Worse than plastic waste: the burning tyres choking India

The British government is already flouting its own rules, allowing scrap tyres to be sent abroad for burning – what will happen post-Brexit asks George Monbiot in The Guardian?

 

‘Every month, thousands of tonnes of used tyres leave our ports on a passage to India.’ Illustration: Sébastien Thibault/The Guardian


What we see is not the economy. What we see is the tiny fragment of economic life we are supposed to see: the products and services we buy. The rest – the mines, plantations, factories and dumps required to deliver and remove them – are kept as far from our minds as possible. Given the scale of global extraction and waste disposal, it is a remarkable feat of perception management. 

The recent enthusiasm for plastic porn – footage of the disgusting waste pouring into the sea – is a rare reminder that we are still living in a material world. But it has had no meaningful effect on government policy. When China banned imports of plastic waste a year ago, you might have hoped that the UK government would invest heavily in waste reduction and domestic recycling. Instead, it has sought new outlets for our filth. Among the lucky recipients are Malaysia, Thailand and Vietnam, none of which have adequate disposal systems – as I write, our plastic is doubtless flooding into their seas. There’s a term for this practice: waste colonialism.

Our plastic exports are bad enough. But something even worse is happening that we don’t see at all. Every month, thousands of tonnes of used tyres leave our ports on a passage to India. There they are baked in pyrolysis plants, to make a dirty industrial fuel. While some of these plants meet Indian regulations, hundreds – perhaps thousands – are pouring toxins into the air, as officials look the other way. When tyre pyrolysis is done badly, it can produce a hideous mix: heavy metals, benzene, dioxins, furans and other persistent organic chemicals, some of which are highly carcinogenic. Videos of tyre pyrolysis in India show black smoke leaking from the baking chamber, and workers in T-shirts, without masks or other protective equipment, cleaning tarry residues out of the pipes and flasks. I can only imagine what their life expectancy might be. 

India suffers one of the world’s worst pollution crises, which causes massive rates of disease and early death. There is no data on the contribution made by tyre pyrolysis plants, but it is doubtless significant. Nor do we know whether British tyres are being burned in plants that are illegal, as our government has failed to investigate this. It seems prepared to break its own rules on behalf of the companies exporting our waste. And this is before Brexit.

Unlike plastic waste, there is a ready market for used tyres within the UK. They are – or were – compressed into tight blocks to make road foundations, embankments and drainage beds. It’s not the closed-loop recycling that should be applied to everything we consume, let alone the radical reduction in the use of materials required to prevent environmental breakdown. But it’s much better than what’s happening to our discarded tyres now. The companies that made these blocks have either collapsed or are in danger of going that way, as they can no longer buy scrap tyres: Indian pyrolysis plants pay more.

I was contacted by a leading tyre block broker, David L Reid. He was halfway through a major order from a local authority when his supplies dried up. The contract was lost, and the local authority had to switch to stone, costing it a further £200,000. He has other interests, so is able to weather this disruption, but his company, like others, has had to cease trading. With some of his former competitors, he has been frantically trying to discover what the government is playing at, so far with little success.

Government guidelines seem clear enough: exporters must be able to demonstrate that the final destination of the waste they send to other countries “operates to human health and environmental protection standards that are broadly equivalent to the standards within the EU”. But when one tyre block company tested the UK Environment Agency’s willingness to enforce this rule, by asking whether it could send tyres to pyrolysis plants in Africa that “will not meet UK and EU pollution controls”, the agency told him “your suggested business plan is acceptable as long as the relevant procedures and documents are completed correctly”. 

The UK government’s due diligence consists of asking tyre exporters which companies they intend to sell to, then asking the Indian government whether those companies are legit. It has made no efforts to discover whether the firms receiving these tyres are their final destination, or whether the Indian government is properly regulating them. It has no figures for UK tyre exports to India. Arguing that they are classed as “green waste”, it washes its hands of them as soon as they leave our shores.

