Why the Dutch are euthanising physically healthy children – and could the UK be next?

Lisa, aged 40, is waiting to hear if she will be allowed to die. She is married and has two young children who don’t know she plans to end her life. There is just one more medication she has been told to try to treat her chronic depression, and then, she says, her request for euthanasia will be approved. The hardest part will be leaving her children, but she feels she has no choice. She plans to tell them, with the help of a grief counsellor, when she has set a date for her death.

“It’s not that I want to die, it’s that I don’t want to live this life anymore,” she says. “I’ve tried everything there is.”

Lisa, not her real name, is one of a small but growing number of people in the Netherlands choosing to end their lives on the basis of mental rather than physical illness. “My husband said, ‘as a human I can understand’, because he sees me suffering, and he can understand it’s enough,” she says. “But he said, ‘as a father of a child, it’s so difficult for me’. Because he takes care of the boys now. And he says, ‘one day, you will not be there, and I will have to raise the boys on my own. That’s not how it should be’.”

It may be shocking to read that an otherwise healthy 40-year-old mother of two could be euthanised, but in the Netherlands, where Lisa lives, it is perfectly legal.

Euthanasia (where a doctor administers a lethal medication) and assisted suicide (where the patient administers it themselves) were formally legalised for psychological suffering as well as terminal physical illness in the EU member state in 2002. Cases were initially controversial and rare – according to the Regional Euthanasia Review Committees (RTE) annual reports, only four had been recorded by 2010. But they have been steadily increasing since. And over the past five years, they have risen sharply: from 68 cases in 2019 to 138 in 2023.

In the UK, meanwhile, a movement for the legalisation of assisted dying has gained traction. Recent polling suggests that as many as two-thirds of the population support it. Last month, politicians in Jersey voted in favour of its legalisation for terminal physical illness.

Similar proposals are passing through parliament in Scotland and on the Isle of Man. Sir Keir Starmer has said he is “committed” to allowing another vote on assisted dying in Westminster should Labour win the general election. As the country where assisted dying has been legal the longest, could the Netherlands be a forecast of its potential long-term consequences?

Some experts warn it may be, including Prof Theo Boer, one of the early architects of Dutch euthanasia practice. Ironically, he has since become its most outspoken critic.

Boer is a professor of healthcare ethics who sat on the euthanasia review committee between 2005 and 2014. He supported the initial legalisation but has become increasingly critical of Dutch euthanasia law in the years since. Boer submitted evidence to Parliament for a debate on assisted dying in the UK.

“It is well known that British advocates of assisted dying argue for a more restricted law than is found in the Low Countries. Here is my prediction: any law that allows assisted dying will come to be experienced as an injustice and will be challenged in the courts,” he wrote. “Why exclude psychiatric patients, many of whom are suffering most heartbreakingly of all?”

But others argue such fears are overblown. Dr Alexandra Mullock, a senior lecturer in medical law at the University of Manchester, says the current UK proposals would “absolutely limit the access to people who have a physical condition that can’t be reversed by treatment. Looking at the Netherlands and Belgium, both those places began with requiring intractable conditions that could not be alleviated by other means … they never required a terminal condition,” she says. “The problem with that eligibility criteria is the fact that psychiatric conditions can be just as terrible and involve just as much suffering as very serious physical illness – a very compelling argument.”

The Netherlands has taken this argument to its logical conclusion. While the law there hasn’t changed in the 20-plus years since it was introduced, over time the interpretation of its criteria has, to include people with mental illness who are suffering unbearably – even those aged under 18.

Those who support assisted dying for psychiatric conditions argue that mental illness can be just as serious as physical illness and that some people do not respond to treatment. That may be true, but its critics say this is evidence of the “slippery slope” that campaigners often cite, and that euthanasia is being normalised as a ‘treatment’ for mental illness rather than a last resort for people who are terminally ill.

“I think everyone in psychiatry accepts euthanasia based on inhumane suffering, but it is still a last option,” says Damiaan Denys, Professor of Psychiatry at the University of Amsterdam and former chairman of the Dutch Psychiatry Association. “There is a worry it is getting too fast, too loose.”

