Physician-assisted death (PAD) – i.e., the prescription and administration of lethal medications by physicians – is increasingly available as an option for people struggling with psychiatric disorders. Although PAD was initially promoted as a means of easing suffering for people with terminal conditions, a growing number of jurisdictions have extended access to all causes of intractable and severe suffering, including psychiatric conditions.

At present, Belgium, the Netherlands and Luxembourg, along with Spain and Switzerland, either explicitly authorize or de facto permit lethal assistance in such cases¹. Canada is scheduled to join this group in March 2024. It is difficult to ascertain how often PAD is used for psychiatric disorders; however, among all PAD cases in Switzerland, 8% of those in Swiss residents and 17% of those in people traveling from other countries for this purpose had documented mental disorders². Overall, available data suggest that the frequency of PAD use in people with psychiatric disorders is increasing¹.

A growing literature is debating the ethics of PAD in psychiatry. For jurisdictions that permit PAD in terminal illnesses, it is commonly argued that to preclude its use for non-terminal conditions that cause immense suffering, including psychiatric disorders, is discriminatory. To proponents of psychiatric PAD, it appears unquestionable that these conditions can cause severe suffering and may be resistant to available treatments, that most people with a psychiatric diagnosis are competent to decide that death is preferable to an indefinite continuation of their current state, and that clinicians can reliably ascertain whether these criteria have been met³.

I have previously detailed in this journal⁴ my concerns about PAD for people with psychiatric disorders. Among the reasons I noted for caution in embracing PAD are its application to disorders very different from treatment-resistant depression (which is often held up as the model of an intractable condition that causes great suffering), including autism, eating disorders, dissociative disorders, and personality disorders. The high proportion of patients with personality disorders seeking PAD, and the well-known reactivity of these conditions to environmental circumstances, raise the question of just how deeply rooted the distress being expressed by such patients might be. Whether a person is experiencing severe suffering, a key criterion for eligibility, is entirely subjective, leaving evaluators with little choice but to accept the patient's assertion that this is the case. Given that intractability is usually judged only by the lack of response to those treatments that a patient is willing to accept, it is common that potentially effective interventions have never been tried by patients seeking PAD. Finally, whether the underlying disorder is driving the person's choice is very difficult to ascertain, leaving the decisional competence requirement little role to play in these cases.

Here, I want to consider what we can learn from the experience with psychiatric PAD, primarily from reports published over the last five years. There has always been concern that PAD would become a replacement for the provision of psychiatric care, especially where such care is not easily accessed. Recent reports from Canada underscore this concern, as exemplified by the account of a woman who sought help at a hospital for suicidal ideation⁵. She was told that the mental health system was “completely overwhelmed”, no inpatient beds were available, and she would have to wait six months to see a psychiatrist as an outpatient. At that point, the counselor assessing her asked if she had ever considered PAD, explained how it worked, and noted that it would alleviate her suffering. All this occurred even though PAD was technically not yet authorized in Canada for people with mental disorders, and reinforces reports from other Canadian jurisdictions.

Along with concern about PAD being used as a substitute for care are data suggesting that patients who are suicidal – and thus should be treated for their intention to end their lives – are disproportionately seeking PAD. A review of studies on the prevalence of personality disorders among PAD requesters noted that in several reports they represented more than 50% of the sample; the authors underscored the substantial frequency of suicidal behavior in personality disorders, its fluctuating nature, and the existence of evidence-based treatments to address it⁶. Another review focused on the disproportionate use of psychiatric PAD for women, who accounted for 69-77% of cases in several series⁷. The authors noted that women also attempt suicide more frequently and typically favor less violent means, such as medication overdose. Hence, they suggested that PAD may be serving as a substitute for self-inflicted suicide, especially for women, and encouraged further research on this question.

