[Medically assisted death in mental disorders. Clinical uncertainties and ethical implications.]

Medical assisted death (MAD), including euthanasia and medically assisted suicide, has been legalized in several European countries, with a progressive extension to mental disorders in Belgium, the Netherlands, and Switzerland. In cases of mental disorders, access to MAD is subject to strict criteria regarding decision-making capacity, severity of suffering, and prognosis; however, these conditions remain particularly controversial in clinical practice. This narrative review and position paper critically examines three key dimensions: the assessment of decisional autonomy in mental disorders, the nature of the wish for death as a possible symptom expression, and the issue of the treatability of psychiatric conditions. The available evidence highlights the intrinsic complexity and uncertainty characterizing psychiatric evaluations, including the fluctuating nature of decisional capacity, the potential reversibility of death wishes, and the probabilistic nature of psychiatric prognosis. These elements support the need for particularly rigorous and cautious clinical assessment. While a priori exclusion of psychiatric patients from MAD may raise ethical concerns related to autonomy and equality, the specific clinical features of severe mental disorders justify a prudential and individualized approach, grounded in careful longitudinal evaluation and exploration of all therapeutic alternatives.