Galderisi et al¹ quite rightly draw our attention to the ethical dilemmas that emerge when one considers ending life. An area fraught with complexity takes a quantum leap when mental ill-health is added.

The need to rethink a position is nothing new. Whilst we may perceive change as gradual, over a decade it may become seismic, and constant re-evaluation of values may be necessary. The ground-shaking judgment in Roe v. Wade case in the US, and its recent reversal, is one example of how what seems right and proper can change overnight.

Even the most ardent supporters of choice would not support physician-assisted dying (PAD) in populations who lack decision-making capability, although some take the view that the Convention on the Rights of People with Disabilities (CRPD)² would dispute that those with mental illness cannot make their own choices.

Where is the boundary? Compromised is not impaired, let alone without value or meaning. In Japan, the Restaurant of Mistaken Orders employs staff with dementia, resulting in 37% of orders being mistaken, but 99% of customers report that they are happy³.

The CRPD emphasizes multiple rights: the right to life (Article 10); to adequate standards of living and social protection (Article 28); to “legal capacity” – that is to legal standing as well as legal agency – on an equal basis with others” (Article 12); “…the existence of a disability shall in no case justify a deprivation of liberty” (Article 14); “…every person with disability has a right to respect for his or her physical and mental integrity on an equal basis with others” (Article 17).

How do we reconcile these rights with the existence of PAD? Not a Pandora's box but a stack. One group states that those with mental illness must be allowed to participate equally. Yet, few psychiatrists would support that those with psychotic beliefs or severe depression should have access to PAD. How are these contrasting views, on conditions which may distort the ability to weigh up and evaluate choices, to be balanced?

The WPA Code of Ethics calls for the autonomy of persons with mental ill-health, but recognizes that involuntary interventions may be required, as a last resort, when less restrictive interventions have failed, to protect safety and to restore the person's autonomy. PAD will never “restore” autonomy; it implements it for a last time! The line of reasoning that permits coercion is in the context of interventions that improve quality of life and return autonomy. There is no reasonable world in which PAD promotes these.

For individuals who lack a formal mental disorder, but are facing the existential angst and distress of a terminal condition, or of unbearable suffering, the guiding principle shifts. The relief of suffering becomes more important. Autonomy takes priority when beneficence is unrealistic, and non-maleficence manifests as not making people suffer more than they choose to.

Many clinicians will be familiar with the lack of parity between physical and mental health care, that the resource allocation is uneven and unequal, particularly galling when the World Health Organization identifies mental ill-health as one of the leading causes of disability-adjusted life years. Is it perverse that a call for parity means access to PAD on an equal basis?

Another thread to concerns about PAD is: “How free is such a decision?”. There are concerns about societal pressures, not only involving human interactions. What is the influence of social media, and is that influence even human? Automated algorithms make a comprehensive and competent assessment of requests for PAD crucial.

Given the finality of PAD, a cautious approach to criteria for consent is appropriate. Apart from the Netherlands and Belgium, countries which have an enshrined right to PAD do not extend that right to minors. One might consider that sensible for those with impaired capacity, whether developmental or pathological.

That frameworks exist for the assessment of capacity does not take away from the need for staff to be properly trained. Despite teaching from national organizations, there is still widespread disparity in the quality of assessments, in this author's experience, even when workshops are delivered at meetings of the European Psychiatric Association or the American Psychiatric Association. Where death is the outcome, this is truly disturbing.

I note that Galderisi et al allege that medical associations have moved to neutrality over time, “perhaps to spare members who participate in these now-legal interventions from being labelled as unethical”. In the UK, the movement of professional associations towards neutrality or being in favour of legalization, whilst lagging behind public opinion, precedes legislative change, suggesting that it is the reverse. Changing attitudes rather than avoiding regulatory proceedings seem to be the cause of the shift⁴.

Another fear, that legalization and normalization of PAD will lead to a decline in palliative care for life-limiting conditions, is not borne out by an international evidence base⁵. Nor is it evident that PAD for psychological causes will open the floodgates, with only 5% of requests on this basis being approved⁶.

As suffering is purely subjective, whether psychic or physical, disputes about its definition seem ironic. On the contrary, discussions about treatability are not subjective and can be evidence based. That only treatments which patients are willing to accept would be used in determining treatability is a challenge to autonomy, when set against societal values that life should be preserved. What is “untreatable” has been well analyzed before in this journal⁷, and the same arguments are as valid here.

At the end of the day, disagreements about definitions do not invalidate the principle. It is the pragmatic that is questioned. Whilst the devil is in detail, it does not mean that the relief of irremediable unbearable suffering does not justify the legalization of PAD. It is a truly terrible decision, one that deserves compassion and empathy. When a process to leave this world is clearly articulated and lawful, evidence from EXIT (Switzerland) shows that, of those enquiring for PAD, 68% make a choice to live⁸.

Societies have to make several hard decisions. When is capacity to exercise a choice for PAD present? What is “untreatable”? At what point is the burden of treatment such that more can be refused whilst retaining access to PAD? What would a compassionate caring process look like? In any case, vigilance to ensure that the principles are maintained, without deviation, will be required. In such a scenario, PAD has a place in civil society. A choice I hope you never need.

