concerning Euthanasia (2002) has similar, albeit differently formulated, key substantive requirements: the physician must come to the conviction, together with the patient, that the request be voluntary, that the disorder be serious and incurable, and must ascertain that the physical or mental suffering of the patient cannot be alleviated.^{Reference Jones, Gastmans and MacKellar2} The procedural requirements and oversight systems in the two jurisdictions are discussed in the following.

Process and oversight systems for EAS

The Belgian Act requires that the physician consult a second physician – a psychiatrist, in cases of psychiatric EAS – and requires a waiting time of at least 1 month for all non-terminally ill cases, including requests based on a psychiatric disorder. Although the Dutch Act requires that the physician consults at least one other independent physician, it does not specify that this be a psychiatrist for psychiatric EAS cases. However, in these cases, a psychiatric consultation is required by the Dutch Euthanasia Review Committees. Both countries have established services providing such consultants: Support and Consultation for Euthanasia in the Netherlands and Life End Information Forum in Belgium. All EAS cases need to be reported to the Regional Euthanasia Review Committees and the Federal Control and Evaluation Commission on Euthanasia, respectively, in The Netherlands and Belgium. These committees review the EAS reports to assess whether the physician who performed EAS conformed to the legal due care criteria.^{Reference Jones, Gastmans and MacKellar2,9}

Current explanations for the difference between psychiatric EAS and suicide

Current explanations for the difference between psychiatric EAS and suicide describe different phenomena, with emphasis on the alleged different role of impulsive action in both cases.^{7,Reference den Hartogh10,Reference Kim, Conwell and Caine11} The American Association for Suicidology states that suicide and EAS, including psychiatric EAS, are in general quite distinct, involving different patient characteristics. They characterise suicide as associated with violent self-destruction, isolation, loss of meaning, ambivalence and psychological pain. On the other hand, they describe persons requesting EAS as engaging in a planned act of self-preservation, experiencing intensified emotional bonds with loved ones.⁷ Others have also characterised suicide as a quasi-impulsive, violent and lonely act, to be distinguished from EAS, which is seen as a carefully executed, non-violent plan in dialogue with others.^{Reference den Hartogh10} Some guidelines on psychiatric EAS state that suicidal behaviour ‘usually involves impulsive behaviour’, as opposed to the death wish in psychiatric EAS.¹² Currently, the same distinction is proposed to explain the different gender distributions in suicide and psychiatric EAS: suicides are violent and impulsive (hence the greater proportion of men), whereas psychiatric EAS is planned and controlled (hence the greater proportion of women).^{Reference van Veen, Weerheim, Mostert and van Delden5}

Such contrasting portrayals of persons who die by suicide and those who die by EAS as fundamentally different rely on unfounded assumptions.^{Reference Kim, Conwell and Caine11} Their key reliance on impulsivity can be challenged, as the role of impulsive action in suicide has been overstated, and only very little suicidal behaviour (lethal or non-lethal) occurs without planning.^{Reference Anestis, Soberay, Gutierrez, Hernández and Joiner13–Reference O'Connor and Nock15} In fact, impulsive attempts are associated with lower psychopathology,^{Reference Anestis, Soberay, Gutierrez, Hernández and Joiner13} whereas individuals who are at particularly high risk for suicide (i.e. those with depression, substance use and/or a history of childhood sexual abuse) are less likely to engage in impulsive attempts. Impulsive action is neither necessary nor sufficient for suicide, and cannot explain the difference between suicide and psychiatric EAS, nor its different gender distributions.

We should therefore re-examine this empirically unsupported assumption. For this purpose, we will consider the usefulness of ideation-to-action theories, which focus on the suicidal process from suicidal ideation to behaviour.^{Reference Klonsky, May and Saffer14–Reference Van Orden, Witte, Cukrowicz, Braithwaite, Selby and Joiner16} This framework has received considerable clinical and research attention.^{Reference O'Connor and Nock15,Reference Turecki, Brent, Gunnell, O'Connor, Oquendo and Pirkis17} Rather than emphasising the role of suicide risk factors, it focuses on the concept of suicide ‘capability’, which determines the transition from suicidal ideation to (lethal and non-lethal) suicidal behaviour. Within this framework, ‘capability’ includes practical factors (knowledge of and access to highly lethal means) and psychological factors (fearlessness of death, pain tolerance), both of which can be acquired over time.^{Reference Klonsky, May and Saffer14–Reference Franklin, Hessel and Prinstein19} In the following sections, we analyse the gender distributions in suicide and psychiatric EAS, and examine the potential role for capability as an alternative, empirically grounded explanation for the relationship between suicide and psychiatric EAS.

