SINCE 2002, when the Netherlands legalised assisted dying, its laws have been held up elsewhere as a model. But recent figures from the Dutch Euthanasia Review Committee have given some campaigners pause. It is not the total number of deaths under the law’s provisions that bother them—though it has increased by 76% since 2010, with more than 5,500 reported cases of euthanasia and assisted suicide in the country last year. Rather, it is 56 individual cases: those who sought, and received, doctor-assisted deaths because of psychiatric disorders. According to Paul Appelbaum of Columbia University’s department of psychiatry, the increase “raises concerns about eliminating people from the population as an alternative to providing them with the medical care and social support they need.”

In a paper published in February Dr Appelbaum analysed regional data published by the Dutch authorities from 2011 to 2014. It seems that one in five patients cited as having a psychiatric disorder and availing of a doctor’s help to die had never been hospitalised for that mental disorder. He fears “mission creep”: that legislation intended to allow the sickest patients to truncate their final suffering is being used as a permanent end to a problem that can wax and wane, and that the system is not doing enough to ensure that death is the settled will of a sound mind. And the same paper reveals that women with psychiatric disorders seem around twice as likely as men with the same disorders to approach doctors for assistance in dying—an unexplained difference that also worries some.

But what is happening in the Netherlands is not contrary to the law, says Anne Ruth Mackor of the University of Groningen’s law faculty. The Netherlands allows doctor-assisted dying for “unbearable” suffering “with no prospect of improvement”. That suffering need not be physical, and the patient need not be near death.“From the beginning [psychiatric] cases were possible under the act as it was implemented in 2002,” she notes.

Dr Mackor is an ethicist on a regional euthanasia-review committee, and also she belonged to a supervisory board that wrote a code of practice for physicians who assist patients to end their lives in 2015. She thinks the rise in doctor-assisted deaths among psychiatric patients is down to wider awareness of the law’s provisions rather than some sort of slippage: the result of 14 years of debate and discussion in the country. Doctors today feel more able to navigate the law’s complexities because they now have more support, as well as years of case studies and experience, she says. “At the beginning there was misunderstanding. Doctors often thought you had to be terminally ill or you had to have cancer.”

Dutch doctors presented with a patient who wishes to die must refer each case to an independent physician, for consideration and to ensure that all due care has been taken. A survey by Dr Mackor and a colleague found that most of those independent doctors were aware of the code of practice, which is reassuring—but that only one in five of those who received the original request were. As patients present a wider variety of ailments, more guidance for doctors is required, she thinks. “We want the code of practice to become more widely known. That some doctors don’t know about it doesn’t mean things aren’t working correctly—but they can always be better.”

At a conference held in Amsterdam last month, a paper was presented describing a study of 100 patients with psychiatric disorders in Belgium, where assisted-dying laws are broadly similar to those in the Netherlands. The patients, who had all requested assistance to die, were tracked by researchers between 2007 and 2011. Nearly half were granted the help they asked for, of whom 35 went ahead and two others committed suicide alone. Eleven, though granted permission, were still alive at the end of the period. Most explained their change of heart by saying that knowing that they had the option to die with a doctor’s help had given them sufficient comfort to enable them to continue living.