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I am getting deja vu, and not just because of sleep deprivation.
As a matter of fact, I have previously addressed the exact same case. In short, I think the doctors did the right thing.
https://www.themotte.org/post/1701/culture-war-roundup-for-the-week/302719?context=8#context
...
"The doctors did the right thing in helping a 29 year old woman with depression kill herself" is quite literally the slippery slope. That's what we're talking about when we call something a slippery slope, that social norms will change so radically, and people will just be all "actually, that's a good thing we changed that!"
Hang on, please explain to me, ideally without referencing slippery slopes at all, what is the precise issue with this 29 year old woman with depression being offered euthanasia?
I try not to brow-beat people with my credentials any more than I can help, but I have experience in both psychiatry and being severely depressed. It would take far worse to make me seek euthanasia, but my depression wasn't as bad as it can truly get. Some forms of dysfunction and agony can truly be hard to discern from a distance. You see a pretty young woman in the prime of her life being consigned to death by uncaring doctors.
I see a tortured soul, who has consented to her doctors trying everything they can feasibly try. If you don't believe me, you can look at the article. Her every day is utter misery, we have no idea how to fix her, at present. And we've tried, tried oh so hard, with no results. I had reasons to cling to life even when my brain screamed it was pointless to get out of bed, I do not care to dictate beyond a very limited extent, how much others should really tolerate.
She is an exception. 99.9% or more of depressed people are not recommended euthanasia. She went through all the loops and hoops, she didn't change her mind. Her very right to do so was challenged, and when I initially engaged with the article, being adjudicated in a court of law. The rules are being followed.
This is a very critical point. By saying "MAID is in principle on the table for depression", you create some incentive to engage with the medical system.
If instead you take the firm stand that suicide is bad and that you will gladly lock up patients who talk about suicidal ideation until they learn to credibly deny having such thoughts, that is sending a very different signal.
As others have pointed out here, anyone who is not bedbound has a BATNA, which is to kill themselves against the wishes of broader society. Unilateral suicides impose great costs on broader society. You can not let your loved ones know lest they call the cops on you -- unless you trust them to approve your defection. While medically, killing a person in a way which is both painless and also not highly disturbing to onlookers is a solved problem, the situation for the average person is very different, and they may well prefer an option which is good at delivering a quick death but traumatizing for the onlookers. Jumping in front of trains has massive externalities, for example.
Knowing that your loved one is opting for MAID for depression is terrible, but what is worse is coming home and finding them dangling from a rope -- without you ever having had a chance to talk to them about it or say goodbye to them. If offering MAID for depression turns 10 suicides into 7 suicides (who do not want to jump through the hoops) plus 1 medically assisted death and two patients who can be treated to a level where their life is positive-sum for them, that seems like a clear win.
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If she wants to kill herself that's one thing. She didn't need assistance. She was young and healthy and could've just hung herself, or jumped off a tall building, or
in front of a trainin some other way that doesn't involve someone else, please. The fact that she couldn't muster up the will to do this, honestly makes me question how suicidal she really was in the first place. After all, thousands of people in the Netherlands do this every year. But unlike the bedridden elderly people that are usually taken as an example in these cases, she certainly always had the option.What I really think we shouldn't be doing as a society is validating or normalizing such a decision. That is not about the details her specific case, but about the example that's set for others. It doesn't even matter if her mental suffering truly were unbearable in some manner. Ultimately only she knows her inner mental state. To an outside observer, she was young and healthy, and she had people who cared about her. (We should all be so lucky!) And we're going to just kill her on request? That shouldn't be normal. It's what's observed from the outside that sets the norm.
Are you seriously suggesting that society prefer depressed people commit suicide by train?
That feels like the most outlandish thing I have read on the internet all week.
Suicides by train are only topped by intentionally driving on a highway in the wrong direction as far as damage to broader society goes.
Suppose you are a train conductor without psychopathy. You go through your routine job of driving the train, listening to music perhaps when suddenly a person steps on the track 50m ahead of you. You sound the whistle and slam the brakes. You have more than a second to contemplate what is about to happen, but no way to stop it. You hear the impact over the sound of the brakes. After the trains comes to a halt, you grab a first aid kit and run back the person you have just hit. If you are lucky you only need a glance to confirm that they are dead, cut apart by your vehicle. Or you might spent the next ten minutes giving CPR to a corpse until the ambulance arrives, hoping for a miracle which is unlikely to happen.
