'Are We All Soviets Now?'

 

'The Hard Thing and The Right Thing are Often The Same'

 

Review of The Vaccine War

 

The U bend of Life

 Why, beyond middle age, people get happier as they get older writes The Economist

Dec 16th 2010

 

ASK people how they feel about getting older, and they will probably reply in the same vein as Maurice Chevalier: “Old age isn't so bad when you consider the alternative.” Stiffening joints, weakening muscles, fading eyesight and the clouding of memory, coupled with the modern world's careless contempt for the old, seem a fearful prospect—better than death, perhaps, but not much. Yet mankind is wrong to dread ageing. Life is not a long slow decline from sunlit uplands towards the valley of death. It is, rather, a U-bend.

When people start out on adult life, they are, on average, pretty cheerful. Things go downhill from youth to middle age until they reach a nadir commonly known as the mid-life crisis. So far, so familiar. The surprising part happens after that. Although as people move towards old age they lose things they treasure—vitality, mental sharpness and looks—they also gain what people spend their lives pursuing: happiness.

This curious finding has emerged from a new branch of economics that seeks a more satisfactory measure than money of human well-being. Conventional economics uses money as a proxy for utility—the dismal way in which the discipline talks about happiness. But some economists, unconvinced that there is a direct relationship between money and well-being, have decided to go to the nub of the matter and measure happiness itself.

These ideas have penetrated the policy arena, starting in Bhutan, where the concept of Gross National Happiness shapes the planning process. All new policies have to have a GNH assessment, similar to the environmental-impact assessment common in other countries. In 2008 France's president, Nicolas Sarkozy, asked two Nobel-prize-winning economists, Amartya Sen and Joseph Stiglitz, to come up with a broader measure of national contentedness than GDP. Then last month, in a touchy-feely gesture not typical of Britain, David Cameron announced that the British government would start collecting figures on well-being.

There are already a lot of data on the subject collected by, for instance, America's General Social Survey, Eurobarometer and Gallup. Surveys ask two main sorts of question. One concerns people's assessment of their lives, and the other how they feel at any particular time. The first goes along the lines of: thinking about your life as a whole, how do you feel? The second is something like: yesterday, did you feel happy/contented/angry/anxious? The first sort of question is said to measure global well-being, and the second hedonic or emotional well-being. They do not always elicit the same response: having children, for instance, tends to make people feel better about their life as a whole, but also increases the chance that they felt angry or anxious yesterday.

Statisticians trawl through the vast quantities of data these surveys produce rather as miners panning for gold. They are trying to find the answer to the perennial question: what makes people happy?

Four main factors, it seems: gender, personality, external circumstances and age. Women, by and large, are slightly happier than men. But they are also more susceptible to depression: a fifth to a quarter of women experience depression at some point in their lives, compared with around a tenth of men. Which suggests either that women are more likely to experience more extreme emotions, or that a few women are more miserable than men, while most are more cheerful.

Two personality traits shine through the complexity of economists' regression analyses: neuroticism and extroversion. Neurotic people—those who are prone to guilt, anger and anxiety—tend to be unhappy. This is more than a tautological observation about people's mood when asked about their feelings by pollsters or economists. Studies following people over many years have shown that neuroticism is a stable personality trait and a good predictor of levels of happiness. Neurotic people are not just prone to negative feelings: they also tend to have low emotional intelligence, which makes them bad at forming or managing relationships, and that in turn makes them unhappy.

Whereas neuroticism tends to make for gloomy types, extroversion does the opposite. Those who like working in teams and who relish parties tend to be happier than those who shut their office doors in the daytime and hole up at home in the evenings. This personality trait may help explain some cross-cultural differences: a study comparing similar groups of British, Chinese and Japanese people found that the British were, on average, both more extrovert and happier than the Chinese and Japanese.

Then there is the role of circumstance. All sorts of things in people's lives, such as relationships, education, income and health, shape the way they feel. Being married gives people a considerable uplift, but not as big as the gloom that springs from being unemployed. In America, being black used to be associated with lower levels of happiness—though the most recent figures suggest that being black or Hispanic is nowadays associated with greater happiness. People with children in the house are less happy than those without. More educated people are happier, but that effect disappears once income is controlled for. Education, in other words, seems to make people happy because it makes them richer. And richer people are happier than poor ones—though just how much is a source of argument (see article).

The view from winter

Lastly, there is age. Ask a bunch of 30-year-olds and another of 70-year-olds (as Peter Ubel, of the Sanford School of Public Policy at Duke University, did with two colleagues, Heather Lacey and Dylan Smith, in 2006) which group they think is likely to be happier, and both lots point to the 30-year-olds. Ask them to rate their own well-being, and the 70-year-olds are the happier bunch. The academics quoted lyrics written by Pete Townshend of The Who when he was 20: “Things they do look awful cold / Hope I die before I get old”. They pointed out that Mr Townshend, having passed his 60th birthday, was writing a blog that glowed with good humour.

Mr Townshend may have thought of himself as a youthful radical, but this view is ancient and conventional. The “seven ages of man”—the dominant image of the life-course in the 16th and 17th centuries—was almost invariably conceived as a rise in stature and contentedness to middle age, followed by a sharp decline towards the grave. Inverting the rise and fall is a recent idea. “A few of us noticed the U-bend in the early 1990s,” says Andrew Oswald, professor of economics at Warwick Business School. “We ran a conference about it, but nobody came.”

Since then, interest in the U-bend has been growing. Its effect on happiness is significant—about half as much, from the nadir of middle age to the elderly peak, as that of unemployment. It appears all over the world. David Blanchflower, professor of economics at Dartmouth College, and Mr Oswald looked at the figures for 72 countries. The nadir varies among countries—Ukrainians, at the top of the range, are at their most miserable at 62, and Swiss, at the bottom, at 35—but in the great majority of countries people are at their unhappiest in their 40s and early 50s. The global average is 46.

The U-bend shows up in studies not just of global well-being but also of hedonic or emotional well-being. One paper, published this year by Arthur Stone, Joseph Schwartz and Joan Broderick of Stony Brook University, and Angus Deaton of Princeton, breaks well-being down into positive and negative feelings and looks at how the experience of those emotions varies through life. Enjoyment and happiness dip in middle age, then pick up; stress rises during the early 20s, then falls sharply; worry peaks in middle age, and falls sharply thereafter; anger declines throughout life; sadness rises slightly in middle age, and falls thereafter.

