Capacity Evaluations of Psychiatric Patients Requesting Assisted Death in the Netherlands

Background: Euthanasia or physician-assisted suicide (EAS) of psychiatric patients is legal in some countries but remains controversial. Objective: 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. A total of 66 cases from 2011-2014 were reviewed. Results: In 55% (36 of 66) of cases, the capacity-speck discussion consisted of only global judgments of patients' capacity, even in patients with psychotic disorders. Further, 32% (21 of 66) of cases included evidentiary statements regarding capacity specific abilities; only 5 cases (8%) mentioned all 4 abilities. Physicians frequently stated that psychosis or depression did or did not affect capacity but provided little explanation regarding their judgments. Physicians in 8 cases (12%) disagreed about capacity; even when no explanation was 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.