"I think we have to respect when people say, 'No—that is enough.'"
June 22, 2015 12:07 PM   Subscribe

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.
Rachel Aviv traveled to Belgium, where euthanasia has been legal since 2002, to report on the complications and consequences that surround the practice of assisted suicide and euthanasia for psychiatric patients: The Death Treatment.
posted by divined by radio (52 comments total) 23 users marked this as a favorite
 
With disorders where the desire to die can be a symptom in and of itself, rather than a response to other symptoms, you've got to be very fucking careful.
posted by showbiz_liz at 12:21 PM on June 22, 2015 [16 favorites]


Previously.
posted by nat at 12:31 PM on June 22, 2015


Am I the only person who found that article extremely creepy?
posted by wuwei at 12:33 PM on June 22, 2015 [6 favorites]


It sure sounds like there ought to be more safeguards in place. And the next of kin should at the very least be notified!

My problem with this is, people who are suicidal are not generally suicidal 100% of the time. If a person has light times and dark times, and in the dark times they want to die and in the light times they want to live - if they've wanted to die before, and then later on been glad that they didn't die - then if you euthanize a suicidally depressed person, are you alleviating someone's incurable pain, or are you murdering the person they might be later on? Or both?
posted by showbiz_liz at 12:43 PM on June 22, 2015 [3 favorites]


if you euthanize a suicidally depressed person, are you alleviating someone's incurable pain, or are you murdering the person they might be later on?

It's a difficult hypothetical, because there is no way to guarantee correctly predicting any one of an individual's future outcomes. If you euthanize someone who is terminally (physically) ill, are you murdering someone who could have possibly been saved (or had their life extended) with an experimental drug? It doesn't seem like there is a neat answer.
posted by a lungful of dragon at 12:51 PM on June 22, 2015 [1 favorite]


I found it creepy, but I also think that there's a lot of creepiness and no satisfactory resolution about this issue. I have a relative who defaults to mumbling "I want to die, I want to die" when they have a bad day....they're dwindling in the grip of a decade-long terminal illness, and it's pretty bad. That's creepy, if you like.

"If you're sufficiently unhappy the national health service will help you find a doctor to help you commit suicide, and sometimes standards may be a little weebly-wobbly" is creepy. "You will live in a demented state on a charity ward covered in bedsores because you're poor and you don't have anyone to take care of you and your illness is brutal but slow" is also creepy. So is "you'll try to kill yourself but keep botching it for years until you finally manage". It's creepy, yes. I tend to think that accepting that it's creepiness all the way down and trying to write as good regulations and practices as possible is the only thing that makes any sense.

The article doesn't seem to suggest (unless I missed something) that people are being pressured to kill themselves, which is one of the things that rightly concerns disability activists. For me, that's the big worry, that paving the way for someone like me to off themselves when they get a bad diagnosis will inevitably devolve into pressuring someone with an expensive but manageable condition to commit suicide.

I do completely agree that people have to have the right to decide to die. There's important other stuff in play in terms of social support so that people don't have to want to die, but if we're going to believe people about how they self report their internal state at all, someone who is saying "I want to die" over a sustained period has to be believed. If we're all "well, you can't really know what you want and in any case it is in the interest of society that we compel you to live"....that's totally creepy; why give people any autonomy at all?
posted by Frowner at 12:51 PM on June 22, 2015 [27 favorites]


Haven't read it all, but a thought here:

While the subhead of the article seems to suggest that depression is not terminal, it certainly seems like it may have been for Ms. De Troyer--a constant presence, with periods of remission. The description of her depression definitely does sound terminal.
posted by qcubed at 1:06 PM on June 22, 2015


In Darkness Visible, William Styron states that suicide can be seen as a rational response to untreatable depression. He describes the pain of depression as a psychic pain, one that hurts no less than the physical. I do wonder if euthanasia helps normalize the concept of suicide, so that those who are suicidal feel less internal resistance to the idea. (I don't know and would actually love to see statistics on this subject.)

As Frowner says, how do we square the concept of autonomy with the idea that the state has some responsibility to preserve the life of its citizens. Do we, as a community, as a nation have a right to say "this pain will pass, you must endure"?
posted by Hactar at 1:07 PM on June 22, 2015 [2 favorites]


1) It scares me that some of the subjects refused to even consider that this might be morally complicated. Like, a lot of people interviewed seemed to think that if you aren't 100% comfortable with on-demand euthanasia, you have no respect for human dignity and might even be a secret Catholic.

2) It scares me that the man's mother was essentially able to doctor-shop for this. Especially having never even had ECT.

I mean I find many of the arguments for euthanasia convincing, but I think people at least need to pay lip service to the idea that it is a complex and difficult decision. A society that is totally blasé about widespread state-sanctioned homicide is uncomfortably dystopian.
posted by vogon_poet at 1:08 PM on June 22, 2015 [16 favorites]


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.

