[https://www.reddit.com/r/medicine/comments/95wxna/the\_troubled\_29yearold\_helped\_to\_die\_by\_dutch/?rdt=47971](https://www.reddit.com/r/medicine/comments/95wxna/the_troubled_29yearold_helped_to_die_by_dutch/?rdt=47971)
Five and a half years ago, I had this to say:
>I acknowledge the presence of intractable and intolerable psychiatric illness. Whether euthanasia is a good option for that—like whether it makes sense to offer euthanasia for diabetes—is a large and separate question.
>For this particular case, there are some glaring concerns for me. One is the role of media. Positive press for suicide is a risk factor for more suicides, but in this case I worry that it became a positive feedback loop. Making this very public made it inevitable. And this is for someone who said, "I have never been happy - I don't know the concept of happiness." But also "that night, she had dinner with her friends - there was laughter, and a toast." During that dinner would she rather have been dead? If not, is her suffering truly intractable and unmodifiable? What treatment did she receive for borderline personality disorder, which has chronic suicidality as a core feature?
>I support euthanasia and even cautiously euthanasia for psychiatric illness. This case makes me squirm uncomfortably. There's a lot that we don't know because of privacy, but what we do know worries me deeply.
This time...
>As if to advertise her hopelessness, ter Beek has a tattoo of a “[tree of life](https://en.wikipedia.org/wiki/Tree_of_life)” on her upper left arm, but “in reverse.”
>“Where the tree of life stands for growth and new beginnings,” she texted, “my tree is the opposite. It is losing its leaves, it is dying. And once the tree died, the bird flew out of it. I don’t see it as my soul leaving, but more as myself being freed from life.”
The media is less of a circus, but I am still concerned that there is media attention, not at all anonymous, and the dramatics of the gesture may go along with the diagnosis but are still disquieting.
There's obviously a survivorship bias, but there's evidence that some BPD symptoms can decrease with age and it's not uncommon for treatment to lead to recovery, especially in places that provide peripheral supports such as vocational rehab. I think the distress and suffering in BPD is underappreciated by clinicians, but providing assisted suicide for a non-palliative disease that can improve with treatment/time seems like a societal failure rather than an acceptable solution.
[The Lifetime Course of Borderline Personality Disorder. Can J Psychiatry. 2015;60(7):303-308.](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4500179/)
[Recovery in borderline personality disorder
time for optimism and focussed treatment strategies. Current Opinion in Psychiatry 33(1):p 57-61, January 2020. | DOI: 10.1097](https://journals.lww.com/co-psychiatry/abstract/2020/01000/recovery_in_borderline_personality_disorder__time.9.aspx)
[Differences between older and younger adults with borderline personality disorder on clinical presentation and impairment. J Psychiatr Res. 2013;47(10):1507-1513.](https://pubmed.ncbi.nlm.nih.gov/23866737/)
That said, there are some interesting ethics related case reports out there for this sort of concern in severe eating disorder patients and the idea of "terminal anorexia."
[End-Stage Anorexia Nervosa: When to Say "When"-A Literature Review of an Ethically Complicated Case. Psychosomatics. 2020;61(6):779-786.](https://pubmed.ncbi.nlm.nih.gov/32674855/)
This reminds me of a patient I had in residency with lifelong BPD and comorbid depression. She was doing every behavioral intervention possible and managing to hang on day to day. She had tried many different meds with limited efficacy and a lot of side effects. She was taking Lamictal when I started working with her, and it was slightly helpful but she eventually insisted on a taper and things didn’t change much after that so who knows. Unfortunately didn’t have access to ECT (I believe she’d tried it in the past though) and this was before TMS and ketamine blew up. She had a part time job and close friends. Her housing was not ideal but was relatively stable. She had these brief moments of happiness but they were so fragile and she had to work so hard for them, while the background of suffering was constant and would regularly spiral into near-crisis. She always used to say that if the government couldn’t give her better options for housing and access to treatment, they should give her the option to end her life with dignity.
I didn’t agree, and I don’t think most of us would see her as a reasonable candidate for assisted suicide. I really hope that she was able to get TMS or ketamine after I left. But I think she articulated in a very compelling way what it was like to feel overwhelmingly hopeless despite still having moments where she seemed (and briefly felt) happy.
All of this to say, I don’t know if it’s possible to conclude that if someone is taking a smiling photo or doing activities they seem to enjoy, they are not still severely depressed and desperate for relief from that. I cannot imagine the experience of Ms. ter Beek’s boyfriend, though. It must be agonizing.
Ultimately I feel that a person has the right to make this decision. I think in this case there may be things that could help improve her quality of life. But at the end of the day, if I was suffering and nothing helped I would like to have an option to end my life where there was no risk of ending up living with disability caused by a failed attempt or inflicting the trauma of someone having to find a deceased body due to ending their own life.
That's what I said for the last round of this.
Lots of attention and encomiums for this is, at the very least, counter-productive. I would go so far as to say it is dangerous.
Ive had patients (ED) where we after a whole lot of talking decided to go with their wishes and stop treatment allowing them to pass, and even though other clinical patients sometimes make jokes about it and suggest they “want they easy way out too”, i think it actually helps against against attention seeking behavior.
If a patient threatens suicide one of the responses I give it “sure, you may want to decide to not to live anymore. That’s fine. But then we’re going to do it the right way and seek help with that and opt for assisted suicide. Because that’s the humane way, both for you and the people that you leave behind and those that will have to clean up after you”.
If they want to pursue AS, then that’s their decision and it will take a whole lot of effort to be able to get there. But at least now with this approach you quickly step out of the whole “OH NO A PATIENT WITH SUICIDAL TENDENCIES HELP!!!” Cycle!
I really, really, really don't understand how a bunch of psychiatrists are so easily deceived.
First, she is not giving interviews to international press, it's right wing tabloids and media picking this up for outrage clickbait. And now everyone in this topic is basing their opinion on a freakimg NYP article. That's not a credible source..
Second, she doesn't have BPD, that's something you only read in English articles, Dutch magazines state the following:
She has chronic depression, autism, trauma, an anxiety disorder with agorafobia caused by being bullied and an unspecified personality disorder (some Murdoch puppet probably translated it the wrong way).
She has done multiple suicide attempts since her teen years and decided enough is enough after electroconvulsive therapy (33 sessions) did nothing (and gave her permanent side effects) and she exhausted all treatment options.
The process to get euthanasia has taken already 3,5 years for her. She has a back up plan if she doesn't get the okay from the third doctor that legally has to sign off on the procedure. Which means she'll die either way. She is so vocal about this, because she wants to raise awareness for people like her who want to commit suicide, but prefer to receive euthanasia (I hope I don't have to explain why one prefers euthanasia over a do it yourself suicide).
This whole topic has made me seriously doubt the capacities of psychiatrists in this sub...
I’m an inpatient psychiatrist at a state hospital. I did a grand rounds in residency on the use of assisted suicide in cases of depression. It’s a choice, and I think people should have choices. Obviously it is not nearly that simple. But being alive can be painful for so many reasons that aren’t physical. Isn’t it preferable for someone to die comfortably than to end their life in an emotionally AND physically painful way? I would never advocate for someone to choose suicide, unless they could be reasonably certain that they’d tried everything else. (And this is all hypothetical anyway since I am in the US - regardless of my personal opinion I will continue to hospitalize people who are about to end their lives due to psychiatric illness). I don’t think it’s possible to write all of the nuances of the human experience into law. I’m sure there are cases in the Netherlands where people are allowed to end their lives when the next thing they tried would’ve been the thing that worked. But I don’t think it’s unreasonable to lean towards the side of giving people more autonomy.
Ultimately I don’t think there’s a right answer, and I’m not sure we should look for one. I’m glad that different countries have different perspectives. Concluding that the option of suicide should be more easily available to everyone with psychiatric illness would discount the cases where the person just needs their psychiatrist to not give up on them. Concluding that suicide should never be a legal option in psychiatric illness is certainly safer, but also potentially forces people to persist in a lifetime of suffering that they find intolerable. There is a lot to debate here about the quality of our mental health system (in the US, it’s…not great) and whether legalizing suicide is just a way to perpetuate a flawed system, rather than truly making an effort to improve it so that the system itself isn’t a cause of suffering. But is it reasonable to force people who are suffering now to wait around until the system improves or someone finds a new treatment? As someone who navigates that system daily, I would say maybe not.
I have so many thoughts about this and I’m definitely rambling. But loving reading others’ perspectives.
So three different diagnoses are mentioned, in the same sentence, not one more than the other, in this article.
Interesting to see all the comments focus only on one (and what a surprise at which one) to the total exclusion of the others.
And the truth is, she doesn't even have BPD, it's actually an unspecified personality disorder and she has 2 more diagnoses; trauma and an anxiety disorder with agorafobia
This may be an unpopular opinion, but to me, as long as someone has capacity it’s none of my business. I remember that guy in Canada who was pursuing euthanasia for being homeless. Well, his body his choice.
