In her diary, Godelieva De Troyer classified her moods by color. She felt “dark gray” when she made a mistake while sewing or cooking. When her boyfriend talked too much, she moved between “very black” and “black!” She was afflicted with the worst kind of “black spot” when she visited her parents at their farm in northern Belgium. In their presence, she felt aggressive and dangerous. She worried that she had two selves, one “empathetic, charming, sensible” and the other cruel.
She felt “light gray” when she went to the hairdresser or rode her bicycle through the woods in Hasselt, a small city in the Flemish region of Belgium, where she lived. At these moments, she wrote, she tried to remind herself of all the things she could do to feel happy: “demand respect from others”; “be physically attractive”; “take a reserved stance”; “live in harmony with nature.” She imagined a life in which she was intellectually appreciated, socially engaged, fluent in English (she was taking a class), and had a “cleaning lady with whom I get along very well.”
Godelieva, who taught anatomy to nurses, had been in therapy since she was nineteen. With each new doctor, she embraced the therapeutic process anew, adopting her doctor’s philosophy and rewriting her life story so that it fit his theory of the mind. She continually dissected the source of her distress. “I am confronted almost daily with the consequences of my childhood,” she wrote to her mother. She’d wanted to be a historian, but her father, domineering and cold, had pressured her to be a doctor. Her mother, who was unhappy in her marriage, reminded her of a “slave.” “New insight,” she wrote in her diary. “Do not want to always nod yes like her and be self-effacing.”
Godelieva was preoccupied with the idea that she would replicate her parents’ mistakes with her own children. She married when she was twenty-three, and had two children. But the marriage was tumultuous and ended in divorce, in 1979, when her son was three and her daughter was seven. Two years later, their father, Hendrik Mortier, a radiologist, committed suicide. As a single parent, Godelieva was overwhelmed. In a diary entry from 1990, when her children were teen-agers, she instructed herself to “let my children be themselves, respect them in their individuality.” But she found herself fighting with her daughter, who was independent and emotionally distant, and depending on her son, Tom, a “victim of my instability,” she wrote. She worried, she told her psychologist, that her children were “now paying for all that has happened generations earlier.”
The happiest time in Godelieva’s life began when she was in her early fifties and had a new boyfriend. She felt as if she had finally moved beyond the dramas of her childhood, an achievement for which she credited her new psychiatrist. “He opens the wound completely, cleans it thoroughly and closes it so it can heal,” she wrote to a friend. Godelieva, who had blond hair and a wistful smile, made many friends during these years. “She was the most beautiful woman,” Tom told me. “People would say to me, ‘Oh, I could fall in love with your mother.’ ” Christiane Geuens, a close friend, said, “People always wanted to know her. When she walked into a room, everyone knew.”
Godelieva was delighted when Tom and his wife had a child, in 2005. She promised that she would make up for her failures as a mother by being an attentive grandmother. In photographs, she is physically affectionate with Tom’s daughter, holding her as she brushes her teeth, or sitting on the bed with her, braiding her hair.
Then, in 2010, her boyfriend broke up with her, and she felt black again. She stopped wearing makeup and doing her hair, and she cancelled dates with friends, she said, because she felt ugly and old. She felt that she had lost her levensperspectief, a Dutch word that refers to the sense that there is something to live for. Tom was only thirty minutes away, but she no longer had the energy to drive to his house. She accused Tom of being insufficiently sympathetic, and Tom, who had just had a second child, blamed her for abandoning him and his family. After several months of fights, they stopped speaking. In her diary, she wrote, “I don’t think there can be fruitful contact with the children with all his aggression toward me.” Tom’s sister, a lawyer who does human-rights work in Africa, also avoided her; she found it too painful to be sucked back into her mother’s depression, which had dominated her childhood. (She has asked not to be named.)
Godelieva felt as if her emotional progress had been an illusion. She had seen the same psychiatrist for more than ten years and had consulted him on every decision, even those involving financial investments and home renovations, but she had now lost faith in his judgment. She complained to friends, “I give him ninety euros, he gives me a prescription, and after ten minutes it’s over.” Her psychiatrist acknowledged that there was no cure for her condition; the best he could do, he said, was listen to her and prescribe antidepressants, as he had been doing for years.
In the summer of 2011, when she was sixty-three, Godelieva met a new doctor. She attended a lecture by Wim Distelmans, an oncologist and a professor of palliative medicine at the Free University of Brussels. Distelmans was one of the leading proponents of a 2002 law in Belgium that permits euthanasia for patients who have an incurable illness that causes them unbearable physical or mental suffering. Since then, he has euthanized more than a hundred patients. Distelmans, who wears leather coats and boots and artfully tossed scarves, has become a celebrity in Belgium for promoting a dignified death as a human right, a “tremendous liberation,” and he gives talks at cultural centers, hospitals, and schools around the country.
In September, 2011, Godelieva saw Distelmans at his clinic. Four months later, she sent an e-mail to her children: “I have filed a euthanasia request with Prof. Distelmans based on psychological distress. I have gone through the entire procedure and am now waiting for the result.”
Tom and his wife had just had their third child. They both taught chemistry at Leuven University College, part of the oldest university in Belgium. When Tom received his mother’s e-mail, he showed it to his supervisor, Lies Verdonck, a doctor who was familiar with Distelmans’s work, and asked her what to do. She said there was no way that Distelmans would approve the euthanasia request without first speaking with the patient’s family. “Stay focussed on your job and your children,” she urged Tom.
At the time, Tom was in the process of searching for a nursing home for Godelieva’s mother, from whom Godelieva was estranged. He was angry that the task had fallen to him, and felt that his mother was being manipulative. She had expressed suicidal thoughts before, and they’d passed, so he decided not to respond to the e-mail. His sister, who was in Africa, replied that she would respect her mother’s decision, but that it hurt her.
On April 20, 2012, three months after Godelieva sent the e-mail, Tom received a short letter from his mother that was written in the past tense. She reported that her euthanasia had been carried out on April 19th, at the university hospital of the Free University of Brussels. “I donated my body to science,” she wrote. On the back of the letter, she’d left the phone number of a friend who had the keys to her house.
Tom immediately drove to the house of the friend, who offered him a drink and then explained that she and her husband had driven Godelieva to the hospital. Tom accused the couple of coöperating with a suicide. They were defensive: they said that it was Godelieva’s choice, and they didn’t want her to have to take a taxi to the hospital alone. Later, they admitted to Tom that in the car Godelieva was chatting and laughing, and they had begun to wonder if they knew her as well as they’d thought.
