Euthanasia for psychological suffering among young people: who sets the boundaries?

At the heart of the debate on euthanasia for psychological suffering lies the interpretation of the suffering criterion outlined in the Dutch Termination of Life on Request and Assisted Suicide Act (Wtl). “The patient’s suffering must be unbearable and without prospect of improvement,” Buijsen explains. “Physicians (psychiatrists) are generally reluctant to accept that suffering caused by a psychiatric disorder can be hopeless.”

The key difference from somatic conditions such as cancer is that the treatability of psychological suffering is less easily defined. “That such suffering can indeed be hopeless and unbearable was already established long ago by the Supreme Court in the Chabot ruling (1994).”

The Chabot Case
In the Chabot case, a psychiatrist assisted a woman suffering from severe depression and complicated grief in ending her life. Though she was not physically ill, Chabot provided her with the means to die. While both the district court and the court of appeal acquitted him on the grounds of necessity, the Public Prosecution Service appealed the case to the Supreme Court.

The Court ruled that a state of necessity may also apply in cases involving psychological suffering in patients who are not terminally ill, and that the existence of a psychiatric disorder does not automatically invalidate a person's capacity to make a free and voluntary request. However, the Court also stressed that extreme caution is required in such cases, and that the patient must be examined by an independent physician — something that had not occurred in this instance. Though Chabot's appeal to necessity was rejected, he was not punished, indicating that his actions were ethically understandable.

According to Buijsen, the problem lies not in the law but in its application: “Most doctors can empathise with the unbearable nature of such suffering, but they are rarely prepared to accept that nothing further can be done to alleviate it.”

Open standards and societal development

The Dutch euthanasia law is deliberately written with open standards — meaning it leaves room for interpretation by medical professionals. Buijsen sees this as a strength: “A law with open standards allows for flexibility in practice, and in that sense, it is also more durable. There's less need for frequent amendment.”

However, that openness can also create friction, especially in public opinion. “Such a law gives many people the impression that the standards are being stretched. Where assisted dying for psychiatric patients was once rare, it is now becoming more common. But to speak of a broadening of the standards is misleading. Rather, we are discovering that the standards allow for more room than previously assumed.”

Critics argue that this broad interpretation leads to uncertainty. Still, Buijsen maintains that it is unlikely that the criterion of hopelessness is being interpreted too loosely. “It is the responsibility of doctors, based on medical and scientific insights, to determine when a patient’s suffering can no longer be alleviated. On this point, there is little risk of overly broad interpretation.”

Young people and psychological development

A recent political motion by the NSC party to temporarily suspend euthanasia for psychological suffering in people under thirty was ultimately rejected, but it stirred debate. Critics argue that young people require additional protection due to their stage of psychological development. Buijsen acknowledges that the law allows room for this concern: “But it is up to the professional community to give shape to the due care criteria of the Wtl. If the profession reaches consensus that suffering in young people can never be deemed hopeless, then that must be laid down in a guideline.”

Whether such a consensus can be reached remains to be seen. The Dutch Association of Psychiatry (NVvP) is currently revising its guidelines. According to Buijsen, the ball is now firmly in the profession’s court: “If lawmakers want to change that, Parliament must amend the law. As it stands, the responsibility lies with the professional community.”

Autonomy versus protection

The tension between patient autonomy and the state’s protective role also plays a part in the euthanasia debate. Buijsen downplays the extent of this tension: “There is only limited friction with autonomy. Contrary to popular belief, the Wtl does not primarily prioritise autonomy. If it did, the law would have granted an enforceable right to euthanasia or assisted suicide. That is not the case.”

Euthanasia, therefore, is not a right but a possibility — and only under strict conditions. “Even in cases of non-terminal illness, the Wtl can be invoked. This is often the case in psychiatric disorders,” Buijsen explains.

The future of the Euthanasia Act

Buijsen rejects the suggestion that the law needs updating to better reflect current practice. “The Wtl is future-proof in this respect. Even before the Wtl came into effect in 2002, the Supreme Court had already determined that there should be no distinction between suffering caused by somatic illness and psychological disorders when it comes to assessing the suffering criterion.”

He reiterates that it is not for politicians to intervene at this stage: “The practice in question is already permitted under the law, though clearer guidance would be helpful. This should be provided for individual practitioners by the profession itself.”

Is political intervention desirable?

In Buijsen’s view, political involvement in medical decision-making is only justified when actions fall outside the scope of the law. “That is not the case here. And if the professional community reaches a consensus, they must formalise it in a guideline.”

So who should decide how euthanasia for psychological suffering — particularly in young people — is shaped? For Buijsen, the answer is clear: “The professional community of psychiatrists, and in particular the NVvP.”

The euthanasia law was designed with open standards to allow room for evolving insights and social change. According to Buijsen, this ensures the law remains relevant over time. But it also places a heavy responsibility on the medical profession, which now faces the difficult task of developing a guideline that balances medical rigour, ethical integrity, and public trust.