Editorial: Ethical and psychiatric considerations in euthanasia and medically assisted suicide (E/PAS)

Editorial: Euthanasia and Medically Assisted Suicide in Psychiatry 2Ethical and Psychiatric Considerations in Euthanasia and Medically Assisted Suicide (E/PAS) In mental health care, suicidality, i.e., not being willing to continue with one's own life, is one of the most altering symptoms occurring in various psychiatric conditions. In these cases, the role of healthcare professionals is to protect the person from the risk of suicide and ensure adequate treatment to address the underlying illness (1)(2)(3). However, just like in nonpsychiatric disorders, there are persons who have received and exhausted state-of-the-art, evidence-and guideline-based treatment and still don't reach sufficient recovery and quality of life, causing subjectively intolerable suffering without a plausible perspective for improvement (3). Furthermore, the distinction between non-psychiatric and psychiatric illnesses in this context may not be completely clear, as mental health issues are often an important comorbidity in somatic illnesses leading to a wish for assisted dying (4). And, in both cases, suicidal symptoms (such as suicide ideations or suicide attempts) can be considered psychologically as a means to mentally reduce the individual suffering (e.g., showing a possible way out if other coping strategies are not available) (5).The question of whether and under which circumstances a medical ill person should be able to receive euthanasia (i.e. by an active deadly intervention) or physician-assisted suicide (i.e., medically provided means to kill oneself; E/PAS) is a significant and contested matter from a bioethical as well as medical perspective debated worldwide. In the case of a mental illness, the situation may be considered even more complex since the wish to die can occur as an inherent part of the psychiatric disease's pathology (6).Western countries exhibit diverse psychiatric regulations and practices concerning E/PAS. While some nations permit these practices under specific conditions associated with unbearable psychiatric suffering or treatment-resistant mental health disorders, others haven't extended them to these disorders yet, allowing E/PAS only under certain medical conditions (4,7). Evaluating the mental decision-making capacity of patients who choose E/PAS and defining 'unbearable psychological distress' are central psychiatric issues in this practice (8).Additionally, the ethical implications of extending E/PAS to minors and individuals with neurological disorders or those depending on life-support treatments uncovers another area warranting comprehensive scrutiny (7). Furthermore, people with mental disorders are often stigmatized (9)(10)(11)(12). It therefore seems plausible that acceptance of assisted dying by healthcare professionals, within the legal system and in the general population, might also be related to stigmatization (13).Building on a previous special issue on assisted dying in persons with mental illness from 2022 (14), this research topic seeks to delve into the evolving psychiatric approaches and policies regarding E/PAS in the recent literature. Table 1 gives an overview of the papers published within the scope of the current research topic sorted by main topic.Please insert Table 1 here ========================================= Most of the submissions were theoretical papers, with one systematic review, two policy and practice reviews, a conceptual analysis, a hypothesis and theory paper, and five perspective papers. This might be an indication that the field is focused on the discourse on actual policies and their future development, and that data-based, empirical research is still underdeveloped.In the research topic description, the editors invited submissions evaluating the prevalence patients with mental disorders, with particular focus on persons diagnosed with severe and persistent mental illness (SPMI, e.g., schizophrenia spectrum disorder, unipolar depression or bipolar disorder, severe personality disorders), and with neurological diagnoses (e.g., dementia, autism spectrum disorder). However, only one paper focused on a specific diagnosis (eating disorders). Further absent topics were studies providing insight into cognitive mechanisms that may influence patients' decisions to access E/PAS, regardless of the presence of mental and/or neurological disorders. Also, there were no papers with a focus on alternative strategies to offer to individuals requesting access to E/PAS for mental disorders sketching out the latest developments in psychiatric and/or neurological fields in this regard.In addition, there were no submissions on refining the standardization of procedures used in the psychiatric evaluation of patients seeking for E/PAS, including research on refining and validating procedures and assessment tools for evaluating mental capacity to make decisions about assisted dying, defining and assessing 'unbearable and unrelievable mental distress', and establishing criteria for 'absence of prospects for improvement'. This list could therefore serve as an inspiration for research that is still needed in the field.Nevertheless, the considerable number of papers collected shows that this is a broad and active research field in psychiatry, and that there is rising awareness in academic and clinical psychiatry. Besides legal considerations, the discussion about E/PAS also reveals significant yet unsolved dualities that challenge health care providers during their everyday work, especially in the field of mental health, such as suicide prevention vs. the "right to die" or keep the role of the undoubtful advocate of life vs. limited means to reduce individual suffering.With the presented article collection, we aim to allow various perspectives on the polarizing topic E/PAS to stimulate further fruitful discussions.