Those who support assisted dying for psychiatric conditions argue that mental illness can be just as serious as physical illness and that some people do not respond to treatment. That may be true, but its critics say this is evidence of the “slippery slope” that campaigners often cite, and that euthanasia is being normalised as a “treatment” for mental illness rather than a last resort for people who are terminally ill.
“I think everyone in psychiatry accepts euthanasia based on inhumane suffering, but it is still a last option,” says Damiaan Denys, professor of psychiatry at the University of Amsterdam and former chairman of the Dutch Psychiatry Association. “There is a worry it is getting too fast, too loose.”
Others argue the law does not go far enough – one Dutch campaign group, Coöperatie Laatste Wil, or Last Wish Cooperative, founded in 2013, is pushing for “last will drugs” or suicide kits to be widely available for people who choose to end their lives rather than continue to suffer.
Lisa is among those experiencing this anguish first hand. She has been an inpatient in a psychiatric hospital an hour outside Amsterdam since September. We meet in the dayroom, where she is filling out an adult colouring book. In her bedroom, the walls are covered with family photos and pictures her sons have drawn. A bouquet of pink and red flowers sits on her bedside table, left over from Mother’s Day.
She initially became ill while pregnant with her first child 10 years ago and has had periods of severe depression ever since – she has been separated from her family and hospitalised on more than one occasion. She says it gets “worse and worse every time. The last two times I also experienced psychosis.”
Treatments including medication, therapy, intensive inpatient treatment and electroconvulsive therapy (ECT) failed. She is so numb from medication that she cannot do the things that used to bring her joy, such as take her children to the zoo, ride horses, or walk the family dog.
Her world has been sapped of colour by her illness – either she is in a black hole of depression or a numb haze, dulled by medication, and everything is grey. “Most of the time, I feel flat,” she says. She requested euthanasia in March this year.
The Dutch story of death on demand began in 1973, when a Dutch GP named Truus Postma was prosecuted for injecting her terminally ill mother with a fatal dose of morphine. Her case sparked a nationwide debate about dignity in death and formed the basis of the the Termination of Life on Request and Assisted Suicide (Review Procedures) Act that came into force in 2002.
A person’s condition must be “unbearable with no prospect of improvement” with “no reasonable alternative” for them to access euthanasia in the Netherlands. This includes people with mental health issues who have exhausted reasonable treatment options but might still have a long life ahead of them.
There are safeguards in place. Requests for euthanasia must be signed off by at least two doctors – a primary physician and specialist (a Support and Consultation for Euthanasia in the Netherlands, or SCEN doctor) – and submitted to a regional board to check they have been carried out lawfully and with due care. For psychiatric cases, a further second opinion from an independent psychiatrist is required.
The Netherlands is one of only a handful of countries to legalise euthanasia for psychological conditions. Belgium passed a law in May 2002 that legalises the practice and assisted suicide for patients in a “futile medical condition of constant and unbearable physical or mental suffering that cannot be alleviated”.
In Luxembourg, it was legalised in 2008. In Canada, where Medical Assistance in Dying (MAID) was introduced in 2016, the criteria is set to expand to include those suffering from mental illness. Originally set for March 2023, then March 2024, a final decision has been pushed back to 2027.
As in Belgium, the Dutch law on assisted dying has never excluded psychological suffering from its remit. There is one record of a case as far back as 1993, before it was formally legalised. The doctor involved was found guilty of assisted suicide but no penalty was imposed.
The RTE releases an annual report detailing how many people have received euthanasia and for which conditions. In 2008, there were two for mental illness; in 2009, there were zero; and in 2010, there were two more.
The landscape changed with the foundation of the Expertisecentrum Euthanasie (EE) in the Hague in 2012. The clinic originated from the Dutch right to die society (NVVE) and offered consultations for people who had a request for assisted death rejected by their general practitioner or psychiatrist. By 2018, the EE was handling 84 per cent of all requests for an assisted death from psychiatric patients.