Medical assistance in dying (MAID) – defined as voluntary euthanasia and/or physician-assisted suicide – for people with a terminal illness is becoming available in more jurisdictions around the world. By contrast, MAID in people with a non-terminal illness and, more specifically, in people with a psychiatric disorder remains a controversial topic.

Belgium is one of the very few countries where euthanasia for unbearable mental suffering caused by a psychiatric disorder is allowed. According to the 2002 Belgian Euthanasia Law, the eligibility criteria are: a) the euthanasia request is made by a legally competent adult patient; b) the request is voluntary, repeated, well-considered, and not the result of external pressure; c) the patient is in a medical condition without prospect of improvement; d) the patient experiences constant and unbearable mental suffering that cannot be alleviated; and e) the suffering is the result of a serious and incurable psychiatric disorder. To assess the fulfilment of these criteria, the attending physician must consult two independent physicians, including a psychiatrist. At least one month should pass between the date of the patient's request and the performance of euthanasia. After the euthanasia is performed, the attending physician must report this to the Federal Control and Evaluation Commission for Euthanasia, which is tasked with the a posteriori control^{1, 2}.

According to the official data in 2020, MAID accounted for 1.9% of all deaths in Belgium. Between 2002 and 2021, a total of 370 patients received euthanasia for unbearable mental suffering caused by a psychiatric disorder. This corresponds to 1.4% of the total number of euthanasia cases, although in recent years the incidence slightly decreased to between 0.9 and 1%. The most common diagnoses (data on 2002-2019, N=325) were mood disorders (55.7%) and personality disorders (19.4%), followed by psychotic disorders (6.2%), anxiety disorders and post-traumatic stress disorder (6.2%), autism spectrum disorder (4.6%), eating disorders (1.5%), and other and/or combination of disorders (6.5%).

Recently, the fundamental rights compliance of the Belgian Euthanasia Law, as applied to euthanasia for mental suffering caused by a psychiatric disorder, was scrutinized in two ground-breaking court decisions^{3, 4}.

In the first of these, the European Court of Human Rights examined whether a euthanasia of a 64-year-old woman with treatment-resistant depression and a personality disorder had violated the state's responsibility to protect her right to life, as well as the right to respect for private and family life of her son, who had only been informed about the euthanasia after it had been performed³.

The Court held that the Belgian legal framework governing euthanasia for mental suffering caused by a psychiatric disorder complied with the conditions set out in an earlier case law on end-of-life decisions. More specifically, it was argued that the Belgian law contains a procedure that can guarantee that a euthanasia request is voluntary. In addition, as required for MAID concerning particularly vulnerable persons, the law provides for increased protective measures for euthanasia in people with mental suffering. In this regard, the Court noted the importance of the obligation to consult two independent physicians, including one psychiatrist, as well as to observe a waiting period.

By contrast, the Court still found a human rights violation in the way the a posteriori control of euthanasia was regulated. In the case at hand, the physician who had performed the euthanasia was the chair of the Federal Commission. Since in monitoring the legal compliance of that case of euthanasia the Commission had relied completely on the anonymous part of the registration document, the chair had inadvertently taken part in approving the euthanasia case without anyone having noticed his involvement. However, as this monitoring should be independent, reporting should not be anonymous if physicians involved in euthanasia are allowed to sit on the Commission³.

In the second case, the Belgian Constitutional Court was petitioned by a judge who was looking into the liability of a physician who had performed the euthanasia of a 38-year-old woman with a personality disorder^1-4. As in previous rulings, the Court confirmed that the Euthanasia Law and its constituting elements and safeguards do not violate the constitution. Since the Belgian Euthanasia Law does not contain any sanctions, the Court was asked to shed light on the penalties that should apply. In accordance with the general provisions of the Criminal Code, any infraction, even of an administrative nature, could be considered murder by poisoning. The Constitutional Court held that this would be disproportionate for the physicians involved in euthanasia, as they would run the risk of being convicted for murder even for infringing upon a legal condition of minor importance. Ruling that this violated the principles of non-discrimination and equality, the Court instructed the Belgian legislature to diversify the applicable system of penalties, with lighter penalties for violations of procedural conditions that are less important to guarantee the fulfilment of the eligibility criteria.

