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Aslam HM, Brodeur J, Links PS. Clinical practice guidelines for the treatment of borderline personality disorder: a systematic review of best practice in anticipation of MAiD MD-SUMC. Borderline Personal Disord Emot Dysregul 2025; 12:13. [PMID: 40211336 PMCID: PMC11983944 DOI: 10.1186/s40479-025-00284-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2024] [Accepted: 02/24/2025] [Indexed: 04/14/2025] Open
Abstract
BACKGROUND Countries permitting assisted dying for mental disorder as the sole underlying condition (MD-SUMC) find that individuals with Borderline Personality Disorder (BPD) constitute a significant proportion of people requesting MAiD. In anticipation of forthcoming changes to Canadian MAiD legislation, clinical practise guidelines will be important in the decision-making process for eligibility to ensure that evidence-based treatments have been exhausted in making determinations of irremediability. AIMS This is a systematic review of international, English-language treatment guidelines for BPD with two primary objectives: First, to identify areas of consensus and disagreement in best practise for the treatment of this disorder and second, to assess whether the guidelines offered insight into defining irremediable BPD and/or its management. METHODS In accordance with PRISMA guidelines, we performed a systematic review of five databases and identified five clinical practise guidelines in the English language. Two authors independently performed data extraction on the core components of these treatment guidelines, which was synthesized into a narrative review. FINDINGS Several conclusions may be drawn about the state of the evidence on BPD treatment. First, psychological therapies are broadly considered the preferred treatment modality for BPD but there is no consensus regarding whether any one intervention is preferable. Second, all guidelines suggest pharmacotherapy may have a role in the management of BPD, but the nature and extent of this is disputed. Third, there is no guidance alluding to, defining, or commenting on the management of irremediable BPD. Finally, there are no Canadian treatment guidelines for BPD. The implications of these findings for MAiD MD-SUMC are discussed.
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Affiliation(s)
- Hira M Aslam
- Department of Psychiatry & Behavioural Neurosciences, McMaster University, Hamilton, ON, Canada.
| | - Jonah Brodeur
- Department of Family Medicine, University of Toronto, Toronto, ON, Canada
| | - Paul S Links
- Department of Psychiatry & Behavioural Neurosciences, McMaster University, Hamilton, ON, Canada
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Bachmetjev B, Airapetian A, Jakubauskienė M, Zablockis R, Čekanauskaitė A. Demographic influences on Lithuanian physicians' attitudes toward medical assistance in dying: a cross-sectional study. Front Psychiatry 2025; 15:1507790. [PMID: 39839129 PMCID: PMC11747323 DOI: 10.3389/fpsyt.2024.1507790] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2024] [Accepted: 12/10/2024] [Indexed: 01/23/2025] Open
Abstract
Background The topic of end-of-life decisions is important due to aging populations and the rising number of terminal illnesses like cancer. As more people experience suffering, the ethical, medical, and legal debates of these decisions become significant to healthcare policy. Understanding medical professionals' attitudes is critical for shaping responsible practices and legislation surrounding end-of-life care. Methods This cross-sectional study explores the attitudes of Lithuanian physicians toward medical assistance in dying (MAID), including euthanasia and assisted suicide (E/PAS), as well as other end-of-life decisions such as Do-Not-Resuscitate (DNR) orders and Living Wills, including decisions involving patients diagnosed with mental illnesses. A survey of 361 physicians in Lithuanian hospitals was conducted between October 2022 and July 2024, using hospital intranets and on-site distribution to guarantee representative sample. The survey included demographic factors such as age, gender, religious beliefs, and professional experience. Statistical analysis was performed using SPSS version 26.0 and R software. Chi-square tests, Fisher's exact tests, and logistic regression models were made to determine relationships, with significance set at p < 0.05. Results The analysis showed that 61.2% of physicians supported assisted suicide for terminally ill patients, while only 19.1% supported it for patients with drug-resistant mental illness. Similarly, 61.5% supported euthanasia for terminal illness. Age, religious beliefs, and professional experience were significant determinants of support, with younger and non-religious physicians more likely to endorse E/PAS. Additionally, 92.2% of respondents supported DNR orders with patient consent, though this dropped to 63.1% without patient consent. Conclusions Lithuanian physicians' attitudes toward E/PAS and other end-of-life decisions are strongly influenced by ethical, religious, and professional considerations. Significantly lower acceptance for psychiatric patients indicates higher sensitivity regarding mental competency and the ethics of E/PAS in such cases. These findings provide important insights for policymakers and healthcare providers in crafting informed and ethical E/PAS guidelines.
