After struggling with mental illness for years, Cornelia Geerts was so desperate to die that she asked her psychiatrist to kill her.
Her sister worried that Geerts' judgment was compromised. The 59-year-old was taking more than 20 pills a day, including antidepressants, an opioid, a tranquilizer, and two medicines often used to treat bipolar disorder and schizophrenia.
But about a year later, on October 7, 2014, Geerts received a lethal dose of drugs from her doctor.
"I know it was Cornelia's wish, but I said to the psychiatrist that it was a shame that someone in treatment for years could just be brought to the other side with a simple injection," said her sister, Adriana Geerts, who believes society should try harder to accommodate the mentally ill.
Cases like Geerts' reveal how difficult it can be to navigate the boundary between individual freedom and protecting vulnerable patients when it comes to euthanasia.
According to confidential documents obtained by the Associated Press, such cases have fueled a clash between leading euthanasia practitioners that suggests doctors may have failed to meet certain legal requirements in some euthanasia cases — although there is no implication that patients were killed improperly.
Aside from Belgium, euthanasia is also legal in Canada, Colombia, Luxembourg and the Netherlands. Only Belgium and the Netherlands allow it for people with mental illness. In most cases, euthanasia is performed on people with a fatal illness like cancer who have only weeks to live.
Euthanasia is not permitted in the U.S., but six states and Washington D.C. allow assisted suicide, where doctors provide people with a deadly dose of medication. People must be terminally ill and the procedure is forbidden for psychological suffering.
"I always regret that we couldn't do something else," said Dr. Lieve Thienpont, one of the psychiatrists who signed off on Geerts' death. "At the same time, I'm part of the relief for the patient."
Like many in Belgium, Thienpont believes that when modern medicine can't relieve pain, euthanasia — when doctors actively kill patients — should be an option. But Thienpont appears more inclined than most to approve euthanasia, some colleagues say.
According to figures that she has published, some doctors believe Thienpont and colleagues at her clinic may have been responsible for up to 40 percent of euthanasia deaths among psychiatric patients in Belgium from 2007 to 2011. Of the approximately 2,000 euthanasia deaths every year, about 40 are psychiatric patients.
The way she manages her euthanasia requests led to a rift earlier this year with Dr. Wim Distelmans, chairman of Belgium's euthanasia review commission.
Internal correspondence provided to the AP show Distelmans and his fellow practitioners said they were being used as a rubber stamp to approve patients referred by Thienpont.
Belgium requires that people seeking euthanasia for psychiatric reasons get an independent consultation from at least two other doctors. The doctors don't have to agree; the law only says that the objective assessments must be sought.
"We found several times that you had already made promises to patients that were referred to us," Distelmans and colleagues wrote, complaining that such "promises" undermined their own attempts to engage with patients and determine if euthanasia was justifiable.
"We want to distance ourselves from this way of working," Distelmans wrote, adding they would no longer accept patients from Thienpont.
Thienpont said the letter raised problems only about how patients were referred, not how she and colleagues were practicing euthanasia. She also blamed the patients for not describing events accurately.
"These patients are very desperate, stressed," she said. "They say things that are not always correct."
Some experts said the split between Thienpont and Distelmans raises alarms about euthanasia in Belgium, especially since the dispute has not been publicly disclosed by the commission overseeing it.
"That suggests some cases of euthanasia have proceeded that have not met the statutory, legal requirements," said Penney Lewis, co-director of the Centre of Medical Law and Ethics at King's College London. "The idea that this is happening behind closed doors is very worrying."
Distelmans did not respond to repeated requests for an interview.
Mental health experts say balancing the finality of euthanasia with the transient nature of many psychiatric illnesses is extraordinarily difficult.
"I'm convinced that in Belgium, people have died where there were still treatment options and where there was still a chance for years and even decades of (quality) life," said Dr. Joris Vandenberghe, a psychiatrist at the University of Leuven, who is working on new euthanasia guidance for the Flemish Psychiatric Association.
Some patients, though, say that euthanasia can save lives.
Amy De Schutter, who endured years of failed treatment at psychiatric institutions, spent months deliberating the best way to kill herself. She had already picked the day of her suicide, but one month before her intended death last year, she was approved for euthanasia.
"It felt like 10,000 kilos was just (lifted)," De Schutter said. Being cleared to legally die at home was comforting enough that De Schutter didn't set an immediate date for euthanasia.
But for some bereaved relatives, the loss of their loved one is compounded by a belief that doctors should have focused on keeping patients alive.
"I think if the doctors had tried to help (my sister) more or proposed other things, she might have felt there was another solution," said Adriana Geerts, who accompanied her sister to the euthanasia clinic despite her own misgivings.
"I wish there had been another way," Geerts said.Let's