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Are people suffering from a persistent, debilitating, and apparently incurable psychiatric condition, such as incapacitating suicidal depression, entitled to physician and/or government assistance in dying? (This procedure is also called “physician-assisted suicide”, or “medical assistance in dying”: MAID).  Of course anybody can kill themselves without the help of doctors or the government, but I’m talking about formal programs, often involving ingestion or injection of pentobarbital or secobarbital. This is available for those suffering from apparently incurable and suicidal mental illness in five countries: Belgium, the Netherlands, Switzerland, Luxembourg, and Spain (see details below the fold). All of these countries require, as is proper, a rigorous vetting program by mental-health professionals and doctors to see if all recourses have been tried and if the patient truly want to die and sees no point in living.

One alternative, legal everywhere and mentioned in the piece below, is voluntary stopping of eating and drinking (VSF), which, depending on what you do, will cause death within a week or two.  Some countries, like the Netherlands, will give hospice care to mentally ill people who are not approved for MAID but choose VSF, helping those patients ease out of life when their bodies start to shut down.

While physician-assisted suicide is legal in many places, including 11 states in the U.S., as well as Washington D.C.—laws permitting it have recently passed in Illinois and New York, and will take effect this summer—these are all for people suffering from terminal medical conditions.  The U.S. and all countries other than the five listed above do not allow physician-assisted suicide for other coniditons, whether or not the government assists or helps pay for it.

For a number of reasons I list below, MAID for psychiatric conditions has become quite controversial,  While I tend to side with those who allow it, I also agree that stringent medical and psychological vetting is necessary before a doctor is allowed to help someone die who has such conditions.  In the Free Press article below, author Rupa Subramanya first describes the death of Iris Dekker in the Netherlands, and then discusses the many issues around the procedure.

Click to read, though you’ll have to be a subscriber.

One gets the feeling from the posted article above, which is generally objective, that Subramanya really does oppose MAID for psychiatric conditions, and partly for religious reasons.  In a new hourlong conversation with Coleman Hughes, however, Subramanya pulls no punches; she clearly doesn’t think MAID is ready for primetime.  Coleman is a bit more in favor of it, but also has reservations.

First, a bit about Iris Dekker, who sought MAID in the Netherlands after over a decade of deep depression and suicidality.  She in fact tried to kill herself twice, once by hanging and once by cutting, but her parents found her in both cases and aborted the attempt. She also had a physical condition that may have been related to her mental illness:

Depression was not new to the Dekkers. Omar [Iris’s father] has a history of it, as do other members of his family. But Iris’s was different. Her symptoms were psychological and physical—a condition called functional neurological disorder, associated with severe psychological distress and depression. It often presents with symptoms like paralysis, seizures, and chronic pain, and was once referred to in medical psychology as hysteria. Iris had spent more than two years in a wheelchair after a seizure left her unable to walk.

In the end, after she had tried everything, including electroconvulsive therapy and ketamine treatment, Iris asked for MAID. But she became worse while waiting for approval and so practiced VSF until she died, with her pain palliated by physicians, at age 19.  Her parents didn’t want her to die, but in the end realized that there was no likelihood of a cure, and supported her. The end:

Watching her fade away, Omar felt the full weight of what was happening. He recalled the final night with his daughter as he held her in his arms and listened to her breathing. “In my heart, as a father—and also as a nurse—I was thinking, I have to do something,” he said. “And at the same time, I knew: No. This is what she wants.”

In her final moments, Iris could no longer speak or respond. When she took her last breath, Omar saw a smile on his daughter’s face.

“She looked so happy,” he said. “I couldn’t give her more love than letting her go.” Iris died on March 1, five days before her 20th birthday.

Letting go of those we love is very hard. We take it for granted that it’s humane when we’re dealing with pets who have terminal medical issues, but we cannot know when animals are undergoing unbearable mental suffering. But humans can tell us.

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It seems obvious, as I said, that Subramanya doesn’t like the idea of MAID, nor does she say how it could be implemented properly.  Statements like these are what makes me feel that way:

The Dekkers agreed to talk to me in detail about their daughter’s decisions—and theirs. They also showed me medical records for Iris. I tried to understand how loving parents could be persuaded that the best decision for their daughter was an early death. What I found was a system that turns young people’s ambiguous wishes into a diagnosis of incurable depression. The process raises questions about the treatment not only of a few teens like Iris who choose to die by euthanasia, but countless others who are confronted with the idea that their psychological suffering is beyond help.

