Skip to main content
×
×
Home

Assessment of decision-making capacity in patients requesting assisted suicide

  • David Shaw (a1), Manuel Trachsel (a2) and Bernice Elger (a3)
Summary

In this editorial, we argue that current attitudes toward terminally ill patients are generally too paternalistic, and that it is wrong to assume that patients suffering from mental health issues (including depression) cannot consent to assisted suicide.

Declaration of interest

None.

  • View HTML
    • Send article to Kindle

      To send this article to your Kindle, first ensure no-reply@cambridge.org is added to your Approved Personal Document E-mail List under your Personal Document Settings on the Manage Your Content and Devices page of your Amazon account. Then enter the ‘name’ part of your Kindle email address below. Find out more about sending to your Kindle. Find out more about sending to your Kindle.

      Note you can select to send to either the @free.kindle.com or @kindle.com variations. ‘@free.kindle.com’ emails are free but can only be sent to your device when it is connected to wi-fi. ‘@kindle.com’ emails can be delivered even when you are not connected to wi-fi, but note that service fees apply.

      Find out more about the Kindle Personal Document Service.

      Assessment of decision-making capacity in patients requesting assisted suicide
      Available formats
      ×
      Send article to Dropbox

      To send this article to your Dropbox account, please select one or more formats and confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your <service> account. Find out more about sending content to Dropbox.

      Assessment of decision-making capacity in patients requesting assisted suicide
      Available formats
      ×
      Send article to Google Drive

      To send this article to your Google Drive account, please select one or more formats and confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your <service> account. Find out more about sending content to Google Drive.

      Assessment of decision-making capacity in patients requesting assisted suicide
      Available formats
      ×
Copyright
Corresponding author
Correspondence: David Shaw PhD, MA, MSc, MML, PGCE, Institute for Biomedical Ethics, University of Basel, Bernoullistrasse 28, 4056 Basel, Switzerland. Email: david.shaw@unibas.ch
References
Hide All
1Grisso, T, Appelbaum, PS. Assessing Competence to Consent to Treatment: A Guide for Physicians and Other Health Professionals. Oxford University Press, 1998.
2Buchanan, AE, Brock, DW. Deciding for Others: The Ethics of Surrogate Decision Making. Cambridge University Press, 1989.
3Parker, M. Judging capacity: paternalism and the risk-related standard. J Law Med 2004; 11: 482–91.
4Werth, J, Benjamin, G, Farrenkopf, T. Requests for physician assisted death: guidelines for assessing mental capacity and impaired judgment. Psychol Public Policy Law 2000; 6: 348–72.
5Ganzini, L, Leong, GB, Fenn, DS, Silva, JA, Weinstock, R. Evaluation of competence to consent to assisted suicide: views of forensic psychiatrists. Am J Psychiatry 2000; 157(4): 595600.
6Okai, OG, Owen, G, McGuire, H, Singh, S, Churchill, R, Hotopf, M. Mental capacity in psychiatric patients: systematic review. Br J Psychiatry 2007; 191: 291–7.
7Hindmarch, T, Hotopf, M, Owen, GS. Depression and decision-making capacity for treatment or research: a systematic review author. BMC Med Ethics 2013; 14: 54.
8Schuklenk, U, Van de Vathorst, S. Treatment-resistant major depressive disorder and assisted dying: response to comments. J Med Ethics 2015; 41: 589–91.
9Swiss Academy of Medical Sciences. Section 4.1: Assisted Suicide. In End-of-life care: 9. Swiss Academy of Medical Sciences, 2013.
10Trachsel, M, Hermann, H, Biller-Andorno, N. Cognitive fluctuations as a challenge for the assessment of decision-making capacity in patients with dementia. Am J Alzheimers Dis Other Demen 2014; 30(4): 360–3.
11Local Authority v Z [2004] EWHC 2817.
Recommend this journal

Email your librarian or administrator to recommend adding this journal to your organisation's collection.

The British Journal of Psychiatry
  • ISSN: 0007-1250
  • EISSN: 1472-1465
  • URL: /core/journals/the-british-journal-of-psychiatry
Please enter your name
Please enter a valid email address
Who would you like to send this to? *
×

Metrics

Altmetric attention score

Full text views

Total number of HTML views: 60
Total number of PDF views: 28 *
Loading metrics...

