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Bioethics ISSN 0269-9702 (print); 1467-8519 (online)


Volume 27 Number 7 2013 pp 402408

doi:10.1111/j.1467-8519.2012.01968.x

ATTITUDES TOWARDS EUTHANASIA AND ASSISTED SUICIDE:


A COMPARISON BETWEEN PSYCHIATRISTS AND OTHER PHYSICIANS

bioe_1968

402..408

TAL BERGMAN LEVY, SHLOMI AZAR, RONEN HUBERFELD, ANDREW M. SIEGEL AND
RAEL D. STROUS

Keywords
attitudes,
euthanasia,
psychiatrists,
physician assisted suicide

ABSTRACT
Euthanasia and physician assisted-suicide are terms used to describe
the process in which a doctor of a sick or disabled individual engages in an
activity which directly or indirectly leads to their death. This behavior is
engaged by the healthcare provider based on their humanistic desire to
end suffering and pain. The psychiatrists involvement may be requested in
several distinct situations including evaluation of patient capacity when an
appeal for euthanasia is requested on grounds of terminal somatic illness
or when the patient is requesting euthanasia due to mental suffering. We
compare attitudes of 49 psychiatrists towards euthanasia and assisted
suicide with a group of 54 other physicians by means of a questionnaire
describing different patients, who either requested physician-assisted
suicide or in whom euthanasia as a treatment option was considered,
followed by a set of questions relating to euthanasia implementation. When
controlled for religious practice, psychiatrists expressed more conservative
views regarding euthanasia than did physicians from other medical specialties. Similarly female physicians and orthodox physicians indicated
more conservative views. Differences may be due to factors inherent in
subspecialty education. We suggest that in light of the unique complexity
and context of patient euthanasia requests, based on their training and
professional expertise psychiatrists are well suited to take a prominent role
in evaluating such requests to die and making a decision as to the relative
importance of competing variables.

INTRODUCTION
Euthanasia and assisted suicide are terms used to describe
the process in which a doctor or a close relative of an
either sick or disabled individual (physically or mentally) engages in an activity which directly or indirectly
leads to the death of the individual. This behavior is
engaged by the relative or health care provider based on
their humanistic desire to end suffering and pain. Euthanasia is not a uniform procedure and reflects a variety
of attitudes and practices.1 Euthanasia terminology is
1

M. Manning. 1998. Euthanasia and physician assisted suicide: Killing


or caring? New York, Paulist Press; D.M. Sawyer, J.R. Williams, F.

complex but several terms have been used to describe


various forms of the process. These include active and
passive euthanasia whereby active euthanasia refers to
a positive act of commission what is being done to in
order to actively terminate life while passive euthanasia
refers to an act of omission some procedure/treatment
will be excluded in order to preclude elongation of the
patients life, which will eventually lead to death. Both
are carried out with the intent to end the patients life.2
The second approach envokes the concepts of voluntary
Lowy. Canadian Physicians and Euthanasia: 2. Definitions and Distinctions. Can Med Assoc J 1993; 148: 25631466.
2
Sawyer et al., op. cit. note 1.

Address for correspondence: Dr. Rael Strous, MD,Director Chronic Inpatient Unit Beer Yaakov Mental Health Center, PO Box 1, Beer Yaakov
70350, Israel. E-mail: raels@post.tau.ac.il
Conflict of interest statement: No conflicts declared
2012 John Wiley & Sons Ltd

