The Capacity to Choose: The Ethics of Euthanasia for Those With Psychiatric Illnesses

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Euthanasia is typically viewed as a controversial practice, even more so as it has been legalized for those with psychiatric illnesses in five countries. Canada has been the most recent country to pass a law that allows euthanasia for those with mental illnesses. This research paper will explore the ethical implications of allowing euthanasia for individuals who face unbearable suffering from a mental illnesses. Through discussing types of physician aided death; the purpose of death with dignity; and the requirements of euthanasia, this paper will come to a conclusion on whether or not euthanasia for those with psychiatric illnesses is ethical. Considerations will include the patient’s right to make decisions; ways to preserve dignity; the value of life through experiences; the responsibilities of doctors; and the consequences of euthanasia. An overarching theme to be dissected in the paper is the discrepancies in euthanasia for those with physical illnesses compared to those with psychiatric illnesses and how this could reveal unjust patterns. By the end of this paper, readers will have an understanding of euthanasia and its ethical implications, as well as the tools to form their own opinions on this pressing issue.

Table of Contents

• Abstract

• Introduction and Context

• Background Information

• Ethical Assertion

• Autonomy

• Dignity

• Instrumentality

• Benefience/Empathy

• Justice

• Consequentialism

• Conclusion

• Restrictions/My Proposal

• Final Remarks

Abstract

Historically, medical assistance in dying (MAID) has been used to mercifully kill those in pain and terminate suffering—even before this concept was formalized. In 1997, Oregon became the first U.S. state to legalize physician assisted suicide (PAS), a type of medically aided death. Nine states and the District of Columbia have followed Oregon’s lead in addition to other states which are also discussing possible legislation (Compassion and Choices). PAS for those with terminal illnesses has also been ratified in various countries around the world. However, some countries have gone further, ratifying euthanasia, a much more contentious practice. Even more controversially, in some countries, ailments do not need to be terminal for one to access any type of medically aided death, only the desire to end extreme suffering from medical conditions is required. Yet, this concept of suffering from a condition has typically been applied to physical ailments. As the troubles and anguish of mental health disorders have become more publicized, many question why euthanasia is only legal for physical pain. Some argue that if the purpose of voluntary euthanasia is to eliminate unbearable suffering, those with extreme mental health problems would fall within that category. To respond to these pleas, five of the nine countries in which euthanasia is legal now consider mental disorders as viable grounds to request aided death. To some, this is a step toward equality, however, others question the competency of those with troubled minds. This situation raises the ethical question: should those with psychiatric disorders also have access to voluntary euthanasia if it is legal for physical pain? I will look at this case using the ethical principles and values of autonomy, empathy, dignity, fairness, the approach of instrumentality, and a consequentialist lens.

Introduction and Context

Physician-Assisted Suicide

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The concept of mercifully ending the lives of those in pain has existed for centuries, even when this was not a formalized concept. Physician aided death, in the modern world, is often viewed as a broad category, referring to death achieved or aided by medical means with the help of medical professionals (Nowels). A significant part of physician aided death is: physician assisted suicide (PAS). In PAS, a physician will authorize a prescription for a medication and instructions on how to take it in a lethal dose for a patient that requests it and follows restrictions on the practice (Dugdale). It is then up to the patient to fill the prescription and take the medication on their own time using their own free will. In fact, about one third of patients who request PAS, are approved for it, and are prescribed the medication, but then go on to change their mind and continue living out the natural duration of their life (End of Life Washington). 

PAS originated as a practice for terminally, physically ill patients, meaning a prognosis of six months left to live, as a way to end suffering caused by said illness. However, some have recognized that suffering is not necessarily defined by how many months an individual may have left to live. From this came the legalization in some areas of the world of PAS, the first being The Netherlands, for patients with chronic, physical illnesses. While chronic illnesses do not inherently have a terminal diagnosis, they undoubtedly can cause immense suffering. 

Euthanasia

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A practice with the same intention as PAS is euthanasia. Euthanasia is the prescription and administration of a lethal dose of medication to a patient who requests it, typically through the form of injection (Goh). Unlike PAS, euthanasia has the guarantee of death because a lethal injection is involved. Following the legal guidelines and policies, a date for administration is set, and the act of ending the life is performed by a professional. However, the key link between PAS and euthanasia is that a life is voluntarily ended in order to cease suffering caused by a terminal or chronic illness (CNN).

In recent years, a mental health epidemic has erupted. Advancements in technology, influence of social media, COVID-19, and lack of resources devoted to mental health issues have all exacerbated this issue. However, one thing that this mental health epidemic has done is bring greater awareness to mental illnesses and the tangible negative impacts they can have. Previously, mental illnesses were typically viewed as less physically painful and silent battles. Therefore, the suffering that mental illness can cause has often been invalidated. However, as many have recently recognized mental illnesses and the pain they can cause as a valid form of suffering, this topic has entered conversations about PAS and euthanasia. Recently, some countries have even ratified PAS and euthanasia for people with psychiatric illnesses, an action that has been largely controversial (Kim et al.).

Background Information

Euthanasia & Physician Assisted Suicide

Euthanasia and PAS are different in the sense that death is a guarantee in euthanasia. It is crucial to understand their differences and the nuances of the two practices. Once again, PAS is only aided by a physician but taking a lethal dose of medicine is an action taken solely by the patient. On the contrary, in euthanasia, administration of a lethal dose of medication is performed by a medical professional. These terms can both be understood by the same principle of a physician aiding death to end suffering (Keown). However, I will not be discussing PAS and my focus will be on euthanasia. It is worth noting, though, that many arguments that I will mention can be applied to conversations about PAS.

