Psychiatrists and Medical Aid in Dying: Entering Uncharted Waters

With the signing of New York’s Medical Aid in Dying Act on February 6, 2026, thirteen United States jurisdictions have authorized procedures for terminally ill adults to obtain and self-administer lethal medications.¹ Bills to legalize medical aid in dying (MAID) are currently under consideration in another thirteen state legislatures, and several are likely to be adopted during current terms.² The moral controversy surrounding this issue, a debate that dates back to Ancient Athens and will likely persist into the foreseeable future, implicates complex aspects of autonomy, paternalism, and equity—none of which will be resolved here.³ A more wieldy, and arguably more pressing, set of concerns stemming from this swath of recent legislation relates to specific effects on psychiatric practice. Legalization of—and potential psychiatric participation in—MAID raises novel ethics and legal challenges. In passing such statutes, and adopting regulations to effectuate them, states must take care to clarify the precise expectations, obligations, and liabilities that MAID imposes upon clinicians who participate, as well as any that may fall upon those physicians who choose not to do so. Doing so may prove more complex than state authorities or participating providers initially realize. This commentary argues that psychiatric participation in MAID differs in meaningful ways from both traditional capacity evaluations and conventional suicide prevention, and therefore demands its own practice standards.

The obligations that may be imposed upon mental health professionals regarding MAID are especially complicated because psychiatric participation in this high-stakes intervention differs from both ordinary capacity evaluations and traditional suicide assessments. In many cases, psychiatrists are effectively being asked to provide a form of “psychiatric clearance” for patients seeking life-ending medication. Yet the profession has historically emphasized suicide prevention and the treatment of psychiatric disorders—particularly depression and other conditions associated with suicidal ideation—that may impair judgment. MAID therefore places clinicians in the unusual position of distinguishing between a rational wish to hasten death in the setting of terminal illness and a potentially treatable manifestation of psychopathology. Determining whether psychiatric symptoms have been adequately addressed before a patient proceeds with MAID may prove far more nuanced than assessing decisional capacity alone.

Against this backdrop, all of the United States jurisdictions in which MAID is legal require that medical professionals assess candidates for decisional capacity, and generally, when psychiatric concerns arise, refer a candidate for further evaluation by a mental health professional.⁴ However, at present, the specifics of how capacity should be assessed for MAID remain generally nebulous. For instance, should psychiatric evaluators rely upon the same assessment tools used in clinical practice when assessing patients for capacity to accept treatment, such as the widely accepted “four abilities” method of Appelbaum and Grisso?⁵ What should the threshold be for capacity in such cases—“more likely than not,” “clear and convincing” evidence, or higher? And should evaluators be expected to have specialized training, such as fellowship accreditation or the equivalent in forensics or consult-liaison psychiatry?

At present, regulatory frameworks in the United States offer minimal, if any, guidance on these matters; the result is that psychiatric assessors default to their general practices. This approach is problematic in that standard tools were not designed for MAID and that MAID differs fundamentally from other medical interventions in that mortality is not a risk but the intended benefit. To be sure, clinicians and courts have long recognized the right of competent patients to refuse life-sustaining interventions such as mechanical ventilation or renal dialysis, even when death is the foreseeable result. MAID differs in that mortality is not merely the anticipated outcome, but the goal, raising difficult questions about whether the threshold for decisional capacity should mirror, or even exceed, the standard required for the refusal of other life-preserving treatment. Arguably, specialized tools should be developed that incorporate the distinctive nature of MAID. In their absence, psychiatric professional organizations should step forward to offer guidance. To a degree, that has happened abroad. Most notably, the Canadian Association of MAiD Assessors and Providers (CAMAP) issued a white paper on the subject in 2020 and followed up with another specific to dementia patients in 2024.^6,7 Yet psychiatric professional organizations in the United States, possibly due to ambivalence or objection to MAID in principle, have been slow to act. That should change: Even organizations that do not wish to endorse MAID must acknowledge the reality of its legalization and offer practice guidelines for how it should be best implemented. Failure to do so will leave their members to grope their way forward alone or, worse, cede authority to policymakers and bureaucrats who do not serve the interests of psychiatrists or their patients.

Another significant challenge for psychiatrists faced with patients seeking MAID relates to the circumstances under which such patients can be referred to another jurisdiction or evaluated for an intervention in another jurisdiction. This issue arises most frequently in states where MAID is not legal. Abetting suicide, often poorly defined, is still a criminal offense in most jurisdictions.^8,9 In theory, a psychiatrist referring a competent patient out of state for MAID, conducting a psychiatric clearance evaluation for MAID to be conducted abroad (eg, in Switzerland), or even discussing the subject with a terminally ill patient could result in prosecution in some jurisdictions. Medical board sanctions for such activities are also possible. Often, only one overzealous prosecutor stands between a physician and a felony charge, so many psychiatrists continue to be reluctant to participate in such referrals or evaluations. Even in jurisdictions where MAID is legal, referral out of state—especially to a jurisdiction with different criteria for MAID—may raise legal and licensure concerns. For example, no US jurisdiction permits MAID for psychiatric suffering or for nonterminal patients. Under the recently passed New York statute, a Manhattan psychiatrist referring a patient with a debilitating but not terminal condition to Switzerland for a MAID consultation might be in violation of the state’s statute on suicide promotion—a class E felony punishable by up to 4 years in prison.¹⁰