. . .With each failure, Iris and her parents heard the same conclusion from specialists: Her condition was “treatment resistant,” and doctors had exhausted their options. In fact, the conclusion that depression such as Iris’s can be incurable is itself controversial among psychiatrists. As one recent paper in Psychological Medicine noted, clinicians “cannot accurately predict long-term chances of recovery in a particular patient with treatment-resistant depression.”

In the podcast with Coleman, Rupa makes it clear that while she’s not opposed to assisted dying, she is pretty much opposed to the process when it’s applied to psychiatric illnesses or even, as is legal in Canada, to people who have incurable suffering from a medical condition, like going blind or having diabetes.  I won’t counter her arguments, though I disagree with many of her claims. I just want to list below some of the reasons people oppose MAID for purely psychiatric conditions.  All of these save the first are mentioned in either the article or in the podcast. I have made the list and give my reactions to it.

1.) Religious reason #1: only God can take a life or determine when someone should die, suicide is against religious dictates, etc. I will not deal with this because I don’t believe there are gods and thus don’t think these reasons are worth considering seriously. But they are of course worth countering and discussing. I simply won’t entertain the proposition that “God knows best.”

2.) You can never tell when depression might be alleviated; many people who tried to kill themselves because of depression have later recovered and think their suicidal ideation was mistaken. True, but for someone like Iris Dekker, who had tried everything, saying “you might get better” is letting someone suffer forever despite having made a gazillion attempts to find a reason to live. Note that Subramanya reports that psychiatric MAID is rare even where legal:

Even in countries that have been at the forefront of assisted dying, psychiatric euthanasia is still rare. The Netherlands had 174 cases of psychiatric euthanasia in 2025—about 1.7 percent of its euthanasia deaths and 0.1 percent of deaths overall. Of the 338 euthanasia applications received at the Euthanasia Expertise Center in 2025 from patients younger than 30 that involved psychiatric suffering, only 11 were approved. None were minors.

This worry can be alleviated by a process of rigorous vetting, which, given the statistics above, seems already in place. While it of course cannot guarantee that someone allowed MAID could some day recover from psychiatric illness, if they’ve tried many ways to get better and yet still remain suicidal after years, it seems cruel for someone else to say that we should let them live because we don’t know what would happen. It is in effect trying to control someone else’s existence.

3.) The slippery slope argument: MAID for mental illness will lead not only to expansion of the process to those who don’t really qualify, but also, as Rupa says, “people who were socially isolated, people who were homeless, people who were on disability and people who just felt a great sense of despair.”

Again, this can be alleviated by rigorous vetting, and by involving doctors and therapists who aren’t in the business of willy-nilly approving candidates for MAID, just as there should be procedures preventing doctors from prescribing opioids for no good reason. Of course no system is perfect, but when you see someone like Iris Dekker, who has suffered greatly for years and wants to die–and has tried to die by her own hand–slippery-slope arguments need to be contested.  There’s no need to go all the way to the bottom of the slope once you step off the summit.

4.) Laws like Canada’s that allow MAID if you’re suffering not from terminal illnesses, but from other medical conditions, are not supportable because you can’t judge what is “intolerable suffering.” 

Again, rigorous vetting is the best way to deal with this.  Who better than (objective) mental-health professionals and doctors can judge whether suffering is “intolerable”. especially when multiple drug and/or psychiatric regimens ahve been tried?

5.) The social argument (from Rupa): suffering should be solved and endured collectively rather than by personal choice. 

Here’s what Rupa says;

We’re fully rational actors making these decisions entirely on our own. But in reality, our choices are shaped by our relationships with people. It’s shaped by the environment that we’re in, and it’s shaped by economic conditions, whether we feel loved, supported, or abandoned. So his argument is that autonomy is never fully independent because we make decisions within this context. I think with Canada, and then you have a political class in a place like Canada that is more than happy to enable all of these things. And so I feel like all of these things have come together in Canada, in the Netherlands as well.

I don’t really understand this argument, but it figures in the example of Rupa’s father (see below). If someone is suffering and can’t be cured, why should this be a problem that can’t be solved by the individual?  And of course the state does get involved when MAID is considered.

6.) Different doctors have different standards for “intolerable suffering.” Further, at least in Canada, some doctors, says Rupa, tend to get on oversight committees who are on board with MAID, so the procedure becomes easier to get. Rupa says this:

I think that some of the doctors I’ve spoken to think that they’re basically God. they feel powerful in making these decisions one doctor I spoke to she’s a prolific maid provider in British Columbia in Vancouver and she loves the limelight she loves talking about the patients she’s euthanized over the years and she started off I think she was a she went from delivering babies to now euthanizing people and she told me look and she said this elsewhere as well that I like to push the boundaries as much as I can when it comes to medical assistance anddying and that was pretty extraordinary to me. [JAC: remember, this is a transcript taken from the podcast, so there are infelicities of speech as well as outright errors in transcription.]

