Assessment of patient decision-making capacity in the context of voluntary euthanasia for psychic suffering caused by psychiatric disorders: a qualitative study of approaches among Belgian physicians

Schweitser, Frank; Stuy, Johan; Distelmans, Wim; Rigo, Adelheid

doi:10.1136/medethics-2019-105690

Cited by 8 publications

(3 citation statements)

References 8 publications

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“…Physicians preferred to assess capacity informally during conversations and believed that experience and intuition were important for capacity assessment. 67 Such informal capacity assessments may be biased based on doctors' personal views on assisted dying. 68 If capacity assessments do not follow a stringent approach in the practice of AS for PMI, as this limited evidence suggests, concerns about epistemic uncertainty regarding decisional capacity seem justified.…”

Section: Decision-making Capacitymentioning

confidence: 99%

Assisted suicide and the discrimination argument: Can people with mental illness fulfill beneficence‐ and autonomy‐based eligibility criteria?

Braun,

Scholten,

Vollmann

2023

Bioethics

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According to the “discrimination argument,” it would be discriminatory and hence impermissible to categorically exclude people with mental illness (PMI) from access to assisted suicide (AS) if AS is accessible to people with somatic illnesses. In objection to this, it could be argued that excluding PMI is not discriminatory, but rather based on their inability to meet certain eligibility criteria for AS. Which criteria are deemed necessary depends on the approach taken to justifying AS. In this article, we describe two distinct ethical approaches to justifying AS and the eligibility criteria they entail and examine whether PMI can fulfill these criteria. A widespread “joint” approach based on beneficence and autonomy assumes that AS is justified when it alleviates the severe and irremediable suffering of a person who autonomously requests AS. An alternative, exclusively autonomy‐based approach assumes that providing AS is justified when a person's request is autonomous, regardless of whether AS is in her best interests. The latter approach underlies an important judgment of the German Federal Constitutional Court from 2020. We argue that PMI can in principle fulfill both beneficence‐ and autonomy‐based eligibility criteria for AS, and that a blanket exclusion of all PMI from AS is thus discriminatory on either approach. However, depending on which approach is taken, there are differences regarding the subgroups of PMI that would be eligible for AS. Whether the exclusion of specific PMI is discriminatory therefore depends on how we understand and justify AS.

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Section: Decision-making Capacitymentioning

confidence: 99%

Assisted suicide and the discrimination argument: Can people with mental illness fulfill beneficence‐ and autonomy‐based eligibility criteria?

Braun,

Scholten,

Vollmann

2023

Bioethics

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“…Instead, the determination of the patient's decisional capacity should solely be established in reference to the quality of the decision-making process and the underlying values expressed. Importantly, capacity is task-specific and may vary over time (17,18,(22)(23)(24)(25).…”

Section: Auto Controlmentioning

confidence: 99%

Improving control over euthanasia of persons with psychiatric illness: Lessons from the first Belgian criminal court case concerning euthanasia

et al. 2022

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BackgroundBelgium is one of very few countries that legally allow euthanasia for suffering caused by psychiatric illness. In the first criminal trial in Belgium of physicians involved in euthanasia, three physicians recently faced the accusation of “murder by poisoning,” for allegedly having failed to comply with several requirements of the Belgian Euthanasia Law in granting the euthanasia request a woman suffering from psychiatric illness. Although all three physicians were acquitted, the case generated much debate among policy makers, medical professionals, and the general public.MethodWe use this trial as the starting point for a critical analysis of the adequacy of the three-level control system established in the Euthanasia Law, as it is applied in the evaluation of euthanasia requests from persons who suffer unbearably from a psychiatric illness. This analysis is based on information presented during the criminal trial as well as information on the euthanasia that was published in the press.ResultsOur analysis highlights substantial problems in the assessment and granting of the euthanasia request. The patient was euthanized without it having been substantiated that her psychiatric illness had no prospect of improvement and that her suffering could not be alleviated. The three-step control system enshrined in the Law and promoted by the Federal Control and Evaluation Commission for Euthanasia appears to have failed at each level.ConclusionTo evaluate requests for euthanasia for mental suffering caused by psychiatric illness, the requirements of the Belgian Euthanasia Law should be complemented by mandating the advice of two psychiatrists, and face-to-face discussions between all physicians involved. In parallel with the process of evaluating the euthanasia request, a treatment track should be guaranteed where reasonable evidence-based treatments and recovery-oriented options are tried.

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“…To our knowledge, only one Dutch and one Belgian study on this topic have shown that the assessment of this criterion differs among individual physicians (i.e. to some extent due to their personal values and belief system), 32 and, in some cases, seems even flawed, which has led to dissensions among physicians on the evaluation outcome. 17 Our study brought an underexposed issue to light: namely, the high emotional strain on almost three quarters of the participating psychiatrists.…”

Section: Interpretation Of Findingsmentioning

confidence: 99%

Euthanasia in adults with psychiatric conditions: A descriptive study of the experiences of Belgian psychiatrists

et al. 2021

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To investigate the experience of psychiatrists who completed assessment procedures of euthanasia requests from adults with psychiatric conditions (APC) over the last 12 months. Between November 2018 and April 2019 a cross-sectional survey was sent to a sample of 753 psychiatrists affiliated with Belgian organisations of psychiatrists to gather detailed information on their latest experience with a completed euthanasia assessment procedure, irrespective of its outcome (i.e. euthanasia being performed or not). Information on 46 unique cases revealed that most APC suffered from comorbid psychiatric and/or somatic disorders, and had received different kinds of treatment for many years prior to their euthanasia request. Existential suffering was the main reason for the request. The entire procedure spanned an average of 14 months, and an average of 13.5 months in the 23 cases that culminated in the performance of euthanasia. In all cases, the entire procedure entailed multidisciplinary consultations, including with family and friends. Psychiatrists reported fewer difficulties in assessing due care criteria related to the APC’s self-contemplation – for example, unbearable suffering on top of the due care criteria related to their medical condition; incurability due to lack of reasonable treatment perspectives. In a few cases in which euthanasia was the outcome, not all legal criteria were fulfilled in the reporting physicians’ opinions. Both positive and negative experiences of the assessment procedure were reported: for example, reduced suicide risk for the APC; an emotional burden and a feeling of being pressured for the psychiatrist. This study confirms that euthanasia assessment in APC entails a lengthy process with diverse complexities, and psychiatrists require support in more than one respect if the assessments are to be handled adequately. Thorough evaluation of current guidelines is recommended: that is, to what extent the guidelines sufficiently address the complexities around (e.g.) assessing legal criteria or involving relatives. We formulate various avenues for further research to build on this study’s insights and to fill remaining knowledge gaps.

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Assessment of patient decision-making capacity in the context of voluntary euthanasia for psychic suffering caused by psychiatric disorders: a qualitative study of approaches among Belgian physicians

Cited by 8 publications

References 8 publications

Assisted suicide and the discrimination argument: Can people with mental illness fulfill beneficence‐ and autonomy‐based eligibility criteria?

Assisted suicide and the discrimination argument: Can people with mental illness fulfill beneficence‐ and autonomy‐based eligibility criteria?

Improving control over euthanasia of persons with psychiatric illness: Lessons from the first Belgian criminal court case concerning euthanasia

Euthanasia in adults with psychiatric conditions: A descriptive study of the experiences of Belgian psychiatrists

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