‘Psychiatric euthanasia, suicide and the role of gender‘ is published in The British Journal of Psychiatry and is written by authors Marie E. Nicolini, Chris Gastmans and Scott Y.H. Kim. This article was selected as RCPsych Article of the Month in January 2022. Read the blog written by author, Marie Nicolini.

Canada is debating expanding its medical assistance in dying law to include mental illness as the sole underlying condition. Initially planned for March 2023, the rollout has now been paused, yet the discussion continues. 

Euthanasia and/or assisted suicide, when primarily based on a mental disorder (often referred to as psychiatric EAS), is permitted in some European countries, such as Belgium and the Netherlands, but remains controversial.

Countries like the Netherlands and Belgium have permitted psychiatric euthanasia since 2002. A person with a mental disorder can ask for euthanasia, provided the request is voluntary and competent, their suffering unbearable, and their condition “irremediable”. 

A consistent finding is the large gender gap: 69-77% of people who die by psychiatric euthanasia are women. Yet this staggering finding has received little attention so far. In this analysis, we examine how the gender gap informs a seemingly unrelated but deeply related issue: the link between psychiatric euthanasia and suicidality.

Consider a woman in her 40s with bipolar and borderline personality disorder, chronic feelings of profound emptiness, and chronic suicidality. She now asks for –and later receives– euthanasia. Our previous research and prominent media reports show that similar cases involving chronic suicidality are more common than expected.

Clinicians working in countries like the Netherlands and Belgium can respond in diametrically opposite ways to a person who wishes to die. They can try to prevent the person’s death or aid them in ending their life. This poses a real moral dilemma.

The standard picture: suicidality is impulsive, and a request for euthanasia is not, so impulsivity can help clinicians differentiate. Yet according to contemporary suicidology, this focus on impulsivity is outdated, and misguided: out-of-the-blue suicidal behavior without prior planning is the exception rather than the rule.

The gender gap shows that people who request and receive psychiatric euthanasia are similar to people with chronic suicidal behavior. Why is this an issue?

Some argue that psychiatric euthanasia is a good thing because it provides a peaceful death to a small number of people who would otherwise die a violent and painful one. In reality, the gender gap shows, euthanasia is more likely provided to suicide attempters who would not otherwise die by suicide.

For every person who dies by suicide, many more attempt suicide. So the pool of people who may ask their physicians to end their lives is much larger than previously assumed.

Without clarity on how physicians should proceed in their decision-making about psychiatric euthanasia, the moral problem is the risk of wrongful death. Given the gender gap, wrongful death will disproportionally affect women.

The gender gap is a canary in the coal mine. The issue merits serious and rigorous attention. This analysis touches on, but cannot do justice to, the broader reasons why women are more likely to think about ending their lives in the first place. 

Explore the entire RCPsych Article of the Month blog series here.