Turn the question upside down, and the pattern still appears. When the British Labour Force Survey asks people whether they are depressed, the U-bend becomes an arc, peaking at 46.

Happier, no matter what

There is always a possibility that variations are the result not of changes during the life-course, but of differences between cohorts. A 70-year-old European may feel different to a 30-year-old not because he is older, but because he grew up during the second world war and was thus formed by different experiences. But the accumulation of data undermines the idea of a cohort effect. Americans and Zimbabweans have not been formed by similar experiences, yet the U-bend appears in both their countries. And if a cohort effect were responsible, the U-bend would not show up consistently in 40 years' worth of data.

Another possible explanation is that unhappy people die early. It is hard to establish whether that is true or not; but, given that death in middle age is fairly rare, it would explain only a little of the phenomenon. Perhaps the U-bend is merely an expression of the effect of external circumstances. After all, common factors affect people at different stages of the life-cycle. People in their 40s, for instance, often have teenage children. Could the misery of the middle-aged be the consequence of sharing space with angry adolescents? And older people tend to be richer. Could their relative contentment be the result of their piles of cash?

The answer, it turns out, is no: control for cash, employment status and children, and the U-bend is still there. So the growing happiness that follows middle-aged misery must be the result not of external circumstances but of internal changes.

People, studies show, behave differently at different ages. Older people have fewer rows and come up with better solutions to conflict. They are better at controlling their emotions, better at accepting misfortune and less prone to anger. In one study, for instance, subjects were asked to listen to recordings of people supposedly saying disparaging things about them. Older and younger people were similarly saddened, but older people less angry and less inclined to pass judgment, taking the view, as one put it, that “you can't please all the people all the time.”

There are various theories as to why this might be so. Laura Carstensen, professor of psychology at Stanford University, talks of “the uniquely human ability to recognise our own mortality and monitor our own time horizons”. Because the old know they are closer to death, she argues, they grow better at living for the present. They come to focus on things that matter now—such as feelings—and less on long-term goals. “When young people look at older people, they think how terrifying it must be to be nearing the end of your life. But older people know what matters most.” For instance, she says, “young people will go to cocktail parties because they might meet somebody who will be useful to them in the future, even though nobody I know actually likes going to cocktail parties.”

Death of ambition, birth of acceptance

There are other possible explanations. Maybe the sight of contemporaries keeling over infuses survivors with a determination to make the most of their remaining years. Maybe people come to accept their strengths and weaknesses, give up hoping to become chief executive or have a picture shown in the Royal Academy, and learn to be satisfied as assistant branch manager, with their watercolour on display at the church fete. “Being an old maid”, says one of the characters in a story by Edna Ferber, an (unmarried) American novelist, was “like death by drowning—a really delightful sensation when you ceased struggling.” Perhaps acceptance of ageing itself is a source of relief. “How pleasant is the day”, observed William James, an American philosopher, “when we give up striving to be young—or slender.”

Whatever the causes of the U-bend, it has consequences beyond the emotional. Happiness doesn't just make people happy—it also makes them healthier. John Weinman, professor of psychiatry at King's College London, monitored the stress levels of a group of volunteers and then inflicted small wounds on them. The wounds of the least stressed healed twice as fast as those of the most stressed. At Carnegie Mellon University in Pittsburgh, Sheldon Cohen infected people with cold and flu viruses. He found that happier types were less likely to catch the virus, and showed fewer symptoms of illness when they did. So although old people tend to be less healthy than younger ones, their cheerfulness may help counteract their crumbliness.

Happier people are more productive, too. Mr Oswald and two colleagues, Eugenio Proto and Daniel Sgroi, cheered up a bunch of volunteers by showing them a funny film, then set them mental tests and compared their performance to groups that had seen a neutral film, or no film at all. The ones who had seen the funny film performed 12% better. This leads to two conclusions. First, if you are going to volunteer for a study, choose the economists' experiment rather than the psychologists' or psychiatrists'. Second, the cheerfulness of the old should help counteract their loss of productivity through declining cognitive skills—a point worth remembering as the world works out how to deal with an ageing workforce.

The ageing of the rich world is normally seen as a burden on the economy and a problem to be solved. The U-bend argues for a more positive view of the matter. The greyer the world gets, the brighter it becomes—a prospect which should be especially encouraging to Economist readers (average age 47).

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60 is the new 80 thanks to Corona

 Patti Waldmeir in The FT

“Better be safe than sorry.” I have never believed that. 

I have lived my first 65 years often turning a blind eye to risk. I lived in China for eight years, enduring some of the worst industrial pollution on earth, despite having asthma. I risked damaging the lungs of my then small children by raising them in a place where their school often locked them in air-purified classrooms to protect them from the smog. 

Before that, I lived for 20 years in Africa, refusing to boil water in areas where it needed boiling, eating bushmeat at roadside stalls — not to mention the escapades that I got up to as a young woman in the pre-Aids era. 

But now, as I peer over the precipice into life as a senior citizen, coronavirus has finally introduced me to the concept of risk. Part of it is the whole “60 is the new 80” paradigm that the pandemic has forced on us — but most of it is that, whether I like it or not, I fit squarely in the category of “at risk” for severe illness or death if I catch Covid-19. 

I have diabetes, asthma and am finishing my 65th year. I don’t live in a nursing home, a jail, a monastery or a convent (as does one close friend with Covid-19), but according to the US Centers for Disease Control and Prevention (CDC), I still qualify as high risk because of my underlying conditions and age. 

So what do I — and people like me, I am far from alone — do now that the world is reopening without us? I’ve got some big decisions to make in the next few days. My youngest child is moving back to our flat outside Chicago after a month living elsewhere: does one of us need to be locked in the bedroom? Do I have to eat on the balcony for two weeks? 

There is no shortage of people, not least President Donald Trump, telling me that all this is simple: vulnerable people should just stay home. But what if they live with other people? What if those people have jobs? And what about our dogs? Our two old mutts are overdue for a rabies shot because the vet was only seeing emergencies. Is it safe for me to take them in now? Can my kids go to the dentist, and then come home to live at close quarters with me? 