Galderisi 等人¹非常正确地提请我们注意当一个人考虑结束生命时出现的道德困境。当心理健康状况不佳时，一个充满复杂性的领域就会发生质的飞跃。

重新考虑立场的必要性并不是什么新鲜事。虽然我们可能认为变化是渐进的，但十多年来它可能会发生巨大的变化，并且可能需要不断地重新评估价值观。美国罗伊诉韦德案中的惊天动地的判决以及最近的逆转就是一个例子，说明看似正确和正当的事情如何在一夜之间发生变化。

即使是最热心的支持者也不会支持在缺乏决策能力的人群中实施医生辅助死亡 (PAD)，尽管有些人认为《残疾人权利公约》(CRPD) ²会质疑那些具有决策能力的人群精神病患者无法自己做出选择。

边界在哪里？妥协并不是受损，更不是没有价值或意义。在日本，错单餐厅雇用了患有痴呆症的员工，导致 37% 的订单出现错误，但 99% 的顾客表示他们很满意³ 。

《残疾人权利公约》强调多项权利：生命权（第 10 条）；适当的生活水平和社会保护（第 28 条）； “法律行为能力”——即法律地位和法律机构——在与其他人平等的基础上”（第 12 条）； “……在任何情况下，残疾的存在都不应成为剥夺自由的理由”（第 14 条）； “……每个残疾人都有权在与其他人平等的基础上尊重其身心健康”（第 17 条）。

我们如何协调这些权利与 PAD 的存在？不是潘多拉魔盒，而是一堆。一个团体表示，必须允许患有精神疾病的人平等参与。然而，很少有精神病学家会支持那些有精神病信念或严重抑郁症的人应该接受 PAD。在可能扭曲权衡和评估选择能力的情况下，如何平衡这些截然不同的观点？

WPA 道德守则呼吁精神疾病患者享有自主权，但也承认，当限制性较小的干预措施失败时，可能需要非自愿干预作为最后手段，以保护安全并恢复患者的自主权。 PAD永远不会“恢复”自主权；这是最后一次实现它！允许强制的推理思路是在改善生活质量和恢复自主权的干预措施的背景下进行的。 PAD 不存在提倡这些的合理世界。

对于那些没有正式的精神障碍，但面临临终状态的存在焦虑和痛苦，或难以忍受的痛苦的人来说，指导原则发生了变化。解除痛苦变得更加重要。当仁慈不切实际时，自治优先，而无恶意则表现为不让人们遭受超出他们选择的痛苦。

许多临床医生都熟悉身心保健之间缺乏对等、资源分配不均和不平等，当世界卫生组织将精神疾病确定为残疾调整生命年的主要原因之一时，尤其令人恼火。呼吁平等意味着平等地获得 PAD，这是否有悖常理？

关于 PAD 的另一个担忧是：“这样的决定有多自由？”。人们担心社会压力，不仅涉及人与人之间的互动。社交媒体的影响是什么？这种影响甚至是人类的吗？自动化算法对 PAD 请求进行全面、有效的评估至关重要。

鉴于 PAD 的最终性，对同意标准采取谨慎的态度是适当的。除荷兰和比利时外，拥有 PAD 权利的国家不会将该权利延伸至未成年人。人们可能会认为这对于那些能力受损的人来说是明智的，无论是发育性的还是病理性的。

能力评估框架的存在并不妨碍工作人员接受适当培训。尽管由国家组织进行教学，但根据作者的经验，即使在欧洲精神病学协会或美国精神病学协会的会议上举办研讨会，评估质量仍然存在广泛的差异。如果结果是死亡，这确实令人不安。

我注意到 Galderisi 等人声称，随着时间的推移，医学协会已经转向中立，“也许是为了让参与这些现已合法的干预措施的成员免于被贴上不道德的标签”。在英国，专业协会走向中立或支持合法化的运动虽然落后于公众舆论，但却先于立法变革，这表明情况恰恰相反。转变的原因似乎是改变态度而不是逃避监管程序⁴ 。

另一种担忧是，PAD 的合法化和正常化将导致对生命有限的疾病的姑息治疗减少，但这一担忧并未得到国际证据的证实⁵ 。出于心理原因的 PAD 也不会打开闸门，只有 5% 的请求得到批准⁶ 。

由于痛苦纯粹是主观的，无论是精神上的还是身体上的，关于其定义的争论似乎很讽刺。相反，关于可治疗性的讨论不是主观的，并且可以基于证据。当与应保护生命的社会价值观相悖时，只有患者愿意接受的治疗才会被用于确定可治疗性，这是对自主权的挑战。什么是“无法治疗”，本杂志之前已经对此进行了很好的分析⁷ ，同样的论点在这里同样有效。

归根结底，关于定义的分歧并不会使该原则失效。受到质疑的是实用主义。虽然魔鬼在细节，但这并不意味着缓解无法挽回的难以忍受的痛苦就不能成为PAD合法化的理由。这确实是一个可怕的决定，值得同情和同情。当离开这个世界的程序明确且合法时，EXIT（瑞士）的证据表明，在询问 PAD 的人中，68% 的人选择继续生活⁸ 。

社会必须做出一些艰难的决定。何时存在行使 PAD 选择权的能力？什么是“无法治愈”？治疗负担到什么程度时才能拒绝更多治疗，同时保留 PAD 的使用权？富有同情心的护理过程是什么样的？无论如何，都需要保持警惕，确保原则得到遵守，不出现偏差。在这种情况下，PAD 在民间社会中占有一席之地。我希望你永远不需要这个选择。