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As the Netherlands alone has long practised legally sanctioned
assisted suicide and euthanasia, its experience is of great interest
to the rest of the world. Of particular significance have been the
Dutch government-sponsored studies conducted by van der Maas and his
colleagues in 19901 and 1995.2,3 Those studies
relied on data collected from a stratified sample of physicians
selected because their practices were likely to involve them in
end-of-life decisions.
In each of the studies, more than 6000 physicians were surveyed and
over 400 were interviewed. Informative data were collected.
However, the investigators' analysis of their data has been
criticised for emphasising procedural problems in the Dutch system
while ignoring more basic substantive flaws, such as whether
patients were offered treatment alternatives that might have made
euthanasia seem unnecessary.4-6 The same might be said of
the article in this issue of the Journal by Onwuteaka-Philipsen et
al7, which draws on the individual interviews with
physicians conducted in 1995 to discuss the use of consultants, a
requirement in the Netherlands in intended cases of assisted suicide
and euthanasia.
The purpose of consultation is to confirm that the attending
physician has followed established guidelines regarding the
voluntary, well-considered nature of the patient's decision, the
presence of suffering that must be unbearable and hopeless, and the
absence of any alternative treatment.
In a substantial number of cases, however, a consultation is not
obtained. Most of these cases involve violation of another Dutch
guideline: although all cases of assisted suicide and euthanasia
must be reported to the authorities, most (59%) are not.2 Only a minority
of unreported cases involve consultants.3 In the most flagrant
violation of Dutch guidelines, consultants are not called: between
900 and 1000 patients' lives are ended without their explicit consent
each year.1,2 In the 1995 study, 21% of
these patients were competent; in the 1990 study, 37% were competent.
A consultant was virtually never called when the lives of competent
patients were ended without their explicit consent.1
Onwuteaka-Philipsen et al report that 42% of the interviewed
physicians had at some time served as a consultant in an assisted
suicide or euthanasia case. More general practitioners than
specialists had done so (49% v. 30%). The authors note that, of the
physicians who had been a consultant more than once, 50% had
previously been consulted by the same physician. In 24% of these
cases, the treating physician and the consultant had previously
acted as consultants for each other. Recognising that such "pairs"
may compromise the independence of the consultants, the authors
appropriately suggest appointing independent consultants.
The Dutch cases I have reviewed warrant the need for concern. The
consultant basically functioned in a pro forma way, asking
questions to confirm that the patient wished to go forward with
euthanasia.8 The current article
indicates that physicians did not actually see the patients in 12% of
consultations. This probably reflects the view frequently
expressed to me by Dutch physicians that the consultations were for
the purpose of meeting legal requirements.
The authors point out that most Dutch physicians do not have much
experience in consulting in assisted suicide and euthanasia cases.
Only 27% of Dutch physicians who have served as consultants have done
so more than three times, and only 3% more than 10 times. The authors
state that "consultants need to have knowledge relevant to
euthanasia and assisted suicide, such as the possibilities of
palliative care. Gaining experience as a consultant seems to be
important for a physician to become comfortable in this role."
No one should assume that experience as a consultant in euthanasia
cases would make physicians knowledgeable about palliative care. My
own experience with a few physicians in the Netherlands who had
performed or been consultants in dozens of euthanasia cases was that
they were surprisingly uninvolved in palliative care. Nor did they
show sensitivity to the ambivalence that accompanies most requests
to die, clearly evident in some of the cases we discussed.8 They seemed to be
facilitators of the process rather than independent evaluators of
the patient's situation who might be able to relieve suffering so that
euthanasia seemed less necessary to the patient. One physician
described his role as easing the doubts of physicians who were
uncertain whether to go forward with euthanasia. He and the other
consultants were certainly knowledgeable in what the authors refer
to as the "medicotechnical" aspects of euthanasia -- they could end
life quickly and efficiently.
The Dutch have been widely criticised for their failure to provide
adequate palliative care or hospice care for terminally ill
patients.9,10 In recent testimony
before the British House of Lords, Zbigniew Zylicz, one of the few
palliative care experts in the Netherlands, emphasised Dutch
deficiencies in palliative care, attributing them partly to the
easier alternative of euthanasia. He saw the lack of hospice care in
the Netherlands and the fact that there are only 70 palliative care
beds in the country as reflections of this easier option.11
The conclusion in the Dutch studies that physicians in the
Netherlands essentially practise euthanasia when there is no other
alternative has been challenged.6,9,12,13 As neither the
attending doctors, nor the consultants, nor the
physician-interviewers in the government-sponsored studies were
trained in palliative care, they were not in a position to make such a
determination. Dr Zylicz, who has devoted his professional life to
relieving the suffering of terminally ill patients and to training
individual physicians in palliative care, finds his task
complicated by the attitude of a medical establishment that insists
on regarding euthanasia as a form of palliative care.14,15 This
attitude encourages physicians to find euthanasia, which is far less
demanding and challenging than what is ordinarily regarded as
palliative care, a suitable alternative.