I asked several medical experts these questions, and they all offered versions of “we haven’t got a clue”. Robert Gabbay, incoming chief scientific and medical officer of the American Diabetes Association, was the most helpful: “Individuals with diabetes are all in the higher-risk category but even within that category, those who are older and with co-morbidities are at more risk — and control of blood glucose seems to matter. 

“You are probably somewhere in the middle” of the high-risk category, he decided. My diabetes is well controlled and I don’t have many other illnesses. “But your age is a factor,” he added. Up to now, I’ve thought I was in the “60 is the new 40 crowd”: now I know there is no such crowd. 

The head of the Illinois Department of Public Health underlined this at the weekend when she gave her personal list of Covid dos and don’ts, including don’t visit a parent who is over 65 with pre-existing conditions for at least a year, or until there is a cure. Dr Ngozi Ezike also said she would not attend a wedding or a dinner party for a year and would avoid indoor restaurants for three months to a year — despite the fact that Chicago’s indoor restaurants reopen on Friday. 

I turned to the CDC, which initially said it would issue new guidance for “at risk” people last week, but didn’t. This would be the same CDC that I trusted when it said not to wear a mask — though 1.3 billion people in China were masking up. Today China, which is 100 times larger by population than my home state of Illinois, has less than three-quarters as many total pandemic deaths. (Yes, I know China has been accused of undercounting cases, but so has the US.) Masks aren’t the only reason; but they are enough of a reason to erode my trust in what the CDC thinks I should do now. 

It doesn’t help that the CDC website lists “moderate to severe asthma” as one of the primary risk factors for poor coronavirus outcomes — while the American Academy of Allergy Asthma and Immunology says “there are no published data to support this determination”, adding that there is “no evidence” that those with asthma are more at risk. Who’s right? 

I need to know: this weekend is the one-year anniversary of the death of my eldest sibling. I’ve chosen not to make the trip to visit his grave in Michigan. Next month, I turn 65, and I want to spend that day with my 89-year-old father: should we rent a camper van, so we don’t infect his household? I thought about a porta potty for the journey, since public toilets are apparently a coronavirus hotspot. When I started searching for “female urination devices” online, I knew it was time to ditch this new “better safe than sorry” persona I’ve assumed under lockdown. 

Maybe it’s time to remind myself of a fact that I once knew: that life is a risky business, and there is only so much I can do about that. I’ll die when it’s my time — probably not a day before or after, coronavirus or no coronavirus.

Privatisation is at the heart of the UK's disastrous coronavirus response

George Monbiot in The Guardian

Amid the smog of lies and contradictions, there is one question we should never stop asking: why has the government of the United Kingdom so spectacularly failed to defend people’s lives? Why has “this fortress built by Nature for herself against infection”, as Shakespeare described our islands, succumbed to a greater extent than any other European nation to a foreseeable and containable pandemic?

Part of the answer is that the government knowingly and deliberately stood down crucial parts of its emergency response system. Another part is that, when it did at last seek to mobilise the system, crucial bits of the machine immediately fell off. There is a consistent reason for the multiple, systemic failures the pandemic has exposed: the intrusion of corporate power into public policy. Privatisation, commercialisation, outsourcing and offshoring have severely compromised the UK’s ability to respond to a crisis.

Take, for example, the lethal failures to provide protective clothing, masks and other equipment (PPE) to health workers. A report by the campaigning group We Own It seeks to explain why so many doctors, nurses and other hospital workers have died unnecessarily of Covid-19. It describes a system built around the needs not of health workers or patients, but of corporations and commercial contracts: a system that could scarcely be better designed for failure.

Four layers of commercial contractors, each rich with opportunities for profit-making, stand between doctors and nurses and the equipment they need. These layers are then fragmented into 11 tottering, uncoordinated supply chains, creating an almost perfect formula for chaos. Among the many weak links in these chains are consultancy companies like Deloitte, whose farcical attempts to procure emergency supplies of PPE have been fiercely criticised by both manufacturers and health workers.

At the end of the chains are manufacturing companies, some of which have mysteriously been granted monopolies on the supply of essential equipment. These private monopolies have either failed to meet their contracts, or provided defective gear to the entire NHS, like the 15m protective goggles and the planeload of useless surgical gowns that had to be recalled.

Instead of stockpiling supplies, as emergency preparedness demands, companies in these chains have been using just-in-time production systems, whose purpose is to cut their costs by minimising stocks. Their minimised systems could not be scaled up fast enough to meet the shortfall. Where there should be a smooth, coordinated, accountable programme, there’s opacity, byzantine complexity and total chaos. So much for the efficiencies of privatisation.

The pandemic has also exposed the privatised care system as catastrophically unfit and ill-prepared. In 1993, 95% of care at home was provided publicly by local authorities. Now, almost all of it – and almost all residential care – is provided by private companies. Even before the pandemic, the system was falling apart, as many care companies, unable to balance the needs of their patients with the demands of their shareholders, collapsed, often with disastrous consequences.

Now we discover just how dangerous their commercial imperatives have become, as the drive to make care profitable has created a fragmented, incoherent system, answerable sometimes to offshore owners, that fails to meet basic standards, and employs harassed workers on zero-hour contracts. If there is one thing we have learnt from this pandemic, it’s the need for a publicly owned, publicly run National Care Service – the care equivalent of the NHS.
It could all become much worse, due to another effect of corporate power. A report by the Corporate Europe Observatory shows how law firms are exploring the possibility of suing governments for the measures they have taken to stop the pandemic. Many trade treaties contain a provision called “investor state dispute settlement”. This enables corporations to sue governments in opaque offshore tribunals, for any policies that might affect their “future anticipated profits”.

So when governments, in response to coronavirus, have imposed travel restrictions, or requisitioned hotels, or instructed companies to produce medical equipment or limit the price of drugs, the companies could sue them for the loss of the money they might otherwise have made. When the UK government commandeers private hospitals or the Spanish government prevents evictions by landlords, and stops water and electricity companies from cutting off destitute customers, they could be open to international legal challenge. These measures, which override democracy, have already hampered attempts by many governments, particularly of poorer nations, to protect their people from disasters. They urgently need to be rescinded.