To become a tyre trader, all you need to do is fill in a “U2 environmental exemption” form. Then you can buy used tyres from garages, ostensibly for bundling into construction blocks. But there appears to be nothing in British law (or at least in its implementation) to prevent you from using this licence to put them in a shipping container and send them to India.

I put questions to the government about these issues but, despite repeated requests, it failed to send me a response on time. Reid has approached the environment secretary, Michael Gove, his Labour shadow, Sue Hayman, Liam Fox and other MPs and officials, all without answers. Does anyone care? Are the lives of people in India worth nothing to politicians in this country?

It appears that among the first people to export used tyres to India, in 2009, was Richard Cook. He is the former Conservative parliamentary candidate for East Renfrewshire who channelled £435,000 (the origins of which remain mysterious) through Northern Ireland and into the leave campaign in England and Scotland. Investigations by openDemocracy and BBC Northern Ireland alleged that his shipment was classified as illegal by both the Indian government and UK regulators. Indian law at the time forbade used tyre imports. Cook denied the allegations. After I tried to speak to him, his solicitor rang to say “we have intimated a claim for damages against the BBC for defamation” and would not be making any further comment.

In principle, the government could be held to account on this issue by European law. But if this is the way it is prepared to operate before Brexit – flouting its own rules on behalf of British exporters – imagine what it might do after we have left the EU. Every child is taught a basic environmental principle: you clear up your own mess. Our government seems happy to dump it on other people.

Utopia for Realists

The commitment to EU integration must not be underestimated

Wolfgang Munchau in The FT

Aachen is close to the Dutch city of Maastricht, which gave its name to what is probably the most important European treaty of modern times. The treaty of Aachen, signed last week by German chancellor Angela Merkel and French president Emmanuel Macron, is of a different category. But you would be wrong to underestimate its significance. This treaty will set an agenda, just as the Franco-German Elysée Treaty did in 1963. And agendas matter in European discourse.

If you want to think of an analogy, consider the Werner Plan. In December 1969, in the twilight days of the Bretton Woods system of semi-fixed exchange rates, EU leaders held a summit in The Hague to set up a working group to study monetary union. It was headed by Pierre Werner, Luxembourg’s prime minister at the time. Economists were right at the time to dismiss the discussion of a future monetary union as pie-in-the-sky, just as defence experts today are right to dismiss talk about a European army. The Werner Report was an unrealistic road map to a single currency. But it nevertheless managed to put this hugely significant policy agenda on the table. It was another 30 years until the introduction of the euro. But without this first, failed step, it would never have happened. 

One of the many reasons why the UK is leaving the EU has been a persistent tendency to underestimate such symbolism. Another is the entrenched belief that the golden era of EU integration is behind us. The widespread dismissal in the UK press of the Aachen Treaty is very much in that tradition. 

Being in denial about integration does not square with the facts on the ground. I have often criticised the German government’s handling of the eurozone crisis. But I have never had any doubt about Germany’s ultimate commitment to monetary integration. The Aachen treaty provides no concrete solutions, but at the very least it underlines that commitment. Germany and France say, essentially, that they will do whatever it takes. Like Saint Augustine before them, they just do not want to do it yet. 

But they may not be able to wait too long. The EU must make some fundamental choices on the future of its dysfunctional monetary union. In the decade since the financial crisis, many of the problems in both the real economy and the financial sector have been left unaddressed. The so-called banking union has failed in its principal objective to break the doom loop between banks and sovereign borrowers. Italy continues to bail out its banks. I expect Germany to do the same very soon. 

The latest economic indicators suggest that the downturn is going to be steeper than previously thought. If short-term interest rates do not rise above -0.4 per cent at the top of the economic cycle, you know you have a very sick underlying economy. The European Central Bank’s latest bank lending survey suggests that credit conditions are now beginning to tighten in Italy, while the Netherlands is suffering from a financial bubble. In other words, we are entering a period in which policy reform will soon be on the agenda. 