Others argue the law does not go far enough – one Dutch campaign group, Coöperatie Laatste Wil, or Last Wish Cooperative, founded in 2013, is pushing for “last will drugs” or suicide kits to be widely available for people who choose to end their lives rather than continue to suffer.

Lisa is among those experiencing this anguish first hand. She has been an inpatient in a psychiatric hospital an hour outside Amsterdam since September. We meet in the dayroom, where she is filling out an adult colouring book. In her bedroom, the walls are covered with family photos and pictures her sons have drawn. A bouquet of pink and red flowers sits on her bedside table, left over from Mother’s Day.

She initially became ill while pregnant with her first child 10 years ago and has had periods of severe depression ever since – she has been separated from her family and hospitalised on more than one occasion. She says it gets “worse and worse every time. The last two times I also experienced psychosis.”

Treatments including medication, therapy, intensive inpatient treatment and electroconvulsive therapy (ECT) failed. She is so numb from medication that she cannot do the things that used to bring her joy, such as take her children to the zoo, ride horses, or walk the family dog.

Her world has been sapped of colour by her illness – either she is in a black hole of depression or a numb haze, dulled by medication, and everything is grey. “Most of the time, I feel flat,” she says. She requested euthanasia in March this year.

The Dutch story of death on demand began in 1973, when a Dutch GP named Truus Postma was prosecuted for injecting her terminally ill mother with a fatal dose of morphine. Her case sparked a nationwide debate about dignity in death and formed the basis of the The Termination of Life on Request and Assisted Suicide (Review Procedures) Act that came into force in 2002.

A person’s condition must be “unbearable with no prospect of improvement” with “no reasonable alternative” for them to access euthanasia in the Netherlands. This includes people with mental health issues who have exhausted reasonable treatment options but might still have a long life ahead of them.

There are safeguards in place. Requests for euthanasia must be signed off by at least two doctors – a primary physician and specialist (a Support and Consultation for Euthanasia in the Netherlands, or SCEN doctor) – and submitted to a regional board to check they have been carried out lawfully and with due care. For psychiatric cases, a further second opinion from an independent psychiatrist is required.

The Netherlands is one of only a handful of countries to legalise euthanasia for psychological conditions. Belgium passed a law in May 2002 that legalises the practice and assisted suicide for patients in a “futile medical condition of constant and unbearable physical or mental suffering that cannot be alleviated”.

In Luxembourg, it was legalised in 2008. In Canada, where Medical Assistance in Dying (MAID) was introduced in 2016, the criteria is set to expand to include those suffering from mental illness. Originally set for March 2023, then March 2024, a final decision has been pushed back to 2027.

As in Belgium, the Dutch law on assisted dying has never excluded psychological suffering from its remit. There is one record of a case as far back as 1993, before it was formally legalised. The doctor involved was found guilty of assisted suicide but no penalty was imposed.

The RTE releases an annual report detailing how many people have received euthanasia and for which conditions. In 2008, there were two for mental illness; in 2009, there were zero; and in 2010, there were two more.

The landscape changed with the foundation of the Expertisecentrum Euthanasie (EE) in the Hague in 2012. The clinic originated from the Dutch right to die society (NVVE) and offered consultations for people who had a request for assisted death rejected by their general practitioner or psychiatrist. By 2018, the EE was handling 84 per cent of all requests for an assisted death from psychiatric patients.

“The expertise centre was actually started because so many psychiatrists were reluctant to give euthanasia even though patients matched the legal criteria,” says Prof Denys. “Its first role was to execute the requests of patients who [met legal criteria] but whose psychiatrists were unable to do it or reluctant to do it. But five years ago, the centre started a ‘marketing campaign’ to invite psychiatrists to do it themselves. And so you see an increase in psychiatrists performing euthanasia on their patients.”

Prof Denys published a research paper on the EE in July last year and drew some troubling conclusions. “The waiting list is two years. And interestingly … when we analysed the data, we noticed that that waiting list resulted in a lot of people changing their mind,” he says. “But it is possible in some cases, if the patient finds a psychiatrist, and a second one, that it can be done in six weeks – it can go very, very fast. It depends … on how skilled you are at convincing people you want to die.”