Again, choose well known and objective physicians; that is the best you can do. And of course usual more than just two or three doctors. Remember that MAID for mental illness is not yet legal in Canada.

7.) Hastening death is “the path of least resistance”, and in many cases may be less expensive and time-consuming than treatment for years and years. Here’s another quote from Rupa:

You do have cases where people can change their minds, but eventually the system decides that it should be the option. There was another case of a man with cancer who became delirious and very unresponsive in hospital. And according to this report, the doctors aroused him, shook his head and interpreted his blinks and the responses he was mouthing as consent and then proceeded to kill him that very same day. So basically, what all of this tells me is that. . .  there’s a medical culture now which is hastening death. And, you know, as one ethicist put it to me, he said this is the path of least resistance now.

If the law is made with the input of ethicists, this should be prevented. Again, the solution seems to be rigorous vetting and oversight rather than letting people suffer forever. And of course you can give control over your medical treatment to others via “do no resuscitate” orders and the like (I have these).

8.) MAID “normalizes” euthanasia and suicide.  Another quote from Rupa:

Hughes: Are you saying because of MADE, we’re entering this culture of normalization of suicide? And because of that, Some young people, they form that expectation that like, yeah, I have a right to die because of this culture. And then if they get rejected, they seek other means where like maybe in the past, without that culture of normalizing euthanasia and suicide, maybe they wouldn’t have even gone down the road. Is that sort of what you’re implying?

Subramanya: Yeah.

“Normalizing euthanasia” does not necessarily mean making it the go-to option.  And we are talking about euthanasia, not “regular” suicide.

9.) Religious reason #2: One role of religion should be to keep people off the slippery slope. Here’s an exchange from the podcast:

Hughes: But if you don’t have a religious view that life is sacred and that suicide is a sin, then it’s possible to talk yourself into it and kind of reason your way into ending your life if you really are at a low point and you are suffering, right? Is that what this is?

Subramanya: Yes, I think religion is certainly one institution when you look at the fact that as I mentioned earlier We’ve become a very individualistic society where suffering is no longer done communally, it’s not experienced communally, but on your own, where previously, you know, you’d go to the church or to the temple or to the mosque or whatever religion you belong to. But now, you know, a lot of us live in isolation, especially young people, you know, who are, I think, we’re still seeing some of the effects of the pandemic rapidly. right now where young people have been struggling with loneliness and alienation and mental health issues and then where suicide is not treated as something that you prevent but increasingly something that you facilitate so religion for sure. If you’re talking about how institutions once played a very important role in making us feel connected, that’s changed quite a bit.

Subramanya seems to have forgotten that it is also religion that’s been the main obstacle to any form of MAID, even for terminal illness (Mother Teresa is one example of someone who thought Jesus will take people when he’s ready). Is Subramanya suggesting that we should try to foist religious solutions onto someone seeking MAID?  Too late: religion is disappearing now, and you don’t go proselytizing someone who is suffering.

When Subramanya tells this story about her father, who found a reason to live, she seems to use it as an example of why anyone, however ill, can find a reason to live.  But people differ in how they bear suffering:

. . . I learned that my father in India was diagnosed with primary central nervous system lymphoma. They found a cyst in his brain and he needed a very urgent brain biopsy. As I was writing about Keanu’s death, this 27-year-old young person with type 1 diabetes and blindness and that he had given up on life, I was watching my own father fight desperately to hold on to his. And five months later, my father can’t speak because the part of the brain on which they operated controls speech. He has undergone chemotherapy and radiation.

He’s doing really well. His cancer is in remission. But what strikes me most is Not just merely his resilience, it is his desire to live. I mean, despite the pain and exhaustion, the loss of speech, the humiliations that he’s experienced, that serious illness brings about in people. You mentioned your mother who had who died of cancer. He’s soldiering on. He still loves life. And he wants more time. He’s fighting for every single day. And he finds joy in ordinary moments.

So, you know, for me, you know, as someone who’s written quite extensively about death, I look at my father and I wonder like what Why is he so different from someone who is 73 years old here in Canada, perhaps given a similar diagnosis and chooses made? Or why does a 28-year-old give up on life? And I don’t think my father in India is an outlier in the sense that he wants to live as much as possible. I think in places like India, you still have strong cultural family ties. I think religion continues to be extremely important. And I think these are factors, these are things that are increasingly, they’re disappearing in the West.

