Psychiatry and medically assisted dying: What has it got to do with us? Where are we up to?

By Dr Jane Whittaker, retired Child and Adolescent Psychiatrist, PhD Student, Centre for the History of Science, Technology, and Medicine, University of Manchester.

I am at a difficult age: like many of my generation I have cared for dying relatives whilst at the same time the realities of my own aging body creep up on me. As I type, the House of Lords are debating the Terminally Ill Adults (End of Life) Bill, applicable to England and Wales, after it was passed in the Commons earlier this year. At that time, the Royal College of Psychiatrists also shared its views in a thoughtful document responding to the Bill’s proposals.¹ Discussions in various spheres have been eloquent and, at times, heated. This is as it should be. The Terminally Ill Adults Bill is one of the most serious pieces of legislation of our lifetimes: the state granting powers to one group of citizens to prescribe lethal medication to assist in ending the lives of another group of its own citizens. I still do not know what I think about the Bill; the professional implications are clearly complex, but this is also deeply personal, as evidenced by some of the stories in the press and the Houses of Parliament. In situations like this, I often look to history to help me. Rather like clinical practice, when struggling, it’s worth going back to the history and reformulating.

This is not the first time this type of legislation has been considered in the UK parliament, but previous bills have not gone beyond debate. The issue has been part of public discourse for much longer, of course. The Voluntary Euthanasia Society, for example, was founded in 1935. It is still with us, having changed its name to Dignity in Dying in 2006.² This time, not least because of Esther Rantzen’s campaign, the Bill has generated a lot of additional interest.

Importantly for psychiatry, two things are especially relevant. Firstly, in the current legislative process here in England and Wales, psychiatrists have been identified as having a key role in judging the capacity of a person wishing to end their lives. Instead of seeking to dissuade people wanting to die by suicide, we will be asked to be participants in assessing a person who has expressed the desire to end their lives, and confirming that they have capacity to decide to do this. Secondly, in some legislative frameworks, including Switzerland, Belgium and the Netherlands, patients suffering from primarily psychiatric disorders can receive medical assistance to end their lives. In recent years, in other jurisdictions, patients with depression, personality disorders and eating disorders have died with medical help, including from psychiatrists. The laws in countries that permit the practice for this group of patients represent one form of the ‘slippery slope’ that those opposed to assisted dying fear. And in some jurisdictions with assisted dying legislation for people with terminal illness only, there have been recorded cases of malnutrition caused by severe anorexia nervosa being deemed as a terminal illness. The challenge for psychiatrists participating in this kind of decision-making about lives that no longer feel worth living is desperately difficult. After all, we are trained to help stop people from dying by suicide, are we not?

Figure 1 – An early poster for the Euthanasia Society. Source: Wikimedia Commons.

The idea of a ‘good death’ is as ancient as recorded history. In Ovid’s classic poem ‘Metamorphoses,’ the elderly, impoverished but devoted couple Baucis and Philemon offer their meagre hospitality to two strangers who appear at their door, having been turned away by wealthier neighbours. As is often the case in mythology, the two strangers turn out to be gods. In return for the elderly couple’s generosity, the gods grant them a wish. The husband replies

“We ask to be priests and to guard your temple; and since we have passed our years together in peace, let the same hour carry us off, so I need not look upon my dear wife’s grave, nor she have to bury my body”³

Their wish is granted and, after years of service to the temple, both become trees, with time at the end to say goodbye to each other. The story is of piety and service, as well as mutual devotion. Their story is echoed by that of the former Dutch prime minister and his wife, Dries and Eugenie van Agt, who were both ninety-three years old and in poor health when they opted for help to die together. After being married for over seventy years, they died hand in hand.⁴

Figure 2 – Baucis and Philemon entertain Zeus and Hermes. Credit: Philemon and Baucis providing food and shelter for Jupiter [Zeus] and Mercury [Hermes] who are disguised as travellers. Engraving after Sir P.P. Rubens. Wellcome Collection. Source: Wellcome Collection.

This presents an idealised image of good deaths, shared and surrounded with love and dignity. Several European countries, including the Netherlands and Belgium, as well as Canada, New Zealand, and Colombia, along with some states of both the US and Australia, have legislation that permits medical assistance in dying. According to the press coverage, Dries and Eugenie van Agt’s deaths fulfilled the criteria largely recognised as pre-requisites for such legislation. These criteria are that the person’s suffering is extreme; that they are close to death; and have capacity to make the decision. Variations are found across different countries. In some – Canada, for example – an expectation of closeness to death is not invariable, with extent of suffering being the main criteria.⁵

Psychiatrists and their colleagues spend a lot of their working lives trying to persuade people not to end their lives. The idea that all suicides are preventable underpins a ‘zero tolerance’ approach to suicide prevention.⁶ However, academic articles and recent news reports have revealed cases of people with histories of psychiatric problems who have sought out medical assistance to die.⁷ After all, our patients can and do suffer extreme pain. Psychological and emotional suffering can be just as unbearable as physical suffering. But, surely, we are no longer so siloed in our thinking to see physical and psychological disorders as distinct entities. So, assisted dying will have a lot to do with psychiatry and from all branches of the specialism.