The evaluation of a request for MAID in the context of a psychiatric disorder is clinically challenging. First, the assessment of the decisional capacity of psychiatric patients who request MAID may be more complex than for other patients^{1, 2, 5}. It is emphasized by opponents of MAID in people with a psychiatric disorder that their competence can be severely impacted by the illness^{1, 6, 7}. Although a cautious approach is therefore necessary, there is no reason to presume that people with a psychiatric disorder cannot possess the required decisional capacity. This capacity should be assessed case by case and held to a high standard, considering the nature and possible consequences of the request. In this light, it is highly advisable to conduct a formal evaluation of the capacity of psychiatric patients who request MAID.

Second, there is no consensus or authoritative guidance on how to define or measure unbearable mental suffering^{1, 7, 8}. This entails a risk that unbearable mental suffering is too readily accepted. Although treatment refractoriness is a clinical reality, MAID should only be considered after all reasonable biological, psychological, social and recovery-oriented treatment options have failed. When a patient refuses such treatments, this should not lead physicians to conclude that the mental suffering cannot be alleviated and the psychiatric illness is without prospect of improvement. Hence, the request for MAID should not be granted.

In 2017, the Flemish Society of Psychiatry published recommendations to guide clinicians in these difficult decisions⁷. They recommend following a two-track approach in the evaluation of a euthanasia request by a psychiatric patient. One track should examine the fulfilment of the eligibility criteria. Importantly, it is suggested to always involve at least two psychiatrists, who preferably are experts of that specific psychiatric disorder. In the second track, the psychiatric patient should be actively supported in exploring all remaining therapeutic and recovery-based options. This two-track approach combines respect for the autonomy of the patient with the obligation to protect that person's right to life. It implies that, while the euthanasia request is being assessed, the psychiatric patient continues treatment and his/her psychiatrist remains involved.

These recommendations inspired the Belgian Order of Phy-sicians to adopt more stringent deontological standards for physicians who consider a euthanasia request from a psychiatric pa-tient. These physicians are now obliged to comply with additional due care criteria: at least two of the three physicians involved should be psychiatrists; the physicians should come to a jointly formulated opinion about the fulfilment of all due care criteria; euthanasia should not be performed unless all reasonable treatment options have been tried and failed; and patients should be encouraged to involve their relatives in the euthanasia procedure. Combined, the legal and deontological due care criteria help ensure that a euthanasia request for mental suffering caused by a psychiatric disorder is appropriately addressed.

世界上越来越多的司法管辖区正在为患有绝症的人提供死亡医疗援助 (MAID)——定义为自愿安乐死和/或医生协助自杀。相比之下，MAID 对于非绝症患者，更具体地说，对于精神疾病患者来说仍然是一个有争议的话题。

比利时是极少数允许对精神疾病造成的难以忍受的精神痛苦实施安乐死的国家之一。根据2002年比利时安乐死法，资格标准是： a) 安乐死请求由具有法律能力的成年患者提出； b) 该请求是自愿的、重复的、经过深思熟虑的，而不是外部压力的结果； c) 患者的健康状况没有改善的希望； d) 患者遭受持续的、难以忍受的、无法缓解的精神痛苦； e) 痛苦是由严重且无法治愈的精神疾病造成的。为了评估是否满足这些标准，主治医生必须咨询两名独立医生，包括一名精神科医生。从患者提出要求到实施安乐死之间至少要经过一个月。安乐死实施后，主治医生必须向联邦安乐死控制和评估委员会报告，该委员会负责事后控制^{1, 2} 。

根据2020年官方数据，MAID占比利时所有死亡人数的1.9%。 2002年至2021年间，共有370名患者因精神疾病造成难以忍受的精神痛苦而接受安乐死。这相当于安乐死病例总数的 1.4%，尽管近年来发生率略有下降至 0.9% 至 1% 之间。最常见的诊断（2002-2019年数据，N=325）是情绪障碍（55.7%）和人格障碍（19.4%），其次是精神障碍（6.2%）、焦虑症和创伤后应激障碍（6.2%） ）、自闭症谱系障碍（4.6%）、饮食失调（1.5%）以及其他和/或多种疾病的组合（6.5%）。

