Guest post by Jeff Kirby (Professor, Department of Bioethics, Faculty of Medicine, Dalhousie University).
Many members of the international public were surprised and/or shocked to hear that Frank Van Den Bleeken, an incarcerated murderer-rapist, was scheduled to be euthanized in Belgium over the weekend. The issue has been in the news since last September when the Belgian Federal Euthanasia Commission accepted Van Den Bleeken’s application for euthanasia, and an Appeals Court in Brussels approved a deal that enabled his transfer from prison to a medical clinic where the procedure was to be performed. For about the last twenty years, Van Den Bleeken has been living in a ‘regular’ prison in Bruges, where he was admitted after his second set of sexual assault offenses.
It may be interesting to briefly explore and unpack the reasons why there has been such a public outcry about Van Den Bleeken’s scheduled euthanasia. In my view, some of these reasons are related to the divergence in Van Den Bleeken’s circumstances from those of the paradigm circumstances in which euthanasia is usually performed. Another factor appears to have more to do with prevailing, discriminatory attitudes toward persons who are imprisoned while living with significant mental illness.
There is a particular set of circumstances in which assisted dying practices, such as continuous deep sedation, assisted suicide and euthanasia, are typically considered and performed. The person is usually suffering from some form of physical-health-based, terminal illness which is expected to end her/his life within a few weeks. He/she is suffering from intractable profound/unbearable suffering that has proven to be refractory to a set of standard acute and palliative care treatment modalities that have been consented to by the patient. The distress experienced by the patient is most often primarily physical in nature, although it is not unusual for there be secondary, co-mingled and interacting psychological and socio-relational distress elements.
Van Den Bleeken’s circumstances differ from these paradigm assisted death circumstances in a variety of ways. It has been reported that his underlying medical illness is psychiatric, i.e., presumably some form of severe paraphilic disorder, and that his suffering is primarily psychoexistential in nature. From a psychological health perspective, his current life circumstances are very grim – he spends most of his time alone in his prison cell. He recognizes that he will not be released into the community (and, reportedly, he does not desire this due to his personal fear of reoffending). The quality of his imprisoned life is likely to be further degraded by his status as a member of several, intersecting, oppressed social groups, i.e., persons with severe and persistent psychiatric illness, persons who are incarcerated for sexual assault crimes, persons with childhood sexual trauma (a reported component of Van Den Bleeken’s clinical history), etc. His day-to-day, lived experience is likely consistent with three of Iris Marion Young’s ‘faces of oppression’: marginalization, powerlessness and violence. It is not very difficult to imagine that a person in Van Den Bleeken’s circumstances could be experiencing profound/unbearable psychoexistential distress. Although this type of suffering is more difficult to evaluate and quantify than physical distress, one could argue that ‘self-perceived unbearable suffering’ is ‘self-perceived unbearable suffering’, regardless of the underlying primary etiology. Such a view is consistent with the WHO’ definition of health – “a state of … physical, mental and social well-being” and its description of palliative care as a therapeutic approach that aims to enhance quality of life “through the prevention and relief of suffering by means of early identification … assessment and treatment of pain and other problems, physical, psychosocial and spiritual.”
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Another significant divergence from paradigm assisted death circumstances of relevance to the ‘consequences domain’ is Van Den Bleeken’s projected survival without euthanasia intervention. He is 52 years old and it has been reported that he is not suffering from an identified terminal or chronic disabling physical illness. One of the perceived ‘bad effect’ consequences of legalized assisted dying practices (that require the direct engagement and agency of healthcare providers) is hastening of death. When life could potentially be foreshortened by years or decades (as opposed to a few days or weeks), this can appear to many to be a pretty big deal. Form a ‘proportionality’ perspective, because of the extended life expectancies in scenarios such as that of Van Den Bleeken, it is more difficult in to support a claim that euthanasia constitutes an appropriate, proportional response to the experience of profound suffering in the ‘here and now’. However, Van Den Bleeken’s circumstances do meet the criteria set out in Section 3 of The Belgian Act on Euthanasia – he is an adult with the capacity to make his/her own decisions “in a medically futile condition of constant and unbearable physical or mental suffering that cannot be alleviated, resulting from a serious and incurable disorder caused by illness or accident” (lack of proximity to anticipated ‘natural death’ does not preclude successful application for euthanasia in Belgium). By Benelux country standards, Van Den Bleeken’s euthanasia would not constitute a (North American dreaded) ‘slip’ in the legally-recognized indications for an assisted death.
Another reason for the public’s negative response to the news of Van Den Bleeken’s potential euthanization is the view of some that his assisted death would unfairly shorten/mitigate the punishment for his serious crimes. The sisters of Van Den Bleeken’s initial victim have reported to media sources that they would prefer that he languish indefinitely in prison. However, it seems to me that society’s needs for punishment and a deterrent to others in the face of a terrible crime (if there is any such need at all for someone who was deemed ‘not criminally responsible’ for the initial murder-rape) have already been met through Van Den Bleeken’s prolonged incarceration. The reason he remains in prison is to protect societal members from his possible, future criminal actions as a free agent. This legitimate need for societal protection/safety can be equally met by further, indefinite incarceration or (a self-chosen) death.