In the discussion on common defence, we may only be at the point where we were in 1969 on monetary integration. The external event to prompt a rethink in Berlin and Paris has been repeated threats by President Donald Trump that the US will leave Nato. Even in the unlikely event of this happening, Germany and France would not be in a position to create a joint army. Germany, in particular, is politically not ready; it spends only 1.2 per cent of its gross domestic product on defence, as opposed to France’s 2 per cent. The German constitution mandates that any decision to deploy troops has to be agreed by the Bundestag. Attitudes towards military engagement differ fundamentally between the two.  
Aachen will not shift German political views on defence. But I would not rule out that, over time, it could become more acceptable for a German government to raise defence spending targets — so long as this occurs in a European context. After the Werner report came a series of loose currency arrangements followed by the European exchange rate mechanism. The way to a common army is not only paved with good intentions but with many small steps, such as a pooling of defence procurement. 

In the preamble to the Aachen treaty France and Germany promise to take their “bilateral relations to a new level”. One day, while you are looking the other way, that will actually happen.

Global Rich Gathered in Davos to Push for Rules Enabling Digital Colonisation

How the right tricked people into supporting rampant inequality

An LSE study has traced how we have come to swallow the meritocracy myth. This narrative needs to change writes Polly Toynbee in The Guardian

  

‘Talking to people using food banks and too often you hear people absorbing the blame. “I should have tried harder at school,” is a frequent refrain.’ Photograph: Murdo Macleod for the Guardian


Why don’t people rebel? The wonder of decades of rising inequality across the west is how placidly people put up with it. UK wages are still below 2008 levels, a growing sector of jobs are nasty – non-unionised, achingly hard, with workers treated worse, the boot on the employer’s foot despite low unemployment. You might call Brexit a kind of protest – but that can be overdone: the vote was swung largely by comfortable older Tory voters in the shires, led – or misled – by privileged ideologues.

Those on the progressive left have been perplexed that rising social injustice hasn’t led to much sign of the oppressed rising up, either in the ballot box or in protest. New research out on Wednesday from the London School of Economics suggests some explanations – though these will be of precious little comfort. Looking at surveys across the OECD’s 23 developed western countries since the 1980s, Dr Jonathan Mijs of the London School of Economics International Inequalities Institute monitors how, as countries become less equal, attitudes of the majority shift in the wrong direction.


Both rich and poor delude themselves they are ordinary

People come to believe more strongly that their country is a meritocracy where hard work and talent take people to the top. They are less likely to think structural inequalities or birth help or hinder people’s rise. The US, home of the American Dream – the myth that everyone has an equal chance to rise from log cabin to White House – is the most unequal, yet 95% now firmly believe in meritocracy, fewer in structural injustice. The UK, Australia and New Zealand are not far behind, sharing this Anglophone disease, a societal “body dysmorphia”: other European countries are less inclined to justify inequality, though the movement has been in that direction. This is the neoliberal triumph over hearts and minds.

The meritocracy myth comes with other tropes, especially placing the blame on the poor, with decreasing social empathy. Believing people sink through their own fault is the necessary adjunct for proving the mega-wealthy got there by merit alone.

In Britain, where inequality shot through the roof in the mid-80s and has stayed there ever since, we have seen how despising inequality’s losers has been deliberately fostered by governments. The Public and Commercial Services Union representing job centre staff, published a pamphlet this week outlining the decline in support for social security, and those who receive it. Remember the sheer spite of Peter Lilley, Tory social security secretary, in 1992 singing to his party conference a Mikado pastiche of a “little list” of people to be despised: “young ladies who get pregnant just to jump the housing queue” and “benefits offenders” making “bogus claims”. From then on the rightwing press and Benefits Street mockery set the tone of public contempt for anyone in need. Iain Duncan Smith used to send out juicy examples of benefit cheats to selected rightwing newspapers, without government figures showing fraud at just 1.1% of the benefits budget. In 2013, Ipsos Mori found that the public think £24 in every £100 is fraudulently claimed.

