Assisted Suicide and Euthanasia in Mental Disorders: Ethical Positions in the Debate between Proportionality, Dignity, and the Right to Die

Abstract

The admission of people suffering from psychiatric and neurocognitive disorders to euthanasia and physician-assisted suicide (E/PAS) in some European and non-European countries represents a controversial issue. In some countries, the initial limitation of E/PAS to cases of severe physical illness with poor prognosis in the short term has been overcome, as it was considered discriminatory; thus, E/PAS has also been made available to subjects suffering from mental disorders. This decision has raised significant ethical questions regarding the capacity and freedom of self-determination; the family, social, and economic contexts; the social consideration of the sense of dignity and the pressure on the judgment of one’s personal value; the contextual therapeutic possibilities; the identification of figures involved in the validation and application; as well as the epistemological definitions of the clinical conditions in question. To these issues must be added the situation of legislative vacuum peculiar to different countries and the widespread lack of effective evaluation and control systems. Nonetheless, pessimistic indicators on global health status, availability of care and assistance, aging demographics, and socioeconomic levels suggest that there may be further pressure toward the expansion of such requests. The present paper aims to trace an international overview with the aim of providing ethical support to the debate on the matter. Precisely, the goal is the delimitation of foundations for clinical practice in the complex field of psychiatry between the recognition of the irreversibility of the disease, assessment of the state of physical and mental suffering, as well as the possibility of adopting free and informed choices.

Aspects and dilemmas of euthanasia in modern times

“…35 Determination of the objective state of affairs and the contemporary euthanasia situation is inevitable, in order to really help the dying, before euthanasia itself. 36 Patient aware of the inevitable end and his torments in pain and weakness, loss of reason, ability to live, wanted to participate in his death actively, with his own hand and even with the help of someone else's. If he was no longer able or he didn't have the will, courage and ability to do it.…”

Suicide Attempt without a Mental Health Diagnosis

“…It must be taken into account that mental disorders, especially depression, are very prevalent and its incidence increases with age, reaching a suicide peak over 80 years. In elderly people, affective symptoms can present in a more latent and insidious way and normally have greater cognitive and behavioural effects [ 2 , 5 , 10 ].…”

“…This term of disability is likely to involve doubts on doctors when they have to urgently evaluate a patient that ask for EAS, considering that previous literature found similar profiles between patients who requested it and psychiatric patients who commit suicide [ 2 , 3 ]. Moreover, studies support that 40% of suicide patients had no previous psychiatric condition and 37% of suicides had no axis I diagnosis [ 4 , 5 , 6 ].…”