Euthanasia for mental suffering in young people: a critical global perspective

Medical assistance in dying (MAID) on psychiatric grounds remains deeply controversial, particularly when applied to young adults. In the Netherlands, an increasing number of such requests are made by young women under 30 years, often with complex trauma histories or neurodevelopmental disorders (e.g., autism, attention-deficit/hyperactivity disorder) and intersecting vulnerabilities1. The growing prevalence of such cases among young people with complex psychiatric profiles raises fundamental questions about autonomy, irremediability, and the moral authority of medicine. This ethical complexity intensifies when one considers the widespread shortage of accessible mental health care for psychiatric patients. In the Netherlands, over 100,000 patients are on a waiting list for mental health care on an annual basis. At least 20,000 vacancies are expected to open up in the Dutch mental health care sector in the near future. This sector has the highest absenteeism rate, at over 8%, and many professionals are retiring, discouraged by the administrative burden. In the Netherlands, no legal, ethical or clinical distinction is made – with respect to MAID – between somatic and mental suffering, or between a physical terminal illness, unavoidably leading to death, and chronic mental suffering. Yet, phenomenologically, they are worlds apart2. Physical illnesses often have a measurable trajectory; mental suffering is dynamic, relational, existentially driven and context-dependent. A further ambiguity lies in the question of definitional authority. Who decides what constitutes “unbearable suffering”? Whose judgment counts in establishing that suffering is “irremediable”? Psychiatric assessments of irremediability rely heavily on subjective interpretation, with little empirical consensus or prognostic accuracy. For conditions such as treatment-resistant depression, clinicians cannot reliably predict long-term outcomes, making the irremediability criterion epistemologically unstable. This uncertainty is compounded when considering young adults. It is questionable whether individuals under the age of 25 can consistently meet the threshold of decisional capacity required for MAID1. Especially in cases of persistent low mood and a narrow focus on the underlying death wish, young individuals often lack the experiential perspective needed to imagine recovery or alternative futures, undermining the reflective balance required for informed consent. Mental suffering is often due to a complex interplay of trauma, meaning, social marginalization, and emotional pain. For young women with histories of complex trauma, requests for euthanasia may reflect not only mental illness but also structural neglect, relational isolation, or a cry for recognition. Some euthanasia requests are the endpoint of unconscious self-destructiveness rather than lucid end-of-life planning3. In such cases, the clinical response should be containment and understanding, not terminal intervention. A common rationale for euthanasia in psychiatric settings is the claim that it prevents violent or traumatic suicides. Yet this argument does not withstand scrutiny. Suicidality is a common and chronic symptom in psychiatric populations, not an isolated end-stage event. There is broad consensus that the clinical approach includes managing risk and treating the underlying cause, not providing euthanasia. There is no evidence that availability of MAID reduces overall suicide rates4, which is perhaps unsurprising given that completed suicides occur predominantly among men, while euthanasia requests for mental suffering are primarily submitted by women. In fact, the presence of MAID as a socially sanctioned death route may deepen suicidal fixation in vulnerable individuals. The ecological and psychological risks of offering death as an exit strategy are rarely acknowledged in policy frameworks. Despite the moral gravity of euthanasia decisions, MAID in psychiatric patients is often overseen by physicians operating without multidisciplinary oversight or psychodynamic training. A growing number of cases are handled by older or retired doctors, sometimes without active psychiatric supervision. Physicians, who face important barriers in trauma-informed care, may unconsciously act out countertransference in such situations, colluding with self-destruction instead of offering containment3. The Dutch Psychiatric Association has developed detailed guidelines facilitating euthanasia for mental suffering, emphasizing clinical autonomy and individual judgment. However, this position sharply contrasts with those taken by sister organizations in countries such as the UK and Canada, which have expressed strong reservations or outright opposition to psychiatric MAID. The UK Royal College of Psychiatrists5 has stated unequivocally that it cannot support the Terminally Ill Adults (End of Life) Bill in its current form, citing insufficient safeguards and lack of meaningful psychiatric oversight. This position reflects a broader ethical stance that mental suffering cannot be equated with terminal illness and requires distinct and robust assessment pathways. Similarly, the Canadian Psychiatric Association6 has consistently urged caution. In response to proposed legislation expanding MAID eligibility to individuals with mental illness as the sole condition, the Association highlighted the absence of clinical consensus on irremediability, risks of misinterpreting suicidal ideation, and the need for enhanced training and ethical oversight. These concerns were influential in prompting the Canadian federal government to delay MAID expansion for psychiatric conditions until at least 2027. Though legally allowed, the Belgian Society for Psychiatrists decided not to support MAID for mentally suffering patients younger than 28, for the same reasons mentioned above – that is, the risk of not being able to judge objectively the death wish, suffering and treatment refractoriness. The Dutch model thus represents an international outlier, a system where psychiatric MAID is operationalized without a formal distinction between mental and physical suffering and with limited interdisciplinary input. Such disciplinary closure stifles debate, sidelines alternative narratives, and undermines democratic oversight. When dissenting voices are ignored, a small group of activists may exercise disproportional great influence1. The appropriation of the sole right to decide on ethical frameworks for euthanasia by Dutch medical interest groups not only demonstrates a failure to recognize the complexity and scope of this ethical issue, but also excludes other scientific disciplines and public opinion on the basis of misplaced medical authority. Internationally, the practice of psychiatric MAID in the Netherlands has raised concerns. The United Nations (UN) Committee on the Rights of Persons with Disabilities warned that euthanasia for people with psychosocial disabilities violates their right to life and reinforces structural ableism7. The International Society for Psychological and Social Approaches to Psychosis8 similarly warned that normalizing death as an outcome for mental illness undermines therapeutic hope and violates professional ethics. The Dutch model of psychiatric euthanasia exposes a painful tension at the heart of medicine: on what grounds is medical expertise solely responsible for existential mental suffering? The current practice raises more questions than it answers. At the very least, it demands serious international scrutiny, robust ethical debate, and cross-disciplinary regulation. Euthanasia may be ethically defensible, but its use in the context of youth, trauma and emotional distress must never become routine. In navigating this terrain, we must hold fast to the principle articulated by C. Saunders9: “There is so much more to be done, even when nothing can be done”.