The Pursuit of Death on Psychiatric Grounds
Around a decade ago, a patient in the Netherlands went to his doctor with a request for euthanasia. He was in his 40s, suffering from depression and psychosis, and haunted by feelings of despair, which treatments had not relieved. As Dorothea Touwen, a medical ethicist who reviewed his case, later recalled, his physician agreed that no more could be done. So, as permitted by Dutch law, he received drugs to end his life — likely a coma-inducing drug followed by a medication that stopped his breathing.
For Touwen, who used to regularly analyze reports of death by euthanasia, it was one of the first times she’d encountered a euthanasia case for mental health reasons from someone so young. “When you’re 40 and otherwise healthy, there’s so much life that you take away by deciding to want to die,” she told Undark. Yet, the man’s relative youth meant he also faced years of suffering if denied access to medically assisted death. The committee agreed that the doctor’s decision had been correct and had met the requirements of the law.
But the case stuck in Touwen’s mind.
“I have thought of it again, because in the past few years of course we’ve seen several cases of even younger patients — sometimes even teenagers. And I don’t doubt the integrity of the physicians who work with these people and in the end decided to give them euthanasia,” she said. “But at the same time, I am worried.”
Today, around a dozen countries and 11 U.S. jurisdictions allow euthanasia or some form of assisted dying, usually when a person is terminally ill; politicians in the United Kingdom recently voted in support of a proposal to legalize the practice. In the Netherlands, cancer is the most common reason why people choose to end their lives, but Dutch law also allows physician-assisted death in cases of mental suffering, alongside Belgium, Spain, Luxembourg, and Switzerland, which also permit the practice on psychiatric grounds.
In recent years, Dutch psychiatrists have seen a steep upswing in requests for medical assistance in dying, or MAID, on psychiatric grounds, rising from an average of about 30 per year from 2012 to 2018 to 895 in 2023 — though some research suggests those numbers are likely an undercount. (Just a fraction of these requests were granted and pursued.) Some clinicians are concerned about the number of young people seeking the procedure, and want to put more guardrails in place, like a higher age requirement. Others, meanwhile, are calling for fewer barriers, arguing that euthanasia is the most humane approach when a patient is experiencing treatment-resistant mental anguish. And others are calling for balance — not for an age limit, but for more rigorous criteria for younger patients.
Experts in other countries are watching the debate. In February of last year, after a previous delay and just weeks before the policy was due to roll out, Canada, which currently allows medical assistance in dying for patients with deteriorating health due to a serious illness or disability, delayed legalizing euthanasia for patients suffering solely from mental health conditions for three years in order to introduce guidelines and give clinicians time for training and education. A former president of the Canadian Psychiatric Association described the practice as “providing death under false pretenses to many individuals who would have improved.”
To Touwen, euthanasia is still a valid option for patients with psychiatric disorders, even though it presents the hardest of ethical choices. It is sensitive, “due to the fact that psychiatric illness does something with your brain and your way of thinking, and possibly with your ability to decide and to weigh your interests,” she said. “There’s always, always this question: Did this person really want to die, or was the wish to die a symptom of his disease?”
In the Netherlands, the vast majority of euthanasia cases in 2023 were carried out by general practitioners, who must obtain a second opinion from an independent clinician and determine that the patient’s suffering is “unbearable, with no prospect of improvement.”
All cases are reviewed by regional boards like the one Touwen sat on, which retrospectively assess whether the medically assisted death was done according to protocol. In 2023, out of roughly 9,000 cases, most in patients with cancer, there were five in which the ethics boards deemed due care had not been taken, opening the physician up to potential criminal liability and up to 12 years in prison.
“There’s always, always this question: Did this person really want to die, or was the wish to die a symptom of his disease?”
But euthanasia on psychiatric grounds is more complicated to obtain. In 2018, the Dutch Psychiatric Association published updated guidelines specifically for mental health requests, such as advising clinicians to check whether a patient’s loved ones are aware of their request. Doctors and psychiatrists wary of the procedure increasingly refer patients to the Expertisecentrum Euthanasie, or the Euthanasia Expertise Center, an organization that offers assisted death and also gives doctors training and support; protracted waiting lists at the center mean it may take months or years before a patient is evaluated. Despite the delays, the country has seen a gradual rise in the number of procedures as demand has increased. In 2023, there were 138 cases of euthanasia on psychiatric grounds, up from 68 cases in 2019.
Experts stress that most people — up to nine out of 10 — ultimately withdraw their requests. Still, between 2020 and 2023 there were 52 cases involving patients under 30, including three 18-year-olds, a 17-year-old, and a 16-year old, according to figures cited in parliament. (The law allows euthanasia for minors aged 12 and up with parental consent, and from the age of 16 as long as parents are involved.)
