Psychiatric patients and the decisional authority in the context of euthanasia. Is the psychiatrist a competent gatekeeper?

By Frank Schweitser

In Belgium people with an incurable psychiatric disorder can file a request for euthanasia claiming unbearable psychic suffering. For the request to be accepted, it has to meet stringent legal criteria. Psychiatrists play an important role in the evaluation of these criteria.

One of the legal requirements is that the patient possess decision-making capacity. In euthanasia cases for patients with a psychiatric disorder, the assessment of decision-making capacity can be complicated. A wish to die may itself be a symptom of a depressive disorder. It may disappear when the underlying depression is treated. Hence, the decision-making capacity of the patient requesting euthanasia, must be rigorously evaluated. Physicians still have a duty to protect vulnerable psychiatric patients with hope of recovery.

The physician’s evaluation of the decision-making capacity plays a key role in the Belgian law. If the patient has the necessary decision-making capacity to decide on euthanasia (and the other legal requirements are met), the decisional authority will be left with him, which means the request can be granted. When this capacity is lacking, the patient cannot receive euthanasia. Surrogates cannot take a decision in this matter, because euthanasia is legally defined as the explicit request of the patient.

One of the main goals of the study is to provide an insight in the practice of the evaluation of the decision-making capacity. Another is to pave the way for an ethical discussion that can support a refinement of this practice where necessary.

In our qualitative study we conducted 22 face to face interviews with Belgian psychiatrists (19) and neurologists (3), two medical specialties often seen as having expertise in patient decision-making capacity. Most of them had experience with euthanasia requests. We focused on their experiences, views and knowledge.

In our article we gave special attention to the cognitive ability approach, one of the approaches discussed in the Belgian and Dutch guidelines on euthanasia in the context of psychiatry. According to this approach four abilities constitute decision-making capacity – communication, understanding, appreciation, reasoning.

One of the important findings of our study is that there are different opinions and views on decision-making capacity among physicians. We observed for example differences in the way the abilities of the cognitive ability approach were valued in relation to competence. Another example is the claim of some physicians that they take additional elements into consideration when assessing decision-making capacity, like the emotions of the patient and the degree to which decisions are in line with the core values and the life history of the patient.

We believe that personal values and beliefs of physicians influence their approach. That raises the question if there’s a way to make the assessment of decision-making capacity less arbitrary.


Paper title: The 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.

Authors: Frank Schweitser1, Johan Stuy1, Wim Distelmans2, Adelheid Rigo3


1 Philosophy and Moral Sciences, Vrije Universiteit Brussel.

2 Medicine, Vrije Universiteit Brussel

3 Centre for Family Studies, University College Odisee, Schaarbeek

Competing interests: None.








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