Updated | Doctors in Belgium are granting a 24-year-old woman who is suffering from depression but is otherwise healthy the right to die as she qualifies for euthanasia under the Belgian law, even though she does not have a terminal or life-threatening illness. 
 
 The 24-year-old woman, known simply as Laura, has been given the go-ahead by health professionals in Belgium to receive a lethal injection after spending both her childhood and adult life suffering from "suicidal thoughts", she told local Belgian media. 
 
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 Laura has been a patient of a psychiatric institution since the age of 21 and says she has previously tried to kill herself on several occasions. She told journalists: "Death feels to me not as a choice. If I had a choice, I would choose a bearable life, but I have done everything and that was unsuccessful." The date of Laura's death is yet to be decided. 
 
 Belgium passed a law to legalise euthanasia in 2002, the second country in the world to do so after the Netherlands. The law states that Belgian doctors can "help patients" to end their lives if they freely express a wish to die because they are suffering from intractable and unbearable pain. 
 
 Dr Marc Van Hoey, a general practitioner and president of the Right to Die Association in northern Belgium, is a vocal supporter of the legislation. Van Hoey told the Independent newspaper that he believes that sometimes euthanasia is the kindest option. "I've seen quite a lot of persons dying in - how do you say in proper English - agony?" Van Hoey said. "I never saw that when I gave someone euthanasia he or she asked for." 
 
 Over the past few years there has been a sharp increase in the number of euthanasia cases in Belgium. In 2013, there were 1,807 deaths recorded compared with 1,432 in 2012. More than half of last year's cases were patients aged 70 and over but there are increasing numbers of young people requesting to die legally, with the majority citing depression as their "intractable and unbearable pain." 
 
 However, not everyone is in favour of the law. Carine Brochier, a project manager with the Brussels-based European Institute of Bioethics, tells Newsweek that she believes too many people are dying as a result of Belgium's liberalised euthanasia laws. 
 
 She argues that many people who experience psychological suffering and treatable mental illnesses may be wrongly given the go ahead for euthanasia because "there is absolutely no way for healthcare professionals to measure another person's mental suffering to decide if they should receive euthanasia." 
 
 "Euthanasia is not the answer to all human suffering," Brochier continues. "We need to develop better palliative care for people," something she believes Belgium is not currently doing. 
 
 Earlier this year in February, the parliament in Belgium passed a bill also allowing euthanasia for terminally ill children without any age limit, by 86 votes to 44. The vote makes it the first country in the world to have legalised euthanasia without an age limit. 
 
 In the Netherlands, the first country to legalize euthanasia, sick children are allowed to request it, but only if they are 12 years or older. 
 
 As of June 2015, euthanasia is legal in the Netherlands, Belgium, Colombia and Luxembourg. 
 
 Update: After comments from readers, the headline of this article was updated to better reflect that the woman is physically healthy, but has severe problems with her mental health. ||||| The 24-year-old woman, named only as ‘Laura’, told doctors she had suffered from depression since she was a child and wished to end her life, local newspaper De Morgen reported. 
 
 Laura, who entered a psychiatric facility when she was 21, told the publication: “life, that’s not for me.” 
 
 "Death feels to me not as a choice. If I had a choice, I would choose a bearable life, but I have done everything and that was unsuccessful," she told the newspaper. 
 
 Laura, currently planning her funeral as well as her final words to her mother and grandmother, claims her parents had her too young and although her upbringing with her grandparents granted her “security, peace and structure” it was not enough. 
 
 “Even though my childhood certainly contributed to my suffering, I am convinced that I had had this death wish even though I grew up with a quiet, stable family.” 
 
 In the extensive interview, Laura recounts how as a six-year-old child she unknowingly picked up a loaded gun and thought about ending her life. “If I had known this at that time, I might have pulled the trigger. I can easily imagine.” 
 
 The date of Laura’s death is yet to be decided, but she may become part of a small increase in younger individuals seeking to end their lives. 
 
 Belgium legalised euthanasia in 2002, with approximately 1,400 cases every year since then. In 2013, the same year that the number of requests to die spiked at over 1,800, the Belgian parliament passed an amendment extending the law to terminally ill children. ||||| Image copyright Ronald Hissink/De Stentor 
 
 In January a young Dutch woman drank poison supplied by a doctor and lay down to die. Euthanasia and doctor-assisted suicide are legal in the Netherlands, so hers was a death sanctioned by the state. But Aurelia Brouwers was not terminally ill - she was allowed to end her life on account of her psychiatric illness. 
 
 "I'm 29 years old and I've chosen to be voluntarily euthanised. I've chosen this because I have a lot of mental health issues. I suffer unbearably and hopelessly. Every breath I take is torture…" 
 
 A team from the Dutch TV network, RTL Nieuws spent two weeks recording Aurelia as she journeyed towards her date with death - 2pm on Friday, 26 January. On a whiteboard in her home, she crossed off the days with a heavy black marker pen. 
 
 During those last weeks, she spent her time with loved ones, doing craftwork and riding her bike in Deventer, the city she adored. She also visited the crematorium - the place she had chosen for her own funeral service. 
 
 Media playback is unsupported on your device Media caption Aurelia Brouwers visits the facility where she will be cremated in nine days' time 
 
 In many ways her story is uniquely Dutch. Euthanasia is against the law in most countries, but in the Netherlands it is allowed if a doctor is satisfied a patient's suffering is "unbearable with no prospect of improvement" and if there is "no reasonable alternative in the patient's situation". 
 