Euthanasia was used solely to relieve suffering for those who had a terminal diagnosis in the final months of their lives (Hiatt). However, it is becoming increasingly common to find euthanasia (in a country where it was already lawful) legal for chronic and unbearable pain without a terminal diagnosis. ​​While, for some people, mental illnesses may result in a shortened lifespan for various reasons, including the inability to seek health care, self-medication with alcohol and drugs, etc., most mental illnesses are not directly terminal.

Many mental illnesses may also cause an individual to partake in acts of self-harm and other dangerous actions which could lead to death, but mental illnesses in of themselves do not inherently limit lifespans. This fact has caused many to see the connections between mental and physical illnesses and therefore look at this dilemma through an ethical lens (George).

Voluntary vs. Involuntary Euthanasia

Another crucial nuance of the euthanasia discussion is the consent of the patient. While the euthanasia in this discussion is voluntary, as the patients choose this intervention, euthanasia can also be involuntary. Involuntary euthanasia is when people are killed by medical means against their will—technically murder under the guise of a medical practice. The intention of euthanasia, when done by physicians following their medical and ethical duties, is to eliminate extreme suffering at the request of the competent patient. There have been some unethical misuses (for maleficent reasons, not to reduce suffering) in the past, for example using involuntary euthanasia on many groups (e.g. Jews during WWII). In these instances, euthanasia was not used as a means of ending suffering for the individual; it was used as a means of eradicating a group of people—a much different context than that of euthanasia in the situation about which I am concerned. 

Despite past unethical misuses that harmed vulnerable peoples, euthanasia has historically been used mercifully/beneficently (Hohendorf). The term euthanasia comes from the Greek words eu (well) and thanatos (death) and is often literally translated as 'good death' (University of Missouri). Despite the connotation that euthanasia holds for many, it is not a malicious practice when done voluntarily for the purpose of relieving extreme suffering. While involuntary euthanasia has played a large role in global history and shaping the modern world, this conversation will only delve into voluntary euthanasia (University of Missouri). 

Euthanasia Accessibility

Euthanasia for physical ailments is currently legal in nine countries, namely, New Zealand, Colombia, Germany, Spain, The Netherlands, Belgium, Luxembourg, Switzerland, and Canada (BBC, USNews, Linares). Newfound awareness about the severity of many mental illnesses has caused many to argue that those with mental disorders suffer too, if in a different way as those with physical illnesses. This reasoning concludes that individuals with psychiatric illnesses therefore deserve the same end of life options (Nicolini et al.). Given such pleas, five countries, in which euthanasia for those with physical illnesses is legal, have legalized euthanasia for people with psychiatric illnesses. In chronological order of when euthanasia (for those with psychiatric disorders specifically) was legalized, these five countries are: The Netherlands (2002), Belgium (2002), Switzerland (2006), Luxembourg (2008), Canada (2021). Only New Zealand, Colombia, Germany, Spain have legalized euthanasia but not ratified it for psychiatric patients (BBC). 

Euthanasia for those with psychiatric illnesses looks extremely different from country to country. Depending on the country, there are varying restrictions on euthanasia/the patient (Nicolini et al.). Some countries require that euthanasia requests must be voluntary and well-considered, meaning that the patient is choosing this option after thinking through the consequences and any alternatives. Another criteria that the request must fit is a lack of external pressure—a requirement only in Belgium, Luxembourg, and Canada. This means that no coercion has impacted the patient’s desire in requesting euthanasia. Belgium and Luxembourg even have the prerequisite that requests need to be repeated to show consistently demonstrated interest and that the patient will not change their mind about euthanasia over a course of time. 

Another dissimilarity of the restrictions between countries is the condition that the patient is in which has led them to request euthanasia. Some countries say that the patient must have a chronic condition or unbearable suffering with no prospect of improvement, while others simply require that suffering can not be alleviated. Canada, on the other hand, has ruled that euthanasia for those with psychiatric illnesses is legal as long as suffering cannot be relieved under conditions the patient finds acceptable. This is incredibly different from most of the other countries that offer this practice because Canadian law does not require that euthanasia be the immediate last resort. By saying “suffering cannot be relieved under conditions the patient finds acceptable,” this creates a new gray area in determining who has access to euthanasia. Switzerland, though, on the opposite end from the other four countries, has no necessary criteria about the state/condition of the patient (besides, of course, the fact that they must have a mental illness that has caused them suffering). 

Another measure put in place to safeguard euthanasia is a waiting period from the day it is requested to the day it can be administered. The goal in this is to prevent patients with inconsistent wishes to be euthanized from actually having access to euthanasia—an even larger concern when considering that these patients have a mental illness. Depending on the country, this waiting period may vary from ten days in Canada to one month in Belgium. Some countries such as, Luxembourg, The Netherlands, and Switzerland do not require a waiting period at all. Without a waiting period, one could request euthanasia and hypothetically receive it the same day—one of the main apprehensions of those who oppose euthanasia.

*This table represents the general restrictions on euthanasia in place in the countries where it is legal for those with psychiatric illnesses. The year depicts the year that euthanasia for those with psychiatric illnesses was made legal (some of these countries had euthanasia for those with physical illnesses legal previously).