Attitudes towards Euthanasia and Assisted Suicide


vs. involuntary euthanasia. Voluntary euthanasia refers
to the patients voluntarily request to end his or her life
while involuntary euthanasia refers to euthanasia decided
upon by the healthcare provider without any patient
request and involves a patient who may or may not have
the capacity to express such an opinion.3
These sensitive topics have evoked controversy
amongst professionals in the medical field and philosophers for generations. The dilemmas appear to stem from
an ongoing preoccupation of the medical profession with
death, the spectrum of which ranges from the enemy
which needs to be fought to the embracing of an inevitable aspect of the life continuum. The physician
dilemma encompasses several dimensions including the
legal and public aspect as well as professional, personal
and clinical. The legal domain refers to the relationship
between the act and potential criminality. For example
in most European countries current legislation regards
euthanasia or physician assisted-suicide as illegal acts
mandating punitive measures. The professional aspect
refers to the perception of the act. Should euthanasia be
considered a medical procedure and should it be an integral part of the medical discipline? If so, under what
conditions should this occur? The third dimension is the
private aspect which relates to the personal involvement
of the physician in the process. Should one himself or
herself become involved and if so, under what circumstances?4 All these are clearly questions of existential
medical ethics including exploring issues of the value of
life, the value of death and the value of the individuals
autonomy in any given society.
The relationship between psychiatry and euthanasia
is complex. The psychiatrists involvement may be
requested in several distinct situations. For example, an
appeal for euthanasia may be requested on the grounds of
terminal somatic illness. In this situation the psychiatrist
might be asked to evaluate the patients capacity to communicate his wish and understand fully the implications
and consequences of the request/decision.5 The impact of
the patients mental state as well as the contribution
of other psychosocial factors to this decision will also be
evaluated. In the Netherlands and Belgium, where legislation permits euthanasia, psychiatric evaluation is not
mandated by law which further complicates the picture.6
A different and less common situation that might
involve psychiatrists is a situation in which the patient is
requesting euthanasia due to mental suffering resulting

403

from mental illness. In Belgium and the Netherlands


legislation allows euthanasia due to mental suffering emanating from mental disorder. However in the
Netherlands only 3% of requests are due to mental
disorder and of these only 2% are approved. Most of
the requests are submitted by patients with affective
disorders. Upon approval, the psychiatrist as the treating
physician is expected to carry out the act of euthanasia/
assisted-suicide.7
In order to explore the phenomenon at a conceptual
level in Israel, in this study we conducted a survey to
explore attitudes of psychiatrists to euthanasia and
physician-assisted suicide and compared this data with
that of a group of physicians from a variety of other
medical subspecialties.

METHODS
Study population and design
For the purposes of this exploratory survey study, a
specially designed questionnaire was presented by two
members of the research team (TB and AS) at a number
of sites and settings including psychiatric hospitals and
general medical hospitals. All participants were Israeli
citizens currently employed by their respective hospitals.
Participants were requested to complete the form anonymously, in a voluntary fashion, and to submit it to the
researcher directly or by mail. Considering the sensitive
nature of the questionnaire and the setting in which it was
administered, the questionnaire was kept as short and
simple as possible in order to ensure confidentiality and a
high response rate.
The survey consisted of a statement explaining the
study, the voluntary nature of the questionnaire, as well
as the commitment to confidentiality. In addition to
demographics, such as age, gender, marital status, occupation and years of experience (calculated from first
year of residency), participants were also asked whether
they regarded themselves as secular/religious/ traditional Jewish or other. The study protocol and instrument was approved by the Beer Yaakov Mental Health
Center and Geha Mental Health Center ethical research
review committee (IRB).

Study questionnaire
3

Ibid.
4
J.R. Williams, F. Lowy, M. Sawyer. Canadian Physicians and
Euthanasia: 1. An Approach to the Issue. Can Med Assoc J 1993; 148:
12931297.
5
P.S. Appelbaum & T. Griso. Assessing Patients Capacity to Consent
to Treatment. New Eng J Med 1988; 319: 16351638.
6
K. Naudts, C. Ducatelle, J. Kovacs et al. Euthanasia, the Role of the
Psychiatrist. Br J Psychiatry 2006; 188: 405409.

2012 John Wiley & Sons Ltd

The study questionnaire included seven vignettes describing seven different patients who either requested
physician-assisted suicide or in whom euthanasia as a
treatment option was suggested for their condition (See
7

Ibid.

