Willingness of Dutch general practitioners to grant and perform Euthanasia and Assisted Suicide: A mixed methods study comparing psychiatric and somatic cases and the factors guiding their decisions

Abstract Background The Netherlands legalized euthanasia and assisted suicide (EAS) in 2002, permitting requests from both somatic and psychiatric patients under strict conditions. However, physicians are not obligated to comply. General practitioners (GPs), who receive most EAS requests, play a central role in this process. Although EAS for somatic conditions is common in the Netherlands, psychiatric EAS remains relatively rare and controversial, despite a growing number of requests. This study explores how Dutch eneral practitioners willingness to grant and perform EAS requests differs between psychiatric and somatic patients and compares the underlying decision-making processes. Methods A concurrent mixed-methods design was employed, combining a quantitative survey and qualitative interviews. The survey included sociodemographic and attitudinal questions, experience with EAS, and six randomized vignettes varying by somatic and psychiatric diagnosis (cancer, depression) and method (euthanasia or assisted suicide) to examine willingness to perform EAS. Semi-structured interviews explored GPs reasoning and experiences in more depth. Results GPs were significantly less likely to grant psychiatric than somatic EAS requests (OR = 0.02, 95% CI 0.009–0.04). Religious GPs were less likely to approve EAS (OR = 0.31, 95% CI 0.11–0.85), and euthanasia was favored over assisted suicide (OR = 2.3, 95% CI 1.31–4.03). Psychiatric diagnosis type and prior experience receiving psychiatric requests showed no significant effect. Willingness to perform EAS was higher for somatic (95.1%) than psychiatric cases (45.6%). Prior experience performing psychiatric EAS was associated with a lower likelihood of restricting their willingness to somatic cases alone (OR = 0.15, 95% CI 0.02–0.73). Interviews underscored the greater complexity of psychiatric EAS, citing challenges in assessing due care criteria, empathizing with requests, ethical dilemmas, extended processes, and lack of confidence. Psychiatric cases were more often referred to specialists. Conclusions Dutch GPs are less willing to grant and perform EAS for psychiatric patients compared to somatic ones. This may reflect difficulties assessing due care criteria, clinical uncertainty, difficulties empathizing, prolonged processes and ethical complexity, highlighting the need for clearer guidelines, targeted training, and stronger support for GPs involved in psychiatric EAS.