Tom felt his mind shutting down. He drove to his mother’s house, which he hadn’t visited in more than a year. She had just completed an addition to the first floor: before they separated, she and her ex-boyfriend had wanted to grow old in the house without worrying about stairs. The interior of the house was decorated with framed photographs of her grandchildren. Large drawings of Tom and his sister hung on the living-room wall.
In the drawer of Godelieva’s bedroom desk, Tom found drafts of several farewell letters that she had written to friends, her neighborhood association, and a chorus that she sang in, as well as a master list with an “X” by each name, as if she were composing thank-you notes after a party. She thanked her friends for their companionship, apologized for causing them pain, and explained that “the loneliness, no chance of a cure after forty years of therapy, nothing to look forward to—all this has led me to see that the only thing remaining is a dignified end of life.”
There was also a draft of a long letter to her children, which was far more emotional than the one she had sent. “I have not been able to handle the rift with you, Tom,” she wrote. “I have loved you very much but you have not seen it as such.” She then addressed her three grandchildren: “I have missed you very much.” She also wrote, before crossing it out, “I will not see my grandchildren grow up and that causes me pain.”
In his mother’s living room, Tom found an article about Distelmans in De Morgen, a leading Flemish newspaper, which featured a large photograph of him sitting on a bed, wearing jeans, a patterned shirt, and a silver bangle bracelet. The reporter described Distelmans as a doctor who “cannot stand injustice.” Distelmans spoke about his disdain for doctors who assume that they know what their patients need, and told the reporter that the “euthanasia law has such a symbolic value. People have a voice.”
Tom also discovered a booklet, produced by LEIF (Life End Information Forum), an organization founded by Distelmans, that outlined the medical and legal options available to people who are dying or want to die. On the final page, the authors introduced an excerpt from “Utopia,” by Thomas More, who describes a world in which “officially sanctioned euthanasia is regarded as an honorable death.” In More’s ideal society, government officials and priests visit suffering invalids and say, “Why don’t you break out and escape to a better world?”
In Belgium, euthanasia is embraced as an emblem of enlightenment and progress, a sign that the country has extricated itself from its Catholic, patriarchal roots. Distelmans, who was brought up as a Catholic and then rejected the Church, told me that his work is inspired by an aversion to all forms of paternalism. “Who am I to convince patients that they have to suffer longer than they want?” he said.
Belgium was the second country in the world, after the Netherlands, to decriminalize euthanasia; it was followed by Luxembourg, in 2009, and, this year, by Canada and Colombia. Switzerland has allowed assisted suicide since 1942. The United States Supreme Court has recognized that citizens have legitimate concerns about prolonged deaths in institutional settings, but in 1997 it ruled that death is not a constitutionally protected right, leaving questions about assisted suicide to be resolved by each state. Within months of the ruling, Oregon passed a law that allows doctors to prescribe lethal drugs for patients who have less than six months to live. In 2008, Washington adopted a similar law; Montana decriminalized assisted suicide the year after; and Vermont legalized it in 2013.
The right-to-die movement has gained momentum at a time of anxiety about the graying of the population; people who are older than sixty-five represent the fastest-growing demographic in the United States, Canada, and much of Europe. But the laws seem to be motivated less by the desires of the elderly than by the concerns of a younger generation, whose members derive comfort from the knowledge that they can control the end of their lives. Diane Meier, a professor of geriatrics at Mount Sinai School of Medicine, in New York, and one of the leading palliative-care physicians in the country, told me that “the movement to legalize assisted suicide is driven by the ‘worried well,’ by people who are terrified of the unknown and want to take back control.” She added, “That is not to say that the medical profession doesn’t do a horrible job of protecting people from preventable suffering.” Like most doctors who specialize in palliative care, a field focussed on quality of life for patients with severe and terminal illnesses, she thinks legalizing assisted suicide is unnecessary. “The notion that if people don’t kill themselves they’re going to die on a ventilator in the hospital would be humorous if it weren’t so serious,” she said. She believes that the angst propelling the movement would be diminished if patients had greater access to palliative care and if doctors were more attentive to their patients’ psychological suffering.
In Oregon and Switzerland, studies have shown that people who request death are less motivated by physical pain than by the desire to remain autonomous. This pattern of reasoning was exemplified by Brittany Maynard, a twenty-nine-year-old newlywed who moved to Oregon last year so that she could die on her own terms rather than allowing her brain cancer to take its course. Her story appeared on the cover of People, which described her as having the “soul of an adventurer and the heart of a warrior.” She became the poster child for assisted death—a far more palatable one than Jack Kevorkian, who had previously filled that role. Unlike the patients whom Kevorkian attended to with his makeshift “suicide machine,” Maynard appeared neither passive nor vulnerable. Since her death, seven months ago, lawmakers in twenty-three U.S. states have introduced bills that would make it legal for doctors to help people die.
Opponents have warned for years that legalization will lead to a “slippery slope,” but in Oregon fewer than nine hundred people have used lethal prescriptions since the law was passed, and they represent the demographic that is least likely to be coerced: they are overwhelmingly white, educated, and well-off. In Belgium and in the Netherlands, where patients can be euthanized even if they do not have a terminal illness, the laws seem to have permeated the medical establishment more deeply than elsewhere, perhaps because of the central role granted to doctors: in the majority of cases, it is the doctor, not the patient, who commits the final act. In the past five years, the number of euthanasia and assisted-suicide deaths in the Netherlands has doubled, and in Belgium it has increased by more than a hundred and fifty per cent. Although most of the Belgian patients had cancer, people have also been euthanized because they had autism, anorexia, borderline personality disorder, chronic-fatigue syndrome, partial paralysis, blindness coupled with deafness, and manic depression. In 2013, Wim Distelmans euthanized a forty-four-year-old transgender man, Nathan Verhelst, because Verhelst was devastated by the failure of his sex-change surgeries; he said that he felt like a monster when he looked in the mirror. “Farewell, everybody,” Verhelst said from his hospital bed, seconds before receiving a lethal injection.
The laws seem to have created a new conception of suicide as a medical treatment, stripped of its tragic dimensions. Patrick Wyffels, a Belgian family doctor, told me that the process of performing euthanasia, which he does eight to ten times a year, is “very magical.” But he sometimes worries about how his own values might influence a patient’s decision to die or to live. “Depending on communication techniques, I might lead a patient one way or the other,” he said. In the days before and after the procedure, he finds it difficult to sleep. “You spend seven years studying to be a doctor, and all they do is teach you how to get people well—and then you do the opposite,” he told me. “I am afraid of the power that I have in that moment.”