The effectiveness of our health system is also threatened by the trade treaty the UK government hopes to sign with the US. The Conservatives promised in their manifesto that “the NHS is not on the table” in the trade talks. But they have already broken their accompanying promise, “we will not compromise on our high environmental protection, animal welfare and food standards”. Earlier this month, they voted that measure out of the agriculture bill. US companies are aggressively demanding access to the NHS. The talks will be extremely complex and incomprehensible to almost everyone. There will be plenty of opportunities to give them what they want while fooling voters.

Boris Johnson’s central mission, overseen by Dominic Cummings, is to break down all barriers between government and the power of money. It is to allow private interests to intrude into the very heart of government, while marginalising the civil service. This helps to explain why Johnson is so reluctant to let Cummings go. The disasters of the past few weeks hint at the likely results.

'A deluge of death': how reading obituaries can humanise a crisis

Those brief features have long provided readers with a moment of connection that help us stay in touch with our humanity writes Oscar Schwartz in The Guardian


 

Obituaries can help readers stay in touch with humanity during an overwhelming crisis. Photograph: Kzenon/Alamy Stock Photo


Over the past few weeks, we’ve learned how to think a little more like epidemiologists. Each morning, we pore over statistical models that offer grim projections about how many people might get sick, when hospital beds will run short, how many might die within our age bracket. The coronavirus pandemic, in other words, has been a plague of statistics – and our expectations about the future have suddenly come to hinge on abstractions.

In opposition stands the obituary. These brief features, a cross between a short story and a death notice, have long provided readers with a moment of particular connection within the impersonal headlines. In a crisis of this magnitude, finding the emotional space to care about a single death can feel purposeless, unnecessary. But for many obituary writers past and present, there is a belief that this unique and embattled form of journalism can help us stay in touch with our humanity.

“It’s a deluge of death at the moment,” said Adam Bernstein, obituaries editor at the Washington Post. “When you see a figure like ‘50,000 people have died’, those are numbers that make the mind reel. But it’s very hard to touch people’s hearts with numbers – that’s where we come in.” 

Bernstein has been working on the death beat at the Post since 1999, and for the past decade has led a team that prides itself on the obituary craft. A good obituary, according to Bernstein, reveals surprising, intimate details about a life. “Maybe this person was most famous for being a criminal, but maybe they were also a roguish criminal with a terrific sense of humor,” Bernstein said. “Those details are what connect us to other human beings and our task is to find them.”

Since writing his first obituary as an intern at a newspaper in Bakersfield, California, Bernstein has relished the task. “It’s the hidden gem of the newsroom,” he said. But in the past month, the work has become increasingly taxing as the list of deaths they confront each morning balloons. They have churned out obituaries for notable deaths, like John Prine and Lee Konitz, while some non-coronavirus-related deaths have been sidelined.

There is also a sense of dread and suspense involved in monitoring those who have become ill. “If a well-known person is sick and it’s looking dire we make sure we have a story ready to go,” he said. “It feels like an endless game of Russian roulette and you just never know what the next day will bring.”

Janny Scott can relate to the experience of writing obituaries in a time of crisis. On 11 September 2001, Scott, then a young reporter on the New York Times metro desk, was assigned to cover, simply, “the dead”. With the city in chaos and no official victim count forthcoming, she and her colleagues trawled the streets of Manhattan collecting missing persons flyers that had become the city’s gloomy wallpaper.

As days passed, it became clear that most of the missing had died. “We began calling families and contacts, trying to piece together who these people were,” Scott told me. From these conversations, Scott and her colleagues began drawing up 250-word thumbnail sketches of those who had been lost, which were run at the back of the paper under the title “Portraits of Grief“. The paper ran almost 2,000 of these mini-obituaries in the coming months. “In New York, reading the portraits became some kind of religious ritual that helped us grieve together,” Scott said.

Obituaries and death notices can also serve an important political function during a crisis. In 1989, when obituaries at major newspapers still refused to cite Aids as a cause of death, the Bay Area Reporter published an eight-page section titled Aids Deaths, which listed all the people who had died from the illness during the previous year. Obituaries have similarly functioned as a form of advocacy around the opioid crisis, providing parents with a chance to publicly address the issue of addiction and connect with others in the community dealing with similar hardship.

As local newspapers across the nation continue to fold, however, most obituaries are now published on memorial sites, such as legacy.com, which hosts notices for more than 70% of all US deaths. During the current pandemic, these sites provide an accessible way for families to memorialize those lost at a time when obituary writers are otherwise overwhelmed.

“But the local news obituary is more than a death notice or a eulogy,” Kay Powell said. “It really should be an objective news story about one person’s life.” Powell worked at the Atlanta Journal-Constitution from 1996 to 2009, where she wrote close to 2,000 obituaries about “extraordinary ordinary people”. The church choir singer who had a frontal lobotomy and donated his brain to science, the boy who sang at Martin Luther King Jr’s funeral, the woman who was Flannery O’Connor’s secret pen pal for 30 years. 

Powell told me that she often fell in love with her recently deceased subjects and tried to impart this affection to her readers. But as a journalist, she also prided herself on accuracy and objectivity. She would never euphemize cause of death, believing that wider social truths about disease, mental health, addiction could be communicated more effectively through the experience of an individual. “When it is the name of somebody right there in your community, these issues are no longer some arbitrary thing affecting some number of people somewhere else,” she said.

The psychologist Paul Slovic has referred to this greater concern for the one over the many as a product of “psychic numbing”, a psychological glitch whereby, as the number in a tragedy increases, our empathy decreases. For many of us, this has intensified as the weeks pass. As the death count rises, cold-eyed statistical thinking that would have a few months ago seemed abhorrent becomes part of our daily news diet.

Of course, thinking about the pandemic in numbers is crucial. Demographic analysis shines a light on systemic truths that the individual story cannot, like how this virus is disproportionately taking lives in communities of color.

But Powell, who is in her 70s and sheltering in place alone, told me that engaging with the granularity of human suffering can shock people back into a sense of moral responsibility. “The emotion makes it harder to deny the reality of what’s happening here,” Powell said. “In the end, it keeps us better informed.”

