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Cited by 19Ethics and bioethics in healthcarePalliative and Oncologic CarePalliative Care and End-of-Life Issues

Medical Assistance in Dying: Challenges for Psychiatry

Open access
Jones, Roland M., Simpson, Alexander I. F.·2018·Frontiers in Psychiatry
DOI 10.3389/fpsyt.2018.00678PMC PMC6295549
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Abstract

Medical Assistance in Dying (MAiD), which comprises euthanasia and medically assisted suicide, is practiced in a growing number of countries and jurisdictions. In countries where it is permitted, the individual who requests it must be experiencing severe pain and suffering, but not all countries require the individual to be terminally ill. In some countries the suffering may be caused by a mental disorder in the absence of physical illness or disease. The consideration of mental illness as the sole indication for MAiD is likely to be considered in more jurisdictions. However, the ethical duties of a doctor to promote health, reduce suffering and protect life may conflict with one another when viewed from the perspective of MAiD. Arguments in favour of including mental illness as a sole qualifier for MAiD include the respect for the autonomy of the individual, and the equivalence of mental illness with physical illness. Arguments against, include the view that the protection of life is paramount, and the “slippery slope” of ever more permissive practices that fail to protect the vulnerable in society. Given the ethical and other practical concerns, there is a need for psychiatric bodies internationally to provide guidance on this issue.

AI snapshot

Written from the paper’s full text.

TL;DR

This commentary reviews legal and ethical challenges raised by medical assistance in dying (MAiD) when mental illness is the primary or sole condition. It summarizes arguments for and against extending MAiD to serious mental illness and calls for international psychiatric bodies to develop guidance.

Key findings

  • MAiD in at least one form is permitted in Belgium, Canada, Columbia, Germany, Luxemburg, Netherlands, Switzerland, and seven US jurisdictions, with case law but no federal law in Japan; active euthanasia is permitted in only five countries—Belgium, Netherlands, Luxembourg, Columbia, and Canada—and recent legislation enacted permission in Hawaii.
  • Four jurisdictions permit MAiD for non-terminal disorders including mental illness as the primary or only cause of suffering: Belgium, the Netherlands, Luxembourg, and Switzerland; Canada’s position is described as ambiguous and under debate. Psychiatric MAiD is relatively uncommon but appears to be rising in Belgium and the Netherlands, for a diverse range of disorders and emotional states including personality disorders and loneliness.
  • Table 1 reports annual figures including Belgium 1,807 (2014), Netherlands 5,516 (2015), Switzerland 1,004 (2015), Canada approximately 1,500 per year since introduction, Oregon 105 (2015), Washington 212 (2016), California 111 (2016), Colorado 50 (2017), Luxembourg 10 (2016), Vermont 13 approximately per year, Columbia 10–15 approximately per year, and District of Columbia 0.
  • The American Psychiatric Association and Royal Australian and New Zealand College of Psychiatrists have considered and rejected MAiD for people who request it for mental disorder; the WPA has not formally adopted a position, while the Madrid Declaration emphasizes promotion of health, reduction of suffering, protection of life, and caution that patients’ views may be distorted by mental illness such as depression.

Methods

  • Design: narrative commentary/review of legal and ethical issues; the authors state they wish to briefly summarize the ethical debates for and against MAiD for mental illness.
  • Data/sample: jurisdictional MAiD provisions summarized in Table 1 (countries and US states, legislation, eligibility criteria, annual numbers) and selected literature on psychiatric MAiD and ethics.
  • Analysis: narrative synthesis of arguments for MAiD (autonomy vs. paternalism; equivalence with physical illness) and against it (protection of life is paramount; the slippery slope), with reference to professional body positions and the Madrid Declaration.

Limitations

  • The paper does not report a formal limitations section. It states that the literature on MAiD for non-terminal disorders is “small but building,” that Canada’s position is ambiguous in law and currently subject to debate, and that the WPA has not formally adopted a position.
  • Evident from the text: no systematic search strategy or inclusion criteria are described, and the table’s annual figures come from different years (footnotes a–e) with some values unknown or approximate, limiting comparability.
  • Evident from the text: the ethical arguments are presented as debate rather than empirical findings, and no primary data collection or outcome analysis is reported.

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

Integrity signals

Registry

Crossref · 10.3389/fpsyt.2018.00678

Cites

13 of 13 references verified0 citation errors · 0 not checkable

Statistics

Nothing to recompute.