Although doctors in Belgium had been covertly performing euthanasia before it was legalized, the majority of them opposed the euthanasia law, according to a survey conducted at the time. The chairman of Belgium’s largest medical association cautioned against making “the exception the rule.” But the political composition of the Belgian government had recently shifted; for the first time since the Second World War, secular politicians (liberals, socialists, and the Green Party) had more power than Christian Democrats, who resisted legalization. Peter Backx, the former editor of Belgium’s largest medical journal, said that the law seemed like a “bit of political revenge.” At the Senate hearings on the law, the phrase “self-determination” was repeated ninety-seven times.
The right to a dignified death is viewed as an accomplishment of secular humanism, one of seven belief systems that are officially recognized by the government. Belgian humanism, which was deeply influenced by the nineteenth-century Freemasonry movement, offered an outlet for those who felt oppressed by the Church, but it has increasingly come to resemble the kind of institution that it once defined itself against. Since 1981, the Belgian government has paid for “humanist counsellors,” the secular equivalent of clergy, to provide moral guidance in hospitals, prisons, and the armed forces. Humanist values are also taught in state schools, in a course called non-confessional ethics, which is taken by secular children from first through twelfth grade, while religious students pursue theological studies. The course emphasizes autonomy, free inquiry, democracy, and an ethics based on reason and science, not on revelation. Jan Bernheim, an emeritus professor of medicine at the Free University of Brussels, who studies ethics and quality of life, told me that euthanasia is “part of a philosophy of taking control of one’s own existence and improving the objective conditions for happiness. There is an arrow of evolution that goes toward ever more reducing of suffering and maximizing of enjoyment.”
The Belgian Council of Ministers appointed Wim Distelmans to serve as the chairman of the Federal Control and Evaluation Commission, which reviews euthanasia deaths to insure that doctors have complied with the law. In terminal cases, two doctors need to confirm that the patient’s suffering stems from an incurable illness. For non-terminal cases, three doctors must agree. But doctors have adopted increasingly loose interpretations of disease. Distelmans told me, “We at the commission are confronted more and more with patients who are tired of dealing with a sum of small ailments—they are what we call ‘tired of life.’ ” Although their suffering derives from social concerns as well as from medical ones, Distelmans said that he still considers their pain to be incurable. “If you ask for euthanasia because you are alone, and you are alone because you don’t have family to take care of you, we cannot create family,” he said.
Last year, thirteen per cent of the Belgians who were euthanized did not have a terminal condition, and roughly three per cent suffered from psychiatric disorders. In Flanders, where the dominant language is Dutch, euthanasia accounts for nearly five per cent of all deaths. (The percentage is lower in the southern, French-speaking parts of Belgium.) The Flemish media have adopted a mostly uncritical approach to euthanasia, running numerous articles about the courage of people who have chosen to die. Last year, De Standaard, a prominent Flemish newspaper, published a long tribute to a depressed mother who was euthanized after being abandoned by her boyfriend and becoming disillusioned by her psychiatric care. “I am forever grateful to her that she handled this so well,” her twenty-four-year-old son told the paper. “I am so glad we were able to say goodbye in a beautiful way.”
The suicide rate in Belgium (excluding cases of euthanasia) is the second-highest in Western Europe, a phenomenon often attributed to the Flemish personality type known as “binnenvetter,” a person who holds emotions inside. Joris Vandenberghe, a professor of psychiatry at the University of Leuven and a member of the Belgian Advisory Committee on Bioethics, said that he finds euthanasia requests therapeutically useful, because they prompt patients who would not otherwise seek medical help to consult with doctors about their feelings of hopelessness. He said that most of his patients, even those who are approved for euthanasia, end up deciding that they want to live. But he rejects the idea that suicide is always an indication of pathology. “There’s a whole philosophical history of looking at suicide as a rational choice,” he said. “We, as humans, have the possibility to weigh our own life and decide to end it.”
Tom believes that everyone is suicidal in at least some small way. In his early twenties, the impulse was strong. “There was a red light constantly flickering above me,” he said. He undertook what he called “aggressive reading”: Dostoyevsky, Antonin Artaud, Freud, Sándor Ferenczi, Tolstoy, Carl Jung. He found himself drawn to theories of suffering. He wanted to know what it was that made one person survive and another give up.
When Tom was twenty-two, he enrolled in graduate school, for chemistry, but instead of studying he researched his father’s suicide. He often took the train to Ghent, where his father had worked, and interviewed his colleagues and friends. Godelieva, following the advice of her psychiatrist at the time, hadn’t told her children how their father died; she said only that he suffered from headaches. Tom and his sister quickly figured it out. Tom began to see his father as a kind of Dorian Gray figure: he had lived extravagantly, seeking pleasure, success, and distraction. He drove a new Mercedes while he owed millions of Belgian francs and was under the threat of legal action. “He could not see himself as he really was,” Tom recalled. He left a suicide note on his bathroom mirror that said, “I am a victim of the shit that exists in the world today.”
In her diary, Godelieva wrote that she couldn’t comprehend why her husband would kill himself. But at other times she felt that she understood perfectly—“I am just like him,” she wrote—but she said that, for the sake of the children, she could never do the same. Neither Tom nor his sister thought that she would have killed herself on her own. She was passive, dependent, and averse to risk. She didn’t like to make a mess. Most of all, she trusted her doctors’ authority. Distelmans was the last in a series of charismatic and accomplished doctors whose theories she had revered. After finding strength in their guidance, she eventually became disillusioned by each treatment. “I can still hardly believe how many amateurs are walking around in this medical field,” she wrote to a friend in the late nineties, after giving up on another therapist.
When Tom read his mother’s daily planner, he saw that she had met with Distelmans at least six times in the past eight months. Seven weeks before her death, she donated twenty-five hundred euros to LEIF, the organization that Distelmans had founded. On the bank-transfer form she had written, “Thanks to the staff at LEIF.”
Until Godelieva’s death, Tom had never given much thought to euthanasia, though he was vaguely in favor of it. “Distelmans was just a voice I heard on the radio from time to time,” he told me. Tom was brought up as an atheist, and in school he had studied non-confessional ethics. When the euthanasia law was passed, he and his wife, who were in the same graduate program, had recently fallen in love. They assumed that the law was for old people who were already dying.
