Should assisted dying for psychiatric disorders be legalized in Canada?
Open accessAbstract
The Supreme Court of Canada ruled in Carter v. Canada [1][1] that competent, consenting adults whose suffering is due to a “grievous and irremediable” medical condition should have access to some form of medical assistance in dying and invited Parliament to develop a regulatory regime along
AI snapshot
Written from the paper’s full text.
TL;DR
This commentary argues that legalizing assisted dying for psychiatric disorders in Canada would likely extend beyond severe refractory depression and place vulnerable patients at risk of premature death. It contends that broad, vague criteria for “irremediable” illness and capacity make reliable safeguards unlikely.
Key findings
- The paper argues that eligibility would not be limited to severe, refractory depression: in Belgium and the Netherlands, assisted dying has been provided to people with chronic schizophrenia, posttraumatic stress disorder, severe eating disorders, autism, personality disorders, and prolonged grief.
- A review of 66 Dutch case summaries found that most patients receiving assisted dying for a psychiatric condition were deemed to meet the “irremediable” criterion while refusing recommended treatments; physicians disagreed about medical futility in almost a quarter of cases and about capacity in 8 of 66 cases.
- In a Belgian case series, a psychiatrist assessed 100 consecutive psychiatric patients requesting assisted dying and deemed all 100 to have “no prospect of improvement” due to “treatment resistance”; 14 had psychotic disorders, and all 100 were deemed “capable.”
- The paper cites low approval: in a Netherlands survey, 28% of the public and 1 out of 3 health professionals approved of assisted dying for patients with psychiatric disorders; in a Canadian poll of 1517 people, only 22% supported legalizing it for psychological suffering. It also notes Belgium’s review commission found only 1 of more than 10,000 reported euthanasia cases failed to meet criteria.
Methods
- Design: a commentary/analysis article, not a primary empirical study, examining Canadian legal developments (Carter v. Canada, Bill C-14, Parliamentary Special Joint Committee recommendations) alongside evidence from Belgium and the Netherlands.
- Data/sample: cited published case series (100 Belgian patients), a review of 66 Dutch case summaries described as unpublished data, surveys of Dutch health care professionals and the public, a Canadian public opinion poll of 1517 people, and euthanasia review body reports.
- Analysis: argumentative synthesis of legal criteria, clinical assessments of irremediability and decision-making capacity, and review-body accountability to argue against legalizing assisted dying for psychiatric disorders.
Limitations
- Not stated in the paper: the article does not include a formal limitations section.
- Evident from the text: it is a commentary/argument rather than a systematic review or primary study, and it relies on selected published cases, surveys, and an unpublished review of Dutch case summaries.
Model-written summary. Check it against the paper before relying on it.
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Cites
Statistics
Claims the paper makes
0 of 22 cited sources checked · 0 supported · 0 flagged
- Findingown data
In the authors' review of 66 Dutch case summaries (unpublished data), most capacity determinations were reported as a simple global judgment of capacity, even for patients with disorders that increase the risk of incapacity.
“In our review of 66 case summaries in the Netherlands (unpublished data), the capacity determination in most cases was reported as a simple global judgment of capacity, even for patients with disorders that increase the risk of incapacity.”
Quote in the paperSubstantial claim- Rests on an assumption: Assessing capacity requires applying broad criteria to complex clinical situations.
- Findingcitation
In 8 of those 66 cases, physicians disagreed about the patient's capacity status.
“In 8 of the 66 cases, physicians disagreed about the patient's capacity status.6”
Quote in the paperSubstantial claim0 of 1 sources checked- cites [6]
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- Premisecitation
The evidence indicates that most such patients can reach remission with high-quality treatment.
“However, evidence suggests that most such patients can achieve remission if given high-quality treatment.7”
Quote in the paperSubstantial claim0 of 1 sources checked- cites [7]
Not checked in the free run.
- Interpretationcitation
If assisted dying were legalized for psychiatric conditions, eligibility would not be confined to severe, refractory depression.
“If assisted dying is legalized for patients with psychiatric conditions, it will not be just for severe, refractory depression.”
