Self-Identified Palliative Psychiatrists Should Disclose Their Views on Psychiatric Euthanasia

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COMMENTARY

In their piece, “Palliative Psychiatry and Assisted Suicide for Mental Illness: Not 1 and the Same,”¹ Buchman and Levitt take issue with my commentary, “‘Palliative Psychiatry’ and Assisted Suicide: Compassion? Abandonment? Or Something Far Worse?”² While Buchman and Levitt label my comments as “mischaracterizations,” unfortunately their own piece, which they credit their Toronto colleague Sheehan aiding them with, itself mischaracterizes my commentary. Buchman and Levitt accuse me of “conflating” palliative psychiatry with psychiatric euthanasia, when I do the opposite—in my first paragraph, I write that assisted suicide policies for mental illness “reflect neither palliative medicine, nor psychiatric care.”

Buchman and Levitt object to my comment that “palliative psychiatry takes a dangerous turn when discussions invariably lead to advocacy for assisted suicide policies for mental illness,” yet ignore that the same paragraph explicitly references concepts of “palliative psychiatry,” “terminal psychiatric illness,” and “end stage psychiatric disorder” as presented in the specifically identified piece by Yager, Treem, and Strouse, “End-of-Life Care for Patients With Psychiatric Disorders.”³ That piece is focused on palliative psychiatry and does explicitly end with statements that “end-of-life issues of patients with psychiatric disorders also raise considerations of medical aid in dying (MAiD) for patients with intractable suffering attributed to their disorder.”

I regret Buchman and Levitt choose to label my statements as “mischaracterizations” rather than accurately reflecting their context. As pointed out in a recent piece in the American Journal of Bioethics, “A (White) Senator, Doctor and Lawyer Walk Into a Bar…and Appropriate the Assisted Dying Narrative,” those advising caution about MAiD expansion have often been subject to ad hominem attacks to dismiss the evidence-based concerns they have raised (I personally have faced racial tropes by senior white colleagues, for example accused of “invading” McMaster University rounds on MAiD that I had been invited to attend).⁴

When Buchman and Levitt write “To our knowledge, there is no scholarly literature where palliative psychiatry is used to advocate for [psychiatric euthanasia] policy,” this misses the point and deflects from the real issue (in fact, I agree with Buchman and Levitt’s sentiment that little scholarly evidence supporting psychiatric euthanasia exists). The point is that in the real world, palliative psychiatry discussions and proponents have fueled advocacy for psychiatric euthanasia, including Canada’s rapid expansion of assisted suicide policies.

One of Buchman and Levitt’s collaborators, Mona Gupta, MD, who they have coauthored multiple publications with on palliative psychiatry and on MAiD, and with whom they as cochairs have collaborated with on multiple CIHR funded projects including “A Community of Practice for Palliative Care”⁵ and “Palliating Mental Illnesses,”⁶ is recognized as one of the most prominent psychiatrist activists in Canada pushing for, and shaping, MAiD expansion to mental illness. Gupta has authored/coauthored numerous documents calling for MAiD for mental illness,^7,8 chaired the federal panel on MAiD and mental illness,⁹ and led the working group developing state-funded education modules on MAiD and mental disorders. Gupta is also the activist I point out in my earlier piece who testified that the 2:1 gender gap of women to men receiving psychiatric euthanasia in Europe “does not concern” her.

While I agree with Buchman and Levitt that palliative care and MAiD are not the same thing, they wrongly accuse me of conflating the 2. Nor am I saying that all palliative psychiatrists advocate for psychiatric euthanasia (I suspect some are likely quite opposed to it). However, their umbrage over my rightly identifying that palliative psychiatry discussions have been used to support advocacy for psychiatric euthanasia, as they must be aware, is misplaced.

For my part, I am disturbed by Buchman and Levitt’s characterization that improvements in quality of life (QOL) are only accidental “byproducts” of general psychiatry, and their apparent attempt to appropriate patient-centered care as being the exclusive purview of palliative psychiatry. Trying to outline what palliative psychiatry encompasses from their perspective is one thing; claiming ownership of patient-centered care and QOL as being key considerations exclusive to palliative psychiatry, and not foci of general psychiatry, is something entirely different. I suspect many of my general psychiatry colleagues would be surprised, and likely offended, to have their practices and QOL goals of care dismissively described as just “byproducts.” Even to the extent that historical research has focused on symptom scales, there is increasing emphasis in general psychiatry internationally to ensure QOL considerations are embedded in research completely unrelated to palliative psychiatry,¹⁰ and Buchman and Levitt’s appropriation of QOL as somehow exclusive to palliative psychiatry seems unseemly.