Now it seemed to Tom that there were few people reflecting critically on the law. Three days after his mother’s death, the leading Belgian humanist association named Distelmans one of ten “heroes of self-determination” in the past fifty years, at a celebration for Flemish Heritage Day. When Tom complained to the ombudsman at the hospital of the Free University of Brussels, the ombudsman replied that everything had proceeded according to his mother’s “free will.” Even Godelieva’s friends reserved judgment; few had realized that she suffered from clinical depression. At her memorial service, people skirted the issue. They told one another that you never know how someone is feeling inside, and that “every house has its own cross,” an attitude that Tom described as typically Flemish. Tom likes to joke that he must have some secret French roots, because he finds it nearly impossible to contain his feelings.
Godelieva’s friend Christiane Geuens told me that she knew that Godelieva was upset about her breakup, but she never imagined that she was considering euthanasia. Less than two weeks before she died, Godelieva had spent all day at Geuens’s home. Godelieva lit a fire and then sat on the couch, wrapped in a blanket, and told stories. The only indication that something was off was the movie she decided to watch. She wanted to see “Sophie’s Choice.” She had already seen the movie and read the book, and afterward she went on about her identification with Sophie, who was so burdened by her past that she committed suicide. Geuens didn’t see how their situations were comparable, but Godelieva said that they were the same.
A week after his mother’s death, Tom e-mailed a psychiatrist named Lieve Thienpont, whose name he had seen several times in his mother’s daily planner. “May I ask why you approved active euthanasia for my mother and why I was never involved in that decision?” he wrote. Thienpont invited him to meet with her and Distelmans, both of whom are founding members of Ulteam, a clinic for patients who have questions about ending their lives. In the past three years, nine hundred patients have come to Ulteam, half of whom complained that they were suffering psychologically, not physically.
On May 15, 2012, Tom went to Distelmans’s clinic, a small brick modernist building in a residential suburb on the outskirts of Brussels. He brought his colleague Steven Bieseman along for moral support. “I was there to help Tom control his emotions, because he can be quite hot-tempered,” Bieseman, a doctor, told me.
They sat at a conference table, and Distelmans explained that he never rushes his decisions. He said that he had urged Godelieva to contact her children, but that she had not wanted to inform them. He asked Tom why he had scheduled the meeting.
“Because you killed my mother,” Tom replied.
Distelmans responded calmly that it was Godelieva’s “absolute wish” to die.
Tom said that his mother’s “absolute wish” was also to be a good grandmother. He had brought some of her papers and letters, and he began reading from the draft of her suicide letter to him and his sister. “I feel frustration and sadness because I have not been able to build a connection,” he read. Then he showed them an apology letter that he had written to his mother when he was twenty, after one of many fights. “Forgive me,” he read. “You have dealt with the worst. . . . You care about me. I am not living up to your expectations. That hurts. I don’t know how to deal with that.”
Distelmans was silent. “He was very cool, very distant,” Bieseman said. “He didn’t seem to be touched.”
When Tom saw that his reading had elicited no response, he pushed his chair back from the table and stood up. Bieseman recalled, “He was screaming, ‘You went along with the madness of my mother! You went along with her tunnel vision, her defeatism. You’ve just taken away the suffering of one person and transposed it to another!’ ”
Distelmans repeated that he was certain that Godelieva had wanted to die, and that this was her right. Then he said that it seemed there was nothing left to discuss. They all stood up and shook hands, and Tom and Bieseman left the clinic.
Distelmans told me that he had no doubts about the way he handled Godelieva’s case. He explained that she was “a very nice person, a very warm person,” and that she had “wanted to do one decent thing in her life, and that is to die in a decent way, because the rest of her life was such a horrible mess.” When I asked if he worried about transference—perhaps she had idolized him or depended too much on his opinion—he laughed and said, “I’ve never met a patient who is willing to die to please someone else.”
Thienpont, whose practice is mostly devoted to issues surrounding euthanasia, was similarly confident about the decision to end Godelieva’s life. Since Ulteam opened, in 2011, Thienpont said it has been “overrun by psychiatric patients”—a phenomenon that she attributes to the poor quality of psychiatric care in the country. In Belgium, it is not uncommon for patients to live in psychiatric institutions for years. Outpatient care is minimal, poorly funded, and fragmented, as it is in most countries. In a new book, called “Libera Me,” Thienpont urges doctors to accept the limits of psychiatry, and argues that some patients live with so much pain, their thoughts unceasingly directed toward death, that their mental illnesses should be considered “terminal.” Before approving a euthanasia request, she does not require patients to try procedures that they think are invasive. Godelieva had never had electroconvulsive therapy, though it is effective for about half of patients with depression. “Sometimes it really is too late,” Thienpont told me. “If the patient’s energy is gone, then it is not humane to say, ‘Well, maybe if you go to a hospital that specializes in your problem for two more years it will help.’ I think we have to respect when people say, ‘No—that is enough.’ ”
Euthanasia for psychiatric patients was rare in the early years of the law, but patients complained that they were being unfairly stigmatized: psychic suffering, they argued, was just as unbearable as physical pain. Like cancer patients, they were subjected to futile treatments that diminished their quality of life. Dirk De Wachter, a professor of psychiatry at the University of Leuven and the president of the ethics commission for the university’s psychiatric center, said that he reconsidered his opposition to euthanasia after a patient whose request he had rejected committed suicide. In 2004, she set up a camera in front of a newspaper office in Antwerp and set herself on fire.
De Wachter believes that the country’s approach to suicide reflects a crisis of nihilism created by the rapid secularization of Flemish culture in the past thirty years. Euthanasia became a humanist solution to a humanist dilemma. “What is life worth when there is no God?” he said. “What is life worth when I am not successful?” He said that he has repeatedly been confronted by patients who tell him, “I am an autonomous decision-maker. I can decide how long I live. When I think my life is not worth living anymore, I must decide.” He recently approved the euthanasia of a twenty-five-year-old woman with borderline personality disorder who did not “suffer from depression in the psychiatric sense of the word,” he said. “It was more existential; it was impossible for her to have a goal in this life.” He said that her parents “came to my office, got on their knees, and begged me, ‘Please, help our daughter to die.’ ”
De Wachter told me, “I don’t want to kill people—I don’t think psychiatrists should kill people—but when the suffering is so extreme we cannot look the other way.” When he gives lectures, he tries to appeal to Christian audiences by saying, “If Jesus were here, I think he would help these people.”