Out of all of the restrictions, one of the most pertinent to this discussion is the psychiatric consult. A key concern about euthanasia for those with psychiatric disorders is their capacity to make such a big decision using informed consent. Capacity is generally defined as the “ability of a patient to understand the benefits and risks of, and the alternatives to, a proposed treatment or intervention (including no treatment)” (AAFP Foundation). Informed consent is making a decision after being fully aware of the foreseeable/intended consequences and implications. Considering that capacity is the basis of informed consent—one cannot fully consent to something if they do not know the consequences of it—it is crucial that an individual choosing euthanasia fully understands its life-ending impact. The general idea (or at least hope) is that a psychiatric consultation in the context of euthanasia be less of a counseling session and more of a determination of capacity. For many who have already seen psychiatrists this may not seem completely different from typical sessions, but the ultimate goal is to understand whether or not the patient maintains a level of understanding of their situation. For that reason, Belgium requires a psychiatric consultation before one can go through with euthanasia (PBS). Once the patient is deemed capable of making their own choice and there is proof of their mental suffering, then they have the green light to receive euthanasia. Considering that the individual who is requesting euthanasia for themself has to directly give their own consent, the implication is that if they are deemed incapable to make this decision they will continue to suffer with their illness.

While many have commended Belgium for including this requirement of a psychiatric consultation, others point out a double standard. Before receiving euthanasia in Belgium, people with physical illnesses are not required to meet with a psychiatrist. Those with physical and mental suffering are equally required to get the opinion of an expert in their illness before requesting euthanasia. For those with mental disorders, a professional would be a psychiatrist which is where a psychiatric consultation comes into play. But for those with physical illnesses in Belgium, patients typically are not required to visit some form of psychiatrist. Seeing an expert in the field of their illness is usually a medical professional who does not specialize in psychiatry. Many question if it is unjust to require psychiatric consultations for mental illnesses but not for physical illnesses. Others, though, often suggest that because mental illnesses inherently affect the brain, requiring a psychiatric consult is part of ensuring that the patient is actually making a voluntary and informed decision.

Regardless of complaints of Belgium, those who endorse psychiatric consults are often concerned by some countries, specifically The Netherlands and Switzerland, because they have bypassed this consultation, and mentally ill people requesting euthanasia do not need proof of their capacity. In these countries, similarly to Belgium, those who request euthanasia on the terms of physical pain, do not need to meet with a psychiatrist (Government of The Netherlands). Many, in turn, question if not only mental pain but physical pain too should be grounds for a required psychiatrist’s approval before euthanasia can be approved. This could potentially fall under the requirement of a doctor/the medical field to do no harm and ensure that a patient has the capacity, in any situation, to make this decision.

Overarching laws have also been put into place in order to restrict the practice of euthanasia for those with psychiatric illnesses. While some countries strictly abide by regulations to prevent any potential slippery slopes, other nations, including Luxembourg and Canada, have virtually no preventative laws. However, these two countries that do not have formalized laws still do maintain restrictions on euthanasia—the practice is not wholly unregulated. Furthermore, some countries with less intense regulations on euthanasia, such as Switzerland, have local organizations that impose restrictions on the usage of euthanasia. For example, in Switzerland and The Netherlands, psychiatric consultations are not written into law, but are imposed by local authorities (Alliance Vita).

Clearly, each country that has legalized euthanasia for those with mental disorders has gone about it in their own way. But some question if the standardization of this practice globally (if even possible) would make it more ethically acceptable given the specific situation of a psychiatric patient who would ultimately have the capacity for this choice. Yet, other countries find this proposed standardization concerning and do not want these laws to be ratified overseas. For example, euthanasia is largely a topic of contention in the U.S. as it is illegal in all situations, due to concerns about slippery slopes, safety, vulnerability, coercion, capacity, etc. (Pereira). However, with euthanasia recently becoming legal for physical and psychiatric illnesses in Canada, this topic is becoming much more relevant in North America than it has ever been before. 

Ethical Assertion

This issue has become largely polarized and politicized between those who support euthanasia for individuals with mental illnesses and those who do not. On one hand, legalization of euthanasia for those with psychiatric disorders could be a step toward greater equality in the medical field and proves that patient autonomy is valued in the relief of suffering whether it be physical or mental. On the other hand, some argue that this ignores the possible lack of competency of patients with mental health issues, and could lead to a slippery slope where euthanasia is available to many who should not have this option. As well, many feel that, as a whole, euthanasia conflicts with the responsibility of a doctor to do no harm because, despite it being voluntary, ending a life (to some) inherently causes harm.

After consideration of different perspectives and arguments on this compelling topic, I have determined that euthanasia for those with psychiatric illnesses is ethical due to the values of autonomy, dignity, empathy, the approach of instrumentality as well as the framework of consequentialism. Many see euthanasia for those with physical illness as more “ethically correct.” However, in order to preserve justice within the medical field, euthanasia for those with mental illnesses should also be ethically permissible as long as regulations are firmly maintained to ensure that this practice does not expand to those who cannot autonomously make this decision due to coercion, despair, or a factor of their illness. My argument that euthanasia is ethical for those with mental illnesses largely follows the same justification of euthanasia for those with physical illnesses. Due to this, I will discuss these ethical considerations in a way that can frame arguments about euthanasia for those with physical illnesses as well.

Autonomy

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Definition

One of the main arguments, and a guiding bioethical principle, for this discussion is autonomy. Autonomy is one’s right to self-governance in which patients have the right to make their own decision regarding their life and course of medical treatment. Respecting an individual’s autonomy is one of the central goals of ethics as long as it is balanced with other values and considerations. This idea of respecting a patient's autonomy would then apply to whether or not they want to be voluntarily euthanized (if they fit criteria).

Coercion & Consent

Autonomy is important to consider because in the medical field there has long been a struggle between valuing the patient's wishes on one hand, and respecting what doctors and society determine is the most acceptable or most ethical option. As long as anyone requesting euthanasia is fully capable of giving their informed consent, recognizing that euthanasia will be their final step in life, then their right to choose euthanasia is ethically permissible. However, autonomy by definition means that no coercion can be present.