Politically, the mystery is why politicians got away with making things unfairer after the lid blew off top earning in the 80s. Now there’s less chance of owning a home, fewer savings, more debt and public services deteriorating. Cedric Brown, the first fat-cat shocker to catch the public eye, rewarded in 1995 for privatising British Gas with a salary of £475,000 (47 times that of his average employee), and a £600,000 incentive deal, comes from more innocent days. FTSE 100 CEOs now earn £4m.

Yet riots are extraordinarily rare – the French have always done it: it’s in their founding revolutionary DNA, and it helps to keep them less unequal than the Anglophones. Fear of revolution in cold war years kept unions strong and boardrooms wary of excess: the mid-70s, famed for union militancy, were the most equal years in British history.

This research suggests that as countries get more unequal people live in greater social isolation, locked within a narrow income group. Their friends and family share the same incomes, segregated by neighbourhood and marry similar partners. Children mix less in socially segregated schools. People no longer see over the high social fences so they don’t know how the other half lives, Mijs finds.

Ignorant of the facts, everyone wrongly places themselves on the income scale closer to the middle. Both rich and poor delude themselves they are ordinary. But telling people the facts doesn’t change their attitudes: increasingly they cling to a moral belief that people rise by merit, sinking for lack of it. Spend time talking to people using food banks or in Citizens Advice Bureaus knocked down by benefit sanctions, and too often you hear people absorbing the blame. “I should have tried harder at school,” is a frequent refrain, as if no other forces were at play. Talk to the mega-rich – I once conducted focus groups of earners up to £10m – and they are wilfully ignorant about their super-privilege, unshakable in believing their superior merit.

The right captured the story, the emotions, the moral framing: social democrats need to seize it back with a narrative of immorality that is more compelling. The British Social Attitudes survey suggests a swing back towards empathy with the swelling numbers of poor – more than £4m children. But still inheritance tax remains the most reviled of all taxes. The right forever try to prove the poor are stupider by nature than the rich, but Professor Steve Jones, celebrated geneticist, when asked about the heritability of intelligence, replies deftly that the most important heritable trait, by miles, is wealth.

The new elite’s phoney crusade to save the world – without changing anything

Today’s titans of tech and finance want to solve the world’s problems, as long as the solutions never, ever threaten their own wealth and power. by Anand Giridharadas in The Guardian 


A successful society is a progress machine. It takes in the raw material of innovations and produces broad human advancement. America’s machine is broken. The same could be said of others around the world. And now many of the people who broke the progress machine are trying to sell us their services as repairmen.

When the fruits of change have fallen on the US in recent decades, the very fortunate have basketed almost all of them. For instance, the average pretax income of the top 10th of Americans has doubled since 1980, that of the top 1% has more than tripled, and that of the top 0.001% has risen more than sevenfold – even as the average pretax income of the bottom half of Americans has stayed almost precisely the same. These familiar figures amount to three-and-a-half decades’ worth of wondrous, head-spinning change with zero impact on the average pay of 117 million Americans. Globally, over the same period, according to the World Inequality Report, the top 1% captured 27% of new income, while the bottom half of humanity – presently, more than 3 billion people – saw 12% of it. 

That vast numbers of Americans and others in the west have scarcely benefited from the age is not because of a lack of innovation, but because of social arrangements that fail to turn new stuff into better lives. For example, American scientists make the most important discoveries in medicine and genetics and publish more biomedical research than those of any other country – but the average American’s health remains worse and slower-improving than that of peers in other rich countries, and in some years life expectancy actually declines. American inventors create astonishing new ways to learn thanks to the power of video and the internet, many of them free of charge – but the average US high-school leaver tests more poorly in reading today than in 1992. The country has had a “culinary renaissance”, as one publication puts it, one farmers’ market and Whole Foods store at a time – but it has failed to improve the nutrition of most people, with the incidence of obesity and related conditions rising over time.