René Stockman, the director of a Catholic organization, Brothers of Charity, which says that it runs a third of the psychiatric institutions in Belgium, told me, “They are using our Christian vocabulary in a new context. They say they are ‘saving’ people from their bad lives, through ‘mercy’ and ‘compassion.’ I cannot accept that.” He sees euthanasia as a failure of both psychiatry and medical education. “Any questions about ethics—they say, ‘Oh, we need a specialist for that.’ They are not learning to reflect morally on what they are doing.”
The Belgian Euthanasia Law (2002) defines euthanasia as the physician's “act of deliberately ending a patient's life at the latter's request,” by administering life-ending drugs.1 In Europe, psychological suffering stemming from either a somatic or mental disorder is acknowledged as a valid legal basis for euthanasia only in Belgium, the Netherlands and Luxembourg.2 In the Netherlands and Luxembourg, the term ‘assisted suicide’ is used when the life-ending drugs are taken orally, but in Belgium, the term ‘euthanasia’ is used whether the drugs are received orally or intravenously.
In all three countries, the law stipulates substantive and procedural criteria that must be met for euthanasia to be legally performed. The substantive criteria are almost identical (with the exception of different age limits), but there are slight differences in the procedural criteria (eg, the number of physicians who must be consulted and the necessity of a written request).2–4
In Belgium, specific criteria and procedures are clearly spelt out, including that the physician must report to the Federal Control and Evaluation Commission (FCEC) within four working days after the act of euthanasia, for review of all legal requirements relating to the case.1,3,5 It is also stated that if there are any doubts or irregularities, the FCEC can ask the physician who performed the euthanasia procedure for additional information, or the case can be referred to Belgium's public prosecutor.1,3,5
The Belgian Euthanasia Law indicates explicitly that requests for euthanasia from non-terminally ill adults or ‘emancipated minors’ (ie, minors who are legally independent from their parents) suffering from ‘unbearable and untreatable’ somatic and psychiatric disorders can be granted, as well as those from terminally ill patients.1
‘Unbearable’ suffering can be understood as a subjective term. By its nature, the extent to which the suffering is unbearable must be determined from the perspective of the patient himself or herself, and may depend on his or her physical and mental strength and personality.6 According to the Law, a physician has to come to a level of mutual understanding with the patient about the extent of his or her unendurable suffering.1
‘Untreatable’ is a more objective term. According to the guidelines of the Dutch Psychiatric Association (NVvP), any therapeutic option for a particular condition must meet the following three requirements: (1) it must offer a real prospect of improvement, (2) it must be possible to administer adequate treatment within a reasonable period of time and (3) there must be a reasonable balance between the expected treatment results and the burden of treatment consequences for the patient.7
Euthanasia for patients with unbearable somatic suffering is the subject of fierce ethical debate, and the debate is even fiercer in cases of unbearable psychiatric suffering.
In 2002, the Belgian legislature had foreseen the possibility of life-ending assistance for psychiatric patients, following long political debates on the issue of self-determination. Delbeke has briefly summarised the arguments as follows.6 The main argument in favour of providing life-ending assistance to psychiatric patients is that their suffering can be equally unbearable as the somatic suffering of other patients. The main argument against providing such assistance is that suicide prevention is a primary purpose of psychiatric care and a key focus of training for psychiatrists. From the psychiatrist's perspective, if the psychiatric patient has no further prospect of improvement, continues to suffer unbearably and persists with his or her wish to die, the psychiatrist finds himself or herself in the position of having to accept the validity of this wish, if all legal requirements can be fulfilled and all possibilities of mistakes and abuses can be carefully avoided. Some opponents reject this particular point of view because termination of life for non-terminally ill patients is unacceptable and incompatible with their views that life has to be protected at all costs. Furthermore, it should be borne in mind that the suffering associated with somatic disorders can also induce psychological suffering, such that there often exists a combination of physical and psychological suffering, which is called multicausality of suffering, and which may imply presence of mental illness. Not only the nature and origin of the suffering, but also the longer life expectancy make euthanasia for psychiatric patients more problematic and less acceptable for opponents.6
The specific complexity of this category of patients therefore requires the application of stricter conditions and criteria. “The Belgian legislature has registered a stricter approach for non-terminally-ill patients. Because unbearably suffering patients with a psychiatric condition are not suffering from a life-threatening (somatic) disease, they will generally fall under these stricter procedural conditions.” 8
Proponents and opponents of euthanasia generally agree on the importance of making every possible effort to offer patients the best attainable quality of life, including the best possible quality for the end of their lives when they consider their lives to be unbearable. For that reason, stringent procedures have to be adhered to, and monitoring and evaluation remain crucial.9
In Belgium, a valid request for euthanasia must be made in writing, without coercion, by an adult or an emancipated minor who is legally competent and conscious at the time of making the request.1,3,5,10 To be considered for euthanasia, an adult or emancipated minor must be “in a medically futile condition of unbearable and untreatable physical or psychological suffering, resulting from a serious and incurable disorder caused by accident or illness.”1 Based on Belgium's expanded Euthanasia Law (2013), a request for euthanasia from a “minor with the capacity of discernment” is also eligible for consideration, but only if the patient is “in a medically futile condition of unbearable physical suffering” due to an untreatable terminal illness.11 If a physician determines that a patient requesting euthanasia meets these criteria, this must be confirmed by the assessment of a second, independent consulting physician.1,3,5 When the patient is not expected to die in the near future, additional advice is required from a third physician, who should be a psychiatrist or medical specialist in the patient's pathology.1,3,5 This second and third physician's advice is requested but is not binding.6
A patient is considered to be in a medically futile situation, or treatment-resistant, if the suffering is unbearable and untreatable, and there is no prospect of any improvement. According to the Law, physician and patient must both come to the conclusion that there is no reasonable alternative left to relieve the patient's suffering.1 If the psychiatrist has reason to believe that the patient could experience further benefit from treatment options, then life-ending options cannot be granted.6
Since legalisation of euthanasia in Belgium in 2002, the number of euthanasia deaths reported by the FCEC has increased each year, rising from 742 in 2004/2005 (including 9 (1.2%) with neuropsychiatric disorders)12 to 2086 in 2010/2011 (including 58 (2.8%) with neuropsychiatric disorders).13,14 (The year 2004/2005 was the first year that neuropsychiatric disorders were specified in the FCEC data). This rise over a 6-year period may reflect a true increase or better reporting of cases of euthanasia.5 Proportionally, no differences with regard to gender, age, diagnoses or the nature of the patients’ suffering were observed over these years. Between 2008 and 2011, for a total of 3612 euthanasia deaths, the FCEC reported a male-to-female ratio of 51:49, and 2% of these deaths involved patients aged 20–39 years, 21.5% were aged 40–59 years, 51.5% were aged 60–79 years and 25% were 80 years or older.13,14 Overall, 45% of the patients died in a hospital, 45% at home and 10% elsewhere.13,14 The barbiturate, sodium thiopental, was the life-ending drug used in the vast majority of cases.13,14 Over 91% of these patients were terminally ill, while 8.5% suffered from a non-terminal condition.
