Forensic-psychiatric and medico-legal challenges in euthanasia and assisted suicide for patients with mental disorders: balancing autonomy, vulnerability, and professional responsibility

Background: Euthanasia and assisted suicide (EAS) in individuals with mental disorders represents a complex and controversial area at the intersection of clinical practice, bioethics, and medico-legal evaluation. While suffering is inherently subjective in both psychiatric and somatic conditions, psychiatric contexts are characterized by greater fluctuation, contextual dependence, and prognostic uncertainty, which complicate the assessment of its severity, persistence, and potential reversibility in medico-legal evaluations. Methods: A structured narrative review of the international literature was conducted, focusing on clinical, ethical, and medico-legal aspects of EAS in psychiatric contexts. Regulatory frameworks and empirical contributions were analyzed to identify key domains and areas of ongoing debate. Results: Five interconnected domains emerge as central to psychiatric EAS assessment: decision-making capacity, irremediability of suffering, subjective suffering and voluntariness, and safeguard systems. Across jurisdictions, considerable variability exists in legal models and clinical approaches, although a shared emphasis on repeated, multidisciplinary, and well-documented evaluation processes is evident. Persistent challenges include the absence of standardized criteria for irremediability, inter-rater variability in capacity assessment, and the difficulty of distinguishing between psychopathology- related suicidality and well-considered requests for assisted death. Discussion: The available literature suggests that psychiatric EAS requires particularly careful and structured evaluation processes, given the inherent complexity and variability of mental disorders. Multidisciplinary approaches involving clinical psychiatry, forensic psychiatry, and legal medicine may contribute to improving consistency, transparency, and medico-legal robustness. Longitudinal assessment and detailed reconstruction of clinical history appear to be key elements in supporting reliable decision making. Conclusions: Psychiatric EAS remains an evolving and methodologically challenging topic. While uncertainties cannot be fully resolved, structured and multidisciplinary evaluation processes may help enhance the consistency and ethical sustainability of assessments in this context.