404

T. Bergman Levy, S. Azar, R. Huberfeld, A. M. Siegel and R. D. Strous

Appendix A). Each vignette was followed by a set of


similar questions relating to implementation of euthanasia in the particular case. The psychiatrists and physicians
were asked to rate their degree of response using a four
point Likert scale ranging from a definite disapproval to
definate approval.

Statistical analysis
Severity data were analyzed as ordinal (5-point scale) and
continuous (overall average). Routine sample descriptive
statistics were applied to the data. Dependence between
variables was tested using Pearson correlation coefficients, and 2x2 chi-square tests. The effects of profession
and sex were analyzed using t-tests, and Mann-Whitney
tests, as appropriate according to the variables nature.
Interactions between sex and profession were tested using
2x2 analysis of variance (ANOVA) models. Effect-sizes
(ES) were calculated using Cohens d method. The alpha
levels of .05 were kept, in order to consider all possible
relevant results as leads for further research.

RESULTS
Study sample
The sample included 103 subjects; all were physicians of
different subspecialties in medicine. Sex segregation was
59 males (58.4%) and 42 females (two cases had missing
data). The average age was 43.4 (SD = 10.6, range 2872
years), and the average number of years in practice was
15.3 (SD = 11.9, range 144 years). Most of the subjects
(n = 90, 91%) were married, 6 were single, 2 divorced and
1 a widower. With respect to level of religious affiliation,
most defined themselves as secular (n = 79, 78.2%), 12
were traditional, 8 orthodox, and 2 reported being atheists (2 cases had missing data). The group was divided
into two according to medical subspecialty: psychiatrists
(n = 49, 47.6%) and other subspecialties (n = 54, 52.4%).
Associations with background variables were tested. A
significant association was found between subspecialty
and level of religiosity (c2 = 12.8, df = 3, p = 0.005) with
lower rates of orthodoxy (0%) and the traditional (8.2%)
among psychiatrists compared to other medical subspecialties (15.4%, and 15.4%, respectively). In addition, psychiatrists were older (47.2) and more experienced (20.0)
compared to other medical subspecialties (40.1, 11.1
years, respectively) (t = 3.6, df = 99, p < 0.001; t = 4.0,
df = 100, p < 0.001, respectively). No associations were
found between subspecialty and gender or marital status.

Study questions
The reliability of items on the questionnaire was
tested within each vignette using internal reliability tests

(Cronbachs a coefficient), and was found to be satisfying (all alpha values greater than 0.8). The reliability of
items between vignettes was high, alpha = 0.96. Accordingly, the items within each vignette were summed up
for each subject. A higher sum indicated greater acceptance of euthanasia (i.e. a more liberal attitude). Similarly, a total score was computed for each subject based
on the seven case vignettes. The associations between
the vignettes as well as the total scores were all high and
significant.

Associations between study variables


1. Associations between subspecialty and scores of
case vignettes and total score were tested using
grouped t-tests. No significant association was
found (all p values >0.1). However, see 3 below for
analysis between medical specialties when orthodox
physicians excluded (orthodox physicians only in
non-psychiatrist group).
2. Associations between gender and scores were tested
using t-tests. Significant associations were observed
on vignettes 3 and 4 as well as the total score. This
was due to higher scores among men compared to
women. Gender by practice effects were tested using
2X2 ANOVA models. No significant gender by
speciality interaction was found.
3. Associations between level of religious affiliation
and scores were tested using one-way ANOVAs.
The analyses were performed following exclusion
of subjects who reported being atheists. Significant associations were found with all vignettes as
well as total score. These effects were due to significantly lower scores of orthodox participants, while
secular and traditional participants did not differ.
Because orthodox participants were all part of the
other subspecialties (none of whom were psychiatrists), it was impossible to test for interactions
of subspecialty and level of religious affiliation.
Therefore, the practice effect following the exclusion of orthodox participants (in this analysis
atheists were included) were re-analyzed. Significant
associations were observed on vignettes 4, 5 and the
total score. The scores of vignettes 4, 5 and total
score were lower among psychiatrists compared to
other subspecialties.
4. Associations between years of practice and scores
were tested using Pearson correlations. No significant association was observed.
5. Marital status was combined into married and
not-married. Associations were tested using t-tests.
No significant association was observed. The same
analysis was repeated following the omission of
orthodox participants but this also had no effect.

