Psychiatric patients requesting euthanasia: Guidelines for sound clinical and ethical decision making

May combine two claims.

The five analysed initiatives are well in keeping with the legal requirements but are often more stringent.

“The initiatives are well in keeping with the legal requirements but are often more stringent.”

• AssumptionRests on an assumption: The five selected initiatives are the relevant and representative Belgian guidelines on euthanasia requests by psychiatric patients.

Classified as probably not a substantial claim. May combine two claims. The quote only partly states this claim.

Guideline IV indicates that the perception of being a burden can be grounded in the patient's awareness that this burden is a real and logical consequence of one's psychopathology, and that this type of rational internal pressure need not be a reason to reject the patient's euthanasia request in advance.

“In this regard, one of the guidelines (IV) indicates that the perception of being a burden can be grounded in the patient's awareness that this burden is a real and logical consequence of one's psychopathology.”

• AssumptionRests on an assumption: The five selected initiatives are the relevant and representative Belgian guidelines on euthanasia requests by psychiatric patients.

Classified as probably not a substantial claim. May combine two claims.

Although the initiatives are similar in intent, some differences in approach were found, reflecting different ethical stances towards euthanasia and an emphasis on practical clinical assessment versus broad ethical reflection.

“Although the initiatives are similar in intent, some differences in approach were found, reflecting different ethical stances towards euthanasia and an emphasis on practical clinical assessment versus broad ethical reflection.”

• AssumptionRests on an assumption: The five selected initiatives are the relevant and representative Belgian guidelines on euthanasia requests by psychiatric patients.

Classified as probably not a substantial claim. May combine two claims.

Guideline IV specifies the clinical assessment of mental competence on the basis of four criteria: four cognitive competencies, a properly considered euthanasia request with appropriate emotions, rejection of a request attributable directly to a symptom of the disorder, and a sufficient degree of practical rationality.

“Representing the professional group of psychiatrists, one of the guidelines (IV) specifies the clinical assessment of mental competence on the basis of four criteria.”

• AssumptionRests on an assumption: The five selected initiatives are the relevant and representative Belgian guidelines on euthanasia requests by psychiatric patients.

Classified as probably not a substantial claim. May combine two claims.

The five guidelines acknowledge that mental competence can be reduced due to a patient's psychopathology but emphasise that this is not automatically the case.

“The five guidelines that are the topic of this paper acknowledge that mental competence can indeed be reduced due to a patient's psychopathology (e.g.temporary psychoses), but they emphasise that this is not automatically the case.”

• AssumptionRests on an assumption: The five selected initiatives are the relevant and representative Belgian guidelines on euthanasia requests by psychiatric patients.

May combine two claims.

Shortcomings of the initiatives relate to uncertainty regarding the way in which attending physicians should manage negative or conflicting advices, or patients' suicide threats in case of refusal.

“Shortcomings of the initiatives relate to the aftercare of patients whose euthanasia request is rejected, and to uncertainty regarding the way in which attending physicians should manage negative or conflicting advices, or patients' suicide threats in case of refusal.”

• AssumptionRests on an assumption: The five selected initiatives are the relevant and representative Belgian guidelines on euthanasia requests by psychiatric patients.

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

The importance of a decision-making policy that includes many actors (e.g. the patient's relatives and other care providers) and of good aftercare for the bereaved are rightly stressed in the initiatives.

“Apart from the additional safeguards suggested, the importance of a decision-making policy that includes many actors (e.g. the patient's relatives and other care providers) and of good aftercare for the bereaved are rightly stressed.”

• AssumptionRests on an assumption: The five selected initiatives are the relevant and representative Belgian guidelines on euthanasia requests by psychiatric patients.

May combine two claims.

Most of the guidelines (II-V) identify reasons to assume that some psychiatric patients can make a reasoned, well-considered choice for termination of life, accompanied by suitable emotions, and to a certain degree also irrespective of psychopathology.

“In the context of a euthanasia request, most of the guidelines (II-V) identify reasons to assume that some psychiatric patients can make a reasoned, well-considered choice for termination of life, accompanied by suitable emotions, and to a certain degree also irrespective of psychopathology.”

• AssumptionRests on an assumption: The five selected initiatives are the relevant and representative Belgian guidelines on euthanasia requests by psychiatric patients.

Classified as probably not a substantial claim. May combine two claims.

Regarding the evaluation of the patient's mental competence, four of the guidelines highly recommend taking sufficient time and making use of hetero anamnesis (II-V) and interdisciplinary consultation (I-V).

“Regarding the evaluation of the patient's mental competence, four of the guidelines highly recommend taking sufficient time and making use of hetero anamnesis (II-V) and interdisciplinary consultation (I-V).”

• AssumptionRests on an assumption: The five selected initiatives are the relevant and representative Belgian guidelines on euthanasia requests by psychiatric patients.

Classified as probably not a substantial claim.

According to the guidelines, the patient's request must be spread out over a period of several months, in order to exclude a 'flash of the moment'-decision and to allow sufficient time to assess the origin and evolution of the death wish (I-V).

“The patient's request must be spread out over a period of several months, in order to exclude a 'flash of the moment'-decision and to allow sufficient time to assess the origin and evolution of the death wish (I-V).”

• AssumptionRests on an assumption: The five selected initiatives are the relevant and representative Belgian guidelines on euthanasia requests by psychiatric patients.

Classified as probably not a substantial claim.

Some guidelines (II, IV, V) recommend excluding irrational internal pressure originating from the patient's psychopathology in terms of a perceived sense of guilt or feeling of being a burden to others.

“However, some of the guidelines (II, IV,V) also recommend excluding irrational internal pressure originating from the patient's psychopathology in terms of a perceived sense of guilt or feeling of being a burden to others.”

• AssumptionRests on an assumption: The five selected initiatives are the relevant and representative Belgian guidelines on euthanasia requests by psychiatric patients.

Probably not a substantial claim: may not pass S4 (based).

Physicians face great difficulties regarding the evaluation of mental competence in psychiatric patients.

“However, physicians face great difficulties regarding the evaluation of mental competence in psychiatric patients.”

Probably not a substantial claim: may not pass S3 (load-bearing).

Some guidelines (II and IV) acknowledge that the patient-physician interaction can be strongly influenced by pathological personality characteristics of which the patient may be unaware.

“However, and especially in case of personality disorders, some guidelines (II and IV) acknowledge that the patientphysician-interaction can be strongly influenced by pathological personality characteristics of which the patient may be unaware.”

• AssumptionRests on an assumption: The five selected initiatives are the relevant and representative Belgian guidelines on euthanasia requests by psychiatric patients.