I don't know how to comment on the article without sounding fighty. It could be that I just shouldn't try commenting at all, since I start from a basic position of distrust of psychiatry. But what I want to say is that when I read this part of the article, my blood ran cold. And then, in the very next sentence:

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.

I absolutely believe people have a right to die when and as they see fit. I absolutely believe, though, that people have a right to the kind of care that will help them not to feel like monsters, first. And if your system of healthcare cannot address that first, then it sure as hell doesn't get to "help" you die.

I mean--and here's where it gets fighty--you've got a diagnosis like borderline personality disorder which is essentially Hysteria 2.0, a disorder that guarantees you will be treated by the psych field as though you are purposefully annoying and a burden. You ought not be allowed to kill people with BPD. I have, based on my experience of being diagnosed and treated for it, literally zero faith in any practitioner's objectivity when it comes to this disorder, and my faith drops into the negative numbers if it comes to trusting that an annoyed psychiatrist has the necessary [whatever moral quality] is needed to determine whether your demise should be licensed.

In oncology, in other fields, you get to visit the palliative medicine doc. You're going to die; let's see how we can make your final days less painful and awful. But what is on display here is, "We have no palliative care, we're not going to offer anything to ameliorate your pain. If current standards of care aren't working for you, let's go straight to death."

It is an ugly abdication from the moral duty of medicine to lessen pain. Again: I have no problem acknowledging a right to die. But I think that that right must go hand in hand with a right to have one's pain--physical or psychic--addressed in an effective way long, long before assisted death becomes an option.
posted by mittens at 1:08 PM on June 22, 2015 [38 favorites]


I mean--and here's where it gets fighty--you've got a diagnosis like borderline personality disorder which is essentially Hysteria 2.0, a disorder that guarantees you will be treated by the psych field as though you are purposefully annoying and a burden. You ought not be allowed to kill people with BPD.

Just for anyone who may have overlooked it in the article:
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.’ ”
posted by vogon_poet at 1:13 PM on June 22, 2015 [6 favorites]


Yeah, you're right about that. When I read this, I was chilled:

[De Watcher) 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.’ ”

Her parents were begging him to relieve them of the burden of a daughter with BPD, and he did it. I know BPD is hell for other people, but this is unconscionable.
posted by Countess Elena at 1:14 PM on June 22, 2015 [13 favorites]


Trust me folks. A lifelong and unrelenting depression can absolutely be terminal. It certainly feels that way, anyway. It's something that's so hard to explain to people, even those who have experienced occasional bouts of depression. De Troyer's classification of her moods by color are pretty spot-on.

My therapist and I discuss this very subject now and again. I totally support a person's right to end their life in cases such as this.
posted by Thorzdad at 1:14 PM on June 22, 2015 [15 favorites]


oh, jinx.
posted by Countess Elena at 1:14 PM on June 22, 2015


There's a reason this guy is considered a hero and not a meddling jerk who got in the way of peoples' rights.

People should be able to make the choice to die, but people also shouldn't have to die just because their brains are telling them they ought to die one day, and something else entirely the next.
posted by showbiz_liz at 1:18 PM on June 22, 2015 [2 favorites]


I remember reading about an imagined society in which death, as a punishment/treatment, could only be administered after a judging entity came to understand the subject so much that understanding became a kind of love.
posted by amtho at 1:21 PM on June 22, 2015


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.

I think this is an important point and one that is worth giving a lot of thought to. The connection between assisted suicide and pain is a lot weaker than the connection between assisted suicide and disability. In the U.S., at least, attitudes toward people with disabilities are still pretty discriminatory. In many states, too, from what I understand, we do a terrible job of providing -- or even offering -- services that help people to express their autonomy after they have acquired a disability. Still less do we offer counseling to understand that autonomy and dignity are not the same thing.

I think it's at least possible that assisted suicide is an expression of ableism, and that troubles me quite a bit.
posted by gauche at 1:25 PM on June 22, 2015 [14 favorites]


I think it's at least possible that assisted suicide is an expression of ableism, and that troubles me quite a bit.

I just want to put a little pressure on this idea. It may be true as far as many conditions go, but I know from my own family's experience that unmanageable pain and slow cognitive decline - even with very, very good care and family support - can still cause intelligent, morally serious people to wish they could kill themselves.

I think that it's really, really important not to start saying that all people with [X type of condition] obviously just need better care and more social services [unless by "better care" you mean "care that is virtually a cure"].

