Euthanasia and Physician Assisted Suicide in Dementia: Decision-making Capacity Revised

Abstract

Euthanasia and physician assisted suicide (combined and referred to as “Physician Assisted Dying”, and abbreviated as PAD) are legally permitted in the Netherlands provided that both a set of criteria of due care is met, and that the case is reported to the municipal pathologist. One of these criteria states that the practicing physician must be convinced that the request is both voluntary and well-considered. This requires the physician to determine that the person requesting PAD has sufficient decision-making capacity for this choice. In light of the increasing number of granted requests for PAD on people suffering from dementia in the Netherlands and the expected increase in occurrence of dementia in the years to come, the need to evaluate several approaches to the concept, criteria and standards of competence becomes a matter of great importance. Evaluating these issues is a starting-point from which we will be able to answer the question which criteria and standards of competence are justifiable in cases where people suffering from dementia request physician-assisted dying. As the dominant approach on the criteria of competence (by Appelbaum and Grisso) is unable to do justice to the reality of decision-making, the possibilities for an enriched set of criteria is investigated. Moreover, a process-related standard of competence including the outcome is proposed to account for the influence of contextual factors in the decision-making process. As a result, a set of enriched criteria and a variable standard of competence is proposed by means of a framework for “Embedded Competence”.