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Cited by 43Personality Disorders and PsychopathologyPalliative and Oncologic CarePalliative Care and End-of-Life Issues

Euthanasia and assisted suicide in patients with personality disorders: a review of current practice and challenges

Open access
Mehlum, Lars, Schmahl, Christian, Berens, Ann, Doering, Stephan, Hutsebaut, Joost, Kaera, Andres, Kramer, Ueli, Moran, Paul Anthony +6 more·2020·Borderline Personality Disorder and Emotion Dysregulation
DOI 10.1186/s40479-020-00131-9PMC PMC7391495
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Abstract

Background: Over the last two decades an increasing number of countries have legalized euthanasia and physician-assisted suicide (EAS) leading to considerable debate over the inherent ethical dilemmas. Increasing numbers of people with personality disorders, faced with unbearable suffering, have requested and received assistance in terminating their lives. EAS in people with personality disorders has, however, received very sparse attention from clinicians and researchers. In this paper, we examine the literature on the practice and prevalence of EAS in people with personality disorders to date and discuss the associated challenges for research and practice. Methods: Narrative review of the literature combined with the authors’ collective experience and knowledge of personality disorders. Results: In six of the eight countries where EAS is currently legal, mental disorders are accepted as disorders for which EAS may be granted. In four of these countries, EAS in minors with mental disorders is also accepted. Our literature search resulted in 9 papers on the subject of EAS in people with personality disorders. These studies suggest that most clinicians who grant EAS have indeed perceived their patients’ suffering as chronic, unbearable and untreatable without prospect of improvement. The majority of patients with personality disorders had tried some form of psychotherapy, but very few had received any of the relevant evidence-based treatments. The decision to grant EAS based on a perception of the patient’s illness as being untreatable with no prospect of improvement, could, thus, in many cases fail to meet the due care criteria listed in EAS laws. People with personality disorders more often wish for death for extended periods of time than people without these disorders. However, there is ample empirical data to show that suicidal tendencies and behaviour can be treated and that they fluctuate rapidly over time. Conclusions: In light of our findings, we believe that the current legislation and practice of EAS for people with personality disorders is based on an inadequate understanding of underlying psychopathology and a lack of awareness about the contemporary treatment literature. Moreover, we assert that this practice neglects the individual’s potential for having a life worth living.

AI snapshot

Written from the paper’s full text.

TL;DR

This narrative review examines euthanasia and physician-assisted suicide (EAS) in people with personality disorders, finding that personality disorders are prominent among psychiatric EAS cases despite a very limited evidence base. The authors argue that current legislation and practice often rest on outdated assumptions that personality disorders are untreatable and neglect the fluctuating nature of suicidal wishes and the availability of effective treatments.

Key findings

  • In six of the eight countries where EAS is legal, mental disorders are accepted as disorders for which EAS may be granted; in four of these countries, EAS in minors with mental disorders is also accepted.
  • The literature search found only 9 papers on EAS in people with personality disorders: 2 empirical articles, 4 literature reviews, and 3 comments/letters to the editor.
  • In a Belgian retrospective study of the first 100 consecutive patients requesting euthanasia for psychological suffering, 50 had a personality disorder (27 borderline, 3 dependent, 2 histrionic, 18 other/PD not otherwise specified); all were reported as having chronic, constant, unbearable suffering “without prospects of improvement, due to treatment resistance.” Of all 100 requests, 48 were accepted and 35 carried out, but the number with PD was not specified.
  • Dutch data show that in 2018, 4% of all deaths were due to EAS, and among 6,126 EAS cases about 1% involved patients with a mental disorder. In reviews of psychiatric EAS cases, 52% of the first 66 published cases had personality disorders or difficulties, and in a later analysis of 116 cases, PD was judged likely in 74 (just under two-thirds) but explicitly diagnosed in only 48 (41%); 72% had received some psychotherapy, while only one patient (1%) had received a standard PD-specific evidence-based treatment.

Methods

  • Narrative review of the literature combined with the authors’ collective experience and knowledge of personality disorders from clinical practice, clinical research, treatment development, and national policy involvement.
  • Medline (OVID) was searched for peer-reviewed articles and letters to the Editor published in English through October 2019 using MeSH terms including “Euthanasia,” “Suicide, Assisted,” “Personality Disorders,” and “Borderline Personality Disorder”; no language or time filters were applied.
  • The search yielded 9 papers, whose main findings and conclusions were summarized; no formal meta-analysis or systematic quality appraisal is described.