I surmise that there's a huge difference in people's response to this stuff depending on whether they have personal/social/familial experience with conditions that would be manageable in a just society or personal/social/familial experience with brutal declines that are basically not stabilizable or manageable, and it's important not to assume that one maps onto the other.
posted by Frowner at 1:30 PM on June 22, 2015 [9 favorites]


Came here to be supportive of what Thorzdad said. Two of my best friends (now mid-40s) have suffered from chronic depression their whole lives. They hate it. It's horrible for them. It's interfered with their relationships, their ability to hold jobs, everything. They've both tried everything they can possibly think of: different medications, which didn't work, and endless talk therapies and self-help workshops. Nothing has really worked. The only thing people say to them now is "well, cheer up, maybe some day you'll find a medication that works." One of them the other day said that managing her depression all day, every day, is effing exhausting, and that she hopes she will not live into her 70s or 80s. And all I can say is "I love you, and I hope that some day you will not be suffering."
posted by sockerpup at 1:35 PM on June 22, 2015 [10 favorites]


Yeah, there's a pretty big difference between chronic pain (physical or psychological) and disabilities that are more about impaired functioning.
posted by Jacqueline at 1:37 PM on June 22, 2015


Citing examples of people who have benefited or might benefit from euthanasia doesn't mean that euthanasia can't sometimes be improperly applied.
posted by showbiz_liz at 1:41 PM on June 22, 2015 [4 favorites]


Citing examples of people who have benefited or might benefit from euthanasia doesn't mean that euthanasia can't sometimes be improperly applied.

Yes, precisely, just as citing examples of people who might be forced to kill themselves doesn't mean that some people can't - legitimately and seriously - want to kill themselves. My point being that these are two very separate issues, and in these conversations here, I feel like we never get much further than people who have very, very different experience with chronic illness, death and disability trying to insist that, properly understood, there is only one important experience on this issue.
posted by Frowner at 1:55 PM on June 22, 2015 [11 favorites]


Trust me folks. A lifelong and unrelenting depression can absolutely be terminal. It certainly feels that way, anyway. It's something that's so hard to explain to people, even those who have experienced occasional bouts of depression.

Amen.

What happens when you spend decades of your life trying every method of assistance that's made available to you and nothing works? How far are we willing to go to compel people to keep trying to relieve their own suffering when they've already done so much? How much are we going to manually extract from them, or demand them to give freely of themselves? When will we let them say, "OK, enough"? And what happens when our proposed treatments sound worse to them than death? Are we really going to say, "Well, it doesn't sound worse than death to me, so you're SOL, bub"?

F'rex I've never had ECT done but I've seen a whole hell of a lot of people immediately before and after they have and it isn't anything I can imagine going through -- for me and me alone, getting strapped to a gurney, anaesthetized, and having my brain repeatedly put into a seizure state in hopes of temporarily lifting my depression is absolutely a fate worse than death. Just... no. I would rather die than go through that specific experience, even as I acknowledge that it can temporarily do wonders for about half of its recipients. I've had loads of medication and loads of therapy and I have been overwhelmingly lucky in this life but even though all of these things have helped to some degree or another, nothing has ever put any kind of dent in the howling hollowness inside. It sounds dramatic because it just is. I've been falling asleep praying to a deity I don't even believe in to somehow make it so that I don't wake up for 33 years straight, since my very first memories, before kindergarten. It gets old. You get so tired, bone tired. And I'm tired. So I'm waiting.

One of the worst things about lifelong mental illness is that it gets to a point where no one will trust what you say or think ever again. Worse, nearly everyone -- your friends, your family, your most treasured and cherished confidante -- will remain passionately invested in trying to convince you to mistrust your own thoughts. Acknowledgment that sometimes things just can't be fixed is so devastatingly rare, eventually you just stop trying to explain it and shut all of your feelings inside because then at least people will stop feverishly attempting to convince you that you're wrong about how much suffering you can really endure. So I guess I would agree that the article is creepy insofar as it's generally considered creepy to delve so deeply into the morality of assisted suicide, but more than anything, it just really made me want to move to Belgium.
posted by divined by radio at 1:55 PM on June 22, 2015 [44 favorites]


How far are we willing to go to compel people to keep trying to relieve their own suffering when they've already done so much?

Well, seeing as the assumption is that they are not well and therefore incapable of real decision-making? It seems like as a society we're willing to go as far as possible until the only way they can end it is in a messy fashion.
posted by qcubed at 2:06 PM on June 22, 2015


Yes, precisely, just as citing examples of people who might be forced to kill themselves doesn't mean that some people can't - legitimately and seriously - want to kill themselves. My point being that these are two very separate issues, and in these conversations here, I feel like we never get much further than people who have very, very different experience with chronic illness, death and disability trying to insist that, properly understood, there is only one important experience on this issue.

I think that if we're debating whether it's fine to kill people, then cases where people wrongly died are pretty important to balance with cases where people wanted to die and then did.

I never said that there weren't cases where people legitimately and seriously want to kill themselves. But by ONLY focusing on those people, does the Belgian system facilitate wrongful deaths among other people?

Asking that question does not mean automatically taking away the rights of every person who might seek euthanasia. NOT asking that question seems like basically shrugging your shoulders and accepting that some people will die who might have chosen to live.
posted by showbiz_liz at 2:09 PM on June 22, 2015 [2 favorites]


I think implicit in your last paragraph, liz, is that being alive is necessarily considered a good thing, which, to be honest, I don't know if I wholly agree with.

