Psychiatric Euthanasia in the Netherlands: Young People, Procedural Medicine, and the Limits of Psychiatry

COMMENTARY

When the Netherlands enacted the Termination of Life on Request and Assisted Suicide Act in 2002, the law was widely understood as the codification of an already existing, narrowly circumscribed medical practice. Euthanasia was intended for individuals with terminal somatic illness, unbearable suffering, and no realistic prospect of recovery. The law rested on due care criteria rather than explicit diagnostic boundaries, reflecting the Dutch preference for procedural flexibility over substantive moral limits. Euthanasia thus is permitted when strict criteria are met, including unbearable suffering with no prospect of improvement, a voluntary and well considered request made with full decisional capacity, lack of viable treatment options (irremediability), consultation by an independent physician trained to assess due care criteria in euthanasia cases (SCEN-physician), and, in the case of psychiatric euthanasia, an independent psychiatrist.

From the beginning, as unbearable suffering was a fundamental criterion for eligibility, mental suffering was not formally distinguished from other kinds of suffering nor formally excluded from eligibility. Legislators assumed that professional medical organizations would provide the necessary restraint. For nearly 2 decades, this assumption held. Psychiatric euthanasia remained extremely rare, not because of legal barriers, but because psychiatrists themselves were deeply reluctant. Core criteria such as irremediability, decisional capacity, and unbearable suffering were widely regarded as epistemologically unstable in mental illness, particularly in adolescents and young adults whose psychological development was still ongoing.

That professional restraint has weakened rapidly over the past several years. What had long been treated as a theoretical possibility has become an organized clinical pathway. Requests for euthanasia on psychiatric grounds have risen sharply, with a disproportionate increase among young adults and, more recently, minors. The Dutch model, once presented internationally as careful and balanced, is now attracting attention for a different reason: growing uncertainty about whether psychiatry has crossed a boundary it cannot coherently justify.^1,2

A Steep and Accelerating Increase Among Youth

The numerical trend among youth underscores why concern has intensified. For many years, psychiatric euthanasia in the Netherlands was virtually nonexistent. Between 2002 and 2010, only 1 or 2 cases per year were reported across all age groups.³ This changed markedly after 2011. According to data published by the Regional Euthanasia Review Committees, the number of psychiatric euthanasia cases increased from 2 in 2011 to 138 in 2023, followed by a further sharp rise to 219 cases in 2024, representing an increase of roughly 60% in a single year.⁴

Within this expansion, youth euthanasia cases are increasingly prominent. Between 2020 and 2024, the number of euthanasia cases for individuals under 30 rose from 5 to 30, a 6-fold increase, representing over 9% of all premature deaths (suicide + assisted dying) in that age group in the Netherlands.^4,5 When requests rather than completed euthanasia are considered, the numbers are worrying. Given that an estimated 3% of youthful (<24 years) applicants receive euthanasia,⁶ the estimated number of youthful applicants in 2024 would total 7300. Although rejection and withdrawal rates remain substantial,⁶ and the Dutch euthanasia law has remained unchanged, multiple sources indicate a gradual lowering of the effective threshold for granting euthanasia on psychiatric grounds. Population-level data show a rapid increase in cases, particularly among youth, without corresponding changes in prognostic certainty or treatment effectiveness. This expansion is accompanied by shorter assessment trajectories, a more permissive interpretation of “irremediable suffering,” and a strong concentration of cases among a small number of physicians.^4,6-11

When euthanasia deaths are considered alongside suicides, assisted dying now accounts for a growing proportion of premature deaths among young adults, particularly young women,¹² raising serious concerns about contagion effects, shifting cultural norms, and the population-level consequences of introducing medicalized death into the care landscape for youth with mental suffering.

Professional Reluctance and Activist Capture

Despite media portrayals, most Dutch psychiatrists remain uneasy about psychiatric euthanasia, especially for youth. Surveys and internal debates consistently show deep division, moral discomfort, and concern about role confusion. Many psychiatrists continue to see suicide prevention, long-term relational care, and containment of despair as core professional duties that now sit uneasily alongside assisted death.

