In 2002, the Netherlands was the first country in the world to legalize euthanasia. Today, Dutch euthanasia is moving away from “straightforward” cases where a patient has a terminal illness like cancer—and into more oblique territory.

Since 2009, there has been a significant increase in euthanasia for patients with dementia and psychiatric illness. Doctors are also more open to euthanizing elderly patients who have an “accumulation of old-age complaints” rather than an actual terminal illness.

At the forefront of these developments is the Life End’s Clinic, based in The Hague. The clinic employs 40 doctors who provide euthanasia to patients whose own GPs refuse to assist. In 2016, there were 60 reported instances of euthanasia for patients with psychiatric illness. Of those, 46 were administered by Life’s End Clinic doctors. They were responsible for 40 percent of all instances of euthanasia for dementia patients. For patients with an accumulation of old-age complaints, nearly 50 percent of instances of euthanasia were administered by Life’s End Clinic doctors.

The clinic describes itself as an “expertise center for complex euthanasia requests.” Their doctors admit their decision to grant a request, when a patient’s own doctor has refused, can be subjective at times.

This was illustrated in the controversial 2016 documentary Life’s End Clinic (Levenseindekliniek) which aired on Dutch public television. The filmmakers interviewed Ans Dijkstra, who was 100 years old and requested euthanasia even though she does not have a terminal illness. She described her suffering thus: “It’s the one-dimensionality and the pain. All my fingers are stiff. I drop everything. I do nothing right. I think, ‘What am I still living for?’ My arm hurts in the night. I have trouble getting up in the morning.”

She was ultimately euthanized by a Life’s End Clinic doctor. He said, “I have the feeling that Mrs. Dijkstra’s case completely fits within the law. But also within my own boundaries. Given Mrs. Dijkstra’s situation, I understand her request very well. It’s relatable. So my feelings tell me to say not no, but yes. And perhaps the feelings of her GP told him the exact opposite.”

Euthanasia for patients with physical terminal illnesses is widely accepted by the Dutch people. But the new developments are controversial. The Life’s End Clinic documentary provoked a national debate. Viewers were particularly troubled by the case of dementia patient Hannie Goudriaan, 68. Some wondered if her husband was the one pushing for her death. In the documentary, he says, “If [the euthanasia] doesn’t go through then Hannie will soon have to go to a care home. If she goes to a care home, I won’t visit her anymore because I won’t go visit an empty person. If Hannie doesn’t see me for a month then she won’t recognize me anymore and then I won’t feel like visiting her anymore.”

Moments before she received the fatal injection, Mrs. Goudriaan indicated she would like it to happen in another room—possibly to get away from the television camera. Her husband told her to stay seated where she was.

To become eligible for euthanasia, Dutch law says a patient must have unbearable suffering with no treatment alternatives. The day before her death, Mrs. Goudriaan is still driving her car. Her husband calls this “autopilot.” She drives them both to a cafe where they share a drink with friends. She then drives them to a speed-skating competition. Afterward, she dances along to the music of a brass band.

Some Dutch viewers were outraged. Victor Lamme, a professor of cognitive neuroscience at the University of Amsterdam, wrote an op-ed saying Mrs. Goudriaan’s death is proof that Dutch euthanasia is on a “slippery slope and is being used to solve very different problems than unbearable suffering.”

Surprisingly, some of the Netherlands’ most prominent euthanasia supporters have joined in the criticism. In June, psychiatrist Boudewijn Chabot published an op-ed in a major Dutch newspaper arguing that the current euthanasia law does not offer sufficient protection to patients with dementia or psychiatric illness. His op-ed is remarkable because he played a critical role in making euthanasia available to psychiatric patients. In 1991, he euthanized a 50-year-old woman with severe depression but no terminal illness. He was convicted but received no sentence and kept his medical license. The Dutch Supreme Court reviewed his case and ruled that psychological suffering can be considered the same as physical suffering.

Chabot directs much of his ire at the Life’s End Clinic. He is horrified that their psychiatrists do not have a long-term treatment relationship with a patient yet are legally permitted to euthanize them. “Without a treatment relationship, most psychiatrists cannot reliably determine if the desire to die is the patient’s most important, long-term wish. That’s difficult even within a treatment relationship. But a psychiatrist from the Life’s End Clinic can determine this in fewer than 10 ‘in-depth’ conversations?”