I also think that because it's a fundamental assumption of your argument, the disagreement in view may not be resolvable?
posted by qcubed at 2:12 PM on June 22, 2015 [3 favorites]


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.”

This stuck out at me, because... well, I think that's not true. I think of parents who murder their disabled (especially autistic) children, and I think: what about someone who thinks their existence makes them a burden on their families? What about someone whose family actively makes them think they're a burden and chips away at that? When there are so few resources for support for disabled people--and their caregivers--and societal messages frequently signal 'your needs are not important enough to make room for,' well, where do you think someone might get the idea that their dying would please others? You bring that up quietly enough, for long enough, and some people get angry about it and some people just internalize it and decide it's probably true. For that reason, Distelman's response seriously worries and upsets me.

I think there's a lot to what mittens has to say about support systems and disability here that the article really doesn't engage with. And I think that there's been enough really horrific incidents with caregivers abusing or killing disabled people--including people with mental disorders, possibly especially those with mental disorders--that easily accessible euthanasia does not sit well with me. The possibility of parents being able to argue for their daughter's death is one that is rife with opportunities for abuse.
posted by sciatrix at 2:17 PM on June 22, 2015 [23 favorites]


I think implicit in your last paragraph, liz, is that being alive is necessarily considered a good thing, which, to be honest, I don't know if I wholly agree with.

No. You're putting words in my mouth. I support euthanasia. I just don't support its blind application to people who might not actually want it, because I don't think that wanting something today, in the grips of a particularly bad bout of a disease that whispers "hey kill yourself" in your ear, necessarily implies that you wouldn't enormously regret that decision later on. If you could.
posted by showbiz_liz at 2:20 PM on June 22, 2015 [1 favorite]


I didn't mean to put words in your mouth--I do think, however, I may have misunderstood your point.

I'll admit I don't know the whole Belgian setup, but it does seem like, overall, that there is a process one has to go through to be approved? The best one can do, I suppose, is continually refine it, but there will always be limits--and I don't know if it's worth it to prohibit euthanasia until the process is perfect.
posted by qcubed at 2:22 PM on June 22, 2015


If we accept the idea that euthanasia is an appropriate treatment for depression, then we must also accept and come to grips with the idea that the people who try and prevent suicides (guards on bridges, suicide helpline workers) are actually the bad guys, since they interfere with bodily autonomy and deny people the right to self-administered medical treatment.
posted by Avenger at 2:29 PM on June 22, 2015 [7 favorites]


I just don't support its blind application to people who might not actually want it, because I don't think that wanting something today, in the grips of a particularly bad bout of a disease that whispers "hey kill yourself" in your ear, necessarily implies that you wouldn't enormously regret that decision later on. If you could.

I think that rash, sudden decisions are more likely somewhere there isn't a route towards euthanasia. People kill themselves all the time because of depression, often in messy or painful ways because there isn't an alternative; having a system where there is a process which takes some time would seem to me to be perhaps a good way to stop some impulse decisions.
posted by lesbiassparrow at 2:36 PM on June 22, 2015 [7 favorites]


The more I think about this culture the more worried I get. The article talks about a culture of, of almost "praise for those who commit suicide" and then there's the explicit discussion of how there are not good psychiatric social services available in Belgium. If we value freedom and release from pain so much, are we as a society willing to pay for it? Because death is cheap. Supporting people who may not immediately--or ever--get "better" and stop needing direct support is much more expensive.

The pro-euthanasia ethos of personal freedom and standing on one's own described in the article just... worries me so much. Sometimes we have to depend on each other, sometimes permanently. It seems as if the focus on personal autonomy elides the point that your choices can become very artificially restricted when you don't have good support structures to count on. What happens when people get so tired because available assistance is not all that available, and it requires jumping through a mass of bureaucratic hoops to get through? What do we make more easily accessed--euthanasia, or support?
posted by sciatrix at 2:37 PM on June 22, 2015 [11 favorites]


If Belgium offered "euthanasia on demand," without having to demonstrate any reason whatsoever -- well, I think that would be a bad idea for other reasons, but at least it wouldn't involve the state in making judgments about what is and is not too terrible to expect people to live with. I'm actually less bothered by the inclusion of mental illness than by the inclusion of physical disabilities that don't necessarily involve actual pain. If you have some variety of suffering that's terrible and apparently permanent, but not actually linked to mental or physical illness -- guilt over something you'd done in the past, for instance, or apparently unending grief for your child who died ten years ago -- Belgium won't lend official legitimization to your belief that your life is not worth living. But in the case of partial paralysis, or simultaneous deafness and blindness, it will. How is that not ablist?

Also, I thought a large part of the rationale for assisted suicide was that the patients who needed it were physically weakened by their illness and, without assistance, either wouldn't be able to commit suicide at all or could only do it with the direct help of their family or friends, which would be very hard on those people. That seems not to apply to cases of depression and other mental illnesses. There are some methods of "homemade" suicide that are widely acknowledged to be quick, painless or almost painless, and effective. So can't we just admit mentally ill people's right to kill themselves (not criminalizing attempted suicide, etc) without giving it governmental help and implied approval?