Perhaps the public should be outraged by Van Den Bleeken’s circumstances for a different reason – the fact that he has not been provided with appropriate forensic psychiatric services for the past two decades. Human rights advocates have recognized and recently drawn needed attention to this injustice. The related negative publicity is likely the primary reason why Belgian’s Justice Minister interceded last week to revoke Van Den Bleeken’s application for euthanasia and arrange for him to be transferred from Bruges to a new, ‘short stay’ forensic psychiatric centre in Ghent. Transfer to an appropriate, specialized facility in the Netherlands, which had originally been requested by Van Den Bleeken, has the potential to unfavourably highlight the current lack of comprehensive forensic psychiatric services in Belgium.
Although the public’s negative reaction to this sensational ‘euthanasia-in-the-news’ event is understandable, further consideration of, and reflection on, the relevant complex factors and challenging context could change the minds of some about the moral status of euthanasia in these particular circumstances – it certainly has mine.
There’s a good reason he probably shouldn’t be eligible for euthanasia or assisted dying. He’s likely perfectly capable of killing himself – provided access to the means and a bit of privacy. Why involve third parties when suicide is both legally and ethically less problematic? I don’t believe any decision made while under a prison regime can confidently be assumed to be uncoerced.
There are no appropriate prison based psychiatric services for sex offenders if by ‘appropriate’ you mean ‘can be shown to be effective in reducing recidivism’. The reoffending rate for most kinds of sex offenders is quite low anyway.
In Australian prisons sex offender programs are mostly used to add to the punishment regime. They are often unavailable or interrupted but are needed for parole. They can be quite personally abusive and those who administer them are often just as hostile towards sex offenders as are guards and other prisoners. They’ve never been shown to substantially reduce reoffending rates.
A lot of forensic psychiatry and psychology in prisons is abusive. The practitioners don’t often see their patient as the client; rather they work for the state protecting the public from their patients. Their tools for predicting dangerousness are almost completely useless and their ‘therapies’ are often more about prison management than patient care.
Forensic psychiatrists aren’t part of the medical profession. They’re part of the security state.
Thanks for your comments, ‘cabrogel’.
I offer a few brief responses:
1) It cannot be assumed that Mr. Van Den Bleeken has access to the necessary means to commit suicide in his present circumstances.
2) I agree that informed choice is often compromised by dire/extremis circumstances, but there is no obvious way to mitigate all coercive elements in this context. Rather than precluding all personal decision making on the basis of such influence, I think that incarcerated individuals with capacity should have the opportunity to make some meaningful choices in their highly- constrained lives, including the initiation of a request for consideration of an assisted death.
3) Good psychiatric care for persons living with paraphilic disorders is not all about prevention of recidivism. It is also possible (and probable) that individuals in Mr. Van Den Bleeken’s circumstances have psychiatric co-morbidities, e.g., PTSD secondary to their own childhood sexual trauma, that may respond to psychotherapeutic and/or psychopharmacological interventions.
4) All psychiatists (and other psychiatric healthcare providers) have mutiple responsibillities and competing obligations that they are challenged to balance as best they can. Respect fot the self-determination of their patients and the duty to maintain confidentially of personal healh information often collide with their obligations to protect both their patients and the public.
1) Nor can it be assumed he currently has access to assisted suicide. I am suggesting he be given such access in preference to being given euthanasia. More to the point I’m suggesting his right to commit suicide should be restored before considering his right to be helped to do it.
2) The legislation surrounding euthanasia originally emphasised capacity for free choice. Since then it has been eroded to the point where those legally assumed to be unable to exercise it – such as the psychotically ill and the demented – have been allowed to ‘choose’ suicide. The issue here isn’t just a question of individual consumer choice, it’s whether we want to abandon the semblance of protection against coercive euthanasia of the institutionalised and disempowered. It would be very easy to keep prison numbers down if it was just a matter of ensuring prisoners didn’t want to live.
3) Quite possible. But are you suggesting that treating them is likely to imbue Mr Bleeken with the desire to go on under his current circumstances? Either his suicidality is a symptom of mental illness – in which case we shouldn’t be helping it to kill him – or it’s not, in which case all the therapy in the world will change nothing unless it can change his life circumstances, say, by making him fit for release.
4) Indeed they do. My comment didn’t come from some theoretical assessment of the overlapping responsibilities of mental health care providers. It came from years of experience in prison advocacy involving over a dozen cases of imprisoned sex offenders complaining about their ‘therapy’. It also came from multiple meetings with prison forensic psychiatrists, including sharing forums with them at mental health conferences. Their tools are generally ineffective and their attitudes towards their patients generally hostile. They are far more likely to harm than help their patients. The best way to avoid forced drugging with antipsychotics in prison is to tell a prison doctor you need antipsychotics.