Coercion occurs when someone besides the patient will try to change the patient’s opinions or shape their thoughts with force. Coercion could consist of someone convincing an ill family member that they are a burden and therefore should request to be euthanized.

Autonomy is supposed to be a reflection of an individual’s wishes, values, and goals. When coercion is present, and an individual is acting under the influence of another’s wishes, it is no longer considered an autonomous choice. Additionally, it is crucial to understand that autonomy does require informed consent—meaning one consents, without any coercion, to something while being informed of the consequences and alternatives, including the consequences of not doing anything. By nature, this means an individual must have capacity to have autonomy, as capacity impacts one’s ability to comprehend consequences of the actions they take. 

Paternalism

Not only is respect for autonomy considered in this discussion but also one’s reason for voluntarily choosing euthanasia. Many choose euthanasia because it puts choices, that illnesses often take away, back in the patient’s hands. Many want to feel in control of their body and their mind—qualities that are typically hindered by illnesses. Therefore a patient that is suffering may choose euthanasia as a way of gaining control over themself. Being able to choose what treatment and generally what one’s life looks like is not only applicable to physical illnesses but mental illnesses as well (given the patient has capacity in both situations). Yet, many question the competency of those with mental disorders, more so than those with physical illnesses, to make this decision. This is largely due to the mental-nature of a psychiatric illness and the fact that they disturb an individual’s thoughts, feelings, and actions. 

Rejecting euthanasia for those with psychiatric illnesses could become paternalistic (Dembo et al.). Out of all people faced with trauma, pain, and suffering, why are only those with mental health issues are not competent enough to make their own decision? Yes, there are some cases where those with mental illnesses are in fact not in the right state of mind to make such a substantial decision (which is to be determined by a professional). However, the same can be said about those with physical illnesses as well. Psychiatric disorders are not synonymous with lack of capacity. Many who suffer from mental illnesses can still make fully informed, consensual, and autonomous decisions. 

Physician paternalism often stems from the responsibilities that physicians must follow according to the Modern Hippocratic Oath. Many physicians will act with paternalism when following their own ideas of what doing no harm or promoting good means. When there is a concern that a patient may not have capacity, advising them to take a certain path that is in their best interests or ensuring that their wishes are sincere and well informed is considered “soft” paternalism. On the other hand, when an individual actually makes the decision for the patients themselves when they, the patients, are able to act autonomously, this oversteps the line of caring and becomes “hard” paternalism (Stanford University). Soft paternalism is largely seen as a necessary measure to take whereas hard paternalism is more so an infringement on autonomy.

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Doctors should aim to respect a decision when it is in their patient’s best interests (a balance of ethical, medical, and legal reasoning). Many patients who do have mental illnesses can still make decisions while understanding the consequences. With fully informed and competent patients, sometimes physicians will need to respect a decision about treatment or non-treatment that the physician (and sometimes others) does not believe is in the patient's best interests. Assuming that every single person with a psychiatric disorder is incapacitated and restricting all with mental disorders based on this misconception oversteps soft paternalism. However, if a certified psychiatrist, deems a patient unable to make an informed decision, some measure of caring paternalism is necessary. Soft paternalism is meant to protect vulnerable groups, but this idea of looking out for others should not turn into a complete restriction of autonomy.

Physician Abilities

Another concern that relates to autonomy is the ability of doctors to reliably determine who is capable of choosing euthanasia. This ability is often questioned when the suffering stems from a psychiatric disorder. There is no standard measure of capacity and no simple tools to determine if an individual should have the right to make decisions for themselves. So, when it comes to mental illnesses many are concerned that even doctors or psychiatrists, the professionals of the field, would not be able to fully confirm whether or not an individual truly understands the consequences of their actions. At the moment, there truly is no fool-proof way to measure capacity given its subjectivity and abstract nature. As a result, psychiatrists can only do their jobs to the very best of their ability when it comes to consultations such as those required in Belgium prior to receiving euthanasia. Despite this, some question if that is enough given that a human life is on the line.

Preemptively eliminating euthanasia as an option under the guise that all with mental illnesses have impaired capacity restricts autonomy. Despite the blanket concerns about differing levels of capability to make this decision, the principle of respect for autonomy maintains that both the physically and mentally ill deserve the right to have a choice in their path of medical treatment. This right should not be restricted on the grounds that those with mental disorders cannot make an informed decision. While this may be true for some, it is too broad an assumption to apply to everyone with a mental disorder. However, there still is a degree of uncertainty when it comes to determining capacity in of itself.

Dignity

One of the key purposes of euthanasia has always been to allow one to die with dignity during a period of suffering. Humanity is seen as the special value that each individual holds, as well as the ability to be compassionate, fair, etc. Dignity is often seen as the recognition of this inherent humanity and by preserving what one views as their humanity, their dignity is maintained as well. Therefore, death with dignity is when an individual can pursue physician aided death in a humane, dignified way. Many point out that physical illnesses can take a toll on an individual and often reduce their humanity or change the core foundation of the person themself. An extreme physical illness has the potential to infringe on, or deteriorate, one’s dignity. From this arises the concept of death with dignity and that euthanasia would allow someone to preserve their dignity and humanity in a situation that typically reduces it (Death With Dignity). Considering that serious mental disorders can similarly affect one’s humanity, this same logic would apply for those with psychiatric disorders. Therefore, those with mental and physical pain should both have an equal right to dignity or recognition that their inherent humanity could be at risk due to a severe illness.

Yet, some argue that in any case ending a life cannot be considered dignified. Some see good palliative care (comfort care with no medical intervention that is intended to try to treat or cure the underlying terminal condition) as a way of achieving dignity and preserving humanity. But, the concept of instrumentality, which will be further discussed, says that ending a life can be dignified by an individual's determination. Therefore, dignity could look different depending on the point of view, as people value life differently (Yale University).

