17-year-old Noah Pothoven recently died in the Netherlands. When she was eleven, she faced sexual harassment, and at fourteen she was raped by two men. The traumatic experience led to serious problems: the girl struggled with depression, anorexia and post-traumatic stress disorder for many years - and last year, when she was sixteen, she turned to a clinic that performs euthanasia.
In the Netherlands, the procedure has been legal since 2002, including for those who are struggling with mental disorders - moreover, it is available to minors. For a person to be eligible for euthanasia, several conditions must be met. First of all - unbearable suffering, with no hope that the condition will improve. A person must make a decision voluntarily, without pressure from others, having full information about his condition, prospects and what choice is still possible in his case. Permission for euthanasia must be approved by an independent doctor, and a medical professional must be present during the procedure, regardless of whether it is performed by the doctor or the patient (the latter is technically classified not as euthanasia, but as assisted suicide). For adolescents twelve to sixteen years old, parental consent is required, sixteen to seventeen years old should discuss the decision with their parents, although the latter's consent in this case is no longer required.
The last condition is the reason why Noah Pothoven was refused: she submitted an application without notifying her parents about it. “They think I'm too young to die,” she said in an interview last year. “They think that I need to finish my trauma treatment first and that my brain has yet to grow and form. This will have to wait until the twenty-first birthday. It broke me - I can't wait that long. " Due to the fact that Noah Pothoven openly spoke about the desire to commit suicide, the news of her death in foreign media was initially regarded as news of euthanasia. Only later it turned out that Noah died without the involvement of medical specialists at home: she refused to take medicine, as well as eat and drink.
Another high-profile story happened last January. Orelia Brouwers, a twenty-nine-year-old resident of the Netherlands, committed what is called assisted suicide - she drank poison under the supervision of a doctor who gave her the drug. Browvers was authorized for the procedure due to a mental health condition. She faced severe anxiety, depression, eating disorders and psychosis; engaged in self-harm and repeatedly tried to commit suicide, and also spent almost three years in a psychiatric clinic. “I am twenty-nine and I chose voluntary euthanasia. I go for this because I have a lot of mental health problems. My suffering is unbearable and hopeless. Every breath is torture for me …”- said Browvers. She spent the last couple of weeks of her life with loved ones - and also left orders for her own funeral during this time.
Most often, when we talk about euthanasia, we imagine an elderly person struggling for years with a serious, possibly incurable disease - for example, with terminal cancer - who would like to die on his own terms. A minor girl struggling with invisible psychological illnesses does not fit into this traditional scheme. Nevertheless, there are situations in which people decide to euthanize because of mental health conditions - albeit not yet so common.
The debate over whether euthanasia is in principle permissible has been going on for several days.Views on it remain polarized: while some insist that a person has the right to die on their own terms, others say that affordable euthanasia undermines the idea of the basic value of life: some lives seem to be more worthy than others. While some say that euthanasia is not needed if there is high-quality palliative care, others say that the decision to end a life always remains private and does not concern other people and the state in any way. It is not surprising that such different views are reflected in legislative practice.
Perhaps the most famous classification of the practice itself is the division into voluntary and involuntary euthanasia. Despite the threatening language, this is not about murder. In the first case, the patient makes a conscious decision himself; in the second, other people make the decision for him. Involuntary euthanasia is used when a person, in principle, cannot give informed consent (for example, if he is in a coma) - often on the basis of wishes that he expressed earlier. In addition, there is passive euthanasia (the patient is disconnected from life support systems) and active euthanasia (the doctor deliberately does something that should interrupt the patient's life, for example, injects a special drug). Finally, there is the so-called assisted suicide, when the patient himself acts: for example, doctors give him a drug that should interrupt his life, and he injects it on his own in the presence of a specialist.
Legally active euthanasia remains an uncommon procedure. Besides the Netherlands, it is also legal or decriminalized in Belgium, Colombia and Luxembourg. Doctor-assisted suicide is possible, for example, in Switzerland, Germany and Canada. In the United States, assisted suicide is available in several states - California, Oregon, Vermont, Washington, and Montana.
Those who would like to end their lives
due to mental health conditions, there are more
Euthanasia for mental health reasons is proving to be even rarer, with the Netherlands and Belgium being the only countries where it is relatively common. At the same time, the demand for it in recent years has seriously increased - perhaps because they began to talk more about it, or because the attitude towards the procedure itself is gradually changing. For example, in the Netherlands, the number of cases of euthanasia from 2010 to 2015 increased by 75% - from 3136 to 5516. Those who would like to terminate their lives due to a mental health condition also increased: if in 2010 only two were performed the procedure, then in 2015 - 56 people, and in 2017 - already 83 people. The number of cases of euthanasia in dementia also increased significantly: 25 in 2010 against 109 in 2015 and 169 in 2017.
