(Don't) Kill Me Now

Voluntary euthanasia and the limits of autonomy

This one is a bit heavier than usual. If you’re not in the right headspace for it, please take a break and return later. If you want something lighter (and stuffed with science and science fiction), check out my new essay in Clarkesworld magazine on how (not?) to build future-proof babies.

Tine’s story

On April 27^th, 2010, a 38-year-old Belgian woman named Tine Nys received a lethal injection. She had asked for it. Belgium is one of only eight countries in the world where voluntary euthanasia for 'unbearable psychological suffering' is legal. (For a broader discussion about assisted dying, check out the excellent ‘Assisted dying is not suicide’ by

Lauren Cortis

.)

Before her request, Tine had undertaken several suicide attempts and she had been diagnosed with borderline personality disorder (a diagnosis she did not accept) and Asperger's syndrome.

She passed away in her small apartment, surrounded by family. That, however, was not the end of it.

To get the required three signatures, Tine consulted several doctors, some of whom lacked an extensive therapeutic history with her. That, plus the limited time between her initial request and the euthanasia – four months – raised doubt among Tine's family members about whether or not the consultation process had been sufficiently thorough, and they sued the three physicians who had approved Tine's euthanasia request.

Ten years later, in 2020, the court of assizes (the highest Belgian court with criminal jurisdiction) acquitted the three physicians. In 2023, the physician who delivered the fatal injection was acquitted of an additional charge of malpractice.

Challenge 1: (no?) end in sight

Tine's case made the news, but she is far from the only person who has pursued euthanasia for unbearable psychological suffering. A 2015 study included 100 patients from an outpatient psychiatric clinic in Flanders (the Dutch-speaking part of Belgium) who had requested euthanasia. Almost half of the patients had their request approved, and over a third eventually had the procedure carried out. Eight patients who had their request approved chose not to go through with the procedure, because, in their words, "having the option provided enough peace of mind to continue living."

This brings us to the first difficulty with voluntary euthanasia for psychological suffering: psychological despair cannot be proven to be incurable or terminal. For well-defined, degenerative physical conditions it is easier to track the decline and chart the inevitable outcome. While mind and body, psychology and physiology, are not separate entities, it is harder to envision an inescapable endpoint for 'mental' conditions. To return to Tine: Before her euthanasia request, she and her fiancé had ended their relationship, which, in the words of one of her friends, "left her broken" and resulted in a suicide attempt. Could time have turned the tide, despite Tine's troubled history? We don’t know. We can't know. 

Mental anguish also has a subjective and context-dependent component. When researchers analyzed testimonials from 26 psychiatric patients who requested euthanasia, they identified five domains of suffering in these patients: medical, intrapersonal, interpersonal, societal, and existential. This led the researchers to the conclusion that,

Euthanasia should never be seen (or used) as a means of resolving societal failures.

It does not take a stretch of the imagination to acknowledge that people with certain mental health issues or neurodevelopmental variations have to deal with stigmatization, lack of proper care, and a world that is not accommodating to their needs and wants. That in itself can lead to mental suffering and it's not euthanasia that should be pursued as a solution for this. In philosophical parlance, mental suffering is a necessary but not a sufficient condition for euthanasia for unbearable psychological suffering. At the same time, having the option to choose voluntary euthanasia can – so some psychiatrists argue – help reduce the stigma by empowering patients and validating their suffering. The risk remains, however, that supporting euthanasia for mental suffering might lead to an extension of the practice without proper safeguards and extensive consultations with professionals.

Challenge 2: whose autonomy?

This 'option to choose' brings us the second challenge for voluntary euthanasia for mental suffering: autonomy. Proponents of voluntary euthanasia (disclaimer: I count myself among them) tend to invoke autonomy as a guiding principle. The ‘option to choose’ in the previous paragraph requires a combination of autonomy ('self-governing') and agency ('the capability to act').

Some mental health challenges can impact agency, though. Depression, demoralization, existential distress, and family dysfunction are all known to have an impact on agency even if the affected individuals themselves don't experience it this way. I did not know Tine, so I can't even begin to guess to which extent these elements were relevant to her situation. There is a certain insidiousness to mental suffering. It is a slow-acting, erosive poison that gnaws away at your deepest self.

I have to admit this gives me pause. I remain a staunch defender of people's rights to live and die as they choose (provided they don't harm others). Those rights include the right to choose euthanasia for mental suffering. At the same time, both autonomy and agency are limited by default. Our environment, social conditions, upbringing, relationships, health, and so on have a lot to say about what we think, do, and feel.

Perhaps one route through this moral quagmire is recognizing these limits to agency and autonomy. A broader notion of autonomy is the 'autonomy as ideal' approach, which involves shared decision-making between patient and physician – agency – as well as an appreciation for the broader context, such as the societal factors or stigma we ran into earlier.

The right to choose euthanasia for unbearable psychological suffering is – to me – crucial in a society that values individual autonomy. Yet that right in itself is not sufficient to have a euthanasia request granted. Context matters, access to proper care matters, finding help and hope matters.

As for Tine, I hope that she found peace at last.