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Affiliation(s)
| | | | - Marija Jakubauskienė
- Public Health Department, Faculty of Medicine, Institute of Health Sciences, Vilnius University, Vilnius, Lithuania
| | - Rolandas Zablockis
- Clinic of Chest Diseases, Immunology and Allergology, Faculty of Medicine, Institute of Clinical Medicine, Vilnius University, Vilnius, Lithuania
| | - Asta Čekanauskaitė
- The Centre for Health Ethics, Law and History, Faculty of Medicine, Institute of Health Sciences, Vilnius University, Vilnius, Lithuania
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Masnou N, Quintanas A, Planas C, Planes A. [Euthanasia: a mixed-methods study on referents' experience in Catalonia]. GACETA SANITARIA 2024; 38:102435. [PMID: 39631240 DOI: 10.1016/j.gaceta.2024.102435] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/10/2024] [Revised: 10/15/2024] [Accepted: 10/19/2024] [Indexed: 12/07/2024]
Abstract
OBJECTIVE To identify strengths and challenges in the provision of assistance in dying (PAM) based on the experiences of the Catalan Health Institute (ICS) euthanasia referents. METHOD Mixed-methods study (n=31), using two closed-ended questionnaires (quantitative analysis) and two structured interviews with open-ended fields (qualitative analysis), self-administered via email. All ICS referents (n=50) received them. The first questionnaire (n=31) and interview (n=12) were addressed to all referents. The second questionnaire (n=7) and interview (n=6) were directed only to those who had also directly participated in a PAM. The results were triangulated and are presented as an integrated analysis. RESULTS From the integration of quantitative and qualitative responses, six thematic blocks emerged: 1) dedication and compensation; 2) training; 3) weak points and difficulties; 4) emotional and psychological impact; 5) considerations on end-of-life issues; and 6) motivations and advice from contacts. From the joint analysis, proposals for improvement were concluded: compensate for the workload that PAM implies, improve training, ensure that conscientious objection is in accordance with the law, and review aspects of the LORE, as procedures, deadlines, interdisciplinarity, ambiguities, and excluded cases. It was established: the usefulness of the referent role; respecting patient autonomy offsets negative emotions in professionals; PAM promotes reflection on the purposes of medicine. CONCLUSIONS Euthanasia referents' experiences can guide other professionals and suggest guidelines for institutional leaders and health managers.
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Affiliation(s)
- Núria Masnou
- Departamento de Donación y Trasplantes, Hospital Universitario Dr. Josep Trueta, Girona, España; Comisión de Garantía y Evaluación de Catalunya (CGAC), España.
| | - Anna Quintanas
- Departamento de Filosofía, Universidad de Girona, Observatorio de Ética Aplicada a la Acción Social, Psicoeducativa y Sociosanitaria, Girona, España
| | - Carla Planas
- Comité de Ética Asistencial, Hospital Universitario Dr. Josep Trueta, Girona, España
| | - Albert Planes
- Centro de Atención Primaria Santa Eugènia de Berga, Barcelona, España; Comisión de Garantía y Evaluación de Catalunya (CGAC), España
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Jones EK, Orchard V. Neurodiversity and disability: what is at stake? MEDICAL HUMANITIES 2024; 50:456-465. [PMID: 38360797 DOI: 10.1136/medhum-2023-012808] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 01/28/2024] [Indexed: 02/17/2024]
Abstract
Neurodiversity has come hugely to the fore in recent years in a variety of contexts, and is now subject to academic debate, activist discussion, and increasingly embedded in a range of institutional and corporate settings in the Global North, from workplaces to early years education, from psychotherapy to mainstream political discourses. The term has gained traction in Medical Humanities, as well as debate within bioethics, philosophy of psychology, and of law. Institutionally, it is now relied on in therapeutic practice, autism service provision, as well as in higher education, in particular. In this conceptual article we examine what is at stake in these usages and the implications in need of scrutiny. We resituate neurodiversity in relation to questions of disability by examining the deployment of neurology as the basis for identity, rights and benefits. The emergence of the term and the understandings to which it gives rise, we argue, leave out urgent questions of what is at stake for disabled people in a political climate of increasing harshness and ableism.
