Should euthanasia and assisted suicide for psychiatric disorders be permitted? A systematic review of reasons
Abstract
Background: Euthanasia and assisted suicide (EAS) based on a psychiatric disorder (psychiatric EAS) continue to pose ethical and policy challenges, even in countries where the practice has been allowed for years. We conducted a systematic review of reasons, a specific type of review for bioethical questions designed to inform rational policy-making. Our aims were twofold: (1) to systematically identify all published reasons for and against the practice (2) to identify current gaps in the debate and areas for future research. Methods: Following the PRISMA guidelines, we performed a search across seven electronic databases to include publications focusing on psychiatric EAS and providing ethical reasons. Reasons were grouped into domains by qualitative content analysis. Results: We included 42 articles, most of which were written after 2013. Articles in favor and against were evenly distributed. Articles in favor were mostly full-length pieces written by non-clinicians, with articles against mostly reactive, commentary-type pieces written by clinicians. Reasons were categorized into eight domains: (1) mental and physical illness and suffering (2) decisional capacity (3) irremediability (4) goals of medicine and psychiatry (5) consequences for mental health care (6) psychiatric EAS and suicide (7) self-determination and authenticity (8) psychiatric EAS and refusal of life-sustaining treatment. Parity- (or discrimination-) based reasons were dominant across domains, mostly argued for by non-clinicians, while policy reasons were mostly pointed to by clinicians. Conclusions: The ethical debate about psychiatric EAS is relatively young, with prominent reasons of parity. More direct engagement is needed to address ethical and policy considerations.
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The severity of suffering in persons with mental disorders may be more difficult to evaluate from an external perspective.
“the severity of suffering may be more difficult to evaluate from an external perspective”
From Assisted suicide in persons with mental disorders: a review of clinical-ethical arguments and recommendations (2024) · cites this paper as [5]
The wish to die in persons with mental disorders may be a symptom of their mental disease and not an autonomous choice.
“their wish to die may be a symptom of their mental disease and not an autonomous choice”
From Assisted suicide in persons with mental disorders: a review of clinical-ethical arguments and recommendations (2024) · cites this paper as [5]
Prognostic uncertainty in mental illness makes it more difficult to determine whether severe suffering is treatment-resistant.
“the prognostic uncertainty in mental illness makes it more difficult to determine whether the severe suffering is, in fact, treatment-resistant”
From Assisted suicide in persons with mental disorders: a review of clinical-ethical arguments and recommendations (2024) · cites this paper as [5]
Cases of assisted dying in patients with eating disorders have been documented in the United States, the Netherlands, and Belgium.
“cases have been documented in the United States (2), the Netherlands (6–10), and Belgium (11–13).”
From Assisted death in eating disorders: a systematic review of cases and clinical rationales (2024) · cites this paper as [9]
Some studies indicate that Dutch euthanasia guidelines allow for significant physician discretion.
“However, some studies indicate that these guidelines allow for significant physician discretion (9, 10).”
From Assisted death in eating disorders: a systematic review of cases and clinical rationales (2024) · cites this paper as [9]
The wish to die in persons with mental disorders may be more variable over time.
“the wish to die may be more variable over time”
From Assisted suicide in persons with mental disorders: a review of clinical-ethical arguments and recommendations (2024) · cites this paper as [5]
Decision-making competence in persons with mental disorders may be compromised by their illness and more difficult to assess.
“decision-making competence may be compromised by their illness and more difficult to assess”
From Assisted suicide in persons with mental disorders: a review of clinical-ethical arguments and recommendations (2024) · cites this paper as [5]
Using similar arguments about discriminatory application of the law, several jurisdictions have extended physician-assisted death to people whose distress results from ostensibly untreatable mental disorders.
“Thus, with similar arguments about discriminatory application of the law, several jurisdictions have extended physician-assisted death to include persons whose distress is the result of ostensibly untreatable mental disorders 222 .”
From Ethical challenges in contemporary psychiatry: an overview and an appraisal of possible strategies and research needs (2024) · cites this paper as [222]
Physician assisted death (PAD) for patients with a psychiatric disorder is legally possible in only a few countries, including the Netherlands, Belgium, Luxembourg, Switzerland, and soon Canada.
“An even more controversial topic is whether to allow PAD for patients with a psychiatric disorder, which is possible in only a few countries, such as the Netherlands, Belgium, Luxembourg, Switzerland and soon also Canada (1).”