Quote in the paperSubstantial claim - Premisecitation
Belgian and Dutch practice has extended assisted dying to people with chronic schizophrenia, PTSD, severe eating disorders, autism, personality disorders, and prolonged grief.
“In Belgium and the Netherlands, medical assistance in dying has been provided to people with chronic schizophrenia, posttraumatic stress disorder, severe eating disorders, autism, personality disorders and even prolonged grief.5,6”
Quote in the paperSubstantial claim0 of 2 sources checked- cites [5]
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- cites [6]
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- Premisecitation
Most people seeking assisted dying for psychiatric reasons have traits that impair their ability to cope with adversity, such as personality disorders and social disconnection.
“Most people who request it for such reasons have characteristics that compromise their ability to cope with adversity, including personality disorders and social disconnection.6”
Quote in the paperSubstantial claim0 of 1 sources checked- cites [6]
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- Interpretationcitation
The eligibility criterion of an irremediable condition is inherently vague and unreliable, even for the severe cases that advocates usually cite when proposing to include psychiatric disorders.
“Furthermore, the key eligibility criterion of “irremediable” condition is inherently vague and unreliable, even when applied to the types of severe cases usually mentioned by those who advocate for including psychiatric disorders in the legislation for assisted dying.”
Quote in the paperSubstantial claim - Premisecitation
The Senate passed Bill C-14 even though it had first voted to remove the requirement that death be reasonably foreseeable.
“The Senate ultimately passed the bill, despite initially voting to remove the requirement for reasonably foreseeable death.4”
Quote in the paperNot a substantial claim0 of 1 sources checked- cites [4]
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- Interpretationreasoning
The Parliamentary Special Joint Committee's recommendation that irremediable does not require a patient to undergo treatments unacceptable to them could have especially serious consequences for patients with psychiatric conditions.
“The Parliamentary Special Joint Committee on Physician-Assisted Dying's recommendation that “irremediable … does not require the patient to undertake treatments that are not acceptable to the individual” could be particularly consequential for patients with psychiatric conditions.”
Quote in the paperNot a substantial claim - Interpretationreasoning
The evidence indicates that concentrating on severe depression is too narrow and overlooks genuine threats to patients with mental illness.
“However, evidence suggests this focus is too narrow and fails to consider real threats to patients with mental illness.”
Quote in the paperSubstantial claim - Interpretationcitation
On the basis of published Belgian and Dutch cases, a patient with 20 years of chronic depression, many medication trials, electroconvulsive therapy, and a current multi-year depressive episode would probably be judged to satisfy the irremediable criterion.
“Based on published cases in Belgium 5 and the Netherlands, 6 such a patient would likely be deemed to meet the “irremediable” criterion.”
Quote in the paperSubstantial claim0 of 2 sources checked- cites [5]
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- cites [6]
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- Premisecitation
Women request and receive assisted dying for psychiatric disorders more than twice as often as men.
“Women are more than twice as likely as men to request 4 and receive 5 assisted dying for psychiatric disorders, but we do not know why.”
Quote in the paperNot a substantial claim0 of 2 sources checked- cites [4]
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- cites [5]
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- Premisecitation
In a recent poll of 1,517 Canadians, only 22% supported legalizing assisted dying for psychological suffering.
“In a recent public opinion poll of 1517 Canadians, only 22% supported legalizing assisted dying for psychological suffering.12”
Quote in the paperNot a substantial claim0 of 1 sources checked- cites [12]
Not checked in the free run.
- Premisecitation
The number of people who have requested and received assisted dying for psychiatric reasons in countries that permit it appears to be increasing.
“But the pool of people who might request it because of a psychiatric disorder is potentially large, and the number who have requested and received it for such reasons in the countries that allow it appears to be on the rise.6,10”
Quote in the paperNot a substantial claim0 of 2 sources checked- cites [6]
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- cites [10]
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- Premisecitation
In a Belgian case series, a psychiatrist assessed 100 consecutive patients with psychiatric conditions who requested assisted dying, and all 100 were judged to have no prospect of improvement because of treatment resistance.
