Dominic Sisti, PhD, is an associate professor in the Department of Medical Ethics & Health Policy and the director of the Scattergood Program for the Applied Ethics of Behavioral Health Care. Sisti is also the host of 

, our monthly multimedia series on medical ethics in modern healthcare. 

Dominic Sisti, PhD

Medical Ethics Unpacked: Ethical Considerations for Euthanasia & Medically-Assisted Suicide

00:00 - The Parity Between Mental and Physical Illness

05:09 - Requiring Treatment Before Considering Euthanasia 

08:19 - The Complexity of Egosyntonic Psychiatric Conditions 

11:21 - The Potential for "Terminal Addiction" 

16:30 - The Societal Impact and Implications of Psychiatric Euthanasia

, hosts Dominic Sisti, PhD, and Steve Levine, MD, continue their deep dive into the controversial topic of medical aid in dying (MAID) and euthanasia for individuals with severe psychiatric conditions. Part 2 of a 2-part series, this episode shifts from foundational concepts to the intricate ethical considerations surrounding these practices, touching on autonomy, capacity, treatment equity, and societal implications.

Sisti, an associate professor in the Department of Medical Ethics & Health Policy and the director of the Scattergood Program for the Applied Ethics of Behavioral Health Care at the University of Pennsylvania, begins by discussing the notion of parity between psychiatric and physical illnesses in evaluating eligibility for MAID, calling attention to recent research from Kious et al—who argues that mental illnesses should be given equal ethical consideration as physical conditions, though he acknowledges the challenges in assessing long-term trajectories for psychiatric disorders. For instance, conditions like borderline personality disorder may remit over time, but requiring patients to endure suffering for years in anticipation of potential improvement raises moral concerns.

Levine, a psychiatrist and the senior vice president of Patient Access at Compass Pathways, builds on this by exploring how psychiatric illnesses often blur the line between mental and physical health, emphasizing that mental health conditions, like depression or anorexia nervosa, can have physical manifestations that further complicate prognosis and decision-making.

The discussion highlights critical issues with capacity evaluations. Levine outlines the nuanced frameworks used to assess a patient’s ability to make decisions about MAID and stresses the dynamic nature of capacity, which can fluctuate with psychiatric symptoms. Both agree that insufficient or inconsistent evaluations, as seen in some jurisdictions permitting psychiatric euthanasia, risk undermining the ethical integrity of these practices.

Sisti cites evidence from Belgium and the Netherlands, where "assertions" of capacity rather than thorough assessments have led to controversial cases, particularly among patients with mood or personality disorders. The gender disparity in psychiatric euthanasia, with women disproportionately represented, adds another layer of ethical complexity, raising questions about justice and societal biases.

The conversation also examines whether patients should be required to attempt all available treatments, including experimental options, before pursuing MAID. While Sisti suggests this could prevent premature decisions, Levine cautions against infringing on autonomy, noting that some patients may validly reject certain treatments. They grapple with cases like anorexia nervosa, a psychiatric condition with high mortality rates, and whether its ego-syntonic nature—where patients often do not view their condition as a problem—impedes true capacity for MAID decisions.

Finally, the hosts address societal implications. Sisti warns that expanding access to psychiatric euthanasia without addressing underlying structural issues, such as inadequate mental health care and social determinants like poverty and isolation, risks normalizing preventable suffering. Levine reflects on how offering MAID as an option might paradoxically provide hope for some patients but could also undermine their optimism for recovery.

As they conclude, both Levine and Sisti emphasize the need for robust ethical frameworks, thorough capacity evaluations, and thoughtful policymaking to navigate this morally complex issue. They encourage listeners to engage with the growing body of bioethics literature and reflect on how these debates shape our understanding of autonomy, human suffering, and the value of life.

Relevant studies and documentation mentioned in this episode:

Doernberg, Samuel N., John R. Peteet, and Scott YH Kim. "Capacity evaluations of psychiatric patients requesting assisted death in the Netherlands." Psychosomatics 57, no. 6 (2016): 556-565.

Kim, Scott YH, Raymond G. De Vries, and John R. Peteet. "Euthanasia and assisted suicide of patients with psychiatric disorders in the Netherlands 2011 to 2014." JAMA psychiatry73, no. 4 (2016): 362-368.

Kious, Brent M., and Margaret Battin. "Physician aid-in-dying and suicide prevention in psychiatry: A moral crisis?." The American Journal of Bioethics 19, no. 10 (2019): 29-39.

Nicolini, Marie E., Scott YH Kim, Madison E. Churchill, and Chris Gastmans. "Should euthanasia and assisted suicide for psychiatric disorders be permitted? A systematic review of reasons." Psychological medicine 50, no. 8 (2020): 1241-1256.

Nicolini, Marie E., Chris Gastmans, and Scott YH Kim. "Psychiatric euthanasia, suicide and the role of gender." The British Journal of Psychiatry 220, no. 1 (2022): 10-13.

Sisti, Dominic, J. John Mann, and Maria A. Oquendo. "Suicidal behaviour is pathological: implications for psychiatric euthanasia." Journal of Medical Ethics (2024).

Relevant disclosures for Sisti include Lykos Therapeutics and Tactogen. Relevant disclosures for include Levine include Compass Pathways.

This podcast explores complex and sensitive topics, including medically assisted suicide and the ethics of euthanasia. The views and opinions expressed by the hosts and guests are their own and do not necessarily reflect those of HCPLive or MJH Life Sciences. This content is intended to encourage thoughtful discussion and does not constitute medical advice or endorsement of any particular position. Listeners are encouraged to approach these subjects with care and consult appropriate resources for further information.

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In part 2 of this 2-part discussion, hosts discuss ethical considerations and the growing evidence base around euthanasia and medical assistance in dying.