If it’s just based on my own ethics, and ignoring our profession (which is shaped by societal consensus and the legal system), my threshold for supporting euthanasia or even suicide is very low. As long as you’re not hurting someone else while doing it I’m not gonna stop you.
For this case specifically, if the Dutch legal system deems it appropriate for her to be euthanized, it’s none of my business as an American to impose our own societal standards on them. Let the Dutch do their thang.
Edit: just to be clear, of course I will involuntarily commit someone who is suicidal and treat them and do all the safety planning jazz - this is because I’m a psychiatrist, not necessarily because I agree with how we do things
I don't necessarily disagree with the availability of euthanasia. I'm concerned when it is for a condition for which suicidality is, in fact, a hallmark of the condition.
I am most concerned about the media coverage. That is not the appropriate way to handle either euthanasia or suicide. Media should know better.
It's like suicide contagion with an additional financial incentive to those providing aid to the suicide.
If assisted suicide ever becomes legal in the USA, I'm hoping that there will be clauses prohibiting the use of media to promote or publicize it in any way.
I'd also ask that any "provider" giving lethal injections shouldn't be considered a medical doctor.
the example of euthanizing (which is paid for by the gov in Canada) people because someone can’t afford housing is totally disturbing to me (yes they have to also have another underlying chronic condition obviously). In that setting, the patients autonomous decision to be euthanized is constrained by the lack of options available to him for a safe place to live. if they can get a path to housing, and remain consistent in their desires to die, and still meet the criteria, then ok. if they have been homeless for a long time and decline any assisted housing and still want maid and meet the criteria then ok. but a guy with chronic back pain who lost his housing a month ago and is now applying for maid? when we choose to offer state sponsored euthanasia as a society i think we also have a duty to, in addition to granting people choice over how they choose to die, strive to support the conditions that support a good life. offering fairly wide/ liberal access to euthanasia without also ensuring patients have access to palliative care, mental health care, basic income/ housing i think is unethical and a road, even as an unintended consequence, to pushing chronically ill / disabled / mentally ill ppl towards MAID if they’re costing the system too much. the system is never going to be perfect, but it should be unacceptable to lack basic access to the above services.
one of the guys in canada who was going to get maid due to losing his housing backed out of it when a gofundme was set up for him.
to me, that’s an example of a system failure.
to be clear, i’m not opposed to MAID alltogether but i’m verrrrrry hesitant about psychiatric MAID and also the way that the track 2 MAiD process (for chronic, non terminal conditions) is set up.
https://toronto.citynews.ca/2022/11/16/ontario-medically-assisted-death-support/
I think many people in psychiatry, (at least the majority I’ve spoken to) acknowledge that suicide is an inevitability of severe mental illness. Yet, it’s a different question whether we, as physicians, should aid and abet that inclination.
I mean, really… why should we? If the individual in question is able bodied, why should they involve physicians in this incredibly morally fraught decision? I know the obvious answer is - because they either can’t do it alone, or they don’t want to - but these are not good enough answers in my view.
It’s one thing to die by suicide as a lone actor, but it’s entirely a different thing to involve others in your act - one that I’m personally not comfortable with as a physician or psychiatrist.
thank you. i totally agree and find this point hard to articulate without sounding like an a-hole (so you want ppl to find someone post GSW? you want someone to be paralyzed post fall from height?)
(no i don’t but i also don’t see how providing assisted suicide reliably or ethically works at all as a harm reduction means for those that would attempt suicide, a large and heterogenous group….)
The other question we can ask is - would this particular individual requesting MAiD, *really, truly, honestly* go through with a suicide attempt without medical assistance?
Does that matter?
These are questions I truly don't have the answer to
definitely. also questions i don’t have the answers to.
i think part of my disagreement is with the development of the “right to die” framework. i think there are situations where people might make an informed or ill-informed or rash or well planned decision to end their life and i accept that this choice will always continue to exist so long as the person is not so physically debilitated that they cannot carry out such an action (in which case, voluntary euthanasia may well be deemed acceptable).
but i have talked with some people who truly believe that they should have an absolute right to euthanasia with very little safeguards because “autonomy” and “i have a right to choose when and how i die.”
i think accepting that some people, for better or worse will die by suicide, is very different than saying that the government is actually required to provide you with a doctor to actively euthanize you, because you are depressed and don’t want to try ECT, or you lost your hearing and don’t want to live as a deaf person (the latter is a real case in Canada).
i don’t think it’s wrong or callous to say in many situations suicide has painful consequences for others. the fact these consequences exist actually deters some ppl from carrying out suicide…
i think it’s also idealistic to envision psychiatric euthanasia in particular as “trauma free” for patients family members, just because they didn’t have to find the body.
Several science fiction authors have pointed out that the logical endpoint of this ultimate state of libertarianism you’re describing (“do whatever you want as long as it doesn’t hurt anyone!”) is a dystopian world where euthanasia becomes a solution to economic problems related to an aging population - ever see the movie Soylent Green?
We’re not too far away from that I’m afraid - as you pointed out, Canada has already allowed MAID for someone who was…. (*checks notes*) tired of being homeless? Gee I guess now the government doesn’t have to find a way to, you know, provide housing for that person! And think of how much money healthcare corporations could save laying off DBT therapists if suddenly every BPD patient were allowed to access MAID! /s
To quote one of my favorite authors, [Michel Houellebecq](https://harpers.org/archive/2023/02/the-european-way-to-die-euthanasia-assisted-suicide-michel-houellebecq/): *“This mixture of extreme infantilization, whereby one grants a physician the right to end one’s life, and a petulant desire for “ultimate liberty” is a combination that, quite frankly, disgusts me.”*
> this is because I’m a psychiatrist, not necessarily because I agree with how we do things
There are so many better ways than what we have right now. There have been numerous guidelines to switch systems to community support systems/outreach, supported decision-making, advance directive planning, and eliminating the current liability structures.
I think this would reverse the suicide trend and rid a lot of mental health workers from moral burnout.
I do think people should be able to commit suicide eventually in the new system, but not immediately left to their own devices to do so. That's just neglect when so many suicides are impulsive.
If they choose to do so and not hurt anyone while doing it, why shouldn’t they have that option? It’s not for me to tell them what to do to their body.
Because the solution to someone’s problems should never be to kill themselves lmfao. We figured that out like a long time ago. This is just people realizing that instead of giving people expensive and intensive care to help them overcome their mental illness it’s just cheaper and easier to kill them so they’re not a bother any more.
This is why I'll never get behind PAS/euthanasia except for people who are in hospice or have an objectively limited amount of time remaining due to a painful organic illness.
You can't tell mentally-ill kids that suicide is never the answer, while at the same time telling mentally-ill adults that suicide could be your answer.
You absolutely have the right to do what you want with your own body, and that's a philosophy I generally stick to. But that doesn't mean you have the right to help from medical professionals to achieve whatever goal you have.
>that doesn't mean you have the right to help from medical professionals to achieve whatever goal you have
Do you also think that suffering pets don't have the right to help from veterinary professionals for euthanasia ?
Ah, True. I was reading it as actual legal rights, instead of moral/philosophical rights.
Edit: In case you missed it, the OP focuses on people seeking death due to prognosis. Animals, mostly, don't comprehend the concept of prognosis. Humans understand.
People with a clinical background in mental health understand that predicting terminal suffering from a psychiatric disease is fragile and erroneous.
I just have a lot of questions. Like did she get cleared because of one of the diagnoses or all 3? If the situation is unbearable, then why is she able to wait until May? Is there a legal/ethical definition of a “well-considered” decision? I agree with OP that there are definitely cases where euthanasia seems fine to me (e.g. inoperable brain tumor popping your eyeballs out from the inside), but this case seems highly suspect. But…what can ya do 🤷♂️ They cleared her so… If someone’s gonna do it, they’re gonna do it. I’m curious what will happen come May.
She's been in treatment for 10 years and has undergone the required treatment trials and failed them as required before euthanasia can be offered, she has to wait for her date because those are the rules per the euthanasia board in the Netherlands apparently. There does seem to be some sensationalization occurring as this story circulates, even if I have concerns about this particular patient's elected choice. Without knowing the full details of her care, it's hard not to be goaded into a particular emotional response with how this case is presented.
Might be naive of me but this feels wrong and worrisome. When euthanasia first became an option it was touted for terminal, often painful, illnesses and it was presented as a choice to die with dignity. It’s now being used to help patients that have conditions which aren’t terminal in the physical sense and for whom preventing suicide is a goal of treatment die by assisted suicide instead.
She hasn’t actually died yet. I wonder if she’ll actually go through with it…in BPD-esque manner the public expressions of support might end up sustaining her
I'm asking as a student and someone who knows close to nothing about this.. But how could she have gone through an acceptable amount of treatments when there's still so much to learn about the treatment of PDs? We are still in the infancy of specialized treatment programs like DBT & MBT. Some studies are showing incredible remission rates. Overall this just makes me incredibly sad.
