Medical Ethics Unpacked: Ethical Foundations and Background of Euthanasia & Medically-Assisted Suicide

Welcome to Medical Ethics Unpacked!

In their inaugural episode of Medical Ethics Unpacked, hosts Steve Levine, MD, a psychiatrist, and Dominic Sisti, PhD, a bioethicist, begin a 2-part discussion examining medically-assisted suicide, often referred to as medical assistance in dying (MAID), and euthanasia, particularly in the context of severe psychiatric conditions. Part 1 of the discussion featured above focuses on foundational concepts and the broader context of MAID, laying the groundwork for an in-depth ethical discussion in part 2.

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, introduces 2 critical questions at the heart of the debate: determining whether individuals with severe psychiatric illnesses have the capacity to make autonomous decisions about euthanasia and whether psychiatric conditions can be considered terminal. As Sisti notes, these questions are particularly challenging given the complexities of suicidality, which is both a symptom of certain psychiatric illnesses and a factor influencing the desire for euthanasia.

Sisti also examines data from jurisdictions where psychiatric euthanasia is legal, such as Belgium and the Netherlands, noting trends like gender disparities and inconsistent capacity evaluations that raise concerns about equity and justice. He emphasizes the need for robust societal safeguards to ensure that MAID is not prematurely offered to individuals whose suffering might be mitigated through other means.

Later, Levine provides a clinical perspective, delving into the distinction between capacity and competence, explaining how capacity evaluations are conducted by physicians, and discussing the nuances of suicidality as a dynamic and context-dependent phenomenon. He highlights the episodic nature of conditions like major depressive disorder and the potential for recovery through treatments, such as ketamine or psychedelics. However, he acknowledges the limitations of psychiatric care, including gaps in treatment effectiveness and accessibility, which complicate decisions regarding MAID.

Levine also raises the philosophical question of whether a wish to die is always pathological or whether it can sometimes be an expression of autonomy, further blurring the lines in this debate.

The episode sets the stage for part 2, which will explore the ethical considerations surrounding MAID and euthanasia in greater depth. Levine and Sisti aim to address the broader implications of permitting euthanasia in psychiatric populations, touching on justice, societal values, and the role of clinicians in these life-and-death decisions. Stay tuned for the continuation of this complex and thought-provoking discussion.

Relevant studies and documentation mentioned in this episode:

1. Doernberg, Samuel N., John R. Peteet, and Scott YH Kim. "Capacity evaluations of psychiatric patients requesting assisted death in the Netherlands." Psychosomatics 57, no. 6 (2016): 556-565.
2. Kim, Scott YH, Raymond G. De Vries, and John R. Peteet. "Euthanasia and assisted suicide of patients with psychiatric disorders in the Netherlands 2011 to 2014." JAMA psychiatry73, no. 4 (2016): 362-368.
3. Kious, Brent M., and Margaret Battin. "Physician aid-in-dying and suicide prevention in psychiatry: A moral crisis?." The American Journal of Bioethics 19, no. 10 (2019): 29-39.
4. Nicolini, Marie E., Scott YH Kim, Madison E. Churchill, and Chris Gastmans. "Should euthanasia and assisted suicide for psychiatric disorders be permitted? A systematic review of reasons." Psychological medicine 50, no. 8 (2020): 1241-1256.
5. Nicolini, Marie E., Chris Gastmans, and Scott YH Kim. "Psychiatric euthanasia, suicide and the role of gender." The British Journal of Psychiatry 220, no. 1 (2022): 10-13.
6. Sisti, Dominic, J. John Mann, and Maria A. Oquendo. "Suicidal behaviour is pathological: implications for psychiatric euthanasia." Journal of Medical Ethics (2024).

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.