Journal of Bioethical Inquiry

, Volume 14, Issue 1, pp 151–157 | Cite as

Four Reasons Why Assisted Dying Should Not Be Offered for Depression

  • Thomas Blikshavn
  • Tonje Lossius Husum
  • Morten MagelssenEmail author
Critical Perspectives


Recently, several authors have argued that assisted dying may be ethically appropriate when requested by a person who suffers from serious depression unresponsive to treatment. We here present four arguments to the contrary. First, the arguments made by proponents of assisted dying rely on notions of “treatment-resistant depression” that are problematic. Second, an individual patient suffering from depression may not be justified in believing that chances of recovery are minimal. Third, the therapeutic significance of hope must be acknowledged; when mental healthcare opens up the door to admitting hopelessness, there is a danger of a self-fulfilling prophecy. Finally, proponents of assisted dying in mental healthcare overlook the dangers posed to mental-health services by the institutionalization of assisted dying.


Assisted dying Euthanasia Major depression Physician-assisted suicide Treatment-resistant depression 


  1. Berghmans, R., G. Widdershoven, and I. Widdershoven-Heerding. 2013. Physician-assisted suicide in psychiatry and loss of hope. International Journal of Law and Psychiatry, 36(5–6): 436–443.CrossRefPubMedGoogle Scholar
  2. Bowes, L., C. Joinson, D. Wolke, and G. Lewis. 2015. Peer victimisation during adolescence and its impact on depression in early adulthood: Prospective cohort study in the United Kingdom. British Medical Journal 350: h2469.CrossRefPubMedPubMedCentralGoogle Scholar
  3. Brådvik, L., and L. Crona. 2009. Long-lasting recovery in chronic severe depression. Follow-up of two cases, 46 and 50 years after their first admissions for depression. Medical Science Monitor 1(10): 31–35.Google Scholar
  4. Chiles, J.A., and K.D. Strosahl. 2008. Clinical manual for assessment and treatment of suicidal patients. American Psychiatric Association Publishing.Google Scholar
  5. Ciarrochi, J., L. Bilich, and C. Godsell. 2010. Psychological flexibility as a mechanism of change in acceptance and commitment therapy. In Assessing mindfulness and acceptance processes in clients: Illuminating the theory and practice of change, edited by R.A. Baer, 51–75. New Harbinger Publications.Google Scholar
  6. Crona, L., and L. Brådvik. 2012. Long-term course of severe depression: Late remission and recurrence may be found in a follow-up after 38–53 years. Mental Illness 4(2), e17.CrossRefPubMedPubMedCentralGoogle Scholar
  7. De Carlo, V., R. Calati, and A. Serretti. 2016. Socio-demographic and clinical predictors of non-response/non-remission in treatment resistant depressed patients: A systematic review. Psychiatry Research 240: 421–430.CrossRefPubMedGoogle Scholar
  8. Dunlop, B.W. 2015. Prediction of treatment outcomes in major depressive disorder. Expert Review of Clinical Pharmacology 8(6): 669–672.CrossRefPubMedGoogle Scholar
  9. Fekadu, A., L.J. Rane, S.C. Wooderson, K. Markopoulou, L. Poon, and A.J. Cleare. 2012. Prediction of longer-term outcome of treatment-resistant depression in tertiary care. The British Journal of Psychiatry 201(5): 369–375.CrossRefPubMedGoogle Scholar
  10. Fried, E.I. 2015. Problematic assumptions have slowed down depression research: Why symptoms, not syndromes are the way forward. Frontiers in Psychology 6: 309.CrossRefPubMedPubMedCentralGoogle Scholar
  11. Hayes, S.C., J.B. Luoma, F.W. Bond, A. Masuda, and J. Lillis. 2006. Acceptance and commitment therapy: Model, processes and outcomes. Behaviour Research and Therapy 44(1): 1–25.CrossRefPubMedGoogle Scholar
  12. Hayes, S.C., K.G. Wilson, E.V. Gifford, V.M. Follette, and K. Strosahl. 1996. Experiential avoidance and behavioral disorders: a functional dimensional approach to diagnosis and treatment. Journal of Consulting and Clinical Psychology 64(6): 1152.CrossRefPubMedGoogle Scholar
