In Belgium and the Netherlands, euthanasia is legally possible for patients with intolerable physical and/or mental suffering that cannot be relieved and is due to an incurable medical condition. If the condition in not terminal, extra precautions are demanded. Psychiatric conditions are not excluded and can legally qualify after explicit, deliberate, well considered and repeated request.

Using ethical analysis, we aim to determine the problems that arise and precautions that are needed if euthanasia is requested and considered in patients with intolerable suffering due to a psychiatric condition.

Four problems arise that are specific for or more acute in those situations.

1. (1) Distinguishing whether the death wish is a symptom or a deliberate well considered choice parallels the assessment of decision making capacity.

2. (2) Distinguishing the face value of the request from the implicit meanings and interpersonal dynamics underlying the request.

3. (3) If the psychiatric condition is not progressive and degenerative, evolution and prognosis is uncertain and future partial recovery and relief remains a possibilty.

4. (4) The process of carefully evaluating a euthanasia request inevitably takes time, in the meantime undermining hope and orientation toward life, both crucial to safeguard the chances for partial recovery.

A stepwise approach is presented that takes these four problems into account.

From an ethics of care perspective, extra precautions and evaluations are necessary beyond the judicial framework when dealing with a euthanasia request from a patient with intolerable suffering due to a psychiatric condition.