Once again we see religion mentioned as a way to keep people off the slippery slope of MAID. But what if you are not religious and cannot force yourself to believe? Someone like me, for instance.

In the end, I see both the article and podcast (not Hughes) infected with religiously-tinged arguments. I’ve long viewed the Free Press, while ideologically appealing in several ways, as too soft on religion—too eager to see it as caulk for our “god-shaped” holes.  This article may be one example.

Click on “continue reading” below to see descriptions of the five countries medical assistance in dying is legal for those with psychiatric issues:

From Grok:

My question:  Which countries allow medical assistance in dying for psychiatric problems or other mental issues?

How Grok answered:

As of May 2026, a small number of countries explicitly permit medical assistance in dying (MAiD, which includes physician-administered euthanasia or physician-assisted suicide) where a psychiatric disorder or other mental health issue is the sole underlying medical condition (or the primary source of unbearable suffering). In these jurisdictions, the person must generally be an adult with decision-making capacity, make a voluntary and well-considered request, experience constant and unbearable suffering with no prospect of reasonable improvement, and have exhausted relevant treatment options. Psychiatric cases remain relatively rare (typically 1–2% of total MAiD cases where data are available).Here is the current list of countries where this is allowed:

• Netherlands: Euthanasia is legal for psychiatric disorders under the 2002 law if the patient has “unbearable suffering with no prospect of improvement.” This has been in practice for over two decades, with official reports documenting dozens of cases annually (e.g., 115 psychiatric cases in 2021).
• Belgium: Euthanasia is permitted for “constant and unbearable physical or mental suffering” from an incurable condition (including psychiatric disorders) since the 2002 law. Requests require multiple written statements, medical confirmation, and review. Psychiatric cases are reported (e.g., 26 in 2022).
• Luxembourg: The 2009 law allows euthanasia or assisted suicide for an incurable medical condition causing unbearable physical or mental suffering with no prospect of improvement. Psychiatric disorders qualify under the same criteria as in the other Benelux countries.

 

• Switzerland: Assisted suicide (not physician-administered euthanasia) is permitted. A 2006 Federal Supreme Court ruling explicitly extended this to individuals with “incurable, permanent, severe psychological disorders,” provided the person has decision-making capacity and the wish is autonomous (not a symptom of a treatable mental disorder). Right-to-die organizations facilitate this, often with psychiatric evaluation.
• Spain: The 2021 Organic Law on the Regulation of Euthanasia allows MAiD (euthanasia or assisted suicide) for a “serious and incurable illness” or “serious, chronic, and incapacitating condition” causing constant and unbearable suffering (physical or mental). While a 2023 Constitutional Court ruling sought to limit purely psychiatric cases to those with a somatic basis, practice and recent cases (including a high-profile 2026 euthanasia of a 25-year-old woman with mental illness after legal proceedings) confirm eligibility is possible under the law’s broad criteria.

Understanding, at a deep level, the differences between legitimate science and pseudoscience is increasingly critical in our modern world. Science, in my opinion, is perhaps the most powerful tool humans have collectively developed for understanding the universe in which we find ourselves. (I would clarify that it is complementary with philosophy which is important to ensure that we are thinking clearly, rigorously, and consistently.) Pseudoscience pretends to be scientific but is essentially doing it wrong. There are many underlying reasons for the existence of pseudoscience – it is sometimes just poor quality science due to poor training or sloppy technique, it may result from a motivation to achieve a desired result rather than letting the empirical chips fall where they may, researchers may not appreciate their own biases, or it may be part of a dedicated campaign motivated by profit, politics, ideology, religion, culture, or just wishful thinking.

I spend a lot of time studying and writing about certain classic pseudosciences because I think they are especially instructive, and acupuncture is definitely on the short list.  I just wrote about it last week, specifically about a gullible article in the NYT which has bought into the pro-acupuncture propaganda. That piece resulted in lots of feedback, some of which doubled-down or extended the pseudoscientific arguments often made for acupuncture, so I wanted to reply to some of those and further clarify my position.

One common feature of pseudoscience is the use of vague or fluctuating definitions. Science requires unambiguous definitions, which is why it so often relies on technical jargon which evolves to be incredibly precise. This is one of the things I love about science, and why I think everyone should study it to some degree, at least enough to become functionally scientifically literate. Science forces you to think clearly, precisely, and consistently. If we take a seemingly simple question, for example, such as “does acupuncture work”, we first have to operationally define “acupuncture” and also “work”. You also have to include – work for what? I am usually careful to do so when addressing this question.