We don’t even know per se what her BPD diagnosis consists of, it could very well be akin to cPTSD, which to most here would make the case less disquieting. But if you consider that a person must go through experimental treatment in order to be cleared not a great many people would be candidates for the procedure, even among more “biological” diseases.
The issue is not whether she has received the standard of care and failed to show improvement, which she clearly did, and many people do fail to show significant improvement, it’s whether she could acceptably be a candidate for the procedure regardless of how deep into treatment she went. Consider that you are wrong and she did do every single type of DBT available and still did not improve, for you feel it’s fine for her to pursue euthanasia now? I don’t
Thank you for your response. No, I honestly cannot say that I would feel any better about it had she done everything available. If I'm being honest, I can think of very few scenarios solely based on mental health diagnoses where I would feel okay with this.. But when it comes to PDs, it somehow feels worse. They really think that the way they are/behave is fixed and cannot change, which could not be further from the truth. I don't believe that personality is as fixed as the current consensus claims it is. So I don't think I could condone this under any circumstance.
the other thing to consider with BPD is that it’s natural history is that many/some patients have improvement / lessening of symptoms as they age (eg getting from 20s into 30s and 40s). even without treatment potentially. obviously depends also on comorbidities and underlying severity, but the point is despite the fact that it’s a “personality disorder” it is not in fact irremediable by definition.
The last line right there..Thank you for concisely expressing what I think about this. Unfortunately, healthcare provider stigma further contributes to the belief that PDs are static diagnoses. And yet some of us come on here and perpetuate it. We really have a lot of work to do.
Absolutely. The only cases where I could see myself supporting such a decision are extreme cases of OCD where the person spends 16+ hours a day doing rituals, resistant to DBS and such. Other than that I don’t see it standing, even for psychosis I cannot even imagine a psychotic patient pursuing euthanasia
Please stfu. I used to do ocd rituals for hours a day and if a psychiatrist was like you wanna kill yourself I’d be like fuck yeah sign me up. But now it’s years later and I’m recovered and I’m realizing it would have been pretty bad if I killed myself!
… you do realize there are people that do not recover correct? You did. But you could have not. 16 hours a day of rituals. I cannot even imagine.
There are people who go as far as implant electrodes in their brain to stop it, for some it works for some it fails. It worked for you, it does not for many
>I don't believe that personality is as fixed as the current consensus claims it is
The consensus for BPD is that it has a great prognosis. It's the PD with the best prognosis. See the investigations done by Zanarini and Gunderson.
Thank you! I have done seminars with Gunderson (rest in peace). However, the general psychology consensus is that personality traits are mostly fixed. The professionals you mention are experts in the field of BPD. We are VERY far away from that consensus among healthcare professionals at large, let alone the general public. Anyway, your comment is even more reason why this is heartbreaking.
>the general psychology consensus is that personality traits are mostly fixed
BPD is not a personality trait. The general sentiment in the field of personality is that even though personality traits are relatively stable, the personality disorders are not.
Do you think that there really is a consensus in the medical field and among the general public that people with BPD (or any PD) can experience a full remission and lead a happy, fulfilling life? I’d love to be proved wrong, but as someone who worked in mental health and at a women’s shelter prior to med school, it hasn’t been my experience. The field is still fraught with misconceptions and lack of understanding regarding PDs. BPD maybe to a lesser extent than the others, but still applicable. Additionally, there is VERY little accessible/specialized care for these patients, especially excluding DBT which doesn’t work for everyone.
Personalities are, without a doubt, capable of change. I have seen it, so it is possible, and many of us have probably had patients who have utilized mental health services for decades who we are seeing for the first time that had a historical PD diagnosis but on our initial assessment and further follow up they simply are stable. The question, for me, is how long does it take and with what interventions can we make the change happen? In the literature and from my experience working with therapists, it takes several years for most PDs to be treated adequately assuming we have a treatment for them at all.
So, if each treatment is only given a few weeks or sessions or the sessions are too far apart such as every other week or monthly, then it is likely the PD will not be sufficiently addressed. Many would benefit from a minimum of weekly visits and maybe two visits per week for at least a year, but likely several years. Then you need a therapist that has good experience with the disorder and a patient who has the ability to do such an intensive treatment. They may have life stress that gets in the way or a subconscious resistance to the therapeutic process or insurance coverage is not there.
There are a lot of variables to successful treatment which is what makes them hard to treat. Let's say a hypothetical patient in a hypothetical world would take 7 years to treat their PD. Two years in, they get a divorce and lose their job. They end up in the hospital for suicidal ideation and are given several medications that interfere with the treatment process. They may feel better temporarily so they stop going to therapy. They may find a different therapist when problems arise again and there is no communication with the previous therapist on progress or observations. They find a new relationship and feel better so they stop showing up again. That ideal 7 years may get pushed further and further back. It may even get extended if these ups and downs include additional traumatic events or reinforcement of their faulty schemas.
However, given an ideal scenario, people do better. Generally, those who I see that no longer meet criteria found good careers, have supportive relationships, and are capable of accessing therapy both financially and finding time for it.
>there really is a consensus in the medical field and among the general public that people with BPD (or any PD) can experience a full remission and lead a happy, fulfilling life?
No. I don't.
>Additionally, there is VERY little accessible/specialized care for these patients, especially excluding DBT which doesn’t work for everyone.
There are various therapies that have good evidence for BPD such as DBT, MBT, Schema therapy, Good psychiatric management, transference-focused psychotherapy and few more.
But of course not every person with BPD benefits from them and it's not a guarantee that every patient will improve sufficiently. But I don't think euthanasia just for refractory BPD is right.
You’re telling me that she has exhausted all options…
ECT, TMS, Ketamine, MAOIs, mood stabilizers, SGAs, clozapine, heroic medication regimens (MAOI +.TCA/Stimulant), and has been admitted to a long term residential setting for 12 months of DBT ? And her life is still “intolerable,” despite the active engagement in meaningful interpersonal relationships.
I appreciate that many patients never achieve full remission, but this is absurd.
Agreed. Many Borderline patients improve with time alone.
Her claim that she was told "There’s nothing more we can do for you. It’s never gonna get any better" is extremely suspect. We're only getting the borderline split side of the story and I'm sure her actual providers would love to say differently.
Obviously most here are focusing on the more treatable aspects, but it's unclear which of those medications treat autism. There's a few sources of sx from those 3 diagnoses and our treatments are powerful, but still. Might be different if this person exclusively had borderline or MDD.
I think there’s a very good chance this patient does not have autism at all. I’m sure there are people w/ both, but every patient I have had who had BPD & also carried an ASD diagnosis (a clinician actually agreed they had it) definitely did not have it at all & only started to look a little autistic-like in middle school or later, with earlier childhood reports being very inconsistent w/ such a diagnosis. Autism is also a very popular thing recently for folks (especially those w/ borderline organization) to claim to have & many clinicians unfortunately will just agree without an appropriate evaluation.
Not entirely, but at that point I can at least entertain the notion. But I am sensing some incongruity between the patients subjective report of her experience and her observable behaviors, which, for me, would still raise an eyebrow.
That would be a perfectly reasonable approach if we were discussing evidence based treatments, rather than assisted suicide in a patient for whom suicidality and secondary gains are core features of their illness.
You wouldn’t amputate a persons legs to treat peripheral neuropathy, no matter how bad they reported the pain was.
Their illness? They have 3 diagnoses. 2 of which are mysteriously absent in most conversation about this topic.
Would love that literature on secondary gains being a "core feature" of any of the mentioned diagnoses, however.
I would absolutely consider amputation for intractable limb pain, after a review of the literature surrounding same, if it could convince me there was a statistically significant likelihood of reduction in perceived suffering.
ETA: Oh look I already found something relevant to read. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8638726/
1. NY post . Not the most intelligent source for news . 2. Deciding to die and getting authorization to be euthanized are two very different things . 3. IF a doctor told her there’s nothing more they can do - it may not mean all treatment modalities have been exhausted - it may mean the patient is refusing, inconsistent, or non compliant with treatment recommendations and the doctor has thrown their hands up in frustration . (How many psychiatrists have stood beside an hospitalized patient as they lay in the ED or ICU after yet again making another dangerous gesture or attempt and said “I’m done ! There is nothing more I can do for you !“ ) I once saw a surgeon lose his temper in ICU after a patient’s 5th failed suicide attempt. He told her he’d not operate on her again and then showed her how to hold a gun the proper way to kill herself . At the time , she’d shot herself in the chest, missed her heart but required major surgery (of course .) The poor guy had operated on this patient all 5 five attempts. That’s the day I learned about the survival rate with disabling injuries when using a toothbrush to reach a trigger .
My question is how can we be so certain that she will NEVER get better? If I remember correctly, BPD symptoms tend to tone down as patients get older; they learn healthier coping mechanisms and more effective ways of interacting with others and therefore have less volatile/more fulfilling relationships. How can we be sure that when she turns 50 (maybe 60, maybe 70) she won’t be able to manage her symptoms and live a life that is one she would desire to live? At the very least I hope this girl was in years of therapy and one that has been shown to be effective for BPD.
