AMSTERDAM — Legalized euthanasia and assisted suicide have the longest history in the Netherlands. Seventeen years ago, the two practices became legal, under what were supposed to be very limited circumstances, available only to those undergoing “unbearable” suffering with “no reasonable alternatives” for relief.

But time has brought a loosening of definitions and a level of comfortability with the practices, increasingly extending their availability far beyond patients with terminal conditions and extreme pain.

The Guardian recently reported that “well over a quarter” of deaths in the Netherlands in 2017 were “induced.” This included 6,585 who died by euthanasia; around 1,900 who killed themselves; and 32,000 “who died under palliative sedation.”

In a long-form piece published by The Guardian, Christopher de Bellaigue examines the increased popularity of the practices and the expanding availability of euthanasia and assisted suicide to include the young and the mentally (though not physically) ill.

He also notes that the increase in demand has some doctors and ethicists balking at the practice and questioning whether the Netherlands has headed down the oft-referenced “slippery slope” of having gone too far in letting people choose when to die.

“The process of bringing in euthanasia legislation began with a desire to deal with the most heartbreaking cases — really terrible forms of death,” Theo Boer, an ethics teacher at the Theological University of Kampen, told The Guardian. “But there have been important changes in the way the law is applied. We have put in motion something that we have now discovered has more consequences than we ever imagined.”

Those opposed to assisted suicide and euthanasia often do so out of concern for the possibility of coercion, or the impossibility of predicting whether someone’s condition or mental state might improve with additional care. Many disability groups actively campaign against it, arguing that it discriminates against the disabled, making insurance companies more likely to pay for their deaths than their ongoing care.

Ethicist Berna Van Baarsen shares similar concerns. Sometimes patients write advance directives, requesting assisted suicide once they deteriorate past a certain point, while they are still fully physically and mentally competent. But these patients may adjust to their new circumstances and change their minds, but be unable to communicate, making it nearly impossible to know whether their original requests still stand.

Van Baarsen resigned from her position on a euthanasia-case review board last year, citing her qualms with these types of cases, which are common.

“It is fundamentally impossible to establish that the patient is suffering unbearably because he can no longer explain it,” she told the Dutch daily Trouw.

She has also recently lamented that “legal arguments” often weigh more heavily on committees that approve people’s requests for euthanasia, “while the moral question of whether in certain cases good is done by killing threatens to get snowed under,” The Guardian reported.

“The underlying problem with the advance directives is that they imply the subordination of an irrational human being to their rational former self, essentially splitting a single person into two mutually opposed ones. Many doctors, having watched patients adapt to circumstances they had once expected to find intolerable, doubt whether anyone can accurately predict what they will want after their condition worsens,” de Bellaigue wrote.

De Bellaigue also detailed another disturbing case, in which a doctor went on vacation at a time when one of her patients had requested euthanasia, but she had declined his case, at least for the time. When she came back, another doctor had euthanized her patient.

“... [G]uilt was a factor; if she hadn’t gone away, would her patient still be alive? Now she was making plans to leave the practice, but hadn’t yet made an announcement for fear of unsettling her other patients. ‘How can I stay here?’ she said. ‘I am a doctor and yet I can’t guarantee the safety of my most vulnerable patients,’” de Ballaige wrote.

Currently, a doctor is being investigated in the first case of euthanasia malpractice in the Netherlands. The case was the kind Van Baarsen was wary about: The woman in the case had signed an advance directive, requesting euthanasia if she was still mentally competent at the time it was carried out.

After getting dementia and being confined to a nursing home, the woman was secretly slipped a sedative by the doctor in question and then given a lethal injection. While the woman fought the doctor, her family held her down.

Prosecutors say they are investigating the doctor for administering euthanasia to a woman who had voiced different desires about euthanasia at different times and for euthanizing her without checking to be sure it was her wish at the time. Two other cases investigating possible euthanasia malpractice have been dropped.

De Ballaige wrote that these cases may be the cause of a 9% drop in euthanasia and assisted suicide that has been reported for the first nine months of 2018.

Boer told The Guardian that when he speaks to lawmakers from other countries considering legalized euthanasia and assisted suicide, he points to the Netherlands as a warning.

“Look closely at the Netherlands because this is where your country may be 20 years from now,” he said.

Euthanasia and assisted suicide are legal only in a handful of states in the U.S., though there has been a recent push to legalize the practice in more places, in part due to the high-profile case of Brittany Maynard, a 29-year-old with terminal cancer who ended her life via assisted suicide in 2014. Compassion and Choices, which advocates for legalized euthanasia and assisted suicide, helped publicize her death.

Catholic social teaching holds assisted suicide and euthanasia to be “morally unacceptable.” The Catechism of the Catholic Church states that “even if death is thought imminent, the ordinary care owed to a sick person cannot be legitimately interrupted. The use of painkillers to alleviate the sufferings of the dying, even at the risk of shortening their days, can be morally in conformity with human dignity if death is not willed as either an end or a means, but only foreseen and tolerated as inevitable. Palliative care is a special form of disinterested charity. As such it should be encouraged.”

“Everyone is responsible for his life before God who has given it to him. It is God who remains the sovereign Master of life. We are obliged to accept life gratefully and preserve it for his honor and the salvation of our souls. We are stewards, not owners, of the life God has entrusted to us. It is not ours to dispose of,” it adds.

In June 2016, Pope Francis denounced assisted suicide as part of a “throwaway culture” that offers a “false compassion” and treats a human person as a problem. Addressing medical professionals from Spain and Latin America at the Vatican, the Pope criticized “those who hide behind an alleged compassion to justify and approve the death of a patient.”

“True compassion does not marginalize anyone, nor does it humiliate and exclude — much less considers the disappearance of a person as a good thing.”