The tools for becoming an entrepreneur appear to be more accessible than ever, for the student who learns coding online or the Uber driver – but the share of young people who own a business has fallen by two-thirds since the 1980s. America has birthed both a wildly successful online book superstore, Amazon, and another company, Google, that has scanned more than 25m books for public use – but illiteracy has remained stubbornly in place, and the fraction of Americans who read at least one work of literature a year has dropped by almost a quarter in recent decades. The government has more data at its disposal and more ways of talking and listening to citizens – but only a quarter as many people find it trustworthy as did in the tempestuous 1960s.

Meanwhile, the opportunity to get ahead has been transformed from a shared reality to a perquisite of already being ahead. Among Americans born in 1940, those raised at the top of the upper middle class and the bottom of the lower middle class shared a roughly 90% chance of realising the so-called American dream of ending up better off than their parents. Among Americans born in 1984 and maturing into adulthood today, the new reality is split-screen. Those raised near the top of the income ladder now have a 70% chance of realising the dream. Meanwhile, those close to the bottom, more in need of elevation, have a 35% chance of climbing above their parents’ station. And it is not only progress and money that the fortunate monopolise: rich American men, who tend to live longer than the average citizens of any other country, now live 15 years longer than poor American men, who endure only as long as men in Sudan and Pakistan.

Thus many millions of Americans, on the left and right, feel one thing in common: that the game is rigged against people like them. Perhaps this is why we hear constant condemnation of “the system”, for it is the system that people expect to turn fortuitous developments into societal progress. Instead, the system – in America and across much of the world – has been organised to siphon the gains from innovation upward, such that the fortunes of the world’s billionaires now grow at more than double the pace of everyone else’s, and the top 10% of humanity have come to hold 85% of the planet’s wealth. New data published this week by Oxfam showed that the world’s 2,200 billionaires grew 12% wealthier in 2018, while the bottom half of humanity got 11% poorer. It is no wonder, given these facts, that the voting public in the US (and elsewhere) seems to have turned more resentful and suspicious in recent years, embracing populist movements on the left and right, bringing socialism and nationalism into the centre of political life in a way that once seemed unthinkable, and succumbing to all manner of conspiracy theory and fake news. There is a spreading recognition, on both sides of the ideological divide, that the system is broken, that the system has to change.

Some elites faced with this kind of gathering anger have hidden behind walls and gates and on landed estates, emerging only to try to seize even greater political power to protect themselves against the mob. (We see you, Koch brothers!) But in recent years a great many fortunate Americans have also tried something else, something both laudable and self-serving: they have tried to help by taking ownership of the problem. All around us, the winners in our highly inequitable status quo declare themselves partisans of change. They know the problem, and they want to be part of the solution. Actually, they want to lead the search for solutions. They believe their solutions deserve to be at the forefront of social change. They may join or support movements initiated by ordinary people looking to fix aspects of their society. More often, though, these elites start initiatives of their own, taking on social change as though it were just another stock in their portfolio or corporation to restructure. Because they are in charge of these attempts at social change, the attempts naturally reflect their biases.

For the most part, these initiatives are not democratic, nor do they reflect collective problem-solving or universal solutions. Rather, they favour the use of the private sector and its charitable spoils, the market way of looking at things, and the bypassing of government. They reflect a highly influential view that the winners of an unjust status quo – and the tools and mentalities and values that helped them win – are the secret to redressing the injustices. Those at greatest risk of being resented in an age of inequality are thereby recast as our saviours from an age of inequality. Socially minded financiers at Goldman Sachs seek to change the world through “win-win” initiatives such as “green bonds” and “impact investing”. Tech companies such as Uber and Airbnb cast themselves as empowering the poor by allowing them to chauffeur people around or rent out spare rooms. Management consultants and Wall Street brains seek to convince the social sector that they should guide its pursuit of greater equality by assuming board seats and leadership positions.