Intellectually, you know that you did not kill the person, they killed themselves. Still, it was your train. You know that it is not feasible to slow trains down to speeds where they will no longer be used as a method of suicide. If you had reacted a tenth of a second faster, it would not have made any difference. But still, you wonder while you lay sleepless in bed, held awake by the images and sounds which have burned themselves into your memory.
Driving trains is your job, a profession you spent years to learn. It is high responsibility, but also very routine. Before you had hit that person, it was not very stressful, most of the time. But now your brain anticipates that any second, another person might step on the track in front of you, and you would be just as helpless to do anything about it as the first time.
Personally, I would take the life of a physician who assists a suicide of a depression patient after all the process is done a ten times over the life of that train driver.
Okay, not a train. That's an asshole thing to do. If you're going to commit suicide, don't involve other people.
I included it because it's the stereotypical thing to do (at least around here), but thinking a bit further, it's probably that way because when someone does it, everyone in the train knows. Probably most people have been on a train that's been delayed because of a train suicide. Other methods of suicide don't get that attention.
I do absolutely think we shouldn't be offering assisted suicide to people who are physically capable of unassisted suicide.
This is surprisingly hard to do. Someone needs to find the body and unless you plan carefully this can easily be a random bystander or group of random bystanders (and planning carefully is hard when you are suicidal).
Usually EMS and healthcare get involved and seeing someone who has committed suicide can be deeply harmful (especially if it's gruesome like a gunshot to the head). Often they'll have to run a code on the body even if it's clearly dead which is....awful.
Then you have to think about the family and friends of the deceased. Having a close contact or family commit suicide is a risk factor for suicide it hurts people around you in a way that just dying doesn't.
Yes, suicide is bad. Ideally there would be no suicide at all. This is part of my point.
When we do something in an official manner, we thereby give it a stamp of approval. We should not approve bad things if we can avoid it. Because by doing so, we are saying that the bad thing shouldn't be considered as all that bad. We are shifting the norms and encouraging more of it. We can't always avoid this, but we should at least always try.
If someone's dying anyway, say with terminal cancer, and we artificially keep him alive at that point (which we've gotten quite good at), we are merely prolonging his suffering. At that point, sure, just end it humanely.
But this person (and see my other comment, there are more) was not actually dying. She was in fact physically healthy. There is no argument to be made that we are prolonging her suffering. We are not actively doing anything. There is no argument to be made about freedom either. If you are physically capable of killing yourself, you always have this option.
She could've ended her own life herself at any time. And that would still be bad, even if it truly is the least bad option it's still bad, but we would at least have avoided giving the act an official stamp of approval. And maybe she never would've killed herself, and then there would've been one less suicide. This is the point that I was trying to make.
And it does seem to be accelerating. I looked up the statistics (see my other comment for the sources). There were 14 euthanizations for purely psychiatric reasons in 2014. By 2024, this had grown to 219. In the same year, there were 1819 traditional suicides. So by now, for every ten suicides we're adding an eleventh.
Sorry I don't really have a dog in this fight I just wanted to make that point specifically.
In truth I remain somewhat undetermined about how to handle this specific issue which is awkward given the possibility of it appearing in my clinical practice, however my plan is to just follow legal, regulatory, and hospital frameworks and stay out of the ethical side of this thing.
That said it is worth dialing in just how miserable certain classes of patients are. Again I'm not convinced we should assist them in dying but certain patients have a lived experience that is comparable or worse than the more typical examples (dying of chronic disease, intractably bad life experiences, significant chronic pain*).
For instance someone with severe borderline personality disorder may find themselves zigzagging from being too happy to wanting to kill themselves to burning down their relationships to getting fired to whatever on a regular basis. With associated involuntary suicidal ideation it can approach a point where the life experience is almost abhuman, miserable, and devoid of the traditional pleasures of existence.
That's a reasonably good case, especially since some people like this may struggle to successfully kill themselves because the system does a good job of preventing it and because the problem isn't pure depressive misery, therefore it becomes challenging to overcome the routine desire to live.
Again not necessarily advocating here just pointing out if you had chance to interact with one of these people you might go....oh yeah, I get it, holy shit (or might not).
*Although best we can tell this is somewhat linked to psychic distress.
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The pilot of Germanwings flight 9525 would like to have a word with you.
I knew when I wrote this that someone would come up with another exotic counterexample. I will not try to argue that flying a plane into a mountain is a special case of going the wrong way on a highway either.
Fine. I retract my claim and say that they are the second most harmful commonly occurring suicides, and patiently wait for someone to explain to me why that is still wrong.
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Severely depressed people are famously known for being well motivated and agentic.
