Is letting a 17-year-old die morally equivalent to killing her?

A spate of news articles appeared yesterday, reporting that Dutch 17-year-old mental patient Noa Pothoven was euthanized. This formulation—she was euthanized—caused outrage in certain circles. This is factually incorrect, they say. She was not euthanized. She took her own life.

What are the facts of the case? She was sexually attacked and assaulted three times, beginning at age 11, which led to severe depression and anorexia. She wrote an autobiographical account of her troubles. At age 17, she decided she had had enough. With her parents’ acquiescence, she refused food and drink, and last Sunday, she died.

So why do people like Politico correspondent Naomi O’Leary and Reason writer Elizabeth Nolan Brown insist that she was not euthanized? Because Noa’s problems, as the latter writer puts it, “did not come to an end with the state permitting a doctor to kill her.” She chose to commit suicide, while her parents and doctors stood by and did nothing, respecting her wish to die. That’s not euthanasia, O’Leary and Brown say. O’Leary found this to be infuriating “misinformation.”

To this, many others respond: of course it’s euthanasia. What else do you call it when a doctor stands by and allows a patient to starve herself to death—all the more tragic in this case because the patient is just 17 years old?

The question looks like an unresolvable semantic one. But logic-chopping ethicists come to the rescue with a distinction: Noa was subjected to passive, not active euthanasia. The difference, as the BBC explains, lies in the difference between killing and letting die. Nobody killed Noa (in fact, she asked for help, and was rightly refused); but they did let her die.

If you leave it at that, no one is the wiser, because the real questions, clearly, are: (1) Is there a moral difference between active and passive euthanasia in this case? And: (2) Did Noa’s parents and doctors do right or wrong?

Given a case that sounds so outrageous to some, it is easy to glibly declare that there is no difference. But there are plenty of cases in which there certainly seems to be a difference between killing and letting die. Changing the case makes this rather clearer. Suppose a 50-year-old man like me is severely depressed and wants to die. Is there a difference between you shooting him through the head, and his doing the same thing while you stand by idly? (Let’s assume it’s you could easily and safely take the gun away; perhaps the gun is on the table, closer to you, I say I will kill myself in ten minutes, and I have already made clear that I will not fight you for the gun.) Clearly there is a difference between killing and permitting suicide, in this case. But wherein lies the difference?

There are a couple differences, actually. First, in the case of active euthanasia, you are taking action. We can ask the question, “Why did you pull the trigger?” We can ask a similar question in the second case, “Why didn’t you stop him?” but the questions are actually quite different.

Second, more to the point and more importantly, to permit active euthanasia requires that we adopt policies, moral and legal, that distinguish between murder and euthanasia. But there is no such requirement if we permit only passive euthanasia: here we need only adopt policies to distinguish between suicide and passive euthanasia. (For one thing, it’s not passive euthanasia if nobody knows you’re committing suicide.)

Active euthanasia is more morally fraught because it resembles murder, and murder is rightly regarded as one of the very worst crimes it is possible to commit. But allowing someone to commit suicide looks very different indeed from murder, because the motives are deeply different. If you stand by while your 50-year-old friend commits suicide, you might very well feel guilty later, and people might well blame you for doing something wrong (or rather, for not doing what you should have done); but nobody can sensibly accuse you of murder.

Ultimately—as is the case with most ethical questions—it is ultimately about the policies, the rules, the principles. Do we want to be a society that approves of people committing suicide? Should that be regarded as a real possibility for people? Should it figure into their calculations as an option, sometimes? And then, if so—do we want to take the morally fraught step of helping people to carry out this dreadful choice?

Let’s briefly consider both sides here.

The more conservative approach points to the impact that the choice has on others, that the policy has on society at large, and whether we even have the right to throw away a gift given to us by the divine. No man is an island, and the official approval of suicide causes trauma far beyond that experienced by a person suffering in bodily pain or depression. The trauma is compounded when others participate in carrying out the decision. In the case of Noa, consider the lifelong trauma her dramatic act will have on her parents, family, friends—and now also the broader society in which other 17-year-olds might be tempted to solve their problems this way.

The reason that liberals and libertarians are typically in favor of euthanasia (passive at least, and often active as well) is that this respects the choice of the individual. Whether to go on living is a deeply personal decision, they say. Hence society’s rules should permit a negative outcome if that is our choice. If this encourages others (or rather, alerts them to the possibility) to do the same, perhaps that’s for the best. Why should people be forced to live if they don’t want to? Even if there are some awful consequences, this is the price we pay for freedom.

This is not an easy question, and you’re frankly an idiot if you pretend that it is. But there’s a complicating factor in Noa’s case. She was young, just a few years older than my son. I can’t imagine “permitting” him to commit suicide as I stood by. The idea fills me with horror.