 These criteria may be more straightforward to apply in the case of someone with a terminal diagnosis from untreatable cancer, who is in great pain. And the vast majority of the 6,585 deaths from euthanasia in the Netherlands in 2017 were cases of people with a physical disease. But 83 people were euthanised on the grounds of psychiatric suffering. So these were people - like Aurelia - whose conditions were not necessarily terminal. 
 
 I have never been happy - I don't know the concept of happiness Aurelia Brouwers 
 
 Aurelia Brouwers' wish to die came with a long history of mental illness. 
 
 "When I was 12, I suffered from depression. And when I was first diagnosed, they told me I had Borderline Personality Disorder," she says. "Other diagnoses followed - attachment disorder, chronic depression, I'm chronically suicidal, I have anxiety, psychoses, and I hear voices." 
 
 Aurelia's doctors would not endorse her requests for euthanasia. So she applied to the Levenseindekliniek - the End of Life Clinic - in The Hague. This is a place of last resort for those whose applications have been rejected by their own psychiatrist or GP. The clinic oversaw 65 of the 83 deaths approved on psychiatric grounds in the Netherlands last year, though only about 10% of psychiatric applications are approved, and the process can take years. 
 
 "The psychiatric patients we see are younger than others," says Dr Kit Vanmechelen, a psychiatrist who assesses applicants and performs euthanasia, but was not directly involved in Aurelia's death. 
 
 "Aurelia Brouwers is an example of a very young woman. And that makes it harder to make the decision because in those cases, you take away a lot of life." 
 
 Image copyright RTL Nieuws, Sander Paulus 
 
 During her last two weeks of life, Aurelia was often distressed and had self-harmed. 
 
 "I'm stuck in my own body, my own head, and I just want to be free," she said. "I have never been happy - I don't know the concept of happiness." 
 
 "She was really not as stable during the day," remembers Sander Paulus, the RTL Nieuws journalist who spent much of that last fortnight with her. "You just felt there was a lot of pressure in her head. She didn't speak that well any more - except when we talked about euthanasia. She was very clear on that." 
 
 But does clarity mean someone has the mental capacity to choose death over life? According to Dutch law, a doctor must be satisfied a patient's request for euthanasia is, "voluntary and well-considered". 
 
 Find out more 
 
 Listen to Linda Pressly's report, Euthanasia - Aurelia's story, for Crossing Continents on BBC Radio 4, at 11:00 on Thursday 9 August 
 
 Or catch up later on the BBC iPlayer 
 
 Aurelia Brouwers argued she was competent to make the decision. But could a death wish have been a symptom of her psychiatric illness? 
 
 "I think you never can be 100% sure of that," says Kit Vanmechelen. "But you must have done everything to help them diminish the symptoms of their pathology. In personality disorders a death wish isn't uncommon. If that is consistent, and they've had their personality disorder treatments, it's a death wish the same as in a cancer patient who says, 'I don't want to go on to the end.'" 
 
 Image copyright RTL Nieuws, Sander Paulus 
 
 This view is not universally held by psychiatrists in the Netherlands. 
 
 "How could I know - how could anybody know - that her death wish was not a sign of her psychiatric disease? The fact that one can rationalise about it, does not mean it's not a sign of the disease," says psychiatrist Dr Frank Koerselman, one of the Netherlands' most outspoken critics of euthanasia in cases of mental illness. 
 
 He argues psychiatrists should never collude with clients who claim they want to die. 
 
 "It is possible not to be contaminated by their lack of hope. These patients lost hope, but you can stay beside them and give them hope. And you can let them know that you will never give up on them," he says. 
 
 Image copyright RTL Nieuws, Sander Paulus Image caption Aurelia Brouwers as a child 
 
 Aurelia Brouwers' death provoked huge debate in the Netherlands, and made headlines around the world. No-one has suggested it was illegal, although critics have asked whether it was the kind of case for which the 2002 legislation allowing euthanasia was enacted. 
 
 I don't want to abandon my patients who are not able to go on with their lives Dr Kit Vanmechelen 
 
 Opinions divide on whether there was an acceptable alternative. For example Kit Vanmechelen argues that when people apply for euthanasia on psychiatric grounds, in some cases they will kill themselves if they don't get it. In her view, they should be regarded as people with terminal illnesses. 
 
 "I've treated patients that I knew were going to commit suicide," she says. "I knew. They told me, I felt it, and I thought, 'I can't help you.' So to have euthanasia as an alternative makes me very grateful we have a law. The ones I know will commit suicide are terminal in my opinion. And I don't want to abandon my patients who are not able to go on with their lives. That makes me willing to perform euthanasia." 
 
 "I simply disagree," says Frank Koerselman. "My whole career I worked with suicidal patients - none of them was terminal. Of course I had patients who committed suicide, but as a matter of fact these were always cases when you didn't expect it." 
 
 In RTL's film, Aurelia Brouwers talks about attempts to end her own life. 
 
 "I think I tried about 20 times. I was critical a few times, but I often got to hear that my heart and lungs were so healthy. The doctors said, 'It's a miracle, she made it.'" 
 
 Image copyright RTL Nieuws, Sander Paulus Image caption The last food shopping trip 
 
 And surviving a suicide attempt is not unusual - people do it every day. 
 