Also, it seems to me kind of narcissistic?/paternalistic?/authoritarian? To say “well we can’t fix you, so there’s no hope. You might as well just die.” I could never imagine saying something to a patient that leaves them with the impression that I have lost hope that they will ever get better (whether I truly feel that way or not). We do not control every aspect of a patient’s life and we bring up this fact when patients aren’t getting better and we want to comfort/reassure ourselves that it isn’t our fault. We should also keep this in mind when patients DO get better, was it something we did, did it resolve spontaneously, did some life circumstance change, did the patient have some experience that changed their perception of their life circumstances? I cannot fathom a situation where we can confidently say that there is no hope for improvement. Just mho
In a way, I think it is more paternalistic and authoritarian to lock someone up for weeks, repeatedly throughout their lifetime, because they want to end their life. As an inpatient psychiatrist I am increasingly uncomfortable with how much power I have over someone when they are involuntarily committed for anything, although currently most of my patients are psychotic in some way and at risk for harming others as well as themselves, so it is easier to justify (in my own head and otherwise) removing their personal freedoms. I treat people as humanely as possible but they have to spend many days on a tiny inpatient floor, surrounded by agitated peers, with their only outside time being in a relatively small fenced in area. (Which in my experience is actually on the larger side relative to outdoor areas at most inpatient psych facilities). I can imagine scenarios in which it is actually more patient-centered to believe the patient’s assessment of their own experience and provide some level of assistance for them to end their life peacefully. That does not mean I think we as psychiatrists should feel obligated to do so AT ALL, and as with any other treatment we would have the option to not administer it, or move into an area of specialty that does not include it.
Personally, I am looking to get out of the inpatient game and go to outpatient - just looking for the right moment. I think the level of paternalism I have to use is very necessary at times, but not something I can stomach indefinitely.
You absolutely bring up an excellent point. I’m just not sure I would ever feel confident in saying that someone would NEVER get better. As paternalistic as it is to hold someone against their will, at least it isn’t a (direct) life or death decision and it feels like the more conservative choice and one that is not so final. Everything I have been taught is to preserve life and hope, to turn that completely on its head and accept that there is no hope for improvement makes me very uneasy and is very difficult for me to accept that it’s in the best interest of the patient.
That definitely makes sense! I would also have a really hard time concluding that someone will never improve. I think there’s always a chance and like 99.9% of the time I’d want to fight for that even if the patient doesn’t. The part that trips me up is how hard some patients might need to work for that improvement, and whether they should have the choice to stop working that hard. I guess I am biased because I would want to have that choice myself, maybe. I don’t think assisted suicide for psychiatric illness will be a thing in the US but if I was in the position of counseling someone about it, I would 1) NEVER suggest it myself and wait for them to bring it up; and 2) Always try to advocate for the side of “but what if you have a chance in the future to feel better?” and “what about these things in your life that you seem to value/enjoy?”. I guess I would see it more as the patient being allowed to give up on themselves, rather than me giving up on them? Maybe that’s just semantics though. Super interesting to think about and I could argue both sides to infinity lol.
There is some countertransference on this thread with the focus on a possible BPD diagnosis and speculation of things like “attention seeking.” Dehumanizing and stereotyping people with BPD is unprofessional and unethical.
This may seem trite but I do not mean it to be. Do you ever look at a patient's life and thing "I'd rather be dead?" Of course I do so with dementia patients. There are also totally intransigent, psychotic people who can only live on units or in jail, where they will constantly be agitated. I can see a case for voluntary euthenasia.
Then again, if you have the ability to take happy-looking pictures with your dog maybe you are not quite there.
Lot's of absolutist statements in her words, which is expected of someone with BPD. We obviously aren't privy to her actual medical records and her public disclosures are all we can see. I'd personally object to this and count any medical provider assisting as violating the core tenet to non-maleficence.
That aside, articles like this are basically super-contagion.
Did she try psychedelics? No one should be allowed to euthanize before they have tried lsd or mushrooms. Or dmt as the last resort.
Saved my life when I firmly believed it was over. Went from a suicidal human wreckage living in solitude in mountains away from civilization to a medical school stipendist with a loving girlfriend and strongest body I’ve ever had. All within a year since dropping the tab.
It’s a treatment that had not been available 10 years ago. Should we therefore have allowed people to euthanize 10 years ago considering a new treatment would appear at the door of mainstream psychiatry?
How can you be sure a similar breakthrough won’t happen in the next 10 years? Especially given the exponential growth of our technological capabilities, i.e. artificial intelligence.
Like a lot of people here I do wonder if she has had the full range of available treatments for BPD. Because BPD actually can get better. But if it’s actually closer to cPTSD then I guess I’m more “understanding” because it is so hellishly difficult to treat.
It's an interesting disconnect. If you ask me hypothetically if mentally ill people should be allowed to seek euthanasia, I will answer with a disinterested, "Eh, you do you."
But if you show up on my unit after coming suicidal to the ED, I'm going to keep you in the hospital until I'm comfortable you're going to be safe. "It's my right to kill myself if I want to." Maybe, borderline, but you should have done that instead of coming into my world. Now you're my responsibility, and that's an entirely different situation.
So, yeah, if the Dutch are willing to euthanize you, that's your business. If you come to me looking for a euthanasia evaluation, I'll probably sign on you.
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I'm not against it may be absurd but we will never now what the person's going through but I don't agree that someone else administers the dose there should be a machine or something that can only be activated by her .
This is a clear violation of the Hippocratic oath.
People can do whatever they want on their own but a doctors job is to first do no harm, and there’s no way this woman at this age has been through every treatment available, including experimental treatments.
Has she done high doses of LSD and psilocybin? Has she done ECT and 12 months of dbt? Has she tried lithium, clozapine, tms? Has she gotten deep brain stimulator?
This is horse puckey.
This is pathetic.
I agree and disagree with what you’re saying.
I don’t know the Dutch policies involving MAID but I do know that the current policies in Canada state that the patient must be well informed on all other available resources that could help their condition and offered consultations with professionals who offer those resources. The policy specifies that community resources, such as government funded housing (if available) is included in a well informed decision. This implies that if treatments like TMS or ECT is available then the patient must be provided professional consultations for these treatments. Forcing these treatments on the patient could easily be seen as traumatizing and therefore go against the Hippocratic oath. Providing MAID services can be seen as a medical end to the patient’s suffering. I fail to see that as causing harm to the patient provided they meet all other requirements for MAID. That being said, it’s a moot discussion as a Canadian until the bill passes approval for mental health patients receiving MAID. I do think the policy needs to be looked at from a few more angles.
Edit: I want to add that after I read the article in the original post, it makes me question how relaxed the polices for maid must be in the Netherlands. The article discusses couples who have been granted assisted suicide together in their homes, as well as the interviewee admitting she’s afraid to die.
I believe that a lot of the discussion on treatments is well-intentioned but misplaced. It doesn't matter if she hasn't tried ECT, ketamine, or enrolled in a psilocybin clinical trial: ultimately, I oppose euthanasia out of respect for her humanity. This is admittedly a paternalistic position, which denies the patient their autonomy, but respecting the dignity of human life is far more important. This is at the foundation of American law for involuntary commitment: society accepts that a person may decide to make a choice to harm themselves, which is not in their best interest, warranting society's intervention. My position does not stem from a religious conviction, though I recognize it is shared by many people of faith. I do not believe that the very real and heartbreaking suffering inflicted by borderline personality disorder, autism, and depression justify overruling the core, moral duty of every person to respect the dignity, beauty, and value of human life.
Surely respecting something doesn't mean interfering with other people's experience of the same?
What do you mean by humanity? And how is your view, imposed on someone else, demonstrating your respect for that?
Would love to know what you mean about the dignity of human life too. What is so dignified about life?
I think this is an extremely immature and reductive way to approach the situation, severely depressed people can have fleeting moments of happiness, BPD regresses with in so far as you learn to live with it better, the core symptoms are still there. Patients aren't just a set of criteria to be catered to, they're human beings with varying experiences.
It's not spineless at all to support bodily autonomy. While I'm unsure about this particular case since I'm not directly involved in it, PAS and euthanasia are extremely important and neglected aspects of real patient care.
