Capacity Evaluations of Psychiatric Patients Requesting Assisted Death in the Netherlands

Abstract

Objective Euthanasia or physician-assisted suicide (EAS) of psychiatric patients is legal in some countries but remains controversial. This study examined a frequently raised concern about the practice: how physicians address the issue of decision-making capacity of persons requesting psychiatric EAS. Methods A review of psychiatric EAS case summaries published by the Dutch Regional Euthanasia Review Committees. Directed content analysis using a capacity-specific 4 abilities model (understanding of facts, applying those facts to self, weighing/reasoning, and evidencing choice) was used to code texts discussing capacity. 66 cases from 2011-2014 were reviewed. Results In 55% (36 of 66) of cases the capacity-specific discussion consisted of only global judgments of patients’ capacity, even in patients with psychotic disorders. 32% (21 of 66) of cases included evidentiary statements regarding capacity-specific abilities; only 5 cases (8%) mentioned all four abilities. Physicians frequently stated that psychosis or depression did or did not impact capacity but provided little explanation regarding their judgments. Physicians in 8 cases (12%) disagreed about capacity; even when no explanation is given for the disagreement, the review committees generally accepted the judgment of the physician performing EAS. In one case, the physicians noted that not all capacity-specific abilities were intact but deemed the patient capable. Conclusion Case summaries of psychiatric EAS in the Netherlands do not show that a high threshold of capacity is required for granting EAS. Although this may reflect limitations in documentation, it likely represents a practice that reflects the normative position of the review committees.

Technology for Our Future? Exploring the Duty to Report and Processes of Subjectification Relating to Digitalized Suicide Prevention

“…Such a conflict or dynamic between alleviating suffering and preventing harm by suicide is also visible in the Dutch policy and mental health context, where, on the one hand, suicide is high on the political agenda but, on the other hand, in cases of unbearable suffering that cannot be treated anymore in the opinion of psychiatrists physician-assisted suicide is allowed also for people with mental illnesses [39][40][41]. A recent newspaper article has suggested that psychiatrists in particular, compared to other physicians, are very reluctant to participate in euthanasia, even when they acknowledge unbearable suffering, with people with psychiatric illnesses who have a death wish more likely to seek help with the Dutch End of Life Clinic ('Levenseindekliniek'), compared to people with for instance terminal cancer or dementia who are more likely to be helped through routes other than this 'last resort' [42].…”

“…Leeman argues that psychiatrists owe it to their patients to treat each of their situations as unique, thus not immediately dismissing every case of suicidal ideation as irrational (see also Hewitt 2010). Interestingly however, recent evidence on capacity evaluations of psychiatric patients in the Netherlands who request euthanasia points to an opposite trend, where psychiatrists presume capacity (and thus rationality) despite evidence of a mental illness present that could cloud a patient's judgment [39].…”

Physician Aid-in-Dying: Practical Considerations

“…These statistics raise questions regarding the role of psychiatrists in administering voluntary active euthanasia or physician aidin-dying and the evaluation of capacity, because a large number of the physicians who administered voluntary active euthanasia were psychiatrists and less than half of the case subjects with a psychiatric diagnosis had a second opinion from a psychiatrist. Another review of these same 66 case subjects concluded that there was no evidence of a mandatory high threshold of patient capacity before administration of euthanasia (14). Documentation of capacity-specific criteria among these case subjects has shown that 55% demonstrated global assertion of capacity and 46% had at least one capacity-specific ability (e.g., understanding information, ability to reason, or appreciation of the consequences to self ), but there is no evidence that all four Appelbaum capacity criteria were met (14, 15) (see box).…”

“…In the United States, because physician aid-in-dying is approved on a state level, there is variability in the regulatory agencies overseeing the practice. Lack of strict regulations in the Netherlands has led to cases in which medically assisted suicide was done for patients with impaired cognition or psychiatric disorders (14) and to extension of the practice among vulnerable populations (9). Thus, what should the role of psychiatrists be in ensuring that depression is adequately screened among individuals requesting physician aid-in-dying?…”

Euthanasia and assisted suicide for people with an intellectual disability and/or autism spectrum disorder: an examination of nine relevant euthanasia cases in the Netherlands (2012–2016)

“…EAS for mental suffering has been fiercely debated. Arguments have focused on the difficulty of assessing the patient’s subjective perception and complaints and on the challenges in assessing the patient’s capacity of judgement, which may be impaired by psychiatric conditions such as severe depression [ 10 – 12 ]. Arguments in favour of including both mental and physical suffering as legally acceptable grounds for EAS focus on the fact that a key objective of such legislation is to relieve suffering.…”