Claims the paper makes

0 of 12 cited sources checked · 0 supported · 0 flagged

  • Premisecitation
    § Medical Assistance in Dying: Challenges for Psychiatry

    The American Psychiatric Association and the Royal Australian and New Zealand College of Psychiatrists have considered and rejected the use of MAiD for people who request it for mental disorder.

    “The American Psychiatric Association [APA (10)] and the Royal Australian and New Zealand College of Psychiatrists [RANZCP (11)] have considered and rejected the use of MAiD for people who request it for mental disorder.”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites [10] Position Statement on Medical Euthanasia 2016

      Not checked in the free run.

    • cites [11] Position Statement 67: Physician Assisted Suicide. 2016

      Not checked in the free run.

  • Interpretationreasoning
    § Medical Assistance in Dying: Challenges for Psychiatry

    What distinguishes the four European countries from the rest of the world is that MAiD can be accessed by people who have non-terminal conditions including mental illness as the primary or only cause of suffering.

    “What distinguishes the four European countries from the rest of the world (Canada's position is ambiguous in law and is currently subject to debate), is that MAiD can be accessed by people who have non-terminal conditions including mental illness as the primary or only cause of suffering.”
    Quote in the paperSubstantial claim
  • Premisecitation
    § Medical Assistance in Dying: Challenges for Psychiatry

    Outside this, mental illnesses are not terminal.

    “Outside this, mental illnesses are not terminal (13).”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [13] Simpson, 2018, Medical assistance in dying and mental health: a legal, ethical, and clinical analysis, Can J Psychiatry Rev Can Psychiatrie source

      Not checked in the free run.

  • Premisecitation
    § Medical Assistance in Dying: Challenges for Psychiatry

    MAiD for non-terminal disorders is permitted in Belgium, the Netherlands, Luxembourg, and Switzerland.

    “MAiD for non-terminal disorders is permitted in Belgium, the Netherlands, Luxembourg, and Switzerland.”
    Quote in the paperSubstantial claim
  • May combine two claims. 7
  • Classified as probably not a substantial claim. 9

  • May combine two claims.

    Findingcitation
    § Medical Assistance in Dying: Challenges for Psychiatry

    Psychiatric MAiD is relatively uncommon, but its use appears to be rising in Belgium and the Netherlands and for a diverse range of disorders and emotional states, including personality disorders and loneliness.

    “Although psychiatric MAID is relatively uncommon, its use appears to be rising in Belgium and the Netherlands and for a diverse range of disorders and emotional states, including personality disorders and loneliness (2, 3).”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites [2] Kim, 2016, Euthanasia and assisted suicide of patients with psychiatric disorders in the Netherlands 2011 to 2014, JAMA Psychiatry source

      Not checked in the free run.

    • cites [3] Thienpont, 2015, Euthanasia requests, procedures and outcomes for 100 Belgian patients suffering from psychiatric disorders: a retrospective, descriptive study, BMJ Open source

      Not checked in the free run.

  • Classified as probably not a substantial claim.

    Premisecitation

    The APA and RANZCP positions emphasize that there is a profound ethical duty of a doctor that cannot be reconciled with participation in the killing of a patient.

    “The APA and RANZCP positions on this issue emphasize that there is a profound ethical duty of a doctor that cannot be reconciled with participation in the killing of a patient.”
    Quote in the paperSubstantial claim0 of 2 sources checked
    • cites [10] Position Statement on Medical Euthanasia 2016

      Not checked in the free run.

    • cites [11] Position Statement 67: Physician Assisted Suicide. 2016

      Not checked in the free run.

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

    Interpretationnone given
    § Medical Assistance in Dying: Challenges for Psychiatry

    The consideration of mental illness as the primary indication for MAiD is likely to be encountered in more jurisdictions.

    “However, the consideration of mental illness as the primary indication for MAiD is likely to be encountered in more jurisdictions.”
    Quote in the paperNot a substantial claim

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

    Premisenone given
    § Medical Assistance in Dying: Challenges for Psychiatry

    A number of jurisdictions and medical bodies accept that in terminal illness, when death is imminent, the relief of suffering and respect for a competent wish to die supersedes the ethical duty to protect life.

    “A number of jurisdictions and medical bodies accept that in terminal illness, when death is imminent (see table), the relief of suffering and respect for a competent wish to die supersedes the ethical duty to protect life.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Premisecitation
    § Medical Assistance in Dying: Challenges for Psychiatry

    Most tests of competence to consent to medical treatment require that the person can 'weigh' the information and 'appreciate' consequences of their decision, yet the ability to do this may be impaired by the effects of mental disorder.

