Autonomy Under Uncertainty: Are We Overestimating Decision-Making Capacity in Psychiatric End-of-Life Contexts?

The assessment of decision-making capacity is central to legal and ethical frameworksgoverning assisted dying. In psychiatric contexts, however, this assessment remainsparticularly complex. While current approaches emphasise procedural competence—understanding, reasoning, and expression of choice—growing concern exists that suchcriteria may not fully capture how psychopathology influences evaluative judgment. Thispaper examines a central controversy: whether existing frameworks risk overestimatingautonomy in patients with complex psychiatric conditions. Drawing on conceptual andempirical literature, it contrasts two perspectives: one that considers current safeguardssufficient, and another that highlights the epistemic limitations of capacity assessmentsin the presence of affective and trauma-related disturbances. The paper argues that thecore issue is not whether autonomy should be respected, but how it should be definedand operationalised in contexts where the processes underpinning valuation maythemselves be altered.