Alongside this broad reluctance, however, a small but highly visible group of psychiatrists has actively promoted psychiatric euthanasia as an expression of compassion and respect for autonomy. Their influence has been amplified through close alignment with advocacy organizations, most notably the KEA (in Dutch, Knowledge Center for Euthanasia in Mental Disorders). KEA consists largely of relatives of youth who died after euthanasia for mental suffering. According to its website, its aim is to increase knowledge and societal acceptance of euthanasia for mental suffering, to improve access to euthanasia trajectories, and to support and advocate for patients with mental illness who request euthanasia, as well as their relatives and involved professionals. While presenting itself as a foundation for recognition and dignity, KEA operates as an activist organization, lobbying policymakers, engaging strategically with media, and exerting public pressure on dissenting professionals.⁸

In this framing, complex mental suffering rooted in trauma, social marginalization, developmental vulnerability, and failures of care are increasingly presented as a medical dead end. Structural deficits in mental health services, including long waiting lists and fragmented care, fade into the background. Professional hesitation is reframed as cruelty or paternalism rather than as clinical prudence.

The Radicalization of a Public Figure

This shift has been personified by Menno Oosterhoff, a retired Dutch psychiatrist whose actions have profoundly shaped public perception.¹³ In an 11-month period, he performed 12 euthanasia procedures for mental suffering, including cases involving youth and at least 1 minor. He publicly described his trajectory as a moral awakening, introducing the term “mentally terminal” to suggest an analogy between mental suffering and terminal somatic illness.¹⁴

The concept has no grounding in psychiatric science or developmental psychology, but it proved rhetorically powerful. Oosterhoff recorded euthanasia conversations with a minor and made them available online.⁹ The material was later removed as the footage caused significant distress among clinicians, ethicists, and child psychiatrists. Yet, rather than prompting restraint, it increased his visibility. He became a frequent guest on television talk shows and published a bestselling book, positioning himself as a moral pioneer.

Colleagues reported troubling practices.⁹ Young patients were sometimes redirected toward euthanasia pathways while their treating teams were still actively engaged and believed meaningful improvement was possible. The message implicit in such interventions was that persistence in treatment could be bypassed if even one clinician was willing to declare suffering irremediable. The clinical authority of ongoing therapeutic relationships was thus undermined by a parallel pathway oriented toward death.

Suicide Prevention Turned Upside Down

A central justification advanced by proponents is that psychiatric euthanasia prevents violent or lonely suicides. While emotionally compelling, this claim fails empirically. Epidemiological analysis demonstrates that even under optimistic assumptions, euthanasia functions as a profoundly inefficient and harmful preventive strategy. Approximately 9 young individuals would need to die by euthanasia to prevent 1 suicide.

This result reflects a fundamental base-rate problem. Even among high-risk psychiatric populations, suicide remains a rare event. Introducing euthanasia as a sanctioned outcome reframes suicidality from a symptom requiring containment into a potential treatment endpoint, an acceptable “treatment plan.” For youth with trauma histories and narrowed future perspectives, this can entrench death-focused thinking rather than alleviate it.

The institutional response to growing concern has been revealing. A group of psychiatrists submitted a letter to the Dutch Public Prosecution Service to raise alarm about the activities of the KEA foundation and Thanet, a web-based pro-euthanasia initiative. This letter argued that the combined media activism of KEA and the policy-driven pressure created by Thanet substantially contributed to the well-known Werther or contagion effect,¹⁵ as repeated television appearances and newspaper stories were followed by a sharp rise in euthanasia requests from youth, raising serious concern that the Netherlands was drifting toward a harmful and irresponsible practice.^2,8

Procedure Without Principle

The Dutch situation is marked by the absence of consensus on foundational questions. There is no shared understanding of decisional capacity in youth with complex trauma, no reliable way to establish psychiatric irremediability, and no agreement on how to distinguish chronic suicidality from a stable euthanasia request. Concepts such as “unbearable suffering” and “medical basis” remain deeply contested.

In this vacuum, variability between psychiatrists is extreme. Patients can search for permissive clinicians, and once euthanasia has been suggested by one professional, it becomes exceedingly difficult for others to refuse. Social media and sympathetic media coverage amplify these dynamics, producing contagion effects. Requests spike after high-profile stories, particularly among young women.

