Canadian Psychology / Psychologie canadienne © 2017 Canadian Psychological Association

2017, Vol. 58, No. 3, 292–304 0708-5591/17/$12.00 http://dx.doi.org/10.1037/cap0000107

COMMENTARY / COMMENTAIRE

Furthering the Discussion on a Physician-Assisted Dying Right for the

Mentally Ill: Commentary on Karesa and McBride (2016)
Dylan Davidson and Jocelyn A. Lymburner
Kwantlen Polytechnic University

In June 2016, Canada joined the handful of nations that have legalized physician-assisted dying (PAD). Yet,
with legislation restricting PAD to the terminally ill, many have been left contending for the right to PAD in
cases of debilitating chronic illness, including, but not limited to, severe mental illness. This commentary
serves to evaluate and continue the discussion of Canadian PAD for the mentally ill as introduced by Karesa
and McBride (2016), present and compare the results of our own research, and promote ongoing discourse on
this subject. Karesa and McBride (2016) surveyed psychologists regarding a prospective role for their
profession in the PAD process, as well as their attitudes toward PAD. We evaluate their methodology and
findings, suggesting manners in which future investigations of psychologists’ attitudes toward PAD can be
improved. Implementing some of these suggestions, our own study assessed n ⫽ 201 Canadian undergrad-
uates’ attitudes toward PAD for 2 mental illnesses (schizophrenia, depression) as compared with PAD for
physical illness (multiple sclerosis [MS]). In a repeated measures design, participants read vignettes depicting
individuals who suffer grievously from 1 of MS, schizophrenia, or depression. In accordance with the primary
hypotheses, schizophrenia and depression received lower levels of support for PAD, and were perceived as
involving less suffering, rationality, and futility of treatment compared to MS. Our study provides further
insight into the ways in which people differentiate physical and mental illnesses, and our discussion adds a
Canadian perspective to a pressing subject that, to date, has not been thoroughly investigated.

Keywords: physician-assisted dying, mental illness, schizophrenia, depression, multiple sclerosis

Despite increasingly liberal attitudes in the Western world,
physician-assisted dying (PAD) remains a fiercely debated sub-
ject—legally, ethically, and morally. In many cases, PAD is con-
ceived as a procedure reserved for patients suffering from a ter-
minal illness, whereas support of PAD for nonterminal illness is
more limited (McCormack & Fléchais, 2012). In their investiga-
tion of psychologists’ attitudes toward PAD, Karesa and McBride
(2016) broach a controversial yet pressing topic— both in terms of
their discussion of PAD for the mentally ill, as well as their
discussion of a prospective role for psychologists in the PAD
process. Both proponents and opponents of PAD have been ap-
prehensive about extending the right to PAD to the mentally ill
(Appel, 2007). Many hold that patients with mental illness are
inherently unable to make a rational request for PAD, due to
distortions of perception or affect caused by mental illness (Cholbi,
2013). Yet, proponents of a PAD right for the mentally ill argue
that, despite undeniable ethical challenges, it is possible to cau-
tiously and responsibly proceed with PAD if a patient suffers
greatly with no prospect of relief, and if he or she clearly expresses
Dylan Davidson and Jocelyn A. Lymburner, Department of Psychology,
Kwantlen Polytechnic University.
Correspondence concerning this article should be addressed to Jocelyn
A. Lymburner, Department of Psychology, Kwantlen Polytechnic Univer-
sity, 12666 72nd Avenue, Surrey, BC V3W 2M8, Canada. E-mail: jocelyn
.lymburner@kpu.ca
a voluntary, enduring, and well-considered request for PAD
(Berghmans, Widdershoven, & Widdershoven-Heerding, 2013).
Karesa and McBride’s (2016) investigation was conducted in light
of the Supreme Court of Canada’s initial ruling that PAD be restricted
by severity and futility, rather than by type of illness (Carter v.
Canada, 2015). However, in June 2016, Bill C-14 (Parliament of
Canada, 2016) restricted PAD to Canadians whose natural death is
reasonably foreseeable in light of their medical condition. The nature
of Canada’s PAD legislation has stirred controversy among oppo-
nents of PAD, as well as those who support PAD for chronic and/or
mental illness. While PAD in Canada is presently restricted to termi-
nally ill patients, legal battles and public uproar regarding a PAD right
for nonterminally ill patients are ongoing (Canadian Bar Association,
2016). Interestingly, while Karesa and McBride’s (2016) survey of
psychologists (foremost experts in mental health) demonstrated
greater support of PAD for a terminally ill patient compared to a
mentally ill patient, 28.9% of the psychologists were neutral or
supportive regarding the mentally ill patient’s right, potentially sug-
gesting that PAD for the mentally ill may be appropriate in select
cases. It appears inevitable that relevant legislative debates will re-
surface in the future, given that developments in the law can be
conceived as faint echoes of societal expectations (Benabou & Tirole,
2011).
In a recent survey conducted by the Canadian Medical Associ-
ation, only 29% of surveyed physicians were open to personally
providing medical aid in dying (Vogel, 2015). Of those who would
consider providing assistance, only 43% would aid in cases of