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Death on demand: has euthanasia gone too far?

Countries around the world are making it easier to choose the time and manner of your death. But doctors in the world’s euthanasia capital are starting to worry about the consequences by Christopher de Bellaigue in The Guardian

Last year a Dutch doctor called Bert Keizer was summoned to the house of a man dying of lung cancer, in order to end his life. When Keizer and the nurse who was to assist him arrived, they found around 35 people gathered around the dying man’s bed. “They were drinking and guffawing and crying,” Keizer told me when I met him in Amsterdam recently. “It was boisterous. And I thought: ‘How am I going to cleave the waters?’ But the man knew exactly what to do. Suddenly he said, ‘OK, guys!’ and everyone understood. Everyone fell silent. The very small children were taken out of the room and I gave him his injection. I could have kissed him, because I wouldn’t have known how to break up the party.”

Keizer is one of around 60 physicians on the books of the Levenseindekliniek, or End of Life Clinic, which matches doctors willing to perform euthanasia with patients seeking an end to their lives, and which was responsible for the euthanasia of some 750 people in 2017. For Keizer, who was a philosopher before studying medicine, the advent of widespread access to euthanasia represents a new era. “For the first time in history,” he told me, “we have developed a space where people move towards death while we are touching them and they are in our midst. That’s completely different from killing yourself when your wife’s out shopping and the kids are at school and you hang yourself in the library – which is the most horrible way of doing it, because the wound never heals. The fact that you are a person means that you are linked to other people. And we have found a bearable way of severing that link, not by a natural death, but by a self-willed ending. It’s a very special thing.”

This “special thing” has in fact become normal. Everyone in the Netherlands seems to have known someone who has been euthanised, and the kind of choreographed farewell that Keizer describes is far from unusual. Certainly, the idea that we humans have a variety of deaths to choose from is more familiar in the Netherlands than anywhere else. But the long-term consequences of this idea are only just becoming discernible. Euthanasia has been legal in the Netherlands for long enough to show what can happen after the practice beds in. And as an end-of-life specialist in a nation that has for decades been the standard bearer of libertarian reform, Keizer may be a witness to the future that awaits us all.

In 2002, the parliament in the Hague legalised euthanasia for patients experiencing “unbearable suffering with no prospect of improvement”. Since then, euthanasia and its close relation, assisted dying, in which one person facilitates the suicide of another, have been embraced by Belgium and Canada, while public opinion in many countries where it isn’t on the national statute, such as Britain, the US and New Zealand, has swung heavily in favour.

The momentum of euthanasia appears unstoppable; after Colombia, in 2015, and the Australian state of Victoria, in 2017, Spain may be the next big jurisdiction to legalise physician-assisted death, while one in six Americans(the majority of them in California) live in states where it is legal. In Switzerland, which has the world’s oldest assisted dying laws, foreigners are also able to obtain euthanasia.

If western society continues to follow the Dutch, Belgian and Canadian examples, there is every chance that in a few decades’ time euthanasia will be one widely available option from a menu of possible deaths, including an “end of life” poison pill available on demand to anyone who finds life unbearable. For many greying baby boomers – veterans of earlier struggles to legalise abortion and contraception – a civilised death at a time of their choosing is a right that the state should provide and regulate. As this generation enters its final years, the precept that life is precious irrespective of one’s medical condition is being called into question as never before.

As the world’s pioneer, the Netherlands has also discovered that although legalising euthanasia might resolve one ethical conundrum, it opens a can of others – most importantly, where the limits of the practice should be drawn. In the past few years a small but influential group of academics and jurists have raised the alarm over what is generally referred to, a little archly, as the “slippery slope” – the idea that a measure introduced to provide relief to late-stage cancer patients has expanded to include people who might otherwise live for many years, from sufferers of diseases such as muscular dystrophy to sexagenarians with dementia and even mentally ill young people.

Perhaps the most prominent of these sceptics is Theo Boer, who teaches ethics at the Theological University of Kampen. Between 2005 and 2014, Boer was a member of one of the five regional boards that were set up to review every act of euthanasia and hand cases over to prosecutors if irregularities are detected. (Each review board is composed of a lawyer, a doctor and an ethicist.) Recent government figures suggest that doubts over the direction of Dutch euthanasia are having an effect on the willingness of doctors to perform the procedure. In November, the health ministry revealed that in the first nine months of 2018 the number of cases was down 9%compared to the same period in 2017, the first drop since 2006. In a related sign of a more hostile legal environment, shortly afterwards the judiciary announced the first prosecution of a doctor for malpractice while administering euthanasia.

It is too early to say if euthanasia in the Netherlands has reached a high-water mark – and too early to say if the other countries that are currently making it easier to have an assisted death will also hesitate if the practice comes to be seen as too widespread. But it is significant that in addition to the passionate advocacy of Bert Keizer – who positively welcomes the “slippery slope” – Boer’s more critical views are being solicited by foreign parliamentarians and ethicists who are considering legal changes in their own countries. As Boer explained to me, “when I’m showing the statistics to people in Portugal or Iceland or wherever, I say: ‘Look closely at the Netherlands because this is where your country may be 20 years from now.’”

“The process of bringing in euthanasia legislation began with a desire to deal with the most heartbreaking cases – really terrible forms of death,” Boer said. “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.”

Bert Keizer carried out his first euthanasia in 1984. Back then, when he was working as a doctor in a care home, ending the life of a desperately ill person at their request was illegal, even if prosecutions were rare. When a retired shoemaker called Antonius Albertus, who was dying of lung cancer, asked to be put out of his misery, Keizer found that two sides of himself – the law-abiding doctor and the altruist – were at odds.

“Antonius wasn’t in pain,” Keizer told me, “but he had that particular exhaustion that every oncologist knows, a harrowing exhaustion, and I saw him dwindle before me.” In the event, Keizer, who as an 11-year-old watched his mother suffer an excruciating death from liver disease, went with the altruist. He injected 40mg of Valium into Antonius – enough to put him in a coma – then gave him the anti-respiratory drug that ended his life.