Buchman and Levitt suggest my commentary is “likely to perpetuate stigma about the intentions of palliation, confuse palliative psychiatry with end-of-life care exclusively, and lead to barriers in developing a patient-centered, compassionate approach that could offer a potential alternative care pathway for individuals suffering intolerably from mental illness.” Buchman and Levitt themselves contribute to the very problems and confusion they accuse me of perpetuating. Consistent with language used in MAiD advocacy, they opine that “Palliative psychiatry accepts that some cases of severe and persistent mental illness can be irremediable.”¹¹ Aside from the controversies over whether mental illnesses can be predicted to be irremediable, Buchman and Levitt become guilty of the very charge they (wrongly) level against general psychiatry—their statement reveals their own assumption bias that the only focus of “remediable” or “irremediable” is illness symptom reduction, which is precisely what they accuse general psychiatry of (ironically, nonpalliative psychiatrists, myself included, have argued for years that “irremediability” must not be narrowly viewed purely from an illness and symptom lens, but must include QOL, biopsychostructural considerations and the whole patient lived experience).¹²

Buchman and Levitt have described the concept of “futility” in palliative psychiatry to include cases of severe and persistent mental illness that, according to them, “can be considered a terminal illness.”¹³ Their constructed narrow focus on “futility” of general psychiatry “interventions” is similarly reductive and needlessly (even dangerously) exclusionary—it perpetuates stigma and a straw person fallacy that the rest of psychiatry only focuses interventions on illness and symptoms, and pushes “aggressive” treatments as its primary goal, with, as they claim, QOL simply as a “byproduct.” This denigrates our community of general psychiatry colleagues who value patient-centred care, programs whose express focus is the whole patient (for example, my Department of Psychiatry at Sunnybrook has explicitly adopted “Lives Worth Living” as our overarching principle for our strategic goals), and established models outside palliative psychiatry that expressly focus on patient experiences separate from symptom reduction (such as acceptance and commitment therapy, which has a field leader colleague working at Buchman and Levitt’s own institution¹⁴).

In a paper they coauthored with Gupta, Buchman and Levitt reference a Radbruch et al paper¹⁵ and write “there is an emerging consensus that palliative care is ‘the active holistic care of individuals across all ages with serious health-related suffering.’”¹⁶ The actual definition Radbruch et al conclude with in their referenced paper is “Palliative care is the active holistic care of individuals across all ages with serious health-related suffering due to severe illness and especially of those near the end of life”[emphasis added]. Buchman, Levitt, and their coauthor’s not insignificant exclusion of “and especially of those near the end of life” is highly relevant in obscuring a key difference between what has traditionally been considered “palliative” care, and the broader scope that Buchman and Levitt attempt to claim under the umbrella of “palliative psychiatry.” Unlike what traditionally falls under scope of palliative medicine, the vast majority of psychiatric illnesses do not lead to foreseeable death. This obvious dissonance is likely 1 key element perpetuating confusion about palliative psychiatry.

With Buchman and Levitt explicitly advocating for concepts of “futility,” “terminal mental illness,” and “irremediability,” it seems strange to refuse disclosing their views regarding psychiatric euthanasia, as Buchman and Levitt do by declining to “comment on the ethics of [psychiatric euthanasia] specifically or wade into the debate as to whether MAiD should fall under the umbrella of palliative care.” Former UN special rapporteur on the rights of persons with disabilities Gerard Quinn has described MAiD expansion as “one of the defining issues of the early twenty-first century,”¹⁷ and Canada (where Buchman and Levitt work) is in the midst of a heated debate regarding psychiatric euthanasia that the world is watching.

Considering this, if palliative psychiatry advocates chose to distance themselves and pretend they are simply uninvolved observers on the sidelines of the actively evolving issue of MAiD for mental illness, even while they concurrently push forward concepts of “futility,” “terminal mental illness,” and “irremediability” that are intimately related to advocacy for psychiatric euthanasia, that abdication and denial will continue to foster confusion about their field’s relationship to psychiatric euthanasia. Instead, self-identified palliative psychiatrists should own up to the obvious potential overlapping issues and transparently articulate, rather than decline to disclose their opinions and potential biases, one way or the other, regarding psychiatric euthanasia. Doing otherwise artificially and untenably removes them from critical discussions that, like it or not, palliative psychiatry is an intimate part of.