State MAID statutes generally protect psychiatrists from liability for good faith participation in the process. Several jurisdictions, including Oregon and Washington, go further by shielding participating psychiatrists from being sanctioned or excluded from professional organizations for participation, but most statutes do not do so, and the recent trend has not favored these protections. So, in a state like Montana, where the state medical association has strongly opposed member participation in MAID, conducting such an assessment could, in theory, lead to expulsion from the state’s leading medical organization for unethical conduct.¹¹ This draconian penalty has not yet been imposed—but possibly because no Montana Medical Association members have so far dared to participate in such evaluations. Or, if they have, they have not acknowledged doing so publicly. Whether or not MAID statutes should include such safe harbor laws is a thorny issue, pitting the free expression rights of organizations against the practice autonomy of members. Any providers participating in MAID should be aware of the potential professional consequences of such engagement and what protections are afforded to them.

The ethical challenges for psychiatrists are likely to expand in the near future as states grapple with expanding MAID to those suffering from mental illness—as may take place in Canada, after several postponements, in 2027.¹² Whether the current US bans should be preserved as bright-line rules, or whether exceptions should exist for patients with decisional capacity suffering from intractable illness, may even put MAID supporters at odds.¹³ Particularly controversial will be whether severe and refractory psychiatric disorders alone should ever qualify as conditions sufficiently hopeless or irremediable to justify MAID. Cases involving chronic treatment-resistant illness, such as severe anorexia nervosa or debilitating somatic symptom disorder, underscore both the profound suffering that may motivate such requests and the difficulty of distinguishing enduring pathology from potentially treatable conditions. The subtle nature of “diminished capacity” demands that, if such exceptions are created, extra care be taken to ensure precise standards and safeguards against abuse.

Psychiatrists evaluating patients for MAID may find themselves asked to assess not merely decisional capacity, but the extent to which suffering itself has become intolerable and irremediable. Distinguishing between suffering arising from an enduring medical condition and distress exacerbated by inadequately addressed depression or demoralization may prove especially difficult, especially if uncertainty exists regarding whether all psychiatric and psychosocial interventions have been exhausted. In this context, one must emphasize that the vast majority of individuals who benefit or are harmed by MAID never use it: rather, many beneficiaries are patients with social capital who take solace in the sense of control they obtain from knowing that, in extreme circumstances, MAID might be an option, while the victims are those patients, often from historically marginalized communities, who eschew healthcare for fear of being coerced to end their lives prematurely. At the same time, some experienced MAID assessors have suggested that coercion opposing MAID may in practice prove more common than coercion toward it, underscoring the complexity of evaluating voluntariness in either direction. Any consideration of expanding MAID into the arena of patients with mental illness must take these competing interests into account.

Finally, as views on MAID remain diverse, clear guidance must be established for allowing such disagreements at the level of clinical practice. In jurisdictions in which MAID is legal, no psychiatrists should find themselves pressured to engage in the process; at the same time, eligible patients should not be denied access to a legally authorized medical intervention. As a long-time supporter of legalized MAID, I have recently participated in a working group of the Academy of Consultation-Liaison Psychiatry (ACLP) whose goal is to develop best practices for psychiatric participation. The committee also includes highly respected MAID opponents. The goal is not to resolve the deep philosophical and moral divisions on a subject upon which people of wisdom and goodwill strongly disagree, but to hammer out the details of how—where MAID is legalized—psychiatrists willing to do so can participate. Psychiatric participation in MAID may therefore require a distinct evaluative framework, one that extends beyond traditional decisional-capacity determinations. At a minimum, such an approach should encompass assessment of decisional capacity itself, differentiation of suicidality from rational end-of-life decision-making, careful consideration of potentially treatable psychiatric contributors to suffering, and evaluation of voluntariness—including both coercion toward MAID and coercion intended to prevent it. At a minimum, future psychiatric guidelines should address competency standards for evaluators, recommend approaches for assessing suicidality versus rational end-of-life decision-making, and offer protections for both participating and nonparticipating clinicians. At present, the widespread legalization of MAID in the United States appears inevitable. Making sure that the implementation is done with care and precision, and with the input of psychiatric professionals, is essential to prevent this expanding practice from going off the rails.

Article Information

Published Online: July 1, 2026. https://doi.org/10.4088/JCP.26com16382
© 2026 Physicians Postgraduate Press, Inc.
J Clin Psychiatry 2026;87(3):26com16382
Submitted: February 16, 2026; accepted June 3, 2026.
To Cite: Appel JM. Psychiatrists and medical aid in dying: entering uncharted waters. J Clin Psychiatry 2026;87(3):26com16382.
Author Affiliations: Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, New York.
Corresponding Author: Jacob M. Appel, MD, 140 Claremont Ave #3D, New York, NY 10027 ([email protected])
Financial Disclosure: Dr Appel has no disclosures or conflicts of interest.
Funding/Support: No financial support or funding supported this article.
ORCID: Jacob M. Appel: https://orcid.org/0000-0003-3523-9145