292
 PHYSICIAN-ASSISTED DYING FOR THE MENTALLY ILL
nonterminal illness, and only 19% in cases of psychological suf-
fering. Similarly, the Angus Reid Institute (2016) polled the Ca-
nadian public and found that only 22% of respondents felt psy-
chological suffering on its own is justifiable for PAD. It appears
that many believe “physical” illness warrants greater access to
PAD than mental illness, yet little research explicitly measures the
source of these beliefs. In light of these momentous developments
in Canadian law, and the resulting debates, we investigated Cana-
dian undergraduates’ attitudes and rationale concerning PAD for
mental illness as compared with PAD for physical illness. The
purpose of this commentary is threefold: To evaluate and continue
the discussion of Canadian PAD for the mentally ill as introduced
by Karesa and McBride (2016), to present and compare the results
of our own research, and to promote ongoing discourse on this
subject that, to date, has not been thoroughly investigated.
Attitudes Toward Physician-Assisted Dying:
Literature Review
An initial exploration of the research landscape concerning
attitudes toward PAD will set the stage for a closer examination of
Karesa and McBride’s (2016) investigation, as well as our own
research. Despite considerable debate in the literature regarding
the ethical nature of PAD for the mentally ill, empirical research
investigating attitudes on this topic is scarce. However, attitudes
toward PAD as a general practice, or in the context of terminal
illness, have been studied extensively—primarily in the Western
world. In general, research on attitudes toward PAD tends to
present moderate levels of support, in many cases ranging from
⬃30 – 60%.
In a sample of physicians practicing in Vermont, Craig et al.
(2007) found that 38.2% believed in the legalization of PAD, 16%
believed it should be prohibited, 26% believed it should not be
legislated, and 15.7% were undecided on the issue. Interestingly,
physicians who regularly cared for patients with terminal illness
through the end of their life were significantly less likely to
support legalization (34%) compared to those who did not regu-
larly care for terminal illness patients (48%). It is possible that
increased involvement with dying patients implores reduced will-
ingness to “give up” on them (Craig et al., 2007; Emanuel et al.,
2000; Lindblad, Löfmark, & Lynöe, 2008). Emanuel et al. (2000)
surveyed 3,299 oncologists in the United States and found that
only 22.5% supported PAD for terminal illness with enduring pain.
A great deal of research has revealed more conservative atti-
tudes toward PAD among medical professionals compared to the
general public. For example, Seale (2009) evaluated 3,733 U.K.
physicians’ attitudes toward PAD and compared them to a sample
of 1,080 members of the general public from the British Social
Attitudes Survey (using the same methodology). In the case of
PAD for terminal illness, 35.2% of physicians and 61.6% of the
public believed that PAD definitely or probably should be allow-
able under the law. For incurable, nonterminal illness, 21.7% of
physicians and 41.3% of the public agreed that PAD definitely or
probably should be allowed. Similarly, Lindblad et al. (2008)
surveyed Swedish physicians and found that 34% of the surveyed
physicians supported the legalization of PAD, while 39% opposed,
and 25% were “doubtful.” In a follow-up study, Lindblad, Löf-
mark, and Lynöe (2009) found that 73% of a sample of the
Swedish public were in favour of PAD, while 12% were opposed,
293
and 15% were undecided. In a Canadian study, Claxton-Oldfield
and Miller (2015) found relatively high levels of support for PAD
in a comparison of attitudes among hospice palliative care (HPC)
volunteers and the general public. Sixty-five percent of HPC
volunteers and 72% of the public supported the legalization of
PAD. Yet, 74% of HPC volunteers and 55% of the public still
preferred HPC for themselves over PAD if they were to become
terminally ill. Claxton-Oldfield and Miller’s (2015) findings sug-
gest that among those who would not take the option themselves,
many may still believe in an individual’s right to choose PAD.
Overall, support for PAD generally appears to be moderate in
the Western world, but a more comprehensive literature base is
necessary to accurately compare differences in attitudes between
nations, populations, occupations, and most notably, types of ill-
nesses. Despite the relevance of patient mental health status during
end-of-life care, psychologists are traditionally not directly in-
volved in the PAD process—a likely explanation as to why little
research has measured psychologists’ attitudes toward PAD. Thus,
Karesa and McBride’s (2016) investigation aids in addressing this
gap in the literature base.
Attitudes Toward Physician-Assisted Dying:
Methodological and Analytical Considerations
Measuring attitudes toward PAD remains important because of
potential future developments in the legal landscape, particularly
in nations where PAD is under legislative review or has recently
been legalized. It is imperative that the best practices for accurately
measuring these attitudes be determined and utilized in order to
maintain an accurate account of the stance held by the public and
professionals such as physicians or psychologists. In terms of
methodology, we value Karesa and McBride’s (2016) decision to
employ vignettes as a means of gauging psychologists’ attitudes
toward PAD for depicted patients with either terminal or mental
illness. It is clear, particularly to mental health professionals, that
there is great diversity both between and within mental illness.
Different forms of mental illness can involve different symptoms,
levels of impairment, and quality of life outcomes. Undoubtedly, a
patient who has suffered from treatment-refractory schizophrenia
for decades presents a less hopeful situation compared to a patient
only recently diagnosed with major depressive disorder. Simulta-
neously, individuals with the same illness classification may ex-
perience multiple different symptoms and outcomes. For instance,
two individuals diagnosed with schizophrenia may experience
entirely different symptoms, despite sharing the same diagnostic
label (American Psychiatric Association, 2013). While compelling
arguments have been made that it is ethically irresponsible to grant
PAD to any individual with mental illness, we posit that it is
inadequate to ask participants their attitudes toward PAD for the
mentally ill without first specifying the nature of a depicted pa-
tient’s quality-of-life status. Vignettes are the ideal approach for
broaching these sorts of sensitive social conversations, as they
simulate the complexities associated with the subject (Finch,
1987), thereby allowing us to approximate and understand the
nature of informed reactions to real-world scenarios (Schoenberg
& Ravdal, 2000). In the context of PAD, this sort of simulation can
foster consideration of the patient’s individual circumstances—not
only their type of illness, but their unique expression of the illness.
The vignette approach invites participants to make normative
294 DAVIDSON AND LYMBURNER
responses to a set of specific circumstances, rather than asking
them to make generalisations about a specific population (Finch,
1987). Thus, had more vignettes been employed, Karesa and
McBride’s (2016) findings may have demonstrated different levels
of support for PAD depending on the form of mental illness
depicted in the vignette.
Karesa and McBride’s (2016) investigation allows us to ascer-
tain basic information from their descriptive statistics; for instance,
participants clearly expressed greater support of PAD for the
terminal illness patient. However, a statistical comparison of atti-
tudes toward PAD for terminal illness versus mental illness on a
number of factors (e.g., willingness to support the client’s request,
ability to remain neutral, etc.), as well as tests for significant
differences between psychologists’ professional and personal
opinions regarding PAD, would have been more informative.
Inferential statistics confer a deeper understanding of the results,
and often new information that is unattainable through a glance at
the descriptive data.
Following the vignettes, Karesa and McBride (2016), asked
psychologists to offer their personal and professional opinions
concerning patient rights to refuse medical treatment and receive
assistance in dying. We question the degree of discriminant valid-
ity present between the constructs of personal and professional
opinions. Unfortunately, a scan of the literature did not reveal to us
any central explanation regarding usage of these constructs within
the context of attitudes research, nor serve to repeal our concerns.
Furthermore, only minor differences were observed between psy-
chologists’ personal and professional opinions. Thus, while it is
possible that the psychologists’ personal and professional opinions
simply align on these issues, it is unclear whether they were even
capable of compartmentalizing these different opinions. If attitudes
toward PAD are to be measured using the dichotomy of “personal
versus professional opinion,” the boundaries of these constructs
must be clearly defined for participants and readers alike. Supple-
menting this notion is the fact that a notable portion of the
psychologists expressed uncertainty or inability to remain profes-
sionally neutral when working with a client requesting PAD
(21.4% for the terminal illness vignette; 45.8% for the mental
illness vignette), thereby potentially discrediting their ability to
possess diverging personal and professional opinions. Overall, it is
our perspective that the data concerning psychologists’ opinions
on the rights to refuse medical treatment and receive assistance in
dying should be viewed tentatively, at least until clarification of
the boundaries constituting personal and professional opinions,
and how psychologists would be able to compartmentalize these
opinions during their response, are provided.
In finding low support of PAD for the mentally ill among the
surveyed psychologists, Karesa and McBride (2016) concluded
that this finding is unsurprising, given that PAD for the mentally