Professional organizations such as the Dutch Psychiatric Association and the Dutch Royal Medical Association have largely avoided public confrontation with these issues, fearing that strong critique might endanger euthanasia more broadly. As a result, psychiatry has drifted into a role for which it is poorly equipped: adjudicating existential despair and social failure through medical procedures.

The state has not slowed this process. On the contrary, psychiatrists were increasingly portrayed as obstructive or overly cautious. In response, the Ministry of Health supported initiatives such as Thanet, explicitly designed to accelerate psychiatric euthanasia practice.¹⁶ Hesitation was reframed as resistance to progress.

No principled national debate has taken place. The Supreme Court ruled psychiatric euthanasia legally permissible, and Dutch society moved directly to implementation. Moral deliberation was replaced by procedural compliance, a pattern with deep historical roots in Dutch governance.

Concluding Thoughts

The Dutch experiment with psychiatric euthanasia, particularly in youth, can no longer be described as cautious, balanced, or exemplary. What has emerged over the past decade is an unstable configuration in which activism, procedural regulation, and moral avoidance increasingly substitute for clinical humility and epistemic restraint. Practices that appear on paper to respect individual autonomy generate, at the population level, predictable and troubling effects: contagion phenomena following media exposure, forum shopping among clinicians, widening diagnostic claims of irremediability, and the steady medicalization of social, developmental, and existential distress. These are not incidental side effects but structural consequences of introducing medicalized death into a domain characterized by uncertainty, plasticity, and ongoing development. Psychiatric disorders have long existed at the margins of health care, and society. Such propagation of resignation and therapeutic nihilism further marginalizes our patients and justifies society’s restraint from funding the often expensive interventions that they need. Accordingly, the United Nations Committee on the Rights of Persons with Disabilities, in its 2024 review, formally urged the Netherlands to reconsider its euthanasia practices because of insufficient protection for vulnerable individuals.¹⁷

In this context of polarization, institutional hesitation, and unresolved ethical disagreement, clinical practice has begun to fragment. Professional associations have largely refrained from taking a strong public stance, fearing that critique of psychiatric euthanasia might endanger euthanasia more broadly within Dutch society. Oversight mechanisms remain largely procedural, and psychiatry is increasingly asked to adjudicate existential despair and social failure through medical criteria it cannot reliably define. The result is a vacuum in which individual institutions are left to improvise their own responses to an escalating and emotionally charged problem.

It is against this background that the recently developed guideline by Accare has attracted attention.¹⁰ Accare, a major provider of child and adolescent mental health care, formulated its internal guideline in response to the increasing number of euthanasia requests among youth encountered in clinical practice. The guideline emphasizes extreme restraint, developmental vulnerability, the ongoing maturation of the brain into the mid-20s, and the fundamental unpredictability of psychiatric trajectories in youth. It states that euthanasia should in principle not be provided to minors or young adults and stresses the importance of exploring the meaning of a death wish within relational, familial, and social contexts rather than treating it as evidence of irremediable illness. As reported in a recent news report, clinicians working with youth describe the guideline as an attempt to restore professional space for doubt, dialogue, and care in an environment where euthanasia has become increasingly normalized.¹⁰

The emergence of such institutional guidelines should be understood not as a solution, but as a symptom. They reflect the absence of a coherent national framework capable of holding together legal permissibility, clinical uncertainty, developmental science, and moral responsibility. Youth with severe mental suffering do not primarily need more refined procedures for death. They need time, continuity, relational safety, and systems capable of holding despair without prematurely foreclosing the future. The Dutch system, as it currently functions, offers certainty where humility is required and procedural clarity where ethical wisdom is lacking. No one can say with confidence where this trajectory will end. What is increasingly clear is that psychiatry, positioned as arbiter of death in the lives of youth, is being asked to carry a responsibility it cannot ethically or scientifically sustain.

Dr van Os is a professor of psychiatry and the chair of the division of neuroscience at Utrecht University Medical Center in the Netherlands.

Dr van Rooij is a consultant psychiatrist, Aelbrecht GGZ, Waalre, the Netherlands.

Dr Komrad is a psychiatrist on the teaching staff of Johns Hopkins Hospital in Baltimore, Maryland. He is also a clinical assistant professor of psychiatry at the University of Maryland in Baltimore and on the teaching faculty of psychiatry at Tulane University and Louisiana State University in New Orleans, Louisiana.

References

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