64 International TheEconomistNovember13th 2021
sia is a shortcut to death, like a csection is
a shortcut to birth, he argues. In the Neth
erlands as a whole, one death in 25 is as
sisted, he notes, but in some cities that fig
ure can be as high as one in seven.
The choice to die is often murkiest for
those with dementia. In 2016 a Dutch wom
an with severe Alzheimer’s awoke during
her euthanasia and, as she struggled, her
family had to hold her down. Before de
mentia overcame her, she had made a writ
ten request for euthanasia, and the doctor
prioritised that choice. In 2020, after the
doctor was cleared of wrongdoing, the Su
preme Court clarified that doctors cannot
be prosecuted for carrying out euthanasia
on patients with advanced dementia, even
if they no longer express an explicit wish to
die. The Netherlands averages around two
such cases a year.
Bert Keizer, a geriatrician who has car
ried out some of the Netherlands’ most
controversial euthanasia cases, is deeply
uneasy about the new guidelines. Eutha
nasia usually happens with the agreement
of the patient, doctors and the family. But
in cases of dementia, he muses, “the one
who it’s all about’‘ is “removed from the
event”. Implicit in the court’s ruling is a
judgment that the person one was has
more value than the person one has be
come. A patient who wanted to live could
be denied that choice. What lies ahead
Swiss law, by contrast, mandates that those
seeking to kill themselves be mentally
competent. This can create a different fear.
Alex Pandolfo has earlyonset dementia.
He has decided to die in Switzerland, yet he
has postponed the day of his death once. If
he waits too long, he will doom himself to
the future he does not want.
Some proponents of assisted dying are
pressing to expand eligibility, to include
those who feel they have lived a “complet
ed life”. In 2020 the liberal d66 party in the
Netherlands proposed a law to make sui
cide pills available to people over 75 who
felt they were done living. Critics point to
research from the University of Humanis
tic Studies in Utrecht, which shows that
death wishes in older people are subject to
change, and in some cases are caused by
loneliness and isolation. Few truly want to
die, and those who do often meet other cri
teria for euthanasia, a commission found
in 2016. Supporters say it is important to
offer the choice, even though few will take
it in the end. Just 3% of the members of
Dignitas, which campaigns for assisted dy
ing, end up getting help to end their lives.
Some who are tired of life, or unwilling
to endure its decay, do choose to press
ahead. At 76, Dawn VoiceCooper, who suf
fered from debilitating but not lifethreat
ening ailments, saw her future and did not
want to live it: the pain of having her earssyringed; the indignity of swimming with
a colostomy bag; the diminishing freedom
to move as her arthritic joints stiffened.
Life was exhausting and would only be
come more so. “I don’t want to die but I
can’t live like this,” she said. In October she
travelled from her home in Britain to an in
dustrial estate on the edge of a Swiss forest.
After listening to Nick Drake’s “Day is
Done”, she died, with her friend Mr Pandol
fo (and a tabloid reporter) by her side.
“Many people are not waiting for laws
to pass,” warns Katie Engelhart, author of
“The Inevitable”, a book about the rightto
die movement. It reveals a secret world
where people, fed up with restraints im
posed by laws or doctors, order lethal sub
stances over the internet. Their reasons are
often existential rather than physical: a
loss of purpose, fear of being a burden or of
losing their dignity. People who seek death
through legal channels have similar rea
sons. In Oregon the most common con
cerns among people who qualify to die ow
ing to terminal illness include loss of en
joyment (94%), loss of autonomy (93%)
and loss of dignity (72%).
Some shrug this off, arguing that “as
sisted dying is not suicide.” But Ms Engelhartbelievesthatsuchdeathsareinevita
blylinkedtothestricturesaroundassisted
dying.InNewSouthWales,Australia,for
example,oneinfivepeopleovertheageof
40 whokillthemselveshavea terminalor
debilitatingillness.Yetmanylonelysui
cidesarenotplannedandconsidered,soa
blackmarketinsuicidecanbringterrible
risks.Earlierthisyeara 28yearoldDutch
womandiedaftertakinga substancefrom
anaffiliateofLastWillCooperative,a right
todieorganisation,itseemsimpulsively.
Severalmembersofthegroup,including
itsleader,havesincebeenarrested.Prose
cutorssuspect the groupis involvedin
dozensofdeaths.
IntheWest,assisteddyingishelpingto
change theculture ofdeath. People are
talking about it more, and even scripting it,
says Naomi Richards, a British anthropolo
gist. Death is becoming an event to be
scheduled, controlled, reached via a byway
past ageing or suffering. In an Instagram
age, it is possible to imagine a “good death”
being idealised and curated. Ellen Wiebe, a
Canadian doctor, says she has helped peo
ple die “on a beach, in a forest and in the
middle of a party”. Such deaths may seem
particularly appealing when, for genera
tions, dying has been medicalised and hid
den, and during a pandemic in which so
many have died alone in hospital.
For those left behind, an assisted death
can feel like a blessing or a curse. Some,
such as Tom Mortier, who has taken his
mother’s case to the European Court of Hu
man Rights, feel angry and resentful that a
relative was taken too soon. But most find
solace. Heather Cooke’s son, Aaron Ball,
chose to die last year, at 42, while suffering
from metastatic colon cancer. Ms Cooke
suffers the agony of a mother who has lost
her only child, but she is also comforted
that he died in peace, at home, surrounded
by his family. Medicallyassisted dying was
a “gift” for us, shesays.“But I understand
why people fear it.”nMindful of the difficulties
Canada, access to MAID* for those with a mental
illness, % responding by age group, February 2021Source:Ipsos *Medicalassistance in dying2Boomer(56+)GenX(40-55)Millennial(24-39)GenZ(1
-23)To t a l02550 75 100Somewhatoppose StronglyopposeStrongly support Somewhat support