Willingness of Dutch general practitioners to grant euthanasia and assisted suicide requests: a comparative study of physical and mental health conditions.

backgroundThe Netherlands legalised euthanasia and assisted suicide (EAS) in 2002, permitting requests from both physical and mental health conditions under strict conditions. However, physicians are not obliged to comply. General practitioners (GPs), who receive most EAS requests, play a central role in the process of evaluating and granting EAS requests from both patient groups. Although EAS for individuals with a physical health condition is common in the Netherlands, EAS for individuals with a mental health condition remains relatively rare and controversial, despite a growing number of requests. This study explores how Dutch general practitioners' willingness to grant and perform EAS requests differs between physical and mental health conditions and compares the underlying decision-making processes.

methodsA concurrent mixed-methods design was employed, combining a quantitative survey and qualitative interviews. The survey was completed by 103 GPs and included sociodemographic and attitudinal questions, experience with EAS, and six randomised case examples varying by physical and mental health condition (cancer, depression) and method (euthanasia or assisted suicide) to examine willingness to grant EAS requests. Semi-structured interviews with 13 GPs explored their reasoning and experiences in more depth.

resultsGPs were significantly less likely to grant EAS requests from individuals with a mental health condition compared to those with a physical health condition (OR = 0.02, 95% CI [0.009-0.04]). Religious GPs were less likely to grant requests (OR = 0.31, 95% CI [0.11-0.85]), and euthanasia was favoured over assisted suicide (OR = 2.3, 95% CI [1.31-4.03]). Diagnosis type and prior experience receiving requests from individuals with a mental health condition showed no significant effect. Willingness to perform EAS was higher for physical health conditions (95.1%) than for mental health conditions (45.6%). Prior experience performing EAS in individuals with a mental health condition was associated with a lower likelihood of restricting willingness to physical health conditions alone (OR = 0.15, 95% CI [0.02-0.73]). Interviews highlighted the greater complexity of EAS in the context of mental health, citing challenges in assessing due care criteria, empathising with requests, ethical dilemmas, extended processes, and lack of confidence. For requests from individuals with a mental health condition, GPs reported requiring additional input from mental health specialists and more often referred these cases to the Expertise Center Euthanasia (ECE).

conclusionsDutch GPs are less willing to grant and perform EAS requests from individuals with a mental health condition compared to those with a physical health condition. This may reflect difficulties in assessing due care criteria, clinical uncertainty, challenges in empathising, prolonged processes, and ethical complexity. These findings highlight the need for better implementation of existing guidelines in GP practice, alongside targeted training and stronger support for GPs-including timely access to psychiatric expertise and SCEN consultations, and close collaboration with the Expertise Center Euthanasia (ECE).