“In a case series, a psychiatrist assessed 100 consecutive cases of Belgian patients with psychiatric conditions who requested assisted dying; 5 all 100 patients were deemed have “no prospect of improvement” due to “treatment resistance,” which suggests vagueness of the applied criterion.”
Quote in the paperSubstantial claim0 of 1 sources checked- cites [5]
Not checked in the free run.
- Interpretationown data
The evidence indicates that rigorous thresholds with carefully articulated justifications are not necessarily used in capacity assessments.
“Evidence, however, indicates that this is not necessarily the case.”
Quote in the paperSubstantial claim- Rests on an assumption: Some psychiatric conditions, including psychotic illnesses, neurocognitive disorders, severe depression, anorexia nervosa, and intellectual disability, may raise the risk of incapacity, although a psychiatric diagnosis should not be equated with incapacity.
- Rests on an assumption: Assessing capacity requires applying broad criteria to complex clinical situations.
- Interpretationreasoning
There is a serious gap between the idealized basis on which assisted dying for patients with psychiatric conditions is advocated and the reality of its practice, as shown by evidence from Belgium and the Netherlands.
“There is a gap between the idealized basis upon which medical assistance in dying is advocated for patients with psychiatric conditions and the reality of its practice.”
- Also stated in: § Abstract · boosted
“We believe there is a serious gap between the idealized basis upon which assisted dying for patients with psychiatric conditions is advocated and the reality of its practice, as reflected in evidence from Belgium and the Netherlands.”
Quote in the paperSubstantial claim- Rests on an assumption: There is a lack of discussion and evidence-based guidance on evaluating people who request assisted dying because of prolonged grief, autism, schizophrenia, or personality disorders.
- Rests on an assumption: Some psychiatric conditions, including psychotic illnesses, neurocognitive disorders, severe depression, anorexia nervosa, and intellectual disability, may raise the risk of incapacity, although a psychiatric diagnosis should not be equated with incapacity.
- Rests on an assumption: Assessing capacity requires applying broad criteria to complex clinical situations.
- Rests on an assumption: The number of people who might request assisted dying because of a psychiatric disorder is potentially large.
- Also stated in: § Abstract · boosted
- Interpretationreasoning
Because the criteria used to regulate assisted dying are necessarily broad, legalizing it for psychiatric conditions will likely put already vulnerable patients at risk of premature death.
“Because of the necessarily broad criteria used to regulate assisted dying, legalizing the practice for psychiatric conditions will likely place already vulnerable patients at risk of premature death.”
- Also stated in: § Abstract · plain
“A policy for access to assisted dying by nonterminally ill patients with psychiatric conditions will put many vulnerable and stigmatized people at risk.”
Quote in the paperSubstantial claim- Rests on an assumption: The number of people who might request assisted dying because of a psychiatric disorder is potentially large.
- Also stated in: § Abstract · plain
- Premisecitation
In the Netherlands study, physicians disagreed about medical futility in nearly one quarter of cases.
“In fact, judgments of medical futility vary between physicians; in the Netherlands study, physicians disagreed about medical futility in almost a quarter of the cases.6”
Quote in the paperSubstantial claim0 of 1 sources checked- cites [6]
Not checked in the free run.
- Interpretationreasoning
The Belgian case series result, in which all 100 patients were judged to have no prospect of improvement due to treatment resistance, suggests that the applied criterion is vague.
“which suggests vagueness of the applied criterion.”
Quote in the paperSubstantial claim - Premisecitation
Some patients who request assisted dying for a psychiatric illness may not satisfy the criteria for mental capacity.
“A further concern is that some patients who request assisted dying because of a psychiatric illness may not meet the criteria for mental capacity.8”
Quote in the paperSubstantial claim0 of 1 sources checked- cites [8]
Not checked in the free run.
- Interpretationreasoning
The assumption that only patients with true irremediable depressive disorders would have access to assisted dying, after careful assessment of decision-making capacity using rigorous thresholds, is not supported by evidence.
“Specifically, the assumption that only patients with true irremediable depressive disorders would have access to assisted dying -after careful assessment of their decision-making capacity based on rigorous thresholds -is not supported by evidence.”