Probably not a substantial claim: may not pass S4 (based).

No research on Belgian cases of euthanasia for psychological suffering in psychiatric patients has been conducted.

“Remarkably, however, no such research on Belgian cases has been conducted.”

May combine two claims.

Analysis of the biennial reports of the Belgian Federal Control and Evaluation Commission for Euthanasia indicates that euthanasia for psychological suffering in psychiatric patients was virtually nonexistent between 2002 and 2007, increased to an average of eight per year between 2008 and 2010, then to approximately 30 per year between 2011 and 2013, and to approximately 60 per year in 2014 and 2

“Analysis of the biennial reports of the Belgian Federal Control and Evaluation Commission for Euthanasia (FCECE) indicate that, whereas euthanasia for psychological suffering in psychiatric patients was virtually nonexistent between 2002 and 2007, numbers increased to an average of eight per year between 2008 and 2010, then to approximately 30 per year between 2011 and 2013, and to approximately 6”

• cites Dierickx, Deliens, Cohen, & Chambaere, 2017 sourceNot checked yet

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• cites Federal Control and Evaluation Committee for Euthanasia, 2004, 2006, 2008, 2012, 2014, 2016, 2018Not checked yet

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Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

Suicidality receives specific attention in three guidelines (III-V), with a distinction made between acute and rational suicidal ideations and plans.

“Suicidality receives specific attention in three guidelines (III-V), as this is inherent to many psychiatric disorders.A distinction is made between acute and rational suicidal ideations and plans.”

• AssumptionRests on an assumption: The five selected initiatives are the relevant and representative Belgian guidelines on euthanasia requests by psychiatric patients.

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

Involuntary admission to a psychiatric ward should only be considered in cases of acute suicidality, resulting from a serious psychiatric disorder, and only when the patient's safety cannot be ensured via voluntary treatment (IV).

“Involuntary admission to a psychiatric ward should only be considered in cases of acute suicidality, resulting from a serious psychiatric disorder, and only when the patient's safety cannot be ensured via voluntary treatment (IV).”

• AssumptionRests on an assumption: The five selected initiatives are the relevant and representative Belgian guidelines on euthanasia requests by psychiatric patients.

Classified as probably not a substantial claim.

The two-track approach is characterized by focusing on life by continuing treatment of the patient, in parallel with a focus on death by assessing the patient's euthanasia request.

“This approach is characterized by focusing on life by way of continuing treatment of the patient, in parallel with a focus on death by way of assessing the patient's euthanasia request.”

Classified as probably not a substantial claim. May combine two claims.

Guideline IV strongly disagrees with the view that a recently discovered psychiatric diagnosis is an additional reason to consider the patient to be in a medical condition without prospect of improvement, and recommends that new diagnoses should be seen as a reason to explore the possibility of improvement.

“One guideline (IV) strongly disagrees with such a view and recommends that new diagnoses should be seen as a reason to explore the possibility of improvement.”

• AssumptionRests on an assumption: The five selected initiatives are the relevant and representative Belgian guidelines on euthanasia requests by psychiatric patients.

Classified as probably not a substantial claim.

The patient's treating physician may also be the patient's attending physician as long as the two-track approach and referrals to independent consulted physicians are guaranteed.

“The patient's treating physician may also be the patient's attending physician as long as the two-track approach and referrals to independent consulted physicians are guaranteed (IV).”

• cites IVNot checked yet

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Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

The guidelines differ in their recommendations for cases when patients refuse reasonable treatment options: one guideline (III) indicates that no consensus was found, while other guidelines (II, IV) recommend that euthanasia must not be carried out in such a case.

“The guidelines differ in their recommendations for cases when patients refuse reasonable treatment options.One guideline (III) indicates that no consensus was found on this issue, while other guidelines (II, IV) recommend that the euthanasia must not be carried out in such a case.”

• AssumptionRests on an assumption: The five selected initiatives are the relevant and representative Belgian guidelines on euthanasia requests by psychiatric patients.

Classified as probably not a substantial claim.

Some guidelines clearly go beyond legal requirements with their explicit recommendation of a two-track approach.

“As regards the decision-making process that precedes the granting or refusal of euthanasia requests, some of the guidelines clearly go beyond the legal requirements with their explicit recommendation of a two-track approach.”

• cites IINot checked yet

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• cites IVNot checked yet

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• cites VNot checked yet

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Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

In its information brochure for physicians, the Federal Control and Evaluation Commission for Euthanasia states that the consulted physicians must not have a therapeutic relationship with the patient nor be a relative or a hierarchical subordinate or superior to the attending physician.

“However, in its information brochure for physicians, the Federal Control and Evaluation Commission for Euthanasia states that the consulted physicians must not have a therapeutic relationship with the patient nor be a relative or a hierarchical subordinate or superior to the attending physician (Federal Control and Evaluation Committee for Euthanasia, 2015).”

• cites Federal Control and Evaluation Committee for Euthanasia, 2015Not checked yet

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Probably not a substantial claim: may not pass S3 (load-bearing).

Some guidelines (III, V) refer to persisting intense debates in the literature regarding whether, and if so when, a psychiatric condition can be considered incurable as these types of conditions frequently change over time.

“Some guidelines (III, V) refer to persisting intense debates in the literature regarding the question as to whether, and if so when, a psychiatric condition can be considered incurable as these types of conditions frequently change over time (Broome & de Cates, 2015;Claes et al., 2015;Kelly, 2017;Schuklenk & van de Vathorst, 2015;Trachsel, Irwin, Biller-Andorno, Hoff, & Riese, 2016;Vandenberghe, 2”

• cites Broome & de Cates, 2015Not checked yet

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• cites Claes et al., 2015Not checked yet

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• cites Kelly, 2017 sourceNot checked yet

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• AssumptionRests on an assumption: The five selected initiatives are the relevant and representative Belgian guidelines on euthanasia requests by psychiatric patients.

Classified as probably not a substantial claim.

Guideline IV states that the first consulted psychiatrist, like the attending physician, needs to address the underlying reasons for the euthanasia request.

“This guideline states that the first consulted psychiatrist, like the attending physician, needs to address the underlying reasons for the euthanasia request.”

• cites IVNot checked yet

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Classified as probably not a substantial claim. May combine two claims.

Several guidelines (I, III-V) recommend that two of the consulted physicians should be psychiatrists instead of one, as prescribed by the Euthanasia Law, and that in their assessment these psychiatrists need to pay specific attention to evaluating the causal relationship between the patient's medical condition and her suffering.