Limitations

  • The authors state that firm conclusions about prevalence figures and proportions are difficult because of the limited number of studies and cases reported in each study.
  • The paper notes a severe lack of research on what influences physicians’ decisions when dealing with EAS requests, on whether misperceptions occur in this context, and on how many patients with PD requesting euthanasia could have been treated effectively.
  • Evident from the text: this is a narrative review relying partly on the authors’ experience, based on only 9 papers, and it notes that the Belgian study did not specify or operationalize “treatment resistance” or how it was measured.

Model-written summary. Check it against the paper before relying on it.

Integrity signals

Registry

Crossref · 10.1186/s40479-020-00131-9

Cites

30 of 30 references verified0 citation errors · 0 not checkable

Statistics

Nothing to recompute.

Claims the paper makes

0 of 34 cited sources checked · 0 supported · 0 flagged

  • Findingnone given

    These studies suggest that most clinicians who grant EAS have perceived their patients' suffering as chronic, unbearable and untreatable without prospect of improvement.

    “These studies suggest that most clinicians who grant EAS have indeed perceived their patients’ suffering as chronic, unbearable and untreatable without prospect of improvement.”
    Quote in the paperSubstantial claim
  • Findingcitation

    In the study of Thienpont et al., patients with PD were perceived as being untreatable.

    “This seems to have been the case with patients with PD in the study of Thienpont et al. [8] who were perceived as being “untreatable”.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [8] Thienpont L, et al. Euthanasia requests, procedures and outcomes for 100 Belgian patients suffering from psychiatric disorders: a retrospective, descriptive study. BMJ Open. 2015;5(7):e007454. source

      Not checked in the free run.

  • Findingcitation

    The Federal Control and Evaluation Committee on Euthanasia in Belgium reports that about 3% of EAS cases are mainly linked to mental disorders.

    “The Federal Control and Evaluation Committee on Euthanasia in Belgium reports [7] that about of 3% of EAS-cases are mainly linked to mental disorders.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [7] Euthanasia, F.C.a.E.C.o. Fifth report to the Parliament (2010–2011). 2012 [cited 2019; Available from: http://www.senate.be/www/webdriver?MItabObj=pdf&MIcolObj=pdf&MInamObj=pdfid&MItypeObj=application/pdf&MIvalObj=83889004.

      Not checked in the free run.

  • Findingcitation

    Most of the people who request EAS for mental illness appear to be experiencing multiple mental health problems.

    “Most of the people who request EAS for mental illness appear to be experiencing multiple mental health problems.”
    Quote in the paperNot a substantial claim
  • Findingcitation

    In a Dutch study, a lower proportion of physicians found it conceivable that they would grant EAS in patients with mental illnesses (34%) than the proportion who found it conceivable that they would grant EAS in patients with physical illnesses, such as cancer (85%).

    “In a Dutch study, a lower proportion of physicians found it conceivable that they would grant EAS in patients with mental illnesses (34%) than the proportion who found it conceivable that they would grant EAS in patients with physical illnesses, such as cancer (85%) [27].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [27] Bolt EE, et al. Can physicians conceive of performing euthanasia in case of psychiatric disease, dementia or being tired of living? J Med Ethics. 2015;41(8):592–8. source

      Not checked in the free run.

  • Classified as probably not a substantial claim. 14
  • May combine two claims. 23

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Findingcitation

    In total, 48 of the 100 euthanasia requests were accepted, of which 35 were carried out, but the authors do not specify how many of these had a PD diagnosis.

    “In total, 48 of all of the 100 euthanasia requests were accepted, of which 35 were carried out, but the authors do not specify how many of these had a PD diagnosis.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [8] Thienpont L, et al. Euthanasia requests, procedures and outcomes for 100 Belgian patients suffering from psychiatric disorders: a retrospective, descriptive study. BMJ Open. 2015;5(7):e007454. source

      Not checked in the free run.

  • May combine two claims.

    Findingcitation

    Among the 50 patients with a personality disorder, 27 had borderline PD, 3 had dependent PD, 2 had histrionic PD, and 18 had some other PD or PD not otherwise specified.