    “Most tests of competence to consent to medical treatment require that the person can “weigh” the information and “appreciate” consequences of their decision (7), yet the ability to do this may be impaired by the effects of mental disorder.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [7] Grisso, 1998 source

      Not checked in the free run.

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

    Premisenone given
    § Medical Assistance in Dying: Challenges for Psychiatry

    Switzerland and Germany in some circumstances allow aid in dying by people other than doctors.

    “Switzerland and Germany in some circumstances, allow aid in dying by people other than doctors.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Premisecitation

    There is a risk that practices are prone to abuse, and that there is a 'slippery slope' of ever more permissive practices that will fail to protect those who are most in need of protection.

    “There is a risk that practices are prone to abuse, and that there is a “slippery slope” of ever more permissive practices that will fail to protect those who are most in need of protection (15).”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [15] Pereira, 2011, Legalizing euthanasia or assisted suicide: the illusion of safeguards and controls, Curr Oncol source

      Not checked in the free run.

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

    Interpretationnone given
    § Medical Assistance in Dying: Challenges for Psychiatry

    The mental illness that might rarely be seen as meeting end of life care criteria is likely confined to a small group of persons with intractable anorexia nervosa for whom their mental illness can result in serious medical sequelae similar to conditions seen in end of life cases.

    “The mental illness that might rarely be seen as meeting end of life care criteria is likely confined to a small group of persons with intractable anorexia nervosa for whom their mental illness can result in serious medical sequelae similar to conditions seen in end of life cases.”
    Quote in the paperNot a substantial claim

  • Classified as probably not a substantial claim.

    Premisecitation
    § Medical Assistance in Dying: Challenges for Psychiatry

    The Madrid Declaration emphasizes three medical duties: to promote health, relieve suffering and protect life.

    “The Madrid Declaration emphasizes three medical duties: to promote health, relieve suffering and protect life.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [12] Madrid Declaration on Ethical Standards for Psychiatric Practice

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    There is a small but growing literature on 'palliative' mental health care that asserts the need to recognize that current treatments, acceptable to the person, will still leave the person suffering and that as with some physical illnesses, recovery or cure is not obtainable.

    “Indeed, there is a small but growing literature on “palliative” mental health care that asserts the need to recognize that current treatments, acceptable to the person, will still leave the person suffering and, that as with some physical illnesses, recovery or cure is not obtainable (14).”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [14] Dembo, 2018, For their own good: a response to popular arguments against permitting Medical Assistance in Dying (MAID) where mental illness is the sole underlying condition, Can J Psychiatry Rev Can Psychiatrie source

      Not checked in the free run.

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

    Interpretationreasoning
    § Medical Assistance in Dying: Challenges for Psychiatry

    In considering MAiD in non-terminal disorders, these duties may be seen to be in conflict with one another.

    “However, in considering MAiD in non-terminal disorders, these duties may be seen to be in conflict with one another.”
    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
    § Medical Assistance in Dying: Challenges for Psychiatry

    Active euthanasia is currently permitted in only five countries: Belgium, Netherlands, Luxembourg, Columbia, and Canada; recent legislation enacted permission in Hawaii.

    “Active euthanasia is currently permitted in only five countries, namely Belgium, Netherlands, Luxembourg, Columbia and Canada, and recent legislation enacted permission in Hawaii.”
    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
    § Medical Assistance in Dying: Challenges for Psychiatry

    MAiD in at least one of its forms is permitted in Belgium, Canada, Columbia, Germany, Luxemburg, Netherlands, Switzerland, and seven jurisdictions of the USA, and there is case law but no federal law permitting MAiD in Japan.

    “MAiD in at least one of its forms is permitted in Belgium, Canada, Columbia, Germany, Luxemburg, Netherlands, Switzerland, and seven jurisdictions of the USA (see Table 1), and there is case law, but no federal law that has permitted MAiD in Japan.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Premisecitation
    § Medical Assistance in Dying: Challenges for Psychiatry

    The majority of jurisdictions where MAiD is permitted require that the individual is terminally ill, but four jurisdictions have broader criteria including non-terminal disorders causing intractable or unbearable pain or a grievous and irredeemable medical condition.

    “The majority of jurisdictions where MAiD is permitted require that the individual is terminally ill, but four jurisdictions have further criteria for MAiD that include a broader range of situations in which a non-terminal disorder causes the person “intractable” or “unbearable pain” or is “a grievous and irredeemable medical condition” (1).”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [1] Emanuel, 2016, Attitudes and practices of euthanasia and physician-assisted suicide in the United States, Canada, and Europe, JAMA source

      Not checked in the free run.