  13. Hindmarch, T., M. Hotopf, and G.S. Owen. 2013. Depression and decision-making capacity for treatment or research: a systematic review. BMC Medical Ethics 14(1): 54.CrossRefPubMedPubMedCentralGoogle Scholar
  14. Joiner, T.E. 2010. Myths about suicide. Cambridge, Mass.: Harvard University Press.Google Scholar
  15. Kendell, R., and A. Jablensky. 2003. Distinguishing between the validity and utility of psychiatric diagnoses. American Journal of Psychiatry 160(1): 4–12.CrossRefPubMedGoogle Scholar
  16. Kenny, M., and J. Williams. 2007. Treatment-resistant depressed patients show a good response to mindfulness-based cognitive therapy. Behaviour Research and Therapy 45(3): 617–625.CrossRefPubMedPubMedCentralGoogle Scholar
  17. Kissane, D.W., and B.J. Kelly. 2000. Demoralisation, depression and desire for death: Problems with the Dutch guidelines for euthanasia of the mentally ill. Australian and New Zealand Journal of Psychiatry 34(2): 325–333.PubMedGoogle Scholar
  18. Kogstad, R., Ekeland, and J. Hummelvoll. 2011. In defence of a humanistic approach to mental health care: Recovery processes investigated with the help of clients’ narratives on turning points and processes of gradual change. Journal of Psychiatric and Mental Health Nursing 18(6): 479–486.CrossRefPubMedGoogle Scholar
  19. Krupnick, J.L., S.M. Sotsky, S. Simmens, et al. 1996. The role of the therapeutic alliance in psychotherapy and pharmacotherapy outcome: Findings in the National Institute of Mental Health Treatment of Depression Collaborative Research Program. Journal of Consulting and Clinical Psychology 64(3): 532–539.CrossRefPubMedGoogle Scholar
  20. Lambert, M.J. 2013. Bergin and Garfield’s handbook of psychotherapy and behavior change. Hoboken, NJ: John Wiley & Sons.Google Scholar
  21. Leichsenring, F., and S. Rabung. 2008. Effectiveness of long-term psychodynamic psychotherapy: A meta-analysis. JAMA 300(13): 1551–1565.CrossRefPubMedGoogle Scholar
  22. Linehan, M. 1993. Cognitive-behavioral treatment of borderline personality disorder. Guilford Press.Google Scholar
  23. Luoma, J.B., and J.L. Villatte. 2012. Mindfulness in the treatment of suicidal individuals. Cognitive and Behavioral Practice 19(2): 265–276.CrossRefPubMedGoogle Scholar
  24. Malone, K.M., M.A. Oquendo, G.L. Haas, S.P. Ellis, S. Li, and J.J. Mann. 2000. Protective factors against suicidal acts in major depression: Reasons for living. American Journal of Psychiatry 157(7): 1084–1088.CrossRefPubMedGoogle Scholar
  25. Maltsberger, J.T., and D.H. Buie. 1974. Countertransference hate in the treatment of suicidal patients. Archives of General Psychiatry, 30(5): 625–633.CrossRefPubMedGoogle Scholar
  26. Markanday, S., J. Data-Franco, L. Dyson, et al. 2012. Acceptance and commitment therapy for treatment-resistant depression. Australian and New Zealand Journal of Psychiatry: 0004867412446491.Google Scholar
  27. Materstvedt, L.J. 2013. Palliative care ethics: The problems of combining palliation and assisted dying. Progress in Palliative Care 21(3): 158–164.CrossRefGoogle Scholar
  28. McIntyre, R.S., Filteau, L. Martin, et al. 2014. Treatment-resistant depression: Definitions, review of the evidence, and algorithmic approach. Journal of Affective Disorders 156: 1–7.CrossRefPubMedGoogle Scholar
  29. Meyer, B., Pilkonis, J.L. Krupnick, M.K. Egan, S.J. Simmens, and S.M. Sotsky. 2002. Treatment expectancies, patient alliance and outcome: Further analyses from the National Institute of Mental Health Treatment of Depression Collaborative Research Program. Journal of Consulting and Clinical Psychology 70(4): 1051–1055.CrossRefPubMedGoogle Scholar
  30. Miller, J.F. 1985. Inspiring hope. The American Journal of Nursing 85(1): 22–28.PubMedGoogle Scholar
  31. Mueller, T.I., M.B. Keller, A.C. Leon, et al. 1996. Recovery after 5 years of unremitting major depressive disorder. Archives of General Psychiatry 53(9): 794–799.CrossRefPubMedGoogle Scholar
  32. Piet, J., and E. Hougaard. 2011. The effect of mindfulness-based cognitive therapy for prevention of relapse in recurrent major depressive disorder: A systematic review and meta-analysis. Clinical Psychology Review 31(6): 1032–1040.CrossRefPubMedGoogle Scholar