Keizer was not investigated after reporting an unnatural death at his own hand, and his career did not suffer as he feared it might. But what, I asked him, had prompted him to break the law, and violate a principle – the preservation of life – that has defined medical ethics since Hippocrates? Keizer paused to brush away a spider that had crawled uninvited on to my shoulder. “It was something very selfish,” he replied. “If ever I was in his situation, asking for death, I would want people to listen to me, and not say, ‘It cannot be done because of the law or the Bible.’”

Over the past few decades the Bible has been increasingly sidelined, and the law has vindicated the young doctor who put Antonius to sleep. As people got used to the new law, the number of Dutch people being euthanised began to rise sharply, from under 2,000 in 2007 to almost 6,600 in 2017. (Around the same number are estimated to have had their euthanasia request turned down as not conforming with the legal requirements.) Also in 2017, some 1,900 Dutch people killed themselves, while the number of people who died under palliative sedation – in theory, succumbing to their illness while cocooned from physical discomfort, but in practice often dying of dehydration while unconscious – hit an astonishing 32,000. Altogether, well over a quarter of all deaths in 2017 in the Netherlands were induced.

 

MPs in Victoria, Australia, embrace after the passing of the Voluntary Assisted Dying bill in 2017. Photograph: David Crosling/EPA

One of the reasons why euthanasia became more common after 2007 is that the range of conditions considered eligible expanded, while the definition of “unbearable suffering” that is central to the law was also loosened. At the same time, murmurs of apprehension began to be heard, which, even in the marvellously decorous chamber of Dutch public debate, have risen in volume. Concerns centre on two issues with strong relevance to euthanasia: dementia and autonomy.

Many Dutch people write advance directives that stipulate that if their mental state later deteriorates beyond a certain point – if, say, they are unable to recognise family members – they are to be euthanised regardless of whether they dissent from their original wishes. But Last January a medical ethicist called Berna Van Baarsen caused a stir when she resigned from one of the review boards in protest at the growing frequency with which dementia sufferers are being euthanised on the basis of a written directive that they are unable to confirm after losing their faculties. “It is fundamentally impossible,” she told the newspaper Trouw, “to establish that the patient is suffering unbearably, because he can no longer explain it.”

Van Baarsen’s scruples have crystallised in the country’s first euthanasia malpractice case, which prosecutors are now preparing. (Three further cases are currently under investigation.) It involves a dementia sufferer who had asked to be killed when the “time” was “right”, but when her doctor judged this to be the case, she resisted. The patient had to be drugged and restrained by her family before she finally submitted to the doctor’s fatal injection. The doctor who administered the dose – who has not been identified – has defended her actions by saying that she was fulfilling her patient’s request and that, since the patient was incompetent, her protests before her death were irrelevant. Whatever the legal merits of her argument, it hardly changes what must have been a scene of unutterable grimness.

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.

The second conflict that has crept in as euthanasia has been normalised is a societal one. It comes up when there is an opposition between the right of the individual and society’s obligation to protect lives. “The euthanasia requests that are the most problematic,” explains Agnes van der Heide, professor of medical care and end-of-life decision-making at the Erasmus Medical Centre in Rotterdam, “are those that are based on the patient’s autonomy, which leads them to tell the doctor: ‘You aren’t the one to judge whether I am to die.’” She doesn’t expect this impulse, already strong among baby boomers, to diminish among coming generations. “For our young people, the autonomy principle is at the forefront of their thinking.”

The growing divisions over euthanasia are being reflected in the deliberations of the review boards. Consensus is rarer than it was when the only cases that came before them involved patients with late-stage terminal illnesses, who were of sound mind. Since her resignation, Berna Van Baarsen has complained that “legal arguments weigh more and more heavily” on the committees, “while the moral question of whether in certain cases good is done by killing, threatens to get snowed under”.

In this new, more ambiguous environment, the recent dip in euthanasia numbers doesn’t seem surprising. Besides their fear of attracting prosecutors’ attention, some doctors have been irked by the growing public perception that they are no-questions-asked purveyors of dignified death, and are pushing back. For Dutch GPs, fielding demands for euthanasia from assertive patients who resent the slightest reluctance on the part of their physician has become one of the more disagreeable aspects of their job.

“In the coldest weeks of last winter,” Theo Boer told me, “a doctor friend of mine was told by an elderly patient: ‘I demand to have euthanasia this week – you promised.’ The doctor replied: ‘It’s -15C outside. Take a bottle of whisky and sit in your garden and we will find you tomorrow, because I cannot accept that you make me responsible for your own suicide.’ The doctor in question, Boer said, used to perform euthanasia on around three people a year. He has now stopped altogether.

Although he supported the 2002 euthanasia law at the time, Boer now regrets that it didn’t stipulate that the patient must be competent at the time of termination, and that if possible the patient should administer the fatal dose themselves. Boer is also concerned about the psychological effect on doctors of killing someone with a substantial life expectancy: “When you euthanise a final-stage cancer patient, you know that even if your decision is problematic, that person would have died anyway. But when that person might have lived decades, what is always in your mind is that they might have found a new balance in their life.”

In November 2016, Monique and Bert de Gooijer, a couple from Tilburg, became minor celebrities when a regional paper, the Brabants Dagblad, devoted an entire issue to the euthanasia of their son, an obese, darkly humorous, profoundly disturbed 38-year-old called Eelco. His euthanasia was one of the first high-profile cases involving a young person suffering from mental illness. Of the hundreds of reactions the newspaper received, most of them supportive, the one that made the biggest impression on the de Gooijers came from a woman whose daughter had gone out one day, taking the empty bottles to the store, and walked in front of a train. “She envied us,” Monique told me as I sat with her and Bert in their front room, “because she didn’t know why her daughter had done it. She said: ‘You were able to ask Eelco every question you had. I have only questions.’”

Privately, even surreptitiously undertaken, suicide leaves behind shattered lives. Even when it goes according to plan, someone finds a body. That openly discussed euthanasia can cushion or even obviate much of this hurt is something I hadn’t really considered before meeting the de Gooijers. Nor had I fully savoured the irony that suicide, with its high risk of failure and collateral damage, was illegal across Europe until a few decades ago, while euthanasia, with its apparently more benign – at least, more manageable – consequences, remains illegal in most countries.