Of all the terminally ill patients, cancer accounted for almost 77%, while 15% had other somatic disorders, approximately 3% were linked to neuropsychiatric disorders and 5% had multiple or other disorders.13,14
Among the non-terminally ill patients, cancer accounted for about 10%, while 40% had other somatic disorders, 24% were linked to neuropsychiatric disorders, and 26% had multiple or other disorders.13,14
The overall objectives of this study are: first, to report on characteristics of psychiatric patients requesting euthanasia because of psychological suffering; and second, to describe the formal assessment procedures and outcomes of the euthanasia requests. To the best of our knowledge, this is the first study to explore the determinants, procedures and outcomes of euthanasia requests in a relatively large group of psychiatric patients with psychological suffering.
This paper describes a retrospective case note review of the first 100 consecutive patients who requested euthanasia for psychological suffering associated with psychiatric disorders between October 2007 and December 2011. All consecutive cases were selected from among patients at an outpatient psychiatric clinical setting in the Dutch-speaking region of Belgium, where the first author and psychiatrist (LT) works, with intake beginning after LT completed LEIF (Life End Information Forum) training in March 2007 (the first case was in October of that year) and ending in December 2011 (ie, when LT joined ULTEAM—a newly founded central institute in Belgium to manage end-of-life cases—and thus stopped managing new requests for euthanasia at her private practice). Since 2012, no new follow-up studies were performed as this would have required a new study protocol and IRB request. The data analysis was closed at the end of 2012, and the data analysis and writing were conducted in 2013/2014.
All patient information had been recorded in full in the patient files, providing a clear database of information for analysis and follow-up. Sociodemographic data (age, gender, employment and living circumstances) and diagnoses were analysed. Decisions on euthanasia requests (including referrals for further testing/treatment), number of consultations, circumstances of euthanasia procedures and patient outcomes, were also analysed. By including all consecutive cases that met the selection criteria within a specified time frame, selection bias was minimised.
The psychiatric diagnoses were made according to the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV) classification. LT was involved in the counselling, referring and evaluation of all patients, as a consultant physician. At the end of 2012, all 100 patients or their practitioners were contacted to establish whether the patients were still alive and, if not, how they had died.
This study was a retrospective, non-interventional medical record analysis study of 100 patients requesting euthanasia in the context of psychological suffering. Given the nature of the study, the Ethics Committee confirmed that obtaining informed consent from the patients included in the study was not required on condition that the medical records were coded and made anonymous.
Implementation of the Euthanasia Law in clinical practice
To translate the Euthanasia Law into clinical practice in Belgium, the psychiatrists and/or LEIF practitioners among the authors (LT, WD, KA and PPDD) developed a four-track approach based on the guidelines of the Dutch Psychiatric Association (NVvP),7 which were issued in 2004 and revised in 2009, and also adapted to the requirements of the Belgian Euthanasia Law. LEIF, established in 2003 in Belgium, is a service that refers people to qualified healthcare professionals for assistance with end-of-life matters, and also offers training programmes for physicians.4,15 The NVvP guidelines are the first on this subject and are written in the same language used in the Dutch-speaking region of Belgium; therefore, they serve as a practical and valid basis for the application of the Belgian Euthanasia Law in the context of this study. For all patients in the sample, the four-track approach has been used. Further details about this approach are being prepared for publication separately.
The four tracks can be described as follows:
There must be a thorough evaluation through multiple consultations regarding the specific determinants and conditions of ‘unbearable and untreatable psychological suffering’ in each case. LT ascertained the psychiatric diagnoses, mental state and history of each patient after consultation with the treating practitioner(s), and made a thorough review of the case file and full psychiatric evaluation of the patient.
All therapeutic options that could alleviate suffering, including palliative care, must be discussed with the patients and their practitioners. For these discussions, LT used the following NVvP guidelines about these therapeutic options: (a) the therapy must offer a real prospect of improvement, (b) it must be possible to administer adequate treatment within a reasonable period of time and (c) there must be a reasonable balance between the expected results and the treatment burden for the patient.7
All procedural aspects should be explained to, and discussed with, the patient. Only when the patient repeatedly expresses the wish to die, and the patient's physician or psychiatrist indicates that the patient's reasons for this wish are sufficiently tangible and reasonable, will the formal request for euthanasia be filed and the planning begin.7 According to the Law, at least 1 month must elapse between the written request (which will be kept on file by the patient's practitioner) and the implementation of euthanasia.
The patient's family and/or significant others should be involved. Legally, the physician is required to discuss the wishes of the patient with the relatives named by the patient. Consent from the relatives is not required, and the attending physician needs the patient's permission to inform family members of the euthanasia request.1,3 Fostering acceptance in the patient's social environment can give the patient the opportunity to pass away in a serene atmosphere, surrounded by family and/or friends, whose mourning process can thus also be softened.
One hundred consecutive psychiatric patients requesting euthanasia based on psychological suffering associated with psychiatric disorders during the study period were included.
The patients included 23 men and 77 women, age ranging 21–80 years, with an average age at intake of 47±13 years (mean±SD); the average was 46±16 years for men (range 22–79 years) and 47±12 years for women (range 21–80 years). The age–gender distribution is shown in figure 1. The majority (n=81) had been professionally inactive for an extended period of time, including 8 who were retired and 73 who were medically unfit for work (they were either receiving disability living allowances or had taken early retirement). Fourteen patients were still working or temporarily on sick leave. One patient was a student, one was imprisoned and one was receiving a subsistence income from the Public Social Welfare Agency (data on income/employment were not available for two patients). Fifty-nine patients were living alone while 41 were living with one or more companions.
Frequency of age in 100 psychiatric patients who requested euthanasia, by gender.
Referral, diagnoses and mental state
The 100 patients included in the study were referred for psychiatric counselling by LEIF (n=36), their general practitioners (n=21), their consulting psychiatrists (n=24), their consulting psychotherapists (n=10) or otherwise (n=9).