The demographic profile of patients who have sought euthanasia for mental illness is strikingly different to those with terminal physical illnesses, who are mainly aged 60-plus, with a fairly equal balance between men and women. As part of his research, Denys and his colleagues analysed records from the EE between 2012 and 2018, and found the majority of patients were younger single women with a diagnosis of depressive disorder. In this period, the EE rejected 653 requests – in the majority of cases, because the patients weren’t deemed to have tried enough treatments – and approved 154.

In total, 65 per cent of those who had a euthanasia request granted were women. While most euthanasia deaths for physical illness are carried out for those aged 60 and above, 60 per cent of this cohort were under 60; 18 per cent were younger than 40. One patient was under 20.

Denys is of the opinion that, more than genuinely wanting to die, the majority of these patients “don’t know how to solve life. They’re out of answers, out of solutions. And the only thing they can imagine – which is paradoxical, as it’s the end of life – is that dying is the solution.”

In the Netherlands as in the UK, rates of mental illness are increasing – especially among young people. A 2022 survey found that more than half of Dutch young people aged 16-25 have experienced symptoms of mental ill health (53.3 per cent). In 2022, a quarter (26 per cent) of adults met the criteria for a mental illness including anxiety, depression and addiction. Twelve years ago, the figure was 17 per cent.

In the UK, the outlook is similarly grim, exacerbated by the impact of the coronavirus pandemic. One in six children aged five to 16 were identified as having a probable mental health problem in July 2021, a marked increase from one in nine in 2017. The amount of people aged 16 and over with common mental health problems rose by 20 per cent between 1993 to 2014, in both men and women. Last year, 1.2 million people were on the waiting list for community mental health services.

Lisa is young to be pursuing euthanasia, but she is by no means the youngest. In 2018, the assisted suicide of a 29-year-old woman named Aurelia Brouwers with a long history of depression, anxiety and Borderline Personality Disorder (BPD) made international headlines. More recently Zoraya ter Beek – also 29, with similar diagnoses – was granted euthanasia. She died in May. But it was in October 2023 that a new line was crossed with the euthanasia of Milou Verhoof, a young woman with a diagnosis of BPD, who died aged just 17.

Her mother, Mireille Verhoof, was in Milou’s childhood bedroom with her when she died. “It was like my heart was torn into pieces and she took a piece away with her,” she says. But her parents – Mireille and her husband Louis, a businessman – had accepted and even supported her “death wish”, even though under Dutch law their explicit permission is not required.

“Together as a family we learned to bear and endure [it]. We don’t regret supporting her. If we could go back, I don’t know where it went wrong,” she says. “As a parent, now, when I see other kids her age, I think, ‘Why my girl? Why didn’t she make it?’ But we can’t turn it back. I wish she was here, but I could not have her live longer in this tragedy she was in.”

Speaking outside a restaurant in Amsterdam, roughly an hour and a half from the family home in Breda, Mireille is calm and composed. She has brought a series of photographs with her to show me – Milou swimming with dolphins, on a walk in the woods, hugging the family dog, Puck, on the beach.

She had a happy, middle-class upbringing and was “very social, soft, and very sensitive,” says Mireille. “We always said to each other, my husband and I, that the only one we were not going to expect any trouble from is our girl. She was so nice and so sweet. Always, always laughing … That was what made her vulnerable, I think.”

Milou and her elder brother, Daan, who has Downs Syndrome, were inseparable. When Daan became seriously ill and spent a month in a coma, Milou, then aged 11, started having nightmares and flashbacks. Her mental health quickly deteriorated.

“The years that followed were dominated by treatments, medication and hospital admissions,” she says. By the time she was 15, Milou was depressed, struggled seriously with self-harm, and was given a diagnosis of BPD, which manifests in emotional instability, impulsive behaviour and unstable relationships. (Her mother believes the diagnosis of BPD was inaccurate, and Milou was actually suffering from post-traumatic stress disorder.) During this period, she was sexually assaulted, which only came out when Milou was an inpatient in hospital.