“This is one of the reasons why several of the guidelines (I, III-V) recommend that two of the consulted physicians should be psychiatristsinstead of one, as prescribed by the Euthanasia Lawand that in their assessment of the fulfilment of the due care criteria these psychiatrists need to pay specific attention to evaluating the causal relationship between the patient's medical condition and her”

• AssumptionRests on an assumption: The five selected initiatives are the relevant and representative Belgian guidelines on euthanasia requests by psychiatric patients.

Classified as probably not a substantial claim.

Diverging views exist on the precise meaning of the requirement of causality in the Euthanasia Law.

“Diverging views exist on the precise meaning of the requirement of causality in the Euthanasia Law (III) ((Belgisch Raadgevend Comité voor Bio-ethiek (Belgian Advisory Committee on Bioethics), 2017).”

• cites Belgisch Raadgevend Comité voor Bio-ethiek (Belgian Advisory Committee on Bioethics), 2017Not checked yet

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Probably not a substantial claim: may not pass S3 (load-bearing).

Some guidelines (II, IV) recommend that both the attending and the consulted physicians have several conversations with the patient.

“Some guidelines (II, IV) recommend that both the attending and the consulted physicians have several conversations with the patient.”

• cites IINot checked yet

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• cites IVNot checked yet

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Classified as probably not a substantial claim. May combine two claims.

The guidelines formulate more objectifiable criteria to evaluate the requirements for the patient's suffering: suffering should be assessed in multiple consultations spread out over time, and by thorough patient observation and examination of the patient's medical history and life context.

“The guidelines formulate more objectifiable criteria in order to evaluate the various requirements for the patient's suffering: the suffering should be assessed in multiple consultations with the patient that are spread out over time, and the assessment should, more specifically, be made by means of thorough patient observation and examination of the patient's medical history and life context.”

• AssumptionRests on an assumption: The five selected initiatives are the relevant and representative Belgian guidelines on euthanasia requests by psychiatric patients.

Classified as probably not a substantial claim. May combine two claims.

Due to the complexity of euthanasia requests for psychological suffering, it is suggested or prescribed that two, instead of one, of the consulted physicians should be psychiatrists and that they should assess all substantive due care criteria, instead of only the criteria that the Law requires them to assess.

“Due to the complexity of euthanasia requests for psychological suffering, it is suggested (IV, V) or prescribed (I) that two, instead of one, of the consulted physicians should be psychiatrists and that they should assess all substantive due care criteria, instead of only the criteria that the Law requires them to assess (IV, V).”

• cites IVNot checked yet

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• cites VNot checked yet

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• cites INot checked yet

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Probably not a substantial claim: may not pass S3 (load-bearing).

Guideline IV advises that the attending physician is the first to be consulted by the patient.

“It is advised by guideline IV that the attending physician is the first to be consulted by the patient.”

• cites IVNot checked yet

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Probably not a substantial claim: may not pass S3 (load-bearing).

Guideline III explicitly prefers the approach of the Dutch Psychiatric Association Guideline, which states that it is part of the clinical and ethical duty of the psychiatric profession to follow all state-of-the-art medical procedures before a euthanasia request can be regarded as legally eligible.

“By contrast, guideline III explicitely prefers the approach as prescribed in the former (and adopted in the recently revised) Guideline of the Dutch Psychiatric Association, stating that it is part of the clinical and ethical duty of the psychiatric profession to follow all the state-of-the-art medical procedures before a request for euthanasia can be regarded as legally eligible.”

• cites IIINot checked yet

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Classified as probably not a substantial claim.

Guideline III questions the Commission's assumption that the final judgment on the non-alleviability of suffering should be left to the patient herself.

“Guideline III questions the Commission's assumption that the final judgment on the non-alleviability of the suffering should be left to the patient herself, when the Commission states that euthanasia can be performed if the patient's refusal of further treatment options is based on 'severe treatment-related side effects or treatment applications perceived as unbearable'.”

• cites IIINot checked yet

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• AssumptionRests on an assumption: Non-alleviability of suffering clearly encompasses a medical component and is closely related to the criterion that a prospect of improvement should be absent.

Probably not a substantial claim: may not pass S3 (load-bearing).

According to guideline IV, all legal requirements should be assessed by each of the physicians involved, albeit not necessarily to the same extent.

“According to guideline IV, all legal requirements should be assessed by each of the physicians involved, albeit not necessarily to the same extent.”

• cites IVNot checked yet

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Classified as probably not a substantial claim. May combine two claims.

It is proposed or made mandatory to also involve the patient's treating physician in the procedure, although never as one of the consulted physicians, in view of the risk of a biased assessment.

“In addition, it is proposed (II, IV, V) or made mandatory (I) to also involve the patient's treating physician in the procedure, although never as one of the consulted physicians, in view of the risk of a biased assessment.”

• cites IINot checked yet

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• cites IVNot checked yet

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• cites VNot checked yet

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Probably not a substantial claim: may not pass S3 (load-bearing).

An interdisciplinary evaluation of the patient's suffering is strongly recommended by all the guidelines.

“An interdisciplinary evaluation of the patient's suffering is strongly recommended by all the guidelines.”

• AssumptionRests on an assumption: The five selected initiatives are the relevant and representative Belgian guidelines on euthanasia requests by psychiatric patients.

Classified as probably not a substantial claim. May combine two claims.

The two-track approach is based on two fundamental, although not absolute, ethical values: respect for patient autonomy by respecting and taking seriously a patient's death wish, and the duty to protect human life by first exploring meaningful life perspectives.

“This view is based on two fundamental, although not absolute, ethical values: respect for the autonomy of the patient by respecting and taking seriously a patient's death wish, and the duty to protect human life by first exploring meaningful life perspectives for a patient who has expressed a death wish (II, IV, V).”

• cites IINot checked yet

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• cites IVNot checked yet

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• cites VNot checked yet

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Probably not a substantial claim: may not pass S3 (load-bearing).

Some guidelines consider the opportunity to discuss the euthanasia request with persons the patient wants to talk to a quintessential criterion.

“Some guidelines consider this a quintessential criterion (II, IV, V).”

• cites IINot checked yet

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• cites IVNot checked yet

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• cites VNot checked yet

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Classified as probably not a substantial claim.

According to the former Dutch guideline and some Belgian guidelines (II-V), therapeutic options for a particular condition should be considered if they meet three requirements: a real prospect of improvement, the possibility to administer adequate treatment within a reasonable period of time, and a reasonable balance between the expected treatment results and the burden of treatment for thepatient

“According to the former (and recently revised) guideline as well as some of the Belgian guidelines (II-V) discussed in this paper, therapeutic options for a particular condition should be considered if they meet the following three requirements: 1) a real prospect of improvement; 2) the possibility to administer adequate treatment within a reasonable period of time; and 3) a reasonable balance”

• AssumptionRests on an assumption: The five selected initiatives are the relevant and representative Belgian guidelines on euthanasia requests by psychiatric patients.