ill is not a frequently recognised practice. Infrequent recognition of
this practice may indeed inherently serve as a deterrent for ex-
pressing a supportive viewpoint toward PAD for the mentally ill.
However, it is also worth considering that, because psychologists
are indebted to the prevention of harm and the promotion of
vitality among their patients, posing the dilemma of granting a
PAD right to those with severe mental illness may yield more
positive results among populations less intimate with mental ill-
ness. If true, this phenomenon would mirror findings in the liter-
ature regarding oncologists’ generally lower support of PAD for
the terminally ill. Professional experience with mental illness is but
one of many factors that may influence attitudes toward PAD for
the mentally ill. We feel that it is vital to explore these factors
under the premise that mental illness is diverse, and that sweeping
judgments regarding its suitability for PAD should be transposed
with judgments based on individual patient circumstances.
Mental Illness and Physician-Assisted Dying:
Unique Implications
While general attitudes toward PAD have been measured ex-
tensively, little of this research evaluates attitudes toward PAD for
the mentally ill specifically. Karesa and McBride (2016) contribute
to the addressing of this gap, and their findings regarding higher
support for PAD in the case of terminal illness compared to mental
illness reflects a general trend observed in this limited literature
base (McCormack & Fléchais, 2012). For example, Bolt, Sni-
jdewind, Willems, van der Heide, and Onwuteaka-Philipsen
(2015) measured 1,456 Dutch physicians’ willingness to perform
PAD in cases of cancer, miscellaneous physical illness, mental
illness, dementia, and general tiredness of living. Clear discrepan-
cies arose regarding support for each illness: Cancer (85%), mis-
cellaneous physical illness (82%), early-stage dementia (40%),
mental illness (34%), advanced dementia (29 –33%), and being
tired of living (18 –27%). Similarly, Kouwenhoven et al. (2013)
compared attitudes toward PAD among Dutch physicians, nurses,
and the general public. They found that cancer with physical
symptoms received significantly more support for PAD (physi-
cians, 77%; nurses, 49%; public, 65%) compared to cancer without
physical symptoms (physicians, 37%; nurses, 36%; public, 39%).
Interestingly, severe chronic depression (physicians, 35%; nurses,
36%; public, 28%) received similar ratings to cancer without
physical symptoms.
Such findings demonstrate a clear distinction between terminal
and chronic illness with regard to professional and public support
for PAD. Thus, we posit that comparing attitudes toward PAD for
the terminally ill and the mentally ill does not provide an apt basis
for understanding the unique implications of patient psychopathol-
ogy in the PAD process. Foremost, participants asked to indicate
their attitudes toward PAD for both terminal and mental illness are
presented with a stark contrast in the urgency and futility of the
illnesses, which may manufacture decreased ratings of support of
PAD for mental illness, particularly among professionals who are
beholden to promoting mental health patients’ vitality and resil-
ience. A more informative comparison that could have been posed
to Karesa and McBride’s (2016) sample of psychologists would
have been one of attitudes toward PAD for those with chronic
mental illness versus those with chronic physical illness. In re-
moving terminality from the equation, comparing attitudes toward
PAD for these categories of illness allows for a more precise and
equitable measurement of the factors that may preclude or reduce
mental illness’ suitability for PAD. Given that the right to PAD for
terminally ill individuals has now been legislated in Canada and a
number of other countries, we suggest that a more pressing and
relevant focus for future research is on attitudes toward PAD for
nonterminal illnesses, including mental illness. We argue that there
exist three primary concerns related to both the legitimacy of a
request for PAD and key aspects of the Supreme Court of Can-
ada’s ruling: The severity of the illness in question, the rationality
 PHYSICIAN-ASSISTED DYING FOR THE MENTALLY ILL
of the patient, and prospects for treatment. It is these concerns that
specifically appear to divide support of PAD for the mentally ill.
The Question of Unbearable Psychological Suffering
Some opponents of PAD for the mentally ill believe that the
very act of comparing mental suffering to pain resulting from
failure of bodily functioning is depreciative of those suffering from
such physical debilitation (Cholbi, 2013). Others may contend that
psychological suffering is never truly unbearable, or that it is less
authentic than physical suffering (Cholbi, 2013; Dembo, 2013).
Certainly, it is true that physical suffering (e.g., being wheelchair-
bound) is more tangibly observable than mental suffering (Brown,
Elliott, & Paine, 2013; Cholbi, 2013). Thus, one might conclude
that no form of mental illness warrants equal or greater consider-
ation of access to PAD.
Despite some challenges in quantifying mental suffering, nu-
merous studies have observed poor quality of life outcomes in
patients with severe mental illness, and a strong relationship be-
tween increased severity of mental illness and reduced quality of
life (Rogers, Hengartner, Angst, Ajdacic-Gross, & Rössler, 2014;
Williams, Sands, Elsom, & Prematunga, 2015). Indeed, psycho-
logical health issues and disorders are the leading cause of dis-
ability in Canada (Canadian Mental Health Association, 2012;
Mental Health Commission of Canada, 2014). Furthermore, for
requests of PAD brought on by physical or terminal illness, mental
suffering still weighs heavily in physicians’ decisions to grant
requests (Dembo, 2010). Many advocates believe that patients
should be allowed to choose when to end their own lives, and that
they should be allowed to avoid unwanted distress, be it physical
or psychological (Appel, 2007).
Rationality in the Throes of Severe Mental Illness
Many stress that a desire for PAD resulting from psychopatho-
logical suffering is inherently irrational (Berghmans et al., 2013;
Cholbi, 2013; Dembo, 2010). Arguably, the sheer difficulty of
determining competence in patients with severe mental illness
weighs against the notion of granting these individuals the right to
PAD (Moskowitz, 1996). In many cases, mental illness distorts
judgment and increases the risk of miscommunication—a legiti-
mate, critical concern within the context of PAD (Brown et al.,
2013). Certainly, an individual in the throes of severe mental
illness may underestimate their treatment prospects (Appel, 2007),
and notably, many suicides do result from untreated, but presum-
ably treatable, mental illness (Berghmans et al., 2013).
On the other hand, many contend that if a request for PAD stems
from a thorough and realistic evaluation of one’s past, present, and
future life situation, and not purely from thought patterns caused
by a mental illness, then requesting PAD can be considered a
rational response (Berghmans et al., 2013; Dembo, 2010; Groene-
woud et al., 1997). Appel (2007) claims that the practitioner values
of maximizing autonomy and minimising suffering logically lend
themselves to competent, chronically mentally ill individuals as
well. It may be that that patients deserve an evaluation of their
competency to request PAD, as opposed to decisions resting on the
assumption that mental illness is invariably tied to an absence of
competence (Appel, 2007).
295
Treatment Prospects for Severe Mental Illness
Most cases of mental illness are treatable to some extent,
whereby therapy and/or medication often instill even a modicum
of hope for a better future (Berghmans et al., 2013). A potential
concern is that allowing PAD for the mentally ill would suppress
motivation to improve the quality of social and medical resources
for these patients (Dembo, 2013). Mental health professionals are
obligated to investigate the source of and treat issues causing
suicidal ideation. If a patient requests PAD due to unbearable
mental suffering, this obligation is at odds with professionals’
obligation to relieve patients’ suffering (Appel, 2007; Dembo,
2010). Some argue that even entertaining the option of PAD with
a mental health patient compromises a vital component of the
doctor-patient relationship—the prevention of demoralization and
the promotion of hope (Berghmans et al., 2013).
True as it may be that mental illness often occurs for a limited
duration, some forms of mental illness can severely and/or chron-
ically impair patients for many years (Cholbi, 2013). In select
cases, severe mental illness can be refractory to even the most
extreme methods of treatment (Dembo, 2010). Difficult as it may
be to conceive of granting PAD to one whose illness could be
remedied in the future, it is also distressing to imagine an individ-
ual with refractory mental illness who would feel forced to die in
solitude and fear (Dembo, 2010), or even one who dies naturally
after a lifetime of suffering in the hope of treatment. It is here that
the fundamental duty of mental health professionals is most im-
portant—is it possible that by refusing to support or administer
PAD, one would be committing the “harm” of prolonging the
irremediable suffering that these professionals are so indebted to
prevent (Dembo, 2010)?
Other Potential Influences on Attitudes Toward PAD
for the Mentally Ill
A variety of reasons may exist for both supporting and opposing
PAD for the mentally ill. Clear possibilities include general atti-
tudes toward PAD (i.e., PAD for terminal illness), as well as the
primary issues presented in the Canadian federal law: Namely, the
severity of the illness, the patient’s rationality, and treatment
prospects. These factors play a large role in determining attitudes
toward PAD for any form of illness, and are subject to greater
scrutiny in cases of mental illness. However, opinions on such a
complex issue undoubtedly are subject to more internalized influ-
ences. Religiosity, stigma toward mental illness, and level of
familiarity with mental illness are potential, but relatively unex-
plored influences on support of PAD for the mentally ill.
