Euthanasia and assisted suicide in the context of psychiatric disorders: sharing experiences from the Low Countries

Feeling that their suffering is acknowledged and having the opportunity to talk about their request for MAiD-MD can ease the suffering of people living with mental disorders, give them hope, build trust in the therapeutic relationship, and lead them to consider new therapeutic avenues, or decrease their desire to die.

“Feeling that their suffering is acknowledged and having the opportunity to talk about their request for MAiD-MD can ease the suffering of people living with mental disorders, give them hope, build trust in the therapeutic relationship, and lead them to consider new therapeutic avenues, or decrease their desire to die [20, 58].”

In the Netherlands, the number of MAiD-NT cases increased from n = 2 in 2011 to n = 83 in 2017.

“In the Netherlands, the number of MAiD-NT cases increased from 2011 (n = 2) to 2017 (n = 83) [64]”

In facilitating access to EAS for individuals with SE-AN, there is a significant gender skew and psychiatric diagnoses within the use of EAS in some countries (i.e., eating disorders, personality disorders, trauma, autism).

“we must also consider the significant gender skew and psychiatric diagnoses within the use of EAS in some countries (i.e., eating disorders, personality disorders, trauma, autism) [71–73].”

In jurisdictions where psychiatric EAS is permitted, regulatory models rely on reinforced safeguards designed to ensure voluntariness, informed consent, and protection of vulnerable individuals.

“In jurisdictions where psychiatric EAS is permitted, regulatory models rely on reinforced safeguards designed to ensure voluntariness, informed consent, and protection of vulnerable individuals”

In the Netherlands and Belgium, EAS for mental disorders has been regulated for over a decade within detailed procedural frameworks requiring multiple independent consultations, documentation of exhaustive treatment attempts, and ex post review by national commissions.

“In the Netherlands and Belgium, EAS for mental disorders has been regulated for over a decade within detailed procedural frameworks requiring multiple independent consultations, documentation of exhaustive treatment attempts, and ex post review by national commissions”

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”

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”

Literature from the Netherlands and Belgium describes a system characterized by reinforced safeguards and multilayered oversight.

“Literature from the Netherlands and Belgium, the two countries with the longest-standing regulation of EAS for mental disorders, describes a system characterized by reinforced safeguards and multilayered oversight.”

The available evidence indicates that decision reliability tends to increase when assessments are conducted longitudinally, involve multidisciplinary input, and are supported by detailed clinical documentation.

“The available evidence indicates that decision reliability tends to increase when assessments are conducted longitudinally, involve multidisciplinary input, and are supported by detailed clinical documentation”

The literature delineates at least two predominant bioethical orientations: a liberal-autonomist model, exemplified by the Netherlands and Belgium, which prioritizes self-determination, and a precautionary model, reflected in jurisdictions such as Italy, which emphasizes vulnerability protection and minimization of evaluative error.

“From a comparative perspective, the literature delineates at least two predominant bioethical orientations: a liberal–autonomist model, exemplified by the Netherlands and Belgium, which prioritizes self-determination, and a precautionary model, reflected in jurisdictions such as Italy, which emphasizes vulnerability protection and minimization of evaluative error ( 4 , 7 – 9 ).”

Approvals for EAS in young adults are rare and typically subject to heightened evaluative thresholds, given the fluctuating nature of psychological suffering in youth and its responsiveness to relational and social interventions.

“As noted by Schweren and other Dutch authors, approvals in this age group are rare and typically subject to heightened evaluative thresholds, given the fluctuating nature of psychological suffering in youth and its responsiveness to relational and social interventions ( 3 , 7 ).”

Evaluating decision-making capacity in psychiatric EAS cannot be reduced to a one-time certification, but must be conceived as a structured, repeated clinical-evaluative process embedded in a multidisciplinary framework that balances protection of autonomy with safeguarding of vulnerability.

“evaluating decision-making capacity in psychiatric EAS cannot be reduced to a one-time certification, but must be conceived as a structured, repeated clinical-evaluative process embedded in a multidisciplinary framework that balances the protection of autonomy with the safeguarding of vulnerability”

The commission serves as an institutional forum for integrating expertise, more effectively balancing autonomy and protection than decisions made by individual clinicians.

“In this configuration, the commission serves as an institutional forum for integrating expertise, more effectively balancing autonomy and protection than decisions made by individual clinicians ( 3 , 7 , 9 ).”

Documented longitudinal assessment emerges as a key safeguard in psychiatric contexts.

“In light of these factors, documented longitudinal assessment emerges as a key safeguard in psychiatric contexts ( 3 , 7 , 8 ).”

Longitudinal assessment allows clinicians to track the stability or evolution of the patient's will over time, reducing the risk of making irreversible decisions during acute psychopathological episodes or transient crises.

“Longitudinal assessment also allows clinicians to track the stability or evolution of the patient’s will over time, reducing the risk of making irreversible decisions during acute psychopathological episodes or transient crises ( 3 , 7 ).”

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 ).”