And the 25-year-old -- generally I think an adult is an adult, but nobody has any business helping a 25-year-old commit suicide because of a mental illness, because most mental illnesses don't emerge until adolescence or early adulthood. 25 is way, way too early in the course of a mental illness to know that it will continue to be unbearable.
posted by ostro at 2:45 PM on June 22, 2015 [4 favorites]


Also, I thought a large part of the rationale for assisted suicide was that the patients who needed it were physically weakened by their illness and, without assistance, either wouldn't be able to commit suicide at all or could only do it with the direct help of their family or friends, which would be very hard on those people.

I've never heard that as part of the rationale. It's always been more along the lines of wanting a professional to assist because otherwise, your average person is likely to fuck it up somehow and just end up doing more damage to themself.
posted by Etrigan at 3:23 PM on June 22, 2015 [1 favorite]


yea, everyone's circumstances are different, but part of it is just being able to have a conversation and talk about it with your physician and significant others as a legitimate option; not about psychiatric patients per se, but on npr recently:

-Coded Talk About Assisted Suicide Can Leave Families Confused
-Stories About assisted suicide
-Stories About euthanasia

think of parents who murder their disabled (especially autistic) children

agency and consent are issues of course as is the implicitness (or not) of 'burden' but it seems like discussions lacking agency -- itself a debate -- quickly veer into post-natal 'abortion' territory and the moral grounding of eugenics, trait desirability and cultural acceptance of cognitive diversity. not that that's necessarily a separate issue, but it does broaden the landscape a bit...
posted by kliuless at 4:29 PM on June 22, 2015 [2 favorites]


This thread is relevant to this discussion.
posted by Faint of Butt at 5:33 PM on June 22, 2015


I have to disagree regarding suicide hotline workers and bridge guards being bad guys (at least, in an ideal system).

We already limit who can provide medical care: licensed professionals within their scope of practice. Sometimes it can be annoying and seemingly unnecessary (Yes, I'll come in for a visit to get my antibiotic script for my annual bout of strep throat. Sure, take a culture, it's the highlight of my year! Maybe you can give me an extra for next year? No? You just love that strep breath smell, don't you), but the downsides to not regulating medical services outway the positives.

So if euthanasia is an acceptable treatment, we can also aim for provision of that treatment to be through the medical system, where there are both informed consent and health professionals who can rule out any potential medication side effects, acute diseases ( that might prevent informed consent prior to evaluation), and implementation of said treatment. Bridge guards and suicide hotline worker are just making sure parties are truly fully informed etc.
posted by ghost phoneme at 5:47 PM on June 22, 2015


What I find interesting is how the doctors seem to be the ones administering the fatal treatment in the Belgian system. I understand a doctor taking a more active role if the patient is physically unable to dose themselves, but I would think that leaving the final act of swallowing the pill or pushing the plunger up to the patient would preserve the sense that they chose this and are doing it for themselves.
posted by dr_dank at 6:29 PM on June 22, 2015


I'm in favor of euthanasia, and I do think it should be an option for psychiatric patients, but it does seem like this situation is missing a few safeguards.
posted by salvia at 9:13 PM on June 22, 2015


If we accept the idea that euthanasia is an appropriate treatment for depression, then we must also accept and come to grips with the idea that the people who try and prevent suicides (guards on bridges, suicide helpline workers) are actually the bad guys...

I don't think that necessarily follows. We can accept that some people will want or need to end their life without accepting that they can do it in a way, place or time which will be dangerous and/or traumatic for others. And perhaps the role of a suicide helpline might change a bit in focus, encouraging callers to make a considered decision with the advice of their doctor or therapist instead of as a spur of the moment decision they may regret later.
posted by harriet vane at 1:40 AM on June 23, 2015 [1 favorite]


Without speaking to the aspects of vulnerable adults being pressured by caregivers and family, I have long believed that you should be able to stroll into your doctor or ring the euth-center and apply to be let die. There is a six month waiting period where you are provided with therapy, medication, other assisting technology and you promise to comply in return or the guarantee that if you still want to after the program is done, you're golden, they'll sort you out in a dignified, "safe" manner. No one should be forced to live against their will.
posted by Iteki at 2:23 AM on June 23, 2015 [4 favorites]


This is pretty much what I was talking about when I said, in this comment, that I expect suicide to be gradually destigmatized.

