Four Reasons Why Assisted Dying Should Not Be Offered for Depression
Open accessAbstract
Recently, several authors have argued that assisted dying may be ethically appropriate when requested by a person who suffers from serious depression unresponsive to treatment. We here present four arguments to the contrary. First, the arguments made by proponents of assisted dying rely on notions of "treatment-resistant depression" that are problematic. Second, an individual patient suffering from depression may not be justified in believing that chances of recovery are minimal. Third, the therapeutic significance of hope must be acknowledged; when mental healthcare opens up the door to admitting hopelessness, there is a danger of a self-fulfilling prophecy. Finally, proponents of assisted dying in mental healthcare overlook the dangers posed to mental-health services by the institutionalization of assisted dying.
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Empirical work highlights the limited predictive accuracy of clinicians when estimating recovery trajectories in major depressive and related disorders.
“Empirical work also highlights the limited predictive accuracy of clinicians when estimating recovery trajectories in major depressive and related disorders.22”
From Medical Assistance in Dying for the Sole Underlying Condition of Mental Disorder (MAiD MD-SUMC): an analysis and qualitative evidence synthesis (2026) · cites this paper as [22]
The unpredictability of the development of psychiatric disorders and the possibility of long-term remission make it difficult to judge whether the suffering is 'without prospect of improvement'.
“Moreover, the unpredictability of the development of psychiatric disorders and the possibility of long-term remission, make it difficult to judge whether the suffering is ‘without prospect of improvement’[18–20].”
A lack of holistic care for people living with mental disorders has been documented: psychosocial dimensions and interactional factors are often overlooked compared to biological dimensions.
“A lack of holistic care for people living with mental disorders has also been documented: psychosocial dimensions and interactional factors are often overlooked compared to biological dimensions [23].”
From Medical assistance in dying for people living with mental disorders: a qualitative thematic review (2023) · cites this paper as [23]
Discussions have repeatedly invoked the person with treatment-resistant depression as the paradigm case of an irremediable psychiatric condition.
“Discussions have repeatedly invoked ‘the person with treatment-resistant depression’ as the paradigm case of an irremediable psychiatric condition (Blikshavn, Husum, & Magelssen, 2017; Broome & de Cates, 2015; Miller, 2015; Schuklenk & van de Vathorst, 2015; Steinbock, 2017), often assuming that treatment-resistant depression (TRD) is, by definition, irremediable.”
From Irremediability in psychiatric euthanasia: examining the objective standard (2023) · cites this paper as Blikshavn et al., 2017
Treatment-resistant depression is often assumed in discussions to be by definition irremediable.
“Discussions have repeatedly invoked ‘the person with treatment-resistant depression’ as the paradigm case of an irremediable psychiatric condition (Blikshavn, Husum, & Magelssen, 2017; Broome & de Cates, 2015; Miller, 2015; Schuklenk & van de Vathorst, 2015; Steinbock, 2017), often assuming that treatment-resistant depression (TRD) is, by definition, irremediable.”
From Irremediability in psychiatric euthanasia: examining the objective standard (2023) · cites this paper as Blikshavn et al., 2017
Non-biological social factors, such as social support, can affect chances of recovery in psychiatry.
“Finally, our findings provide preliminary evidence for the claim that non-biological social factors, e.g. social support, can affect chances of recovery in psychiatry (Blikshavn et al., 2017; Cowley, 2013; Jansen et al., 2019; Kelly, 2017; Kissane & Kelly, 2000; Miller & Appelbaum, 2018; Pearce, 2017; Schoevers et al., 1998).”
From Irremediability in psychiatric euthanasia: examining the objective standard (2023) · cites this paper as Blikshavn et al., 2017
This struggle is a confirmation of earlier conceptual work that identified this as a specific challenge for psychiatry.
“which is a confirmation of earlier conceptual work that identified this as a specific challenge for psychiatry.20”
From Establishing irremediable psychiatric suffering in the context of medical assistance in dying in the Netherlands: a qualitative study (2022) · cites this paper as [20]
Concerns have been expressed that expanding MAiD eligibility to potentially vulnerable people sends a problematic message, especially to those struggling to find meaning in their lives.