For this reason, death with dignity should be granted to both those with physical and mental illnesses to preserve humanity when they meet all other necessary criteria. For those who do not see euthanasia as a dignified practice, this is by no means something that is necessary to pursue. Only those who desire euthanasia would pursue it as this is a voluntary practice.

Instrumentality

Instrumentality is an ethical approach that says human life is not a supreme or intrinsic good, rather, it is instrumental. Some believe that the value of one’s humanity is the existence life itself. However, instrumentality says the worth is not of the human life alone but of the worthwhile experiences that this human lives through. Under the approach of instrumentality, life’s purpose is a means to an end of enjoying activities (Keown). Whether or not a life is no longer worth living is to be determined by the person when their own suffering consistently outweighs or diminishes their worthwhile experiences in life. If a patient does not think their life is worth living—and maintains capacity—then instrumentality believes that society should not put them through more suffering. Therefore, it would be within those patients’ rights to request that their life be terminated through euthanasia. 

Another key facet of the instrumentality approach is that the possibility of a cure should not be overlooked, especially if it means that there could be a renewal of worthwhile experiences in the future. Instrumentality looks at experiences long-term and not in a single moment. Therefore, if treatment has the potential to end the suffering that outweighs positive experiences, it should be pursued. Still, while treatment should, logically, be the primary option, this does not take into account that treatment can be costly, lengthy, and not always successful. As a result, for many people with mental illnesses and physical illnesses treatment is not plausible. Therefore, if one fits required standards to be allowed access to euthanasia, the concept of instrumentality says they should have that right as long as treatment is not “acceptable” to the person (as Canadian laws on euthanasia put it). 

For these reasons, the approach of instrumentality is important in this discussion of euthanasia as it further provides evidence as to why people with physical and/or mental disorders (who meet all necessary criteria) should have the autonomy to end their life with dignity when they see fit. Those who view life only as an instrumental good meant as a vessel for worthwhile experiences may value their life differently than doctors or society would.

Beneficence/Empathy

The Modern Hippocratic Oath is a core institution of ethics in the medical field. Most doctors take a pledge using some version of the Hippocratic Oath and most abide by it as a general code of ethics, swearing to follow certain duties and ideologies (Tyson). In this Oath, it states:

"Sympathy, and understanding may outweigh the surgeon's knife or the chemist's drug" - Modern Hippocratic Oath

This quote is saying that doctors should be empathetic and understand that medical treatment cannot always solve the issue at hand. This builds upon the bioethical principle of beneficence and following a course of action that will produce the most good. Doctors should always do what is best for their patient (beneficence) even when that course of action may not improve one’s state of physical health. Beneficence is not exclusive to doing what will cure someone or make them healthier (mentally or physically). If that was always the goal, at what point would doctors be imposing more suffering when trying to make someone better? Doctors are required to do no harm. However, in situations where a patient has requested euthanasia, further efforts to treat or cure will impose unwanted pain and suffering when it is known that further efforts to treat or cure are unlikely to be successful. Or, such efforts only have a slight chance of being curative while simultaneously exposing the patient to great risk of side effects and/or pain and suffering. Imposing this suffering would do the opposite of no harm.

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While this idea of beneficence applies to psychiatric disorders and physical conditions, mental health issues are often put on the back burner. Physical illnesses are generally much easier to judge and comprehend because doctors can see and process them with their own eyes. However, one cannot fully understand mental struggles, making it harder to accept that they are a valid form of anguish. Yet, this idea that the judgment of mental pain is always subjective is also true about judgment of physical pain. When patients with physical illnesses request euthanasia on the grounds that they are going through unbearable suffering, doctors have to trust their word. This is the same when patients have mental health issues—doctors must trust that their patients are truthfully explaining their situation. In both situations, there is the same need for the suffering of the patient to be validated by the doctor, which is always dependent on the trust that builds the core of the doctor-patient relationship. Ultimately, doctors should have empathy and try to understand their patients’ suffering, after which, the best option that takes into consideration how the patient feels can be determined.

Justice

Another key component of this conversation is the principle of justice. Physical illness and mental illness are often interwoven. When one has a severe physical condition, this can lead to an increased risk of depression, anxiety, and other mental illnesses. As well, many with mental illnesses may find themselves in physical pain (Mental Health America). Physical pain has long been known as a potential obstruction to sound decision-making. Yet, certain societies have an easier time ethically permitting euthanasia when said person has a physical illness. Could anyone facing extreme pain and suffering (internal or external) ever be fully competent? If not, would this argument about capacity then eliminate euthanasia on a whole if an individual with severe pain or suffering would always be deemed not to have the ability to exercise a competent decision to choose euthanasia?

Despite some biases between mental versus physical illnesses, society has been taking steps to recognize that psychiatric disorders can be just as damaging as physical ones. Euthanasia should follow this same trajectory. However, many say that factors leading to mental health issues are caused by society and can be amended whereas physical illnesses are rarely caused by social attitudes. Regardless, this is not always the case: many clinical/chronic mental illnesses are genetic and run in families. While society should be working to lessen its negative impact on mental health issues, it is unjust to recognize that physical suffering is “suffering enough” and therefore deserves access to voluntary euthanasia, while still saying that mental suffering should not have that same option available. 

Allowing voluntary euthanasia for physical suffering while denying it for mental suffering, contributes to the stigma in society that mental health issues are not as bad, not as serious, or do not require the same attention as “real pain.” This misconception about mental illnesses has drastically impacted the current mental health epidemic. In fact, only 2% of the national health budget is allocated to mental health issues. This shows the biases of society and how they impact views of who needs medical care and resources (World Health Organization).