Conferences and ideas festivals sponsored by plutocrats and big business – such as the World Economic Forum, which is under way in Davos, Switzerland, this week – host panels on injustice and promote “thought leaders” who are willing to confine their thinking to improving lives within the faulty system rather than tackling the faults. Profitable companies built in questionable ways and employing reckless means engage in corporate social responsibility, and some rich people make a splash by “giving back” – regardless of the fact that they may have caused serious societal problems as they built their fortunes. Elite networking forums such as the Aspen Institute and the Clinton Global Initiative groom the rich to be self-appointed leaders of social change, taking on the problems people like them have been instrumental in creating or sustaining. A new breed of community-minded so-called B Corporations has been born, reflecting a faith that more enlightened corporate self-interest – rather than, say, public regulation – is the surest guarantor of the public welfare. A pair of Silicon Valley billionaires fund an initiative to rethink the Democratic party, and one of them can claim, without a hint of irony, that their goals are to amplify the voices of the powerless and reduce the political influence of rich people like them.

 

Bill Clinton and Richard Branson at a Clinton Global Initiative event in New York in 2006. Photograph: Tina Fineberg/AP

This genre of elites believes and promotes the idea that social change should be pursued principally through the free market and voluntary action, not public life and the law and the reform of the systems that people share in common; that it should be supervised by the winners of capitalism and their allies, and not be antagonistic to their needs; and that the biggest beneficiaries of the status quo should play a leading role in the status quo’s reform.
This is what I call MarketWorld – an ascendant power elite defined by the concurrent drives to do well and do good, to change the world while also profiting from the status quo. It consists of enlightened businesspeople and their collaborators in the worlds of charity, academia, media, government and thinktanks. It has its own thinkers, whom it calls “thought leaders”, its own language, and even its own territory – including a constantly shifting archipelago of conferences at which its values are reinforced and disseminated and translated into action. MarketWorld is a network and community, but it is also a culture and state of mind.

The elites of MarketWorld often speak in a language of “changing the world” and “making the world a better place” – language more typically associated with protest barricades than ski resorts. Yet we are left with the inescapable fact that even as these elites have done much to help, they have continued to hoard the overwhelming share of progress, the average American’s life has scarcely improved, and virtually all of the US’s institutions, with the exception of the military, have lost the public’s trust.

One of the towering figures in this new approach to changing the world is the former US president Bill Clinton. After leaving office in 2001, he came to champion, through his foundation and his annual Clinton Global Initiative gatherings in New York, a mode of public-private world improvement that brought together actors like Goldman Sachs, the Rockefeller Foundation and McDonald’s, sometimes with a governmental partner, to solve big problems in ways plutocrats could get on board with.

After the populist eruption that resulted in Hillary Clinton’s defeat in the 2016 US election, I asked the former president what he thought lay behind the surge of public anger. “The pain and road rage we see reflected in the election has been building a long time,” he said. He thought the anger “is being fed in part by the feeling that the most powerful people in the government, economy and society no longer care about them or look down on them. They want to become part of our progress toward shared opportunities, shared stability and shared prosperity.” But when it came to his proposed solution, it sounded a lot like the model to which he was already committed: “The only answer is to build an aggressive, creative partnership involving all levels of government, the private sector and nongovernment organisations to make it better.”

In other words, the only answer is to pursue social change outside of traditional public forums, with the political representatives of mankind as one input among several, and corporations having the big say in whether they would sponsor a given initiative or not. The public’s anger, of course, has been directed in part at the very elites he had sought to convene, on whom he had gambled his theory of post-political problem-solving, who had lost the trust of so many millions of people, making them feel betrayed, uncared for and scorned.

