Evaluation of Competence to Consent to Assisted Suicide: Views of Forensic Psychiatrists
Linda Ganzini et al., Evaluation of Competence to Consent to Assisted Suicide: Views of Forensic Psychiatrists, 157 AM. J. PSYCHIATRY 595 (2000).
Mental health evaluation has been proposed as an important safeguard for patients requesting physician-assisted suicide (PAS). Mental health experts have been identified as the persons best qualified to protect those patients' autonomy by determining whether the request is competent and voluntary.
There are several unanswered practical issues in assessing the capacity of a patient who wants to hasten death. In a survey of Oregon psychiatrists, 6% were very confident, 43% were somewhat confident, and 51% were not at all confident that they could, in the context of a single consultation, determine if a mental disorder or depression impaired the judgment of a patient requesting assisted suicide. Because psychiatry has viewed suicidality as a priori psychopathological, mental health professionals have neither had experience in determining specific competence to consent to assisted suicide nor developed guidelines and independent standards for this evaluation. Whether psychiatrists can agree about what these standards and guidelines should be is an unresolved question.
Among psychiatrists, forensic psychiatrists have the greatest expertise in assessing decision-making capacity in a variety of situations. This study reports the results of a national survey of 456 board-certified forensic psychiatrists, 290 of which returned the survey.
Although 80% of respondents indicated that they considered suicide ethical in some or all circumstances, only 66% believed that suicide with a physician's assistance was ever ethical. On the question of what conditions under which PAS should be legally permitted for a competent patient, 37% responded "never," 19% would legalize PAS only for the terminally ill, 39% would legalize it for patients who are either terminally ill or hopelessly ill with physical suffering but not terminally ill, and 5% would legalize it for any competent patient.
Three percent of the psychiatrists believed that a psychiatric evaluation was not necessary as a safeguard, and 24% indicated that psychiatric participation in determining competence would be unethical. The remaining respondents indicated that this evaluation should be recommended but not required (12%), required in some cases (22%), and required in all cases (39%). Psychiatrists who responded that PAS was sometimes or always acceptable differed significantly in their views of the psychiatrist's role. Sixty-one percent of the psychiatrists who believed that PAS was never acceptable also believed that psychiatric evaluation in these cases would be unethical. …