    “Among the 50 patients with a PD, 27 had borderline PD (BPD), 3 had dependent PD, 2 had histrionic PD and 18 had some other PD or PD not otherwise specified.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [8] Thienpont L, et al. Euthanasia requests, procedures and outcomes for 100 Belgian patients suffering from psychiatric disorders: a retrospective, descriptive study. BMJ Open. 2015;5(7):e007454. source

      Not checked in the free run.

  • May combine two claims.

    Findingcitation

    The most common disorders among the 100 patients were treatment resistant mood disorders (n = 58) and personality disorders (n = 50), with 29 patients having both types of disorder.

    “The most common of these disorders were treatment resistant mood disorders (n = 58) and personality disorders (n = 50), whereas 29 patients had both types of disorder.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [8] Thienpont L, et al. Euthanasia requests, procedures and outcomes for 100 Belgian patients suffering from psychiatric disorders: a retrospective, descriptive study. BMJ Open. 2015;5(7):e007454. source

      Not checked in the free run.

  • May combine two claims.

    Findingnone given

    The majority of patients with personality disorders had tried some form of psychotherapy, but very few had received any of the relevant evidence-based treatments.

    “The majority of patients with personality disorders had tried some form of psychotherapy, but very few had received any of the relevant evidence-based treatments.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S4 (based).

    Findingnone given

    EAS in people with personality disorders has received very sparse attention.

    “Nevertheless, EAS in this group has received very sparse attention.”
    Quote in the paperNot a substantial claim

  • Classified as probably not a substantial claim.

    Findingcitation

    Thienpont and colleagues conducted a retrospective analysis of medical records of the first 100 consecutive patients who requested euthanasia for psychological suffering associated with mental disorders between 2007 and 2011.

    “Thienpont and colleagues [8] conducted a retrospective analysis of medical records of the first 100 consecutive patients (23 men and 77 women) who requested euthanasia for psychological suffering associated with mental disorders in the years between 2007 and 2011.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [8] Thienpont L, et al. Euthanasia requests, procedures and outcomes for 100 Belgian patients suffering from psychiatric disorders: a retrospective, descriptive study. BMJ Open. 2015;5(7):e007454. source

      Not checked in the free run.

  • May combine two claims.

    Findingcitation

    In all patients with PD, suffering was reported to be chronic, constant and unbearable, without prospects of improvement due to treatment resistance.

    “In all patients with PD suffering was reported to be chronic, constant and unbearable, “without prospects of improvement, due to treatment resistance” [8].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [8] Thienpont L, et al. Euthanasia requests, procedures and outcomes for 100 Belgian patients suffering from psychiatric disorders: a retrospective, descriptive study. BMJ Open. 2015;5(7):e007454. source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Findingcitation

    In 2018, 4% of all deaths in the Netherlands were due to EAS, and among all cases of EAS (N = 6126) around 1% involved patients with a mental disorder according to the Dutch regional euthanasia review committees.

    “In 2018, 4% of all deaths in the Netherlands were due to EAS, and among all cases of EAS (N = 6126) around 1% involved patients with a mental disorder according to the Dutch regional euthanasia review committees (RTE) [9].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [9] RTE. Regional Euthanasia Review Committees - Annual Report 2018. 2019 [cited 2019 Dec 1]; Available from: www.euthanasiecommissie.nl.

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingcitation

    The prevalence of PD was higher in patients who were younger.

    “The prevalence of PD was higher in patients who were younger.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [10] Kim SY, De Vries RG, Peteet JR. Euthanasia and assisted suicide of patients with psychiatric disorders in the Netherlands 2011 to 2014. JAMA Psychiatry. 2016;73(4):362–8. source

      Not checked in the free run.

  • May combine two claims.

    Findingcitation

    In the study by Kim et al., depressive disorders (55%), posttraumatic stress disorder and other anxiety disorders (42%) were prominent, 52% of patients had personality-related problems, and social isolation or loneliness were mentioned in 56% of cases.

    “In the study by Kim et al. [10] depressive disorders (55%), posttraumatic stress disorder and other anxiety disorders (42%) were prominent whereas 52% of the patients had personality-related problems, sometimes without a formal PD diagnosis, more so in younger patients. Social isolation or loneliness were mentioned in 56% of the cases.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [10] Kim SY, De Vries RG, Peteet JR. Euthanasia and assisted suicide of patients with psychiatric disorders in the Netherlands 2011 to 2014. JAMA Psychiatry. 2016;73(4):362–8. source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S4 (based).