You might have heard, most likely as a semi-serious observation, that the side effect profile of most antidepressants includes increased risk of suicide.
Ever wonder why? It is because depression affects multiple part of the brain, and antidepressants can start fixing some parts before the other. In other words, you accidentally fix someone's motivation and agency before restoring their mood, and you suddenly have someone who is very energetically motivated to kill themselves.
People often do not know their inner mental state. If you care to criticize this, then just about nothing in psychiatry remains standing. There is nothing, in principle, stopping a sane person from talking into thin air, and gibbering about the CIA watching him. Yet this is a reliable metric for psychotic illness. In a similar manner, what do you think the usual stereotypes are of how a depressed person looks and behaves?
The reason that psychiatry is not purely stamp-collecting is because said stamps allow us to mail cheques we can often cash. A diagnosis of depression usually leads to a treatment of depression. It's not perfect, in very rare circumstances, such as hers, literally nothing worked. If she wants to lie after all of that (and there is a lot of "all of that"), then she's earned the right to kill herself.
She's always had it, and never lost it. This was part of my point. It's the official approval that I disapprove of.
This is not the way in which I meant it. By outsiders I meant the general public, society as a whole, not her psychiatrists, who I'm sure knew what they were doing and tried their best. Because even if I grant that this was the right decision in this particular individual case, I still oppose it because of the example that it sets.
The picture that is shown is of a (physically at least) healthy 29-year-old, who has people who care about her. When someone like that commits suicide, it should not get a societal stamp of approval. Let alone that we should do it for her. This will cause the societal norm around suicide to shift.
I think that we shouldn't be giving the general public the idea that society approves of just stepping out of life if you're not feeling it. I grant you that that's not actually what happened in this case. But that is what it looks like. You know what the fancy words mean, but remember that to a layman, "depression" means "not feeling it".
And in fact, I've just found another depressed 29 year old woman who was euthanized. I forgot the name of the first one, googled "euthanized depressed 29 year old" and immediately found another. This made me go and look up the statistics. Here they are, in Dutch, but summarizing: in 2014 there were 14 cases of euthanasia for purely psychiatric reasons. This is the first year for which there is data, so presumably the first year this was even done. By 2024 this had grown to 219. Line go up fairly quickly.
Meanwhile, there were 1819 "traditional" suicides in 2024. So by now, for every ten suicides we're adding an eleventh. More than that.
This really looks to me like official approval causing the social norms to shift, in turn causing the psychiatrists too (who are after all also part of society) to be more free in granting approvals, causing the norm to shift further.
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I'm not necessarily pro suicide, but I think the idea that pursuing bureaucratic rather than kinetic means to suicide indicates a lack of seriousness is backwards.
One can jump off a bridge instantly on a whim, and of the people who have done it and survived many said they regretted it instantly.
Where euthanasia has a 100% success rate, and requires serious intent over an extended period of time.
Interesting idea for an RCT: Some portion of euthanasia subjects are head faked, put under anesthesia, then when they wake up you ask them if they regretted their decision. If they still want to die you kill them on the second try.
Probably because jumping off a bridge is awesome; it's the largest adrenaline rush I've had bar none including skydiving. Seems likely to (at least temporarily) break a suicidal mindset right there. I doubt the APA would approve bungi jumping even as an experimental therapy though.
Is it inexcusably awful that I think we should be utilizing the "wants to and is approved to die" demographic for experiments like that?
Fuck it, harness them up and toss them off a bridge. Let them drive dangerous car races, or play airsoft with live ammunition. See if it alters their feelings about death.
Russian Roulette as therapy? Mind you, I think that was the original purpose.
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So life sucked for her. Life sucks for a lot of people. Giving people who see no point in living (a surprising amount of people, most of whom are too anaesthetised to realise it) a societally sanctioned way of killing herself (this is clearly what she was after) is a pretty slippery slope. We'll see how slippery pretty soon after AGI, I think.
The manner of someone's death matters not as much as the fact of the premature death. One could theorize some nightmarish ways to go that could traumatize the bereaved but generally, it doesn't matter.
I stubbed my toe this morning. That puts me in the same category as people screaming from the agony of testicular torsion, childbirth, or a subarachnoid hemorrhage. It is helpful to deny them painkillers because I've walked it off.
I do not understand how you fail to see that the degree of sucking matters. If your mother complains of a mild headache, you pop down to the chemist for some Tylenol. If she is screaming with an arrow in her guts in the middle of the Amazon, you would be very kind to give her the opportunity to extend her life for a few minutes or hours, at least an opportunity to let her demonstrate moral character in the face of adversity.
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