Dutch law permits an elderly person who is still compos mentis to write a legal declaration requesting euthanasia once they develop advanced dementia. This declaration is then treated the same way a verbal request from a terminal cancer patient would be. Chabot thinks that is absurd. If dementia patients are going to be euthanized, they need a special set of legal guidelines.

Chabot also criticises the Dutch committee that oversees euthanasia. He believes they give doctors far too much leeway. He also says their reports exclude information that might stoke controversy, such as the fact that doctors sometimes secretly slip a sedative into a dementia patient’s food before administering the fatal injection.

Interestingly, the committee itself is also unhappy with its work. Each year, they find a couple cases where a doctor acted negligently. Under Dutch law, these doctors should be prosecuted but this has never happened. Starting in the 1970s, a series of court cases paved the way for the legalization of euthanasia in 2002. But since then, the courts have been completely absent. Doctors themselves are determining the boundaries.

Earlier this year, the head of the oversight committee, Jacob Kohnstamm, went to Parliament to plead for some actual judicial oversight. “I think lawmakers intended for a jurisprudence to be developed,” he told MPs. He asked for a legal mechanism whereby his committee could send ground-breaking new cases to the Supreme Court for review.

Ethicist Theo Boer, a former member of the oversight committee, told Dutch media that such judicial reviews would have lifted a burden off his shoulders. “There were some cases that just crossed your pain threshold. You can accept the euthanization that took place but you ask yourself if it’s desirable for this category of patients to receive euthanasia,” he said.

Life’s End Clinic doctors are regularly among those found to be negligent. But the absence of legal consequences has taught them to take it in stride. “We always have an internal discussion about what went wrong,” says Gerty Casteelen, a psychiatrist, in the documentary Life’s End Clinic. “We learn a great deal from that, but we’ve also learned to relativize the ‘negligent’ ruling. Seven out of nine matters went right and two didn’t go completely right. You didn’t totally fail but you also didn’t get an A+.”

Despite the controversy surrounding the new developments in euthanasia, Dutch left-wing political party D66 recently proposed the Completed Life Bill. It would legalize euthanasia for any person age 75 or over who decides their life is “complete.” Pia Dijkstra, an MP with D66, drafted the bill. She was asked on Dutch news why she chose 75 as the minimum age. She shrugged and said, “Of course it’s always difficult to set an age limit. We have age limits for many questions, like when can you vote.”

D66 played a critical role in the original legalization of euthanasia in 2002. They openly acknowledge their goal is to eventually legalize euthanasia for any adult who wishes to die. In March, D66 leader Alexander Pechtold said on a political talk show, “I hope that in the future our civilization will have reached a point where if you wish [to die] – with full comprehension, without external pressure, and over the long-term – then we can make that a possibility.” He sees the Completed Life Bill as an important step in that direction.

The Completed Life Bill enjoys support from a wide variety of parties across the political spectrum. Thierry Baudet, leader of the small, far-right party Forum for Democracy, said, “We support the initiative. It’s a conflict of two values. The first is self-determination. The second is the legitimate threat that your kids or grandkids will come to you and say, ‘It’s time for you to leave.’ The current protections we have in the law—two medical doctors have to take a look—are sufficient protection against this type of abuse.”

Dutch political parties are currently negotiating to form a new governing coalition. This process involves setting Parliament’s legislative agenda. The Completed Life Bill is the political hot potato of the negotiations. D66 is part of the proposed coalition, but so are two Christian parties who are opposed to the bill. If the coalition goes ahead, the Completed Life Bill will likely be shelved for the time being. However, that may not make much difference. As Ans Dijkstra illustrated in Life’s End Clinic, seniors without a terminal illness are already being euthanized under existing law.

It’s fair to say that euthanasia in the Netherlands has reached a crossroads. The Dutch are fully aware that they are entering new territory. Will they plunge in further or will they decide to take a step back?

Emma Elliott Freire is freelance writer living in South Africa. She has also been published in Chronicles and The Federalist.