    Findingnone given

    Currently, there is a scarcity of research into the question of whether patients with PD who requested EAS were offered evidence-based PD-specific treatment.

    “Currently, there is a scarcity of research into the question of whether patients with PD who requested EAS were offered evidence-based PD-specific treatment.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingcitation

    The majority (72%) of patients with PD had received some form of psychotherapy, but mostly of unspecific nature, and only one patient (1%) had received any of the standard PD-specific evidence-based treatments currently in existence.

    “The majority (72%) of patients with PD had received some form of psychotherapy, but mostly of unspecific nature, and only one patient (1%) had received any of the standard PD-specific evidence-based treatments currently in existence.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [11] Nicolini ME, et al. Euthanasia and assisted suicide of persons with psychiatric disorders: the challenge of personality disorders. Psychol Med. 2019:1–8.

      Not checked in the free run.

  • Classified as probably not a substantial claim.

    Findingown data

    The literature search resulted in 9 papers on the subject of EAS in people with personality disorders.

    “Our literature search resulted in 9 papers on the subject of EAS in people with personality disorders.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingcitation

    Among the 116 cases published by the RTE, a diagnosis of PD was likely in just under two-thirds of cases (n = 74), although a PD diagnosis had been explicitly made by the patients' doctors in only 48 (41%) cases.

    “Among the 116 cases published by the RTE, a diagnosis of PD was likely, according to the authors’ clinical judgement, in just under two-thirds of cases (n = 74), although a PD diagnosis had been explicitly made by the patients’ doctors in only 48 (41%) cases.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [11] Nicolini ME, et al. Euthanasia and assisted suicide of persons with psychiatric disorders: the challenge of personality disorders. Psychol Med. 2019:1–8.

      Not checked in the free run.

  • May combine two claims.

    Premisenone given

    A wish for death and an increased risk of suicide may be prominent, although less well documented, among people with other personality disorders.

    “A wish for death and an increased risk of suicide may be prominent, although less well documented, among people with other personality disorders.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Interpretationreasoning

    People with personality disorders on average more often contemplate death and may have a stronger wish for death for more extended periods of time than people without these disorders.

    “It follows from the above that people with personality disorders on average more often contemplate death and may have a stronger wish for death for more extended periods of time than is the case for people without these disorders.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Premisecitation

    There is ample empirical data to show that suicidal tendencies and behaviour can be treated and that they fluctuate rapidly over time.

    “However, there is ample empirical data to show that suicidal tendencies and behaviour can be treated and that they fluctuate rapidly over time.”
    Quote in the paperSubstantial claim0 of 2 sources checked
    • cites [21] Glenn CR, et al. Evidence base update of psychosocial treatments for self-injurious thoughts and behaviors in youth. J Clin Child Adolesc Psychol. 2019;48(3):357–92. source

      Not checked in the free run.

    • cites [22] Hawton K, et al. Psychosocial interventions following self-harm in adults: a systematic review and meta-analysis. Lancet Psychiatry. 2016;3(8):740–50. source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductnone given

    The study does not specify or operationalize the concept of treatment resistance or how it was measured.

    “The study does not specify or operationalize the concept of “treatment resistance” or how it was measured.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Interpretationreasoning

    These tendencies of thinking about suicide or wishing for suicide are very likely learnt dysfunctional behaviours, and they fluctuate rapidly.

    “Rather they are very likely learnt dysfunctional behaviours, and they fluctuate rapidly.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S2 (checkable), S4 (based).

    Interpretationreasoning

    This practice neglects the individual's potential for having a life worth living.

    “Moreover, we assert that this practice neglects the individual’s potential for having a life worth living.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based). May combine two claims.

    Premisenone given

    Suicidal behaviour is frequently seen in people with antisocial personality disorder, where it is often associated with severe problems in interpersonal relations and with the justice system.

    “Suicidal behaviour is frequently seen in people with antisocial personality disorder, where it is often associated with severe problems in interpersonal relations and with the justice system.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Interpretationcitation

    A higher level of clinical expertise may follow a reduced willingness to grant EAS for mental illnesses.