最近，两项开创性的法院判决^3、4仔细审查了比利时安乐死法（适用于因精神疾病造成的精神痛苦而实施安乐死）的基本权利合规性。

在第一个案件中，欧洲人权法院审查了对一名患有难治性抑郁症和人格障碍的 64 岁妇女实施安乐死是否违反了国家保护其生命权以及权利的责任。为了尊重她儿子的私人和家庭生活，她儿子是在安乐死实施后才得知的³ 。

法院认为，比利时关于因精神疾病造成精神痛苦而实施安乐死的法律框架符合早期关于临终决定的判例法中规定的条件。更具体地说，有人认为比利时法律包含一个可以保证安乐死请求是自愿的程序。此外，根据《MAID》对特别弱势群体的要求，法律规定加强对精神痛苦者实施安乐死的保护措施。在这方面，法院指出咨询两名独立医生（包括一名精神科医生）以及遵守等待期的义务的重要性。

相比之下，法院仍然认为对安乐死事后控制的监管方式侵犯了人权。在本案中，实施安乐死的医生是联邦委员会主席。由于委员会在监督该安乐死案件的法律遵守情况时完全依赖登记文件的匿名部分，因此主席无意中参与了安乐死案件的批准，而没有人注意到他的参与。然而，由于这种监测应该是独立的，如果参与安乐死的医生被允许担任委员会成员³ ，那么报告不应是匿名的。

在第二起案件中，一名法官向比利时宪法法院提出请愿，该法官正在调查对一名患有人格障碍的 38 岁女性实施安乐死的医生的责任^1-4 。与之前的裁决一样，法院确认《安乐死法》及其构成要素和保障措施不违反宪法。由于比利时安乐死法不包含任何制裁措施，因此要求法院阐明应适用的处罚措施。根据《刑法》的一般规定，任何违法行为，即使是行政性质的违法行为，都可以被视为投毒杀人。宪法法院认为，这对于参与安乐死的医生来说是不成比例的，因为即使是违反了次要的法律条件，他们也将面临被判谋杀罪的风险。法院裁定这违反了非歧视和平等原则，指示比利时立法机构使适用的处罚制度多样化，对违反对保证满足资格标准不太重要的程序条件的处罚较轻。

在精神疾病的背景下评估 MAID 请求在临床上具有挑战性。首先，对请求 MAID 的精神病患者的决策能力的评估可能比其他患者更复杂^1,2,5 。 MAID 的反对者强调，患有精神疾病的人的能力可能会受到疾病的严重影响^1,6,7 。因此，尽管采取谨慎的态度是必要的，但没有理由认为患有精神疾病的人不具备所需的决策能力。应根据具体情况评估这种能力，并保持高标准，同时考虑请求的性质和可能的后果。有鉴于此，强烈建议对请求 MAID 的精神病患者的能力进行正式评估。

其次，对于如何定义或衡量难以忍受的精神痛苦，尚无共识或权威指导^1,7,8 。这就带来了一种风险，即难以忍受的精神痛苦太容易被接受。尽管治疗难治性是临床现实，但只有在所有合理的生物、心理、社会和康复治疗方案均失败后才应考虑 MAID。当患者拒绝此类治疗时，医生不应得出这样的结论：精神痛苦无法减轻，精神疾病没有改善的希望。因此，MAID 的请求不应被批准。

2017 年，佛兰德斯精神病学协会发布了建议，指导临床医生做出这些困难的决定⁷ 。他们建议在评估精神病患者的安乐死请求时采用双轨方法。其中一项应检查是否满足资格标准。重要的是，建议至少有两名精神科医生参与，他们最好是该特定精神疾病的专家。在第二个轨道中，应积极支持精神病患者探索所有剩余的治疗和基于康复的选择。这种双轨方法将对患者自主权的尊重与保护患者生命权的义务结合起来。这意味着，在评估安乐死请求的同时，精神病患者将继续接受治疗，并且他/她的精神病医生仍然参与其中。

这些建议促使比利时医师协会对考虑精神病患者安乐死请求的医生采取更严格的义务论标准。这些医生现在必须遵守额外的应有注意标准：所涉及的三名医生中至少有两名是精神科医生；医生应就所有应有护理标准的履行情况达成共同意见；除非尝试了所有合理的治疗方案并失败，否则不应实施安乐死；应鼓励患者让其亲属参与安乐死程序。法律和义务论的应有护理标准相结合，有助于确保因精神疾病造成的精神痛苦而提出的安乐死请求得到适当处理。