I worry that through the inevitable process of society valuing what is cheapest/easiest, material considerations will push for a loosening of strictures (both moral and legal) on suicide. It will be an inevitable result of a society that is growing more fractured and pathological, with a breakdown of the family, more anomie and isolation that result from the pursuit of individualism, people living alone and isolated without rich social networks, in societies that do not place a premium on collective responsibility for people's well-being. In the absence of these safety nets and a decline of community, no one has to "intend" for suicide to become acceptable; it will just happen, as more people choose it due to a lack of other options, and it will explained and justified in palatable terms. What seems really awful, to me, is that it will never be explained as "suicide is becoming popular because we don't have the collective will to defeat the problems that lead people to do it," but it will be misleadingly explained as people "dying with dignity" and the ugliness and horror of a society that doesn't take care of its members so they are forced to kill themselves as an alternative to an awful, destitute, solitary life of feeble suffering will not be discussed.
posted by jayder at 6:09 AM on June 23, 2015 [6 favorites]


Belgian citizen here. Over here, by many people the NYT article was viewed as sensationalist and misleading, focusing on some exceptional cases. To me, the article is an unfair and dishonest personal attack on Wim Distelmans. Distelmans is a hero and has won several major awards for his laudable fight to the right to a dignified end of life. If suffering is incurable, untreatable and unbearable and all therapeutic options are exhausted, euthanasia is warranted. Distelmans is very diligent and strict in how he applies these criteria, as can also be seen in how he handled the Van Den Bleeken case.

The De Troyer case is in itself very unusual because this is the first time after 11 years of practising euthanasia an official complaint has been lodged against him. He was right not to inform the family of the women, he is not allowed to do it if she does not want it because of doctor-patient confidentiality. Distelmans urged her twice to call her children, but she chose not to do it.
posted by Deece BJ Pancake at 6:31 AM on June 23, 2015 [4 favorites]


Distelmans urged her twice to call her children, but she chose not to do it.

He was free, at that point, to cease his relationship with her, since any thinking person would understand that assisting suicide in a case like hers would be felt as an assault on the survivors.

I understand that the feelings of the survivors are not always paramount. But part of the point of the assisted suicide is the ability for the family to emotionally prepare. It is shocking, horrific, to find a member of your family has committed suicide in the normal way. It stays with you.

It stays with you particularly when that death is sending a message. I think of my uncle in this regard. It wasn't his suicide itself that was shocking, but his method, his placement, his timing--shotgun, front of his house, when he knew family would be by to visit within a day--these spoke of a depression and rage at his increasing frailty, an anguish that had to be addressed. But that rage was directed as much outward as inward. He wanted the family to see. He wanted them to hurt. And that simply was not fair.

If he had been given another option--a cleaner, more discreet option--one that prepared the family for what was coming, it still would have been a moment full of grief and pain, but the ragged aggression and shock of it would have been much lessened.

We can ask: If Distelmans had been thinking about the message of De Troyer's death, if he had seen it as possibly manipulative, possibly aggressive, could he have insisted on her communicating with the children first, as a condition of treatment? Wouldn't that have made more sense?
posted by mittens at 6:51 AM on June 23, 2015


I'm glad an actual Belgian showed up. I'm curious -- is it considered gauche or offensive or out-of-touch to express any discomfort or opposition to euthanasia?

That was the impression I got from the article, but it also seems like the author either had her own agenda, or was giving us the situation filtered through Tom De Troyer's perspective.
posted by vogon_poet at 6:51 AM on June 23, 2015 [2 favorites]


I'm glad an actual Belgian showed up. I'm curious -- is it considered gauche or offensive or out-of-touch to express any discomfort or opposition to euthanasia?
I wouldn't go so far as to say it's viewed as gauche or offensive, but it would definitely be seen as out-of-touch by the majority of people, based on my experience (see also Tom Mortier being accused of secretly being an deeply catholic activist after he expressed his criticism of Distelmans). To give you a picture, when the euthanasia laws were recently expanded (to include minors in exceptional cases) only the christian parties (cd&v, cdh) and the now fortunately irrelevant racist party (vlaams belang) voted against. Meaning that even the biggest (conservative) party N-VA did not have major issues even with what is currently the most far-reaching euthanasia regulation in the world.
However, in such controversial and publicized cases, like the exceptional situations described in this article, many people in Belgium also express their discomfort. In such cases, where it can be argued that the procedures are lacking or that healthcare and support of psychiatric patients is lacking, this also gets strongly debated in newspapers and so on. But in my feeling, it gets framed as a discussion on how very bad things can happen because of imperfections in the law and our society, and not really as an ethical debate on the merits of euthanasia in psychological suffering in general.

I understand that the feelings of the survivors are not always paramount. But part of the point of the assisted suicide is the ability for the family to emotionally prepare. It is shocking, horrific, to find a member of your family has committed suicide in the normal way. It stays with you.
I agree that here it is very important to be sensible and prudent to whatever extent possible. However, in this case the patient informed her relatives that she was looking into euthanasia a few months beforehand, as I remember it. I am sure her death was still very hurtful and shocking, but not to the extent of the aggressive suicide you describe. I am not sure if there were really aggresive, manipulative intentions in this case. Based on the limited information I have, I can still understand how a doctor would make the same call as Distelmans.
posted by Deece BJ Pancake at 7:36 AM on June 23, 2015 [3 favorites]


But in my feeling, it gets framed as a discussion on how very bad things can happen because of imperfections in the law and our society, and not really as an ethical debate on the merits of euthanasia in psychological suffering in general.

