Euthanasia for mental illness?: Canada and the Netherlands

Until you consider the context.

It was made by Mark Holland, Canada's minister for health, as he confirmed in February that legislation expanding the country's remit for assisted suicide to people with “grievous and irremediable” mental illnesses would be put on hold until 2027.

The "question here is a state of readiness", he said: the healthcare system was not ready to take on the additional demand and complexities.

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Canada already has the highest rate of assisted suicides in the world (13,241 in 2022) and in August last year the president of Quebec's commission on end-of-life-care, Dr Michel Bureau, warned in an interview that "more and more...the cases receiving medical aid in dying are approaching the limits of the law".

He issued a memo to doctors in the province reminding them that only patients with serious and incurable diseases causing unbearable suffering were eligible for Medical Assistance in Dying (MAID), and that requests must be approved by two physicians.

Bureau also cautioned medics not to "shop" around for a favourable second opinion, adding that he was concerned some medics were coming under pressure from elderly patients who wanted to die but whose medical problems did not meet the legal criteria.

"Medical aid in dying is not there to replace natural death," he added.

It was against this backdrop that the plan to expand MAID was paused.

Psychiatrists giving evidence to government committees had also warned that it would be difficult to say whether someone with a psychiatric disorder was beyond treatment and to decipher "rational" requests from those motivated by suicidal ideation.

It was the second time in 18 months that the law - due to take effect on March 17 - had been postponed.

Assisted dying around the world (2021) (Image: Humanists UK)

Meanwhile, on the other side of the Atlantic, there has been growing consternation about what lies behind the rising number of psychiatric-related euthanasia cases in the Netherlands - where the practice has been legal, albeit rare, for more than 20 years.

In 2010, a total of 3,136 deaths by physician-assisted suicide or euthanasia were registered in the Netherlands, of which only two were in response to mental illness.

By 2023, psychiatric causes accounted for 138 out of the 9,068 deaths registered - a 25-fold increase in the rate.

“The trend is undeniable,” said Sisco van Veen, a psychiatrist and end-of-life ethics researcher at Amsterdam University Medical Centre.

“The trend is upward.”

Debates about the role of assisted suicide in mental illness have been sparked by rising numbers of cases in the Netherlands, and controversial plans to extend the law in Canada (Image: Getty)

Nonetheless, only 10% of psychiatric-related requests are granted.

Terminal cancer still accounts for the vast majority of cases (56% last year), and more than 70% of all patients are over 70.

However, a string of recent high profile Dutch cases involving physically healthy young people who are opting to end their lives for mental health reasons have sparked an ethical conundrum: is it an alarm bell for a failing healthcare system, or a sign that the misery if psychiatric illness is being taken seriously?

In Scotland, the debate is essentially background noise.

However, it comes as MSPs weigh up proposed legislation that could make Scotland the only part of the UK to provide assisted dying on the NHS.

The Bill - tabled at the Scottish Parliament on March 28 by LibDem MSP Liam McArthur - would limit the provision to adults who are terminally ill, of sound mind, resident in Scotland for at least a year, and able to self-administer the drugs to end their life.

Two independent doctors would have to assess the patient and approve their request.

Critics argue that when Canada's MAID programme was introduced in 2016, it too was limited to the terminally ill.

It was extended in 2021 to people living with "grievous and irremediable" medical conditions following a successful legal challenge by civil liberties campaigners who argued that the previous law unfairly excluded people with long-term disabilities, such as degenerative diseases.

The "slippery slope" argument goes that once you open the door to assisted dying, more and more groups of people will demand the right to walk through.

The counter is that there are other examples - such as the state of Oregon in the United States - where assisted dying has remained restricted to mentally competent terminally ill adults since it came into being in 1997.

No one can predict with certainty where Scotland might end up in the long-run.

MSPs are considering proposals for an assisted dying law, which would be limited to those who are terminally ill (Image: Getty)

The Netherlands - which legalised euthanasia in 2002 - stipulated from the outset that it covered "unbearable suffering with no prospect of relief", whether the cause is mental or physical.

In 2023, there were 336 cases for dementia, which falls somewhere in the middle.

It was the case of 28-year-old Zoraya ter Beek which went viral, however, after she went public on April 1 to discuss her forthcoming euthanasia in early May.

She said she looked forward to being "freed" from crippling depression, autism and borderline personality disorder after psychiatrists told her there was "nothing more we can do".

She plans to die on her couch at home. A doctor will administer a sedative, followed by a drug to stop her heart.

The case has split opinion, with some likening the rise in such suicides to a "contagion" fanned by social media.

Others blame a plague of loneliness, closures of specialist hospital units for teenagers, or "traumatising" psychiatric treatments.

Boudewijn Chabot, a psychiatrist who stressed that he was "not against euthanasia in psychiatry or severe dementia", added that he was nonetheless "extremely concerned that doctors are trying to solve social misery due to lack of treatment and care, by opening the gate to the end".

NVVE, a Dutch pro-euthanasia lobby group, insists that "a death wish from people suffering from a psychiatric condition [must be] taken as seriously as the death wish from people suffering from a physical one".

And so we arrive back at this strange medical dichotomy: if you accept parity, must it extend to assisted suicides?

Is it dereliction of duty to enable such deaths - or a form of discrimination to deny them?