Jim van Os, a psychiatrist and professor at the University Medical Center Utrecht, questions whether teens whose brains are still developing can ever meet the legal criteria. “In the case of adolescents, I think per definition there is an issue of capacity,” he said. “So the capacity to sort of oversee your decision in a broader perspective.”
Researchers have also noted a rise in young women seeking euthanasia. The number of women under 30 who underwent euthanasia on psychiatric grounds rose from three in 2020 to 17 in 2023.
In 2022, Astrid van Kleef’s daughter, Nicole, was among those young people who underwent euthanasia at the Euthanasia Expertise Center. As a teen, Nicole experienced violent sexual assault, which led to anorexia, complex PTSD, and a dissociative disorder. As a young adult, she was assaulted again. She also received an autism diagnosis in 2021. Nicole studied nutrition in college — “She was very clever,” van Kleef recalled — but battled depression and struggled to get her practice off the ground. She tried medication, and even residential treatment, but in January 2021 confided in her mom that she had applied for euthanasia.
Van Kleef was devastated. “First I couldn’t believe it, and then I was convinced, we will change things,” she said. “But what is most important about people who cannot live and don’t want to live or cannot live this life anymore, you have to listen to them.”
Many Dutch psychiatrists see euthanasia as having profound value. One of its more vocal exponents is Menno Oosterhoff. In 2023, he co-authored a book called “Laat Me Gaan,” or “Let Me Go” with psychiatrist Kit Vanmechelen, describing the evolution of the Dutch approach to euthanasia on psychiatric grounds and what it involves. The book features diary entries by Esther Beukema, for whom Oosterhoff offered a second opinion before she underwent euthanasia in 2021 after a years-long struggle with her mental health (Beukema is listed as a co-author.)
In “Let Me Go,” Oosterhoff and Vanmechelen described their sense of responsibility as clinicians. “It is not an easy choice,” they wrote in Dutch. “Killing someone who still has years to live is no small thing, but leaving someone to a fate of (a high probability of) years of unbearable suffering or suicide is not either.”
Despite delays, the Netherlands has seen a gradual rise in the number of procedures as demand has increased. In 2023, there were 138 cases of euthanasia on psychiatric grounds, up from 68 cases in 2019.
After the book’s release, Oosterhoff said he was besieged by requests and carried out 13 euthanasia procedures that year. “More than once a week I’m called by someone who is desperate and, when I have to say no, it’s very difficult,” he said. In certain cases, he views their suffering as equal to that caused by any physical disease — and for patients whose symptoms are resistant to other treatment, sees their conditions as terminal. “Psychiatric disorders are very often chronic disorders, we can’t treat them,” he said. “It would be much nicer when we could make people healthy again, but when we can’t, it’s good that we can help them,” in another way.
Oosterhoff co-founded the KEA Foundation, the Knowledge Center for Euthanasia for Psychological Conditions, which aims to reduce suicides and “put euthanasia for mental illnesses on the map,” according to a translation of the foundation’s website, which is written in Dutch. Oosterhoff points out that there are currently about 1,900 suicides per year in the Netherlands compared with 138 cases of euthanasia on psychiatric grounds. “A lot of the suicides are not impulsive,” he said. With better access to euthanasia, he said, “I think that then the number of suicides will go down,” though he noted he cannot prove that’s the case.
Touwen — who, as a medical ethicist, does not treat patients — noted that suicidal ideation forms part of many psychiatric conditions. She has heard of patients who, once they began discussing euthanasia with their doctor, felt understood, allowing them to recover or at least cope with their lives. But some psychiatric patients do kill themselves, she said. “And I think the grief and sorrow of the people who are left behind may be worse if they come home and find their beloved child hanging from a rope than when they are involved in this whole process, and know that this person felt being heard and felt being cared for and looked after, and then chose death.”
Yet whether allowing access to euthanasia on psychiatric grounds prevents suicide is unclear. And van Os said that managing suicidal risk is standard in psychiatry. “Fifty percent of patients with mental disorders, particularly severe mental disorders, are suicidal,” van Os said. “There’s nothing new of managing suicidal risk in people.”
The suicide risk is highest among older men who have health issues and live alone, he observed. Although they are more likely to experience mental health disorders, young women are at comparatively lower risk for suicide, he said. Yet van Os’s experience suggests that “the group who is asking for euthanasia are young women.”
The reason behind those rising requests is unclear. Some point to recent government administrations’ disinvestment from mental health services for Dutch youth: Touwen told Undark that services have markedly declined as a result and waitlists for treatment have lengthened.
“We know that that can cause copycat effect, or that can be alluring to other people who are struggling at this point.”