“concerns have been expressed about the message sent by the expansion of MAiD eligibility to potentially vulnerable people [23], who may be struggling to find meaning to their lives [24].”
From Medical assistance in dying for people living with mental disorders: a qualitative thematic review (2023) · cites this paper as [23]
The introduction of MAiD-MD into the continuum of care can affect the therapeutic relationship, which is closely correlated with patients' hope for improvement, a key facilitator of recovery.
“The introduction of MAiD-MD into the continuum of care can affect the therapeutic relationship [17, 48, 59], which is closely correlated with patients’ hope for improvement [37], a key facilitator of recovery [23, 52].”
From Medical assistance in dying for people living with mental disorders: a qualitative thematic review (2023) · cites this paper as [23]
Another primary concern surrounds the quality and continuity of care, and adding MAiD-MD as an option exacerbates this concern.
“Another primary concern surrounds the quality and continuity of care [19], and adding MAiD-MD as an option exacerbates this concern [23, 54].”
From Medical assistance in dying for people living with mental disorders: a qualitative thematic review (2023) · cites this paper as [23]
Loss of hope can give rise to a self-fulfilling prophecy by reinforcing the patient's sense of hopelessness and compromising their potential for recovery.
“Such loss of hope can give rise to a self-fulfilling prophecy [23, 37, 51] by reinforcing the patient’s sense of hopelessness and compromising their potential for recovery [51].”
From Medical assistance in dying for people living with mental disorders: a qualitative thematic review (2023) · cites this paper as [23]
Healthcare professionals' involvement or support of MAiD-MD could affect patients' resilience and the therapeutic relationship and potentially influence the patient to lose hope that their situation will improve.
“Healthcare professionals’ involvement or support of MAiD-MD could also affect the resilience of patients [60], the therapeutic relationship [26, 48, 60] and potentially influence the patient to lose hope that their situation will improve if they have the impression that the healthcare professional is abandoning the therapeutic project [23, 37].”
From Medical assistance in dying for people living with mental disorders: a qualitative thematic review (2023) · cites this paper as [23]
It is very difficult to give a reliable prognosis for psychiatric suffering, even for patients who have extensive treatment histories, because little is known about the etiology of psychiatric suffering, there are hardly any reliable biomarkers, descriptive diagnostic reliability is relatively low, and it is difficult to predict the effects of treatment.
“Secondly, it is very difficult to give a reliable prognosis for psychiatric suffering, even for patients who have extensive treatment histories (16, 17). This has different reasons: little is known about the etiology of psychiatric suffering, there are hardly any reliable biomarkers, descriptive diagnostic reliability is relatively low and it is difficult to predict the effects of treatment (18).”
From Physician Assisted Death for Psychiatric Suffering: Experiences in the Netherlands (2022) · cites this paper as [17]
Psychiatric diagnostic categories necessarily include patients with widely differing aetiology and maintenance factors underlying the current symptoms and behaviour.
“Consequently, “diagnostic categories are bound to include patients with vastly different aetiology and maintenance factors that underlie the current symptoms and behaviour,” [11]”
From Is the exclusion of psychiatric patients from access to physician-assisted suicide discriminatory? (2019) · cites this paper as [11]
Even when patients have not responded to a wide variety of treatments over an extended period, there remains hope that they will eventually improve.
“But even if patients are non-responsive to a wide variety of treatments for an extended period of time, there is still hope that they will eventually improve.”
From Is the exclusion of psychiatric patients from access to physician-assisted suicide discriminatory? (2019) · cites this paper as [11]
Psychiatric diagnostic categories, unlike somatic ones, are merely descriptions of behaviour based on symptoms rather than on the causal psychopathological mechanisms of the illness.
“Firstly, the diagnostic categories of mental illnesses -unlike those of somatic illness -are merely descriptions of behaviour.”