    “This could mean that with higher level of clinical expertise may follow a reduced willingness to grant EAS for mental illnesses.”
    Quote in the paperNot a substantial claim

  • Classified as probably not a substantial claim.

    Study design and conductreasoning

    It is difficult to reach firm conclusions about prevalence figures and proportions based on the limited number of studies and cases reported in each study.

    “It is difficult to reach firm conclusions about prevalence figures and proportions based on the limited number of studies and cases reported in each study.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Premisecitation

    To be granted euthanasia in Belgium, a person must be in a medically futile condition of unbearable and untreatable physical or psychological suffering, resulting from a serious and incurable disorder caused by accident or illness.

    “To be granted euthanasia in Belgium, to date the country with the most liberal EAS legislation, a person must be “in a medically futile condition of unbearable and untreatable physical or psychological suffering, resulting from a serious and incurable disorder caused by accident or illness” [6].”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [6] Belgian Ministry of Justice. Law on euthanasia of May 28, 2002. Belgish Staatsblad Moniteur Belge 2014. Available from: http://www.ejustice.just.fgov.be/mopdf/2014/03/12_1.pdf#Page67.

      Not checked in the free run.

  • May combine two claims.

    Interpretationcitation

    In most cases even severe suicidal tendencies and self-harming behaviour can be treated and individuals can be helped to recover.

    “However, in most cases even severe suicidal tendencies and self-harming behaviour can be treated and individuals can be helped to recover.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Interpretationreasoning

    The current legislation and practice of EAS for people with personality disorders is based on an inadequate understanding of underlying psychopathology and a lack of awareness about the contemporary treatment literature.

    “In light of our findings, we believe that the current legislation and practice of EAS for people with personality disorders is based on an inadequate understanding of underlying psychopathology and a lack of awareness about the contemporary treatment literature.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Premisecitation

    Emotional and behavioural dysregulation is characteristic of BPD and is closely linked to suicidal behaviour.

    “Emotional and behavioural dysregulation is characteristic of BPD and is closely linked to suicidal behaviour [13].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [13] Sher L, et al. Clinical features and psychiatric comorbidities of borderline personality disorder patients with versus without a history of suicide attempt. Psychiatry Res. 2016;246:261–6. source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    An important aspect of BPD individuals' problems is their difficulty with regulating their relationships with other people and maintaining nurturing close interpersonal relationships over time.

    “An important aspect of BPD individuals’ problems is their difficulty with regulating their relationships with other people maintaining nurturing close interpersonal relationships over time [14].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [14] Linehan MM. Cognitive-behavioral treatment of borderline personality disorder. New York: Guilford Press; 1993.

      Not checked in the free run.

  • May combine two claims.

    Interpretationcitation

    The most prevalent PD diagnosis in the Thienpont study was Borderline PD, which although often a long-term condition, is not an incurable disorder.

    “The most prevalent PD diagnosis in this particular study was Borderline PD, which although often a long-term condition, is not, contrary to popular belief, an incurable disorder.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Premisecitation

    Over the past twenty years, treatment studies have shown that a diverse range of manualized treatments for BPD such as dialectical behaviour therapy, transference-focused psychotherapy, mentalization based therapy, or schema therapy are effective with medium to large effect sizes and remission achievable in a high percentage of cases.

    “Over the past twenty years, treatment studies have flourished showing that a diverse range of manualized treatments for BPD such as dialectical behaviour therapy (DBT), transference-focused psychotherapy (TFP), mentalization based therapy (MBT), or schema therapy are effective with medium to large effect sizes and remission achievable in a high percentage of cases [28, 29].”
    Quote in the paperSubstantial claim0 of 2 sources checked
    • cites [28] Cristea IA, et al. Efficacy of psychotherapies for borderline personality disorder: a systematic review and meta-analysis. JAMA Psychiatry. 2017;74(4):319–28. source

      Not checked in the free run.

    • cites [29] Stoffers JM, et al. Psychological therapies for people with borderline personality disorder. Cochrane Database Syst Rev. 2012;8:CD005652.

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S2 (checkable), S4 (based).

    Interpretationreasoning

    The current legislation and practice of EAS for people with personality disorders is based on an inadequate understanding of these peoples' needs and their potentials for having a life worth living.

