The most controversial issue in the Dutch euthanasia practice concerns the performance of euthanasia in a case of a patient in an advanced state of dementia on the basis of a request that is laid down in an advance directive. This is particularly controversial when such a patient, although lacking decisional capacity on the matter, shows signs of a wish to live. In two important verdicts of April 21 2020 the Dutch Supreme Court has ruled that a request that has been made competently cannot be revoked incompetently. In this comment I consider two recent documents from Dutch professional organisations that are contrary to these decisions, in particular a guideline stating that on a proper understanding of decisional capacity the expression of a wish to live of a demented person, however inarticulate, should always be considered to be made competently.

The experience of serious illness or injury frequently results in increased vulnerability. In cases in which decision-making capacity is compromised, this vulnerability is compounded by threats to a patient\'s autonomy. This case report presents an opportunity to explore the elaborately entwined relationship between autonomy and vulnerability in patients with severe impairment who are reliant on surrogate decision-makers. Expanded views of autonomy and vulnerability are applied to the case of a young woman with a severe and life-altering spinal cord injury and iatrogenic loss of decisional capacity to illustrate how one can experience enhanced autonomy despite special vulnerability and can be made less vulnerable through surrogate-mediated autonomy. Also revealed is how attitudes and actions of surrogates can potentiate pathogenic vulnerability and disturb the balance between patient autonomy and vulnerability. Through methodical review and robust deliberation, clinical ethics committees can play a stabilizing role in helping distressed care teams reconcile the two.

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