2012 John Wiley & Sons Ltd

Attitudes towards Euthanasia and Assisted Suicide

DISCUSSION
Observations indicate that when controlled for religious practice, psychiatrists participating in this study
expressed more conservative views regarding euthanasia
than did physicians from other medical specialties.
Overall, physicians who considered themselves religious
orthodox indicated more conservative views concerning
euthanasia in general compared to the subpopulation of
physicians who considered themselves either traditional
or secular. Similarly female physicians indicated more
conservative views on euthanasia compared to male
physicians. None of these associations were related to
age, seniority or marital status.
While these results are certainly interesting, our findings contrast those of Cohen et al.,8 who surveyed a
group of 938 physicians in the state of Washington for
their attitudes towards euthanasia and assisted-suicide.
In their study they noted attitudes of doctors to be polarized, with psychiatrists the most supportive of these two
practices. While the reason for the difference compared to
our study is not completely clear, it may be suggested that
the disparity is most likely due to inherent differences in
emphases in specialty education. Israeli psychiatrists are
nurtured in a professional environment with the specter
and shadow of the activities of the Nazi psychiatrists.
While all medical specialists have grown up in a country
whose foundations arose after the devastation and atrocities of the Holocaust and all citizens are well sensitized to
the scars of that period despite the 65 years or so elapsed,
psychiatrists are especially sensitized to this period. This
is given the central role of psychiatrists during this period
with respect to forced sterilization and euthanasia of the
mentally-ill by means of gassing, shootings, stabbings,
injections and starvation (considered the simplest method
at the time).9 During this time, psychiatrists made special
use of their power and expertise to carry out for the first
time in history mass extermination of their mentally-ill
patients. Thus it may be suggested that Israeli psychiatrists have more internalized the lessons of this period by
virtue of the nature of their patient population and professional activities. It is conceivable that their awareness
of what transpired during this time is very much etched
upon the consciousness of the Israeli psychiatrist by
means of due emphasis made on lessons gleaned from this
period during training and post training academic activities (research and clinical). This would form the basis of

J.S. Cohen et al. Attitudes toward Assisted Suicide and Euthanasia


among Physicians in Washington State. New Eng J Med 1991; 331:
8994.
9
R.D. Strous. Hitlers Psychiatrists: Healers and Researchers turned
Executioners and its Relevance Today. Harv Rev Psychiatry. 2006; 14:
3037.

2012 John Wiley & Sons Ltd

405

their conservative approach in medicine to euthanasia


and physician assisted-suicide as reflected in their study
questionnaire responses.
Nevertheless, at least one other study similarly found
more conservative attitudes to euthanasia among psychiatrists. Results from a Norwegian study suggested
that since psychiatrists only have relatively limited professional contact with terminally-ill patients, their lack
of experience with such circumstances allows them a
certain distance and disconnect associated with a more
conservative outlook.10 However this distance could also
have had the opposite effect leading to a more extremist
approach to euthanasia specifically in light of the rare
possibility of coming in to contact with any such situation. Further empiric investigation would be required in
order to substantiate any of these speculations.
In the Netherlands, apart from special situations,
euthanasia and physician assisted-suicide are forbidden
by law. In the event that the physician feels the need to
relieve the patient from unbearable suffering that shows
no hope of improving in the future, the physician is
required to follow various guidelines set out by the Dutch
Medical Association.11 This would relate directly to the
decision and to the prognosis under the circumstances.
With regard to decision related issues, the choice has to
be voluntary, to be arrived at independently after rationally considering the issues and to be without any undue
influence by any other parties. In addition, it is required
that all relevant and significant information, medical
or other, be taken into context by the patient making the
decision. The decision needs to be consistent and not on
the spur of the moment or spontaneous. This would be
especially in the case of extreme pain when the context
of time may be seen as less important. Prognosis related
factors would permit euthanasia under certain circumstances particularly if there was no possible appropriate
medical cure available, within an appropriate time.
While these above criteria may be appropriate for
general medical practice, they become vague in the field
of psychiatry. The very concepts of autonomy and voluntariness in the context of psychiatric illness engender
difficult ethical and philosophical questions. It could also
be possible that preoccupation by psychiatrists regarding
failed treatment for depression (leading to suicide) may
also have resulted in such a conservative approach to
physician assisted-suicide. Indeed, in a study that surveyed the matter of euthanasia in clinical psychiatry
practice in Holland, it was found that the percentage of
10
R. Frde, O.G. Aasland & E. Falkum. The Ethics of Euthanasia
Attitudes and Practice among Norwegian Physicians. Soc. Sci. Med.
1997; 45: 887892.
11
R.A. Schoevers, F.P. Asmus & W.V. Tilburg. Physician Assisted
Suicide in Psychiatry: Developments in the Netherlands. Psychiatric
Serv 1998; 49: 14751480.

