Commentary
Podcast
Author(s):
In part 2 of this 2-part discussion, hosts discuss ethical considerations and the growing evidence base around euthanasia and medical assistance in dying.
Welcome to Medical Ethics Unpacked!
00:00 - The Parity Between Mental and Physical Illness
05:09 - Requiring Treatment Before Considering Euthanasia
08:19 - The Complexity of Egosyntonic Psychiatric Conditions
11:21 - The Potential for "Terminal Addiction"
16:30 - The Societal Impact and Implications of Psychiatric Euthanasia
In this episode of Medical Ethics Unpacked, hosts Dominic Sisti, PhD, and Steve Levine, MD, continue their deep dive into the controversial topic of medical aid in dying (MAID) and euthanasia for individuals with severe psychiatric conditions. Part 2 of a 2-part series, this episode shifts from foundational concepts to the intricate ethical considerations surrounding these practices, touching on autonomy, capacity, treatment equity, and societal implications.
Sisti, an associate professor in the Department of Medical Ethics & Health Policy and the director of the Scattergood Program for the Applied Ethics of Behavioral Health Care at the University of Pennsylvania, begins by discussing the notion of parity between psychiatric and physical illnesses in evaluating eligibility for MAID, calling attention to recent research from Kious et al—who argues that mental illnesses should be given equal ethical consideration as physical conditions, though he acknowledges the challenges in assessing long-term trajectories for psychiatric disorders. For instance, conditions like borderline personality disorder may remit over time, but requiring patients to endure suffering for years in anticipation of potential improvement raises moral concerns.
Levine, a psychiatrist and the senior vice president of Patient Access at Compass Pathways, builds on this by exploring how psychiatric illnesses often blur the line between mental and physical health, emphasizing that mental health conditions, like depression or anorexia nervosa, can have physical manifestations that further complicate prognosis and decision-making.
The discussion highlights critical issues with capacity evaluations. Levine outlines the nuanced frameworks used to assess a patient’s ability to make decisions about MAID and stresses the dynamic nature of capacity, which can fluctuate with psychiatric symptoms. Both agree that insufficient or inconsistent evaluations, as seen in some jurisdictions permitting psychiatric euthanasia, risk undermining the ethical integrity of these practices.
Sisti cites evidence from Belgium and the Netherlands, where "assertions" of capacity rather than thorough assessments have led to controversial cases, particularly among patients with mood or personality disorders. The gender disparity in psychiatric euthanasia, with women disproportionately represented, adds another layer of ethical complexity, raising questions about justice and societal biases.
The conversation also examines whether patients should be required to attempt all available treatments, including experimental options, before pursuing MAID. While Sisti suggests this could prevent premature decisions, Levine cautions against infringing on autonomy, noting that some patients may validly reject certain treatments. They grapple with cases like anorexia nervosa, a psychiatric condition with high mortality rates, and whether its ego-syntonic nature—where patients often do not view their condition as a problem—impedes true capacity for MAID decisions.
Finally, the hosts address societal implications. Sisti warns that expanding access to psychiatric euthanasia without addressing underlying structural issues, such as inadequate mental health care and social determinants like poverty and isolation, risks normalizing preventable suffering. Levine reflects on how offering MAID as an option might paradoxically provide hope for some patients but could also undermine their optimism for recovery.
As they conclude, both Levine and Sisti emphasize the need for robust ethical frameworks, thorough capacity evaluations, and thoughtful policymaking to navigate this morally complex issue. They encourage listeners to engage with the growing body of bioethics literature and reflect on how these debates shape our understanding of autonomy, human suffering, and the value of life.
Relevant studies and documentation mentioned in this episode:
Relevant disclosures for Sisti include Lykos Therapeutics and Tactogen. Relevant disclosures for include Levine include Compass Pathways.
Editor's Note:
This podcast explores complex and sensitive topics, including medically assisted suicide and the ethics of euthanasia. The views and opinions expressed by the hosts and guests are their own and do not necessarily reflect those of HCPLive or MJH Life Sciences. This content is intended to encourage thoughtful discussion and does not constitute medical advice or endorsement of any particular position. Listeners are encouraged to approach these subjects with care and consult appropriate resources for further information.