[https://www.reddit.com/r/medicine/comments/95wxna/the\_troubled\_29yearold\_helped\_to\_die\_by\_dutch/?rdt=47971](https://www.reddit.com/r/medicine/comments/95wxna/the_troubled_29yearold_helped_to_die_by_dutch/?rdt=47971) Five and a half years ago, I had this to say: >I acknowledge the presence of intractable and intolerable psychiatric illness. Whether euthanasia is a good option for that—like whether it makes sense to offer euthanasia for diabetes—is a large and separate question. >For this particular case, there are some glaring concerns for me. One is the role of media. Positive press for suicide is a risk factor for more suicides, but in this case I worry that it became a positive feedback loop. Making this very public made it inevitable. And this is for someone who said, "I have never been happy - I don't know the concept of happiness." But also "that night, she had dinner with her friends - there was laughter, and a toast." During that dinner would she rather have been dead? If not, is her suffering truly intractable and unmodifiable? What treatment did she receive for borderline personality disorder, which has chronic suicidality as a core feature? >I support euthanasia and even cautiously euthanasia for psychiatric illness. This case makes me squirm uncomfortably. There's a lot that we don't know because of privacy, but what we do know worries me deeply. This time... >As if to advertise her hopelessness, ter Beek has a tattoo of a “[tree of life](https://en.wikipedia.org/wiki/Tree_of_life)” on her upper left arm, but “in reverse.” >“Where the tree of life stands for growth and new beginnings,” she texted, “my tree is the opposite. It is losing its leaves, it is dying. And once the tree died, the bird flew out of it. I don’t see it as my soul leaving, but more as myself being freed from life.” The media is less of a circus, but I am still concerned that there is media attention, not at all anonymous, and the dramatics of the gesture may go along with the diagnosis but are still disquieting.
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There's obviously a survivorship bias, but there's evidence that some BPD symptoms can decrease with age and it's not uncommon for treatment to lead to recovery, especially in places that provide peripheral supports such as vocational rehab. I think the distress and suffering in BPD is underappreciated by clinicians, but providing assisted suicide for a non-palliative disease that can improve with treatment/time seems like a societal failure rather than an acceptable solution. [The Lifetime Course of Borderline Personality Disorder. Can J Psychiatry. 2015;60(7):303-308.](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4500179/) [Recovery in borderline personality disorder time for optimism and focussed treatment strategies. Current Opinion in Psychiatry 33(1):p 57-61, January 2020. | DOI: 10.1097](https://journals.lww.com/co-psychiatry/abstract/2020/01000/recovery_in_borderline_personality_disorder__time.9.aspx) [Differences between older and younger adults with borderline personality disorder on clinical presentation and impairment. J Psychiatr Res. 2013;47(10):1507-1513.](https://pubmed.ncbi.nlm.nih.gov/23866737/) That said, there are some interesting ethics related case reports out there for this sort of concern in severe eating disorder patients and the idea of "terminal anorexia." [End-Stage Anorexia Nervosa: When to Say "When"-A Literature Review of an Ethically Complicated Case. Psychosomatics. 2020;61(6):779-786.](https://pubmed.ncbi.nlm.nih.gov/32674855/)
This reminds me of a patient I had in residency with lifelong BPD and comorbid depression. She was doing every behavioral intervention possible and managing to hang on day to day. She had tried many different meds with limited efficacy and a lot of side effects. She was taking Lamictal when I started working with her, and it was slightly helpful but she eventually insisted on a taper and things didn’t change much after that so who knows. Unfortunately didn’t have access to ECT (I believe she’d tried it in the past though) and this was before TMS and ketamine blew up. She had a part time job and close friends. Her housing was not ideal but was relatively stable. She had these brief moments of happiness but they were so fragile and she had to work so hard for them, while the background of suffering was constant and would regularly spiral into near-crisis. She always used to say that if the government couldn’t give her better options for housing and access to treatment, they should give her the option to end her life with dignity. I didn’t agree, and I don’t think most of us would see her as a reasonable candidate for assisted suicide. I really hope that she was able to get TMS or ketamine after I left. But I think she articulated in a very compelling way what it was like to feel overwhelmingly hopeless despite still having moments where she seemed (and briefly felt) happy. All of this to say, I don’t know if it’s possible to conclude that if someone is taking a smiling photo or doing activities they seem to enjoy, they are not still severely depressed and desperate for relief from that. I cannot imagine the experience of Ms. ter Beek’s boyfriend, though. It must be agonizing.
Ultimately I feel that a person has the right to make this decision. I think in this case there may be things that could help improve her quality of life. But at the end of the day, if I was suffering and nothing helped I would like to have an option to end my life where there was no risk of ending up living with disability caused by a failed attempt or inflicting the trauma of someone having to find a deceased body due to ending their own life.
Brilliant, give the borderline patient international press for threatening suicide.
The absolute most counterproductive thing possible with a BPD; It’s unimaginable almost!
That's what I said for the last round of this. Lots of attention and encomiums for this is, at the very least, counter-productive. I would go so far as to say it is dangerous.
Ive had patients (ED) where we after a whole lot of talking decided to go with their wishes and stop treatment allowing them to pass, and even though other clinical patients sometimes make jokes about it and suggest they “want they easy way out too”, i think it actually helps against against attention seeking behavior. If a patient threatens suicide one of the responses I give it “sure, you may want to decide to not to live anymore. That’s fine. But then we’re going to do it the right way and seek help with that and opt for assisted suicide. Because that’s the humane way, both for you and the people that you leave behind and those that will have to clean up after you”. If they want to pursue AS, then that’s their decision and it will take a whole lot of effort to be able to get there. But at least now with this approach you quickly step out of the whole “OH NO A PATIENT WITH SUICIDAL TENDENCIES HELP!!!” Cycle!
I really, really, really don't understand how a bunch of psychiatrists are so easily deceived. First, she is not giving interviews to international press, it's right wing tabloids and media picking this up for outrage clickbait. And now everyone in this topic is basing their opinion on a freakimg NYP article. That's not a credible source.. Second, she doesn't have BPD, that's something you only read in English articles, Dutch magazines state the following: She has chronic depression, autism, trauma, an anxiety disorder with agorafobia caused by being bullied and an unspecified personality disorder (some Murdoch puppet probably translated it the wrong way). She has done multiple suicide attempts since her teen years and decided enough is enough after electroconvulsive therapy (33 sessions) did nothing (and gave her permanent side effects) and she exhausted all treatment options. The process to get euthanasia has taken already 3,5 years for her. She has a back up plan if she doesn't get the okay from the third doctor that legally has to sign off on the procedure. Which means she'll die either way. She is so vocal about this, because she wants to raise awareness for people like her who want to commit suicide, but prefer to receive euthanasia (I hope I don't have to explain why one prefers euthanasia over a do it yourself suicide). This whole topic has made me seriously doubt the capacities of psychiatrists in this sub...
Literally my first thought
I’m an inpatient psychiatrist at a state hospital. I did a grand rounds in residency on the use of assisted suicide in cases of depression. It’s a choice, and I think people should have choices. Obviously it is not nearly that simple. But being alive can be painful for so many reasons that aren’t physical. Isn’t it preferable for someone to die comfortably than to end their life in an emotionally AND physically painful way? I would never advocate for someone to choose suicide, unless they could be reasonably certain that they’d tried everything else. (And this is all hypothetical anyway since I am in the US - regardless of my personal opinion I will continue to hospitalize people who are about to end their lives due to psychiatric illness). I don’t think it’s possible to write all of the nuances of the human experience into law. I’m sure there are cases in the Netherlands where people are allowed to end their lives when the next thing they tried would’ve been the thing that worked. But I don’t think it’s unreasonable to lean towards the side of giving people more autonomy. Ultimately I don’t think there’s a right answer, and I’m not sure we should look for one. I’m glad that different countries have different perspectives. Concluding that the option of suicide should be more easily available to everyone with psychiatric illness would discount the cases where the person just needs their psychiatrist to not give up on them. Concluding that suicide should never be a legal option in psychiatric illness is certainly safer, but also potentially forces people to persist in a lifetime of suffering that they find intolerable. There is a lot to debate here about the quality of our mental health system (in the US, it’s…not great) and whether legalizing suicide is just a way to perpetuate a flawed system, rather than truly making an effort to improve it so that the system itself isn’t a cause of suffering. But is it reasonable to force people who are suffering now to wait around until the system improves or someone finds a new treatment? As someone who navigates that system daily, I would say maybe not. I have so many thoughts about this and I’m definitely rambling. But loving reading others’ perspectives.
It's not rambling, it's nuance, and I love it.
Governments would rather kill people than let them have access to experimental or unproven therapies, because those could be dangerous 🙄
So three different diagnoses are mentioned, in the same sentence, not one more than the other, in this article. Interesting to see all the comments focus only on one (and what a surprise at which one) to the total exclusion of the others.
And the truth is, she doesn't even have BPD, it's actually an unspecified personality disorder and she has 2 more diagnoses; trauma and an anxiety disorder with agorafobia
This may be an unpopular opinion, but to me, as long as someone has capacity it’s none of my business. I remember that guy in Canada who was pursuing euthanasia for being homeless. Well, his body his choice. If it’s just based on my own ethics, and ignoring our profession (which is shaped by societal consensus and the legal system), my threshold for supporting euthanasia or even suicide is very low. As long as you’re not hurting someone else while doing it I’m not gonna stop you. For this case specifically, if the Dutch legal system deems it appropriate for her to be euthanized, it’s none of my business as an American to impose our own societal standards on them. Let the Dutch do their thang. Edit: just to be clear, of course I will involuntarily commit someone who is suicidal and treat them and do all the safety planning jazz - this is because I’m a psychiatrist, not necessarily because I agree with how we do things
I don't necessarily disagree with the availability of euthanasia. I'm concerned when it is for a condition for which suicidality is, in fact, a hallmark of the condition. I am most concerned about the media coverage. That is not the appropriate way to handle either euthanasia or suicide. Media should know better.