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Affiliation(s)
- Eleanor K Jones
- Languages, Cultures and Linguistics, University of Southampton, Southampton, UK
| | - Vivienne Orchard
- Languages, Cultures and Linguistics, University of Southampton, Southampton, UK
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Reichel R, Adam SH, Ehni HJ, Junne F, Herrmann-Werner A, Fallgatter AJ, Zipfel S, Erschens R. Perspectives on physician-assisted suicide in mental healthcare: results of a survey of physicians and medical students. BJPsych Open 2024; 10:e141. [PMID: 39108029 PMCID: PMC11698214 DOI: 10.1192/bjo.2024.731] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Revised: 05/16/2024] [Accepted: 05/20/2024] [Indexed: 01/06/2025] Open
Abstract
BACKGROUND Physician-assisted suicide (PAS) is typically associated with serious physical illnesses that are prevalent in palliative care. However, individuals with mental illnesses may also experience such severity that life becomes intolerable. In February 2020, the previous German law prohibiting PAS was repealed. Patients with severe mental illnesses are increasingly likely to approach physicians with requests for PAS. AIMS To explore the ethical and moral perspectives of medical students and physicians when making individual decisions regarding PAS. METHOD An anonymised digital survey was conducted among medical students and physicians in Germany. Participants were presented with a case vignette of a chronically depressed patient requesting PAS. Participants decided on PAS provision and assessed theoretical arguments. We employed generalised ordinal regression and qualitative analysis for data interpretation. RESULTS A total of N = 1478 participants completed the survey. Of these, n = 470 (32%) stated that they would refuse the request, whereas n = 582 (39%) would probably refuse, n = 375 (25%) would probably agree and n = 57 (4%) would definitely agree. Patient-centred arguments such as the right to self-determination increased the likelihood of consent. Concerns that PAS for chronically depressed patients might erode trust in the medical profession resulted in a decreased willingness to provide PAS. CONCLUSIONS Participants displayed relatively low willingness to consider PAS in the case of a chronically depressed patient. This study highlights the substantial influence of theoretical medical-ethical arguments and the broader public discourse, underscoring the necessity of an ethical discussion on PAS for mental illnesses.
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Affiliation(s)
- Rebecca Reichel
- Department of Psychiatry and Psychotherapy, University Hospital Tuebingen, University of Tuebingen, Tuebingen, Germany
| | - Sophia Helen Adam
- Department of Psychosomatic Medicine and Psychotherapy, University Hospital Tuebingen, University of Tuebingen, Tuebingen, Germany
| | - Hans-Jörg Ehni
- Institute of Ethics and History of Medicine, Eberhard Karls University Tuebingen, Tuebingen, Germany
| | - Florian Junne
- Department of Psychosomatic Medicine and Psychotherapy, Otto von Guericke University Magdeburg, University Hospital Magdeburg, Magdeburg, Germany; and German Center for Mental Health, Magdeburg, Germany
| | - Anne Herrmann-Werner
- Tuebingen Institute for Medical Education, University of Tuebingen, Tuebingen, Germany; and German Center for Mental Health, Tuebingen, Germany
| | - Andreas J. Fallgatter
- Department of Psychiatry and Psychotherapy, University Hospital Tuebingen, University of Tuebingen, Tuebingen, Germany; and German Center for Mental Health, Tuebingen, Germany
| | - Stephan Zipfel
- Department of Psychosomatic Medicine and Psychotherapy, University Hospital Tuebingen, University of Tuebingen, Tuebingen, Germany; and German Center for Mental Health, Tuebingen, Germany
| | - Rebecca Erschens
- Department of Psychosomatic Medicine and Psychotherapy, University Hospital Tuebingen, University of Tuebingen, Tuebingen, Germany
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Gouveia A. Navigating autonomy and decision-making capacity: Legal and ethical considerations in Medical Assistance in Dying for individuals with mental disorders in Portugal. DEATH STUDIES 2024:1-10. [PMID: 38857112 DOI: 10.1080/07481187.2024.2361761] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/12/2024]
Abstract
Portugal has recently amended its absolute prohibition on euthanasia and assisted suicide that now permits it conditionally and exonerates those providing this practice. People with a mental disorder or medical condition that affects their decision-making capacity (DMC), regardless of the mental disorder, its contemporaneity, or its connection to the decision itself are expressly excluded from this service unless they are assessed and deemed capacitous. In the absence of any statute concerning capacity or assisted decision-making, this legislation raises concerns about potential discrimination, conflicting with the presumption of capacity principle. A shift toward a DMC model is proposed. This model allows for the assessment of capacity for specific decisions, addressing the ethical implications of respecting or overriding a terminally ill person's autonomous will for medical assistance in dying. This review paper examines the challenges of assessing DMC in depression and examines several questions of ethical and legislative nature for future consideration.