The admitted fact is that she lacked a mature mental capacity. Moreover, while I don’t really approve of the clinical language, one might say she was ill in addition to being young. Now, typically, as in the case of the 50-year-old, we might credit the person’s choice as being mature and considered, and therefore free and worthy of the respect of a person with dignity. Do we owe a mentally ill young person the duty to dignify her choice as also one that is free? I’m not so sure. She was unformed, and she was not thinking straight. Had she been my daughter, I would have had her committed to an asylum that would help her get better. I would not have respected her choice, being one made by an immature and ill person.

I pity Noa’s parents and doctors. But I also accuse them of doing something very wrong indeed—by not taking action when they clearly should have.

By the way, it’s not lost on me that one might argue that anybody, regardless of age, with severe depression might be thought to be sufficiently impaired that we should not credit his decision to end his life as being free, and hence we should always work against it and instead institutionalize the person. But I’m not making that argument, as it raises further, hard questions. Noa’s case strikes me as being rather clearer. The combination of her youth and her mental incapacity mean that her caregivers had absolutely no obligation to credit her choice.






Please do dive in (politely). I want your reactions!

11 responses to “Is letting a 17-year-old die morally equivalent to killing her?”

  1. Clairvaux

    Absolutely terrible story. It’s not euthanasia. It’s criminal negligence by people who should have known better : her parents, and her doctors. How awful.

    Whatever the trauma she went through, she should have got help and support. Even if that implied a degree of coercion. She was a child, for God’s sake. Of course you would prevent anybody, including an adult, from committing suicide.

    I cannot help noticing that social networks were involved. That might have contributed to the outcome. Such suffering and illnesses do not belong to the Internet. Do not let teenagers be destroyed by the power of online delusions.

    1. It isn’t just that she was allowed to commit suicide. It’s worse than that. Everyone involved had to be on board the notion that she was going to kill herself slowly and painfully over a period of many days. It’s absolutely insane.

  2. Floris Berghe

    Maybe you should read her book first, before judging her and her parents. And I would sincerely hope that you never get into a situation with your son where you are put in a situation to make the decision Noa’s parents had to make. At the same time, I think you can only feel their pain when you’ve lived it. Of course the ‘idea fills you with horror’. That doesn’t make it impossible that in this particular case, they made the right decision. Read Noa’s book.

    1. I disagree. I don’t need to read the book in order to judge the principle of the thing. Moreover, reading the book will not necessarily make your reasoning about the principles involved particularly better. I specifically do not judge the girl; my view is that her condition made her incapable of being a fit judge of her own welfare. I judge her parents and doctors and Dutch society for allowing this insane thing to take place.

      Euthanasia for end-of-life palliative care is one thing. Allowing a 17-year-old girl to commit suicide because she was depressed is another very different thing. What’s next? Involuntary euthanasia for political undesirables? One can only wonder.

      1. Barry Wildhagen

        Trust me Larry… you should really read her book before making judgement calls about the people around her that deeply cared for her. You are lacking context here. You are in no position to judge, that much is clear.

        1. Sorry, I’m afraid I can’t “trust you,“ a stranger whose judgment is completely unknown to me. Of course there are always circumstances on all moral questions, and the details are what make hard moral question hard. That admitted, also on moral questions, principle can certainly override and cut through the complications of circumstance.

          If you want to make a sound argument, you will have to extract what you learn from the book and formulate it in argument form. You seem to be suggesting that, despite the fact that she was just 17 years old, her life was over. If only I would read the book, then I would see that? Is that the point? There was nothing anyone could possibly do? Well, you don’t get to be my age without learning that apparently hopeless situations can turn around. The problem with depression is that it essentially involves a total failure to accept that one has free will. One refuses to live. There is certainly a fatalistic tendency among some in psychiatry and philosophy alike that is perfectly willing to underwrite this fatal attitude.

          By the way, I wasn’t making a judgment about anything beyond the bare question of whether a 17-year-old should be permitted to commit suicide. To do that, I don’t need to read some particular book.

        2. Barry Wildhagen

          I disagree. By judging the bare question of whether a 17-year-old should be permitted to commit suicide, you are ignoring the entire context and history which led up to that decision point. This is what the book will tell you. Many efforts and attempts were made to help her. The way you are framing your argument suggests that the parents and people around her are at fault for not doing anything and have basically let her down and ‘gave up’. Which is evidently not true. Do you know what that feels like as a parent? To watch your child suffer and no matter what you do, what you try, it does not help? You may not agree with the choice that Noa made, but she didn’t take this decision lightly, nor did the people around her in support of that decision. Sometimes, not everything that is broken can be fixed. Accepting that is extremely hard. This is not a simple binary case. There is a lot more to it and I think you are ignoring that in your argument.

        3. I’m not ignoring the context and history, I am positively claiming that the context and history is irrelevant if the only reason she wanted to off herself was that she was depressed (and no one has told me differently).

          Yes, the way I am framing my argument is that her parents and doctors were very much at fault for letting her down and letting her give up. When they stood by and her kill herself, that is precisely what they did.

          Different parents would deal with a depressed child in different way, no doubt.