This raises complex questions for our profession. One position is that excluding patients with psychiatric diagnoses is discriminatory, denying them parity of access to an intervention available to those with physical health problems. The opposing view is the tricky concept of insight – after all, high suicidal intent in a patient with a mental or physical disorder is surely evidence of the severity of that disorder.

Aubrey Lewis, a famous psychiatrist, defined insight for the purposes of his 1934 essay as “a correct attitude to a morbid change in oneself.”⁹ If one is mentally unwell, can one truly decide about the value of one’s own life? In some jurisdictions in which suffering is part of the eligibility criteria for assisted dying, a physician (and this includes psychiatrists) is asked by a patient whether their suffering is so bad that it makes life unbearable enough to warrant medical assistance to die. The notion of what makes a life worth living is a fundamental part of the decisions surrounding assisted dying, as well as a routine question asked by psychiatrists when exploring a person’s wish to die by suicide.

One of the fears held by anti-assisted dying campaigners is that the decision to offer medical assistance in dying will be influenced by others’ views about whether a life is worth living and that it could be extended to other people who are unable to express a view for themselves. This includes being unduly influenced by others. This is a thorny issue for psychiatrists, not least whilst the Royal College grapples with its past relationship with eugenics, and Aubrey Lewis, mentioned above, for a time, endorsed eugenics. The idea was that suffering could be avoided by preventing some lives even beginning. It was a short step in some places to selecting some to have their lives ended. Just as assisted dying is part of mainstream public and intellectual discourse now, so too was eugenics as a means of preventing suffering a century ago.

The notion of lives being judged as worth, or not worth living, led to terrible consequences in Europe and the USA, including forced sterilisation and state-sanctioned homicide. Psychiatrists were active participants in the selection of people whose lives should be ended.¹⁰ Psychiatry will continue to be a major part of the debates around medical assistance in dying. Our history with eugenics, along with treatment interventions used in the past with catastrophic consequences (insulin coma therapy, frontal leucotomy, conversion practices), tells us that we must tread very carefully. I still have not worked out how I feel about assisted dying, for those I care for or perhaps, at some point in the future, for myself. But I do think that the road to (psychiatric) hell can be paved with compassionate intentions.

Figure 3 – The Eugenics Tree – ‘A decade of progress in Eugenics.’. Note psychiatry, psychology, genetics, and history all sit together in the lower left-hand corner. Credit: A decade of progress in Eugenics. Scientific. Wellcome Collection. Source: Wellcome Collection.

References

1. Briefing from the Royal College of College of Psychiatrists for MPs. The Terminally Ill Adults (End of Life) Bill for England and Wales. Report Stage & Third Reading. 16 May 2025
2. Voluntary Euthanasia Society changes name after 70 years to become Dignity in Dying (23 Jan)
3. Ovid (trans David Raeburn), Metamorphoses (Penguin Classics, 2004).
4. Senay Boztas, ‘Duo Euthanasia: Former Dutch Prime Minister Dies Hand in Hand with His Wife’, The Observer, 10 February 2024, section World news [accessed 13 May 2024].
5. Karandeep Sonu Gaind, ‘The next National Apology: Future Canadians Might Regret Expansion of Medically Assisted Dying Laws’, The Conversation, 2021 [accessed 19 August 2024].
6. Bianca M. Dinkelaar, ‘Rational and Irrational Suicide in Plato and Modern Psychiatry’, BJPsych Advances, 26.4 (2020), pp. 229–35, doi:10.1192/bja.2020.2.
7. Harriet Sherwood, ‘Dutch Woman, 29, Granted Euthanasia Approval on Grounds of Mental Suffering’, The Guardian, 16 May 2024, section Society [accessed 16 May 2024]. Brendan D. Kelly and Declan M. McLoughlin, ‘Euthanasia, Assisted Suicide and Psychiatry: A Pandora’s Box’, The British Journal of Psychiatry, 181.4 (2002), pp. 278–79, doi:10.1192/bjp.181.4.278
8. Brendan D. Kelly and Declan M. McLoughlin, ‘Euthanasia, Assisted Suicide and Psychiatry: A Pandora’s Box’, The British Journal of Psychiatry, 181.4 (2002), pp. 278–79, doi:10.1192/bjp.181.4.278.
9. Aubrey Lewis, ‘The Psychopathology of Insight’, British Journal of Medical Psychology, 14.4 (1934), pp. 332–48, doi:10.1111/j.2044-8341.1934.tb01129.x.
10. Rael D. Strous, ‘Psychiatry during the Nazi Era: Ethical Lessons for the Modern Professional’, Annals of General Psychiatry, 6.1 (2007), p. 8, doi:10.1186/1744-859X-6-8.