The momentous nature of a decision to seek PAD – an irreversible and final procedure – suggests the need for great care in evaluating whether the criteria for eligibility are met. However, this appears often not to be the case. A review of 66 cases of PAD from the Netherlands found that, in 55% of cases, documentation of decisional capacity was limited to a global judgment, without assessment of specific capacity-related abilities⁸. Moreover, there was disagreement about capacity among evaluating physicians in 12% of cases in which PAD was carried out anyway. The authors concluded that the decisional capacity of psychiatric patients seeking PAD receives neither a high level of scrutiny nor is subject to a high threshold, an approach that seems to be accepted by the committees that review these cases. In some jurisdictions, a patient with a psychiatric disorder need not be evaluated by a psychiatrist prior to PAD, heightening the probability of inadequate evaluation.

A recent case report from the Netherlands illustrates another reason for careful evaluation: the possibility that a patient has been misdiagnosed and thus has not received effective treatment⁹. In this case, intolerable auditory hallucinations that motivated the request for PAD were found to be due to intrusive thoughts and responded to cognitive-behavior therapy. The authors recommend an “obligatory second opinion by a psychiatrist specialized in the patient's disorder”, which is not currently required.

Where does this leave us? These data suggest that many of the initial worries about psychiatric PAD are being reinforced by ongoing practice. This procedure is susceptible to being used as a replacement for care; it appears to be sought by patients, especially women, as a substitute for trying to end their own lives; and the challenging evaluations of the required criteria seem often to be performed in a perfunctory manner. Although data are not yet available, it is worthwhile thinking about the longer-term impact on psychiatrists and psychiatric patients: the message that their conditions may be hopeless, thus not worth the effort to treat or to receive treatment, and that death is an acceptable alternative. Such a posture conflicts with the traditional stance of psychiatry as a specialty dedicated to sustaining hope, protecting people from the impulse to end their lives, and helping people find meaning in their existence. The prospect of further spread of psychiatric PAD is indeed reason for concern.

医生协助死亡（PAD）——即由医生开具和施用致命药物——越来越多地成为与精神疾病作斗争的人们的一种选择。尽管 PAD 最初被推广为减轻绝症患者痛苦的一种手段，但越来越多的司法管辖区已将其范围扩大到所有导致顽固和严重痛苦的原因，包括精神疾病。

目前，比利时、荷兰和卢森堡以及西班牙和瑞士要么明确授权，要么事实上允许在此类情况下提供致命援助¹ 。加拿大计划于 2024 年 3 月加入该组织。很难确定 PAD 用于治疗精神疾病的频率；然而，在瑞士的所有 PAD 病例中，8% 的瑞士居民和 17% 的来自其他国家的旅行者患有精神疾病² 。总体而言，现有数据表明精神疾病患者使用 PAD 的频率正在增加¹ 。

越来越多的文献正在讨论精神病学中 PAD 的伦理问题。对于允许在绝症中使用 PAD 的司法管辖区，人们普遍认为，排除将其用于导致巨大痛苦（包括精神疾病）的非绝症病症是一种歧视。对于精神病 PAD 的支持者来说，毫无疑问，这些病症可能会导致严重的痛苦，并且可能对现有的治疗有抵抗力，大多数患有精神病诊断的人有能力决定死亡比无限期地延续目前的状态更好，而且临床医生可以可靠地确定是否满足这些标准³ 。

我之前曾在本期刊中详细阐述过⁴我对精神疾病患者 PAD 的担忧。我谨慎对待 PAD 的原因之一是它适用于与难治性抑郁症（通常被认为是导致巨大痛苦的顽固性疾病的模型）截然不同的疾病，包括自闭症、饮食失调、分离性障碍、和人格障碍。寻求 PAD 的人格障碍患者比例很高，而且这些疾病对环境条件的反应众所周知，这些都提出了这样的问题：这些患者所表达的痛苦可能有多根深蒂固。一个人是否正在经历严重的痛苦（资格的关键标准）完全是主观的，评估人员别无选择，只能接受患者的说法。鉴于难治性通常仅通过患者愿意接受的治疗缺乏反应来判断，因此寻求 PAD 的患者通常从未尝试过潜在有效的干预措施。最后，很难确定潜在的疾病是否正在推动人们的选择，因此决策能力要求在这些情况下几乎不起作用。