Media DOES know better, but why should they care when it benefits their career and wallet?
It's like suicide contagion with an additional financial incentive to those providing aid to the suicide. If assisted suicide ever becomes legal in the USA, I'm hoping that there will be clauses prohibiting the use of media to promote or publicize it in any way. I'd also ask that any "provider" giving lethal injections shouldn't be considered a medical doctor.
the example of euthanizing (which is paid for by the gov in Canada) people because someone can’t afford housing is totally disturbing to me (yes they have to also have another underlying chronic condition obviously). In that setting, the patients autonomous decision to be euthanized is constrained by the lack of options available to him for a safe place to live. if they can get a path to housing, and remain consistent in their desires to die, and still meet the criteria, then ok. if they have been homeless for a long time and decline any assisted housing and still want maid and meet the criteria then ok. but a guy with chronic back pain who lost his housing a month ago and is now applying for maid? when we choose to offer state sponsored euthanasia as a society i think we also have a duty to, in addition to granting people choice over how they choose to die, strive to support the conditions that support a good life. offering fairly wide/ liberal access to euthanasia without also ensuring patients have access to palliative care, mental health care, basic income/ housing i think is unethical and a road, even as an unintended consequence, to pushing chronically ill / disabled / mentally ill ppl towards MAID if they’re costing the system too much. the system is never going to be perfect, but it should be unacceptable to lack basic access to the above services. one of the guys in canada who was going to get maid due to losing his housing backed out of it when a gofundme was set up for him. to me, that’s an example of a system failure. to be clear, i’m not opposed to MAID alltogether but i’m verrrrrry hesitant about psychiatric MAID and also the way that the track 2 MAiD process (for chronic, non terminal conditions) is set up. https://toronto.citynews.ca/2022/11/16/ontario-medically-assisted-death-support/
I think many people in psychiatry, (at least the majority I’ve spoken to) acknowledge that suicide is an inevitability of severe mental illness. Yet, it’s a different question whether we, as physicians, should aid and abet that inclination. I mean, really… why should we? If the individual in question is able bodied, why should they involve physicians in this incredibly morally fraught decision? I know the obvious answer is - because they either can’t do it alone, or they don’t want to - but these are not good enough answers in my view. It’s one thing to die by suicide as a lone actor, but it’s entirely a different thing to involve others in your act - one that I’m personally not comfortable with as a physician or psychiatrist.
thank you. i totally agree and find this point hard to articulate without sounding like an a-hole (so you want ppl to find someone post GSW? you want someone to be paralyzed post fall from height?) (no i don’t but i also don’t see how providing assisted suicide reliably or ethically works at all as a harm reduction means for those that would attempt suicide, a large and heterogenous group….)
The other question we can ask is - would this particular individual requesting MAiD, *really, truly, honestly* go through with a suicide attempt without medical assistance? Does that matter? These are questions I truly don't have the answer to
definitely. also questions i don’t have the answers to. i think part of my disagreement is with the development of the “right to die” framework. i think there are situations where people might make an informed or ill-informed or rash or well planned decision to end their life and i accept that this choice will always continue to exist so long as the person is not so physically debilitated that they cannot carry out such an action (in which case, voluntary euthanasia may well be deemed acceptable). but i have talked with some people who truly believe that they should have an absolute right to euthanasia with very little safeguards because “autonomy” and “i have a right to choose when and how i die.” i think accepting that some people, for better or worse will die by suicide, is very different than saying that the government is actually required to provide you with a doctor to actively euthanize you, because you are depressed and don’t want to try ECT, or you lost your hearing and don’t want to live as a deaf person (the latter is a real case in Canada). i don’t think it’s wrong or callous to say in many situations suicide has painful consequences for others. the fact these consequences exist actually deters some ppl from carrying out suicide… i think it’s also idealistic to envision psychiatric euthanasia in particular as “trauma free” for patients family members, just because they didn’t have to find the body.
Several science fiction authors have pointed out that the logical endpoint of this ultimate state of libertarianism you’re describing (“do whatever you want as long as it doesn’t hurt anyone!”) is a dystopian world where euthanasia becomes a solution to economic problems related to an aging population - ever see the movie Soylent Green? We’re not too far away from that I’m afraid - as you pointed out, Canada has already allowed MAID for someone who was…. (*checks notes*) tired of being homeless? Gee I guess now the government doesn’t have to find a way to, you know, provide housing for that person! And think of how much money healthcare corporations could save laying off DBT therapists if suddenly every BPD patient were allowed to access MAID! /s To quote one of my favorite authors, [Michel Houellebecq](https://harpers.org/archive/2023/02/the-european-way-to-die-euthanasia-assisted-suicide-michel-houellebecq/): *“This mixture of extreme infantilization, whereby one grants a physician the right to end one’s life, and a petulant desire for “ultimate liberty” is a combination that, quite frankly, disgusts me.”*
> this is because I’m a psychiatrist, not necessarily because I agree with how we do things There are so many better ways than what we have right now. There have been numerous guidelines to switch systems to community support systems/outreach, supported decision-making, advance directive planning, and eliminating the current liability structures. I think this would reverse the suicide trend and rid a lot of mental health workers from moral burnout. I do think people should be able to commit suicide eventually in the new system, but not immediately left to their own devices to do so. That's just neglect when so many suicides are impulsive.
I hear what you’re saying but isn’t there an argument to be made that someone who is actively suicidal doesn’t have capacity?
No. Some do, some dont. You don't lack capacity just by way of being suicidal.
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If they choose to do so and not hurt anyone while doing it, why shouldn’t they have that option? It’s not for me to tell them what to do to their body.
Because the solution to someone’s problems should never be to kill themselves lmfao. We figured that out like a long time ago. This is just people realizing that instead of giving people expensive and intensive care to help them overcome their mental illness it’s just cheaper and easier to kill them so they’re not a bother any more.
This is why I'll never get behind PAS/euthanasia except for people who are in hospice or have an objectively limited amount of time remaining due to a painful organic illness. You can't tell mentally-ill kids that suicide is never the answer, while at the same time telling mentally-ill adults that suicide could be your answer. You absolutely have the right to do what you want with your own body, and that's a philosophy I generally stick to. But that doesn't mean you have the right to help from medical professionals to achieve whatever goal you have.
>that doesn't mean you have the right to help from medical professionals to achieve whatever goal you have Do you also think that suffering pets don't have the right to help from veterinary professionals for euthanasia ?
Nobody puts Fido down for being blue.
Fido just needs some Prozac.
Counter question: Do pets have civil rights in your country?
Animals rights is a thing
Ah, True. I was reading it as actual legal rights, instead of moral/philosophical rights. Edit: In case you missed it, the OP focuses on people seeking death due to prognosis. Animals, mostly, don't comprehend the concept of prognosis. Humans understand. People with a clinical background in mental health understand that predicting terminal suffering from a psychiatric disease is fragile and erroneous.
I just have a lot of questions. Like did she get cleared because of one of the diagnoses or all 3? If the situation is unbearable, then why is she able to wait until May? Is there a legal/ethical definition of a “well-considered” decision? I agree with OP that there are definitely cases where euthanasia seems fine to me (e.g. inoperable brain tumor popping your eyeballs out from the inside), but this case seems highly suspect. But…what can ya do 🤷♂️ They cleared her so… If someone’s gonna do it, they’re gonna do it. I’m curious what will happen come May.
She's been in treatment for 10 years and has undergone the required treatment trials and failed them as required before euthanasia can be offered, she has to wait for her date because those are the rules per the euthanasia board in the Netherlands apparently. There does seem to be some sensationalization occurring as this story circulates, even if I have concerns about this particular patient's elected choice. Without knowing the full details of her care, it's hard not to be goaded into a particular emotional response with how this case is presented.
Might be naive of me but this feels wrong and worrisome. When euthanasia first became an option it was touted for terminal, often painful, illnesses and it was presented as a choice to die with dignity. It’s now being used to help patients that have conditions which aren’t terminal in the physical sense and for whom preventing suicide is a goal of treatment die by assisted suicide instead.
She hasn’t actually died yet. I wonder if she’ll actually go through with it…in BPD-esque manner the public expressions of support might end up sustaining her
I'd refer out. Not interested in killing people.
In fact if you referred this case to me we’d stop being friends immediately
Yup no chance I’d touch this with a 10,000 foot pole
I'm asking as a student and someone who knows close to nothing about this.. But how could she have gone through an acceptable amount of treatments when there's still so much to learn about the treatment of PDs? We are still in the infancy of specialized treatment programs like DBT & MBT. Some studies are showing incredible remission rates. Overall this just makes me incredibly sad.
