Psychiatric euthanasia examined in the Netherlands.

Alex Schadenberg
Executive Director - Euthanasia Prevention Coalition

Dr Scott Kim

While researching the issue of psychiatric euthanasia I came across an article by Psychiatrist Scott Kim published in the Atlantic on June 6, 2019. The article explains how psychiatric euthanasia is approved in the Netherlands. The article: How Dutch Law Got a Little Too Comfortable with Euthanasia is based on the death of Noa Pothaven, who the english language media originally claimed had died by euthanasia. Kim explains that even though she didn't die by euthanasia, that it was legally possible. Kim states:

I have researched the Netherlands’ experience in detail and written a number of peer-reviewed papers about it. In Dutch usage, the term euthanasia legally covers cases in which medical professionals administer lethal injection and those in which doctors provide drugs that patients ingest to end their life. The Dutch system gives deference to doctors’ expertise; it respects the relationship between an individual doctor and a patient; and it recognizes that mental illness can be painful and debilitating. Yet this system illustrates how priorities that appear logical on their own terms combine, in some cases, to produce disturbing results. A respected Dutch-language medical journal recently reported that an 18-year-old had died via medically assisted suicide for psychiatric problems.

Kim continues:

Until about 2010, the controversial practice of psychiatric euthanasia was rare, despite being permitted since the mid-1990s. Most Dutch psychiatrists—like most other doctors and the Dutch public—disapprove of psychiatric euthanasia. Still, there has been a steady increase, with 83 cases in 2017; the per-capita equivalent in the United States would be about 1,600 cases a year. Unlike euthanasia in general, psychiatric euthanasia is predominantly given to women. Most of these cases involve the End of Life Clinic, a network of facilities affiliated with the largest Dutch euthanasia-advocacy organization. These clinics routinely handle euthanasia requests refused by other doctors. (Noa Pothoven sought euthanasia there but was refused.)

Kim distinguishes between euthanasia for physical reasons compared to psychiatric reasons:

Compared with cases involving cancer or other terminal illnesses, the application of the eligibility criteria in psychiatric euthanasia depends much more on doctors’ opinions. Psychiatric diagnosis is not based on an objective laboratory or imaging test; generally, it is a more subjective assessment based on standard criteria agreed on by professionals in the field. Some doctors reach conclusions with which other doctors might reasonably disagree. Indeed, an otherwise healthy Dutch woman was euthanized 12 months after her husband’s death for “prolonged grief disorder”—a diagnosis listed in the International Classification of Diseases but not in the Diagnostic and Statistical Manual of Mental Disorders used by psychiatrists and psychologists around the world. 

Psychiatric disorders can indeed be chronic, but their prognosis is difficult to predict for a variety of reasons. There is a paucity of relevant, large longitudinal studies. Patients may get better or worse due to psychosocial factors beyond the control of mental-health providers. Also affecting prognoses is the varying quality and availability of mental-health care—which, even in wealthy countries, patients with significant symptoms may not receive. Noa Pothoven and her family had criticized the dearth of care options available in their country for patients like her. Indeed, more than one in five Dutch patients receiving psychiatric euthanasia have not previously been hospitalized; a significant minority with personality disorders did not receive psychotherapy, the staple of treatment for such conditions. When treatments are available, doctors in the Netherlands have the discretion to judge that there are “no alternatives” if patients refuse treatment.

Kim then explains the difficulty with psychiatric euthanasia:

It is not easy to distinguish between a patient who is suicidal and a patient who qualifies for psychiatric euthanasia, because they share many key traits. In some cases, psychiatric euthanasia is simply a highly effective means of suicide, as in the case of a man who attempted suicide, was hospitalized, and then received psychiatric euthanasia. 

In the end, one does not need to be a psychiatrist to appreciate how psychiatric disorders, especially when severe enough to lead to euthanasia requests, could interfere with a patient’s ability to make “voluntary and well considered” decisions—especially when that patient is a minor. The basis for concluding that any teenager with a psychiatric disorder has “no prospect of improvement” and “no alternatives” is likely to be uncertain at best.

Kim concludes that even though Noa Pothoven did not die by euthanasia, the Dutch law would have permitted it.