Another essay on the discriminatory nature of most assisted dying regimes.  I argue that they reflect a hegemony of privilege.

One of the core principles of modern capacity framework is that adults are presumed competent, unless... But how should we fill out the "unless" clause? We recently analyzed one common way of understanding the presumption that can lead to confusion and abuse.  We discuss the paper in this podcast.

Equality arguments abound in debates over assisted dying, and they are double edged swords, as equality considerations often are.  I just wrote a brief sketch of what true equality would require in the debate over legalization of assisted death.

Assisted dying (i.e., euthanasia, assisted suicide, etc.) laws are controversial and quite varied. Some jurisdictions see it as a generic human rights issue (Germany), while others see it as a medical issue (the Netherlands), with variations in between. We analyzed the views of various Swiss experts on its assisted suicide practice and categorized their views according to the role of medicine they prefer in such a regime.

Should the threshold for decision-making capacity vary with risk? It's a debate as old as the concept itself.  To many, the idea that DMC assessments should be risk sensitive is intuitive and commonsense. To others, the idea is paternalistic or incoherent, or both.  Read our grandiosely titled essay on this debate. 

I rarely write for popular media outlets. But here's a recent one  in the Globe and Mail on Canadian euthanasia/assisted suicide policy and practice--a situation that is becoming increasingly controversial, and the uniquely Canadian ideology causing it.

Jurisdictions that allow euthanasia and/or assisted suicide on the basis of 'medical suffering' usually require irremediability as a requirement for eligibility.  Of course, it relies on the accuracy of physicians' judgments of irremediability. Are they accurate and reliable? We review the existing evidence for 'treatment resistant depression' in a recent paper.

Does the concept of epistemic injustice add anything  uniquely useful to psychiatric practice? We argue no, and add that it could even be harmful.

When it comes to the views of UN Committee on Rights of Persons with Disabilities on mental capacity, we come not to praise but bury them.

What are the ethical and policy implications of rapidly acting depression treatments for the practice of physician assisted death?

Most writers with a theoretical background (academic law, philosophy, etc.) tend to assume that physicians are paternalistically biased when assessing decision-making capacity.  Our interview study of 26 experienced consultation psychiatrists from 3 different jurisdictions about the difficulties they face when conducting capacity evaluations sheds some light on that issue, as well as on many others.

Some think it is obvious that we should take risk outcomes of decisions into account when assessing someone's decisional capacity. Others vehemently oppose this as an 'outcomes based' assessment. This longstanding debate is very complex, with writers often talking past each other, and it just might be useful to step back and review systematically the arguments used by both sides.

Does research comparing two 'standard' treatments hold any research risks? If so, how do we go about identifying such risks? 

Eligibility conditions for assisted dying vary among jurisdictions. Several require medically based suffering, as in the Netherlands, but there is a perennial debate over this boundary, as when some advocate for 'completed life' as an eligibility criterion. I recently wrote a commentary showing the incoherence of suffering-based regimes. It builds on two earlier pieces that can be found here and here.

We just published the results of a survey of the US public regarding situations where the 'irremediability' condition for assisted dying (a common criterion especially in jurisdictions that allow non-terminal illness euthanasia) exists only because of lack of resources.

When the criteria for capacity are used loosely and without clear boundaries, there is a danger of unreliable, invalid judgments. How then should assessors apply what are admittedly very vague and broad criteria? Read about it here (short blog explainer) and here (full article).

Why do more women than men receive euthanasia for non-terminal, psychiatric conditions?  Read about it here.

Should age matter when allocating scarce medical resources during  pandemics like COVID-19?  We conducted a deliberative study with English citizens.  You can read the results here.

Most criteria for decision-making capacity are fairly broad, such as 'understanding,' 'reasoning,' 'using or weighing relevant information,' etc.  They are so broad that they might mean different things to different assessors of capacity. Without more specific guidance, it might be difficult to make reliable, valid determinations. My colleagues and I recently analyzed over 130 actual judgments by experienced English courts to see how these concepts are actually applied and developed a typology that should prove helpful in making capacity determinations more transparent and reliable.

Making decisions for people who lack (or are presumed to lack) the capacity to make their own medical decisions can raise very difficult ethical questions.  My colleague Alex Ruck Keene, an experienced English barrister in the Court of Protections, and I recently wrote a paper analyzing the potential unintended yet tragic consequences of how the English capacity law is increasingly being interpreted.

Imagine a clinical trial that compares two treatments that are already widely used by doctors for a given condition. Both treatments are 'within the standard of care' but it's really not known if one is better than the other.  Suppose one treatment is more expensive than the other.  Their comparative effectiveness would be valuable information.  What kind of 'research risk' is there in such a study?  Must research subjects give informed consent to be in such a study? I try to answer these questions in a recent online paper.

As a follow up to our study of published dementia EAS cases in the Netherlands, we provide a more in depth ethical analysis of a key finding from that study: contrary to the often stated view that dementia EAS in the Netherlands only involves either 'early' dementia (fully competent) or 'late' dementia (not competent and reliant on advance directives), there are many cases of patients receiving EAS based on their concurrent request despite significant decisional impairments due to dementia.  

Two articles on euthanasia/assisted suicide and dementia may be of interest for readers. The first is an analysis of published cases in the Netherlands. The second is a survey of public attitudes toward the practice.

Noa Pothoven was a 17 year-old young woman with several psychiatric conditions from the Netherlands who died recently by self-starvation. Her death was initially reported in English speaking media as a euthanasia. I comment on her death and put it in the context of Dutch practice of psychiatric euthanasia here.

We and others have reported that personality disorders are quite common in persons requesting and receiving psychiatric euthanasia. We recently analyzed the Dutch psychiatric euthanasia cases involving persons with prominent personality difficulties (as described in their case reports published by the review committees). 

My colleagues from King's College London (Alex Ruck-Keene, Nuala Kane, and Gareth Owen) and I just published a paper that will be of value to those working on the increasingly studied and debated topic of decision-making capacity. The paper (open access!) is a unique combination of an exposition of how Mental Capacity Act (England and Wales) works in the court system and an empirical review of that court system's experience over its 10 years of using the MCA.