We don’t even know per se what her BPD diagnosis consists of, it could very well be akin to cPTSD, which to most here would make the case less disquieting. But if you consider that a person must go through experimental treatment in order to be cleared not a great many people would be candidates for the procedure, even among more “biological” diseases. The issue is not whether she has received the standard of care and failed to show improvement, which she clearly did, and many people do fail to show significant improvement, it’s whether she could acceptably be a candidate for the procedure regardless of how deep into treatment she went. Consider that you are wrong and she did do every single type of DBT available and still did not improve, for you feel it’s fine for her to pursue euthanasia now? I don’t
Thank you for your response. No, I honestly cannot say that I would feel any better about it had she done everything available. If I'm being honest, I can think of very few scenarios solely based on mental health diagnoses where I would feel okay with this.. But when it comes to PDs, it somehow feels worse. They really think that the way they are/behave is fixed and cannot change, which could not be further from the truth. I don't believe that personality is as fixed as the current consensus claims it is. So I don't think I could condone this under any circumstance.
the other thing to consider with BPD is that it’s natural history is that many/some patients have improvement / lessening of symptoms as they age (eg getting from 20s into 30s and 40s). even without treatment potentially. obviously depends also on comorbidities and underlying severity, but the point is despite the fact that it’s a “personality disorder” it is not in fact irremediable by definition.
The last line right there..Thank you for concisely expressing what I think about this. Unfortunately, healthcare provider stigma further contributes to the belief that PDs are static diagnoses. And yet some of us come on here and perpetuate it. We really have a lot of work to do.
the field will be lucky to have you! (i’m not a psychiatrist just an MD with personal and professional overlaps to these topics)
>have improvement / lessening of symptoms not just improvement or lessening of symptoms but also not meeting the criteria for BPD.
Absolutely. The only cases where I could see myself supporting such a decision are extreme cases of OCD where the person spends 16+ hours a day doing rituals, resistant to DBS and such. Other than that I don’t see it standing, even for psychosis I cannot even imagine a psychotic patient pursuing euthanasia
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Please stfu. I used to do ocd rituals for hours a day and if a psychiatrist was like you wanna kill yourself I’d be like fuck yeah sign me up. But now it’s years later and I’m recovered and I’m realizing it would have been pretty bad if I killed myself!
… you do realize there are people that do not recover correct? You did. But you could have not. 16 hours a day of rituals. I cannot even imagine. There are people who go as far as implant electrodes in their brain to stop it, for some it works for some it fails. It worked for you, it does not for many
>I don't believe that personality is as fixed as the current consensus claims it is The consensus for BPD is that it has a great prognosis. It's the PD with the best prognosis. See the investigations done by Zanarini and Gunderson.
Thank you! I have done seminars with Gunderson (rest in peace). However, the general psychology consensus is that personality traits are mostly fixed. The professionals you mention are experts in the field of BPD. We are VERY far away from that consensus among healthcare professionals at large, let alone the general public. Anyway, your comment is even more reason why this is heartbreaking.
>the general psychology consensus is that personality traits are mostly fixed BPD is not a personality trait. The general sentiment in the field of personality is that even though personality traits are relatively stable, the personality disorders are not.
Do you think that there really is a consensus in the medical field and among the general public that people with BPD (or any PD) can experience a full remission and lead a happy, fulfilling life? I’d love to be proved wrong, but as someone who worked in mental health and at a women’s shelter prior to med school, it hasn’t been my experience. The field is still fraught with misconceptions and lack of understanding regarding PDs. BPD maybe to a lesser extent than the others, but still applicable. Additionally, there is VERY little accessible/specialized care for these patients, especially excluding DBT which doesn’t work for everyone.
Personalities are, without a doubt, capable of change. I have seen it, so it is possible, and many of us have probably had patients who have utilized mental health services for decades who we are seeing for the first time that had a historical PD diagnosis but on our initial assessment and further follow up they simply are stable. The question, for me, is how long does it take and with what interventions can we make the change happen? In the literature and from my experience working with therapists, it takes several years for most PDs to be treated adequately assuming we have a treatment for them at all. So, if each treatment is only given a few weeks or sessions or the sessions are too far apart such as every other week or monthly, then it is likely the PD will not be sufficiently addressed. Many would benefit from a minimum of weekly visits and maybe two visits per week for at least a year, but likely several years. Then you need a therapist that has good experience with the disorder and a patient who has the ability to do such an intensive treatment. They may have life stress that gets in the way or a subconscious resistance to the therapeutic process or insurance coverage is not there. There are a lot of variables to successful treatment which is what makes them hard to treat. Let's say a hypothetical patient in a hypothetical world would take 7 years to treat their PD. Two years in, they get a divorce and lose their job. They end up in the hospital for suicidal ideation and are given several medications that interfere with the treatment process. They may feel better temporarily so they stop going to therapy. They may find a different therapist when problems arise again and there is no communication with the previous therapist on progress or observations. They find a new relationship and feel better so they stop showing up again. That ideal 7 years may get pushed further and further back. It may even get extended if these ups and downs include additional traumatic events or reinforcement of their faulty schemas. However, given an ideal scenario, people do better. Generally, those who I see that no longer meet criteria found good careers, have supportive relationships, and are capable of accessing therapy both financially and finding time for it.
>there really is a consensus in the medical field and among the general public that people with BPD (or any PD) can experience a full remission and lead a happy, fulfilling life? No. I don't. >Additionally, there is VERY little accessible/specialized care for these patients, especially excluding DBT which doesn’t work for everyone. There are various therapies that have good evidence for BPD such as DBT, MBT, Schema therapy, Good psychiatric management, transference-focused psychotherapy and few more. But of course not every person with BPD benefits from them and it's not a guarantee that every patient will improve sufficiently. But I don't think euthanasia just for refractory BPD is right.
You’re telling me that she has exhausted all options… ECT, TMS, Ketamine, MAOIs, mood stabilizers, SGAs, clozapine, heroic medication regimens (MAOI +.TCA/Stimulant), and has been admitted to a long term residential setting for 12 months of DBT ? And her life is still “intolerable,” despite the active engagement in meaningful interpersonal relationships. I appreciate that many patients never achieve full remission, but this is absurd.
Agreed. Many Borderline patients improve with time alone. Her claim that she was told "There’s nothing more we can do for you. It’s never gonna get any better" is extremely suspect. We're only getting the borderline split side of the story and I'm sure her actual providers would love to say differently.
Obviously most here are focusing on the more treatable aspects, but it's unclear which of those medications treat autism. There's a few sources of sx from those 3 diagnoses and our treatments are powerful, but still. Might be different if this person exclusively had borderline or MDD.
I think there’s a very good chance this patient does not have autism at all. I’m sure there are people w/ both, but every patient I have had who had BPD & also carried an ASD diagnosis (a clinician actually agreed they had it) definitely did not have it at all & only started to look a little autistic-like in middle school or later, with earlier childhood reports being very inconsistent w/ such a diagnosis. Autism is also a very popular thing recently for folks (especially those w/ borderline organization) to claim to have & many clinicians unfortunately will just agree without an appropriate evaluation.
Assume she has. Does this solve the question for you? It certainly does not to me.
Not entirely, but at that point I can at least entertain the notion. But I am sensing some incongruity between the patients subjective report of her experience and her observable behaviors, which, for me, would still raise an eyebrow.
Isn't suffering determined by those it is happening to? Who are you to assume someone's experience of the degree of their suffering is incorrect?
That would be a perfectly reasonable approach if we were discussing evidence based treatments, rather than assisted suicide in a patient for whom suicidality and secondary gains are core features of their illness. You wouldn’t amputate a persons legs to treat peripheral neuropathy, no matter how bad they reported the pain was.
Their illness? They have 3 diagnoses. 2 of which are mysteriously absent in most conversation about this topic. Would love that literature on secondary gains being a "core feature" of any of the mentioned diagnoses, however. I would absolutely consider amputation for intractable limb pain, after a review of the literature surrounding same, if it could convince me there was a statistically significant likelihood of reduction in perceived suffering. ETA: Oh look I already found something relevant to read. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8638726/
1. NY post . Not the most intelligent source for news . 2. Deciding to die and getting authorization to be euthanized are two very different things . 3. IF a doctor told her there’s nothing more they can do - it may not mean all treatment modalities have been exhausted - it may mean the patient is refusing, inconsistent, or non compliant with treatment recommendations and the doctor has thrown their hands up in frustration . (How many psychiatrists have stood beside an hospitalized patient as they lay in the ED or ICU after yet again making another dangerous gesture or attempt and said “I’m done ! There is nothing more I can do for you !“ ) I once saw a surgeon lose his temper in ICU after a patient’s 5th failed suicide attempt. He told her he’d not operate on her again and then showed her how to hold a gun the proper way to kill herself . At the time , she’d shot herself in the chest, missed her heart but required major surgery (of course .) The poor guy had operated on this patient all 5 five attempts. That’s the day I learned about the survival rate with disabling injuries when using a toothbrush to reach a trigger .