At the time of the intake consultation with LT, each patient had at least one diagnosis that had been given by his or her practitioner, which was subsequently confirmed by LT (see track 1 in Methods section). Ninety of the 100 patients had more than one diagnosis. Most patients presented with numerous diagnoses, but for the sake of clarity, we report only a maximum of three disorders per patient, taking only the most recent diagnoses for each. Most of the patients suffered from a treatment-resistant mood disorder (n=58, including 48 with major depressive disorder and 10 with bipolar disorder) and/or a personality disorder (n=50), while 29 patients had both. Other psychiatric diagnoses included post-traumatic stress disorder (n=13), schizophrenia and other psychotic disorders (n=14), anxiety disorders (n=11), eating disorders (n=10), substance use disorders (n=10), somatoform disorders (n=9), pervasive developmental disorders (n=8; including 7 with Asperger syndrome—an autism spectrum disorder (ASD)—and 1 with attention deficit hyperactivity disorder), obsessive–compulsive disorders (n=7), dissociative disorders (n=7) and complicated grief (n=6), among others. In addition to their psychiatric disorder(s), 23 patients also had somatic illnesses, including chronic fatigue syndrome and/or fibromyalgia (n=8), or other chronic somatic suffering (n=15).
The 50 patients with personality disorders included borderline personality disorder (27), dependent personality disorder (3), histrionic personality disorder (2), avoidant personality disorder (1), narcissistic personality disorder (1), paranoid personality disorder (1), cluster B personality disorder (1) and personality disorders not otherwise specified (14).
In all patients, the suffering was chronic, constant and unbearable, without prospect of improvement, due to treatment resistance.
All patients were legally competent under the Law. Each patient's capacity for discernment was evaluated during the process, by LT in consultation with the patient's practitioner(s), according to explicit criteria described in the Belgian Legal Doctrine.6
Responses to euthanasia requests
After initial evaluation, and discussions with each patient and his or her practitioner(s) about all therapeutic options that could alleviate suffering, as required by the Euthanasia Law (see tracks 1 and 2 in Methods section), 38 patients were referred for further diagnostic tests and/or treatment to specialised inpatient (n=17) or outpatient (n=21) care facilities. Thirteen of those 38 patients were specifically tested for ASD, and among them 12 received an ASD diagnosis (all were Asperger syndrome). After the further testing/treatment, 17 of these 38 requests for euthanasia were accepted (44.7%) and 10 were carried out.
The other 62 patients were not referred for further testing or treatment because of the clear absence of reasonable therapeutic alternatives for them, as described in the NVvP guidelines. Thirty-one of these 62 patients had their requests for euthanasia accepted (50%) and 25 were carried out.
In total, 48 of the 100 patients’ euthanasia requests were accepted (48%), because LT (psychiatrist), in discussion with the patients’ other practitioners and families, considered the requests to be based on reasons that were sufficiently tangible and reasonable, and because all legal requirements had been fulfilled.
Among all 48 patients whose euthanasia requests were accepted, euthanasia was performed in 35 patients (72.9%), while two committed suicide before the procedure could be implemented and 11 patients decided to either postpone or cancel the euthanasia procedure. Of the latter 11 patients, 8 explained (by phone or mail) that knowing they had the option to proceed with euthanasia gave them sufficient peace of mind to continue their lives, while 2 withdrew their euthanasia requests due to strong family resistance and 1 could not be implemented on the grounds that the patient was imprisoned.
Among the 52 patients whose requests were not accepted, 38 withdrew their requests before a decision was reached, while another 8 continued to pursue their requests, 4 committed suicide and 2 died spontaneously.
Outcomes for patients
By the end of 2012, when follow-up was conducted, 43 of the 100 patients had died. Euthanasia had been performed on 35 patients (9 men and 26 women). Six patients had committed suicide (2 men and 4 women). Two other female patients had died, one after palliative sedation in a psychiatric hospital, and the other due to the terminal stage of anorexia nervosa.
In the six suicide cases, one (woman, aged 51) found the procedure for obtaining the approval for euthanasia to be unbearably long, one (woman, 74) found the waiting time after the approval unbearably long, and one (woman, 42) committed suicide because her family resisted the option of euthanasia, even though the request had been approved. Two patients (both men, 33 and 44) committed suicide after breaking off communication (after requesting euthanasia), and one (woman, 55) committed suicide after staying in a psychiatric ward to which she had been referred.
In the remaining 57 cases (12 men and 45 women), the patients or their practitioners were contacted and it was confirmed that these patients were still alive. In nine cases their requests were still in process and no decision had been reached. In 48 cases, their requests were on hold because they were managing with regular, occasional or no therapy.
Not including an extended history of previous therapy sessions with their respective practitioners, among the 35 patients who underwent euthanasia, the average number of psychiatric counselling sessions with LT following the request for euthanasia was 3.49±4.42 (mean±SD) per patient. The average time between making the request for euthanasia (ie, the first session with LT) and performing the euthanasia procedure was 8.66±9.55 months (mean±SD).
Among the 35 patients who received euthanasia, in 20 cases, the procedure was performed by the patient's general practitioner, in 1 case it was performed by her neurologist and in the other 14 cases the procedure was performed by an LEIF physician consulted for the case.
The barbiturate, sodium thiopental, was used as the main life-ending drug in all 35 euthanasia procedures (31 intravenously, 4 orally). In 28 cases, the procedure took place in domestic surroundings, while 5 took place in the neurology ward of a university hospital, 1 took place in the office of the consulting physician and 1 at the palliative care ward of a general hospital. Thirty of the 35 patients had family and/or friends present at the time of death. In 33 of the 35 procedures, the relatives and the doctors performing euthanasia explicitly reported a calm and smooth passing. In one case, tensions rose due to emotional difficulties for some relatives in fully accepting the patient's wish to die by means of the euthanasia procedure. In another case, the practitioner performing the procedure was inexperienced and became overwhelmed and stressed by the situation, which caused discomfort for the patient.
