Bioethical aspects of Noah Pothoven's suicide. Is the principle of autonomy superior to any other? What value does it have in child and adolescent psychiatry?
Noah Pothoven, 17, decides to end his life. Global emotionalism and self-righteousness are scandalized, both by the severity of the decision and by the incomprehension that someone so young could feel incapable of continuing to survive in the face of such circumstances. psychological pain.
The voices are flying high: euthanasia supporters, opponents, experts in sexual assault and post-traumatic stress, specialists in suicidal behavior, and, to a lesser extent, eating disorder therapists, because what's really making headlines is Noah's rape. There are also those who, without claiming to be experts in anything, declare that the Dutch healthcare system lacks the resources to treat cases like Noah's. Some even ask, "That wouldn't have happened in Spain!"
The clinical case of Noah Pothoven
Noah is a self-demanding and perfectionist girl. Her schoolwork is excellent. Although she is somewhat alexithymic, meaning she has some difficulty verbally expressing her emotions, nothing abnormal is observed in her behavior or emotions.
Everything changed when, at the age of 11, she suffered her first episode of sexual abuse, a situation exacerbated by another episode the following year. Overwhelmed by shame and fear, she chose to remain silent. All her fragile defenses crumbled when, at the age of 14, she was raped by two men. This new traumatic experience produced profound changes in her personality, even in her immature brain: she felt a deep disgust for her body, felt dirty, and, seeing herself as overweight, decided to restrict her food intake. Both the traumatic recollection of the abuse and rape, as well as the rejection of her body image and the self-imposed restrictions, produced profound and unbearable psychological suffering. Despair took hold of her. A clinical picture typical of anorexia nervosa began to develop: weight loss, severe malnutrition, increased exercise, and self-harm, all related to the profound disgust she felt for her body and the food her environment forced her to consume. They bring her a certain psychological relief, especially when memories of the rape overwhelm her and she feels dirty. Self-harm is the only way she can banish the filth from her mind, that unbearable nausea that, in her opinion, makes her feel vile and unworthy. She attempts suicide several times.
Several outpatient treatments were implemented, but given the severity of her medical condition and her refusal to follow instructions, a judge ordered her involuntary admission for six months to a hospital in Achterhoek. Noah describes it as "hell." She continued to refuse food, and her condition worsened rapidly. After a month, seeing that the situation was deteriorating, she was transferred to a juvenile detention center where the policy was that if the illness did not improve, the patient would be moved—which is exactly what happened. In other words, Noah went through three healthcare facilities whose treatment protocols did not meet the requirements for cases as severe as hers.
After six months on the waiting list, she was finally admitted to a center specializing in eating disorders. There, she was fed through a nasogastric tube, and the treatment focused exclusively on her anorexia. Once she regained weight, she continued outpatient treatment with appointments several times a week. But her suicidal thoughts were stronger than her motivation to maintain hope. One of her therapists was child psychiatrist Roland Verdouw, a specialist in post-traumatic stress. It's remarkable how he offers coping advice to patients like her in his book. Winnen of LerenShe is overwhelmed by her personal suffering. She visits a clinic that performs assisted suicide and euthanasia but is not admitted because she does not meet the protocol requirements.
The end is well known. Noah manages to commit suicide in a hospital bed at her home by refusing food and water. She is visited by doctors and politicians and accompanied by her family, powerless in the face of a situation they do not understand, but resigned to the end chosen by their daughter. "Noah doesn't want to die at all. She just longs for peace," her parents say. "Yes. I want peace. I don't want to feel pain," Noah replies.
Bioethical questions
- Euthanasia in non-terminal situations and for psychiatric conditions, as in Noah's case, is permitted in the Netherlands. Psychiatric patients with "long-lasting and unbearable" psychological suffering can request it through their therapist. If two independent psychiatrists confirm the indication, it could be carried out within a month.
- In Noah's case, euthanasia or assisted suicide could have been chosen if his therapists had deemed it appropriate, which doesn't appear to be the case. Therefore, a question arises: how can suicide be permitted without legal intervention? Only if absolute priority is given to... patient autonomyWe could explain the situation. But if everyone who commits suicide (suicide is one of the leading causes of death in our society) does so voluntarily, what is the point of preventing suicidal behavior? And if we really should be preventing it, why wasn't suicide prevention a priority in Noah's case, and why was he allowed to act?
- Another aspect that governments must address is the healthcare or distributional injustice of healthcare resources based on the patients' place of residence. In the Netherlands, this type of care is provided by the municipalities, resulting in significant disparities in healthcare resources depending on the municipalities' financial resources. While this might seem unique to the Netherlands, it also occurs in Spain, not only with shocking differences between Autonomous Communities, but also when it comes to specific pathologies. The mentally ill are the most destitute in terms of healthcare, and when it comes to the psychological problems of children and adolescents, the poverty is appalling. In Europe, at least, there is a specialty of child psychiatry. In Spain, there isn't even that.
- Therefore, when the media, affected by the suicide of such a young person, reported on the inadequate healthcare system for properly handling these cases, remember and denounce the fact that in Spain the situation is infinitely worse. Our children and adolescents suffer and need to be treated by specialists in centers specifically designed for them.