 Monique Arend, like Aurelia Brouwers, was diagnosed with psychiatric illness including Borderline Personality Disorder. People with this condition may self-harm, have intense feelings of anger, find it hard to sustain relationships, and experience emotional instability. Monique made many attempts to kill herself. 
 
 "It happened everywhere - at home, in the forest... But I'm very grateful I'm still alive today," she says. 
 
 Monique is a survivor of violent sexual abuse, and terrifying psychiatric episodes. She thought long and hard about euthanasia. 
 
 "I thought I was a big problem for everyone, and I just didn't want to be that burden, and the pain became unbearable. So I requested the forms for euthanasia, and filled them in. But I never filed them." 
 
 Monique did not file those papers because she found help. In the early days of her illness, a counsellor had advised her not to talk about the abuse - this is when she began to self-harm. But then she found a new therapist who specialised in trauma. 
 
 Where to get help 
 
 BBC Action Line - information and support 
 
 "She told me I'm not crazy, but I'm traumatised - that's a big difference. We worked very hard together - it was very painful. But we went through it, and since then I've been on a recovery trip," Monique says. 
 
 She has written a book about her experiences, and has some advice for people struggling with suicidal thoughts or considering euthanasia in the Netherlands. 
 
 "It's heavy, hard and tough," she says. "But keep a candle burning. Look for people who can support you. You guys are so powerful because you've been through so much - there's still room for you on this planet." 
 
 Image copyright RTL Nieuws, Sander Paulus Image caption Aurelia Brouwers and her whiteboard, with one day to go 
 
 The discomfort around euthanasia for psychiatric patients is partly to do with a concern that all options may not have been explored. At the End of Life Clinic in The Hague more than half of those who come seeking euthanasia on psychiatric grounds are turned away because they have not tried all available treatments. 
 
 "I had a patient who had a lot of treatments, and was convinced nothing more could help him. But he had never been in a clinic to help with abuse of prescription medicine and alcohol," says Kit Vanmechelen. "So I said to him, 'For half a year you must make a real effort to lessen your use of those, and if then you still have a death wish, well, come back and we'll talk.'" 
 
 Like people with diabetes, psychiatric patients are also treated for years, but this is not an argument to stop treatment Dr Frank Koerselman 
 
 But Vanmechelen believes that after a patient has undergone multiple treatments for the same diagnosis, it is reasonable to say, enough is enough. 
 
 This was what Aurelia Brouwers argued too. She had been treated for her illness - she had therapy and took medication - but we do not know the details. 
 
 "We need to get rid of the taboo that you should always remain in treatment, until the bitter end," she said. "For people like me there isn't always a solution - you can't keep taking medicine, you can't pray indefinitely… At some point you just have to stop." 
 
 But people can and do live for decades with psychiatric disorders. 
 
 "They're not treatable like an infection, they're like diabetes - you've got the disease, you will have it the rest of your life, but we, as doctors, are going to make it possible for you to live with it," argues Frank Koerselman. 
 
 "Like people with diabetes, psychiatric patients are also treated for years, but this is not an argument to stop treatment. 
 
 "It's very well known that after the age of 40 things might go much better for people with Borderline Personality Disorder - their symptoms might become much milder." 
 
 Image copyright RTL Nieuws, Sander Paulus Image caption Aurelia Brouwers has a quiet moment in the crematorium 
 
 Aurelia Brouwers died more than a decade before she reached 40. On her last full day on Earth she was visited by her favourite singer, Marco Borsato. That night, she had dinner with her friends - there was laughter, and a toast. On the morning of 26 January she posted for the final time on social media: 
 
 "I'm getting ready for my trip now. Thank you so much for everything. I'm no longer available from now on." 
 
 Aurelia Brouwers' loved ones assembled in her bedroom. Two medics were in attendance. 
 
 "I'm sure that the moment I give the poison - because that's what you do, you give poison - I'm very sure that is the only thing the patient wants at that moment and has wanted for a long period, otherwise I wouldn't be able to do it," says Kit Vanmechelen. 
 
 "In the first meeting with a patient, I tell them, this will be the last question I ask you: 'Are you sure you want this? And if there is a little doubt, we will stop, come back, and talk about it again.'" 
 
 And has that ever happened to her? 
 
 "No. It doesn't happen." 
 
 In Aurelia's case, doctors did not administer the drugs that killed her - she drank the medication herself. 
 
 In the RTL Nieuws documentary, she has a last conversation with Sander Paulus, as she holds the small, sealed medicine bottle. 
 
 "This is the drink," she says. "I know it tastes bitter, so I'm just going to drink it down. And then I'm going to sleep." 
 
 Sander Paulus asks her if she has any doubts. 
 
 "No doubts," Aurelia says. "I'm ready - ready to go on a journey." 
 
 "I hope you find what you're looking for," he says. 
 
 "I definitely will," is Aurelia's reply. 
 
 Aurelia Brouwers turns her back on Sander Paulus, and climbs the stairs. It is just after 2pm on Friday, 26 January, 2018. 
 
 Read more: 
 
 When a one-day-old baby, Paul Joseph Fronczak, was stolen from a Chicago hospital in 1964, the terrible story made headlines across America. Then, two years later, an abandoned boy was identified as the missing baby and handed over to the relieved parents. Years later, Paul began to investigate what had happened - and was shocked by what he found. 
 