Probably not a substantial claim: may not pass S3 (load-bearing).

Some guidelines urge the involvement of all other important caregivers involved in the patient's treatment.

“However, some guidelines also urge the involvement of all other important caregivers involved in the patient's treatment (II, IV, V).”

• cites IINot checked yet

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• cites IVNot checked yet

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• cites VNot checked yet

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Probably not a substantial claim: may not pass S3 (load-bearing).

Guideline V recommends that at least one Commission member needs to be a psychiatrist.

“One guideline (V) recommends that at least one Commission member needs to be a psychiatrist.”

• cites VNot checked yet

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Classified as probably not a substantial claim. May combine two claims.

Guideline I stipulates that euthanasia must not be performed in the psychiatric ward, but in a single-bed room on a somatic ward, in the presence of the patient's treating and attending psychiatrist, and with an anaesthesiologist on stand-by.

“Another guideline (I) stipulates that euthanasia must not be performed in the psychiatric ward, but in a single-bed room on a somatic ward, in the presence of the patient's treating and attending psychiatrist, and with an anaesthesiologist on stand-by.”

• cites INot checked yet

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Classified as probably not a substantial claim.

The guidelines plead for more stringent decision-making procedures.

“The guidelines, however, plead for more stringent decision-making procedures.”

Classified as probably not a substantial claim.

The guidelines recommend that consultations be spread over a longer period than the legally required one-month waiting period.

“As for the number of consultations and the duration of the euthanasia procedure, the guidelines recommend that the consultations be spread over a longer period than the legally required one-month waiting period.”

Probably not a substantial claim: may not pass S3 (load-bearing).

Guideline II refers to the particularly challenging situation of euthanasia in an institutional context as this could act as a potential pull factor for other patients.

“One guideline (II) refers to the particularly challenging situation of euthanasia in an institutional context as this could act as a potential pull factor for other patients.”

• cites IINot checked yet

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Classified as probably not a substantial claim.

Guideline III recommends following the Dutch model, where it is not left to the attending physician to indicate the nature and the content of the advices obtained from the consulted physicians, but the latter are themselves required to submit a report to the Commission.

“Guideline III recommends following the Dutch model, where it is not left to the attending physician to indicate the nature and the content of the advices obtained from the consulted physicians, but the latter are themselves required to submit a report to the Commission.”

• cites IIINot checked yet

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Probably not a substantial claim: may not pass S3 (load-bearing).

Guideline I provides a built-in safeguard in terms of an additional meeting with the Hospital Ethics Committee to a priori discuss and determine whether or not a euthanasia request can be declared admissible for further management and evaluation.

“A built-in safeguard is provided in guideline I in terms of an additional meeting with the Hospital Ethics Committee in order to a priori discuss and determine whether or not a euthanasia request can be declared admissible for further management and evaluation.”

• cites INot checked yet

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Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

Guideline II establishes an a priori and interdisciplinary evaluation committee consisting of three groups: staff members from the facility, at least two staff members of the network with expertise in euthanasia in psychiatry, and at least two members from outside the facility with expertise in euthanasia.

“Guideline II takes a more restrictive stance and establishes an a priori and interdisciplinary evaluation committee consisting of the following 3 groups: 1) staff members from the facility in question: the attending physician, the chief physician of the department, and two other staff members of whom at least one is a non-physician; 2) at least two staff members of the network, with expertise in”

• cites IINot checked yet

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Classified as probably not a substantial claim.

None of these guidelines describes to what extent possible negative advices should affect the euthanasia procedure and/or the final decision.

“However, none of these guidelines describes to what extent possible negative advices should affect the euthanasia procedure and/or the final decision.”

Probably not a substantial claim: may not pass S3 (load-bearing).

Guideline IV advocates detailed written reports of the physician's face-to-face discussions, accessible to all physicians and caregivers involved, to enable an open, transparent round-table discussion, preferably before formal advices are obtained, in order to achieve a broader evaluation horizon and enhance due care.

“One guideline (IV) advocates detailed written reports of the physician's face-to-face discussions, accessible to all physicians and caregivers involved, so as to enable an open, transparent round-table discussion, preferably even before formal advices are obtained, in order to achieve a broader evaluation horizon and enhance the level of due care.”

• cites IVNot checked yet

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Classified as probably not a substantial claim. May combine two claims.

Guideline II strongly advises not only the involvement of an interdisciplinary team but also the provision of extensive additional support, including a central End-of-Life Support Group, a local End-of-Life Support Group, and optionally trained LEIF physicians.

“Guideline II strongly advises not only the involvement of an interdisciplinary team but also the provision of extensive additional support.Going beyond the legal requirements, this additional support is recommended to involve: 1) a central, interdisciplinary End-of-Life Support Group (covering all the psychiatric centers of this network and open to external experts), established in order to gain”

• cites IINot checked yet

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• cites Van Wesemael et al., 2009 sourceNot checked yet

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Probably not a substantial claim: may not pass S3 (load-bearing).

According to guideline I, the patient's death certificate and the other documents that should be submitted to the Commission for a posteriori review should be filled out by the attending psychiatrist and not by any of the other physicians or healthcare professionals involved.

“According to one guideline (I), the patient's death certificate and the other documents that should be submitted to the Commission for a posteriori review should be filled out by the attending psychiatrist and not by any of the other physicians or healthcare professionals involved.”

• cites INot checked yet

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Probably not a substantial claim: may not pass S3 (load-bearing).

Guideline I describes a transparent procedure to be followed for requests of euthanasia for psychological suffering.

“One guideline (I) that we have analysed is an example of such a protocol, in that it is describing a transparent procedure to be followed for requests of euthanasia for psychological suffering.”

Classified as probably not a substantial claim.

Most of the guidelines (I, IV, V) are more restrictive than the Law as they argue that performing euthanasia is only justifiable after obtaining at least two uniformly positive advices from at least two consulted psychiatrists.

“Most of the guidelines (I, IV, V) are more restrictive than the Law as they argue that performing euthanasia is only justifiable after obtaining at least two uniformly positive advices from at least two consulted psychiatrists.”

• cites INot checked yet

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• cites IVNot checked yet

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• cites VNot checked yet

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May combine two claims.

Some guidelines do not specify the required duration, whereas others advocate a waiting period spanning at least 6 months or 1 year taking into account the involvement of all important actors.