Dr Gaind is a professor and governor at the University of Toronto, Chief of Psychiatry at Sunnybrook Health Sciences Centre, Honorary Member of the World Psychiatric Association and recently received the 2025 American Psychiatric Association Assembly Profile of Courage Award for his MAiD work taking “an ethical stand against intimidating pressure for the good of patient care.” He is not a “conscientious objector” to MAiD and previously was physician chair of his former hospital’s assisted dying team. Views expressed are his own and not meant to represent any group he works with.

References

1. Buchman D, Levitt S. Palliative psychiatry and assisted suicide for mental illness: not 1 and the same. Psychiatric Times. March 7, 2025. https://www.psychiatrictimes.com/view/palliative-psychiatry-and-assisted-suicide-for-mental-illness-not-1-and-the-same

2. Gaind KS. “Palliative psychiatry” and assisted suicide: compassion? abandonment? Or something far worse? Psychiatric Times. November 22, 2024. https://www.psychiatrictimes.com/view/palliative-psychiatry-and-assisted-suicide-compassion-abandonment-or-something-far-worse

3. Yager J, Treem J, Strouse T. End-of-life care for patients with psychiatric disorders. Psychiatric Times. 2024;41(9).

4. Gaind KS. A (White) senator, doctor and lawyer walk into a bar…and appropriate the assisted dying narrative. Am J Bioeth. 2025;25(5):41-44.

5. A community of practice for palliative psychiatry. Everyday Ethics Lab. Accessed June 26, 2025. https://everydayethicslab.ca/research/projects/a-community-of-practice-for-palliative-psychiatry/

6. Palliating mental illnesses: developing innovative approaches in mental health care. Everyday Ethics Lab. Accessed June 26, 2025. https://everydayethicslab.ca/research/projects/palliating-mental-illnesses-developing-innovative-approaches-in-mental-health-care/

7. Access to medical assistance in dying for people with mental disorders. Association des Médecins Psychiatres du Quebec. November 2020. Accessed June 26, 2025. https://ampq.org/wp-content/uploads/2025/01/MPQ_DocReflexion_AMM_EN_FINAL.pdf

8. The Halifax Group. MAiD legislation at a crossroads: persons with mental disorders as their sole underlying medical condition. Institute for Research on Public Policy. January 30, 2020. Accessed June 26, 2025. https://irpp.org/research-studies/maid-legislation-at-a-crossroads-persons-with-mental-disorders-as-their-sole-underlying-medical-condition/

9. Final report of the expert panel on MAiD and mental illness. Health Canada. Accessed June 26, 2025. https://www.canada.ca/en/health-canada/news/2022/05/final-report-of-the-expert-panel-on-maid-and-mental-illness.html

10. Luo H, Hirdes A, Heikkilä J, et al. interRAI subjective quality of life scale for mental health and addiction settings: a self-reported measure developed from a multi-national study. Front Psychiatry. 2021;12:705415.

11. Westermair AL, Buchman DZ, Levitt S, et al. Palliative psychiatry in a narrow and in a broad sense: a concept clarification. Aust N Z J Psychiatry. 2022;56(12):1535-1541.

12. Gaind KS. What does ‘irremediability’ in mental illness mean? Can J Psychiatry. 2020;65(9):604-606.

13. Levitt S, Buchman DZ. Applying futility in psychiatry: a concept whose time has come. J Med Ethics. 2021;47(12):60-60.

14. Fung K. Acceptance and commitment therapy: Western adoption of Buddhist tenets? Transcult Psychiatry. 2014;52(4):561-576.

15. Radbruch L, De Lima L, Knaul F, et al. Redefining palliative care-a new consensus-based definition. J Pain Symptom Manage. 2020;60(4):754-764.

16. Levitt S, Cooper RB, Gupta M, et al. Palliative psychiatry: research, clinical, and educational priorities. Ann Palliat Med. 2024;13(3):542-557.

17. Quinn G. Review of: Coelho R, Gaind K, Lemmens T. Unravelling MAiD in Canada: Euthanasia and Assisted Suicide as Medical Care. McGill-Queen’s University Press; 2025.