 Read: The FBI said I was my parents' stolen baby - but I found the truth 
 
 Join the conversation - find us on Facebook, Instagram, YouTube and Twitter. ||||| GHENT, Belgium (AP) — After struggling with mental illness for years, Cornelia Geerts was so desperate to die that she asked her psychiatrist to kill her. 
 
 Her sister worried that her judgment was compromised. The 59-year-old was taking more than 20 pills every day, including antidepressants, an opioid, a tranquilizer, and two medicines often used to treat bipolar disorder and schizophrenia. 
 
 About a year later, on October 7, 2014, her doctor administered a lethal dose of drugs. It was all legal procedure in Belgium, which has among the world’s most permissive euthanasia laws. 
 
 “I know it was Cornelia’s wish, but I said to the psychiatrist that it was a shame that someone in treatment for years could just be brought to the other side with a simple injection,” said her sister, Adriana Geerts. 
 
 Belgium is one of five countries that allow doctors to kill patients at their request, and one of two, along with the Netherlands, that grant the procedure for people with mental illness. The idea is that those with a psychiatric illness should be afforded the same rights as those suffering from a physical one. 
 
 “I always regret that we couldn’t do something else,” said Dr. Lieve Thienpont, one of the doctors who signed off on Geerts’ death. “At the same time, I’m part of the relief for the patient.” 
 
 Like many in Belgium and elsewhere, Thienpont, a respected psychiatrist and prominent euthanasia advocate, believes that when medicine can’t relieve suffering, euthanasia — when doctors actively kill patients — should be an option. And because psychological suffering can be harder to detect, doctors must take patients at their word. 
 
 “You can’t see it on a scan,” she said. “But we have to listen to the patient. We have to believe them because we can’t see (the suffering) always.” 
 
 Cases like Geerts and others have shown, though, how difficult it can be to strike a balance between respecting personal freedom and ensuring that people requesting euthanasia have the mental capacity to make that decision. Many, including Geerts’ sister Adriana, think society should try harder to help struggling people with issues they face in jobs and relationships. 
 
 Thienpont’s approach to managing euthanasia requests has raised concerns even among doctors who support the procedure for psychological suffering. According to copies of letters obtained by The Associated Press, those worries have led to a clash between Thienpont and Dr. Wim Distelmans, chairman of Belgium’s euthanasia review commission, that has not been publicly disclosed. 
 
 The documents do not include accusations that patients were killed who shouldn’t have been, but they suggest doctors may have failed to meet certain legal requirements in some cases. And they highlight how difficult it can be to judge whose pain should end in death. 
 
 Distelmans did not respond to requests by email and telephone for an interview. Thienpont described receiving Distelmans’ letter in February as “a very difficult moment” and said that she and members of Distelmans’ team were still working out how to resolve what she called “internal issues.” 
 
 In the countries where euthanasia is legal — Belgium, Canada, Colombia, Luxembourg and the Netherlands — the vast majority of cases are people with a fatal illness such as cancer who have only weeks or months to live. 
 
 To qualify for euthanasia in Belgium, people must meet a number of criteria, including proving they have “unbearable and untreatable” suffering. Among adults whose lives are ended for psychiatric reasons, the most common conditions are depression, personality disorder and Asperger’s syndrome, a mild form of autism. People diagnosed with early-stage dementia can also request euthanasia, including for the future. 
 
 Euthanasia is not permitted in the U.S., but six states and Washington D.C. allow assisted suicide, where doctors provide people with the means to kill themselves, such as a deadly dose of medication. Patients must be terminally ill and the procedure is forbidden for psychiatric patients. 
 
 As these procedures are slowly becoming more accepted, and in some places where they are already allowed, boundaries are being stretched even further. 
 
 In 2014, Belgium became the first country in the world to expand its original euthanasia law by explicitly allowing it for children, although this cannot be for psychological suffering. The Netherlands, the first country to legalize euthanasia, has proposed extending euthanasia to old, healthy people who feel they have “completed” their lives. Canada, which passed its euthanasia law last year, is facing legal challenges designed to expand access to the procedure. 
 
 The number of people killed for psychological suffering is small — about 40 cases among Belgium’s 2,000 yearly euthanasia deaths. But that’s more than some experts predicted. In 2008, when euthanasia for psychiatric disorders was first broken out, four people were euthanized for psychiatric disorders. By 2015, the latest year for which data are available, that figure was 43. 
 
 ____ 
 
 “WHAT COULD HELP ME TO DIE?” 
 
 As more countries grapple with whether to legalize assisted dying, Thienpont argues they needn’t worry about setting limits on who should be eligible for euthanasia, because only the truly desperate will ask to die. 
 
 “You don’t have to be afraid,” she said. 
 
 One of Thienpont’s patients, Amy De Schutter, says approving euthanasia for psychiatric patients can save lives. 
 
 “We want to live,” said De Schutter, whose request for euthanasia was granted last year, though she didn’t set an immediate date to die. 
 
 De Schutter says she endured years of failed treatment at psychiatric institutions and spent months deliberating how to kill herself. A trained physicist, she calculated the time it would take for an overdose to kick in, considered which bridge she might jump from and listed ways to kill herself in PowerPoint presentations. 
 
 De Schutter had already picked the day of her suicide, but one month before her intended death last year, her euthanasia request was accepted. Once she had been given clearance to legally die at home, she was relieved she wouldn’t have to kill herself. That was comforting enough to her that she didn’t set an immediate date for her euthanasia and has even drawn up a list of things she’d like to do in the meantime. 
 
