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Why extra caution is needed in the case of depressed patients
  1. Govert den Hartogh
  1. Correspondence to Dr Govert den Hartogh, Department of Philosophy, University of Amsterdam, Amsterdam 1012GC, The Netherlands; g.a.denhartogh{at}

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It is disputed whether ‘depression’ refers to a set of closely related psychiatric illnesses characterised by a similar aetiology, or only to a family of symptoms, resulting from very different underlying conditions. Whatever it is, one of its most common symptoms is a mood disturbance: the patient is extremely unhappy, and his negative emotions cannot be understood as an appropriate response to his actual condition or events that have happened in his life. Death wishes are one common expression of this mood disturbance. That is one reason to doubt whether the patient's decision can be considered sufficiently competent to require to be respected. (Or even as ‘voluntary’ enough, but I will set that difficult issue aside.)

Schuklenk and van de Vathorst object that although the judgements about the future made by depressed patients are, given the same evidence, more negative than other people's judgements, it is still controversial whether they are inaccurate.1 But the study they quote as their authority for this statement argues that this is only true as regards the whole population of depressed patients. People with high scores on depressive symptoms really are unduly pessimistic and have difficulty discriminating between more and less likely events. But even if their characteristically negative judgements could still be seen as sufficiently sensitive to evidence, that would not be enough to attribute decision-making authority to them, because decisions do not only depend on judgements but also on affective states, and in their case these are distorted by mood disturbances.

There is a second reason for being restrained in respecting the choice for death of chronically depressed people. Characteristic for such death wishes is a high level of ambivalence, and this explains why so many people after a failed attempt to kill themselves feel grateful …

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  • Competing interests None declared.

  • Provenance and peer review Commissioned; internally peer reviewed.

  • iThe authors make some helpful observations about what should count as a ‘realistic appreciation’.

  • iiExtra caution in the case of psychiatric patients has been required by the Dutch High Court in the famous Chabot case, 21 Jun 1994.

  • iiiSee, for example, ref. 3. The right to decide by what means and at what point his life will end has been recognized by the European Court of Human Rights in Haas v Switzerland, 20 Jan 2011.

  • ivIn particular, case 2011-134404, and five cases in 2013 in which a psychiatrist in his capacity of independent consultant had voiced such doubts, but the reporting doctor had simply approached another consultant, not a psychiatrist.

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