Abstract views

Total abstract views: 71 *
Loading metrics...

* Views captured on Cambridge Core between 27th June 2018 - 22nd July 2018. This data will be updated every 24 hours.

Assessment of decision-making capacity in patients requesting assisted suicide

  • David Shaw (a1), Manuel Trachsel (a2) and Bernice Elger (a3)
Submit a response

eLetters

The advocates of euthanasia in patients suffering from mental illness are going in the wrong direction

Emilie OLIE, MD,PhD, CHU Montpellier
Philippe COURTET, MD,PhD, CHU Montpellier
19 July 2018

Shaw et al. (1) argue that “it is wrong to assume that patients suffering from mental health issue cannot consent to assisted suicide”. But being depressed is the strongest correlate of decision instability, of changing from acceptance of euthanasia to rejecting it at follow up (2). As a matter of fact, the rate of psychiatric patients who, after seeking EAS, no longer wished to die and / or withdrew their requests is quite high(3). In general, caregivers should be aware of the risks of euthanasia or assisted suicide (EAS) for patients suffering from mental health issue. Beyond the paradox of use of EAS criteria corresponding to clinically targets of therapeutic intervention, available data on psychiatric EAS from BENELUX (Belgium, Netherlands and Luxembourg) highlight real issues of such practice. Even EAS defenders criticize the procedure(4), agreeing that : i) a rigorous standardized evaluation involving a biopsychosocial perspective is lacking ; ii) all available treatments are not always tried and access to care not systematically assured. Decision-making capacity evaluation in patients requesting assisted suicide is even more complex in presence of psychiatric disorder. Medicine's ongoing assumption that clinicians and patients are rational decision makers is questionable. All humans (including patients and clinicians) are influenced by seemingly irrational preferences in making choices about risk, time, and trade-offs. By extension, the existence of rational suicide is uncertain. Decisions are considered to be rational when they rely on two core dimensions : being realistic and having minimal ambivalence(5). But how can we rationally consider the options "to be or not to be"? Suicide is known to be an ambivalent choice. In addition, considering that "I would be better off dead" is not sensible because there is no knowledge of "being" after death. The term “understandability” could thus be rather used than “rationality” for suicide. However the ability to understand someone’s wish to die does not mean that suicide is for the best.

Moreover, the irremediable dimension of suffering justifying EAS is unclear because suffering may be improved for some patients when they are heard and taken seriously in their death request. Altogether, it suggests that EAS defenders may be misled by personal beliefs, feelings and values. Are EAS advocates reignited caregivers having forgotten Hippocratic oath “primum non nocere” ? It is important to note that mental illnesses are now recognized to be chronic and disabling, belonging to a group of serious medical illnesses such as cancer, but do not benefit from the same research approach. While the goals of biomedical research for severe somatic illnesses are generally cure and prevention, very little research for the mental illnesses has set the bar this high. Thus to propose an irremediable and definitive solution (death) to a complex and poorly understood phenomenon (suffering) is going in the wrong direction.



1. Shaw D, Trachsel M, Elger B. Assessment of decision-making capacity in patients requesting assisted suicide. Br J Psychiatry. 2018; 213(1): 393-5.

2. Blank K, Robison J, Prigerson H, Schwartz HI. Instability of attitudes about euthanasia and physician assisted suicide in depressed older hospitalized patients. Gen Hosp Psychiatry. 2001; 23(6): 326-32.

3. Thienpont L, Verhofstadt M, Van Loon T, Distelmans W, Audenaert K, De Deyn PP. Euthanasia requests, procedures and outcomes for 100 Belgian patients suffering from psychiatric disorders: a retrospective, descriptive study. BMJ open. 2015; 5(7): e007454.

4. Vandenberghe J. Physician-Assisted Suicide and Psychiatric Illness. N Engl J Med. 2018; 378(10): 885-7.

5. Clarke DM. Autonomy, rationality and the wish to die. Journal of medical ethics. 1999; 25(6): 457-62.

... More

Conflict of interest: None declared

Write a reply

×

Reply to: Submit a response


Your details


Conflicting interests

Do you have any conflicting interests? *