    “We urgently call for a revision of the current legislation and practice of EAS for people with personality disorders which we believe, is currently based on an inadequate understanding of these peoples’ needs and their potentials for having a life worth living.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Interpretationreasoning

    An articulated death wish can be a symptom of the disorder and may in reality convey several other possible messages that have more to do with the patient feeling abandoned, disappointed or angry.

    “As we have pointed out above, such an articulated death wish, can be a symptom of the disorder and may in reality convey several other possible messages, that have more to do with the patient feeling abandoned, disappointed or angry.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S2 (checkable), S4 (based).

    Interpretationnone given

    The current lack of effective psychotropic medication to treat personality disorders could have made many physicians and psychiatrists not specializing in PD treatment less optimistic about the prognosis in people with PDs and the prospects of receiving effective treatment in general.

    “It may be that the current lack of effective psychotropic medication to treat personality disorders could have made many physicians and psychiatrists not specializing in PD treatment less optimistic about the prognosis in people with PDs and the prospects of receiving effective treatment in general.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Interpretationreasoning

    The current practice of EAS for people with personality disorders appears to be based on faulty assumptions about the underlying psychopathology and a lack of awareness about the contemporary treatment literature, particularly on borderline personality disorder.

    “This appears to be based on faulty assumptions about the underlying psychopathology and a lack of awareness about the contemporary treatment literature, particularly on borderline personality disorder.”
    Quote in the paperSubstantial claim
34 of 34

Claims other papers make about this one

Each is checked against this paper’s own text: does it say what the citing paper says it does?

  • There is an ethical distinction between helping a dying person die peacefully and providing death to a non-dying person.

    “the ethical distinction between helping a dying person die peacefully versus providing death to a non-dying person”

    From Debating Euthanasia and Physician-Assisted Death in People with Psychiatric Disorders (2022) · cites this paper as [20]

    The Background section, “A brief history of euthanasia” (page unavailable), describes euthanasia as facilitating dying without pain or suffering. The Discussion section, “Personality disorders and the wish for death” (page unavailable), urges treatment rather than assisted death when a death wish is a symptom of mental disorder. These passages support ethical caution about assisted death, but they do not state a general ethical distinction based on whether a person is already dying. (LLM, conf=0.74)

    Experimental — accuracy not yet measured

  • MAiD-NT may put vulnerable or marginalized people at risk of seeking death as a relief from poverty, loneliness, or other psychosocial stressors.

    “the difficulty that MAiD-NT may put vulnerable or marginalized people at risk of seeking death as a relief from poverty, loneliness, or other psychosocial stressors”

    From Debating Euthanasia and Physician-Assisted Death in People with Psychiatric Disorders (2022) · cites this paper as [20]

    The Results (page not provided) report that social isolation or loneliness was mentioned in 56% of reviewed EAS cases involving mental illness. The Conclusions and recommendations (page not provided) also warn that a wish for death may reflect feeling abandoned. The paper does not establish that poverty drives requests or specifically address a risk to marginalized people; its concern focuses on people with personality disorders. (LLM, conf=0.84)

    Experimental — accuracy not yet measured

  • The prognosis of non-terminal conditions such as most mental illnesses is unpredictable.

    “the unpredictability of prognosis of non-terminal conditions such as most mental illnesses”

    From Debating Euthanasia and Physician-Assisted Death in People with Psychiatric Disorders (2022) · cites this paper as [20]

    The Conclusions and recommendations question judgments that personality disorders have no prospect of improvement, and the Discussion describes changes over time in their symptoms and wishes for death. This supports caution about prognosis for personality disorders, but the paper does not establish that prognosis is unpredictable for most mental illnesses or compare them with terminal conditions. The indexed passages provide no page numbers. (LLM, conf=0.82)

    Experimental — accuracy not yet measured

  • People living with mental disorders may seek medical assistance in dying while not receiving the best treatments for their condition.

    “This suggests that people living with mental disorders may seek medical assistance in dying while not receiving the best treatments for their condition [63].”

    From Medical assistance in dying for people living with mental disorders: a qualitative thematic review (2023) · cites this paper as [63]

    The Results report that among patients with personality disorders in a Dutch EAS case review, most had received some psychotherapy but only one had received a standard disorder-specific evidence-based treatment. This supports the possibility described in the claim, but the evidence concerns personality disorders rather than mental disorders generally. (LLM, conf=0.83)

    Experimental — accuracy not yet measured

Self-check

Percentages, sums and reported differences re-computed from the paper’s own numbers.