406

T. Bergman Levy, S. Azar, R. Huberfeld, A. M. Siegel and R. D. Strous

permission of euthanasia in psychiatry practice was 2%


compared to that of 37% average amongst the general
medical community.12
The clinical psychiatrist in many instances has to deal
with issues of suicidality, how to prevent it, how to identify it and how to manage it. A more permissive attitude
toward euthanasia and doctor assisted-suicide may be
seen by a subset of psychiatrists as cooperation with the
suicide act. Alternatively it may be seen as professional
failure or admission of the limitations of the field in preventing the patient from coming to such consideration of
request for assistance in suicide. It is thus conceivable
that the psychiatry profession is required to maintain a
more rigid approach to these issues and take into consideration how it would appear to the non-psychiatrist community member if the psychiatrist were more indulgent in
approaches to these matters.
A patients request for assisted-suicide is most likely to
be heavy with meaning over and above the concrete
content of the request. These factors include the presence
of depression which reflects the patients frustration and
despair, feelings of guilt in the treatment provider over
failing to prevent progression of his patients illness,
thoughts of failure within the patient for not having
cured himself and thus not being able to satisfy the
physicians wish for clinical improvement, (along with)
anxiety and panic in the face of a painful illness and likely
death.13 All of these deep seated sentiments may exist in
varying degrees among patients and at varying levels of
subconscious or conscious awareness. The question arises
to what extent non-psychiatrist physicians are trained in
the discernment and understanding of these subtle messages and whether they are well enough informed and
competent in order to identify the role that these often
subtle messages play in the patients request and all
the associated factors of transference and countertransference that may accompany the process. It may be
suggested that, based on their training and professional
expertise, psychiatrists are best suited as a group in order
to take a prominent role in evaluating such requests to
die and making a decision as to the validity and extent
of complicating variables under the circumstances. This
would extend to an evaluation of the capacity of the
patient to make such a decision. Even in countries where
there is no law allowing physician assisted-suicide, for the
physician such a request should be a red light demanding
a psychiatric evaluation with sensitivity to an understanding of the patients suffering and despair, which in
turn need appropriate attention and management. Under
such circumstances, it would be fitting for the psychiatrist

