‘There is a danger is will be glamorised’: Psychiatrist warning as physically healthy woman seeks assisted suicide in Dutch case

A leading Irish psychiatrist has warned against legalising assisted suicide in Ireland, in light of a high-profile case from the Netherlands involving a physically healthy 28-year-old woman.

The case of Zoraya ter Beek has made international headlines in recent weeks after the Dutch woman went public with details of her scheduled death next month. Ter Beek, who has autism, and suffers from depression and borderline personality disorder, once aspired to become a psychiatrist but said she had been unable to complete education because of her mental health.

The 28-year-old, who lives in a small village near the German border, said she decided to end her life with the help of a doctor under Holland’s legal assisted suicide regime, after doctors told her that her situation was ‘hopeless.’

Both euthanasia and physician-assisted suicide were legalised in the Netherlands in 2002 after the law was proposed by then Minister for Health, Els Borst. In 2016, the Dutch Minister for Health announced plans to expand the law to allow assisted suicide in cases without a terminal illness, if the person “feels they have complete life.” In April last year, euthanasia in the Netherlands was expanded to include children of all ages who are experiencing “unbearable suffering.”

Consultant psychiatrist, Professor Patricia Casey, a specialist in Adult Psychiatry, told Gript that recent cases unfolding worldwide involving physically healthy young people should provide evidence to Irish lawmakers that “the slippery slope exists,” as she expressed particular concern about those with autism choosing assisted suicide or euthanasia.

Last month, this publication also reported on the Canadian case of an unnamed 27-year-old woman, who was also autistic, and had chosen to die by physician assisted suicide. While the father of the unnamed woman tried to intervene through court action, arguing that she did not have the ability to consent to the death under Canada’s MAiD programme, his intervention was unsuccessful.

There have also been cases in Belgium, where Asperger’s (now subsumed under the autistic spectrum)  is among the most common conditions for which Belgians seek euthanasia on mental health grounds, alongside personality disorders and depression.

Professor Casey pointed to the case of ter Beek, whose story has been reported in The Free Press, saying there is a particular danger that those with autism will find what they think is a “simple solution” in the form of assisted suicide.

“There is a danger that when young, autistic people see a problem that they will look for what they see is a simple solution, or a trendy solution,” she said.

Prof Casey pointed to the reported relationship between gender transition and autism, saying she believes a similar pattern could emerge around assisted dying if it is legalised here. In 2022, the National Gender Service said it had seen an increase in the number of individuals attending the HSE-operated service who had autism spectrum disorder (ASD).  As many as 90 per cent of those who used the HSE’s gender service that year may have been autistic, an audit found.

In October last year, the National Gender Service said that current data indicated that “over 50 per cent” of those seeking gender assessment in the State had autism, and that “this number is increasing.”

“We know that in relation to transition and gender identity, that autistic people are over-represented in that group,” Prof Casey said.

The senior medic continued: “It is possible, and I would say likely, that people with autism will be over-represented in a group seeking euthanasia as well. Both procedures are very, very final. Having part of your body removed to try to change your sex is a very dramatic thing to do. Similarly, ending your life is dramatic, but even more so.”

She says that if a change in the law takes place, she fears one of the problems will be the “romanticisation” and “idealisation” of assisted suicide or euthanasia.

“I was struck by the photograph of 28-year-old Zoraya ter Beek in the Netherlands, who was pictured surreally embraced in the arms of  her boyfriend while announcing that she was due to die on May 28th. This photograph conceals the turmoil and nihilism behind her decision and may well be used in the future to promote assisted dying as a calming answer to one’s problems.”

Prof Casey said young people romanticising suicide had previously been a problem, before “huge efforts” were made to change this.

“In recent years, it was felt that certain elements relating to suicides glorified it. Such as big funerals, guards of honour outside the church and dedications online. This led to guidelines to remove any descriptions that might romanticise what is ultimately a tragedy. These changes, among other clinical interventions, have assisted in reducing the suicide rate.

“Young people didn’t realise that it was a very final thing – and I think exactly the same thing is now happening with assisted suicide and young people. Only, now, in some countries, it is done legally by the State. I think what we will see now will not only be a rise in the number of assisted suicides, but also a rise in the number of unassisted suicides. 

‘IT IS NOW BECOMING GLAMORISED’

“My reason for saying that stems from the work of a colleague of mine, Professor Anne Doherty in the Mater Hospital, examining suicide rates reported in studies from before and after assisted suicide was introduced. Prof Doherty appeared before the Joint Oireachtas Committee on Assisted Dying last November, with the consultant psychiatrist telling Irish politicians that it would be a “travesty” if assisted dying became a “substitute for assistance in living.”

