In 2020, the Federal Constitutional Court ruled that people have the right to make self-determined decisions about their death. Regardless of mental illness or other illnesses. To do this, they are allowed to enlist the voluntary help of others. However, only if this is done “freely and responsibly”, as the Federal Constitutional Court put it.
How should health and social care professionals respond when people express a desire for assisted suicide? Since the Federal Constitutional Court only provided the framework for this decision in its ruling, recommendations for concrete implementation were necessary. That's why more than 30 professional societies have worked together and published the new guidelines for dealing with requests for suicide assistance.
Criteria for free responsibility
The new guidelines therefore focus on 45 criteria that the interdisciplinary specialist societies have developed. They are intended to ensure that the desire to commit suicide actually came about in a “self-determined and freely responsible manner,” as the Federal Constitutional Court formulated it in its 2020 ruling.
To date, there have been no clear guidelines on how to deal with this ethically and legally complex situation in a specific case. Doctors and nurses were therefore often unsure how they should behave. The handling was therefore extremely different.
“It is all the more important that we were able to develop common recommendations despite different professional perspectives and assessments of suicide assistance,” says Jan Schildmann, director of the Institute for the History and Ethics of Medicine at the University Medical Center Halle, who co-wrote the guidelines. The focus of the new guidelines is therefore the professional assessment of whether the decision for assisted suicide can be considered “freely responsible”.
It is based on four key questions:
Qualified assessment
The prerequisite for this assessment should be qualified information and advice. For this purpose, it is recommended to involve a specialist and another independent person who has appropriate specialist expertise in the field of mental health or who works in psychological and psychotherapeutic fields. The results should be structured and documented in writing.
The recommendation also stipulates that there should be at least four weeks between assessment and counseling sessions. This is intended to make it clear whether a decision is actually permanent and demonstrates “inner stability”.
In addition, the advice, the assessment of freedom of responsibility and other steps should take place independently of one another in terms of personnel, organization and economics. "The recommendations were made by interdisciplinary consensus. However, on some points there were individual differing positions that are documented as so-called special opinions," explains Alfred Simon, managing director of the Academy for Ethics in Medicine, which was involved as the leading specialist society.
Freely responsible even with mental illness?
The Federal Constitutional Court has only named individual self-determination and free responsibility as legally accepted criteria for assisted suicide. In other countries, such as Belgium or Canada, there are also specific age limits and other conditions that must be met in order to legally carry out an assisted suicide. This includes, for example, unbearable mental and physical suffering.
The guidelines emphasize that mental illnesses do not fundamentally rule out the possibility of freely deciding to commit suicide. But conversely, this does not mean that free responsibility is definitely given without a mental illness.
The decisive factor for the assessment is the individual professional assessment. Unless it can be assumed that they made a freely responsible decision to commit suicide, those affected should receive offers of support tailored to their needs. If necessary, treatment should be initiated.
Self-determination or life crisis?
According to the professional societies involved, this guideline has been developed as a concrete protection concept. The aim is to guarantee the right of the individual to die independently in the future, but on the other hand not to prematurely provide active euthanasia. It is still banned in Germany.
The guidelines therefore recommend, among other things, carefully exploring death wishes and their background in in-depth discussions. However, they should also be conducted in such a way that it can be recognized whether a mental illness, an acute life crisis or external pressure is affecting the ability to self-determine. In addition to the physical and psychological aspects, the social and spiritual-existential life situation should also be taken into account. Suicide assistance should not be proactively suggested or offered as an option for action.
The goal is to enable self-determined decisions through information and advice. This includes understandable information tailored to the respective situation about alternatives, legal aspects and possible effects on relatives and other third parties.