“Acupuncture”, as defined by just about every source I have ever consulted, is defined as a technique that involves sticking needles into acupuncture points. That seems to be a universal and necessary component to “acupuncture”. The points themselves often differ. There are different traditions, different locations, and different functions of the alleged points. There are other traditional elements to acupuncture, such as the existence of a distinct life force (Qi) that flows through specific channels in the body known as meridians. There is also sometimes described a “de-Qi” sensation, which is itself vaguely defines, but is claimed to indicate when a needle has been placed in the correct location to an adequate depth. Acupuncture may also include moxibustion, which is the burning of herbs on the needles, or “electroacpuncture” which involves electrically stimulating the needles after insertion.

Each of these alleged phenomena must be tested by themselves, controlling for all variables as much as possible. It is possible (speaking hypothetically), for example, that some acupuncture points exist but others do not, or that the points exist but de-Qi is not necessary. Each variable must be isolated as much as possible – the points, needle insertion, electrical stimulation, the patient interaction, etc.

Further, when medical scientists ask whether or not a treatment “works” they are usually talking about “efficacy” (and this is the technical term they will use in the literature and to other experts). Efficacy means that there is a specific beneficial effect established beyond any non-specific or placebo effects. Efficacy can generally only be well-established with double-blind placebo controlled trials. But to be fair, there is a lot of nuance here. Many interventions cannot be ethically blinded (like whether or not someone undergoes surgery), and so efficacy must be inferred from multiple different study types controlling for as many confounding variables as possible. It also helps to use objective outcome measures (such as survival). But it is virtually impossible to make efficacy claims based only on subjective outcomes of unblinded interventions. However – acupuncture can be blinded, so much of this nuance is not relevant here.

So – we can technically restate the question “does acupuncture work” as “do acupuncture points have specific efficacy?” Again, this question must be asked for each potential indication. This question has been investigated with hundreds of trials for dozens of indications, many of which are reasonably rigorous with sham acupuncture or placebo acupuncture controls and reasonable double-blinding. The totality of these studies strongly show that there is no efficacy to any acupuncture points for any indication. We can add this clinical data to what we know about scientific plausibility. It has never been established that acupuncture points exist. There is no physiological or anatomical underlying basis for their existence. There is no reason to hypothesize that they exist outside of cultural beliefs. There is no internal consistency to their number, location, or effects – which follow patterns of cultural tradition, institutional and personal preference. As a scientific concept, acupuncture points are a dead end that have been sufficiently ruled out and should be completely abandoned. We can say the same thing about Qi as a distinct life energy or force, and of meridians as channels through which Qi (or whatever) flows.

It therefore does not matter how desperately one retcons or redefines “acupuncture”. Some respondents tried to say that “Qi” really just refers to known energies, like heat and electricity. That is classic pseudoscience, and historically clear retconning, but it also doesn’t matter. They are stuck in an unscientific approach to the question “does acupuncture work”, which they think they can rescue by redefining acupuncture. Regardless of any definition for the broader concept, science does not work that way. We need to operationally define and isolate specific elements, and we can say that there is no Qi, meridians, or acupuncture points. It is also common to try to redefine “works” as including placebo effects (and then falsely touting how amazingly powerful placebo effects are). Again – this is slight-of-hand, and doesn’t matter to the real question – does sticking needles in acupuncture points have specific efficacy. The answer is clearly no, whatever your thoughts about the practical use of placebo effects in medicine (that’s a separate article).

We can also ask – does sticking needles in the skin have specific efficacy. The answer here also appears to be no – at least in properly controlled trials poking the skin without penetration was as effective as penetrating the skin to a depth typical in acupuncture treatments. In fact there is now a treatment referred to as “dry needling” which is an attempt to divorce the sticking of needles in the skin from any concept of Qi, acupuncture points, or meridians. Is there established efficacy for dry needling for any indication? No. Meta-analyses and systematic reviews show mixed but mostly negative results. It may not be possible yet to rule out a short term mild effect for pain, but that’s it (and even there, some reviews find it is worse than placebo).

But acupuncturists (including some responding to me) insist that dry needling is contained under the umbrella of “acupuncture” (while dry needlers insist it is not acupuncture). This is all a semantic game – and it doesn’t really matter from a scientific perspective. As I discussed – it doesn’t matter how you play with these definitions. Scientifically you have to state a specific, ideally operational, definition and a specific question. When we do this – none of the possible components of acupuncture seem to exist or have specific efficacy.

The post Retconning Acupuncture first appeared on NeuroLogica Blog.

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