Each contradiction between two passages listed here was confirmed by an independent check.

  • Only six listed jurisdictions legalized EAS after 2001

    Minor

    The table dates the Netherlands' law to 2001, not after 2001. Among the seven jurisdictions listed besides Switzerland, only six have dates later than 2001.

  • Four countries are said to allow EAS for minors with mental disorders

    Minor

    The table identifies six countries that allow EAS for mental illness. Of those, only the Netherlands and Belgium have age limits that clearly include minors; Switzerland has no regulation but says it is usually applied only to adults. The other three set a minimum age of 18, so the table does not support a count of four.

2 of 2

Cites

Flagged first, then by citations

Research works printed but not linked: 3

  1. Diller H. Hippokrates. Ausgewählte Schriften. Stuttgart: Reclam; 1994.
  2. Bando C. Assisted Death: Historical, Moral and Theological Perspectives of End of Life Options, in Loyola Law School, vol. 81. Los Angeles: Loyola Marymount University; 2018.
  3. RTE. Regional Euthanasia Review Committees - Annual Report 2018. 2019 [cited 2019 Dec 1]; Available from: www.euthanasiecommissie.nl.

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Authors
Mehlum, L., Schmahl, C., Berens, A., Doering, S., Hutsebaut, J., Kaera, A., Kramer, U., Moran, P. A., Renneberg, B., Ribaudi, J. S., Simonsen, S., Swales, M., Taubner, S., & di Giacomo, E.
Affiliations
  • University of Oslo (NO)
  • Heidelberg University (DE)
  • University of Antwerp (BE)
  • Medical University of Vienna (AT)
  • De Viersprong (NL)
  • Kanta-Hämeen Keskussairaala (FI)
  • University of Bristol (GB)
  • Freie Universität Berlin (DE)
  • Bangor University (GB)
  • University Hospital Heidelberg (DE)
Corresponding author
Mehlum, Lars
ORCID
Venue
Borderline Personality Disorder and Emotion Dysregulation
Publisher
Springer Science and Business Media LLC
Published
2020-07-30
Volume
7
Issue
1
Pages
15-15
ISSN
2051-6673 (ISSN-L)
DOI
10.1186/s40479-020-00131-9
PMC
PMC7391495
OpenAlex
W3045915061
Semantic Scholar
269074e32e4879d329e710e67548da0f97c88dfd
Cited by
42
References
30
Citations by year
2026: 4 · 2025: 6 · 2024: 10 · 2023: 12 · 2022: 5 · 2021: 5
FWCI
2.30
Type
journal article
Language
en
Open access
Licence
Locations
  • Borderline Personality Disorder and Emotion Dysregulation (publishedVersion, cc-by)
  • PubMed Central (publishedVersion, cc-by)
  • PubMed (publishedVersion)
  • Explore Bristol Research (publishedVersion)
  • SERVAL (Université de Lausanne) (publishedVersion, cc-by)
  • Dipòsit Digital de Documents de la UAB (Universitat Autònoma de Barcelona) (submittedVersion, cc-by)
  • IRIS (submittedVersion, cc-by)
  • BOA (University of Milano-Bicocca) (submittedVersion, cc-by)
  • DOAJ (DOAJ: Directory of Open Access Journals) (submittedVersion, cc-by-sa)
  • Bangor University Research Portal (Bangor University) (submittedVersion, other-oa)
  • NORA - Norwegian Open Research Archives (submittedVersion, cc-by)
Topics
  • Social Sciences › Psychology › Clinical Psychology › Personality Disorders and Psychopathology
  • 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, physician-assisted suicide, personality disorders, euthanasia legislation, psychotherapy, suicidal behavior, life worth living, end-of-life decisions

About these checks

Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.

Claims read by deepseek-v4.1-flash under definition version 3 (extract-v3) on 2026-10-08.

Classified by jev-1.13-20260917 (gold-guideline-v0.2) on 2026-10-08.

Statistics and arithmetic are recomputed, not judged.

Confidence bands are shown only for fields calibrated on our annotated test set. None is calibrated yet, so no band is shown.

What counts as a claim ›How we measure confidence ›How we check this ›

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