“Some guidelines do not specify the required duration (I, IV), whereas others advocate a waiting period spanning at least 6 months (II) or 1 year (V) taking into account the involvement of all important actors.”

• cites INot checked yet

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• cites IVNot checked yet

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• cites IINot checked yet

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Probably not a substantial claim: may not pass S3 (load-bearing).

The Flemish Association of Psychiatrists has developed an additional reporting form, attached as an appendix to guideline IV, that could offer guidance for decision-making and final reporting concerning the euthanasia procedure.

“In addition to the document drafted by the Commission that has to be submitted to it as an official report for each of the cases of euthanasia performed, the Flemish Association of Psychiatrists has developed an additional reporting form that could offer guidance for decision-making and final reporting concerning the euthanasia procedure.”

• cites IVNot checked yet

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Classified as probably not a substantial claim. May combine two claims.

Guideline III calls upon the FCECE to follow the Dutch example and increase transparency by reporting on its website anonymised data regarding 10% of reported euthanasia cases and by including identifying data of the physicians involved already in the first part of the report.

“Moreover, this guideline calls upon the FCECE to follow the Dutch example and thus to increase transparency by means of: 1) reporting on its website anonymised data regarding 10% of the reported cases of euthanasia (in proportion to the types of disorder); and 2) including already in the first part of the report the identifying data of the physicians involved, which would allow the members of the”

• cites IIINot checked yet

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Classified as probably not a substantial claim.

When confronted with conscientious objection within the context of performance of euthanasia, the guidelines agree with the advice of the National Board of Physicians that the patient, after being adequately and timely informed, should be referred to a medical institution concerning the further assessment of the euthanasia request.

“When confronted with conscientious objection within the context of performance of euthanasia, the guidelines agree with the advice of the National Board of Physicians (Nationale Raad Orde der Artsen (Belgian National Board of Physicians), 2017) that the patientafter being adequately and timely informedshould be referred to a medical institution concerning the further assessment of the euthanasia”

• cites Nationale Raad Orde der Artsen (Belgian National Board of Physicians), 2017Not checked yet

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Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based).

In contrast to the situation in the Netherlands, in Belgium developments in the interpretation and operationalisation of the substantive and procedural legal requirements, and the potential problems and complexities of the review system are not the subject of systematic scientific research.

“In contrast to the situation in the Netherlands, in Belgium developments in the interpretation and operationalisation of the substantive and procedural legal requirements, and the potential problems and complexities of the review system are not the subject of systematic scientific research.”

May combine two claims.

It is unclear how these guidelines are affecting euthanasia practice, and more specifically euthanasia for psychological suffering.

“it is unclear how these guidelines are affecting euthanasia practice, and more specifically euthanasia for psychological suffering.”

Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based).

Most of these guidelines were only published approximately 15 years after the adoption of the Euthanasia Law.

“most of these guidelines were only published approximately 15 years after the adoption of the Euthanasia Law.”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

The other guidelines contain detailed practical advice for interpreting and assessing the requirements of the Euthanasia Law, and for dealing with various challenges in euthanasia practice.

“They contain detailed practical advice for interpreting and assessing the requirements of the Euthanasia Law, and for dealing with various challenges in euthanasia practice”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

Guideline I refers the patient back to his or her treating physician, whereas the other guidelines only mention the referral procedure in case of conscientious objection by the physician.

“One guideline (I) refers the patient back to his or her treating physician.By contrast, the other guidelines only mention the (not legally required!)referral procedure in case of conscientious objection by the physician.”

Classified as probably not a substantial claim. May combine two claims.

In many respects the guidelines are more stringent than the Law, for instance by stipulating that at least two positive advices should be obtained from at least two psychiatrists, by requiring physicians to follow a two-track approach, and by proposing a more stringent a priori evaluation system.

“In many respects the guidelines are more stringent than the Law, for instance by stipulating that at least two positive advices should be obtained from at least two psychiatrists, by requiring physicians to follow a two-track approach, and by proposing a more stringent a priori evaluation system.”

Classified as probably not a substantial claim. May combine two claims.

The guidelines concern the assessment of all psychiatric patients, irrespective of the nature of their psychiatric disorder (no explicit distinction between former Axis I and II disorders) or treatment setting, but excluding neuropsychiatric disorders (e.g. dementia) and without considering the particular situation of mental retardation and involuntarily committed persons.

“the guidelines concern the assessment of all psychiatric patients, irrespective of the nature of their psychiatric disorder (no explicit distinction between former Axis I and II disorders) or treatment setting, but excluding neuropsychiatric disorders (e.g.dementia) and without considering the particular situation of mental retardation and involuntarily committed persons.”

May combine two claims.

Although all the guidelines stress the importance of a decision-making policy that includes many actors and emphasise the importance of good aftercare for the bereaved, not much attention has been paid to the aftercare of patients whose euthanasia request is rejected.

“Although all the guidelines stress the importance of a decision-making policy that includes many actors (e.g. the patient's relatives and other care providers) and although they emphasise the importance of good aftercare for the bereaved, not much attention has been paid to the aftercare of patients whose euthanasia request is rejected.”

Probably not a substantial claim: may not pass S3 (load-bearing).

Some guidelines put more emphasis on the practical aspects of the clinical assessment (I, II and IV), while others focus more on a broad ethical reflection (III and V).

“Some guidelines put more emphasis on the practical aspects of the clinical assessment (I, II and IV), while others focus more on a broad ethical reflection (III and V).”

Classified as probably not a substantial claim. May combine two claims.

These guidelines are established to assess the euthanasia request, and to manage the euthanasia procedure, of patients who primarily suffer from severe mental disorders.

“these guidelines are established to assess the euthanasia request, and to manage the euthanasia procedure, of patients who primarily suffer from severe mental disorders.”

Probably not a substantial claim: may not pass S3 (load-bearing).

The guidelines contain recommendations that resemble the ones put forward in the former Guideline of the Dutch Psychiatric Association, with minor differences regarding the eligibility of a euthanasia request if a psychiatric patient rejects reasonable treatment options, or regarding the involvement of important others.

“Although these guidelines contain recommendations that resemble the ones put forward in the former Guideline of the Dutch Psychiatric Association, there are minor differences, for instance regarding the eligibility of a euthanasia request if a psychiatric patient rejects reasonable treatment options, or regarding the involvement of important others.”

Probably not a substantial claim: may not pass S3 (load-bearing).

The other guidelines discussed in the paper are published by organisations at the intermediate level between specific, local mental health institutions and overarching bodies such as the National Board of Belgian Physicians.