to be skeptical of a patients desire to die rather than


automatically accepting and cooperating with the
patients request for assisted suicide.
Other variables which may be associated with
doctors views on euthanasia were also explored in this
study, namely the influence of gender and religion on
physicians views. These factors have been investigated
by others and have demonstrated a range of findings.
Some have noted no significant influence of gender on
physician euthanasia views14 while others, similar to our
observations, have noted that females tend to be less
supportive of euthanasia.15 The findings in this study
with respect to the role religion plays in views on euthanasia reflect those found by others16 who investigated
opinions of Jewish physicians regarding end-of-life care
in four hospitals in Israel. They too noted that physicians who defined themselves as religious were far less
likely to be supportive of euthanasia (both permitting
and carrying out the procedure). It is conceivable that
there is a close connection between basic assumptions of
Judaism, the duties of a physician and the value of life,
all of which may significantly influence views on euthanasia and physician-assisted-suicide in a conservative
direction.
Limitations of the study include the sample size, which
while not insignificant, may yield further information
given a larger sample size including valuable data. It
remains difficult to survey all physicians and it is most
possible that those with the strongest views in favor of
euthanasia did not participate out of fear of professional
rejection or shame, notwithstanding the fact that the
study was anonymous.
It may be suggested that we live in an era far distant to
that of the Nazi period and that the risks of involuntary
euthanasia are negligible. Findings from our study
suggest that the issue is far from one of consensus across
specialties and associated with differences in gender and
level of religious affiliation. Attention to patient and physician attitudes on this subject is required at the level
of medical education both during formal studies and
post-medical school continued medical education. With
an aging and increasingly financially strapped medical
system together with a more permissive, open and patient
oriented autonomy-based medical approach, it is conceivable that these issues are going to become of even
more importance in the contemporary dialogue of
medical practice in the near future.

14

Forde et al., op. cit. note 10.


J. Ramirez-Rivera, J. Cruz & F. Jaume-Anselmi. Euthanasia,
Assisted Suicide and End of Life Care: Attitudes of Student, Residents
and Attending Physicians. PRHSJ 2006; 25: 325329.
16
N.S. Wenger & S. Carmel. Physicians Religiosity and End of Life
Care Attitudes and Behaviors. Mt Sinai J Med 2004; 71: 335343.
15

12

J.H. Groenewoud et al. Physician-Assisted death in Psychiatric Practice in the Netherlands. New Eng J Med 1997; 336: 17951801.
13
P.R. Muskin. The Request to Die. JAMA 1998; 279: 323328.

2012 John Wiley & Sons Ltd

Attitudes towards Euthanasia and Assisted Suicide

APPENDIX A: VIGNETTES DESCRIBING


PATIENTS WHO EITHER REQUESTED
PHYSICIAN-ASSISTED SUICIDE OR IN
WHOM EUTHANASIA AS A TREATMENT
OPTION WAS SUGGESTED
Vignette 1
The first vignette refers to a patient with locked in
syndrome. The patient is not able to move or breathe
without the assistance of machine ventilation. He can
communicate his wishes using special computer-assisted
eye movement translation. The patient asks his doctor to
disconnect him from the ventilator and to assist him in
dying. The physicians are asked to answer the following
questions:
1. If this was legal would you have approved disconnecting this patient from the ventilator? If you had
the legal option would you approve of the act?
2. Would you perform it yourself ?
3. If you had been in the same situation as the patient
would you have asked to be disconnected?
4. Do you share the opinion that for cases such as these
euthanasia should be legal?

Vignette 2
The second vignette concerns a patient with Amyotrophic Lateral Stenosis(ALS) in an advanced phase of the
disease (complete paralysis, obvious breathing difficulties
however prior to required ventilation). The patient asks
his doctor not to connect him in the future to a ventilating
machine when required but rather to let him die.
1. If this was a legal option would you approve the
patients request?
After a month the patient was admitted and he now
breaths only with the assistance of a ventilator. He asks
the physician to disconnect him from the machine and let
him die. You are then asked:
1. If you had the legal option would you approve of the
act?
2. Would you perform it yourself ?
3. If you had been in the same situation as the patient
would you have asked to be disconnected?
4. Do you share the opinion that for cases such as these
euthanasia should be legal?

407

medication and opiates. The woman and her family ask


the doctor to help her die and end her misery.
1. If this was legal would you have approved this
patient request?
2. Would you perform it yourself?
3. If you had been in the same situation as the patient
would you have made the same request?
4. Do you share the opinion that for cases such as these
euthanasia should be legal?