Capability, gender and suicide

The difference between the gender distribution in suicide and in suicide attempts is well known, and is referred to as the suicide ‘gender paradox’.^{Reference Schrijvers, Bollen and Sabbe18,Reference Canetto and Sakinofsky20} The most consistently cited explanation for this paradox is the gender difference in methods chosen: women choose less violent and lethal methods than men.^{Reference Schrijvers, Bollen and Sabbe18,Reference Hawton21} For example, men tend to use methods such as hanging or fire-arms, whereas women often choose self-poisoning. Research suggests that differences in capability among those who attempt suicide is why more men die by suicide than women.^{Reference O'Connor and Nock15}

The choice for low lethality methods may indicate lower suicide capability, especially as it relates to the psychological aspects, since these methods may be perceived as involving less physical pain and be relatively less frightening.^{Reference O'Connor and Nock15,Reference Nock, Hwang, Sampson and Kessler22} Furthermore, the robust finding that women show a higher number of non-lethal attempts before a lethal attempt is consistent with the claim that through repeated attempts, women gradually increase their capability and the lethality of their attempts.^{Reference Anestis, Soberay, Gutierrez, Hernández and Joiner13,Reference Van Orden, Witte, Cukrowicz, Braithwaite, Selby and Joiner16,Reference Schrijvers, Bollen and Sabbe18,Reference Isometsa and Lonnqvist23}

We note, however, that other authors emphasise sociocultural beliefs and attitudes toward suicidal behaviour in explaining gender differences in suicide.^{Reference Turecki, Brent, Gunnell, O'Connor, Oquendo and Pirkis17,Reference Dahlen and Canetto24} For example, in Western countries, non-lethal suicidal behaviour is considered more socially acceptable for women than for men, but this may be different in non-Western countries.^{Reference Dahlen and Canetto24} High female suicide rates in countries like China^{Reference Turecki and Brent25} show that women's so-called low capability for suicide in Western countries may vary depending on the sociocultural context.

Capability, gender and psychiatric EAS

The above capability framework suggests a natural explanation of the gender gap in psychiatric EAS, and better conforms to the known literature on suicide than an explanation based on impulsivity. EAS is a painless and highly lethal method of death, which is professionally and socially approved in countries where it is legal. The important psychological components of capability involve the ability to face death and to enact something painful to one's own body.^{Reference Van Orden, Witte, Cukrowicz, Braithwaite, Selby and Joiner16,Reference Franklin, Hessel and Prinstein19} The latter barrier, for instance, is removed when someone receives EAS, as it does not involve pain or violence.

This finding is analogous to the well-known case in suicidology of high female suicide rates in rural China. This is attributed to men's and women's equal access to readily available, non-violent but highly lethal pesticides, as opposed to the less toxic analgesics and psychotropic medications commonly ingested in high-income countries.^{Reference Turecki, Brent, Gunnell, O'Connor, Oquendo and Pirkis17,Reference Schrijvers, Bollen and Sabbe18,Reference Turecki and Brent25,26} The case of rural China shows that mortality significantly increases when persons with a strong death wish have access to non-violent, lethal methods.

If the different gender distributions in suicide and psychiatric EAS are primarily accounted for by differences in capability, we should expect similar gender ratios between those who attempt suicide (as opposed to those who complete suicide) and persons receiving psychiatric EAS. And this is what we find. Men are two to three times more likely to die by suicide than women in most countries, including The Netherlands, whereas women are about twice as likely (2.1:1) to attempt suicide.^{Reference Kim, De Vries and Peteet3,Reference Turecki, Brent, Gunnell, O'Connor, Oquendo and Pirkis17,26,Reference Bernal, Haro, Bernert, Brugha, de Graaf and Bruffaerts27} The women:men ratio in psychiatric EAS (2.3:1) is virtually identical to that of those who attempt suicide, not those who complete it.

This suggests that the relationship between suicide and psychiatric EAS is not based the problematic concept of impulsivity. Rather, capability is more likely to explain why some patients resort to EAS rather than suicide. This suggests that patient profiles of people requesting and receiving psychiatric EAS could be more similar in terms of suicidal behaviour than previously assumed.^{Reference Kim, Conwell and Caine11} Persons with a strong death wish but low capability, who might not die if they attempt suicide, can achieve death if they use EAS instead.