“The other guidelines discussed in this paper are published by organisations at the intermediate level between specific, local mental health institutions such as hospitals and nursing homes, and overarching bodies such as the National Board of Belgian Physicians.”

Probably not a substantial claim: may not pass S3 (load-bearing).

Guideline III calls upon the Federal Control and Evaluation Commission for Euthanasia to increase transparency.

“guideline III calls upon the Federal Control and Evaluation Commission for Euthanasia to increase transparency.”

Probably not a substantial claim: may not pass S2 (checkable).

By providing information on, and proper operationalisations of, the legal due care criteria, these initiatives are important instruments to prevent potential abuses.

“By providing information on, and proper operationalisations of, the legal due care criteria, these initiatives are important instruments to prevent potential abuses.”

• AssumptionRests on an assumption: The five selected initiatives are the relevant and representative Belgian guidelines on euthanasia requests by psychiatric patients.

Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based).

The number of media reports on controversial euthanasia cases in psychiatric patients has increased.

“as well as the number of media reports on controversial cases.”

Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based).

Given the scarcity of data on how thoroughly and uniformly requests are handled in practice, it is unclear to what extent the recommendations made in these guidelines are currently being implemented.

“Given the scarcity of data on how thoroughly and uniformly requests are handled in practice, it is unclear to what extent the recommendations made in these guidelines are currently being implemented.”

• AssumptionRests on an assumption: The five selected initiatives are the relevant and representative Belgian guidelines on euthanasia requests by psychiatric patients.

Classified as probably not a substantial claim.

The legal condition of a well-considered euthanasia request presupposes that the patient has been well-informed by the physician concerning her (psycho)pathology, possible ways to alleviate her suffering, side effects of the available treatment options, and the prognosis with and without treatment.

“The legal condition of a wellconsidered euthanasia request presupposes that the patient has been well-informed by the physician concerning: 1) her (psycho)pathology; 2) possible ways to alleviate her suffering; 3) side effects of the available treatment options; and 4) the prognosis (with and without treatment).”

• cites The Euthanasia LawNot checked yet

  Not checked in the free run.

Probably not a substantial claim: may not pass S4 (based).

Psychiatric disorders, even in the absence of somatic co-diagnoses, are recognised as diagnosable medical conditions.

“Psychiatric disorders, even in the absence of somatic co-diagnoses, are recognised as diagnosable medical conditions.”

Classified as probably not a substantial claim.

In clearly symptom-induced periods of psychopathology, the patient should not be considered eligible for euthanasia.

“In these clearly symptom-induced periods of psychopathology, the patient should not be considered eligible for euthanasia.”

Classified as probably not a substantial claim. May combine two claims.

The considerable increase in cases of euthanasia for psychological suffering and media reports on controversial cases raise concerns about a potentially overly permissive approach.

“However, the considerable increase in cases of euthanasia for psychological suffering and media reports on controversial casesof which one has been referred to the public prosecutor (Mason & Weitenberg, 2015;Symons, 2015) and another one has been referred to the Court of Assize (Hope, 2018) raise concerns about a potentially overly permissive approach (Clifford, 2017).”

• cites Clifford, 2017Not checked yet

  Not checked in the free run.

Classified as probably not a substantial claim. May combine two claims.

The increase in euthanasia cases and media reports on controversial cases prompted several healthcare organisations and committees to develop policies on the management of these requests.

“This has prompted several healthcare organisations and committees to develop policies on the management of these requests.”

May combine two claims.

Under the Belgian Euthanasia Law, euthanasia is allowed not only for patients expected to die within the foreseeable future but also for patients not expected to die within the foreseeable future, in which case additional due care criteria are required.

“Under the Belgian Euthanasia Law, euthanasia is allowed not only for patients who are expected to die within the foreseeable future but also for patients who are not expected to die within the foreseeable future (in which case the Law requires the fulfilment of additional due care criteria).”

• cites The Euthanasia LawNot checked yet

  Not checked in the free run.

Classified as probably not a substantial claim. May combine two claims.

The clinical assessment of these criteria is very difficult and extreme care should be required before a request from a psychiatric patient for euthanasia for psychological suffering is granted.

“As a result, the clinical assessment of these criteria is very difficult and extreme care should be required before a request from a psychiatric patient for euthanasia for psychological suffering is granted (Naudts et al., 2006).”

• cites Naudts et al., 2006 sourceNot checked yet

  Not checked in the free run.

Probably not a substantial claim: may not pass S4 (based).

For psychiatric disorders, even those with an episodic character, symptoms can be chronically and severely persistent, progressive, and/or continuously alternating.

“For psychiatric disorders, even those with an episodic character, symptoms can be chronicly and severely persistent, progressive, and/or continuously alternating.”

Classified as probably not a substantial claim.

At least one of the consulted physicians needs to be a psychiatrist or a specialist in the patient's medical condition.

“At least one of these consulted physicians needs to be a psychiatrist or a specialist in the patient's medical condition.”

• cites LawNot checked yet

  Not checked in the free run.

Probably not a substantial claim: may not pass S2 (checkable), S4 (based).

The constant nature of the suffering can be operationalised when taking into account the origin, evolution, and continuity of the suffering.

“The constant nature of the suffering can be operationalised when taking into account the origin, evolution, and continuity of the suffering.”

Classified as probably not a substantial claim.

The attending physician is required to ascertain that the patient has had the opportunity to discuss the euthanasia request with the persons whom she wants to talk to.

“However, the attending physician is required to ascertain that the patient has had the opportunity to discuss the euthanasia request with the persons whom she wants to talk to.”

• cites Euthanasia LawNot checked yet

  Not checked in the free run.

Classified as probably not a substantial claim.

According to the Euthanasia Law, euthanasia is only allowed if the patient is in a condition of constant and unbearable physical or psychological suffering that cannot be alleviated.

“According to the Euthanasia Law, euthanasia is only allowed if the patient is in a condition of constant and unbearable physical or psychological suffering that cannot be alleviated.”

• cites The Euthanasia LawNot checked yet

  Not checked in the free run.

Classified as probably not a substantial claim. May combine two claims.

The Euthanasia Law requires the consulted physicians to be independent but does not specify how this is to be understood.

“The Euthanasia Law requires the consulted physicians to be independent but does not specify how this is to be understood.”

• cites Euthanasia LawNot checked yet

  Not checked in the free run.

Classified as probably not a substantial claim. May combine two claims.

Addressing underlying reasons could lead to a strong relationship of trust that may include the risk of transference and countertransference, which may decrease objectivity and independent judgment.