From Is the exclusion of psychiatric patients from access to physician-assisted suicide discriminatory? (2019) · cites this paper as [11]
In the literature, treatment-resistant depression is most often understood as non-response to pharmacological treatment, while other available interventions such as psychosocial interventions, electroconvulsive therapy and deep brain stimulation are neglected by that label.
“But secondly, Blikshavn, Husum, and Magelssen argue that treatment-resistant depression is most often understood in the literature as a lack of response to pharmacological treatment, yet there are many other treatments and interventions that are available (e.g.psychosocial interventions, electroconvulsive therapy, deep brain stimulation, etc.) which are neglected by this label [11].”
From Is the exclusion of psychiatric patients from access to physician-assisted suicide discriminatory? (2019) · cites this paper as [11]
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Dødshjelp: Lovverk, praksis og holdninger i de skandinaviske land
Kleiven, D. J. H., Hartling, O. J., Ståhle, F., Horn, M. A., & Magelssen, M. (2020) · doi:10.23865/noasp.96.ch3 · Cited by 4 · see citing works
Self-citationMacri, R., Wagner, F., & Stuckey, M. I. (2020) · Canadian Journal of Community Mental Health · doi:10.7870/cjcmh-2020-009 · Cited by 3 · see citing works
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Craine, P. (2023) · Canadian Journal of Bioethics · doi:10.7202/1108008ar · Cited by 3 · see citing works
Persons with mental disorders and assisted dying practices in Spain: In response to Ramos et al.
Pifarré, J., Esquerda, M., Torralba, F., Bátiz, J., & Bofarull, M. (2024) · International Journal of Law and Psychiatry · doi:10.1016/j.ijlp.2024.101980 · Cited by 5 · see citing works
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Pawluk, A., Arksey, E., Jansens, H., Qiao, S., & McFarlane, L. (2026) · BMJ Open · doi:10.1136/bmjopen-2025-105129
“…inequities and individual clinical prognosis are intertwined; while improved access to mental health care cannot resolve the conceptual challenge of defining irremediability, addressing such inequities may reduce non-clinical pressures that shape how irremediability is experienced and assessed.”
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Ashby, M. A. (2017) · Journal of Bioethical Inquiry · doi:10.1007/s11673-017-9777-x
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Horn, M. A., & Magelssen, M. (2020) · doi:10.23865/noasp.96.ch1
Self-citationFortellinger om død, verdsetting av liv
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Enefer, A. (2021) · LSE law review · doi:10.61315/lselr.139
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The Limits of Parental Authority
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Euthanasia in persons with mental illness: Clinical, ethical, and societal challenges
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- Authors
- Blikshavn, T., Husum, T. L., & Magelssen, M.
- Affiliations
- Akershus University Hospital (NO)
- University of Oslo (NO)
- Corresponding author
- Magelssen, Morten
- Venue
- Journal of Bioethical Inquiry
- Published
- 2016-12-08
- Volume
- 14
- Issue
- 1
- Pages
- 151-157
- ISSN
- 1176-7529 (ISSN-L)
- 1872-4353
- OpenAlex
- W2560566956
- Cited by
- 60
- References
- 52
- Citations by year
- 2026: 3 · 2025: 3 · 2024: 3 · 2023: 5 · 2022: 8 · 2021: 3 · 2020: 22 · 2019: 9 · 2018: 1 · 2017: 3
- FWCI
- 4.27
- Type
- journal article
- Language
- en
- Open access
- green
- hdl.handle.net
- Licence
- Locations
- Journal of Bioethical Inquiry (publishedVersion)
- PubMed (publishedVersion)
- NORA - Norwegian Open Research Archives (submittedVersion, other-oa)
- Topics
- Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Ethics and bioethics in healthcare
- Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Palliative and Oncologic Care
- Social Sciences › Psychology › Clinical Psychology › Suicide and Self-Harm Studies
- Keywords
- assisted dying, depression, treatment-resistant depression, hopelessness, hope, self-fulfilling prophecy, mental health services, recovery from depression
- MeSH terms
- Depression, Humans, Mental Health Services, Physician-Patient Relations, Mental Competency, Suicide, Assisted, Bioethical Issues, Hope
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