 “It felt like 10,000 kilos was just (lifted),” De Schutter said. She says if she hadn’t been in a country where euthanasia was legal, she would have resorted to suicide by now. 
 
 Pierre Pol Vincke wishes his daughter Edith could have gotten that same relief — and perhaps continued to live. “She said, ‘Dad, you understand science, what could help me to die?” said Vincke, a biologist and amateur beekeeper in his garden in Ramillies, Belgium. “I said, as a father, I can’t do that.” 
 
 Doctors refused her euthanasia request, despite years of psychiatric illness. On November 3, 2011, Edith slashed her throat. 
 
 Jean-Jacques De Gucht, a Belgian lawmaker who co-sponsored the amendment that made the procedure available to children, says the law enhances personal freedom and that criticism of the country’s euthanasia policies are misguided. 
 
 “I think one of the greatest gifts you can give to society is to give people the possibility to choose for themselves if they’re in a situation where they’re suffering every day, to choose for themselves how to cope with that pain,” he said. 
 
 _____ 
 
 “WE MUST TRY TO STOP THESE PEOPLE” 
 
 Sophie Nys believes her sister’s euthanasia was granted far too easily. She acknowledges that her sister Tine had long struggled with mental health problems, but said it was unthinkable that those problems warranted her death. Tine’s longtime psychiatrist rejected her request to die, but Tine soon found Thienpont. 
 
 Sophie Nys says that Thienpont diagnosed Tine with Asperger’s and approved her euthanasia request after two or three sessions with Thienpont. Because Asperger’s is “incurable and chronic,” it meets one of the legal requirements for euthanasia. Sophie said her sister was so intent on being euthanized she might have manipulated the test. 
 
 “She knew that if she wasn’t diagnosed with autism or Asperger’s that she would not have a chance (of being euthanized),” she said. Two months after her diagnosis with Asperger’s, Nys was killed, at age 38. 
 
 After Nys’ death, her sister Sophie filed a criminal complaint, alleging irregularities in her sister’s euthanasia procedure, including fumbling efforts to administer drugs and asking her family to confirm that Tine’s heart had stopped. 
 
 Nys later obtained access to her sister’s medical file and found emails between her sister’s doctors attempting to block the investigation into Tine’s death. 
 
 “We must try to stop these people,” Thienpont wrote in one email to her colleagues that was provided to the AP. “It is a seriously dysfunctional, wounded, traumatized family with very little empathy and respect for others,” the message read. “I am starting to better understand Tine’s suffering.” 
 
 The criminal complaint against Thienpont and the other doctors involved in Tine Nys’ death was dismissed last year. The Nys family is appealing the decision. Others who knew Tine Nys have suggested the family’s account is not reliable because they were estranged, and that she was convinced only death would alleviate her misery. 
 
 Thienpont declined to comment on the Nys case, citing medical confidentiality. 
 
 ____ 
 
 “YOUR EUTHANASIA CASES WILL NOT BE TREATED ANYMORE” 
 
 Thienpont’s readiness to grant euthanasia to mental health patients has made some of her own colleagues uncomfortable. 
 
 In 2015, Thienpont was the lead author of a paper published in the medical journal BMJ Open, tracking 100 of her patients who requested euthanasia between 2007 and 2011. Of those, 48 were granted. 
 
 Some doctors were stunned by the high number of requests Thienpont fielded and how many were approved. At some other major psychiatric centers in Belgium, doctors receive only a handful of such requests every year, of which perhaps about 10 to 30 percent are accepted, according to several psychiatrists who deal with such requests. 
 
 “That one single psychiatrist in Belgium has had such a major impact on the practice of euthanasia in psychiatric patients is very alarming,” said Dr. Stephan Claes, a psychiatrist at the University of Leuven. 
 
 Thienpont disputed that characterization, adding that she was not the only psychiatrist signing off on patients’ requests and that her numbers were not unusual. 
 
 But some colleagues, including some of the most prominent euthanasia practitioners in Belgium, have refused to accept her patients. 
 
 Distelmans, a cancer doctor who chairs the euthanasia commission and helped found the clinics known as “End of Life Information Forum,” known by their Flemish acronym, LEIF, has administered the fatal injection to some of Belgium’s most high-profile cases, including a man who had a bungled sex change and deaf twins, aged 45, who were going blind. 
 
 He and Thienpont had a long history of collaboration, with Thienpont’s Ghent-based organization, Vonkel, referring patients to his LEIF clinics. 
 
 But earlier this year, Distelmans and colleagues sent Thienpont a letter that raised concern that some patients may have been killed without meeting a legal requirement that an independent consultation be performed first. 
 
 “Your euthanasia cases will not be treated anymore within our operation,” Distelmans and colleagues wrote in a February 13 letter. “The reason is a difference of opinion on how a request for euthanasia must be approved. We have already communicated this several times orally, but to no avail.” 
 
 Thienpont said the letter raised problems only about how patients were referred, not how she and colleagues were practicing euthanasia, and that Distelmans told her after the letter was sent that he has no concerns about her euthanasia process. She says she has never once received a request from the euthanasia commission to provide more details about her cases. 
 
 Thienpont also blamed the patients for not describing events accurately. 
 
 “These patients are very desperate, stressed,” she said. “They say things that are not always correct.” 
 