From Physician Assisted Death for Psychiatric Suffering: Experiences in the Netherlands (2022) · cites this paper as [1]
Currently, all countries that allow a form of PAD require that a patient has the capacity to make an informed request.
“Currently, all countries that allow a form of PAD require that a patient has the capacity to make an informed request (1).”
From Physician Assisted Death for Psychiatric Suffering: Experiences in the Netherlands (2022) · cites this paper as [1]
Psychiatric suffering is inherently subjective, often fluctuating, and characterized by prognostic uncertainty.
“psychiatric suffering is inherently subjective, often fluctuating, and characterized by prognostic uncertainty”
Unbearable suffering and irremediability are central to EAS legislation yet particularly fragile in psychiatry, where prognosis is heterogeneous and therapeutic response remains highly individualized.
“the interpretation of “unbearable suffering” and “irremediability,” concepts central to EAS legislation yet particularly fragile in psychiatry, where prognosis is heterogeneous and therapeutic response remains highly individualized”
In mental health contexts, the foundational principles of medicine interact dynamically rather than hierarchically, making each evaluative process intrinsically complex and resistant to rigid standardization.
“In mental health contexts, these principles interact dynamically rather than hierarchically, making each evaluative process intrinsically complex and resistant to rigid standardization”
Across all examined systems, there is agreement on the need to document the patient's treatment history in a traceable manner, to conduct repeated assessments over time, and to establish multidisciplinary evaluation processes.
“Across all examined systems, there is agreement on the need to document the patient’s treatment history in a traceable manner, to conduct repeated assessments over time, and to establish multidisciplinary evaluation processes”
Many critical issues remain unresolved: the operational definition of irremediability in psychiatry, the limited availability of validated and context-specific standardized tools for assessing decision-making capacity in EAS contexts, and the distinction between suicidality associated with active psychopathology and autonomous, well-considered requests for assisted death.
“many critical issues remain unresolved: the operational definition of irremediability in psychiatry, the limited availability of validated and context-specific standardized tools for assessing decision-making capacity in EAS contexts, and the distinction between suicidality associated with active psychopathology and autonomous, well-considered requests for assisted death”
The emergence of assisted death requests from patients with mental disorders challenges the epistemic and professional foundations of psychiatric practice, confronting clinicians with a potential conflict between the duty to protect life and the legitimacy of a sustained request for death.
“The emergence of assisted death requests from patients with mental disorders therefore challenges the epistemic and professional foundations of psychiatric practice, confronting clinicians with a potential conflict between the duty to protect life and the legitimacy of a sustained request for death”
The theoretical availability of innovative interventions does not necessarily imply clinical accessibility or patient responsiveness, rendering the judgment of irremediability inevitably complex, dynamic, and highly case-specific.
“the theoretical availability of such options does not necessarily imply clinical accessibility or patient responsiveness, rendering the judgment of irremediability inevitably complex, dynamic, and highly case-specific”
This model represents the most advanced attempt to reconcile autonomy, protection, and professional responsibility in psychiatric EAS.
“this model represents the most advanced attempt to reconcile autonomy, protection, and professional responsibility in psychiatric EAS”
The need for clearer conceptual definitions, procedural transparency, and interdisciplinary dialogue is repeatedly emphasized within the literature as a condition for enhancing consistency, accountability, and ethical sustainability in systems where psychiatric EAS is permitted.
“The need for clearer conceptual definitions, procedural transparency, and interdisciplinary dialogue is repeatedly emphasized within the literature as a condition for enhancing consistency, accountability, and ethical sustainability in systems where psychiatric EAS is permitted”
Although the literature aligns on key principles-centrality of decision-making capacity, need to verify disorder irremediability, and requirement for structured, documented, and supervised evaluative processes-significant differences remain in applied criteria, assessment methods, and clinical-legal outcomes.
“Although the literature aligns on key principles (the centrality of decision-making capacity, the need to verify disorder irremediability, and the requirement for structured, documented, and supervised evaluative processes) significant differences remain in the applied criteria, assessment methods, and clinical-legal outcomes”
Decision-making capacity is a complex, dynamic, and layered construct shaped by the patient's clinical condition at the time of evaluation, relational environment, and individual history.
“It is a complex, dynamic, and layered construct shaped by the patient’s clinical condition at the time of evaluation, relational environment, and individual history”
Evaluation of EAS requests must consider possible differences in intentionality, evaluative context, and professional responsibility between suicidal ideation and a well-considered request for EAS.
