by Zain Khalid
On May 22 this year, Zoraya Ter Beek, a 29-year-old woman from Netherlands, died by euthanasia on grounds of mental suffering. Zoraya had been diagnosed with chronic depression, borderline personality disorder, and autism and had struggled with self-harm and suicidal thinking for several year. She had tried numerous treatments, including 30 sessions of electroconvulsive therapy, until, as she reported her psychiatrist told her, “There’s nothing more we can do for you. It’s never going to get any better.”
Zoraya’s story has much in common with that of Aurelia Brouwers, another 29-year-old Dutch citizen diagnosed with borderline personality disorder, depression and anxiety who had been approved for assisted death (AD) in January 2018 on psychiatric grounds. Aurelia drank poison peacefully at her home after she bade farewell to friends and family, with two medics in attendance, while clutching a stuffed dinosaur as her favorite song played in the background. She had struggled with depression since she was 12, and despite years of treatment, had felt that she was “never happy” and “didn’t know the concept of happiness,” describing every breath she took as “torture.” Dr. Kit Vanmechelen, a psychiatrist at Netherland’s End of Life Clinic, which approved Aurelia’s request for AD noted: “In personality disorders a death wish isn’t uncommon. If that is consistent, and they’ve had their personality treatments, it’s a death wish the same as in a cancer patient who says, ‘I don’t want to go on to the end.’” Aurelia’s story drew international attention to the use of medical aid in dying (MAiD), whereby a patient takes lethal medication provided by a physician, for nonterminal illnesses such as psychiatric disorders.
Zoraya and Aurelia were both young and in good physical health when their requests for assisted death were approved, and death was neither a foreseeable nor a necessary consequence of their qualifying diagnoses. How then, did these diagnoses make them eligible for assisted death?
In the Netherlands, as in Belgium, Luxembourg, and soon in Canada, AD, which encompasses both MAiD and the physician-administered practice of euthanasia, may be accessed on grounds of psychological suffering, so long as patients meet three conditions to qualify: they must be competent to provide voluntary consent, their qualifying illness must be irremediable, and they must establish unbearable suffering on account of it. On these grounds, advocates for AD hope to empower competent patients dealing with chronic and unrelieved psychiatric suffering to choose a dignified means of ending their life when its burdens outweigh benefits for them. They add that withholding AD for psychological suffering unfairly discriminates against the mentally ill.
As a psychiatrist treating patients with serious and persistent mental illness in the U.S., many of whom struggle with chronic suicidality, I find cases like Zoraya and Aurelia’s and the permissive trend in expansion of psychiatric AD they they represent to be deeply worrisome. With AD expanding in legality across the U.S.––11 jurisdictions allow it, at least 12 states are considering bills legalizing it, and others are loosening residency and prescription requirements–– and psychiatric AD gaining traction globally, assistance in dying features increasingly often in my conversations with patients contemplating suicide. Some come to clinical attention because they had been researching AD; others inquire about it while being treated for suicidality. As a future in which psychiatric AD is legal in the U.S. becomes increasingly proximate, I often wonder how I would evaluate AD requests from my chronically suicidal patients.
Evaluating eligibility criteria for psychiatric AD
Distinguishing a competent psychiatric AD request from one that is a result of treatable suicidality with the level of confidence warranted by the gravity and irreversibility of the decision for death remains an unresolved challenge for current psychiatric practice. There are no objective biomarkers for treatable suicidality, and mental illnesses frequently impair patients’ decisional abilities by disrupting relevant cognitive and motivational processes. Depression, for instance, interferes with problem solving and causes hopelessness, prematurely foreclosing prospects for recovery, leading to therapeutic nihilism, and making patients prone to inaccurately pessimistic appraisals of their prognoses. Without reliable ways of discerning whether a decision for psychiatric AD represents pathology or a patient’s autonomous choice, how, if at all, can the competence criteria be safely operationalized?
Further, Dutch and Belgian data on AD also highlight the challenge of establishing irremediability in psychiatric AD requests. Patients in the throes of severe depression or psychosis often decline treatments, as was the case in nearly half of the cases in the Dutch data, and when AD laws such as Canada’s accommodate such refusal by considering it an example of “…conditions unacceptable to the patient” irremediability can hardly be contended when available treatments have not been tried.
For psychiatric illnesses in general, in fact, there is no evidence to support claims of irremediability. Consider Aurelia and Zoraya’s qualifying diagnosis of borderline personality disorder. With cumulative remission rates of 78 to 99% as patients age, and suicidal injury and attempt rates stably dropping from over 60% to under 5% over a 10-year follow-up period, intractability is decidedly not the expected natural course of the illness. Even as psychosocial functioning ––the ability to sustain employment and relationships –– appears to lag in these relatively brief longitudinal studies, prospects for such recovery are not insignificant. With such symptoms as suicidality stably remitting, patients may reconsider their choice for AD despite residual psychosocial impairment. This is especially salient as up to 72 % of patients with personality disorders withdraw their requests for AD. Overall, this evidence contrasts starkly with the opinions informing Zoraya and Aurelia’s approval decisions noted above.
Given these grave issues with autonomy and irremediability-based justifications for psychiatric AD, what explains its growing use, especially in cases like Aurelia and Zoraya’s? The answer may lie in the persuasiveness of claims represented by the third criterion, that of unbearable suffering. Unbearable suffering for mental illness, though, is also not easily characterized, not least because mental illness itself alters, and frequently heightens perceptions of suffering. For patients with borderline personality disorder for instance, the experience of suffering may be heavily conditioned by reactivity and sensitivity to interpersonal and other stressors. Depressed patient may not be able to avail themselves of social or cognitive resources necessary to alleviate distress, setting up a vicious cycle of despondency, from which suicide may seem like the only escape. Treatment of these underlying conditions can alleviate the suffering sufficiently to allow for adaptive problem solving such that suicide then appears less compelling.
Inadequate treatment and an insufficient understanding of current evidence on the course of conditions such as personality disorders can thus lead to misuse of AD in vulnerable psychiatric patients. But this is not an argument for underplaying psychiatric suffering. Though notoriously inept at estimating suffering, physicians remain advocates for relieving it, and rightly averse to invalidating it. As we seek to alleviate psychiatric suffering when we can, we must avoid colluding with its effects when we can’t. As AD access expands across the US, we may be well-advised in maintaining a conservative policy position against psychiatric AD while the problems noted herein remain unresolved. We must, in short, approach with humility these questions of life and death that admit of no easy certainties — and continue to err on the side of life.
Zain Khalid is Assistant Professor at Brown University’s Department of Psychiatry and Human Behavior and a master’s candidate at Harvard Medical School’s Center for Bioethics (M.B.E 2025). He is board certified in adult and forensic psychiatry and practices as a psychiatric intensivist.