 Belgium requires that people seeking euthanasia for psychiatric reasons receive an independent consultation from at least two other doctors in addition to the one who approved the procedure. The doctors don’t have to agree; the law requires only that the objective assessments be sought. 
 
 Despite that latitude, Distelmans complained that Thienpont’s patients were arriving at his clinic with “unrealistic expectations,” presuming that their euthanasia request would automatically be approved. That, he said, made conducting an independent assessment — a statutory requirement — unworkable. 
 
 “We found several times that you had already made promises to patients that were referred to us,” they wrote, and that such “promises” undermined their own attempts to engage with patients and figure out if euthanasia was justifiable. “We want to distance ourselves from this way of working.” 
 
 Penney Lewis, co-director of the Centre of Medical Law and Ethics at King’s College London, said that Distelmans’ objections to Thienpont’s practice, given his role as chair of the national euthanasia commission, were particularly serious. 
 
 “He is someone who is well-versed in reviewing cases to make decisions,” she said. “If he’s saying, ‘I think there’s a concern about one of the legal criteria in your practice,’ that carries much greater weight than if it were just another consultant doctor saying that.” 
 
 _____ 
 
 “A NEED TO BE STRICTER” 
 
 Support for euthanasia, including for psychiatric patients, remains high in Belgium. And the country’s public health minister, Maggie De Block, is a euthanasia advocate who once helped raise money for Distelmans’ clinics. 
 
 But the Nys case and others like it have led some critics to a push for more exacting oversight and tougher approval procedures. 
 
 An increasing number of psychiatrists say the vague provisions of the law give individual doctors too much discretion and believe more rigorous oversight is needed to protect patients. 
 
 Other experts are troubled by the lack of transparency in Belgium. There is one review commission in Belgium and they release little information about cases. In the Netherlands, there are five committees and they release detailed accounts of controversial cases. Since 2002, only one case in Belgium has been referred to prosecutors for further investigation. 
 
 Fernand Keuleneer, who sat on the Belgian national euthanasia commission, said the system is not designed to protect patients in part because cases are only reviewed after their deaths. 
 
 The Flemish Psychiatric Association is now drafting new guidelines, including a requirement that all proven treatments be tried before considering euthanasia. 
 
 “There’s a need to be stricter because now we see that sometimes euthanasia is granted too quickly, too easily, without enough checks and balances,” said Dr. Joris Vandenberghe, a psychiatrist at the University of Leuven, who is working on the guidance. They resemble those already being used in the Netherlands, and are set to be presented in December. 
 
 “I’m convinced that in Belgium, people have died where there were still treatment options and where there was still a chance for years and even decades of (quality) life,” Vandenberghe said. 
 
 _____ 
 
 “I WISH THERE HAD BEEN ANOTHER WAY” 
 
 Doctors say that balancing the finality of euthanasia with the often treatable and sometimes fleeting nature of many psychiatric illnesses is extraordinarily difficult. 
 
 “These are patients who are easily misunderstood because of the disorders they have,” said Dr. Scott Kim, a bioethics expert at the U.S. National Institutes of Health. He said psychiatric patients will often express a wish to die that is transient or a symptom of their condition. “Any patient with a serious psychiatric diagnosis will be in a lot of distress and could technically meet the Belgian requirement of ‘unbearable suffering’ for euthanasia.” 
 
 Psychiatrist Claes said he is convinced treatment options remain for many of the patients with psychological suffering being euthanized. He recalled consulting on the euthanasia request of a woman who was about 25, with issues including borderline personality disorder, self-harming behavior and mood instability. 
 
 “She told me that she already had the permission for euthanasia given by Dr. Thienpont,” he said. “What was really shocking about this patient specifically was that she was very young and a number of therapeutic options had clearly not been tried out sufficiently.” 
 
 But to desperate patients like De Schutter, further restricting euthanasia for psychiatric patients is a form of discrimination that infringes on her autonomy. 
 
 “I can get a loan, I can buy a car, I can (have) kids, I can buy a house (and) do everything that I want to,” she said. “But if I want to end my life, all of a sudden, I can’t think straight anymore? That’s something strange.” 
 
 For some bereaved relatives whose loved ones have been euthanized for psychological reasons, the loss is compounded by a belief that doctors should have instead done what they could to keep their patients alive. 
 
 Although Geerts disagreed with her sister’s request for euthanasia, she accompanied Cornelia to the clinic that morning, in the hopes that she would change her mind. 
 
 “I think if the doctors had tried to help her more or proposed other things, she might have felt there was another solution,” she said. “I wish there had been another way.” 
 
 ____ 
 
 Associated Press writer Jamey Keaten in Zurich contributed to this report. ||||| At 2pm on 26 January, Aurelia Brouwers lay down on her bed to die. Clutching a toy pink dinosaur and listening to her favourite music, the 29-year-old drank her prescribed medication as close friends gathered round. “She asked me to lie next to her. She had a smile on her face, and then she went softly into sleep,” Sjoukje Willering told the Observer. “It was very serene and calm. It was beautiful.” 
 
 Four hours earlier, Brouwers had posted her last message on Facebook. “I’m getting ready for my trip now. Thank you so much for everything. I’m no longer available from now on.” Brouwers died at home in the small Netherlands town of Deventer less than a month after being declared eligible for euthanasia under the country’s 2002 Termination of Life on Request and Assisted Suicide Act, which permits the ending of lives where there is “unbearable suffering” without hope of relief. Her death has triggered a fierce debate in a country that has one of the most permissive euthanasia laws in the world. 
 