What people have been rejecting in the US – as well as in Britain, Hungary and elsewhere – was, in their view, rule by global elites who put the pursuit of profit above the needs of their neighbours and fellow citizens. These were elites who seemed more loyal to one another than to their own communities; elites who often showed greater interest in distant humanitarian causes than in the pain of people 10 miles to the east or west. Frustrated citizens felt they possessed no power over the spreadsheet- and PowerPoint-wielding elites commensurate with the power these elites had gained over them – whether in switching around their hours or automating their plant or quietly slipping into law a new billionaire-made curriculum for their children’s school. What they did not appreciate was the world being changed without them.

Which raises a question for all of us: are we ready to hand over our future to the plutocratic elites, one supposedly world-changing initiative at a time? Are we ready to call participatory democracy a failure, and to declare these other, private forms of change-making the new way forward? Is the decrepit state of American self-government an excuse to work around it and let it further atrophy? Or is meaningful democracy, in which we all potentially have a voice, worth fighting for?

There is no denying that today’s American elite may be among the more socially concerned elites in history. But it is also, by the cold logic of numbers, among the more predatory. By refusing to risk its way of life, by rejecting the idea that the powerful might have to sacrifice for the common good, it clings to a set of social arrangements that allow it to monopolise progress and then give symbolic scraps to the forsaken – many of whom wouldn’t need the scraps if society were working right. It is vital that we try to understand the connection between these elites’ social concern and predation, between the extraordinary helping and the extraordinary hoarding, between the milking – and perhaps abetting – of an unjust status quo and the attempts by the milkers to repair a small part of it. It is also important to understand how the elites see the world, so that we might better assess the merits and limitations of their world-changing campaigns.

There are many ways to make sense of all this elite concern and predation. One is that the elites are doing the best they can. The world is what it is, the system is what it is, the forces of the age are bigger than anyone can resist, and the most fortunate are helping. This view may allow that elite helpfulness is just a drop in the bucket, but reassures itself that at least it is something. The slightly more critical view is that this sort of change is well-meaning but inadequate. It treats symptoms, not root causes – it does not change the fundamentals of what ails us. According to this view, elites are shirking the duty of more meaningful reform.

But there is still another, darker way of judging what goes on when elites put themselves in the vanguard of social change: that doing so not only fails to make things better, but also serves to keep things as they are. After all, it takes the edge off of some of the public’s anger at being excluded from progress. It improves the image of the winners. By using private and voluntary half-measures, it crowds out public solutions that would solve problems for everyone, and do so with or without the elite’s blessing. There is no question that the outpouring of elite-led social change in our era does great good and soothes pain and saves lives. But we should also recall Oscar Wilde’s words about such elite helpfulness being “not a solution” but “an aggravation of the difficulty”. More than a century ago, in an age of churn like our own, he wrote: “Just as the worst slave-owners were those who were kind to their slaves, and so prevented the horror of the system being realised by those who suffered from it, and understood by those who contemplated it, so, in the present state of things in England, the people who do most harm are the people who try to do most good.”

 

Skid Row in downtown Los Angeles. Photograph: Frederic J Brown/AFP/Getty Images

Wilde’s formulation may sound extreme to modern ears. How can there be anything wrong with trying to do good? The answer may be: when the good is an accomplice to even greater, if more invisible, harm. In our era that harm is the concentration of money and power among a small few, who reap from that concentration a near monopoly on the benefits of change. And do-gooding pursued by elites tends not only to leave this concentration untouched, but actually to shore it up. For when elites assume leadership of social change, they are able to reshape what social change is – above all, to present it as something that should never threaten winners. In an age defined by a chasm between those who have power and those who don’t, elites have spread the idea that people must be helped, but only in market-friendly ways that do not upset fundamental power equations. Society should be changed in ways that do not change the underlying economic system that has allowed the winners to win and fostered many of the problems they seek to solve.