Although the Dutch courts have ruled that unrelievable suffering
must be present for a physician to be justified in carrying out
euthanasia, it is increasingly accepted in the Netherlands and
elsewhere that suffering can be considered unrelievable if patients
simply exercise their right to refuse treatment for it. A prominent
Dutch investigator sees a shift away from unrelievable suffering
towards patient choice as the natural progression of a liberal
society's increasing emphasis on autonomy.16
The problem with this position is that it ignores what actually
happens when a suffering patient is confronted with a physician who
does not know how to relieve that suffering except by euthanasia. If
the only alternatives are continued suffering and an early death,
patients are not likely to feel they have a choice.
Study in the United States has shown that the more physicians know
about palliative care, the less they favour legalisation of assisted
suicide and euthanasia; the less they know, the more they favour
it.17 Caring for people at the
end of life is challenging, not only taking considerable skill but
also requiring a great deal emotionally of physicians. Medical
schools and residency training programs have only begun to prepare
physicians to meet this challenge. If they succeed, the question of
"euthanasia consultants" may become irrelevant.
Herbert Hendin
Professor of Psychiatry, New York Medical College, and
Medical
Director, American Foundation for Suicide Prevention, New York, USA
- van der Maas PJ, Van Delden JJM, Pijnenborg L. Euthanasia and other
medical decisions concerning the end of life. New York: Elsevier
Science Inc, 1992.
-
van der Maas PJ, van der Wal G, Haverkate I, et al. Euthanasia,
physician-assisted suicide, and other medical practices involving
the end of life in the Netherlands, 1990-1995. N Engl J Med
1996; 335: 1699-1705.
-
van der Wal G, van der Maas PJ, Bosma JM, et al. Evaluation of the
notification procedure for physician-assisted death in the
Netherlands. N Engl J Med 1996; 335: 1706-1711.
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Hendin H. Seduced by death: doctors, patients, and the Dutch cure.
Issues Law Med 1994; 20: 123-168.
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Keown J. Euthanasia in the Netherlands. In: Keown J, editor.
Euthanasia examined: ethical, clinical, and legal perspectives.
Cambridge: Cambridge University Press, 1995.
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Hendin H, Rutenfrans C, Zylicz Z. Physician-assisted suicide and
euthanasia in the Netherlands: lessons from the Dutch. JAMA
1997; 277: 1720-1722.
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Onwuteaka-Philipsen BD, van der Wal G, Kostense PJ, van der Maas PJ.
Consultants in cases of intended euthanasia or assisted suicide in
the Netherlands. Med J Aust 1999; 170: 360-363.
-
Hendin H. Seduced by death: doctors, patients and assisted
suicide. New York: W W Norton & Company, 1998.
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Zylicz Z. Euthanasia [letter]. Lancet 1991; 338: 1150.
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Dorrepaal KL, Aaronson NK, Van Dam F. Pain experience and pain
management among hospitalized cancer patients. Cancer
1989; 63: 593-598.
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Matthews H. Better palliative care could cut euthanasia [news].
BMJ 1998; 317: 1613.
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Gomez C. Regulating death: euthanasia and the case of the
Netherlands. New York: Free Press, 1991.
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Jochemsen H, Keown J. Voluntary euthanasia: under control?
Further empirical evidence from the Netherlands. J Med Ethics
1999; 25: 16-21.
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Admiraal PV. A physician's responsibility to help a patient die.
In: Misbin RI, editor. Euthanasia: the good of the patient, the good of
society. Frederick, Md: University Publishing Group, 1992.
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Borst-Eilers E. Euthanasia in the Netherlands: brief historical
review and present situation. In: Misbin RI, editor. Euthanasia: the
good of the patient, the good of society. Frederick, Md: University
Publishing Group, 1992.
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Van Delden JJM. Slippery slopes in flat countries -- a response.
J Med Ethics 1999; 25: 22-24.
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Portenoy RK, Coyle N, Kash KM, et al. Determinants of the
willingness to endorse assisted suicide: a survey of physicians,
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©MJA 1999
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