Skip to main page content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
Review
. 2023 Sep;53(12):5729-5747.
doi: 10.1017/S0033291722002951. Epub 2022 Oct 28.

Irremediability in psychiatric euthanasia: examining the objective standard

Marie E Nicolini  1   2 , E J Jardas  1 , Carlos A Zarate Jr  3 , Chris Gastmans  2 , Scott Y H Kim  1
Affiliations
Review

Irremediability in psychiatric euthanasia: examining the objective standard

Marie E Nicolini et al. Psychol Med. 2023 Sep.

Abstract

Background: Irremediability is a key requirement for euthanasia and assisted suicide for psychiatric disorders (psychiatric EAS). Countries like the Netherlands and Belgium ask clinicians to assess irremediability in light of the patient's diagnosis and prognosis and 'according to current medical understanding'. Clarifying the relevance of a default objective standard for irremediability when applied to psychiatric EAS is crucial for solid policymaking. Yet so far, a thorough examination of this standard is lacking.

Methods: Using treatment-resistant depression (TRD) as a test case, through a scoping review in PubMed, we analyzed the state-of-the-art evidence for whether clinicians can accurately predict individual long-term outcome and single out irremediable cases, by examining the following questions: (1) What is the definition of TRD; (2) What are group-level long-term outcomes of TRD; and (3) Can clinicians make accurate individual outcome predictions in TRD?

Results: A uniform definition of TRD is lacking, with over 150 existing definitions, mostly focused on psychopharmacological research. Available yet limited studies about long-term outcomes indicate that a majority of patients with long-term TRD show significant improvement over time. Finally, evidence about individual predictions in TRD using precision medicine is growing, but methodological shortcomings and varying predictive accuracies pose important challenges for its implementation in clinical practice.

Conclusion: Our findings support the claim that, as per available evidence, clinicians cannot accurately predict long-term chances of recovery in a particular patient with TRD. This means that the objective standard for irremediability cannot be met, with implications for policy and practice of psychiatric EAS.

Keywords: aid-in-dying; assisted suicide; euthanasia; irremediability; precision psychiatry; psychiatry; treatment-resistant depression.

PubMed Disclaimer

Conflict of interest statement

M. N., E. J., C. G. and S. K. report no competing interests. C. Z. is listed as a co-inventor on a patent for the use of ketamine in major depression and suicidal ideation. C. Z. is listed as co-inventor on a patent for the use of (2R,6R)-hydroxynorketamine, (S)-dehydronorketamine, and other stereo- isomeric dehydro and hydroxylated metabolites of (R,S)-ketamine metabolites in the treatment of depression and neuropathic pain; and as co-inventor on a patent application for the use of (2R,6R)-hydroxynorketamine and (2S,6S)-hydroxynorketamine in the treatment of depression, anxiety, anhedonia, suicidal ideation, and posttraumatic stress disorders. He has assigned his patent rights to the US government but will share a percentage of any royalties that may be received by the government.

Figures

Fig. 1.
Fig. 1.
Search strategy and selection process.
See this image and copyright information in PMC

References

    1. Alonso, S. G., de la Torre-Díez, I., Hamrioui, S., López-Coronado, M., Barreno, D. C., Nozaleda, L. M., & Franco, M. (2018). Data mining algorithms and techniques in mental health: A systematic review. Journal of Medical Systems, 42(9), 161. doi:10.1007/s10916-018-1018-2. - DOI - PubMed
    1. Appelbaum, P. S. (2017). Should mental disorders be a basis for physician-assisted death? Psychiatric Services, 68(4), 315–317. doi:10.1176/appi.ps.201700013. - DOI - PubMed
    1. Bailey, N. W., Hoy, K. E., Rogasch, N. C., Thomson, R. H., McQueen, S., Elliot, D., … Fitzgerald, P. B. (2018). Responders to rTMS for depression show increased fronto-midline theta and theta connectivity compared to non-responders. Brain Stimulation, 11(1), 190–203. doi:10.1016/j.brs.2017.10.015. - DOI - PubMed
    1. Bailey, N. W., Hoy, K. E., Rogasch, N. C., Thomson, R. H., McQueen, S., Elliot, D., … Fitzgerald, P. B. (2019). Differentiating responders and non-responders to rTMS treatment for depression after one week using resting EEG connectivity measures. Journal of Affective Disorders, 242, 68–79. doi:10.1016/j.jad.2018.08.058. - DOI - PubMed
    1. Bares, M., Novak, T., Brunovsky, M., Kopecek, M., & Höschl, C. (2017). The comparison of effectiveness of various potential predictors of response to treatment with SSRIs in patients with depressive disorder. The Journal of Nervous and Mental Disease, 205(8), 618–626. doi:10.1097/nmd.0000000000000574. - DOI - PubMed

Publication types