The broad fidelity to this law helps make sense of what we observe all around: powerful people fighting to “change the world” in ways that essentially keep it the same, and “giving back” in ways that sustain an indefensible distribution of influence, resources and tools. Is there a better way?

The secretary-general of the Organisation for Economic Co-operation and Development (OECD), a research and policy organisation that works on behalf of the world’s richest countries, has compared the prevailing elite posture to that of the fictional 19th-century Italian aristocrat Tancredi Falconeri, from Giuseppe Tomasi di Lampedusa’s novel The Leopard, who declares: “If we want things to stay as they are, things will have to change.” If this view is correct, then much of today’s charity and social innovation and buy-one-give-one marketing may not be measures of reform so much as forms of conservative self-defence – measures that protect elites from more menacing change. Among the kinds of issues being sidelined, the OECD leader wrote, are “rising inequalities of income, wealth and opportunities; the growing disconnect between finance and the real economy; mounting divergence in productivity levels between workers, firms and regions; winner-take-most dynamics in many markets; limited progressivity of our tax systems; corruption and capture of politics and institutions by vested interests; lack of transparency and participation by ordinary citizens in decision-making; the soundness of the education and of the values we transmit to future generations.” Elites, he wrote, have found myriad ways to “change things on the surface so that in practice nothing changes at all”. The people with the most to lose from genuine social change have placed themselves in charge of social change – often with the passive assent of those most in need of it.

It is fitting that an era marked by these tendencies should culminate in the election of Donald Trump. He is at once an exposer, an exploiter and an embodiment of the cult of elite-led social change. He tapped, as few before him successfully had, into a widespread intuition that elites were phonily claiming to be doing what was best for most Americans. He exploited that intuition by whipping it into frenzied anger and then directing most of that anger not at elites, but at the most marginalised and vulnerable Americans. And he came to incarnate the very fraud that had fuelled his rise, and that he had exploited. He became, like the elites he assailed, the establishment figure who falsely casts himself as a renegade. He became the rich, educated man who styles himself as the ablest protector of the poor and uneducated – and who insists, against all evidence, that his interests have nothing to do with the change he seeks. He became the chief salesman for the theory, rife among plutocratic change agents, that what is best for powerful him is best for the powerless too. Trump is the reductio ad absurdum of a culture that tasks elites with reforming the very systems that have made them and left others in the dust.

One thing that unites those who voted for Trump and those who despaired at his being elected – and the same might be said of those for and against Brexit – is a sense that the country requires transformational reform. The question we confront is whether moneyed elites, who already rule the roost in the economy and exert enormous influence in the corridors of political power, should be allowed to continue their conquest of social change and of the pursuit of greater equality. The only thing better than controlling money and power is to control the efforts to question the distribution of money and power. The only thing better than being a fox is being a fox asked to watch over hens.

What is at stake is whether the reform of our common life is led by governments elected by and accountable to the people, or rather by wealthy elites claiming to know our best interests. We must decide whether, in the name of ascendant values such as efficiency and scale, we are willing to allow democratic purpose to be usurped by private actors who often genuinely aspire to improve things but, first things first, seek to protect themselves. Yes, the American government is dysfunctional at present. But that is all the more reason to treat its repair as our foremost national priority. Pursuing workarounds of our troubled democracy makes democracy even more troubled. We must ask ourselves why we have so easily lost faith in the engines of progress that got us where we are today – in the democratic efforts to outlaw slavery, end child labour, limit the workday, keep drugs safe, protect collective bargaining, create public schools, battle the Great Depression, electrify rural America, weave a nation together by road, pursue a Great Society free of poverty, extend civil and political rights to women and African Americans and other minorities, and give our fellow citizens health, security and dignity in old age.

Much of what appears to be reform in our time is in fact the defense of stasis. When we see through the myths that foster this misperception, the path to genuine change will come into view. It will once again be possible to improve the world without permission slips from the powerful.

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.