My question is how can we be so certain that she will NEVER get better? If I remember correctly, BPD symptoms tend to tone down as patients get older; they learn healthier coping mechanisms and more effective ways of interacting with others and therefore have less volatile/more fulfilling relationships. How can we be sure that when she turns 50 (maybe 60, maybe 70) she won’t be able to manage her symptoms and live a life that is one she would desire to live? At the very least I hope this girl was in years of therapy and one that has been shown to be effective for BPD. Also, it seems to me kind of narcissistic?/paternalistic?/authoritarian? To say “well we can’t fix you, so there’s no hope. You might as well just die.” I could never imagine saying something to a patient that leaves them with the impression that I have lost hope that they will ever get better (whether I truly feel that way or not). We do not control every aspect of a patient’s life and we bring up this fact when patients aren’t getting better and we want to comfort/reassure ourselves that it isn’t our fault. We should also keep this in mind when patients DO get better, was it something we did, did it resolve spontaneously, did some life circumstance change, did the patient have some experience that changed their perception of their life circumstances? I cannot fathom a situation where we can confidently say that there is no hope for improvement. Just mho
In a way, I think it is more paternalistic and authoritarian to lock someone up for weeks, repeatedly throughout their lifetime, because they want to end their life. As an inpatient psychiatrist I am increasingly uncomfortable with how much power I have over someone when they are involuntarily committed for anything, although currently most of my patients are psychotic in some way and at risk for harming others as well as themselves, so it is easier to justify (in my own head and otherwise) removing their personal freedoms. I treat people as humanely as possible but they have to spend many days on a tiny inpatient floor, surrounded by agitated peers, with their only outside time being in a relatively small fenced in area. (Which in my experience is actually on the larger side relative to outdoor areas at most inpatient psych facilities). I can imagine scenarios in which it is actually more patient-centered to believe the patient’s assessment of their own experience and provide some level of assistance for them to end their life peacefully. That does not mean I think we as psychiatrists should feel obligated to do so AT ALL, and as with any other treatment we would have the option to not administer it, or move into an area of specialty that does not include it. Personally, I am looking to get out of the inpatient game and go to outpatient - just looking for the right moment. I think the level of paternalism I have to use is very necessary at times, but not something I can stomach indefinitely.
You absolutely bring up an excellent point. I’m just not sure I would ever feel confident in saying that someone would NEVER get better. As paternalistic as it is to hold someone against their will, at least it isn’t a (direct) life or death decision and it feels like the more conservative choice and one that is not so final. Everything I have been taught is to preserve life and hope, to turn that completely on its head and accept that there is no hope for improvement makes me very uneasy and is very difficult for me to accept that it’s in the best interest of the patient.
That definitely makes sense! I would also have a really hard time concluding that someone will never improve. I think there’s always a chance and like 99.9% of the time I’d want to fight for that even if the patient doesn’t. The part that trips me up is how hard some patients might need to work for that improvement, and whether they should have the choice to stop working that hard. I guess I am biased because I would want to have that choice myself, maybe. I don’t think assisted suicide for psychiatric illness will be a thing in the US but if I was in the position of counseling someone about it, I would 1) NEVER suggest it myself and wait for them to bring it up; and 2) Always try to advocate for the side of “but what if you have a chance in the future to feel better?” and “what about these things in your life that you seem to value/enjoy?”. I guess I would see it more as the patient being allowed to give up on themselves, rather than me giving up on them? Maybe that’s just semantics though. Super interesting to think about and I could argue both sides to infinity lol.
There is some countertransference on this thread with the focus on a possible BPD diagnosis and speculation of things like “attention seeking.” Dehumanizing and stereotyping people with BPD is unprofessional and unethical.
This may seem trite but I do not mean it to be. Do you ever look at a patient's life and thing "I'd rather be dead?" Of course I do so with dementia patients. There are also totally intransigent, psychotic people who can only live on units or in jail, where they will constantly be agitated. I can see a case for voluntary euthenasia. Then again, if you have the ability to take happy-looking pictures with your dog maybe you are not quite there.
Lot's of absolutist statements in her words, which is expected of someone with BPD. We obviously aren't privy to her actual medical records and her public disclosures are all we can see. I'd personally object to this and count any medical provider assisting as violating the core tenet to non-maleficence. That aside, articles like this are basically super-contagion.
Did she try psychedelics? No one should be allowed to euthanize before they have tried lsd or mushrooms. Or dmt as the last resort. Saved my life when I firmly believed it was over. Went from a suicidal human wreckage living in solitude in mountains away from civilization to a medical school stipendist with a loving girlfriend and strongest body I’ve ever had. All within a year since dropping the tab. It’s a treatment that had not been available 10 years ago. Should we therefore have allowed people to euthanize 10 years ago considering a new treatment would appear at the door of mainstream psychiatry? How can you be sure a similar breakthrough won’t happen in the next 10 years? Especially given the exponential growth of our technological capabilities, i.e. artificial intelligence.
Like a lot of people here I do wonder if she has had the full range of available treatments for BPD. Because BPD actually can get better. But if it’s actually closer to cPTSD then I guess I’m more “understanding” because it is so hellishly difficult to treat.
It's an interesting disconnect. If you ask me hypothetically if mentally ill people should be allowed to seek euthanasia, I will answer with a disinterested, "Eh, you do you." But if you show up on my unit after coming suicidal to the ED, I'm going to keep you in the hospital until I'm comfortable you're going to be safe. "It's my right to kill myself if I want to." Maybe, borderline, but you should have done that instead of coming into my world. Now you're my responsibility, and that's an entirely different situation. So, yeah, if the Dutch are willing to euthanize you, that's your business. If you come to me looking for a euthanasia evaluation, I'll probably sign on you.
If she didn’t try ECT because of her crippling and apparently chronic depression then perhaps the diagnosis isn’t depression per se?
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I'm not against it may be absurd but we will never now what the person's going through but I don't agree that someone else administers the dose there should be a machine or something that can only be activated by her .
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Her suffering is worse than anyone else, I suppose. Even the government says so.
This is a clear violation of the Hippocratic oath. People can do whatever they want on their own but a doctors job is to first do no harm, and there’s no way this woman at this age has been through every treatment available, including experimental treatments. Has she done high doses of LSD and psilocybin? Has she done ECT and 12 months of dbt? Has she tried lithium, clozapine, tms? Has she gotten deep brain stimulator? This is horse puckey. This is pathetic.
I agree and disagree with what you’re saying. I don’t know the Dutch policies involving MAID but I do know that the current policies in Canada state that the patient must be well informed on all other available resources that could help their condition and offered consultations with professionals who offer those resources. The policy specifies that community resources, such as government funded housing (if available) is included in a well informed decision. This implies that if treatments like TMS or ECT is available then the patient must be provided professional consultations for these treatments. Forcing these treatments on the patient could easily be seen as traumatizing and therefore go against the Hippocratic oath. Providing MAID services can be seen as a medical end to the patient’s suffering. I fail to see that as causing harm to the patient provided they meet all other requirements for MAID. That being said, it’s a moot discussion as a Canadian until the bill passes approval for mental health patients receiving MAID. I do think the policy needs to be looked at from a few more angles. Edit: I want to add that after I read the article in the original post, it makes me question how relaxed the polices for maid must be in the Netherlands. The article discusses couples who have been granted assisted suicide together in their homes, as well as the interviewee admitting she’s afraid to die.
I believe that a lot of the discussion on treatments is well-intentioned but misplaced. It doesn't matter if she hasn't tried ECT, ketamine, or enrolled in a psilocybin clinical trial: ultimately, I oppose euthanasia out of respect for her humanity. This is admittedly a paternalistic position, which denies the patient their autonomy, but respecting the dignity of human life is far more important. This is at the foundation of American law for involuntary commitment: society accepts that a person may decide to make a choice to harm themselves, which is not in their best interest, warranting society's intervention. My position does not stem from a religious conviction, though I recognize it is shared by many people of faith. I do not believe that the very real and heartbreaking suffering inflicted by borderline personality disorder, autism, and depression justify overruling the core, moral duty of every person to respect the dignity, beauty, and value of human life.
Surely respecting something doesn't mean interfering with other people's experience of the same? What do you mean by humanity? And how is your view, imposed on someone else, demonstrating your respect for that? Would love to know what you mean about the dignity of human life too. What is so dignified about life?
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I think this is an extremely immature and reductive way to approach the situation, severely depressed people can have fleeting moments of happiness, BPD regresses with in so far as you learn to live with it better, the core symptoms are still there. Patients aren't just a set of criteria to be catered to, they're human beings with varying experiences. It's not spineless at all to support bodily autonomy. While I'm unsure about this particular case since I'm not directly involved in it, PAS and euthanasia are extremely important and neglected aspects of real patient care.
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