Religiosity. Numerous studies on attitudes toward PAD have
shown that there exists a negative correlation between religiosity
and support for PAD. This relationship has been observed among
several populations, such as mental health counselling students
(Bevacqua & Kurpius, 2013), undergraduates (Peacock, Heath, &
Grannemann, 2001), and physicians (McCormack, Clifford, &
Conroy, 2012), among others. Danyliv and O’Neill (2015) re-
viewed British Social Attitudes Survey data from 1983–2012 to
determine the role of religion in attitudes toward PAD and found
that general support for PAD increased over time, while religiosity
was the most significant predictor of opposition toward PAD in all
years analysed. Notably, these studies evaluated the relationship
296 DAVIDSON AND LYMBURNER
between religiosity and attitudes toward PAD on a general lev-
el—it is unknown whether this relationship differs for cases of
mental illness, although it is unlikely.
Stigma toward mental illness. In the past few decades, edu-
cation and public awareness regarding mental illness has greatly
increased, but social rejection of those with mental illness has
remained alarmingly stable (Angermeyer & Dietrich, 2006; Scho-
merus et al., 2012). While certain physical illnesses unfortunately
are subjected to stigma, stigma toward mental illness as a whole
tends to be more pronounced (Bahm & Forchuk, 2009; Chaudoir,
Earnshaw, & Andel, 2013; Corrigan et al., 2005). Prejudicial
attitudes can exist in virtually anyone, and a potential concern is
that these attitudes may influence decision making in the context
of PAD. Patients may feel coerced into accepting PAD as a
solution to pressure from family, friends, the health care system, or
society (Appel, 2007; Dembo, 2013). Stigma could cause exces-
sive justification for PAD in the case of mental illness, rather than
as a last resort (Biggs & Diesfeld, 1995), or, alternatively, it could
cause reduced support or administration of PAD due to beliefs that
the mentally ill deserve fewer rights (Werner, 2015). Within the
context of PAD, it may not be the case that quality of life
impairments among the mentally ill are given due consideration.
Familiarity with mental illness. It is unclear to what extent
familiarity with mental illness would relate to support of PAD for
the mentally ill. For example, mental health professionals have
joined both sides of the ethical debate. Those who are familiar with
mental illness may feel that mentally ill patients deserve the right
to PAD, but their experience may also influence greater caution
regarding the patient’s rationality, or increased hope regarding
treatment prospects. Moreover, it is important to note that famil-
iarity with mental illness is a broad concept. A psychologist’s
familiarity with mental illness could be considered a different form
of familiarity compared to an individual who has a relative with
mental illness, or compared to someone who has personally expe-
rienced severe mental illness.
Present Study
Similar to Karesa and McBride’s (2016) study, our research is
also vignette-based. However, given the arguments made earlier
with respect to the breadth of potential mental illnesses, as well as
appropriate comparison groups, we measured Canadian undergrad-
uates’ attitudes toward PAD for two mental illnesses (schizophre-
nia, depression) and one chronic physical illness (multiple sclero-
sis [MS]). MS was selected as a representation of chronic physical
illness due to its often severe impact on quality of life and daily
functioning. Schizophrenia and depression can also entail poor
health outcomes, and were selected to represent chronic mental
illness due to the frequency of which these disorders have been
compared in research studying attitudes toward mental illness
(Angermeyer & Dietrich, 2006). Depression and schizophrenia are
also rather different health conditions, often generating different
feelings surrounding illness severity and rationality, and thus
jointly represent some of the diversity of mental disorders. All
three depicted illnesses are comparable in the sense that they can
involve a range of mild to devastating quality-of-life impairments.
In the present study, participants read vignettes depicting individ-
uals who suffer severely from one of MS, schizophrenia, or de-
pression, and have requested PAD. Following each vignette, par-
ticipants indicated their level of support for granting PAD to the
patient depicted in the vignette, and responded to items designed to
gauge their rationale for their decisions. As such, we add relevant
data to studies such as Karesa and McBride’s (2016), and are able
to more directly address consistent findings of greater support of
PAD for physical illnesses. We additionally evaluated general
attitudes toward PAD, religiosity, stigma toward mental illness,
and familiarity with mental illness as potential predictors for
participants’ level of PAD support.
Based on the extant literature, it was hypothesised that partici-
pants would show greater support of PAD for physical illness
(MS) compared to mental illness (schizophrenia, depression). In
terms of rationale for participants’ decision, it was also hypoth-
esised that the mentally ill patients would be seen as experiencing
less suffering, rationality, and futility of treatment. It was expected
that general attitudes toward PAD (i.e., for terminal illness) would
predict higher support of PAD for each patient, with this relation-
ship strongest for the physical illness (MS). Religiosity was ex-
pected to predict lower levels of support for PAD. Stigma toward
mental illness was also expected to predict negative attitudes
toward PAD for mental illness, due to its tendency to cause beliefs
in the need for restricting or controlling the rights of the mentally
ill. Lastly, due to limited findings regarding support for PAD
among various levels of familiarity with mental illness (i.e., the
general public, medical experts, mental health experts), it was
unclear to what extent this construct would impact support of PAD
for the mentally ill within the same population. Overall, evaluating
these hypotheses provides greater insight as to how and why
people differentiate physical and mental illnesses with regard to
support for PAD.
Method
Design and Procedure
This study constituted a repeated measures design such that
participants indicated their level of support for PAD and rationale
for each depicted illness. Basic demographics, including age, gen-
der, and the number of years spent in postsecondary education
were collected online from an undergraduate student sample. All
participating students, at minimum, had completed or were in the
process of completing an introductory psychology course. Follow-
ing collection of demographics, participants read three randomly
ordered vignettes that depicted fictional individuals who suffer
from one of three illnesses—MS, schizophrenia, or depression—
and who have requested PAD. After reading each vignette, partic-
ipants indicated their level of support for PAD for the depicted
individual, as well as their rationale for their decision. To account
for participants who may select their primary rationale based on
the options located at the top of the list, we randomized the order
of items gauging participants’ rationale for their level of support
for PAD. In addition to the vignettes and vignette response items,
participants completed validated measures of general attitudes
toward PAD, religiosity, stigma toward mental illness, and famil-
iarity with mental illness in order to evaluate these factors as
potential predictors of the relationship between illness type and
level of support for PAD.
 PHYSICIAN-ASSISTED DYING FOR THE MENTALLY ILL
Measures
Vignettes and vignette response items. Participants read vi-
gnettes depicting a fictional man in his 50s with one of MS, schizo-
phrenia, or depression, and who suffered severe quality-of-life im-
pairments due to his illness. In each case, the patient had persistently
requested PAD during states of normal mental health and awareness
which were characterised by good judgment. Each patient had tried
the most common forms of treatment for each illness, as well as
last-resort methods of treatment, to no avail. Vignettes for each illness
were approximately the same length in words. Similar to the vignette
creation process of Karesa and McBride (2016), our schizophrenia
vignette is a heavily modified version of one created by Levy, Azar,
Huberfeld, Siegel, and Strous (2013). The MS and depression vi-
gnettes were constructed based on the modified schizophrenia
vignette in order to ensure comparability. In designing these vi-
gnettes, our intention was to connect distinct perceptions about
mental and physical illness to differences in level of support for
PAD for these illnesses. Thus, it was vital that the vignettes
describe cases of equally severe symptomatology and impact on
quality of life. Pilot tests were conducted to evaluate whether
participants viewed the three illnesses as having equal levels of
severity (rated on a scale from 1–10, where 1 ⫽ Not at all severe,
and 10 ⫽ Extremely severe), and to determine whether modifica-
tions were necessary to balance the vignettes. Results of the first
pilot test revealed significant mean differences between each of
three illnesses. After modifying the vignettes, a second pilot study
(n ⫽ 20) revealed no significant differences, F(2, 38) ⫽ 1.71, p ⫽
.19 between the vignettes in ratings of severity: MS (M ⫽ 8.7,
SEM ⫽ .22); schizophrenia (M ⫽ 8.2, SEM ⫽ .32); and depression
(M ⫽ 8.1, SEM ⫽ .28). The second iteration of the vignettes was
thus used for the present study.
Following each vignette, participants indicated the extent to which
they believed that the depicted individual should have the right to
PAD (1 ⫽ Not at all acceptable, 5 ⫽ Very acceptable). In order to
gauge rationale for their decision, participants then rated their level of
agreement with the following factors (1 ⫽ Strongly disagree, 5 ⫽
Strongly agree): (a) Whether the illness was severe enough for PAD;
(b) Whether the individual was capable of rationally requesting PAD;
(c) Whether the illness could still respond to treatment; (d) Whether
the individual would be a burden on their family and friends should