“the evaluation of EAS requests, although adopting both perspectives the result can be the search to voluntary death, must consider possible differences in terms of intentionality, evaluative context, and professional responsibility”
A growing body of literature advocates supplementing the classical criteria with additional dimensions such as value-consistency of the choice, motivational stability over time, and resilience of the decision to psychopathological and contextual fluctuations.
“a growing body of literature advocates for supplementing the classical criteria with additional dimensions such as the value-consistency of the choice, motivational stability over time, and resilience of the decision to psychopathological and contextual fluctuations”
In cases where EAS is motivated solely by a mental disorder, the international literature suggests that a higher and specific evaluative threshold is required, not as a form of discrimination, but as a proportional response to increased diagnostic and prognostic uncertainty, variability in treatment response, and the need for careful evaluation of suicidality and chronic suicidality possibly in a
“In such cases, the international literature suggests that a higher and specific evaluative threshold is required, not as a form of discrimination, but as a proportional response to increased diagnostic and prognostic uncertainty, variability in treatment response, and the need for careful evaluation of suicidality and chronic suicidality possibly emerging in the context of active psychopathology (”
The literature suggests that the answer to reconciling suicide prevention with assessment of the legitimacy of an assisted death request lies not in a priori exclusion but in a structured, longitudinal, and shared evaluative process capable of distinguishing suicidal ideation associated with active psychopathology from a thoughtful and stable decision over time.
“The literature suggests that the answer lies not in a priori exclusion but in a structured, longitudinal, and shared evaluative process capable of distinguishing suicidal ideation associated with active psychopathology from a thoughtful and stable decision over time ( 1 – 3 ).”
The combination of prognostic uncertainty, the risk of overlap with pathological suicidality, the fragile nature of irremediability, and the complexity of capacity assessment calls for strengthened safeguards, documented longitudinal evaluations, and multidisciplinary decision-making processes.
“The combination of prognostic uncertainty, the risk of overlap with pathological suicidality, the fragile nature of irremediability, and the complexity of capacity assessment calls for strengthened safeguards, documented longitudinal evaluations, and multidisciplinary decision-making processes ( 2 , 3 , 7 , 16 ).”
A priori denial of access to EAS in such cases would amount to a presumption of permanent incapacity, lacking clinical justification and contravening principles of equity, justice, and non-discrimination.
“A priori denial of access to EAS in such cases would amount to a presumption of permanent incapacity, lacking clinical justification and contravening principles of equity, justice, and non-discrimination ( 2 , 4 , 9 ).”
In cases of EAS requests by patients with serious, irreversible, or terminal somatic illnesses who also present with a current or historical psychiatric comorbidity that is not the primary cause of the request, the literature emphasizes the need to avoid automatic or discriminatory approaches based solely on psychiatric diagnosis, advocating for individualized, decision-specific capacity
“In such cases, the literature emphasizes the need to avoid automatic or discriminatory approaches based solely on psychiatric diagnosis, advocating for individualized, decision-specific capacity assessments ( 2 , 4 , 9 ).”
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- Authors
- Nicolini, M. E., Kim, S. Y. H., Churchill, M. E., & Gastmans, C.
- Affiliations
- National Institutes of Health (US)
- KU Leuven (BE)
- Corresponding author
- Nicolini, Marie E.
- Venue
- Psychological Medicine
- Publisher
- Cambridge University Press (CUP)
- Published
- 2020-06
- Volume
- 50
- Issue
- 8
- Pages
- 1241-1256
- ISSN
- 0033-2917 (ISSN-L)
- 1469-8978
- OpenAlex
- W3030034368
- Semantic Scholar
- e64e82622c6ba527b3c086b5989db8068f14807b
- Cited by
- 77
- References
- 84
- Citations by year
- 2026: 7 · 2025: 17 · 2024: 22 · 2023: 12 · 2022: 14 · 2021: 4 · 2020: 1
- FWCI
- 1.34
- Type
- journal article
- Language
- en
- Open access
- closed
- Locations
- Psychological Medicine (publishedVersion)
- PubMed (publishedVersion)
- Lirias (submittedVersion)
- 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
- Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Palliative Care and End-of-Life Issues
- Keywords
- euthanasia, assisted suicide, mental illness, bioethics, ethical arguments, discrimination, decision-making capacity, self-determination, authenticity, refusal of life-sustaining treatment, mental health services
- MeSH terms
- Mental Disorders, Decision Making, Euthanasia, Health Policy, Humans, Psychiatry, Mental Competency, Suicide, Assisted, Personal Autonomy
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