Vignette 4
The fourth vignette refers to a preterm 24 week-old
neonate. He was diagnosed as having Tay-Sacks disease.
(genetic disease with death usually by age of 5). Due to
premature labor the lungs of the newborn are underdeveloped and requires assistance of a ventilator to breath.
The newborn parents request of the doctor not to
lengthen their childs life unnecessarily.
1. If it was legal would you approve the parents
request?
2. If this newborn was already on a ventilator would
you approve disconnecting the ventilator?
3. Would you perform this yourself?
4. If you were the parent would you have asked to do
the same?
5. Do you share the opinion that for cases such as these
euthanasia should be legal?

Vignette 5
The fifth case refers to a an 80-year-old man with severe
mental retardation who has been living all his life in
institutions. Due to severe retardation he never speaks
however his suffering is notable. Recently he had been
frequently hospitalized due to anemia stemming from
inoperable stomach cancer. He is fed by a nasogastric
tube. His caretakers state that he does not understand
what is happening around him and that he should be
helped to die. The physician is asked:
1. If it was legal would you approve this request?
2. Would you perform this yourself?
3. If you were the patient would you have asked to be
euthanized?
4. Do you share the opinion that for cases such as these
euthanasia should be legal?

Vignette 3

Vignette 6

The third vignette refers to a terminally ill woman with


breast cancer (with multiple bone metastasis). She suffers
from severe pain in spite being treated with sedating

The sixth case refers to an 80-year-old man who lives in


an old age institution and is in dire need of constant
supportive care. He is hospitalized often due to anemia

2012 John Wiley & Sons Ltd

408

T. Bergman Levy, S. Azar, R. Huberfeld, A. M. Siegel and R. D. Strous

stemming from inoperable stomach cancer and is fed by


a nasogastric tube. He is coherent, oriented to time and
place, presents no cognitive disability and is aware of his
medical condition and its implications. He is fully capable
of communicating his wishes. This patient explains to his
doctor that he suffers tremendously and does not want
to continue his life in his present condition. He therefore
asks his doctor to assist him to die.
1. If it was legal would you approve this request
2. Would you perform this yourself?
3. If you were the patient would you have asked to be
euthanized?
4. Do you share the opinion that for cases such as these
euthanasia should be legal?

Vignette 7
The final vignette presents the case of a 65 year-old
patient who is diagnosed with chronic paranoid schizophrenia. Although the patient is compliant, his illness is
treatment-resistant. States of complete remission characterized by normal reality testing exist rarely, however
are accompanied by good judgment and complete insight
to the disease. In these relative healthy mental states he
expresses severe emotional suffering due to his illness.
The patient requests his doctor to assist him to die since
he claims not to have strength to cope with the disease,

feels that he is a burden to his family and that the psychiatric profession cannot assist him.
1. If it was legal would you approve this request?
2. Would you perform this yourself?
3. If you were the patient would you have asked to be
euthanized?
4. Do you share the opinion that for cases such as these
euthanasia should be legal?

Tal Bergman-Levy MD is a senior psychiatrist working in an acute


psychiatry ward at the Beer Yaakov Mental Health Center. She specializes in issues of forensic psychiatry and ethics in psychiatry.
Shlomi Azar is a social worker who heads the Hostel for psychiatrically
ill survivors of the Holocaust located on the campus of the Beer Yaakov
Mental Health Center in central Israel. He has a Masters in Social
Work.
Ronen Huberfeld MD is a recently qualified psychiatrist working in an
acute psychiatry ward at the Beer Yaakov Mental Health Center.
Andrew M. Siegel MD is a resident in psychiatry currently based at the
Perelman School of Medicine, University of Pennsylvania.
Rael Strous is an associate professor of psychiatry at the Sackler
Faculty of Medicine, Tel Aviv University. In addition he is the
Director of the chronic inpatient unit at the Beer Yaakov Mental
Health Center. He has published on the subjects of psychiatric genetics,
psychopharmacology. He has published on the subjects of psychiatric
genetics, psychopharmacology, neuroimaging and ethics.

2012 John Wiley & Sons Ltd