World

02.03.14

The Dutch Debate Doctor-Assisted Suicide For Depression

A controversial new clinic that helps the chronically depressed end their lives has The Netherlands wrestling with state-mandated euthanasia.

In 2001 the Dutch legalized euthanasia. Their law, which went into effect in 2002, allowed doctors to end the lives of their patients in the context of a state health care system that emphasized close consultation with family physicians over many years. The termination of life was supposed to be limited to those with “unbearable and hopeless suffering” whose mental faculties were not impaired and who had no other hope of relief.

But recent revelations about the way euthanasia is practiced by one group in The Netherlands, especially for those suffering from psychiatric illnesses, is making even the Dutch feel uncomfortable. The new debate raises questions about the way appointed commissions judge these life-ending practices, and echoes the kinds of ‘slippery-slope’ criticisms often made by right-wing and religious parties in the United States.

Under the Dutch law, the patient must ask repeatedly to die, a second doctor has to agree in writing that euthanasia is justified, and the post-mortem panel made up of a doctor, a jurist and an ethical expert have to confirm that the legal requirements were met. Although the 2002 law always left open the possibility that psychological pain could be sufficient justification for euthanasia, the focus was on those suffering from terminal cancer and similar excruciating physical conditions.

Ten years passed, and practices evolved. In early 2012 a group called the Life-Ending Clinic went into operation for people whose personal physicians refused to terminate their lives or assist their suicides. The clinic has since tested the boundaries of “unbearable suffering.” Among those it has helped to die: people with chronic depression and those who have signed their own euthanasia declaration in the early stages of dementia.

“We consider it self-evident that someone who is terminal can turn to euthanasia,” Life-Ending Clinic Director Steven Pleiter told The Daily Beast. “Now we are entering a phase in which there will be more debate about patients who are not terminally ill, among them psychiatric patients and those with dementia.”

Last year 749 people came to the Life-Ending Clinic with a euthanasia request, of which 133 were granted. Some of the clinic’s numbers are significantly higher than the national average. In its own press release, the clinic says: “The figures over 2013 show a strong growth of euthanasia in these groups.” Referred to are the clinic’s stats in terminating the lives of those with dementia, which totals 18 times the national average, and the psychiatric patients, which the clinic euthanized five times more often.

None of this has anything to do, directly, with Obamacare in the United States. But it does raise in bold relief the sorts of misgivings played on by right-wing politicians like Sarah Palin, who warned in 2009 that somehow “death panels” would decide who lived and who died under the Affordable Care Act. That is not the case in the United States, and PolitiFact awarded Palin’s distortions “The Lie of the Year” in 2009.

Among those it has helped to die: people with chronic depression and those who have signed their own euthanasia declaration in the early stages of dementia.

In 2012, Republican presidential candidate Rick Santorum upped the ante with the outlandish claim that in the Netherlands, old folks live in terror they’ll be euthanized against their will.

“People wear different bracelets if they are elderly. And the bracelet is: ‘Do not euthanize me,’” Santorum claimed. “They have voluntary euthanasia in the Netherlands but half of the people who are euthanized—10 percent of all deaths in the Netherlands—half of those people are euthanized involuntarily at hospitals because they are older and sick. And so elderly people in the Netherlands don’t go to the hospital. They go to another country, because they are afraid, because of budget purposes, they will not come out of that hospital if they go in there with sickness.”        

The Washington Post concluded its fact-checking article on that statement with the judgment, “there appears to be not a shred of evidence to back up Santorum’s claims.”

Although lawful euthanasia is best known as a Dutch phenomenon, it has been legalized in the surrounding countries of Belgium and Luxembourg as well. Just a few weeks ago, Belgium broadened its existing law to include the possibility of euthanasia for children of all ages. The amendment was made primarily to benefit terminally-ill kids. Their legal guardian has to agree and they have to be ‘of sound mind and judgment,’ but still, many view it as a slippery slope to the River Styx.

Video screenshot

Christopher Dickey spoke to CNN International about Beligium's euthanasia law.

The Catholic Church is strongly opposed to the termination of any life, whether after conception, by abortion, or toward the end, through euthanasia. But proponents argue that legalizing the practice only acknowledges and regulates something that people are determined to do in any case.

Take Belgium for instance—according the World Health Organization, it has one of the highest suicide rates on earth, totaling seven daily. Proponents of assisted suicide argue that if there are no mild, medical alternatives, people are forced to find crude and often gruesome ‘solutions,’ leaving family members to face the harsh aftermath.

In the United States, four states (Oregon, Washington, Vermont and Montana) allow some form of physician-assisted suicide while 46 states have deemed it illegal.

Meanwhile, guns, which are widely and legally owned in most of the country, are the favored American means of terminating one’s own life: about 20,000 people a year shoot themselves.

Despite the rational arguments for legal euthanasia as a matter of principle, the questions now being raised in the Netherlands are about practice.        

Psychiatrist Boudewijn Chabot, seen as a pioneer of the euthanasia movement after his conviction in 1991 for helping a female patient die, told the Dutch TV program Nieuwsuur that the law “has gone off the rails.”

“In the last two years things started happening that made me feel uncomfortable,” he said. Many of the Dutch have living wills stating whether they want to be euthanized or not, if they are no longer able to make the decision. But Chabot argues that a written statement made when one is of sound mind should not be considered “completely valid” for “a seriously demented person who no longer knows what it means.”

Chabot warned that the emphasis on a long-term doctor-patient relationship is paramount when it comes to evaluating psychiatric problems. “There are a 100,000 chronic psychiatric patients” in the Netherlands, according to Chabot, and of those “a large segment struggles with and against a death wish.” If the Life-Ending Clinic wants to take on such a responsibility, he said, then it better “get ready.”    

In one highly publicized example last year, the clinic helped a 63-year-old man with severe psychiatric problems to end his life. After a very active career working for government, the patient in question could not face his upcoming retirement. In an interview with the Dutch newspaper NRC Handelsblad the clinic’s psychiatrist, Gerty Casteelen said the man “managed to convince me that it was impossible for him to go on. He was all alone in the world. He’d never had a partner. He did have family but he was not in touch with them. It was almost like he’d never developed as a person. He felt like he didn’t have the right to live. His self-hatred was all consuming.”

The man’s long-term physicians had rejected his request previously. But the clinic’s team evaluated him, read his medical history and decided it was time to close his case— permanently.

Clinic Director Pleiter thinks giving psychiatric patients a chance at assisted suicide is important. “We are dealing with a group of patients that have no other place to go, that are also being ignored by psychiatry,” he said. “We are looking at their requests seriously, we treat them in all fairness. I believe it was a deliberate choice for the lawmakers to offer space legally, to which both patients with physical as well as psychological problems can turn.”

But where does one draw the line? Because these patients are not physically ill, the evaluations of independent psychiatrists are under scrutiny. Does this mean any person suffering from serious depression can shop around until he or she finds someone willing to help with suicide? And euthanasia is not only for old people. How young can you be and still get legal help if you want to die? How far should society go to overcome the biologically inbuilt threshold that makes it hard to take one’s own life by aiding someone to do so?

The controversy surrounding the Life-Ending Clinic’s activities has caused the Dutch press to look at some of the other cases from recent years. In one particularly disturbing case a 35-year-old woman, the youngest to die since the Dutch law was introduced, got help killing herself in 2012. Excerpts of her file were published by Dutch national newspaper Trouw and read like a sad story of clinical depression. But the file also shows an extended period of hopefulness. Not enough apparently. A team of doctors decided there was no cause to wait, and ended her life.

With Christopher Dickey