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Dora Pauwels said she understands Mr. Verhelst’s decision. They became friends after meeting in a psychiatric hospital several years ago, and he turned to Ms. Pauwels for advice after learning she had undergone a sex change herself. “I think it was a good choice for him,” she said of the euthanasia. “He didn’t want to go to a psychiatric ward, and I don’t think they could have helped him. I think the incest was too heavy and too harsh.”

In her spare Antwerp apartment, with its bare concrete floors and window overlooking the train tracks, Ms. Pauwels, 53, listened to Mozart and said her own psychiatric illness has her ready to follow in Mr. Verhelst’s footsteps.

She said she got her approval for euthanasia 18 months ago and will go through with it if her depression and psychosis return — “when hope dies,” she said.

The Mesot sisters disagreed with Mr. Verhelst’s decision but felt they had to support him. Gwen and other friends went on a hot-air balloon ride with him during his last week of life. Marisol invited him to spend his final days under her roof rather than in his own apartment, which he had emptied of his belongings. They believe he would have committed suicide had he not been accepted for euthanasia, so at least this way they had the chance to say goodbye.

Gwen drove him to the hospital the day of his death and was in his room for the injection. “I thought I would be stronger, because I knew he wanted it,” she said. “We must accept that it’s his choice — that was my feeling in the weeks before he was going to die.” But she also prayed he would change his mind. As they pulled into the parking lot, she made one last appeal. “I said, ‘Nathan we can turn around and go back. Please, Nathan.’” He was unmoved, replying, “No Gwen, I want to be up in the sky. I want to die.”