How Dutch policy translates into practice with a psychiatric patient
is evident in a case that has received international attention
and has established assisted suicide for psychiatric patients
as acceptable practice in the Netherlands. Psychiatrist Boudewijn
Chabot assisted in the suicide of a physically healthy but grief-stricken
50-year-old social worker who was mourning the death of her son
two months earlier (Hendin 1994b).
Chabot had accepted his patient, to whom he gave the fictional
name of Netty Boomsma (Chabot 1993), into
treatment in the summer of 1991 with the understanding, common
in the Netherlands, that if she did not change her mind about
not wanting to live, he would assist in her suicide. Netty appears
to have used the agreement to mark time until Chabot felt obliged
to fulfill his promise. He assisted in her suicide a little over
two months after she came to see him, about four months after
her younger son died of cancer at 20. Her first son had killed
himself some years earlier following a rejection by his girlfriend.
Netty had felt he might not have done so had she divorced her
husband earlier and ended an unhappy family life.
Chabot described the case in a written account he sent a number
of colleagues to satisfy the requirement for consultation. Although
two did not think he should go forward and felt bereavement therapy
was indicated, an expert in bereavement therapy thought it was
futile and the majority agreed that Chabot should proceed. None
felt it was necessary to actually see the patient.
Chabot described to me the scene the night he assisted in Netty's
death. He went with a colleague to Netty's home and Netty had
a friend with her. She said she wanted to go ahead. She asked
to go to the room of her younger son. Chabot gave her a liquid
as well as some capsules that a pharmacist had prepared for him.
She opened the capsules as she had been advised and put them in
some yogurt. Jokingly she asked him if he could not have given
her some capsules before to practice. She sat down on the bed
and asked them to turn on the record player which played a Bach
flute sonata that had been played at her son's funeral. She took
the glass and drank the liquid, saying that it was not too bad.
While the music was playing Netty kissed a photograph of her two
sons that was next to the bed. She asked her friend to sit next
to her. Her friend stroked her hair. Netty said she had made a
great effort to fix her hair and her friend was messing it up.
The friend replied she would make it beautiful later. To Chabot,
Netty said, "Why do young kids want suicide?" thinking
of her son.
Chabot recalled saying to her after five minutes, "Think
of your boys." In seven minutes she lost consciousness while
being held by her friend. Then she slept. Her heart stopped in
one-half hour.
Chabot insisted that Netty was not depressed, was not a patient,
but simply a grieving woman who wanted to die. Netty had not exhibited
the sad affect associated with depression; patients obsessively
bent on suicide often do not. In the loss of pleasure that Netty
experienced in activities she previously enjoyed, Netty surely
met that aspect of the criteria established for the diagnosis
of depression. In the sense, however, that any therapy would have
required challenging the premises under which she came, and would
probably have also included some trial on medication, no therapy
could be said to have been undertaken with Netty so one can understand
why Chabot does not regard her as a patient.
Chabot stated that if he did not agree to her terms she would
have never come back. She had also threatened to take matters
into her own hands. I asked why if she did not follow his prescription
for treatment, he would feel obliged to follow hers. Certainly
at the end he seemed to be succumbing to blackmail.
Chabot and a number of other Dutch therapists believe there is
an obligation to assist in the suicide of a suicidal patient if
treatment has not succeeded. They point to cases that they had
been able to involve in psychotherapy because of the promise that
if treatment did not work they would assist in their patients'
suicides. Most therapists, however, find that such patients can
be involved in therapy without such a promise by making it clear
that they accept suicidal feelings as part of the therapy, are
not uncomfortable or frightened by them, and will not go to any
lengths to stop the patient's suicide, conveying that ultimately
the patient is responsible for being alive.