“This could lead to a strong relationship of trust that may include the risk of transference (i.e. the euthanasia request and procedure may provoke feelings in the patients) and countertransference (i.e. the patient's euthanasia request may provoke feelings in the physician), that may decrease the objectivity and independent judgment.”

Probably not a substantial claim: may not pass S4 (based).

Establishing the causal relationship between the patient's medical condition and her suffering is a complex task, even for experienced psychiatrists.

“Obviously, establishing this causal relationship is a complex task, even for experienced psychiatrists.”

Classified as probably not a substantial claim. May combine two claims.

The role of the second consulted psychiatrist should be strictly limited to evaluating the legal due care criteria, with specific attention to the non-alleviability of the suffering, to reduce the risk of bias due to (counter)transference.

“Hence, the role of the second consulted psychiatrist should be strictly limited to evaluating the legal due care criteria, with specific attention to the non-alleviability of the suffering.This should reduce the risk of bias due to (counter)transference.”

Classified as probably not a substantial claim.

If the prominent role of evaluating the causal relationship between the patient's medical condition and her suffering is entrusted to the attending physician alone and not also to the two legally required consulted physicians, it can be problematic if the former is not a psychiatrist.

“If this prominent role is entrusted to the attending physician alone and not also to the two legally required consulted physicians, it can be problematic if the former is not a psychiatrist.”

Classified as probably not a substantial claim.

The rationale behind the two-track approach is that it should not be ruled out that the euthanasia request is a cry for help and the result of suffering that might be adequately addressed by other means.

“The rationale behind this two-track approach is that it should not be ruled out that the euthanasia request is a cry for help and the result of suffering that might be adequately addressed by other means.”

• AssumptionRests on an assumption: The euthanasia request might be a cry for help and the result of suffering that might be adequately addressed by other means.

Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based). May combine two claims.

The evaluation of the legal requirement of incurability is left to the expert opinion of the physician involved as it should be based on the current state of the art of medicine.

“The evaluation of the legal requirement of incurability is left to the expert opinion of the physician involved as it should be based on the current state of the art of medicine.”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

The concept of 'no reasonable treatment perspective' was introduced to address the problem of incurability, and had earlier been proposed and explained in the former guideline of the Dutch Psychiatric Association.

“In some of the guidelines, to address this problem, the concept of 'no reasonable treatment perspective' was introduced, which had earlier been proposed and explained in the former guideline of the Dutch Psychiatric Association (Tholen et al., 2009).”

• cites Tholen et al., 2009Not checked yet

  Not checked in the free run.

Probably not a substantial claim: may not pass S3 (load-bearing).

The advices issued by the consulted physicians are merely advisory.

“The advices issued by the consulted physicians are merely advisory (Delbeke, 2011(Delbeke, , 2012;;Vansweevelt, 2003).”

• cites Delbeke, 2011 sourceNot checked yet

  Not checked in the free run.

• cites [2012]Not checked yet

  Not checked in the free run.

• cites Vansweevelt, 2003Not checked yet

  Not checked in the free run.

Probably not a substantial claim: may not pass S4 (based). May combine two claims.

An interpretative dialogue with the patient's family members and/or important others gives all actors a deeper insight into the patient's social context and background, and it might reveal opportunities to strengthen meaningful relationships, communication, and commitment.

“However, an interpretative dialogue with the patient's family members and/or important others gives all actors a deeper insight into the patient's social context and background, and it might reveal opportunities to strengthen meaningful relationships, communication, and commitment.”

May combine two claims.

The Euthanasia Law stipulates that no physician may be forced to perform euthanasia and that no other person may be obliged to assist in performing euthanasia.

“In order to balance the respect for the autonomy of the patient who requests euthanasia and the physicians' freedom of conscience and professional autonomy, the Euthanasia Law stipulates that no physician may be forced to perform euthanasia and that, similarly, no other person may be obliged to assist in performing euthanasia.”

• cites Euthanasia LawNot checked yet

  Not checked in the free run.

Probably not a substantial claim: may not pass S3 (load-bearing).

If there is doubt as to whether the legal criteria were met, the Commission can by a majority decision decide to open the part which contains the names and addresses of the patient, the attending physician, the consulted physicians, and the other consulted persons.

“If there is doubt as to whether the legal criteria were met, the Commission can by a majority decision decide to open the part which contains the names and addresses of the patient, the attending physician, the consulted physicians, and the other consulted persons.”

• cites LawNot checked yet

  Not checked in the free run.

Probably not a substantial claim: may not pass S4 (based). May combine two claims.

Exploring the underlying reasons for a euthanasia request might open the door for transference and countertransference, and decision making may be seriously affected by such occurrences.

“Considering that exploring the underlying reasons for a euthanasia request might open the door for transference and countertransference, decision making may be seriously affected by such occurences.”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

The anonymous part of the report includes information on the nature of the condition, the nature of the patient's suffering, the reasons why this suffering could not be alleviated, the elements that assured the physician of the voluntary, well-considered, and repeated nature of the request, whether the patient was expected to die within the foreseeable future, and the capacity of all persons and,

“The anonymous part includes information on: 1) the nature of the condition from which the patient suffered; 2) the nature of the patient's suffering; 3) the reasons why this suffering could not be alleviated; 4) the elements that assured the physician of the voluntary, well-considered, and repeated nature of the patient's euthanasia request; 5) whether the patient was expected to die within the”

• cites LawNot checked yet

  Not checked in the free run.

Classified as probably not a substantial claim. May combine two claims.

During the assessment of the euthanasia request, relatives and important others need to be informed regarding the euthanasia procedure, the patient's life perspectives, and the physician's final decision regarding granting or refusing the euthanasia request.

“During the assessment of the euthanasia request, these actors need to be informed regarding: 1) the euthanasia procedure; 2) the patient's life perspectives; and 3) the physician's final decision regarding granting or refusing the euthanasia request.”

Probably not a substantial claim: may not pass S3 (load-bearing).

In accordance with the Law, the Federal Control and Evaluation Commission for Euthanasia is composed of 16 members, appointed on the basis of their knowledge of, and experience with, issues surrounding euthanasia.

“In accordance with the Law, the Federal Control and Evaluation Comission for Euthanasia is composed of 16 members, appointed on the basis of their knowledge of, and experience with, issues surrounding euthanasia.”

• cites LawNot checked yet

  Not checked in the free run.

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

After the euthanasia has been performed, appropriate aftercare is important to deal with the grief and to soften the mourning, but this aspect receives little attention in the guidelines.

“After the euthanasia has been performed, appropriate aftercare is important to deal with the grief and to soften the mourning.However, this aspect receives little attention in the guidelines.”