 For not only was Brouwers young, she did not have a terminal disease such as cancer. She suffered from psychiatric illnesses, including severe anxiety, depression, eating disorders and psychosis. She self-harmed and had attempted suicide numerous times. She had spent nearly three years as an inpatient at a psychiatric hospital, and had served time in prison for arson. 
 
 Some say Brouwers’s death is a terrible illustration of the “slippery slope” inevitably associated with euthanasia legislation. Others who supported legalisation now also fear it has gone too far. Her supporters see her case as an important precedent, an escape to those in hopeless situations. “Every day was so hard. She was in a deep black hole,” said Willering. “She said it felt like a hundred knives being stabbed into her head. She never had a moment of doubt that she wanted it to end.” Her death was inevitable, one way or another, she added. “But she wanted the right to die with dignity, and she wanted other psychiatric patients to know that they also have a choice. This was her message to the world.” 
 
 This month, annual figures from the bodies that review euthanasia cases in the Netherlands showed an 8.1% increase in assisted deaths in 2017, taking the total to nearly 6,600 people. It came on top of a 10% annual increase the previous year. The vast majority had cancer, heart and arterial disease, or diseases of the nervous system, such as Parkinson’s and multiple sclerosis. But 169 had dementia, up from 141 the previous year. And 83 had severe psychiatric illnesses – up from 64 in 2016. “Supply has created demand,” said Professor Theo Boer, who supported the 2002 legislation but resigned from a regulatory body in 2014 amid concern about rising numbers. “We’re getting used to euthanasia, that is exactly what should not happen. We’re no longer speaking about the exceptional situations that the law was created for, but a gradual process towards organised death.” 
 
 The review bodies found that in 99.8% of cases, euthanasia was carried out in line with legal guidelines. However, Dutch prosecutors have recently opened criminal investigations into four cases, and last year an investigation began into a 74-year-old woman with dementia who had requested euthanasia before her illness became severe. Confused and agitated, she had to be restrained by family members to allow a lethal injection to be administered. 
 
 The focus of the current review of Brouwers’s death is a large redbrick house in The Hague, close to a clutch of museums in the north of the city. It houses the Levenseindekliniek – End of Life Clinic – a last resort for those who have been refused euthanasia elsewhere. Brouwers came here after failing to convince her own doctors and psychiatrists that she met the criteria for euthanasia. According to Steven Pleiter, the clinic’s avuncular director, a doctor and a nurse assessed Brouwers and built a relationship with her over a long period. 
 
 Her case was also reviewed by a multidisciplinary group at the clinic. “Aurelia was known to us for years. She was young but had already been suffering for a long time. Our processes are very careful,” Pleiter said. 
 
 The Levenseindekliniek has 62 doctor-nurse teams working part-time, but is on a significant recruitment drive to meet the spiralling demand for euthanasia. In 2012, the first year it was open, the clinic helped 32 people to die. Last year the figure was 750. But, Pleiter pointed out, that was only 30% of 2,500 applicants. One in every four does not meet the legal criteria, another 25% withdraw their request, and 20% die while their cases are being evaluated. Last year 9% of those undergoing euthanasia through the clinic had psychiatric illnesses and 10% had dementia. The costs are covered by the country’s health insurance system. 
 
 “Death by euthanasia is 4% of all deaths in the Netherlands. Is that a slippery slope? I don’t think so,” said Pleiter. Much of the demand was coming from the baby-boomer generation, he added. “They are thinking differently about the way life ends. God and religion are less dominant in their lives. They want more autonomy. But every case is unique.” 
 
 The decision Brouwers had waited so long for came on New Year’s Eve. It was “the best present I could have”, she wrote. “She was very happy, but she also had some hard moments, knowing she had to say goodbye to friends and family,” said Willering. “She was very open about it. You could ask her at any moment, ‘Aurelia, is this really what you want?’ and she would say, ‘Yes, I want to die.’ ” Another friend, Toon Krijthe, also at her bedside when she died, said: “I was glad for her, because I knew this was her only option – and I knew if it wasn’t a yes, she would find another way.” 
 
 Brouwers spent the days until 26 January saying goodbye to friends and working on a television documentary that was broadcast after her death. “She also visited the crematorium to plan and rehearse her funeral,” Krijthe said. “She believed in God, and she prayed, but she didn’t go to church.” 
 
 On the appointed day, two doctors from the Levenseindekliniek were present as Brouwers swallowed the liquid medication prescribed for her. “It took about 10 or 15 minutes for her to fall into sleep. She was very ready for it,” Willering said. She was cremated a week later. Within the Netherlands, it was a huge news story. As well as the television documentary, Brouwers’s death was a front-page story in the regional paper, with an additional six pages inside. “Personally I sympathise with her, and I’m happy she got a humane death,” said Boer, who teaches ethics at the Theological University of Kampen. “But culturally, I’m concerned that her death is being portrayed as a brave solution to severe suffering. She had huge support on social media. 
 
 “A border is being crossed between individual empathy and societal acceptance. If it becomes a societal norm that a person who has a psychiatric condition can opt to die, that is a problem.” 
 