Medical Ethics Unpacked: Ethical Considerations for Euthanasia & Medical Assistance in Dying

Medical Ethics Unpacked: Ethical Foundations and Background of Euthanasia & Medically-Assisted Suicide

00:00 Introduction to Medical Ethics Unpacked

00:45 Key Issues in the Debate on Euthanasia and Mental Illness

07:25 Clinical Perspective on Capacity and Competence

12:45 Challenges in Evaluating Capacity in Mental Illness

19:32 Treatment Options and the Role of Social Structures

In their inaugural episode of Medical Ethics Unpacked, hosts Steve Levine, MD, a psychiatrist, and Dominic Sisti, PhD, a bioethicist, begin a 2-part discussion examining medically-assisted suicide, often referred to as medical assistance in dying (MAID), and euthanasia, particularly in the context of severe 

. Part 1 of the discussion featured above focuses on foundational concepts and the broader context of MAID, laying the groundwork for an in-depth ethical discussion in part 2.

Sisti, an associate professor in the Department of Medical Ethics & Health Policy and the director of the Scattergood Program for the Applied Ethics of Behavioral Health Care at the University of Pennsylvania, introduces 2 critical questions at the heart of the debate: determining whether individuals with severe psychiatric illnesses have the capacity to make autonomous decisions about euthanasia and whether psychiatric conditions can be considered terminal. As Sisti notes, these questions are particularly challenging given the complexities of suicidality, which is both a symptom of certain psychiatric illnesses and a factor influencing the desire for euthanasia.

Sisti also examines data from jurisdictions where psychiatric euthanasia is legal, such as Belgium and the Netherlands, noting trends like gender disparities and inconsistent capacity evaluations that raise concerns about equity and justice. He emphasizes the need for robust societal safeguards to ensure that MAID is not prematurely offered to individuals whose suffering might be mitigated through other means.

Later, Levine provides a clinical perspective, delving into the distinction between capacity and competence, explaining how capacity evaluations are conducted by physicians, and discussing the nuances of suicidality as a dynamic and context-dependent phenomenon. He highlights the episodic nature of conditions like major depressive disorder and the potential for recovery through treatments, such as ketamine or psychedelics. However, he acknowledges the limitations of psychiatric care, including gaps in treatment effectiveness and accessibility, which complicate decisions regarding MAID.

Levine also raises the philosophical question of whether a wish to die is always pathological or whether it can sometimes be an expression of autonomy, further blurring the lines in this debate.

The episode sets the stage for part 2, which will explore the ethical considerations surrounding MAID and euthanasia in greater depth. Levine and Sisti aim to address the broader implications of permitting euthanasia in psychiatric populations, touching on justice, societal values, and the role of clinicians in these life-and-death decisions. Stay tuned for the continuation of this complex and thought-provoking discussion.


The inaugural episode of "Medical Ethics Unpacked" delves into the ethical complexities of medically-assisted suicide (MAID) and euthanasia, particularly for individuals with severe psychiatric conditions. Hosts Steve Levine, MD, and Dominic Sisti, PhD, explore foundational concepts, focusing on the capacity for autonomous decision-making and whether psychiatric conditions can be deemed terminal. They discuss data from jurisdictions where psychiatric euthanasia is legal, highlighting concerns about equity and justice. The episode also examines the philosophical and clinical nuances of suicidality, setting the stage for a deeper ethical exploration in the next episode.

In part 1 of this 2-part discussion, hosts explore the ethical foundation and background of euthanasia and medically-assisted suicide. 

Medical Ethics Unpacked Introductory Episode

In the introductory episode of the new podcast "Medical Ethics Unpacked," hosts Dominic Sisti, PhD, and Steve Levine, MD, invite listeners on a deep dive into the challenging and often controversial issues facing the healthcare industry.

Sisti, associate professor in the Department of Medical Ethics & Health Policy and the director of the Scattergood Program for the Applied Ethics of Behavioral Health Care at the University of Pennsylvania, and Levine, a psychiatrist and the senior vice president of Patient Access at Compass Pathways, bring unique perspectives to this important discussion. Their goal is to provide a platform for exploring the real-world implications of ethical dilemmas, from the allocation of resources to the privacy concerns raised by emerging technologies. In their introductory episode, the hosts explain that the healthcare system is evolving rapidly, and with these changes come new ethical challenges that must be addressed.

The podcast will tackle a different topic each month, drawing on expert insights and real-life case studies. Listeners can expect to hear in-depth conversations on subjects ranging from the ethics of euthanasia to the intricacies of involuntary psychiatric care. Sisti and Levine emphasize that ethical considerations are not just academic, but affect everyday decisions in clinical practice, policy-making, and patient interactions.

By fostering these crucial dialogues, Sisti and Levine hope to help both medical professionals and the general public navigate the complexities of modern medicine. The podcast will be available on popular streaming platforms, and the hosts encourage listeners to subscribe and share the content with their networks.

"Medical Ethics Unpacked" is a new podcast hosted by Dominic Sisti, PhD, and Steve Levine, MD, focusing on ethical challenges in healthcare. The hosts aim to explore real-world implications of ethical dilemmas, such as resource allocation and privacy concerns, through monthly episodes featuring expert insights and case studies. Topics will include euthanasia and involuntary psychiatric care, emphasizing the practical impact of ethics on clinical practice and policy-making. The podcast seeks to guide medical professionals and the public in understanding modern medicine's complexities.

An introductory episode for Medical Ethics Unpacked, a monthly multimedia series hosted by medical ethicist Dominic Sisti, PhD, and psychiatrist Steven Levine, MD, exploring ethical issues in contemporary healthcare. 

Dominic Sisti, PhD

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