Debate ignites in the Netherlands over rise in euthanasia for mental disorders

The Netherlands reported the first case of euthanasia of a minor due to extreme suffering from a mental disorder. The recent announcement didn’t reveal the gender of the adolescent, who was between 16 and 18 years old and no longer required parental consent by law. The parents were informed and supportive of their child’s decision. Requests for euthanasia due to insurmountable suffering have been rising since 2011, with 138 cases in 2023, a 20% increase over the previous year. But it has ignited a debate in the Netherlands over mental health care.

The report of this minor’s assisted death was posted on the website of the Regional Commissions (RTE) that oversee all euthanasia cases. Without delving into specifics to protect the patient’s privacy, the report confirmed that experts reviewed the request and verified that it was sound, voluntary and met the criteria for severity and lack of alternative solutions. As a result, they determined that the doctor who treated the patient acted within the expected standard of care. In 2023, there were 9,068 euthanasia cases, a 4% increase over 2022. These cases accounted for 5.4% of the country’s total deaths last year (169,363).

The Dutch euthanasia law, enacted in 2002, treats both physical and mental suffering equally. Initially, psychiatric cases were rare until 2011. The Expertisecentrum Euthanasie center of expertise for euthanasia was opened in 2013 to support physicians who are helping patients with a request for euthanasia. It also centralized all the requests and immediately noted an increase. In the 20 years since the euthanasia law was passed, patients have increasingly sought more autonomy in end-of-life care.

Psychiatrists face the difficult challenge of balancing the key task of suicide prevention with requests for euthanasia. It’s crucial for them to ensure that the criteria of unbearable suffering is met and euthanasia is the last resort. “In cancer patients with metastasis in the final phase, euthanasia aims to prevent a distressing death. In psychiatric cases, it ends a distressing life,” said Sisco van Veen, a psychiatrist and researcher at Amsterdam University Medical Center. He notes that Dutch studies show rising mental health issues in youth, with unclear causes. “It’s not just in this country. All we can do now is guess how people must be feeling in a world so full of uncertainty.”

Van Veen thinks that preventing pain can be more important than saving a life in special situations. “Overall, what we’re noticing is a shift where it’s becoming more about death as a personal choice and less about suffering.” He believes that as healthcare becomes more managed overall, the idea of managing death doesn’t seem illogical.

Social acceptance

Surveys consistently indicate a high level of social acceptance of euthanasia in the Netherlands — typically around 87%, even for cases involving psychological suffering. Van Veen highlighted that psychiatrists also support euthanasia, and that “in cases of immense suffering, patients may request an expedited assisted death. We are committed to helping patients recover and find hope amid profound suffering.” He also offered some context for the 138 euthanasia cases for mental disorders. “With 4,000 practicing psychiatrists in the country, you might end up being part of one euthanasia case in your career. Euthanasia isn’t something you do every day, but it’s important to know how to handle it effectively.”

The story of Zoraya ter Beek, a 28-year-old Dutch woman, is currently circulating on social media and in the news. She shared a video announcing her impending euthanasia due to mental health issues. Young patients with psychiatric issues typically experience them from a young age, says van Veer. “They may have trauma, depression, eating problems or personality disorders. Their distress is real.” The available treatments don’t always work. “There’s a common belief that mental issues can always be resolved, and indeed, psychiatrists do see patients recovering, even after enduring years of severe psychiatric struggles,” he said. “But psychiatric problems are not only medical, there are also social and psychological factors that are often invisible... Telling someone with depression to play sports or cheer up shows a lack of understanding of their pain.”

Van Veen notes that the euthanasia process in the Netherlands is thorough, involving safeguards and multiple opinions. “In addition to the coroner, there may be five to six doctors involved.” Still, receiving his first request for euthanasia was a shock for van Veen, who thinks laws should “balance patient autonomy and protection.” He believes the Dutch law achieves this balance, and that there are secular (non-religious) reasons to be skeptical about expanding end-of-life options further.

Five legal cases

Dutch doctors must report to the Regional Commissions. The latest 2023 report, released in April, reveals five negligence cases under review by prosecutors and public health officials. “In these five cases, the doctors were unfamiliar with the proper rules or protocol to follow. This highlights the importance of seeking the mandatory second opinion before proceeding with euthanasia,” said RTE president Jeroen Recourt, who acknowledged the euthanasia of the teenager with a psychological disorder.

The Dutch euthanasia law requires the patient to make a voluntary, conscious and repeated request. The doctor must verify that the suffering is unbearable and that there are no options for treatment, cure or improvement. Subsequently, an independent colleague reviews the case and consults with the patient alone to confirm the severity of the situation. “This is the only way to move forward. A second opinion is crucial. It provides guidance to doctors performing euthanasia, ensuring adherence to regulations,” said Recourt.

Dutch law permits both active euthanasia conducted by physicians and assisted suicide, with doctors exclusively entrusted with this duty and exempted from the Penal Code. Violations can result in imprisonment for up to 12 years. The 2023 RTE report notes that while euthanasia is handled very carefully, it remains emotionally taxing for medical practitioners.

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