 However, according to Professor Agnes van der Heide, an end-of-life expert at Erasmus University in Rotterdam, public opinion surveys show “a substantial proportion of our population think the law should be even more liberal – especially with regard to dementia”. Many who see their parents or grandparents in the grip of advanced dementia wish to opt out of such a bleak end-of-life scenario for themselves. 
 
 Not all doctors agree. Last year a group of 220 took out a newspaper advertisement saying they would refuse to euthanise patients with dementia who were unable to give verbal consent, even if the individual had signed a declaration of wishes in advance. “Our moral abhorrence at ending the life of a defenceless person is too great,” they wrote. 
 
 “It’s difficult to see how you can administer a lethal injection to a patient who doesn’t understand what you’re doing. So there is a conflict between doctors and the public,” said Van der Heide. 
 
 Facebook Twitter Pinterest The End of Life Clinic, on the face of it just another house in the north of The Hague. Photograph: Judith Jockel for the Guardian 
 
 Yet some want to go even further. Pia Dijkstra, an MP and member of the centrist-liberal D66 party, has proposed a law allowing anyone over 75, without a diagnosis of physical or mental illness, to request euthanasia. “There is a growing number of older people who want to decide themselves how their life should end – how, when and where, and in a dignified way. They feel their life has been good but it’s now complete. They want control. The existing euthanasia law doesn’t meet their needs,” she said. 
 
 A study is to be carried out before a bill goes to parliament, but Dijkstra said the proposal had the support of 60-70% of the public, with some arguing for no age restriction. “I have had an enormous number of emails and letters from elderly people who want this possibility. But it’s important to have a good debate. And it’s so important to let older people know they are valued by society, and that this should be their choice.” 
 
 It is not good for society to have organised death facilitated by the state Steven Pleiter, clinic director 
 
 Euthanasia advocates say people are helped to die regardless of the law. “About 80% of cases are reported to the review committees, which means 20% are not,” said Van der Heide. Some were in the area of so-called mercy killings, carried out by medical staff or family members; some involve palliative sedation, to relieve suffering but which ends in death. Penney Lewis, head of the Centre of Medical Law and Ethics at King’s College London, said: “Underground euthanasia happens in permissive and prohibitive jurisdictions. It happens everywhere.” 
 
 Despite the permissiveness of Dutch law, many applicants are refused, she said. “There is a lot of debate among Dutch doctors about what constitutes unbearable and hopeless suffering. But I think a model based on suffering is preferable to one based on a diagnosis. 
 
 “I’m not convinced by the ‘slippery slope’ argument. Of course, there’s evidence that the more people understand that this is an option, a greater proportion will avail themselves of it.” 
 
 The “normalisation” of euthanasia is of deep concern to Boer. “It is not good for society to have organised death facilitated by the state. A culture of euthanasia undermines our capacity to deal with suffering, and that is very bad for society.” 
 
 Not only was Aurelia Brouwers young, she did not have a terminal disease. She suffered from psychiatric illnesses 
 
 The Netherlands, Belgium and Luxembourg all have permissive laws on assisted dying and voluntary euthanasia, based on applicants’ suffering, and restricted to citizens of those countries. Switzerland allows assisted dying on compassionate grounds, and some clinics there, such as Dignitas, accept people who are not Swiss residents. 
 
 More restrictive laws exist elsewhere: assisted dying is legal in six US states (California, Colorado, Montana, Oregon, Vermont and Washington) plus Washington DC; in Canada; and in the Australian state of Victoria (after a campaign, pictured above). New Zealand is considering legislation. These are based on the “Oregon model”, which permits assisted dying for people with a terminal illness who are mentally competent and have a defined life expectancy. 
 
 In 2015, MPs in the UK voted against an assisted dying bill by 330 votes to 118. The campaign group Dignity in Dying advocates a law based on the Oregon model, covering people with less than six months to live. “Aurelia Brouwers made her choice in a very different legal context from the one we are campaigning for,” said Tom Davies of Dignity in Dying. The group is supporting Noel Conway, 68, who has motor neurone disease and has mounted a lawsuit to allow him a “peaceful and dignified death” by taking medication prescribed by a doctor. The court of appeal is expected to hear his case in May.
– Euthanasia has been legal in Belgium for more than a decade, and 2013 saw 1,807 euthanasia cases in the country, per the Guardian. Occasionally, individual deaths garner international attention, as in the case of the pair of deaf identical twins who were euthanized in December 2012 after learning they would go blind and not see each other again. Now, another case is grabbing headlines, this time of a woman who has not yet died, but has been granted the right to do so. The Independent has the story of "Laura" by way of the local De Morgen. The 24-year-old does not have a terminal illness; rather, she suffers from depression but, as Newsweek puts it, is "otherwise healthy." She became a patient at a psychiatric facility three years ago after suffering from depression since childhood, she says. "Death feels to me not as a choice. If I had a choice, I would choose a bearable life, but I have done everything and that was unsuccessful," the Independent quotes her as telling the local paper. It hasn't yet been established when she will die. In a piece published last month that has enhanced timeliness now, Rachel Aviv asked in the New Yorker: "When should people with a non-terminal illness be helped to die?" Her article details the case of Godelieva De Troyer, who had suffered from depression since age 19 and, after meeting Wim Distelmans—a professor of palliative medicine who has had a hand in more than 100 deaths by euthanasia—died with his help at age 64 in 2012. Her son has since challenged the laws around euthanasia, laws that Aviv writes "seem to have created a new conception of suicide as a medical treatment, stripped of its tragic dimensions."