At the same time, the legality of the procedure does not yet make it public: the decision is not made quickly and many factors are taken into account. Stephen Plaiter, director of a Dutch euthanasia clinic that Noah Pothoven went to, says it's a time-consuming process. Mental health claims must comply with the law as in all other cases: intolerable condition, lack of hope for improvement, completely voluntary decision, and full understanding of the process and prospects by the patient. According to Plyayer, each application for the procedure is considered in detail, and the clinic staff also visits a potential patient at home and conducts several interviews with him. Consideration of an application for physical illness, he estimates, takes about four to six weeks, but for mental disorders it often takes more time - probably because any assessment here seems more subjective. According to Plyater's observations, in 2018 the clinic received 2,600 applications for euthanasia, a little less than a third of them were associated with mental disorders.In the end, not everyone is allowed to fulfill their plans: last year, the clinic euthanized 727 patients, about fifty of them went to the clinic for mental health.
With all the complex attitude towards euthanasia, in cases where it is associated with a serious physical illness, the decision seems to be more unambiguous. For example, if we are talking about oncological diseases, it is possible to accurately assess whether the treatment is helping the patient, and to present approximate prospects - are there other treatment options and how statistically effective they are in such cases. In situations with the mental sphere, everything is much less clear. How to understand that human suffering is truly unbearable? How to evaluate the effectiveness of treatment? Is suicidal ideation an indicator of euthanasia - or is it just one symptom to be dealt with?
Perhaps this is why the stories of euthanasia for mental disorders are so terrifying - and powerful controversy. There is no single point of view even in the medical community itself: where one specialist considers the situation serious enough to allow euthanasia, another may see a reason to continue treatment, revise its scheme, or even the diagnosis itself. For example, there is a known case when a woman was euthanized a year after her husband's death due to a prolonged grief reaction. This diagnosis is in the International Classification of Diseases, but the American Diagnostic and Statistical Manual of Mental Disorders does not separately highlight it.
The same symptom may be interpreted differently by different specialists. For example, the decision on assisted suicide by the aforementioned Orelia Brouwers caused different opinions. So, Keith Vanmechelen, a psychiatrist who reviews patients' applications for euthanasia, believes that it is impossible to be one hundred percent sure that the desire to commit suicide is a reason to allow the procedure, and not a symptom of an exacerbated state, is impossible. The specialist believes that the main thing in this situation is to try to help the patient as much as possible, and to make sure that the desire to die does not disappear as the treatment proceeds. “I worked with patients who I knew would someday commit suicide,” she says. - I knew. They told me about it, I felt it and thought: "I cannot help you." So I am very grateful to the law for providing an alternative - euthanasia. Patients who are likely to commit suicide sooner or later, in my opinion, can be considered patients at the terminal stage of the disease. I do not want to leave those who cannot cope with their condition. Because of this, I am ready to provide an opportunity for euthanasia."
Not everyone agrees with this point of view. “Throughout my career, I have worked with suicidal patients - and none of them were in the terminal stage. Of course, I have had patients who chose suicide - but it always happened where you least expect it,”says psychiatrist Frank Kerselman.
Many people see depression as something that must be "overcome" over time.
The mental state can change very unpredictably - for example, an external situation that has nothing to do with the treatment process can easily become a trigger for worsening (or, conversely, improving) the state. The approaches and methods of treatment are also rapidly developing: it is quite possible that today it will not be possible to influence the patient's condition, but in the near future new methods of treatment or drugs will appear that will make it possible to make a breakthrough. Noah Pothoven and her family, for example, criticized the situation with psychological assistance in the Netherlands - in their opinion, the existing system is imperfect and cannot help those faced with the same as Noah.
In one of the most famous Dutch euthanasia clinics, more than half of those who apply for the procedure are refused for their mental health - due to the fact that they have not tried all the treatment options. “I had a patient who tried many options and was sure that nothing would help him. But he never lay in a clinic helping people with alcohol and drug abuse, says Keith Vanmechelen. “I told him, 'Within six months, you will need to work hard to reduce abuse.If after that you want to interrupt your life - come back and we will talk about it ".
There are situations when the very changing state of human health creates additional difficulties in making a decision. The most striking example here is dementia: in the Netherlands, people often voice in advance that they would like to end their lives if they encounter serious dementia - for example, if they no longer recognize loved ones. The design seems logical, but only as long as the person's condition has not worsened: you have to decide which is more important - past ideas or current desire. There are cases when people with dementia have resisted the procedure - and here consent seems at least controversial. In a situation of severe dementia, in principle, it is difficult to talk about informed consent and to be sure that a person is completely satisfied with the past decision: perhaps he agrees to euthanasia, or, on the contrary, he would not want to interrupt his life. It is quite possible that in the changed conditions a person will not consider his life as suffering at all - and will want to stay alive.
But the problem is that often mental states are, in principle, considered as "temporary", "fluid". Many people see depression or PTSD as something that must be “overcome” over time, a symptom, and not a condition that may not respond to treatment. Hence the appropriate attitude towards euthanasia for mental health is born. It fits, for example, what the jurist Ronald Dworkin wrote in the introduction to the message in defense of the legalization of euthanasia, which a group of philosophers sent to the US Supreme Court. "The states can ban assisted suicide for those who, quite possibly, will later be grateful that they were not allowed to die." As an example, he cites "a sixteen-year-old teenager suffering from severe unrequited love."
Illustrations: Anya Oreshina