Quote in the paperSubstantial claim- Rests on an assumption: There is a lack of discussion and evidence-based guidance on evaluating people who request assisted dying because of prolonged grief, autism, schizophrenia, or personality disorders.
- Rests on an assumption: Some psychiatric conditions, including psychotic illnesses, neurocognitive disorders, severe depression, anorexia nervosa, and intellectual disability, may raise the risk of incapacity, although a psychiatric diagnosis should not be equated with incapacity.
- Rests on an assumption: Assessing capacity requires applying broad criteria to complex clinical situations.
- Rests on an assumption: The number of people who might request assisted dying because of a psychiatric disorder is potentially large.
- May combine two claims. 7
- Classified as probably not a substantial claim. 3
May combine two claims.
PremisecitationA review of 66 Dutch euthanasia case summaries found that most patients who received assisted dying for a psychiatric condition were judged to meet the criterion while refusing recommended treatments, and many probably did not receive all indicated treatments.
“A review of 66 case summaries of euthanasia published by Dutch regional euthanasia review committees found that most patients who received assisted dying for a psychiatric condition were deemed to have met the criterion while refusing recommended treatments; many likely did not receive all indicated treatments.6”
Quote in the paperSubstantial claim0 of 1 sources checked- cites [6]
Not checked in the free run.
Classified as probably not a substantial claim.
PremisecitationThe Parliamentary Special Joint Committee on Physician-Assisted Dying proposed that the grievous and irremediable criterion covers nonterminal conditions, including psychiatric disorders.
“The Parliamentary Special Joint Committee on Physician-Assisted Dying suggested that the “grievous and irremediable” criterion includes nonterminal medical conditions, including psychiatric disorders.2”
Quote in the paperSubstantial claim0 of 1 sources checked- cites [2]
Not checked in the free run.
Classified as probably not a substantial claim.
PremisecitationBill C-14 treated a grievous and irremediable condition as an advanced, irreversible loss of capabilities in someone whose natural death was reasonably foreseeable.
“The federal government's Bill C-14, on the other hand, defined “grievous and irremediable” as an “advanced state of irreversible decline in capabilities” in a person for whom “natural death has become reasonably foreseeable.”3”
Quote in the paperSubstantial claim0 of 1 sources checked- cites [3]
Not checked in the free run.
May combine two claims.
PremisereasoningUnder the new law, people near death are not differentiated by disorder or disability, including psychiatric disorder, yet a psychiatric disorder would not meet the access criteria for assisted dying.
“The new law does not discriminate among people near death based on their disorder or disability, psychiatric or otherwise; however, assisted dying because of a psychiatric disorder would not fulfill the access criteria.”
Quote in the paperSubstantial claimMay combine two claims.
PremisecitationIn a survey of consultant psychiatrists, most said that assessing decision-making capacity is challenging, and training in capacity evaluations was viewed as inadequate.
“In a survey of consultant psychiatrists, most reported that they find assessment of decision-making capacity to be a challenging task, and training in capacity evaluations was seen as suboptimal.9”
Quote in the paperSubstantial claim0 of 1 sources checked- cites [9]
Not checked in the free run.
May combine two claims.
PremisecitationBelgian and Dutch euthanasia review bodies almost never find that doctors breached the due care criteria; the Belgian review commission found only 1 failure among more than 10,000 reported euthanasia cases.
“However, it is worth noting that the Belgian and Dutch euthanasia review bodies almost never find that doctors have breached the due care criteria; the Belgian review commission found that only 1 out of more than 10 000 reported euthanasia cases failed to meet the criteria.10”
Quote in the paperSubstantial claim0 of 1 sources checked- cites [10]
Not checked in the free run.
May combine two claims.
InterpretationreasoningIt is unlikely that doctors virtually never err in eligibility evaluations for assisted dying; a more plausible explanation is that broad and vague criteria make it hard to hold doctors accountable.
“It seems improbable that doctors virtually never make a mistake when it comes to eligibility evaluations for assisted dying; it is more likely that broad and vague criteria make it difficult to hold doctors accountable.”
Quote in the paperSubstantial claimMay combine two claims.
PremisecitationIn a Dutch survey, only 28% of the public and one third of health professionals approved of assisted dying for patients with psychiatric disorders.