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Affiliation(s)
- Afonso Gouveia
- Psychiatry Service, Mental Health Department, Local Health Unit of Baixo Alentejo, Beja, Portugal
- CHRC, NOVA Medical School, Universidade Nova de Lisboa, Lisbon, Portugal
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Pifarre J, Esquerda M, Torralba F, Bátiz J, Bofarull M. Persons with mental disorders and assisted dying practices in Spain: In response to Ramos et al. INTERNATIONAL JOURNAL OF LAW AND PSYCHIATRY 2024; 94:101980. [PMID: 38493732 DOI: 10.1016/j.ijlp.2024.101980] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/13/2024] [Revised: 03/06/2024] [Accepted: 03/06/2024] [Indexed: 03/19/2024]
Abstract
Ramos et al. paper offers a narrative review of Spanish Organic Law 3/2021, which regulates euthanasia, focusing on its application to individuals with mental disorders. Ramos et al. examine the application of legal prerequisites from an ethical-legal perspective to ascertain the conditions under which psychiatric euthanasia might be considered legitimate and compliant with legal stipulations. Nevertheless, it is apparent that the core ethical inquiries linked to this matter have not been exhaustively investigated. The criteria laid out are, in our assessment, still open to further debate and broader deliberation. Our article emphasizes the need for a comprehensive ethical and legal debate in Spain regarding psychiatric euthanasia. Competency assessment is central to the legislation, but there are concerns about the validity of assessment tools and the subjective nature of interviews. Furthermore, defining irreversible suffering in mental health contexts poses challenges. The article advocates for a deeper understanding of the needs of individuals with mental disorders before considering euthanasia and emphasizes the importance of comprehensive care and psychosocial interventions in reducing the desire for euthanasia. Ultimately, it underscores the ethical complexities of euthanasia in mental health and the necessity of prioritizing comprehensive care in addressing these complexities.
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Affiliation(s)
- Josep Pifarre
- Institut Borja de Bioética, Universitat Ramon Llull, Barcelona, Spain; San Juan de Dios Provincia de España, Madrid, Spain
| | - Montse Esquerda
- Institut Borja de Bioética, Universitat Ramon Llull, Barcelona, Spain; Hospital Sant Joan de Déu Terres de Lleida, Spain.
| | - Francesc Torralba
- Institut Borja de Bioética, Universitat Ramon Llull, Barcelona, Spain
| | - Jacinto Bátiz
- Institut Borja de Bioética, Universitat Ramon Llull, Barcelona, Spain; San Juan de Dios Provincia de España, Madrid, Spain
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Favron-Godbout C, Racine E. Medical assistance in dying for people living with mental disorders: a qualitative thematic review. BMC Med Ethics 2023; 24:86. [PMID: 37875867 PMCID: PMC10594804 DOI: 10.1186/s12910-023-00971-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2023] [Accepted: 10/15/2023] [Indexed: 10/26/2023] Open
Abstract
BACKGROUND Medical assistance in dying (MAiD) sparks debate in several countries, some of which allow or plan to allow MAiD where a mental disorder is the sole underlying medical condition (MAiD-MD). Since MAiD-MD is becoming permissible in a growing number of jurisdictions, there is a need to better understand the moral concerns related to this option. Gaining a better understanding of the moral concerns at stake is a first step towards identifying ways of addressing them so that MAiD-MD can be successfully introduced and implemented, where legislations allow it. METHODS Thus, this article aims (1) to better understand the moral concerns regarding MAiD-MD, and (2) to identify potential solutions to promote stakeholders' well-being. A qualitative thematic review was undertaken, which used systematic keyword-driven search and thematic analysis of content. Seventy-four publications met the inclusion criteria. RESULTS Various moral concerns and proposed solutions were identified and are related to how MAiD-MD is introduced in 5 contexts: (1) Societal context, (2) Healthcare system, (3) Continuum of care, (4) Discussions on the option of MAiD-MD, (5) MAiD-MD practices. We propose this classification of the identified moral concerns because it helps to better understand the various facets of discomfort experienced with MAiD-MD. In so doing, it also directs the various actions to be taken to alleviate these discomforts and promote the well-being of stakeholders. CONCLUSION The assessment of MAiD-MD applications, which is part of the context of MAiD-MD practices, emerges as the most widespread source of concern. Addressing the moral concerns arising in the five contexts identified could help ease concerns regarding the assessment of MAiD-MD.
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Affiliation(s)
- Caroline Favron-Godbout
- Pragmatic Health Ethics Research Unit, Montreal Clinical Research Institute, 110 av. des Pins O, Montreal, QC, H2W 1R7, Canada
| | - Eric Racine
- Pragmatic Health Ethics Research Unit, Montreal Clinical Research Institute, 110 av. des Pins O, Montreal, QC, H2W 1R7, Canada.
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