they continue to live; and (e) Whether the individual’s quality of life
was likely to improve. The first two rationale-based items were
derived loosely from items created by Westefeld, Sikes, Ansley, and
Yi (2004). The remaining items were created to provide a broader set
of options when indicating rationale for the PAD decision.
Euthanasia Support Questionnaire (ESQ; Ho, 1998). The
voluntary euthanasia factor of the ESQ was used to measure
general attitudes toward PAD. Participants read brief statements
about the right to make decisions concerning life and death and
indicated their agreement with each statement. The ESQ’s 6-item
voluntary euthanasia factor is highly reliable (Cronbach’s alpha ⫽
.87), with moderate item-total correlations (.68 –.76, with one
item at .51; Ho, 1998). High internal consistency for the vol-
untary euthanasia factor was maintained in the present study as
well, ␣ ⫽ .88.
Duke University Religious Index (DUREL; Koenig, Parker-
son, & Meador, 1997). The DUREL’s 3-item intrinsic religios-
ity subscale was used to measure the degree to which participants
297
integrate religion into their life. Past psychometric evaluations of
the DUREL have revealed high internal consistency (Cronbach’s
alpha ⫽ .78 and .91), as well as high convergent validity with other
measures of religiosity (r ⫽ .71–.86; Koenig & Büssing, 2010;
Storch et al., 2004). In the present study, internal consistency was
high, ␣ ⫽ .92.
Opening Minds Stigma Scale for Health Care Providers
(OMS-HC; Kassam, Papish, Modgill, & Patten, 2012). We
used the 12-item variant of the OMS-HC to discriminate between
positive and negative dispositions toward the mentally ill. Al-
though the OMS-HC was designed to measure stigma toward
mental illness among various health care providers, we deemed its
items appropriately answerable by a student population. The scale
itself was tested at various levels of health care experience and
knowledge (e.g., medical student, social worker, physician), indi-
cating some flexibility for the responding population. Minor word-
ing changes were necessary for one item in order to adapt the scale
for an undergraduate sample. The 12-item OMS-HC measures two
factors of stigma toward: (a) People with mental illness and (b)
Disclosure of mental illness. Internal consistency reliability esti-
mates for the 12-item version revealed acceptable coefficients for
the tested populations (Cronbach’s alpha ⫽ .73–.74; Modgill,
Patten, Knaak, Kassam, & Szeto, 2014). For the present study’s
sample, ␣ ⫽ .73.
Level-of-Contact Report (Holmes, Corrigan, Williams, Ca-
nar, & Kubiak, 1999). Using a rank-order scoring system, the
12-item Level-of-Contact Report assessed level of exposure to
severe mental illness. During the measure’s development, three
experts on psychiatric disability ranked the items in terms of
intimacy of contact to determine the weight of each item (Holmes
et al., 1999). Among these raters, the mean of rank order correla-
tions summarising interrater reliability was .83.
Statistical Analyses
All analyses were completed using the Statistical Package for
the Social Sciences (SPSS) 22.0. A repeated measures MANOVA
was conducted to evaluate pairwise mean differences between
each illness on the measures of support for PAD, as well as the five
“rationale” items (e.g., whether the illness was perceived as treat-
able), for a total of six dependent variables. In addition, multiple
linear regression analyses aided in determining which measured
variables predict attitudes toward level of support for PAD (the
outcome variable). These potential predictors included the five
rationale items, as well as scale/subscale scores from the ESQ,
DUREL, OMS-HC, and Level-of-Contact Report. An a priori
power analysis was conducted using GⴱPower 3.1 to determine
necessary sample sizes for a standard alpha level (␣ ⫽ .05), a
medium effect size (f2 ⫽ .15), high statistical power (1 ⫺ ␤ ⫽
.95), and 12 predictors. With these parameters, power analysis
indicated a sample size of n ⫽ 182 would be required for regres-
sion analyses, and a lower sample size was required for the
MANOVA procedure. Two predictors were removed from the
final regression models.
Results
A total of n ⫽ 201 undergraduate students completed the survey.
The mean age of participants was M ⫽ 21.64 (SD ⫽ 4.16) and the
298 DAVIDSON AND LYMBURNER
sample was predominantly female (n ⫽ 164; 81.6%). The sample
could be described as moderately religious overall, with an average
score of M ⫽ 7.96 (on a range of 3–15), and a fairly even
distribution of scores across this range. Most students were at an
early stage of their postsecondary education: First year of postsec-
ondary education, n ⫽ 90 (44.8%); second year, n ⫽ 47 (23.4%);
third year n ⫽ 38 (18.9%); fourth year, n ⫽ 20 (10%); fifth year
or later, n ⫽ 6 (3%).
MANOVA Analysis
Due to limitations in how SPSS responds to missing data in its
analyses, a total of n ⫽ 190 participants were included in the
repeated measures MANOVA procedure. Analyses of Shapiro-
Wilk tests indicated violations of the assumption of normality for
each variable. However, the Shapiro-Wilk test is more suitable for
small sample sizes, and is hypersensitive to small deviations from
normality when used in larger samples.
In line with the pilot data, vignettes were rates as equal in
severity (F(2, 398) ⫽ 2.68, p ⫽ .07. Descriptive statistics for
support of PAD are provided in Table 1, while Table 2 displays the
results of the MANOVA analysis. Mean ratings for support of
PAD across the illnesses were as follows: MS (M ⫽ 3.49, SEM ⫽
.08); schizophrenia (M ⫽ 3.12, SEM ⫽ .08); and depression (M ⫽
2.71, SEM ⫽ .08). MANOVA analysis with a Greenhouse-Geisser
correction determined that level of support for PAD significantly
differed based on the type of illness depicted, F(1.87, 353.52) ⫽
57.49, p ⬍ .001, ␩2 ⫽ .23. There were also significant differences
in rationale for support of PAD across the illnesses: Whether the
illness was severe enough for PAD (Greenhouse-Geisser cor-
rected), F(1.92, 362.97) ⫽ 48.56, p ⬍ .001, ␩2 ⫽ .2; whether the
patient was rational enough to request PAD, F(2, 378) ⫽ 61.51,
p ⬍ .001, ␩2 ⫽ .25; whether the illness would likely respond to
treatment, F(2, 378) ⫽ 32.09, p ⬍ .001, ␩2 ⫽ .15; whether the
patient would be a burden on family/friends if they continued to
live, F(2, 378) ⫽ 40.25, p ⬍ .001, ␩2 ⫽ .18; and on whether the
patient’s quality of life was likely to improve, F(2, 378) ⫽ 57.08, p ⬍
.001, ␩2 ⫽ .23. Using the Bonferroni method, pairwise comparisons
of the mean differences between illnesses (see Table 3) revealed
significant differences for all possible comparisons on each item,
with one exception: The schizophrenia and depression patients did
not significantly differ with regards to how rational they were
perceived to be, p ⫽ .45.
Regression Analyses
Multiple sclerosis. A total of n ⫽ 192 participants were
included in the MS regression model (see Table 4). The entered set
of predictors significantly predicted support of PAD for MS, F(10,
Table 1
Descriptive Statistics: Level of Support for PAD Across Illnesses
Illness (n ⫽ 200) 1 2
Multiple Sclerosis 12 (6%) 25 (12.5%)
Schizophrenia 19 (9.5%) 39 (19.5%)
Depression 27 (13.5%) 55 (27.5)
Note. PAD ⫽ Physician-assisted dying; 1 ⫽ Strongly Disagree; 5 ⫽ Strongly Agree.
180) ⫽ 55.8, p ⬍ .001, R2 ⫽ .76. Four significant predictors were
found for support of PAD: Whether participants thought the illness
was severe enough for PAD, ␤ ⫽ .62, t ⫽ 10.08, p ⬍ .001;
whether participants thought the patient would be a burden on their
family/friends, ␤ ⫽ .13, t ⫽ 2.94, p ⬍ .01; intrinsic religiosity,
␤ ⫽ ⫺.09, t ⫽ ⫺2.22, p ⬍ .05; and level of contact with mental
illness, ␤ ⫽ ⫺0.1, t ⫽ ⫺2.53, p ⬍ .05.
Schizophrenia. A total of n ⫽ 190 participants were included
in the schizophrenia regression model (see Table 5). The entered
predictors significantly predicted support of PAD for schizophre-
nia as well, F(10, 179) ⫽ 57.38, p ⬍ .001, R2 ⫽ .76. Four
significant predictors were found for support of PAD for schizo-
phrenia: Whether participants thought the illness was severe
enough for PAD, ␤ ⫽ .58, t ⫽ 8.88, p ⬍ .001; whether participants
thought the patient could rationally request PAD, ␤ ⫽ .09, t ⫽
1.05, p ⬍ .05; whether participants thought the illness would
respond to treatment, ␤ ⫽ ⫺0.14, t ⫽ ⫺2.26, p ⬍ .05; and whether
participants thought the patient would be a burden on their family/
friends, ␤ ⫽ .1, t ⫽ 2.2, p ⬍ .05.
Depression. Finally, n ⫽ 187 participants were included in
the regression model for depression (see Table 6). Once again, the
entered set of predictors significantly predicted support of PAD for
depression, F(10, 176) ⫽ 59.29, p ⬍ .001, R2 ⫽ .77. Six signifi-
cant predictors were found for level of PAD support for depres-
sion: Whether participants thought the illness was severe enough
for PAD, ␤ ⫽ .43, t ⫽ 7.1, p ⬍ .001; whether participants thought
the patient could rationally request PAD, ␤ ⫽ .18, t ⫽ 3.61, p ⬍
.001; whether participants thought the illness would respond to
treatment, ␤ ⫽ ⫺0.15, t ⫽ ⫺2.97, p ⬍ .01; whether participants
thought the patient would be a burden on their family/friends, ␤ ⫽
.11, t ⫽ 2.53, p ⬍ .05; general attitudes toward PAD, ␤ ⫽ .13, t ⫽
2.68, p ⬍ .01; and intrinsic religiosity, ␤ ⫽ ⫺0.09, t ⫽ ⫺2.13, p ⬍
.05.
Discussion
Support for PAD was greatest for the MS patient, followed by
the schizophrenia patient, followed by the depression patient, thus
supporting the primary hypothesis that support would be greater
for physical illness compared to mental illness. In line with our
second hypothesis, rationale for support of PAD followed a similar
trend, such that the MS patient’s condition was perceived as
distinctly severe enough to warrant PAD, as well as involving
more rationality and futility of treatment compared to the schizo-
phrenia and depression patients. Interestingly, participants per-
ceived the schizophrenia and depression patients to be equally
rational/irrational, perhaps suggesting that across the spectrum of
mental disorders, the implications of impaired judgment were clear
to participants. In terms of other reasons given in support of PAD,
3 4 5
52 (26%) 78 (39%) 33 (16.5%)
63 (31.5%) 59 (29.5%) 20 (10%)
77 (38.5%) 30 (15%) 11 (5.5%)
 PHYSICIAN-ASSISTED DYING FOR THE MENTALLY ILL 299