Probably not a substantial claim: may not pass S3 (load-bearing).

The Euthanasia Law requires that, if the attending physician believes that the patient is not expected to die within the foreseeable future, a waiting period of at least one month should be respected between the patient's written request and the performance of euthanasia.

“The Euthanasia Law requires that, if the attending physician believes that the patient is not expected to die within the foreseeable future, a waiting period of at least one month should be respected between the patient's written request and the performance of euthanasia.”

• cites Euthanasia LawNot checked yet

  Not checked in the free run.

Probably not a substantial claim: may not pass S3 (load-bearing).

If upon this examination the Commission decides with a two-thirds majority that the legal criteria have not been met, it is required to refer the case to the Public Prosecutor.

“If upon this examination the Commission decides with a two-thirds majority that the legal criteria have not been met, it is required to refer the case to the Public Prosecutor.”

• cites LawNot checked yet

  Not checked in the free run.

Probably not a substantial claim: may not pass S3 (load-bearing).

The Law stipulates that the attending physician must submit a report within four days after the euthanasia has been performed.

“The Law stipulates that the attending physician must submit a report within four days after the euthanasia has been performed.”

• cites LawNot checked yet

  Not checked in the free run.

Probably not a substantial claim: may not pass S2 (checkable).

One cannot readily transpose existing guidelines from one jurisdiction to another.

“one cannot readily transpose existing guidelines from one jurisdiction to another.”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

Some of the differences between the guidelines reflect different ethical stances towards euthanasia, while others reflect differences in views regarding the practical implementation of the legal due care criteria.

“Some of the differences between the guidelines reflect different ethical stances towards euthanasia, while others reflect differences in views regarding the practical implementation of the legal due care criteria”

Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based). May combine two claims.

Although cases of euthanasia for psychological suffering are still rare, the number is increasing.

“Although cases of euthanasia for psychological suffering are still rare, the number is increasing.”

Probably not a substantial claim: may not pass S4 (based).

Different guidelines might lead to patients directly contacting the end-of-life centers (which take a more permissive approach) at their own initiative, without discussing it first with their treating physician.

“they might also lead to patients directly contacting the end-of-life centers (which take a more permissive approach) at their own initiative, without discussing it first with their treating physician.”

Classified as probably not a substantial claim. May combine two claims.

Different guidelines (some more restrictive than others) may put at risk the uniformity of the physician's own approach regarding practice of euthanasia for psychological suffering involving psychiatric patients and of the patients' right of equality in mental health care.

“different guidelines (some more restrictive than others) may put at risk the uniformity of the physician's own approach regarding practice of euthanasia for psychological suffering involving psychiatric patients and of the patients' right of equality in mental health care”

• AssumptionRests on an assumption: Equality does not require uniformity of treatment for all patients, but rather receiving a treatment that conforms to the regulatory framework and is tailored to the specific situation of the patient.
• AssumptionRests on an assumption: Every patient is entitled to an equal consideration of her (medical) interests.

May combine two claims.

Only a minority of physicians are willing to perform euthanasia for psychological suffering, although the number is increasing over time.

“only a minority of physicians are willing to perform euthanasia for psychological suffering (although the number is increasing over time)”

• cites Bolt, Snijdewind, Willems, van der Heide, & Onwuteaka-Philipsen, 2015 sourceNot checked yet

  Not checked in the free run.

• cites Kouwenhoven et al., 2013 sourceNot checked yet

  Not checked in the free run.

Probably not a substantial claim: may not pass S4 (based). May combine two claims.

A potential 'revolving door' scenario, in which a treating physician who is opposed to euthanasia refers the patient to potential attending or consulted physicians assuming that they will refuse or advise negatively, might increase feelings of despair and suicidal ideation in the patient and may prompt patients to shop around for physicians willing to get involved in the euthanasia procedure.

“This scenario might increase feelings of despair and suicidal ideation in the patient and may prompt patients to shop around for physicians who are willing to get involved in the euthanasia procedure.”

May combine two claims.

The euthanasia case that has been referred to the Belgian public prosecutor in 2015, as well as strong disagreement between some of the end-of-life consultation centers regarding different approaches in the management of euthanasia requests, have contributed to the need for more ethical reflection and transparency on the clinical practice regarding euthanasia based on psychological suffering.

“the euthanasia case that has been referred to the Belgian public prosecutor in 2015, as well as strong disagreement between some of the end-of-life consultation centers regarding different approaches in the management of euthanasia requests (Cheng, 2017), have contributed to the need for more ethical reflection and transparency on the clinical practice regarding euthanasia based on psychological”

• cites Cheng, 2017Not checked yet

  Not checked in the free run.

• cites Haekens, Calmeyn, Lemmens, Bazan, & Van de Vijver, 2017Not checked yet

  Not checked in the free run.

Probably not a substantial claim: may not pass S4 (based).

Mental disorders can vary greatly from patient to patient, even among those who are diagnosed with the same disorders.

“Mental disorders can also vary greatly from patient to patient, even among those who are diagnosed with the same disorders.”

May combine two claims.

As prisoners have the same rights to medical care as any other Belgian citizen, they can also request, and die by means of, euthanasia.

“As prisoners do have the same rights to medical care as any other Belgian citizen, this implies that they can also request, and die by means of, euthanasia.”

• AssumptionRests on an assumption: Prisoners have the same rights to medical care as any other Belgian citizen.

Probably not a substantial claim: may not pass S3 (load-bearing).

Due to the variety in severity of the mental disorders, the patient's treatment may take place in a variety of settings (ambulant versus residential in- or outpatient psychiatric treatment) in the absence of a one-size-fits-all approach.

“due to the variety in severity of the mental disorders, the patient's treatment may take place in a variety of settings (ambulant versus residential in-or outpatient psychiatric treatment) in the absence of a one-size-fits-all approach.”

Probably not a substantial claim: may not pass S4 (based).

As a consequence of the DSM-5 position, the former distinction between Axis I (all clinical psychiatric disorders except personality disorders and mental retardation) and Axis 2 (personality disorders and mental retardation) was abandoned.

“the former distinction between Axis I (all clinical psychiatric disorders except personality disorders and mental retardation) and Axis 2 (personality disorders and mental retardation) was abandoned.”

Probably not a substantial claim: may not pass S3 (load-bearing).

The current DSM-5 indicates that an insufficient scientific basis exists to make distinctions in the type of mental disorders via the multi-axial system.

“the current DSM-5 indicates that an insufficient scientific basis exists to make distinctions in the type of mental disorders via the multi-axial system.”

• cites DSM-5Not checked yet

  Not checked in the free run.