The justifications of euthanasia for physically ill patients could apply to mentally ill patients as well. Therefore, the exclusion of the mentally ill could potentially be viewed as discrimination—a view that has been taken by some proponents of euthanasia for mentally ill people (Nicolini 1245). While many are rightfully concerned about the vulnerability of those with mental health issues and the possibility of their condition clouding their judgment, this is not always the case. For this reason, psychiatric evaluation must be fair to ensure that those with mental illnesses are not excluded from accessing euthanasia solely because they have a mental illness. In summary, the principle of justice weighs in favor of legalizing euthanasia for those with physical and mental disorders.

Consequentialism

Definition

Consequentialism is an ethical framework in which the ethicality of an action is determined based on its consequences with the goal of achieving the greatest good (however that is defined) for the greatest number of people. In the discussion of euthanasia for those with psychiatric disorders, this framework weighs its foreseeable positive and negative consequences. 

Implicit Messages

It is important to unpack how labeling euthanasia for those with mental health issues as “unethical” when it is more broadly seen as “ethical” for physical conditions could send a negative message to society. From doing so arises the question: who is valued enough to be allowed to die with dignity? Could this even question what society legitimizes as true suffering? Lastly, could this set back equality that has been crafted in other fields of medicine? On the other hand, if euthanasia is seen as ethical and a viable option, this could discourage people from seeking treatment and possibly send the message that the life of one with a mental illness is not a life worth living.

 Furthermore, in PAS death is not a guarantee and many patients do not follow through with the act of ending their lives. In contrast, euthanasia is a final step and with certainty, a life will end. This causes many to worry that when euthanasia would potentially be legalized for those with psychiatric illnesses, it would be pursued at increasingly rapid rates. Still, it is important to keep in mind that just because something is legal/ethical, it does not mean that it will be occurring at high rates. If euthanasia rates were dramatically increasing to a concerningly high level, this may point to an issue with the restrictions on euthanasia rather than the actual practice in of itself.

Medical Tourism

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Another consequence of a universal ethical standard of euthanasia for those with psychiatric illnesses would be the major impact on the medical tourism industry. Medical tourism is traveling to another region in order to get medical treatment that may be cheaper, more professional, or illegal in one’s home nation. Euthanasia is not exempt from medical tourism. People have traveled to entirely different continents, especially Europe, just to gain the right to die with dignity. Some even bring their own doctor with them to perform euthanasia on soil where it is legal. For example, 171 people, across the globe, traveled to Switzerland in 2012 in order to achieve the right to die with dignity. However, plane tickets and the cost of bringing a physician along can become quite expensive, making euthanasia tourism inaccessible to many (Rodriguez).

Mental disorders are twice as common among the impoverished than the rich. The risk of schizophrenia is eight times higher in the lowest socioeconomic group compared to the highest group (World Health Organization). Factors, such as debt, unemployment, housing issues, etc., that the poorer groups in society disproportionately face contribute to or trigger mental health issues. Could this mean that in a country where euthanasia is not legal (whether for mental or physical illnesses), only the richest can afford the right to die with dignity through means of medical tourism? For this reason, legalizing euthanasia globally for those with psychiatric disorders could prevent euthanasia tourism as fewer people would need to travel in order to access death with dignity.

On the other hand, many are concerned that legalizing euthanasia globally would be promoting or even advertising euthanasia, largely raising the number of people euthanized. However, restrictions surrounding who can access euthanasia would still apply, so it is not promoting greater euthanasia but more equal euthanasia. This argument is not mutually exclusive from treatment either. Some psychiatrists, physicians, and others opposed to euthanasia are concerned that focusing on euthanasia causes society to forget that treatment and palliative care/hospice is just as, if not more, important to pursue. However, treatment, palliative care, and euthanasia are all utilized for the purpose of reducing suffering so they should not be viewed as completely separate or polar opposites. There should be a balance between the right to end suffering and the right to treatment or comfort care. As it stands, those who are wealthier have more/better treatment options and access to euthanasia/the right to die than those of lower economic status. Discussing further that socioeconomic status should not be the determining factor in the access to euthanasia also sends the message that socioeconomic status should not determine who gets treatment options as well. 

If there was universal acceptance of the idea of euthanasia for the mentally ill being ethical, this would be the first step toward reducing medical tourism for euthanasia, creating equality among social classes, and prompting more discussion about equal access to treatment.

"Moral Degeneration"

A variety of people including citizens, physicians, and historians bring up the dangerous slippery slopes that could occur if euthanasia were to be available to more groups of people. A widely mentioned example of this is the infamous use of euthanasia in WWII by the Nazis and how it led to a genocide of millions. With this historic tragedy in mind, some question if this is the path that society is headed toward—a slippery slope argument on the potential of devaluing human life. While this point brings up important history, it is important to consider how the circumstances described in this paper are far different.

The goal of euthanasia in WWII was to eliminate people that Nazi Germany deemed as inferior. This included, but was not limited to, Jews, peoples of varying physical abilities, political enemies, and those with mental illnesses (Burgess). It is important to note that people were identified as mentally ill based on their answers to a series of arbitrary questions that had no correlation to mental illness (Burleigh et. al). Despite this distinction, due to the fact that this campaign included the extermination of the “mentally ill”, many are quick to equate the Nazis’ practices with modern day ones. The Nazi’s involuntary euthanasia that preyed on vulnerable groups in the hopes of eradication have forever tainted the name of euthanasia, regardless of it now being voluntary. When discussing the Nazis’ use of this practice, society was deemed to have gone through a “moral degeneration”. While this was true for Nazi Germany, the comparison of euthanasia from then to now assumes that modern society will go through this “moral degeneration” again in which doctors and society will become less caring to persons dealing with terminal illness and/or less concerned or sensitive about the taking of life, even if it is requested (Burgess).

