Euthanasia, medically assisted dying or assisted suicide: time for psychiatrists to say no

The practice of euthanasia in adults with psychiatric conditions remains subject to controversy, fiercely dividing clinical and ethical opinions, and sometimes resulting in legal examination.

“As some contest whether and when an APC can meet all legal requirements, the practice remains subject to controversy, fiercely dividing clinical and ethical opinions,2–7 and sometimes resulting in legal examination.8,9”

Psychiatric suffering is inherently subjective, often fluctuating, and characterized by prognostic uncertainty.

“psychiatric suffering is inherently subjective, often fluctuating, and characterized by prognostic uncertainty”

The distinction between a stable, deliberative request for assisted death and suicidal ideation associated with psychopathology requires careful, longitudinal, and context-sensitive assessment.

“the distinction between a stable, deliberative request for assisted death and suicidal ideation associated with psychopathology—a boundary that requires careful, longitudinal, and context-sensitive assessment”

Psychiatry's historical commitment to suicide prevention and life preservation through longitudinal and adaptive therapeutic interventions intensifies the need for a clear ethical and legal framework.

“Psychiatry’s historical commitment to suicide prevention and life preservation through longitudinal and adaptive therapeutic interventions further intensifies the need for a clear ethical and legal framework”

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”

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”

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 (”

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”

Numerous studies highlight that a significant proportion of patients requesting EAS for mental disorders have a history of suicidal ideation or attempts, raising the concern that the desire to die may reflect pathology rather than an autonomous, deliberative choice.

“Numerous studies highlight that a significant proportion of patients requesting EAS for mental disorders have a history of suicidal ideation or attempts, raising the concern that the desire to die may reflect pathology rather than an autonomous, deliberative choice ( 1 , 20 , 21 ).”

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 ).”

Conflating distinctions between intentionality, evaluative context, and professional responsibility risks medicalizing suicide and pathologizing every EAS request, thereby obstructing a fair, rigorous, and clinically grounded assessment.

“Conflating these distinctions risks both medicalizing suicide and pathologizing every EAS request, thus obstructing a fair, rigorous, and clinically grounded assessment ( 1 , 6 ).”

Automatic exclusion of psychiatric patients, even when their diagnosis is not causally related to the end-of-life request, risks institutionalizing stigma.

“The literature highlights how automatic exclusion of psychiatric patients, even when their diagnosis is not causally related to the end-of-life request, risks institutionalizing stigma ( 1 , 4 , 6 ).”