  33. Plakun, E. 2012. Treatment resistance and psychodynamic psychiatry: Concepts psychiatry needs from psychoanalysis. Psychodynamic Psychiatry 40(2): 183.CrossRefPubMedGoogle Scholar
  34. ———. 2006. A view from Riggs—Treatment resistance and patient authority: I. A psychodynamic perspective on treatment resistance. Journal of the American Academy of Psychoanalysis and Dynamic Psychiatry 34(2): 349–366.CrossRefPubMedGoogle Scholar
  35. Pull, C.B. 2009. Current empirical status of acceptance and commitment therapy. Current Opinion in Psychiatry 22(1): 55–60.CrossRefPubMedGoogle Scholar
  36. Regier, D.A., Narrow, D.E. Clarke, et al. 2013. DSM-5 field trials in the United States and Canada, Part II: Test-retest reliability of selected categorical diagnoses. American Journal of Psychiatry 170(1): 59–70.CrossRefPubMedGoogle Scholar
  37. Regionale toetsingscommissies euthanasie. 2015. Accessed June 23, 2016.
  38. Schatzberg, A.F., A.J. Rush, B.A. Arnow, et al. 2005. Chronic depression: Medication (nefazodone) or psychotherapy (CBASP) is effective when the other is not. Archives of General Psychiatry 62(5): 513–520.CrossRefPubMedGoogle Scholar
  39. Schuklenk, U., and S. van de Vathorst. 2015a. Treatment-resistant major depressive disorder and assisted dying. Journal of Medical Ethics 41(8): 577–583.Google Scholar
  40. ———. 2015b. Treatment-resistant major depressive disorder and assisted dying: Response to comments. Journal of Medical Ethics 41(8): 589–591.Google Scholar
  41. Segal, Z.V., Williams, and J.D. Teasdale. 2012. Mindfulness-based cognitive therapy for depression. Guilford Press.Google Scholar
  42. Shamseddeen, W., G. Clarke, K.D. Wagner, et al. 2011. Treatment-resistant depressed youth show a higher response rate if treatment ends during summer school break. Journal of the American Academy of Child & Adolescent Psychiatry 50(11): 1140–1148.CrossRefGoogle Scholar
  43. Smith, J.M., L.B. Alloy, and L.Y. Abramson. 2006. Cognitive vulnerability to depression, rumination, hopelessness, and suicidal ideation: Multiple pathways to self-injurious thinking. Suicide and Life-Threatening Behavior 36(4): 443–454.CrossRefPubMedGoogle Scholar
  44. Souery, D., G.I. Papakostas, and M.H. Trivedi. 2006. Treatment-resistant depression. Journal of Clinical Psychiatry 67(suppl. 6): 16–22.PubMedGoogle Scholar
  45. Tsou, J.Y. 2015. DSM-5 and psychiatry’s second revolution: Descriptive vs. theoretical approaches to psychiatric classification. In The DSM-5 in Perspective, edited by S. Demazeux and P. Singy, 43–62. Springer.Google Scholar
  46. Vevatne, K. 2006. Selvmordsforsøket—Søken mot livet. University of Bergen, Norway.Google Scholar
  47. Walser, R.D., Garvert, B.E. Karlin, M. Trockel, D.M. Ryu, and C.B. Taylor. 2015. Effectiveness of acceptance and commitment therapy in treating depression and suicidal ideation in veterans. Behaviour Research and Therapy 74: 25–31.CrossRefPubMedGoogle Scholar
  48. Wiles, N., L. Thomas, A. Abel, et al. 2013. Cognitive behavioural therapy as an adjunct to pharmacotherapy for primary care based patients with treatment resistant depression: Results of the CoBalT randomised controlled trial. The Lancet 381(9864): 375–384.CrossRefGoogle Scholar
  49. Zettle, R.D., J.C. Rains, and S.C. Hayes. 2011. Processes of change in acceptance and commitment therapy and cognitive therapy for depression: A mediation reanalysis of Zettle and Rains. Behavior Modification 35(3): 265–283.CrossRefPubMedGoogle Scholar

Copyright information

© Journal of Bioethical Inquiry Pty Ltd. 2016

Authors and Affiliations

  • Thomas Blikshavn
    • 1
  • Tonje Lossius Husum
    • 2
  • Morten Magelssen
    • 2
    Email author
  1. 1.Department of Child and Adolescent Mental HealthAkershus University HospitalLørenskogNorway
  2. 2.Centre for Medical Ethics, Institute of Health and SocietyUniversity of OsloOsloNorway

Personalised recommendations