Table 2
MANOVA Results: Effects of Illness Type on Support for PAD and Rationale for Support

Measure Illness M (SD) SEM 95% CI (U, L) F ␩2

Support for PAD 57.49ⴱⴱⴱ .23

MS 3.49 (1.09) .08 (3.33, 3.65)
Sch 3.12 (1.13) .08 (2.95, 3.28)
Dep 2.71 (1.05) .08 (2.56, 2.86)
Illness is severe enough for PAD 48.56ⴱⴱⴱ .2
MS 3.52 (1.11) .08 (3.36, 3.67)
Sch 3.20 (1.15) .08 (3.04, 3.36)
Dep 2.75 (1.10) .08 (2.59, 2.91)
Patient is rational enough for PAD 61.51ⴱⴱⴱ .25
MS 3.83 (.89) .06 (3.71, 3.96)
Sch 3.06 (1.11) .08 (2.90, 3.22)
Dep 2.94 (1.13) .08 (2.78, 3.10)
Illness will respond to treatment in future 32.09ⴱⴱⴱ .15
MS 2.75 (.95) .07 (2.62, 2.89)
Sch 2.97 (1.03) .08 (2.82, 3.12)
Dep 3.35 (.95) .07 (3.21, 3.48)
Patient likely a burden on family/friends 40.25ⴱⴱⴱ .18
MS 2.83 (1.17) .09 (2.66, 3.00)
Sch 2.63 (1.22) .09 (2.45, 2.80)
Dep 2.20 (.99) .07 (2.05, 2.34)
Quality of life is likely to improve 57.08ⴱⴱⴱ .23
MS 2.58 (.98) .07 (2.44, 2.72)
Sch 2.81 (1.05) .08 (2.65, 2.96)
Dep 3.36 (.94) .07 (3.23, 3.50)
Note. PAD ⫽ Physician-assisted dying; MS ⫽ multiple sclerosis; Sch ⫽ schizophrenia; Dep ⫽ depression; CI ⫽ confidence interval.
ⴱⴱⴱ
p ⬍ .001.

the schizophrenia patient’s condition was viewed as distinctly
severe enough to warrant PAD, less likely to respond to treatment,
more likely to be a burden on family/friends, and less likely to
involve improvements in quality of life compared to depression.
Our third hypothesis that general attitudes toward PAD, religi-
osity, stigma toward mental illness, and familiarity with mental
illness would predict support for PAD was only partially sup-
ported. Notably, stigma toward and level of contact with mental
illness did not predict support of PAD for schizophrenia and
depression. Thus, in this study’s sample, internalized beliefs de-
rived from experiences outside of personal prejudices/contact ap-
pear to have contributed more to support of PAD for the mentally

Table 3
MANOVA Results: Pairwise Comparisons Between Illnesses

Illness Illness Mean Diff.

Measure 1 (I) 2 (J) (I ⫺ J) SEM 95% CI (U, L)
ⴱⴱⴱ
Level of PAD support MS Sch .37 .08 (.18, .56)
MS Dep .78ⴱⴱⴱ .08 (.60, .97)
Sch Dep .41ⴱⴱⴱ .06 (.26, .56)
Illness is severe enough for PAD MS Sch .32ⴱⴱⴱ .08 (.12, .51)
MS Dep .77ⴱⴱⴱ .08 (.57, .97)
Sch Dep .45ⴱⴱⴱ .07 (.28, .62)
Patient is rational enough for PAD MS Sch .77ⴱⴱⴱ .09 (.56, .99)
MS Dep .90ⴱⴱⴱ .09 (.68, 1.11)
Sch Dep .12 .08 (⫺.08, .32)
Illness likely to respond to treatment in the future MS Sch ⫺.22ⴱ .08 (⫺.40, ⫺.03)
MS Dep ⫺.6ⴱⴱⴱ .08 (⫺.78, ⫺.41)
Sch Dep ⫺.38ⴱⴱⴱ .07 (⫺.55, ⫺.20)
Patient likely a burden on family/friends MS Sch .21ⴱ .07 (.04, .37)
MS Dep .64ⴱⴱⴱ .08 (.45, .83)
Sch Dep .43ⴱⴱⴱ .07 (.26, .60)
Quality of life is likely to improve MS Sch ⫺.22ⴱ .08 (⫺.40, ⫺.04)
MS Dep ⫺.78ⴱⴱⴱ .08 (⫺.97, ⫺.59)
Sch Dep ⫺.56ⴱⴱⴱ .07 (⫺.73, ⫺.38)
Note. PAD ⫽ Physician-assisted dying; MS ⫽ multiple sclerosis; Sch ⫽ schizophrenia; Dep ⫽ depression;
CI ⫽ confidence interval.
ⴱ
p ⬍ .05. ⴱⴱⴱ p ⬍ .001.
300 DAVIDSON AND LYMBURNER