The idea of the slippery slope is that by legalizing and normalizing euthanasia as ethical for more and more groups of people, we will soon have no control over the use of euthanasia. Many question if society will reach the point of mimicking Nazi practices by targeting and euthanizing people involuntarily who may be viewed as “vulnerable” or who can no longer be cared for. However, euthanasia for those with psychiatric illnesses today looks much different than in WWII. In WWII involuntary euthanasia was performed by Nazis, not modern doctors who vow to protect patients and provide the best solution and care for individuals. The argument behind this slippery slope has less relevance today because the purpose of euthanasia is to reduce suffering in those that want it. The purpose in Nazi Germany was the opposite: to get rid of people viewed as inferior. Furthermore, this method of ending a life can hardly be classified as euthanasia considering it was not “good death”—instead it was genocide. 

After the Nazis were defeated and Germany recovered from WWII, German citizens began advocating for euthanasia for those in immense suffering. This was controversial given how euthanasia had been previously used as means of racial extermination. Regardless, people said that the violence of the Nazi party was an independent instance, arguing that the atrocities of the Nazis should not prevent society from allowing people to die with dignity. (Burleigh et al.)

The use of euthanasia today is much different than the way it was used in WWII and we should not be so quick to equate them as it degrades euthanasia’s current practice, as well as completely puts euthanasia into a different context than the one that is being discussed in this paper. While it is important to learn from history, it is unethical to entirely let past abuses of euthanasia prevent it today when there is an ethical foundation of voluntarily preventing suffering. 

There are also safeguards that would prevent euthanasia abuse from happening. This particular slippery slope depends upon not only the “moral degeneration” of society, but also the doctors who would hypothetically kill patients without hesitation. Regulations such as psychology exams to ensure doctors are fit for the job, laws that restrict who is allowed to request euthanasia, etc. would all be preventative measures to avoid this slippery slope. If a doctor involuntarily euthanized a patient (a rare but legitimate occurrence) necessary correctional measures should be taken. The doctor’s license to practice medicine and administer lethal injections should be revoked and the case should be investigated. However, this situation can only be handled on a case by case basis and should not justify the complete restriction of euthanasia globally.

Accessibility

Image by Nick Youngson from Pix4free

In addition to the moral degeneration of society, yet another slippery slope may arise if one claims euthanasia is ethical: how long will it be until anyone who wants euthanasia can simply have access to it? The concern is that when it is deemed ethical for those with psychiatric disorders another exception will be made. The fear is that soon anyone who simply asks for euthanasia will be allowed access to it. For example, minors in some European countries (e.g. Netherlands, Switzerland) have access to euthanasia—typically a group of people who are viewed as vulnerable. While parental consent is still required before the lethal medication can be administered, this introduces a whole new meaning to euthanasia with new ethical considerations. That is why it is important to have strict regulations that cannot be bypassed, because without them this type of slippery slope is possible. 

Euthanasia is still a very serious topic and there are valid concerns that a possible legalization and declaration of ethicality of euthanasia will encourage more and more people to be voluntarily euthanized. Still, euthanasia would only be used for extreme suffering when treatment is not acceptable or plausible (World Federation Right to Die Societies). While euthanasia may make death with dignity an option for people who should have access to it, not mean that all people will mental illnesses will automatically revert to euthanasia. However, a concern is that euthanasia may create a society that is more so condoning of suicide. This has caused many to fear that an increase in euthanasia accessibility would also lead to an increase in suicide rates (Washington Post). However, the justification, process, and timeline of suicide is much different than euthanasia. If suicide rates do increase abnormally in a given country, this could point to a larger issue in the allocation of resources for mental health problems. Furthermore, it is important not to conflate the two as it can invalidate the purpose and goal of voluntary euthanasia. 

Many, though, do bring up the valid point that legalizing euthanasia makes it more psychologically acceptable to many, therefore, less of a last resort option. But, realistically legalizing euthanasia does not make it easier to access. Doctors may feel more willing to perform euthanasia themselves, but the regulations would be put in place to ensure that only those who should have access to euthanasia are entitled to it. 

Conclusion

Laws about euthanasia often reflect a country’s views surrounding death, the type of services a country provides such as free healthcare (common institution in countries that have legalized euthanasia), and ultimately the values that certain countries choose to prioritize.

For example the countries that do have universal healthcare may prioritize equality and this could have been the justification for ratifying euthanasia for those with psychiatric illness.

However, this value of equality used in countries that have universal health care, as well as values I chose to support my argument, may not be enough to ethically justify euthanasia for other. This is why saying whether or not euthanasia in of itself is ethical is difficult, because each country has a different moral standard and traditionally different values within society.

However, to ensure justice and consistent empathy, dignity, and autonomy, euthanasia standards for physical and mental pain should be relatively the same globally. If standards cannot be enacted the same globally, each country should prioritize offering euthanasia with restrictions in a way that will not lead to foreseeable negative consequences, while staying true to societal values.

After considering the principle of autonomy, the values of dignity, and empathy/beneficence, the approach of instrumentality, the principle of justice, and the framework of consequentialism, I believe that euthanasia for those with psychiatric disorders is ethical. While all of the consequences, foreseeable and unforeseeable, are not limited to those I listed, they do provide evidence that euthanasia should be ethically acceptable for not only physical disorders but mental disorders. Considering that those with mental health issues fit all the same criteria that ethically justify euthanasia for physical illnesses, those with psychiatric disorders should be allowed to choose euthanasia to maintain justice as a core principle in the field of medicine. However, this should be accompanied by strict regulations. 