The family were constantly on high alert. “We were afraid every day that she would succeed in taking her own life … We thought that being on the waiting list [for euthanasia] might reduce the risk of suicide,” she says.

Most of the doctors involved in Milou’s care dismissed her requests for euthanasia, saying she was far too young. Her mother says this left her feeling like her suffering was not being taken seriously and her voice wasn’t being heard. Milou registered with the EE, but was told the waiting list would be years long. Then she heard about a psychiatrist named Menno Oosterhoff.

Much of the Dutch psychiatric profession remains uneasy about euthanasia for psychological suffering. Deciding where to draw the line is an ethical quagmire: how can you discern if a “death wish” is the consequence of a mental illness or a treatable symptom of it? Who decides what level of psychological suffering is “unbearable”? And at the heart of the problem: who is to say a patient – particularly one still in their teens – is beyond help?

One doctor who has walked that ethical tightrope is Oosterhoff, 68, a retired child and adolescent psychiatrist who has been providing second opinions for patients who request euthanasia since 2016. He has been carrying out the procedure himself since last year, and has since euthanised nine patients, one as young as 16.

It was Oosterhoff who helped Milou get the green light for euthanasia and performed the procedure, and it is Oosterhoff who is pushing for Lisa’s request for euthanasia to be approved. He has maintained a close relationship with Milou’s parents and even spoke at her funeral.

He is tall and slightly stern, with unruly grey hair. We meet in the lobby of the Amsterdam University of Applied Sciences, where he is preparing to give a guest lecture on his specialist subject: euthanasia for psychological suffering. Oosterhoff describes it as “a choice between two evils” but has become its primary proponent. “I have sleepless nights,” he says, “but what helps me is the gratitude of people – also of their parents, families and partners.”

Over a 40-plus-year career, Oosterhoff has come to three conclusions: mental illness can cause “unbearable and untreatable” suffering just as physical illness can; the chance of a miracle recovery after years of unsuccessful treatment is, he says, depressingly slim; and so psychiatric patients have as much of a right to a humane, painless death as someone with terminal cancer.

“It is quite unnatural to give a person that is physically healthy a lethal injection,” he says. “But we underestimate the burden of psychiatric illnesses. We say, ‘come on, the sun is shining,’ and so on. The other way is that people suffer unbearably, or that they commit suicide.”

Patients see him as a last resort. Since he co-authored a book on the subject, titled Laat Me Gaan (Let Me Go), and appeared on TV to discuss it, he has been inundated with messages from desperate people hoping he can help speed up their euthanasia requests – so many that he cannot even read or reply to all of them.

“Patients are asking for [euthanasia] in growing numbers, because they realise it is possible.” He admits there is an element of social contagion: “[It’s] not because people are more desperate than earlier, but because they know about its existence.”

The hardest part, he says, is grappling with the morality of his actions. “I don’t know what I am doing in a spiritual sense,” he says. “I hope I end suffering for people – but I don’t know what the meaning of life or suffering is. I can only trust my own conscience, and have to make that decision even when it is against how I was educated and against the general opinion of that moment.”

For Oosterhoff, it began eight years ago when a colleague asked him to provide a second opinion on a patient who had requested euthanasia. The patient in question was a 75-year-old man who was depressed following the death of his wife and had been in a closed psychiatric hospital for a year.

“His story was so convincing that all my theoretical objections disappeared,” Oosterhoff says. “To decide to end someone’s life is a big decision, but not to do it is also a big decision. It would mean that he had to stay in the hospital for the rest of his life, or die by suicide. I was completely convinced that he wouldn’t survive.”

Oosterhoff admits to having doubts. “Sometimes I think, did we open Pandora’s box? How many people will ask for euthanasia? I have no idea. More than the 138 who got it last year,” he says. “It sometimes frightens me that 99 per cent of the world will condemn what I’m doing.”

Still, he remains determined to continue his work, adding: “I have my conscience, and my patients.”

For Lisa, the prospect of death remains a relief. “The only thought I have about it is that it brings me peace, quietness and rest,” she says. “The day I know I don’t have to suffer anymore. I am very sure that this is what I want.”