Table 4
Multiple Regression Results: Predictors of Support for PAD for Multiple Sclerosis

Predictor B SEB ␤ t 95% CI (U, L)

ⴱⴱⴱ
Believing patient’s illness is severe enough for PAD .61 .06 .62 10.08 (.49, .73)
Believing patient is rational enough for PAD .08 .06 .07 1.40 (⫺.03, .19)
Believing patient’s illness will be treatable in future ⫺.03 .07 ⫺.02 ⫺.36 (⫺.16, .11)
Believing patient will be a burden on family/friends if they continue to live .12 .04 .13 2.94ⴱⴱ (.04, .20)
Believing patient’s quality of life will improve if they continue to live ⫺.08 .07 ⫺.07 ⫺1.18 (⫺.22, .06)
General PAD attitude .02 .01 .09 1.69 (⫺.003, .04)
Intrinsic religiosity ⫺.02 .01 ⫺.09 ⫺2.22ⴱ (⫺.05, ⫺.003)
Stigma towards people w/mental illness ⫺.01 .01 ⫺.04 ⫺1.01 (⫺.04, .01)
Stigma towards mental illness disclosure .004 .01 .01 .31 (⫺.02, .03)
Level of contact w/mental illness ⫺.04 .01 ⫺.10 ⫺2.53ⴱ (⫺.06, ⫺.01)
Note. Model summary: F(10, 180) ⫽ 55.8, p ⬍ .001, R2 ⫽ .76. PAD ⫽ Physician-assisted dying.
ⴱ
p ⬍ .05. ⴱⴱ p ⬍ .01. ⴱⴱⴱ p ⬍ .001.

ill. Surprisingly, increased intrinsic religiosity predicted lower
support of PAD for MS and depression, but not schizophrenia. It
seems unlikely that those with strong religious beliefs would
condemn PAD for some illnesses but permit it for others. Thus,
this finding would require replication to determine its validity.
Another finding requiring further investigation is that general
attitudes toward PAD only predicted support of PAD for depres-
sion.
Karesa and McBride (2016) found low support of PAD for
the patient in their mental illness vignette, though 28.9% of the
surveyed psychologists were neutral or supported PAD for the
patient. Considering that PAD for the mentally ill is rarely up
for discussion, they were unsurprised with this finding. Build-
ing on this argument, we suggested that psychologists’ experi-
ences with and duty to prevent harm to mentally ill patients
likely served as an additional barrier to supporting PAD for the
patient in the vignette. Naturally, our undergraduate sample is
collectively less experienced with mentally ill individuals than
Karesa and McBride’s (2016) sample of psychologists, which
may partially explain why support of PAD for mentally ill
patients was comparatively more moderate in the present study.
However, we hold a similar conclusion to Karesa and McBride
(2016)—while participants in the present study were asked to
respond specifically to the depicted individuals’ symptomatol-
ogy, preconceptions about and traditional practices involving
each illness likely still coloured their perceptions of each pa-
tient’s personal condition within the context of PAD. The
finding that stigma did not impact our participants’ decisions
perhaps indicates that these preconceptions were not necessar-
ily prejudicial in nature. For example, although schizophrenia is
often correctly perceived as a more debilitating and less treat-
able illness than depression, this generalisation does not hold
true for all individual cases. When asked to rate the severity of
each patient’s particular illness on a scale from 1–10, ratings
between the illnesses did not differ significantly. Yet, when
asked whether the illness was severe enough to warrant PAD,
differences in ratings did occur. This discrepancy suggests that
individuals may be relying more on internalized schemas for
each illness, rather than the specific facts associated with each
patient’s personal condition. If true, reliance on said internal-
ized schemas serves as an additional barrier to encouraging
participants to focus on patient-specific circumstances con-
veyed in the vignettes.
Collectively, the results suggest that participants viewed MS,
schizophrenia, and depression as distinct entities with regard to
support for PAD. Participants were more likely to support PAD
for physical illness than mental illness. However, it was also
clear that participants neither condemned the notion of extend-
ing PAD to mental illness as a whole, nor treated the two mental
illnesses alike with regard to rationale for support of PAD.
While the Angus Reid Institute (2016) poll found support of
PAD for the mentally ill to be generally low, the present study

Table 5
Multiple Regression Results: Predictors of Support for PAD for Schizophrenia

Predictor B SEB ␤ t 95% CI (U, L)

Believing patient’s illness is severe enough for PAD .57 .06 .58 8.89ⴱⴱⴱ (.44, .69)
Believing patient is rational enough for PAD .01 .05 .09 2.05ⴱ (.003, .19)
Believing patient’s illness will be treatable in future ⫺.14 .06 ⫺.13 ⫺2.26ⴱ (⫺.27, ⫺.02)
Believing patient will be a burden on family/friends if they continue to live .09 .04 .10 2.20ⴱ (.01, .18)
Believing patient’s quality of life will improve if they continue to live ⫺.01 .06 ⫺.01 ⫺.22 (⫺.14, .11)
General PAD attitude .02 .01 .09 1.75 (⫺.003, .05)
Intrinsic religiosity ⫺.01 .01 ⫺.05 ⫺1.10 (⫺.03, .01)
Stigma towards people w/mental illness ⫺.02 .01 ⫺.05 ⫺1.18 (⫺.04, .01)
Stigma towards mental illness disclosure .004 .01 .01 .31 (⫺.02, .03)
Level of contact w/mental illness .01 .01 .02 .45 (⫺.02, .04)
Note. Model summary: F(10, 179) ⫽ 57.38, p ⬍ .001, R2 ⫽ .76. PAD ⫽ Physician-assisted dying.
ⴱ
p ⬍ .05. ⴱⴱⴱ p ⬍ .001.
 PHYSICIAN-ASSISTED DYING FOR THE MENTALLY ILL 301

Table 6
Multiple Regression Results: Predictors of Support for PAD for Depression

Predictor B SEB ␤ t 95% CI (U, L)

ⴱⴱⴱ
Believing patient’s illness is severe enough for PAD .42 .06 .43 7.10 (.30, .53)
Believing patient is rational enough for PAD .17 .05 .18 3.61ⴱⴱⴱ (.08, .26)
Believing patient’s illness will be treatable in future ⫺.17 .06 ⫺.15 ⫺2.96ⴱⴱ (⫺.29, ⫺.06)
Believing patient will be a burden on family/friends if they continue to live .12 .05 .11 2.53ⴱ (.03, .22)
Believing patient’s quality of life will improve if they continue to live ⫺.10 .06 ⫺.08 ⫺1.63 (⫺.21, .2)
General PAD attitude .30 .01 .13 2.68ⴱⴱ (.01, .05)
Intrinsic religiosity ⫺.02 .01 ⫺.09 ⫺2.13ⴱ (⫺.04, ⫺.01)
Stigma towards people w/mental illness .001 .01 .003 .95 (⫺.02, ⫺.02)
Stigma towards mental illness disclosure .001 .01 .003 .09 (⫺.02, .02)
Level of contact w/mental illness .01 .01 .01 .37 (⫺.02, .03)
Note. Model summary: F(10, 176) ⫽ 59.29, p ⬍ .001, R2 ⫽ .77. PAD⫽ Physician-assisted dying.
ⴱ
p ⬍ .05. ⴱⴱ p ⬍ .01. ⴱⴱⴱ p ⬍ .001.

