Psychiatric Euthanasia and the Failure of Imagination

The debate around psychiatric euthanasia is among the most ethically and philosophically complex issues in mental health. Some see it as an act of compassion and bodily autonomy, while others view it as an unacceptable extension of psychiatric power that risks legitimizing and institutionalizing death as a “treatment” for suffering. The conversation has become even more urgent as some countries, including Canada, have expanded medical assistance in dying (MAID) to include psychiatric patients, even when death is not imminent.

A new article in Psychodynamic Psychiatry complicates the conversation further. Titled “Who’s Afraid of Murderous Rage? When Euthanasia Colludes with Self-Destructiveness,” authors Ardalan Najjarkakhaki, Jon Frederickson, and Gerrie Bloothoofd argue that psychiatric euthanasia risks becoming an unconscious enactment of trauma rather than a genuine resolution of suffering. Drawing from psychodynamic theory, the authors explore how transference and countertransference may lead clinicians to collude—often unknowingly—with their patients’ self-destructive impulses.

“The patient’s wish to die always involves a relationship with the clinician, a schema, or an unconscious transference. This evokes conscious and unconscious transference and countertransference feelings that can direct the assessment. The therapist can rationalize that they are eliminating the chronic unbearable suffering of a ‘treatment-resistant’ patient through death. Meanwhile, they may be acting out their own unconscious countertransference feelings. When treatment models do not systematically analyze unconscious transference, countertransference, and enactments, the assessment may enact rather than resolve the patient’s conflicts, failing to address the underlying psychological issues.”

This research challenges the assumption that psychiatric euthanasia is a purely medical or ethical issue, exposing how unconscious dynamics between clinicians and patients can shape life-and-death decisions in ways that reinforce trauma rather than resolve it. By questioning whether suicidality is being treated as a symptom to be understood or a request to be granted, it calls attention to the broader implications of how psychiatry conceptualizes suffering, agency, and care. In a mental health landscape where coercion is often masked as compassion and where systemic failures are rebranded as “treatment resistance,” this analysis urges a deeper reckoning with the power structures and psychological entanglements at play in psychiatric decision-making.

Psychiatric Euthanasia and the Danger of Unexamined Transference

Transference, in psychoanalytic terms, refers to the unconscious redirection of past emotions onto the present relationship with a clinician. Countertransference describes the therapist’s own emotional reactions to the patient—both conscious and unconscious. The authors argue that psychiatric euthanasia presents unique ethical and clinical dangers because it may enact rather than treat a patient’s internal conflicts.

To illustrate their concerns, the authors introduce a hypothetical case of a 32-year-old woman in the Netherlands—generalized from common psychiatric euthanasia cases—who has experienced severe childhood trauma and chronic suicidality. After eight years of psychotrauma therapy, she requests euthanasia from her treating psychiatrist. The psychiatrist agrees, citing her as “treatment-resistant” and concluding that no reasonable alternative remains.

The authors challenge the reasoning behind labeling patients as “treatment-resistant” when they do not respond to certain evidence-based therapies.

“Instead, here the patient was labeled as ‘treatment resistant’ because she did not respond to previous ‘evidence-based’ treatments. That is not a logical argument. Supposedly, since treatment failed, she was ‘treatment resistant.’ Labeling the patient as treatment resistant becomes a substitute for deeper clinical thinking.”

They argue that suicidality in patients with complex trauma is often not just a symptom, but a defense—a way to manage unbearable emotions. The risk, then, is that psychiatric euthanasia becomes a means by which clinicians unwittingly collude with these unconscious dynamics rather than addressing them.

Who Does the Clinician Represent?

The authors urge clinicians to ask critical questions about the nature of the patient’s request:

“When the patient asks for euthanasia, what transference is she enacting with the clinician? … ‘Who do I represent in her past who wanted to kill her?’ Or ‘Who do I represent in her past that she wanted to kill?’”

They highlight how, in patients with severe trauma histories, internal conflicts between a wish to live and a wish to die often become externalized. When clinicians grant euthanasia, they may be stepping into an unconscious role, reinforcing the patient’s belief that they are beyond help or unworthy of survival.

“More severely ill suicidal patients present as if they are not in conflict. Instead, they present as if they want only to die. So where does their wish to live go? In the clinician. The therapist starts to feel anxious, not the patient. The therapist starts to argue for life, not the patient. The therapist feels responsible for whether the patient lives, not the patient.”

From Clinician to Executioner?

The authors warn that psychiatric euthanasia risks reversing the traditional role of a mental health professional. Rather than helping patients process and understand unconscious conflicts, the therapist becomes an agent of their enactment.

“The psychiatrist is asked to collaborate with a psychotic wish and regard it as ‘heroic.’ We could view this as manic denial. Plain denial says killing her is not bad. Manic denial claims killing her is a gift. We not only deny reality; we claim the opposite of reality is true.”

By treating suicidality not as a symptom to be explored but as a request to be fulfilled, clinicians may be abandoning their ethical and clinical responsibility to help patients work through their psychological pain.

A Call for Ethical Reflection

The authors conclude by urging clinicians to recognize psychiatric euthanasia not as a neutral medical act, but as a complex psychological event that requires rigorous analysis of transference and countertransference dynamics. They ask:

“When euthanasia is offered as a solution for psychiatric suffering, is it truly the patient’s suffering being alleviated, or is it the clinician’s?”

If suicidality is an unconscious defense, then fulfilling a request for psychiatric euthanasia is not an act of therapeutic neutrality—it is an act of collusion.

“Our ethical responsibility is to analyze the psychological factors involved in a wish to die. Rather than concretely granting such a wish, we have an ethical obligation to first understand the psychological factors driving the patient’s defenses. Our task is to recognize this pressure as a way they deal with conflict and to understand the feelings and anxiety driving their wish. By doing so, we can help them navigate their inner conflicts rather than engage in the defense they ask us to enact: ending their life.”

As psychiatric euthanasia laws expand internationally, this article raises pressing ethical concerns that must not be ignored. It challenges mental health professionals to consider whether they are truly supporting a patient’s autonomy—or simply enacting their pain. The risk, the authors suggest, is not just that psychiatry fails to help those who suffer, but that it actively participates in their destruction.

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Najjarkakhaki, A., Frederickson, J., & Bloothoofd, G. (2025). Who’s Afraid of Murderous Rage? When Euthanasia Colludes with Self-Destructiveness. Psychodynamic Psychiatry, 1-16. (https://doi.org/10.1007/s12144-025-07487-7)