Restrictions/My Proposal

While I do believe that voluntary euthanasia should be accessible to those with psychiatric disorders, strict regulations are necessary. Considering the circumstances, it is reasonable that there may need to be stringent restrictions on euthanasia for those with psychiatric disorders. But, for the most part, concerns, and therefore restrictions, about euthanasia for those with mental health issues apply to physical illnesses as well given their similarities.

Rules regarding waiting periods, seeing a psychiatrist, and influences of outside sources should be upheld—without them, euthanasia would be ethically impermissible. Those with physical illnesses requesting euthanasia would benefit from the same restrictions that apply to those with mental illnesses. Even a visit with a psychiatrist to determine capacity to make a life-ending decision could be helpful. It is also crucial that the process is not hastened as it is vital to the patient’s understanding and informed consent of the request to die. A psychiatric consultation is one of the most important requirements. While I have argued that those with mental illnesses who are capable of making such a decision should have the choice of euthanasia, there are many who are incapable of doing so. That is why this evaluation is so necessary, especially given how severe and irreversible the consequences are. These restrictions should be firm lines to preemptively stop the possible slippery slope of making euthanasia too accessible. People who are not competent to make this decision, someone who is being forced into it, or an individual whose family consents for them should not have access to euthanasia.

Another restriction that I would like to propose is euthanasia being legal only for those with clinical or chronic mental illnesses as they cause the most long term harm. The patient needs to understand what a lifetime of suffering may look like before they can choose the alternative of euthanasia. Therefore, a person with a mental illness needs to have lived with suffering for some period of time so that they have a realistic understanding of whether they can benefit and live well with medication/therapy and what the course of their mental illness may take. However, this is where the role of the physician and psychiatrist is especially necessary because an understanding of suffering is not always possible. In this instance, trust would be placed in professionals to determine if it is a situational or clinical issue.

Situational mental illnesses typically need time to heal whereas clinical disorders require specific treatment. As well, with situational mental illness there is often that knowledge of the light at the end of the tunnel, or that the suffering cannot last forever. Additionally, situational illnesses are often impacted by factors in society and therefore are subject to change without any treatment. But, for the clinically ill, this light at the end of the tunnel is not guaranteed and is not always possible even with treatment. Certain, situational mental illnesses, depression for example, often can lead to clinical disorders. At the point of an illness becoming clinical, euthanasia would then be ethical because there is evidence that time is not going to cure the illness.

The next key component of euthanasia is that it should always be viewed as a final resort. I believe that it is unethical for euthanasia to be considered freely as any other form of treatment. Euthanasia is only for unbearable suffering and its consequences are so severe that it should always be the very last option that one considers. For mentally ill and nonterminal patients, there are treatment options. I recognize, though, that these treatments may not be realistic for many people, as I mentioned earlier, however, they should still be strongly encouraged and considered prior to making this large decision.

Many do question how this idea of a last resort can apply when illnesses, especially psychiatric ones, are subject to change. With a chronic or clinical illness after treatment has been tried or considered, recovery may be possible, but it is often not foreseeable or guaranteed. This is different for a situational mental illness that hinges much more on the climate the person is living in. People with clinical illnesses have put in the time and at least a heavy consideration of treatment. Despite the possible chance of recovery, euthanasia still would be the last resort as the suffering has continued for a long period of time and options have been tried or considered. This last resort concept applies to physical illnesses too. In cases where the patient does not have a terminal diagnosis, they are morally obligated to consider other alternatives. However, if all options are not viable or would result in more suffering, and necessary criteria to qualify for euthanasia are all met, that is the only time that it is ethical for euthanasia to be granted.

It is also necessary to remember that this decision should not act as grounds to legalize euthanasia for other groups of people. This ethical decision is a separate discussion with its own unique considerations. It does not justify voluntary euthanasia for other groups of people because that would take into account different ethical values, frameworks, and principles. 

Lastly, claiming euthanasia for those with psychiatric illnesses as ethically permissible when criterion are met, does not mean that efforts to prevent and resolve the mental health epidemic should be halted. Prioritizing mental health should be one of the main focuses of a government. Positive changes need to be made in order to limit this growing number of people suffering from mental health issues. The practice of euthanasia should only be to provide a peaceful end for someone who may have gone through extreme pain and suffering in their life; it does not justify the lack of government involvement in improving the mental health of its citizens. Given how little money governments allocate to mental health, it is no surprise that many develop psychiatric illnesses and often wish to end their life. Overly restricting euthanasia only forces an innocent civilian to be held accountable for the lack of education, resources, and prevention provided in their country. 

Final Remarks

Allowing euthanasia for those with psychiatric illnesses would be an ethical solution that recognizes the unmistakable connection between physical and mental health and the inherent intersubjectivity of the two. Euthanasia is meant to relieve unbearable suffering, but if it is only considered ethical for those with physical illnesses and then not for those with psychiatric disorders (who do fit criteria), it is being utilized unjustly. If moves were to be made against euthanasia availability for those with mental disorders (e.g. questioning its ethicality), then other forms of euthanasia should also be condemned. When euthanasia was originally legalized, physical illnesses were viewed as a much higher caliber of suffering than mental illnesses. Permitting euthanasia for those with psychiatric illnesses today would be remedying an injustice in who has access to this way of ending unbearable suffering, despite its cause. Ultimately, euthanasia for those with psychiatric illnesses is ethical based on autonomy, empathy, dignity, justice, the approach of instrumentality, and consequentialism, as long as firmly established restrictions are not violated.

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