I wish the article had acknowledged this -- that a lot of supporters of euthanasia are very uncomfortable with the more egregious situations mentioned in the article. The author gave the impression that the discussion isn't even happening, except between opposing groups of activists. (Which would be terrifying!)
posted by vogon_poet at 7:44 AM on June 23, 2015 [2 favorites]


There are so many layers in that article. The most important one is only hinted at, but many above have already drawn it out: if the health care system is insufficient when it comes to aid for disabilities, care for the mentally vulnerable and palliative care for the dying, euthanasia should not even be on the table. Because then there will be too much pressure to choose death rather than care. Specially in societies where there is not easy access to family care, for whatever reason (and almost all reasons are legitimate, no one should shame hard-working families).

The briefly mentioned anecdote about the borderline patient hit hard. One of my most treasured successes as a teacher is the time when we (as a team) in collaboration with the health-care authorities and parents helped a young borderline patient find their way into education, and eventually graduation and a completely normal job. The patient was very, very ill, and at a point institutionalized for several months. But is now working at a high-end company, in a normal, well payed position, and also has a happy social life, including a partner. Imagine if their parents had supported their death wish during the worst times!

The point of that story is that cross-sector cooperation can work, and that even very extreme mental health issues can be remedied. It was a very expensive experimental process, but in the end, it has spared the community millions, and everyone agreed that if this happens again among our group of institutions, we will do it again. Unfortunately, because of confidentiality rules, our experience is hard to share.

Of course, killing off that person during a depression would have been even cheaper.

My grandparents were all strong supporters of legal, assisted suicide. My first grandfather died during WW2 and I never met him, and don't know what would would have happened if he had lived. But for the other three, the same pattern repeated itself. As long as they were well and good, they claimed they would swallow a pill at the first onset of illness. And when illness arrived, all of them clung to life as if they could change the laws of physics and history of mankind, requiring the most advanced technology and the newest medicine. My conclusion is that you never know how you will feel or react in the future, because you change, and the world changes with you.

I'm not a doctor, but I do research within health-care. And I've seen patients choose palliative care over life-prolonging treatment for a multitude of reasons. Some pro-euthanasia spokesmen see this as a form of suicide. I do not agree. But I have noted that even within this group, emotions run high among devoted family members. And among the people with little or estranged family, there can be a sense of "not wanting to cause more trouble" - dying for the sake of others, wether these other be society or family.

From a legalistic point of view, I cannot see how any society, even the best and wisest, can administer a pro-euthanasia law. I can see why this is happening is societies (similar to my own) where the body of people believe they are the best and wisest on the globe.
And while I am a staunch 3rd generation atheist, I find it worth questioning wether anti-religion/humanism is a moral platform. How can being against something else be a productive, ethical stance?
I would like to be for something - for reason, for democracy, for reproductive rights, for equal rights etc. I'm not per se against religion, as long as it doesn't interfere.
posted by mumimor at 10:39 AM on June 23, 2015 [3 favorites]


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.’ ”

Good grief. As the daughter of a mother with BPD, and knowing from direct experience how much her BPD was sustained and very probably outright caused by the way she was treated by her parents... this is freaking chilling. My mother ended up treating me much the same way – and there are a multitude of reasons for it that have everything to do with those reasons and less with BPD itself, which always seemed so obviously a result of rather than a cause of a very complex context. Anyway. This is A Thing in psychology too: Munchausen syndrome by proxy, " a behaviour pattern in which a caregiver fabricates, exaggerates, or induces mental or physical health problems in those who are in their care. With deception at its core, this behaviour is an elusive, potentially lethal, and frequently misunderstood form of child abuse or medical neglect." The number of times my mother eagerly asked whether I was going to die, and I knew she was asking because that's what she wanted... well, that in and of itself brought on suicidal ideation. Talk about a vicious circle.

I can't help but wonder what was really going on in the case of that young woman, at an age where she could finally envisage being independent of her family, which also happens to be a period in which a lot of abusive, controlling families double down on their control tactics to stop that independence from happening.

And yet I voted for assisted suicide in Oregon, twice. My paternal grandfather passed away of his own choice, while he still felt some dignity, at the end of his battle with prostate + lung cancers. I'm very glad he was able to. Psychological/psychiatrical illnesses, though... the context is so much more complex and murky. Especially in societies where the reason some people with mental illness can't be independent, can't lead fulfilling lives, isn't because of the illnesses they have, but because of how we as a society treat people with those illnesses. It's very different from physical illnesses, where the cause(s), treatment(s), and prognoses are a lot more well-defined and identifiable.
posted by fraula at 12:18 PM on June 23, 2015 [5 favorites]


I really don't buy the argument about episodic illness. Yeah, you might feel glad to be alive again at some point - and then at some point after that you might wish you were dead again. We should trust people to be able to decide whether the balance is worth it. And not to be glib, but I don't expect many who go through with euthanasia regret it. The important part is that nobody else gets to make that choice for you - and there are certainly a number of situations where this is unavoidably complicated and compromised.

there can be a sense of "not wanting to cause more trouble" - dying for the sake of others, whether these other be society or family.