Whatever the act of killing a physically healthy young man tells us about Dutch views of human wellbeing, the demise of Eelco de Gooijer didn’t traumatise a train driver or a weekender fishing in a canal. Eelco was euthanised only after long thought and discussions with his family. He enjoyed a good laugh with the undertaker who had come to take his measurements for a super-size coffin. He was able to say farewell to everyone who loved him, and he died, as Monique and Bert assured me, at peace. There might be a word for this kind of suicide, the kind that is acceptable to all parties. Call it consensual.

“You try to make your child happy,” Monique said in her matter-of-fact way, “but Eelco wasn’t happy in life. He wanted to stop suffering, and death was the only way.” Eelco came of age just as euthanasia was being legalised. After years of being examined by psychiatrists who made multiple diagnoses and prescribed a variety of ineffective remedies, he began pestering the doctors of Tilburg to end his life.

Euthanasia is counted as a basic health service, covered by the monthly premium that every citizen pays to his or her insurance company. But doctors are within their rights not to carry it out. Unique among medical procedures, a successful euthanasia isn’t something you can assess with your patient after the event. A small minority of doctors refuse to perform it for this reason, and others because of religious qualms. Some simply cannot get their heads around the idea that they must kill people they came into medicine in order to save.

 

Protesters in the Hague in 2001, while the Dutch government was debating the legalisation of euthanasia, which passed in 2002. Photograph: Serge Ligtenberg/AP

Those who demur on principle are a small proportion of the profession, perhaps less than 8%, according to the end-of-life specialist Agnes van der Heide. The reason why there is no uniformity of response to requests for euthanasia is that the doctor’s personal views – on what constitutes “unbearable suffering”, for instance – often weigh decisively. As the most solemn and consequential intervention a Dutch physician can be asked to make, and this in a profession that aims to standardise responses to all eventualities, the decision to kill is oddly contingent on a single, mercurial human conscience.

A category of euthanasia request that Dutch doctors commonly reject is that of a mentally ill person whose desire to die could be interpreted as a symptom of a treatable psychiatric disease – Eelco de Gooijer, in other words. Eelco was turned down by two doctors in Tilburg; one of them balked at doing the deed because she was pregnant. In desperation, Eelco turned to the Levenseindekliniek. With its ideological commitment to euthanasia and cadre of specialist doctors, it has done much to help widen the scope of the practice, and one of its teams ended Eelco’s misery on 23 November 2016. A second team from the same clinic killed another psychologically disturbed youngster, Aurelia Brouwers, early last year.

Ideally euthanasia is a structure with three struts: patient, doctor and the patient’s loved ones. In the case of Eelco de Gooijer, the struts were sturdy and aligned. Eelco’s death was accomplished with compassion, circumspection and scrupulous regard for the feelings of all concerned. It’s little wonder that the Dutch Voluntary Euthanasia Society, or NVVE, vaunts it as an example of euthanasia at its best.

After leaving the de Gooijers, I drove northwards, bisecting hectares of plant nurseries, skirting Tesla’s European factory, to a conference organised by the NVVE. Apart from being the parent organisation of the Levenseindekliek, the NVVE, with its membership of 170,000 (bigger than any Dutch political party) and rolling programme of public meetings, is one of the most powerful interest groups in the Netherlands. The conference that day was aimed at tackling psychiatrists’ well known opposition to euthanasia for psychiatric cases – in effect, trying to break down the considerable opposition that remains among psychiatrists to euthanising disturbed youngsters like Eelco and Aurelia.

The conference centre on the outskirts of Driebergen stood amid tall conifers and beehives. I was offered a beaker of curried pumpkin soup while the session that was underway when I arrived – titled “Guidelines for terminating life on the request of a patient with a psychiatric disorder” – came to an orderly close in the lecture hall. Precisely three minutes behind schedule, the Dutch planned-death establishment debouched for refreshments.

I had met my first NVVE member quite by chance in Amsterdam. After watching her mother die incontinent and addled, this woman of around 70 signed an advance directive requesting euthanasia should she get dementia or lose control of her bowels. These conditions currently dominate the euthanasia debate, because so many people in their 60s and 70s want an opt-out from suffering they have observed in their parents. When I mentioned to the woman in Amsterdam the reluctance of many doctors to euthanise someone who isn’t mentally competent, she replied, bristling: “No doctor has the right to decide when my life should end.”

At any meeting organised by the NVVE, you will look in vain for poor people, pious Christians or members of the Netherlands’ sizeable Muslim minority. Borne along by the ultra-rational spirit of Dutch libertarianism (the spirit that made the Netherlands a pioneer in reforming laws on drugs, sex and pornography), the Dutch euthanasia scene also exudes a strong whiff of upper-middle class entitlement.

Over coffee I was introduced to Steven Pleiter, the director of the Levenseindekliniek. We went outside and basked in the early October sun as he described the “shift in mindset” he is trying to achieve. Choosing his words with care, Pleiter said he hoped that in future doctors will feel more confident accommodating demands for “the most complex varieties of euthanasia, like psychiatric illnesses and dementia” – not through a change in the law, he added, but through a kind of “acceptance … that grows and grows over the years”. When I asked him if he understood the scruples of those doctors who refuse to perform euthanasia because they entered their profession in order to save lives, he replied: “If the situation is unbearable and there is no prospect of improvement, and euthanasia is an option, it would be almost unethical [of a doctor] not to help that person.”

After the Levenseindekliniek was founded in 2012, Pleiter sat down with the insurance companies to work out what they would pay the clinic for each euthanasia procedure its doctors perform. The current figure is €3,000, payable to the clinic even if the applicant pulls out at the last minute. I suggested to Pleiter that the insurance companies must prefer to pay a one-off fee for euthanising someone to spending a vast sum in order to keep that person, needy and unproductive, alive in a nursing home.

Pleiter’s pained expression suggested that I had introduced a note of cynicism into a discussion that should be conducted on a more elevated plane. “There’s not an atom in my body that is in sympathy with what you are describing,” he replied. “This isn’t about money … it’s about empathy, ethics, compassion.” And he restated the credo that animates right-to-die movements everywhere: ‘I strongly believe there is no need for suffering.’

