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In response to our recent paper,1 Breen expresses two concerns: first, that it may promote degradation of the euthanasia procedure to checking a tick box, justifying bureaucratic approval of death requests; and second, that destigmatising the euthanasia procedure and promoting discussion of patients’ desires to die may result in patients feeling pressured by authority or society in general to request euthanasia. Research projects like this might then contribute to sliding down a slippery slope with involuntary euthanasia as the end-point.

Partly, these worries concern not our study, but euthanasia in general. However, we are neither legislators, nor representing the Belgian people. We are researchers/clinicians in a democratic country that has legalised euthanasia, and the considerations underlying this decision go far beyond the scope of an exchange of letters. However, we hope to alleviate the expressed concerns.

First, rising euthanasia rates do not necessarily imply a slippery slope: insufficient research is available to establish whether patients feel pressured or to exclude other causes (for example better registration, patients refraining from suicide). The very example Breen cites2 evidences the procedures in place to prevent a slippery slope. These legal proceedings are the consequence of taking due care in monitoring and evaluating euthanasia procedures. The fact that euthanasia is ‘conditionally decriminalised’ means that criminal charges can still be brought in euthanasia cases when legal conditions (for example exclusion of external pressure) are violated. Individual organisations have procedures in place, related to the Dutch and recently published Flemish guidelines on the management of psychiatric euthanasia requests.3, 4 These guidelines emphasise not shying away from patients’ death requests while at the same time continuing to explore all potential rehabilitation options (as we reported, some qualitative evidence suggests that paradoxically, the availability of the ‘ultimate escape’ option to euthanise itself could contribute to rehabilitation).

Given the reality that euthanasia is societally accepted and legal, the conditions under which euthanasia is legal become paramount. Therefore, it is important to carefully monitor this euthanasia decision-making procedure and the outcomes. The practice of euthanasia is anything but a simple tick box exercise, as is depicted by Breen (and to our knowledge, no advocate of euthanasia is in favour of such a tick-box model). Instead, an important step to safeguard a careful and thorough approach is to learn about those requesting euthanasia, and a scientific approach is well suited to do this. Exploring patients’ experiences is a necessary step to avoid a procedure simplified to a tick box. Thus, we share Breen's concern, but believe that protection and advocacy of these patients requires taking them seriously. Supporting health professionals in the difficult conversations about their patients’ desire to die requires some insight into and respect for these patients’ experiences, feelings and beliefs.

We hope to have taken away some concerns regarding this line of research and made clear why this remains such an important matter to study. We thank Breen for his response and this opportunity to better explain the context of our study.

1Verhofstadt, M, Thienpont, L, Peters, G-JY. When unbearable suffering incites psychiatric patients to request euthanasia: qualitative study. Br J Psychiatry. 2017; 211: 238–45.
2Sheldon, T. Dutch geriatrician faces charges over euthanasia case. BMJ 2017; 359: j4639.
3Tholen, AJ, Berghmans, RLP, Huisman, J, Legemaate, J, Nolen, WA, Polak, F, Scherders, MJWT et al. Richtlijn Omgaan met het Verzoek om hulp bij Zelfdoding Door Patiënten met een Psychiatrische Stoornis. [Guideline on How to Deal with Psychiatric Patients’ Requests for Assisted Suicide]. De Tijdstroom, 2009.
4Vlaamse Vereniging voor Psychiatrie VVP [Flemish Association for Psychiatry]. Hoe Omgaan Met Een Euthanasieverzoek in Psychiatrie Binnen Het Huidig Wettelijk Kader? [How to Deal with Euthanasia Requests from Psychiatric Patients within the Legal Framework?]. Kortenberg, Leuven; 2017 (http://vvponline.be/uploads/docs/bib/euthanasie_finaal_vvp_1_dec.pdf).