在这里，我想考虑一下我们可以从精神病学 PAD 的经验中学到什么，主要是从过去五年发表的报告中学到什么。人们一直担心 PAD 会成为精神科护理的替代品，特别是在不易获得此类护理的地方。加拿大最近的报告强调了这一担忧，一名因自杀意念而到医院寻求帮助的妇女的叙述就是例证⁵ 。她被告知精神卫生系统“完全不堪重负”，没有可用的住院床位，她必须等待六个月才能在门诊看精神科医生。此时，评估她的辅导员询问她是否曾经考虑过 PAD，解释了它的作用原理，并指出这会减轻她的痛苦。尽管从技术上讲，加拿大尚未批准 PAD 用于治疗精神障碍患者，但所有这一切都发生了，并证实了加拿大其他司法管辖区的报告。

除了担心 PAD 被用作护理的替代品之外，还有数据表明，有自杀倾向的患者（因此应该因打算结束生命而接受治疗）不成比例地寻求 PAD。对 PAD 请求者中人格障碍患病率的研究回顾指出，在几份报告中，他们占样本的 50% 以上；作者强调了人格障碍中自杀行为的高频率、其波动性以及解决这一问题的循证治疗方法的存在⁶ 。另一项审查的重点是女性不成比例地使用精神科 PAD，在几个系列中，女性占病例的 69-77% ⁷ 。作者指出，女性尝试自杀的频率也更高，并且通常更倾向于采用较少暴力的方式，例如服用过量药物。因此，他们认为 PAD 可能可以作为自杀的替代品，尤其是对于女性来说，并鼓励对这个问题进行进一步的研究。

寻求 PAD 的决定（一个不可逆转的最终程序）的重大性质表明，在评估是否符合资格标准时需要非常谨慎。然而，情况往往并非如此。对荷兰 66 个 PAD 案例的审查发现，在 55% 的案例中，决策能力的记录仅限于全局判断，而没有对具体的能力相关能力进行评估⁸ 。此外，在 12% 无论如何都进行了 PAD 的病例中，医生的评估能力存在分歧。作者得出的结论是，寻求 PAD 的精神病患者的决策能力既没有受到高水平的审查，也没有受到很高的门槛，这种方法似乎被审查这些病例的委员会所接受。在某些司法管辖区，患有精神疾病的患者在进行 PAD 之前不需要由精神科医生进行评估，这增加了评估不充分的可能性。

荷兰最近的一份病例报告说明了仔细评估的另一个原因：患者可能被误诊，从而没有得到有效的治疗⁹ 。在这个案例中，令人难以忍受的幻听促使人们要求进行 PAD，结果发现是由于侵入性想法造成的，并且对认知行为治疗有反应。作者建议“必须由专门研究患者疾病的精神科医生提供第二意见”，但目前并不需要这样做。

这给我们留下了什么？这些数据表明，许多最初对精神病 PAD 的担忧正在因持续的实践而得到加强。该程序很容易被用作护理的替代方法；患者，尤其是女性患者似乎寻求这种方法来代替尝试结束自己的生命；对所需标准的具有挑战性的评估似乎常常是以敷衍的方式进行的。尽管尚无数据，但值得思考对精神科医生和精神病患者的长期影响：他们的病情可能无望，因此不值得努力治疗或接受治疗，死亡是可以接受的信息选择。这种态度与精神病学的传统立场相冲突，精神病学是一门致力于维持希望、保护人们免受结束生命的冲动并帮助人们找到存在意义的专业。精神疾病 PAD 进一步蔓延的前景确实令人担忧。