That not all planned deaths correspond to the experiences of Bert Keizer or the de Gooijer family is something one can easily forget amid the generally positive aura that surrounds euthanasia. The more I learned about it, the more it seemed that euthanasia, while assigning commendable value to the end of life, might simultaneously cheapen life itself. Another factor I hadn’t appreciated was the possibility of collateral damage. In an event as delicately contractual as euthanasia, there are different varieties of suffering.

Back in the days when euthanasia was illegal but tolerated, the euthanising doctor was obliged to consult the relatives of the person who had asked to die. Due to qualms over personal autonomy and patient-doctor confidentiality – and an entirely proper concern to protect vulnerable people from unscrupulous relatives – this obligation didn’t make it into the 2002 law that legalised euthanasia.

This legal nicety would become painfully significant to a middle-aged motorcycle salesman from Zwolle called Marc Veld. In the spring of last year, he began to suspect that his mother, Marijke, was planning to be euthanised, but he never got the opportunity to explain to her doctor why, in his view, her suffering was neither unbearable nor impossible to alleviate. On 9 June, the doctor phoned him and said: “I’m sorry, your mother passed away half an hour ago.”

Marc showed me a picture he had taken of Marijke in her coffin, her white hair carefully brushed and her skin glowing with the smooth, even foundation of the mortuary beautician. Between her hands was a letter Marc had put there and would be buried with her – a letter detailing his unhappiness, resentment and guilt.

There is little doubt that Marijke spent much of her 76 years in torment, beginning with her infancy in a Japanese concentration camp after the invasion of the Dutch East Indies, in 1941, and recurring during her unhappy adulthood in the Netherlands. But Dutch doctors don’t euthanise people because of depression – even if the more extreme advocates of the right to die think they should. As a result, it isn’t uncommon for depressives or lonely people to emphasise a physical ailment in order to get their euthanasia request approved. During his time on the review board, Theo Boer came across several cases in which the “death wish preceded the physical illness … some patients are happy to be able to ask for euthanasia on the basis of a physical reason, while the real reason is deeper”.

In Marijke’s case, the physical reason was a terminal lung disease, which, Marc told me, she both exacerbated and exaggerated. She did this by cancelling physiotherapy sessions that might have slowed its progress, bombarding her GP with complaints about shortness of breath and slumping “like a sack of potatoes” whenever he visited. “To be sure of being euthanised,” Marc said drily, “you need above all to take acting lessons.”

What torments him today is that his mother died while there was hope that her illness could be slowed. “If she had cancer and was feeling pain and it was the last three months of her life, I would have been happy for her to have euthanasia. But she could have lived at least a few more years.”

Defenders of personal autonomy would say that Marc had no business interfering in his mother’s death, but beneath his anger lies the inconsolable sadness of a son who blames himself for not doing more. Marijke’s euthanasia was carried out according to the law, and will raise no alarms in the review board. It was also carried out without regard to her relatedness to other human beings.

For all the safeguards that have been put in place against the manipulation of applicants for euthanasia, in cases where patients do include relatives in their decision-making, it can never be entirely foreclosed, as I discovered in a GP’s surgery in Wallonia, the French-speaking part of Belgium.

The GP in question – we’ll call her Marie-Louise – is a self-confessed idealist who sees it as her mission to “care, care, care”. In 2017, one of her patients, a man in late middle-age, was diagnosed with dementia and signed a directive asking for euthanasia when his condition worsened. As his mind faltered, however, so did his resolve – which did not please his wife, who became an evangelist for her husband’s death. “He must have changed his mind 20 times,” Marie-Louise said. “I saw the pressure she was applying.”

In order to illustrate one of the woman’s outbursts, Marie-Louise rose from her desk, walked over to the filing cabinet and, adopting the persona of the infuriated wife, slammed down her fist, exclaiming, “If only he had the courage! Coward!”

Most medical ethicists would approve of Marie-Louise’s refusal to euthanise a patient who had been pressured. By the time she went away on holiday last summer, she believed she had won from her patient an undertaking not to press for euthanasia. But she had not reckoned with her own colleague in the practice, a doctor who takes a favourable line towards euthanasia, and when Marie-Louise returned from holidays she found out that this colleague had euthanised her patient.

When I visited Marie-Louise several months after the event, she remained bewildered by what had happened. As with Marc, guilt 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.”

While for many people whose loved ones have been euthanised, the procedure can be satisfactory and even inspiring, in others it has caused hurt and inner conflict. Bert Keizer rightly observes that suicide leaves scars on friends and family that may never heal. But suicide is an individual act, self-motivated and self-administered, and its force field is contained. Euthanasia, by contrast, is the product of society. When it goes wrong, it goes wrong for everyone.

Even as law and culture make euthanasia seem more normal, it remains among the most unfamiliar acts a society can condone. It isn’t enough that the legal niceties be observed; there needs to be agreement among the interested parties on why it is taking place, and to what end. Without consensus on these basic motivations, euthanasia won’t be an occasion for empathy, ethics or compassion, but a bludgeon swinging through people’s lives, whose handiwork cannot be undone.

Two years ago the Netherlands’ health and justice ministers issued a joint proposal for a “completed life” pill that would give anyone over 70 years of age the right to receive a lethal poison, cutting the doctor out of the equation completely. In the event, the fragmented nature of Dutch coalition politics stopped the proposal in its tracks, but doctors and end-of-life specialists I spoke to expect legislation to introduce such a completed-life bill to come before parliament in due course.

Assuming it could be properly safeguarded (a big assumption), the completed-life pill would not necessarily displease many doctors I spoke to; it would allow them to get back to saving lives. But while some applicants for euthanasia are furious with doctors who turn them down, in practice people are unwilling to take their own lives. Rather than drink the poison or open the drip, 95% of applicants for active life termination in the Netherlands ask a doctor to kill them. In a society that vaunts its rejection of established figures of authority, when it comes to death, everyone asks for Mummy.

Even those who have grave worries about the slippery slope concede that consensual euthanasia for terminal illness can be a beautiful thing, and that the principle of death at a time of one’s choosing can fit into a framework of care. The question for any country contemplating euthanasia legislation is whether the practice must inevitably expand – in which case, as Agnes van der Heide recognises, death will eventually “get a different meaning, be appreciated differently”. In the Netherlands many people would argue that – for all the current wobbles – that process is now irreversible.