I also think if we are going to talk about the burden placed on family and friends by your decision to die we should also be able to acknowledge that there absolutely can be a burden placed on family and friends by your decision to live - which is to say it seems like a perfectly good reason to want to die, just as it's a perfectly good reason to want to live. There are a lot of problems with friends and family being part of the decision process though - I mean seriously showing up to testify in favor (or against ain't so great either) - and once again when a person isn't capable of going through with it alone there are situations where this seems hard to avoid.

The most convincing argument against to me is the one that's come up in a few variations in this thread - that suicide as an easy solution to hard problems could lead to resources being directed away from other solutions. How convincing I think depends on your level of optimism about humanity's ability to solve those problems. I wouldn't want to demand that people stick around in the world waiting for a cure that won't happen in any conceivable estimation of their lifetimes.

I got extremely upset when somebody I care very very much about asserted that she would probably rather die than go through what seemed to me a pretty routine surgical intervention (for an illness that fortunately she didn't actually have). But that comes down to "I'm always trying my best to be here for you and you're going to just leave over this?" I think that's really unfair but it doesn't mean she doesn't have the right.
posted by atoxyl at 12:18 PM on June 23, 2015 [2 favorites]


“a right to have one's pain--physical or psychic--addressed in an effective way long, long before assisted death becomes an option.”
This.

Part of the issue too – it’s so easy, SO so easy to physically live in modern society. Particularly in the U.S. I mean this in the brutally physical sense. Drop a caveman into downtown Chicago, he’s delighted there’s so much fatty protein and sugars in the giant bins in the alleys. Plenty of shelter too.

This is piece is suicide without context. “Psychological distress” is such a tidy bit of language. Without care for the needs of others there’s no respect for human dignity. And the piece seems to ignore or minimalize, by labeling the people with their illness (“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”) as opposed to exploring the individual circumstances a diverse group would have. If it were just people with autism, say, you’d think something were terribly wrong. Eugenics perhaps.

But the fact that it’s so broad makes me think that people with illnesses that can be cured (anorexia) aren’t getting the emotional, psychological, or social supports that would enable them to deal with the symptoms.

And most of my personal experience bears that out. We don’t exactly leave people to the wolves, but it’s a sort of “I don’t have to run faster than the bear, just faster than you” kind of lack of support system.

Quality of life is a very serious issue. I define myself in very certain terms. And I’ve seen what happens to people in the final years of their lives. It makes dying in combat a more enticing outcome. And that’s devoid of any adolescent romantic ideas about the thing. I’ve seen that end too. Not pretty. But we entirely ignore our elders. We look away from the sick and injured. Dying alone and in pain, alive out of some kind of lip service to the sanctity of life as measured only by a heartbeat, I wouldn’t wish that on anyone.

There’s no formalized system of dying. And a dignified death is not valued because a dignified life is not valued, beyond perhaps “work,” which is in most cases nothing but economic in value.
(someone has to manufacture trucker hats that say “Whoof Arted?” amirite?)

I think there needs to be more oversight, as a society, on the euthanasia process, with notification and discussion and so forth. But it seems dissonant to demand that and yet not state that modern society has to plug in and step up to make sure we have people who might be slipping away covered as much as possible so maybe they do feel they have something to contribute and do have something beyond a paycheck to receive in return.

I talked to an elderly vet a while back. We had some regular talks during some events in Maywood (Chicago suburb). Guy wanted to kill himself. Only reason he told me is because we shared some of the same background. He felt useless and lonely was his reasoning. This is a guy who survived the Bataan death march. Had his wits. Just old was all. Had a ton of wisdom, loads of stories, seen everything, knew almost everything. No one reached out to him. He was just sorta enshrined like a landmark or a rock formation. We'd come read to him or talk to him like a person, but (otherwise) socially he was unteathered.

Nothing worse than waiting with no end to the waiting in sight.
posted by Smedleyman at 6:27 PM on June 23, 2015 [2 favorites]


I have a cousin who's been HORRIBLY depressed since age six (she had a whopping accident and was kept immobile and away from her parents for months), and nothing has ever helped including electroshock, and I've heard at this point she's immobile in bed again. If she wanted to do something like this, I couldn't judge. I don't think it's fair to say that someone has to stay just because they have loved ones who don't want them to go, especially when figuring out how to stop someone's horrible depression may not happen in their natural lifetime. How long can you force them to hold on while they're in hell? I don't think that's okay.
posted by jenfullmoon at 9:37 PM on June 23, 2015 [4 favorites]


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