Capacity is only one aspect of decision-making at life's end

The editorial by Shaw et al in the July edition discussing decision-making capacity to request assisted suicide follows on from a previous report from Belgium also published in the journal entitled ‘When unbearable suffering incites psychiatric patients to request euthanasia: qualitative study.’^{1, 2} There seem to have been no balancing editorials or reports on the merits of effective palliative care in individuals who are terminally ill or in those suffering unbearably. This must be the hand of the editor because it definitely is not the hand of God! Assisted suicide and euthanasia are legal in a minority of jurisdictions. They are illegal in the UK. Everyone knows there is a concerted drive by some to foist death by design on those that will not die when they become a nuisance.

The issue of capacity as a stand-alone faculty of itself is a faulty basis for determining a person's true desires. We all know too well that we often do not do the things we should (even though we have capacity) and end up doing the things we do not want to do – such is our state. This is not a lack of capacity but of ability to follow through on what we wish, and it overrides our decision-making capacity. The human will can cloud our cognition/capacity into doing what it wants. Lying, denial, self-delusion, self-justification are among the many ploys the will uses to suppress capacity, and with it the good, the beautiful and the true are suppressed.

Conscience is also active in decision-making. Issues of end-of-life care are laden with conscience issues. ‘Should I? Shouldn't I? What do people want me to do? I'm a burden on my family’. People at the last stages of life or who are grievously suffering, are at their most vulnerable and are easily swayed one way or another, and may not have the ability to harness their will power, clarity of thought (capacity) and conscientious understanding of what is at stake. What they are being offered is death by design (assisted suicide/euthanasia) not a new lease of life or some other positive intervention, like effective palliation and hope and support.

Everyone spends their lives living, and their behaviour/body language and drive is to live and make the most of life. Now in the closing moments should they not be helped to persevere in their lifelong goal, rather than be defrauded in a definitive decision by a faulty concept of decisional ability? Informed consent and freedom from duress or subliminal or liminal influence along with cognition, emotions, conscience and the enormous impact of a life lived over decades all come into play in crucial decision-making at life's closing moment (days, weeks, months). Capacity is only one of these many faculties (and not the most important) involved in late life decision-making.