          I obviously don’t agree with “the choice that Noa made.” I don’t credit as the free “choice” of a fully-formed, mature adult human being. She was a deeply damaged minor. The only one who had a right to decide if she would commit suicide would be herself as an adult, after everyone had basically done everything they could. At 17 years old, having invested a huge amount of her time in portraying herself as a victim and suicidally depressed person, she wasn’t capable of making a decision that decent adults would respect. The choice I criticize is not hers but the choice her parents and doctors and the Dutch political system made in allowing this to happen.

          “No matter what you do, what you try, it does not help.” Sure, let’s try that for 24 hours. Oh my, it didn’t help. Well, too late now, let’s let our 17-year-old daughter throw her life away. Oh, they tried for years, not a day? OK, how many years is enough? Where do you draw the line?

          I draw the line at adulthood. So, at least 18 years. Probably more like 21 or 25, if a person emerges into adulthood in a severely mentally crippled state. No way in hell should she be given the keys to her own life if you know she’s going to throw them away. Yes, keep trying. For more years.

          Sure, not everything that is broken can be fixed. But a young mind is one thing that can be fixed, for all we know, and it is fatally and outrageously arrogant for caretakers to presume that they know when that is.


  3. Barry Wildhagen

    Also… “What’s next? Involuntary euthanasia for political undesirables? One can only wonder.” This claim makes no sense at all. Western-European laws regarding euthanasia, are extremely strict and drenched in oversight due to the delicacy of the matter. Only the patient takes the initiative on euthanasia, nobody else.

    1. This sort of argument doesn’t discuss the present but grim possible futures, as informed by historical experience. It’s not unlike saying fascism is not possible in Europe because none of those currently in power are fascists: don’t rule out awful end results just because they are presently unlikely or impossible. That’s not even the point.

      Let me say it again. The claim isn’t that the next step definitely is “involuntary euthanasia for political undesirables.” Admittedly, positing as a live possibility that the “next” step could be that really was wrong and rhetorical excess. The point it is that there is an enormous moral difference and giant leap from euthanasia for elderly people badly suffering from an irreversibly fatal condition, to euthanasia for young people mentally suffering from depression. The difference is almost as morally huge and stark as the difference between the latter and involuntary euthanasia for political undesirables.

      Why? Well, consider the big differences between the first two: in one case, we have a definitely terminal condition, a life has been lived and is already mostly over, the person making the decision is a competent adult, and unending physical pain that cannot be relieved. If a person chose to end it then, I think there’s nothing undignified about that. In the second case, we have a psychological condition that no one can possibly know will end in death (as she was age 17, it was a possibility that she could have gotten better); she had a long and potentially satisfying life ahead of her; she was not a competent adult both because of her immaturity and because of the condition itself; and without denying her mental anguish, that’s qualitatively different from physical pain.

      What if we were to make a comparably enormous leap again, not right away, but in 20 or 30 years?

      Well, I can imagine certain oh-so-“enlightened” people saying, in 20 or 30 years, “Look. The presence of these people in our society is the source of so many of our chronic and deeply painful social ills. Their presence leads to great pain in various ways for the rest of us. True, it isn’t pain in themselves but in the rest of us. If you think about it, that just makes it worse. And this is serious, unremitting pain. People were engaging in self-harm over reactions to awful political situations as long as 20 years ago. [Remember, we’re talking about 20 years in a deeply dystopian future.] It’s gotten much worse! We already imprison people for wrongthink in progressive countries. But with an uncensorable Internet, this doesn’t actually help, now does it? We need stronger measures. We’re all in this together; but they have chosen to remove themselves from our society, really. They’re like a cancer in society. We already encourage the ending of our own lives when things get unremittingly painful from terminal diseases like cancer. Why not apply the same principle to ending the lives of people whose continued and deeply harmful habits and speech are very much like a potentially terminal disease. After all, these people really would ruin European (or American) society if they were allowed to get back into power, which they could.”

      I know the analogy is a stretch. I’m not accusing you of being a totalitarian murderer in the making. I’m not even saying this is likely (although, of course, this sort of thing has happened before in Europe, and could happen again). But if we’re going to start throwing away young lives because we arrogantly imagine that they can’t possibly be helped, that means we will be the sort of people who simply don’t value life very highly. We will become, as I explained yesterday, even more committed “antivitists.” The point in any case is that this represents an enormous moral difference that strikes me as being similar to the difference between a society that lets Noa off herself and a totalitarian society that executes its greatest thought criminals.

      So if people like me are pushing back on those arrogant people defending this awful new system, the burden is squarely on their shoulders, as the innovators that permit and even so to speak encourage more death to take place. A larger debate needs to take place, at the very least, before these regressive Dutch practices are exported to the rest of the world.

  4. Kate

    This is a friend of Noa Pothoven’s with a similar life story. Now she has given up and wants to commit suicide. Are you able to help her not to do it?
    I don’t know how to help her.I’m a good word for her, but it’s not enough and I don’t live in Holland.

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