Some psychiatrists, too, say that denying euthanasia requests can negatively affect relationships with patients. When van Os thinks patients do not meet the criteria, they can seek out psychiatrists who are willing to carry it out, he said: “Whilst I’m doing my therapeutic bit, already I’m undermined because a door has been opened by so-called progressive colleagues who have websites saying, ‘It’s beautiful and come here and it can be done.”
Clinicians and researchers also note that media coverage may play a role. When the media highlights accounts of euthanasia on psychiatric grounds, these experts say, the number of requests tends to flare up in the wake. In contrast with suicide, media guidelines for reporting about euthanasia — created by the Euthanasia Expertise Center — were only recently introduced, according to Sisco van Veen, a psychiatrist who has analyzed the media’s portrayal of the topic. The guidelines urge reporters to provide a realistic picture and take care not to romanticize euthanasia. “We know that that can cause copycat effect, or that can be alluring to other people who are struggling at this point,” van Veen said.
After Oosterhoff appeared on a 2023 talk-show episode discussing the euthanasia of a 17-year-old girl, a debate flared over how the media portrays euthanasia on mental health grounds. A group of psychiatrists, including van Os, wrote to the Dutch Public Prosecution Service about their concerns. A battle ensued within the profession. Translating what the Dutch newspaper NRC reported at the time: “Psychiatrists threaten each other with disciplinary complaints and demand apologies.”
But to families, it was painful to witness a public skirmish about their most personal dilemmas. Dutch society should raise questions, Nicole’s mother, Astrid, said, “but discuss it with your own group, and maybe discuss it with somebody from the government, but not by media.”
In 2021, Astrid took her daughter on a holiday in the Caribbean, where they had numerous conversations about Nicole’s struggles. Two weeks in, Astrid flew home as they’d planned, while Nicole stayed on with a friend. When Astrid’s husband picked her up from the airport, she said, “I told him, ‘OK, I understand her. I know we cannot solve this. I know we’re going to lose her.’”
A doctor and psychiatric nurse were assigned to Nicole’s case, and clinicians from the Euthanasia Expertise Center met several times with the family as the date approached. In November 2022, the medication was dispensed by injection in Astrid’s home. A doctor and nurse were present, along with two therapists, and Nicole’s close loved ones. They clinked champagne glasses, and toasted to love and life, before family and friends left the room for the procedure.
More than two years on, reflecting on her daughter’s death, van Kleef recalled telling one of the psychiatrists that she understood her daughter’s decision. “Who am I to ask for my daughter to keep on living?” she had told the counselor. “You cannot even go to live just for me. It’s love to let her go.”
In October, a Dutch politician asked parliament to create a committee that would review policy on euthanasia on psychiatric grounds, and investigate the mental health alternatives available to young people. Dutch medical associations responded by stating that politics should not take the place of doctors.
The Dutch Psychiatric Association is now in the early stages of reviewing its guidelines, with age limit under scrutiny, according to van Veen. Van Os said he thought a higher age limit would emerge, banning euthanasia on psychiatric grounds for patients younger than 25 or 30. But others are wary of how explicit restrictions would play out in practice. Van Veen, who is head of the guidelines committee but spoke in a personal capacity, told Undark that he did not feel a strict age limit was appropriate. Instead, young people might be treated a special group — “and say, ‘OK, if somebody under 30 requests MAID, these are the extra due diligence criteria we want you to follow.’”
He added, “We need a more rigorous due diligence procedure for a 20-year-old with depression, as compared to an 80-year-old with terminal cancer,” he said. “And I think everybody intuitively knows that.”
“Who am I to ask for my daughter to keep on living?”
The debate hasn’t been confined to the Netherlands: In addition to Canada’s decision to put the policy on hold, Belgium, which has similar legislation to the Netherlands, is seeing similar friction. A few years ago, a family took legal action against doctors who performed euthanasia on a 38-year-old woman who had suffered from depression. This had a chilling effect on Belgian clinicians, said Kenneth Chambaere, a sociologist who does research on end of-life care.
In the Netherlands, questions about the policy generally receive a cautious welcome. After eight years on regional euthanasia review committees, Touwen recalled that even when the terms of the law were met, she was sometimes left with doubts. As an ethicist, her role was to ask questions, including uncomfortable ones: “Is this a good thing?” And: “Do we think this was the right thing to do?”
As to whether these decisions may be harder now than they were when she stepped down in 2020, she didn’t say. “Is it more complicated now?” she asked. “Well, it was already complicated. It is still complicated.”
If you or someone you know needs help, the national suicide and crisis lifeline in the U.S. is available by calling or texting 988. There is also an online chat at 988lifeline.org.