Among 100 patients requesting euthanasia based on psychological suffering associated with psychiatric disorders, most had been referred for psychiatric counselling by their own practitioner (n=55) or by LEIF (n=36). Ninety patients had more than one psychiatric disorder at intake; the most frequent diagnoses were depression (n=58) and personality disorder (n=50); 29 patients had both. Thirty-eight patients were referred for further testing and/or treatment. In total, 48 of the euthanasia requests were accepted and 35 were carried out. Among the other 13 patients whose requests were approved, 2 committed suicide before the procedure could be carried out and 11 patients decided to postpone or cancel the procedure (including 8 who said that knowing they had the option to proceed with euthanasia gave them sufficient peace of mind to continue their lives). Overall, 43 patients had died by the time follow-up was conducted by LT at the end of December 2012: 35 had died by euthanasia, 6 by suicide, 1 after palliative sedation and 1 from anorexia nervosa.
Strengths and weaknesses
To the best of our knowledge, this is the first report on a relatively large series of requests for euthanasia based on psychological suffering due to psychiatric disorders. A few studies have explored the determinants of psychological suffering in patients in the context of requests for euthanasia,16,17 but these studies did not exclusively report on patients requesting euthanasia based on unbearable and untreatable psychological suffering due to a psychiatric illness. This retrospective study draws attention to and deepens our understanding of the circumstances of a rather small but severely afflicted subgroup of psychiatric patients. As an indication of the current situation of euthanasia practices in Belgium, 2086 patients died in the 2-year period 2010–2011, after having their euthanasia requests granted; those deaths constituted 1% of all deaths in Belgium during that period, and the non-terminally ill patients (including psychiatric patients) accounted for only a small minority (less than 10%) of that small group.14
Nevertheless, this study has inherent limitations. Some potentially important determinants, such as personal and social background and the details of the psychiatric evaluation, were collected as part of the clinical file but not in a systematic way, as would have been applied in a prospective study. The sample size may have limited the ability to detect statistically meaningful differences based on determinants that may be associated with a euthanasia request being granted, refused or withdrawn. By including all consecutive cases that met the selection criteria within a specified time frame, selection bias was minimised. It is not possible to estimate how representative this sample is of the entire population of similar patients. Comparing characteristics and outcomes of our sample with the national data is not helpful since the FCEC only reports data from patients who died by euthanasia, not from patients who requested euthanasia. Moreover, FCEC does not differentiate between specific determinants of patients suffering predominantly from neurological and psychiatric disorders. Similarly, it is impossible to assess to what extent the findings are generalisable to other groups of similar patients; a larger sample would have strengthened the study in this regard.
Interpretation and implications
In comparison to other studies, our patient group contains more women than men (23 men and 77 women), which is different from the male-to-female ratio in the euthanasia cases carried out for somatic and/or mental reasons as recorded by the FCEC (51:49). This is in line with other reports in the literature, which indicate that women fulfil the diagnostic criteria for mental disorders more often than men, except in the case of substance use disorders.18 Furthermore, demand for mental healthcare19 and utilisation of mental healthcare services20 are higher in women than in men. When compared with the FCEC data, our group of psychiatric patients requested to end their lives at a younger age (median=47 years) than the overall group of patients who have undergone euthanasia for any reason (ie, somatic and/or mental reasons combined), the majority of whom have been older than 60 years. This may be partly explained by the earlier onset and longer course of psychiatric disorders (eg, treatment-resistant mood disorder) compared to the somatic disorders that are usually the basis of euthanasia requests (eg, cancer). It may also be a reflection of the complex nature of psychiatric disorders, which have a sense of hopelessness as a core symptom. Furthermore, the complexity of psychiatric disorders might have led to the initial underdiagnosis of Asperger syndrome in our patient group, the analysis of which is beyond the scope of this report. At intake, patients already had an ASD diagnosis, and 12 more patients (who had further testing/treatment after requesting euthanasia) were diagnosed by dedicated diagnostic work up. All 19 of these patients had Asperger syndrome, with normal to high IQ.
Among the 35 patients in this study who died by euthanasia, 28 died in domestic surroundings and 7 in a clinical setting. Thirty of these patients died with family and/or friends present, in a serene and positive atmosphere, which would have been impossible to attain in the case of unassisted, traumatic suicide. Patients and relatives report their experience of euthanasia as a more humane death than suicide, and they expect a less difficult period of mourning. Bereavement after the suicide of a relative or significant other entails an emotional turmoil that may last a long time, and, in some cases, may end with the mourner's own suicide.21 Accordingly, we note that the fact that their euthanasia request was being considered could not prevent suicide in 6 patients, including 2 of the 48 patients (4.2%) whose euthanasia requests had been approved and 4 of the 52 patients (7.7%) whose requests had not yet been approved. Moreover, the modes of suicide were dramatic, but we cannot provide further details due to respect for patient confidentiality. It is a difficult tightrope to tread: on the one hand, there must be sufficient time to accomplish all legal and medical requirements, on the other, there is a need to take action before the suffering reaches an unbearable level and leads to traumatic suicide. Likewise, a clear distinction should be made between suicidality (in thoughts and behaviour), which is symptomatic of (and/or triggered by) a number of psychiatric disorders, and a well-considered euthanasia request, which includes a patient's statement that his or her suffering is entirely unbearable, and that available treatment and medical assistance has been found to be inadequate. Therefore, we wish to underline that each euthanasia request must be scrutinised as a request for effective and far-reaching treatment, and that any such request demands exploration of all implications and clarification of alternatives. The four-track approach implies that patients are compos mentis—that is, they can make a rational choice; under the Euthanasia Law it is required that patients are legally competent and so their capacity for discernment is thoroughly assessed before any request for euthanasia is considered.
Unanswered questions and recommendations for future research
A literature review made clear that the concept of ‘unbearable suffering’ has not yet been defined adequately, and that views on this concept are in a state of flux.22 It is generally accepted that this concept is considered to be subjective, dependent on personal values, and that it must be determined in the first place by the patient.6 Nevertheless, a psychiatrist should carefully evaluate this in the context of each patient's psychopathology.6 Unfortunately, there are no guidelines for the management of euthanasia requests on grounds of mental suffering in Belgium. Taking into account the ongoing fierce ethical debates, it is essential to develop such guidelines, and translate them into clear and detailed protocols that can be applied in practice. Therefore, further studies are recommended, especially prospective quantitative and qualitative studies, to obtain a better understanding of patients with psychiatric disorders who request euthanasia due to unbearable psychological suffering. Furthermore, these studies could undertake systematic comparisons between groups of psychiatric and non-psychiatric patients, thereby exploring the risk factors for, and origins and degree of, unbearable suffering in both patient groups.
The authors wish to thank Dr Marleen Temmerman for her critical input and comments, and her encouragement for us to publish this work. They also wish to acknowledge the valuable language and technical editing by Jane Patten, of Green Ink, UK.