“In a survey of health care professionals and members of the general public in the Netherlands, only 28% of the public and 1 out of 3 health professionals approved of it for patients with psychiatric disorders.11”
Quote in the paperNot a substantial claim0 of 1 sources checked- cites [11]
Not checked in the free run.
Probably not a substantial claim: may not pass S4 (based). May combine two claims.
InterpretationreasoningBecause the Parliamentary Special Joint Committee recommends that eventually competent mature minors, including those with a psychiatric condition, should be eligible for assisted dying-a practice even Belgium forbids-it is conceivable that without clear wording in Bill C-14, young people with psychological issues could become eligible.
“Because the Parliamentary Special Joint Committee recommends that, eventually, competent mature minors should be eligible for assisted dying, even those with a psychiatric condition (a practice that even the liberal Belgian regime forbids), it is conceivable that without clear wording in Bill C-14, young people struggling with psychological issues could be eligible for assisted dying.”
Quote in the paperNot a substantial claim- Rests on an assumption: The Parliamentary Special Joint Committee recommended prohibiting prior review by a panel or judge and suggested that retrospective review would be sufficient.
The paper relies on this without support.
There is a lack of discussion and evidence-based guidance on evaluating people who request assisted dying because of prolonged grief, autism, schizophrenia, or personality disorders.
“Discussions, much less evidence-based guidance, of how to evaluate people who request assisted dying because of prolonged grief, autism, schizophrenia or personality disorders are lacking.”
The paper relies on this without support.
Some psychiatric conditions, including psychotic illnesses, neurocognitive disorders, severe depression, anorexia nervosa, and intellectual disability, may raise the risk of incapacity, although a psychiatric diagnosis should not be equated with incapacity.
“Although psychiatric diagnoses should not be equated with incapacity, some conditions (e.g., psychotic illnesses, neurocognitive disorders, severe depression, anorexia nervosa and intellectual disability) may increase the risk of incapacity.”
The paper relies on this without support.
Assessing capacity requires applying broad criteria to complex clinical situations.
“Evaluating capacity involves applying broad criteria to complex clinical situations.”
The paper relies on this without support.
The Parliamentary Special Joint Committee recommended prohibiting prior review by a panel or judge and suggested that retrospective review would be sufficient.
“Importantly, the Parliamentary Special Joint Committee also recommended that a prior review system by a panel or judge be prohibited, and it suggested that a retrospective review system would be sufficient.”
The paper relies on this without support.
The number of people who might request assisted dying because of a psychiatric disorder is potentially large.
“But the pool of people who might request it because of a psychiatric disorder is potentially large”
The paper relies on this without support.
Arguments for including mental illness as an eligible condition for assisted dying almost always focus on severe depression.
“Arguments for including mental illness as an eligible condition for assisted dying almost always focus on severe depression.”
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?
Much of the scientific literature on ADE consists of opinion pieces and relies on ethical debates.
“Empirical research on ADE using data is sparse [1], and much of the scientific literature—often consisting of opinion pieces [2,3]—relies on ethical debates [4].”
From Trends in assisted dying among patients with psychiatric disorders and dementia in Belgium: A health registry study (2025) · cites this paper as [3]
Capacity assessments performed in the Netherlands for psychiatric patients seeking assistance in dying have been limited to global assessments rather than more granular, cautious evaluations.
“Capacity assessments performed in the Netherlands for psychiatric patients seeking assistance in dying, for instance, have been limited to global assessments of decision-making capacity, as opposed to more granular, cautious evaluations [9].”
From Is the exclusion of psychiatric patients from access to physician-assisted suicide discriminatory? (2019) · cites this paper as [9]
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A Right to Physician-Assisted Suicide by Stopping Eating and Drinking?