14 of 14

  • The paper relies on this without support.

    The WPA has not formally adopted a position on MAiD as applied to psychiatric conditions.

    “The WPA has not formally adopted a position on MAiD as applied to psychiatric conditions.”

  • The paper relies on this without support.

    Serious mental illness can be a painful, irremediable and severe illness that causes great suffering.

    “There is little doubt that serious mental illness can be a painful, irremediable and severe illness that causes great suffering.”

  • The paper relies on this without support.

    Treatments for serious mental illness may be only partially effective, and may result in side effects intolerable for the person.

    “Treatments may be only partially effective, and may result in side effects intolerable for the person.”

  • The paper relies on this without support.

    For some, the prognosis for relief of symptoms is poor and, despite symptoms of their illness impairing aspects of their function, the person can still competently evaluate their treatment options and chances of their recovery.

    “For some the prognosis for relief of symptoms is poor and, despite symptoms of their illness impairing aspects of their function, the person can still competently evaluate their treatment options and chances of their recovery.”

  • The paper relies on this without support.

    Doctors have little ability to predict who will suffer unremittingly and who will recover partially or fully.

    “they have little ability to predict who will suffer unremittingly and who will recover partially or fully.”

  • The paper relies on this without support.

    There are palliative treatments and other approaches to relieve suffering.

    “There are also palliative treatments and other approaches to relieve suffering.”

  • The paper relies on this without support.

    For patients, that which seemed to be overwhelming may eventually change and become tolerable.

    “For patients, that which seemed to be overwhelming may eventually change and become tolerable.”

  • The paper relies on this without support.

    Doctor's opinions as to the patient's prognosis and competence to make this irreversible decision may be prone to error, not based on scientific evidence, and based on the values and moral judgment of the individual doctor.

    “Doctor's opinions as to the patient's prognosis and competence to make this irreversible decision may be prone to error, not based on scientific evidence, and based on the values and moral judgment of the individual the doctor.”

  • The paper relies on this without support.

    Patients must have confidence in the medical profession, and there is risk of erosion through physician's involvement in roles that may be seen to be at odds with their duty to treat illness and promote health.

    “Patients must have confidence in the medical profession, and there is risk of erosion through physician's involvement in roles that may be seen to be at odds with their duty to treat illness and promote health.”
9 of 9

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?

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.

  • Luxembourg is described as permitting and requiring non-terminal conditions

    Major

    The text identifies Luxembourg as permitting MAiD for non-terminal disorders, while Table 1 describes its provision as being for terminal diseases.

  • Twelve-month eligibility conflicts with a six-month prognosis requirement

    Minor

    The US-jurisdiction table comments allow a 12-month prognosis for a neurodegenerative condition but also require another physician to confirm less than six months to live. On those stated requirements, a patient with seven to twelve months to live could not qualify.

2 of 2

Cites

Flagged first, then by citations

Research works printed but not linked: 1

  1. Position Statement on Medical Euthanasia 2016

Cited by

Sorted by citations

Related

Authors
Jones, R. M., & Simpson, A. I. F.
Affiliations
Centre for Addiction and Mental Health (CA)
Corresponding author
Jones, Roland M.
ORCID
Venue
Frontiers in Psychiatry
Publisher
Frontiers Media SA
Published
2018-12-10
Volume
9
Pages
678-678
ISSN
1664-0640 (ISSN-L)
DOI
10.3389/fpsyt.2018.00678
PMC
PMC6295549
OpenAlex
W2903660685
Semantic Scholar
518aad4f73276c907fe7dc0e99be879842280aa3
Cited by
18
References
13
Citations by year
2026: 1 · 2025: 1 · 2024: 4 · 2023: 1 · 2022: 2 · 2021: 6 · 2020: 3
FWCI
2.15
Type
journal article
Language
en
Open access
Licence
Locations
  • Frontiers in Psychiatry (publishedVersion, cc-by)
  • Europe PMC (PubMed Central) (publishedVersion, cc-by)
  • PubMed Central (publishedVersion, cc-by)
  • PubMed (publishedVersion)
  • DOAJ (DOAJ: Directory of Open Access Journals) (submittedVersion, cc-by-sa)
Funders
  • University of Toronto
  • Department of Psychiatry, University of Toronto
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
medical assistance in dying, euthanasia, assisted suicide, mental illness, patient autonomy, protection of life, slippery slope, vulnerable populations

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