found support that could be described as low-to-moderate,
which may suggest that individuals are slightly more open to
PAD for the mentally ill when faced with specific, severe cases.
On the other hand, the sample used in the present study con-
sisted primarily of young adults, a group that tends to show
more positive attitudes toward PAD. In the present study,
variations were found between illnesses in predictors of support
for PAD. For example, it appears that more factors were con-
sidered when determining level of support for PAD for depres-
sion, perhaps suggesting that the decision regarding the depres-
sion patient was more difficult. In light of these findings, future
research on this subject would do well to recognise the unique
implications of PAD for specific mental illnesses, in addition to
those surrounding PAD for the mentally ill as a whole.
Limitations
Due to limitations in resources and contacts, we collected
data from undergraduate students, though we also see merit in
collecting data from physicians and/or psychiatrists, and share
Karesa and McBride’s (2016) values regarding obtaining psy-
chologists’ unique perspectives on PAD for the mentally ill.
Our sample of undergraduate students served as a proxy for the
general public, and future related studies would benefit from a
more precise assessment of the general public’s thoughts on this
issue. Furthermore, a topic as provocative as PAD may have
caused participants to concede to the social desirability bias or
other demand characteristics, although collecting data online
may have reduced the presence of these demand characteristics,
as participants may have felt more confident behind the veil of
increased anonymity. However, performing online data collec-
tion is a limitation in itself, as having less control over the
survey completion process adversely allows participants to con-
sult with online resources or family members during survey
completion, and so forth. Perhaps the greatest limitation of this
study is that the employed vignettes represent a small handful
of different illnesses, and merely individual expressions of said
illnesses. Karesa and McBride’s (2016) research manages a
similar issue in their usage of two vignettes to represent termi-
nal and mental illness. Yet, PAD is not a procedure based
purely off diagnostic classification of the illness, but rather one
that must also account for the patient’s personal quality-of-life
status, competence, and prospects for the future. Thus, despite
potential response bias resulting from preconceived stereotypes
for each illness, and limitations in generalizability inherent to
the vignette approach, vignettes describing individual patients
remain the most realistic and fair method of evaluating attitudes
toward PAD.
Looking Forward
While an abundance of research has measured attitudes to-
ward PAD among the public, as well as psychiatrists and other
physicians, little research has assessed the opinions of psychol-
ogists, perhaps due to their general lack of direct involvement
with PAD. Karesa and McBride (2016) take an early step in
addressing this gap, but a larger literature base on this subject
would be required to make an informed judgment on psychol-
ogists’ attitudes toward PAD for the mentally ill. The nature of
psychotherapy differs from other medical treatments in the
degree of rapport needed between caregiver and patient (Appel,
2007). Psychologists are highly intimate with mental illness—
arguably more so than any other profession. Thus, while the
opinions of the public and medical experts are undoubtedly
useful, psychologists’ opinions on this issue hold unique value.
It would be particularly advantageous to directly compare the
attitudes of mental illness experts (psychologists) to those of the
general public, and those of individuals who have the greatest
potential to be involved with or perform PAD (physicians).
Collectively, sampling from these populations would provide a
great breadth of information on attitudes toward PAD for the
mentally ill. Future research assessing attitudes toward a wider
range of illnesses would paint a more accurate picture of how
and why people differentiate physical and mental illness with
regard to support for PAD. There is great diversity between and
within mental illnesses, and thus the present study serves a
secondary purpose of instigating more comprehensive investi-
gations of the subject—particularly in Canada and other nations
that will consider extending a PAD right to the mentally ill in
the future.
Conclusion
Any changes to civil rights—particularly those that involve
life and death—warrant analysis to determine public opinion.
302 DAVIDSON AND LYMBURNER
Karesa and McBride (2016) opened an important door in re-
searching Canadian psychologists’ attitudes toward a PAD right
for mentally ill individuals. The present study also addresses a
large gap in the literature base concerning attitudes toward PAD
for the mentally ill, and is one of few studies to investigate
specific rationales for support of PAD. Such combined research
efforts aid us in gaining further insight into how people differ-
entiate physical and mental illnesses, as well as adding to the
literature examining factors that affect perceptions toward men-
tal illness. Our study suggests that people view PAD as less
warranted for those with mental illness, due to perceptions that
these illnesses are not severe enough, involve less rationality,
and are less futile compared to physical illness. Furthermore,
the results suggest that people may rely more on internalized
schemas about mental illness as opposed to patient-specific
facts when forming opinions/making decisions regarding PAD.
It is of the utmost importance that patients with mental illness
retain maximum autonomy and endure minimal suffering. Mea-
suring opinions on this topic contributes to the discussion of
whether allowing PAD for the mentally ill aids in the preser-
vation of these values. While neither positive nor negative
attitudes toward PAD for the mentally ill are inherently incor-
rect, mental illness is highly misunderstood and stigmatized by
the public. Thus, if public opinion is influencing the contexts
surrounding PAD for the mentally ill (decisions, referrals, etc.),
it is important to determine whether these attitudes are formed
for compassionate, well-informed reasons. Attaining a greater
understanding of the rationales that inform end-of-life decisions
for the mentally ill brings us closer to ensuring fair treatment
for all who suffer.
Résumé
En juin 2016, le Canada se joignait à une poignée de nations ayant
légalisé l’aide médicale à mourir. Or, étant donné que la loi
restreint le recours à l’aide médicale à mourir aux malades en
phase terminale, plusieurs luttent pour obtenir le droit à l’aide
médicale à mourir dans les cas de maladie chronique invalidante,
y compris mais sans s’y limiter, les maladies mentales graves. La
présente analyse sert à évaluer et à poursuivre la discussion de
l’aide médicale à mourir au Canada pour les personnes souffrant
de maladies mentales, tel qu’introduite par Karesa and McBride
(2016), à présenter et comparer les résultats de nos propres recher-
ches et à favoriser un discours continu de pensées à ce sujet.
Karesa and McBride (2016) ont sondé des psychologues concer-
nant un rôle éventuel qu’ils pourraient exercer au niveau du
processus de l’aide médicale à mourir ainsi que sur leurs attitudes
vis-à-vis l’aide médicale à mourir. Nous évaluons leur méthodolo-
gie et leurs observations en proposant des façons selon lesquelles
les futures enquêtes au niveau de l’attitude des psychologues
envers l’aide médicale à mourir pourrait être améliorée. Ayant mis
en œuvre ces suggestions, notre propre étude a analysé les attitudes
de n⫽201 étudiants canadiens de premier cycle vis-à-vis l’aide
médicale à mourir par rapport à deux maladies mentales (schizo-
phrénie, dépression) en comparaison avec l’aide médicale à mourir
liée à une maladie physique (sclérose en plaques). À l’aide d’un
schéma de mesures répétitives, les participants étaient invités à lire
des vignettes représentant des individus souffrant gravement de la
sclérose en plaques, de la schizophrénie ou de la dépression.
Conformément aux hypothèses primaires, les personnes souffrant
de schizophrénie et de dépression ont reçu les plus faibles niveaux
de soutien relativement à l’aide médicale à mourir, étant perçues
comme étant assujetties à moins de souffrances, de rationalité et de
traitements inutiles en comparaison avec les personnes souffrant
de sclérose en plaques. Notre étude apporte des éléments supplé-
mentaires sur les façons selon lesquelles les gens distinguent les
maladies mentales et physiques. Notre discussion ajoute également
une perspective canadienne à un sujet urgent, qui jusqu’à mainte-
nant, n’a pas fait l’objet d’enquêtes approfondies.
Mots-clés : aide médicale à mourir, maladie mentale, schizophré-
nie, dépression, sclérose en plaques.
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Received February 1, 2017
Accepted February 13, 2017 䡲
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