Keown, J. (2018) · Cambridge University Press eBooks · doi:10.1017/9781107337909.020
Keown, J. (2018) · Cambridge University Press eBooks · doi:10.1017/9781107337909.030
Keown, J. (2018) · Cambridge University Press eBooks · doi:10.1017/9781107337909.013
Keown, J. (2018) · Cambridge University Press eBooks · doi:10.1017/9781107337909.027
Keown, J. (2018) · Cambridge University Press eBooks · doi:10.1017/9781107337909.029
Keown, J. (2018) · Cambridge University Press eBooks · doi:10.1017/9781107337909.001
Keown, J. (2018) · Cambridge University Press eBooks · doi:10.1017/9781107337909.011
Keown, J. (2018) · Cambridge University Press eBooks · doi:10.1017/9781107337909.010
Keown, J. (2018) · Cambridge University Press eBooks · doi:10.1017/9781107337909.024
Keown, J. (2018) · Cambridge University Press eBooks · doi:10.1017/9781107337909.008
Keown, J. (2018) · Cambridge University Press eBooks · doi:10.1017/9781107337909.022
Keown, J. (2018) · Cambridge University Press eBooks · doi:10.1017/9781107337909.018
Canada’s Euthanasia Legislation
Keown, J. (2018) · Cambridge University Press eBooks · doi:10.1017/9781107337909.028
Assisted Suicide for the Elderly with ‘Completed Lives’
Keown, J. (2018) · Cambridge University Press eBooks · doi:10.1017/9781107337909.021
Keown, J. (2018) · Cambridge University Press eBooks · doi:10.1017/9781107337909.019
Keown, J. (2018) · Cambridge University Press eBooks · doi:10.1017/9781107337909.014
Keown, J. (2018) · Cambridge University Press eBooks · doi:10.1017/9781107337909.031
Keown, J. (2018) · Cambridge University Press eBooks · doi:10.1017/9781107337909.016
Keown, J. (2018) · Cambridge University Press eBooks · doi:10.1017/9781107337909.032
Keown, J. (2018) · Cambridge University Press eBooks · doi:10.1017/9781107337909.004
Keown, J. (2018) · Cambridge University Press eBooks · doi:10.1017/9781107337909.015
Wels, J., & Hamarat, N. (2025) · medRxiv · doi:10.1101/2025.01.09.25320248
Psychological Suffering and the Right to Die: An Islamic Legal Assessment of Euthanasia Requests
Baydar, T. E., & Çelik, R. E. (2026) · Religions · doi:10.3390/rel17060635 · Cited by 1 · see citing works
Marrone, M., Bellacicco, R., Paladini, E., Nuzzo, N., Losacco, D., Isceri, D., Pulin, G., Pititto, F., Viola, G., Violante, M. G., et al. (2026) · International Journal of Law and Psychiatry · doi:10.1016/j.ijlp.2026.102291
- Authors
- Kim, S. Y. H., & Lemmens, T.
- Affiliations
- National Institutes of Health (US)
- Venue
- Canadian Medical Association Journal
- Publisher
- CMA Joule Inc.
- Published
- 2016-06-21
- Volume
- 188
- Issue
- 14
- Pages
- E337-E339
- ISSN
- 0820-3946 (ISSN-L)
- 1488-2329
- PMC
- PMC5047832
- OpenAlex
- W2463987358
- Semantic Scholar
- 1cfee7beb29c84f0b61967c54ebf4ae50f898318
- Cited by
- 68
- References
- 7
- Citations by year
- 2026: 2 · 2025: 2 · 2023: 2 · 2022: 3 · 2021: 5 · 2020: 2 · 2019: 6 · 2018: 38 · 2017: 4 · 2016: 4
- FWCI
- 32.29
- Type
- journal article
- Language
- en
- Open access
- gold
- doi.org
- Locations
- Canadian Medical Association Journal (publishedVersion)
- Europe PMC (PubMed Central) (publishedVersion)
- PubMed Central (publishedVersion)
- PubMed (publishedVersion)
- TSpace (University of Toronto) (submittedVersion, cc-by-nc-nd)
- Topics
- Health Sciences › Health Professions › General Health Professions › Health, Medicine and Society
- 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
- Keywords
- assisted dying, medical assistance in dying, mental illness, euthanasia, Carter v. Canada, Supreme Court of Canada, legalization, end-of-life decisions, Canada
- MeSH terms
- Mental Disorders, Belgium, Canada, Eligibility Determination, Humans, Netherlands, Mental Competency, Suicide, Assisted
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