Referring to her colleague’s research in the area, Professor Casey said:

“Prof Doherty found that the rate of non-assisted suicide increased after assisted suicide was legalised, and I fear we will see exactly the same pattern. I also think it is very nihilistic to say to people, ‘There is no help. Why don’t you go for assisted suicide?’ I mean, it is such a dark thing to say to anybody. I think it should be absolutely taboo, but instead of that, it is now becoming glamorised.”

Asked about the Oireachtas Committee’s decision to recommend assisted suicide for those aged 18 and over, Professor Casey said she fears that the age limit “will creep down” over time.

“This is what has happened in a range of countries. The Netherlands, for instance, didn’t start with euthanasia for young people with mental illness. It legislated initially for those with terminal illness. Similarly in Canada and in Belgium. Now all of those countries are allowing assisted suicide for young people, or for people with mental illness – or a combination of both.”

“There genuinely is a slippery slope, and anyone who believes or argues otherwise is just not living in the real world,” she added. 

Regarding high-profile cases involving young autistic people who have applied and been approved for assisted dying, Prof Casey said she is in “absolutely no doubt that we could see this in Ireland.”

“One of the reasons a young person with autism may be more susceptible is due to the fact that a lot of those with autism have unusual interests and hobbies. For example, some would have an interest in the afterlife, or the occult, or similar. We also know that some individuals who are on the autistic spectrum have very fixed beliefs about things, and so can be quite suggestible.

“Once something has been suggested, the person can fixate on that. I think the interest in unusual things, something we often see in those with ASD, and some of the things that are outside the norm, along with their tendency to fixate on things, would make that person particularly vulnerable. For instance, people with rigid thinking, such as many of those with ASD, find it difficult to consider alternative solutions to problems. And this may render them more than willing to choose this particular pathway to death. 

The consultant psychiatrist at the Hermitage Medical Clinic in Dublin, and former consultant psychiatrist at the Mater Misericordiae University Hospital Dublin, said it can also be the case that some of those with ASD can be “quite isolated, unhappy and sad,” particularly young people who are in mainstream education.

“Being isolated and unhappy in and of itself may contribute to a desire to end one’s life, particularly if it is perceived as some sort of glorious way out,” she said.

She also said social contagion is a factor to be concerned about in the context of the discussion around assisted suicide.

“There will be a social contagion aspect, because as we know, teenagers and young adults are always online now. One person engaging in, or planning, an assisted suicide, will be in touch with others in their group and that contagion effect is very toxic.”

“We must not forget that suicide clusters existed in the recent past, because of social contagion. And it is difficult to escape that prospect in relation to assisted suicide, also.”

Following months of public and private hearings, a Joint Oireachtas Committee last month recommended euthanasia and assisted suicide for vulnerable Irish people.

The Committee, consisting of nine TDs and five senators, was established in early 2023 to consider and make recommendations for legislative and policy change related to a statutory right to assist a person to end their life and a statutory right to receive such assistance.

In its report, the Committee recommended that the Government introduces legislation allowing for assisted suicide in a range of circumstances. The Committee recommended assisted suicide be legalised for a person diagnosed with a disease, illness or medical condition that is both incurable and irreversible; advanced, progressive, and will cause death; expected to cause death within six months (or within 12 months in the case of someone with a neurodegenerative disease, illness or condition; and causing suffering the to the person “that cannot be relieved in a manner that the person finds tolerable.”

Professor Patricia Casey’s objection to assisted suicide and euthanasia mirrors the concerns raised by the College of Psychiatrists in Ireland, the professional body for psychiatrists in the Republic of Ireland. It has persistently affirmed its objection to changing the law, telling the Committee in November that “we can do better” than assisted dying, and that “there is another way” for Ireland.

The body raised a particular concern about the ability to protect vulnerable individuals from coercion if the practise is legalised here. Chief Executive of the professional body, consultant liaison psychiatrist Dr Siobhán McHale, told the Committee in 2021 that “addressing deficiencies” in supports was the correct solution, rather than legalising assisted dying.

“In Ireland, as internationally, we know that there is an unequal distribution of palliative care services, a dearth of psychological and psychiatric supports available to people with challenging health journeys, and insufficient research in end-of-life care, with most ethics proposals explicitly excluding patients at end of life from research,” she said.

“Addressing these deficiencies is the necessary next step, not to enable ending the lives of terminally ill people as a way to avoid these challenges. We can do better,” the committee heard.