Assisted Dying in Persons with Mental Illness

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Background

Even with evidence-based treatment, some patients living with severe and persistent mental illnesses (SPMI) do not achieve a personally satisfying level of psychosocial well-being and functioning. In those patients with SPMI, quality of life is typically reported as low and life expectancy markedly shortened. Well-known as well as novel approaches such as clozapine, ketamine, electroconvulsive therapy (ECT), or deep-brain stimulation (DBS) are available for treatment resistant symptoms but are still not able to reach satisfying outcomes in some cases. Knowledge on how to best care for patients with SPMI is limited, both regarding empirical findings and accepted approaches or guidelines.

Some patients with SPMI may ask for access to assisted dying. Assisted dying encompasses different practices such as voluntary active euthanasia (VAE) or physician-assisted suicide. In VAE which is legal in Canada, the Netherlands, Belgium, and Luxembourg, the physician (or also nurse practitioner in Canada) administers the drugs; in physician-assisted suicide, which is legal in many other countries including some states of the US, Colombia, Germany, or Switzerland, physicians or nurse practitioners (Canada) prescribe the lethal drugs, and the person willing to die take it by themselves.

The legality of these different forms of assisted dying varies considerably between countries and jurisdictions. Assisted dying touches a wide variety of existential questions, basic values and
worldviews about life and death, personal autonomy, liberty, stigma, suffering, and care for and protection of vulnerable persons. Assisted dying for people where mental illness is the sole underlying condition is particularly controversial, given long-standing questions such as what counts as an irremediable mental health condition, if there is a distinction between health and mental health, as well as the long history of violence and power within the psychiatric profession. Further complicating these issues, psychiatry has the clinical and legally enforced duty to protect patients from illness-induced self-harm and suicide, at least partially conflicting with the idea of supporting or enabling assisted dying.

For this Research Topic, we welcome empirical, theoretical, ethics, and philosophical papers on assisted dying in SPMI. We are interested in thoughtful responses to questions such as:

• What criteria should apply to grant a person with SPMI access to assisted dying?
• What is intolerable suffering in mental health and how should this be evaluated?
• Should the patient have a terminal illness, and what does that mean for mental illnesses?
• Is the criterion of treatment resistance/refractoriness of the SPMI necessary for assisted dying, and if yes, how should it be defined and assessed?
• What do people living with SPMI think about assisted dying? Should patients with SPMI who request assisted dying have persisting decision-making capacity, or should there be exceptions, for example through the application of an advance directive?
• In jurisdictions where assisted dying for people with mental illnesses is legal, what should clinical practice guidelines look like? Should there be specific safeguards and/or procedural guidelines for assessment?
• How should healthcare professionals manage assisted dying requests from SPMI patients in prison or in forensic psychiatric facilities?

Keywords: psychiatry, mental illness, assisted dying, suicide, ethics, autonomy, unbearable suffering, decision-making capacity, end-of-life, treatment resistance

Important note: All contributions to this Research Topic must be within the scope of the section and journal to which they are submitted, as defined in their mission statements. Frontiers reserves the right to guide an out-of-scope manuscript to a more suitable section or journal at any stage of peer review.

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