"Culture of death" in the Netherlands: Dutch perspectives.

• Author: Cohen-Almagor, Raphael

ABSTRACT: During the summer of 1999, extensive interviews with some of the leading authorities on euthanasia policy were conducted in the Netherlands. They were asked: Daniel Callahan argues that there is a `culture of death' in the Netherlands. What do you think?

The majority of interviewees disagreed with the statement. They said that the Netherlands is not fundamentally different than other countries. If at all, the Dutch culture is open and tolerant, welcomes debates and plurality of views, and physicians are decent people who wish to help their patients, not to kill them. A small minority acknowledged that there is some truth in Callahan's observations, arguing that the Dutch actually do not welcome critique and are quite conservative in their liberal attitude toward euthanasia.

In March 1999 I visited the Hastings Center in New York. During one of my conversations with Daniel Callahan, he voiced his concern about the situation in the Netherlands, saying that a "culture of death" exists in the country that results in premature death of many patients. Having investigated the Dutch experience for a number of years, in the summer of 1999 I went to the Netherlands to visit the major centers of medical ethics as well as some research hospitals, and to speak with some of the leading figures in euthanasia policy and practice. I wanted to see what people who participate in the public debate think of the situation in the Netherlands, whether they evaluate the situation positively or negatively. For this purpose I raised the issue whether a "culture of death" exists in the Netherlands, to see what their reactions would be. This study reports their answers to this troublesome question. On purpose I refrained from explaining what I mean by a "culture of death." I wanted to know whether the interviewees have different ideas on what would constitute such a culture.

This question came late in the interviews. I admit that I did not ask it during all of the interviews for fear that the interviewee might walk away. Some of them did not appreciate this line of questioning, and I did not want to end the interview prematurely. Indeed, the question did upset some of the remaining interviewees.

Methodology

Before arriving in the Netherlands, I wrote to some distinguished experts in their respective fields: medicine, psychiatry, philosophy, law, social sciences and ethics, asking to meet with them in order to discuss the Dutch policy and practice of euthanasia. Only one--Dr. Chabot--explicitly declined my request for an interview. (1)

The interviews took place during July-August 1999, in the Netherlands. They lasted between one to three hours each. Most interviews went on for more than two hours during which I asked more or less the same series of questions. (2) During the interviews I took extensive notes that together comprise some 200 dense pages. Later the interviews were typed and analyzed.

The interviews were conducted in English, usually in the interviewees' offices. Four interviews were conducted at the interviewees' private homes, and four interviews in "neutral" locations: coffee shops and restaurants. Two interviews were conducted at the office kindly made available to me at the Department of Medical Ethics, Free University of Amsterdam.

The interviews were semi-structured. I began with a list of fifteen questions but did not insist on all of them when I saw that the interviewee preferred to speak about subjects that were not included in the original questionnaire. With a few interviewees I spoke only about their direct involvement in the practice of euthanasia. This article reports the answers to only one of the questions concerning the Dutch socio-medical culture. For limitations of space I cannot possibly report the extensive answers to my fifteen questions. This is done in my forthcoming book Euthanasia in the Netherlands.

The Question and Interviewees' Responses

The question was posed as follows: Daniel Callahan argues that there is a `culture of death' in the Netherlands. What do you think?

The majority of interviewees rejected Callahan's statement tout court. A small minority that objects to the euthanasia policy and practice agreed with the statement. Henk Leenen, one of the forefathers of the euthanasia campaign, was surprised by my question and looked somewhat offended. (3) He said: "We do not have a `culture of death.' We strive to prevent the slippery slope. In the 1960s, the same criticism was voiced in regard to the legalization of abortion. Presently, the Netherlands, with its liberal policy on abortion, has the lowest rate of abortion in the world, in proportion to its size. There was no slippery slope as a result of the liberal abortion law." Leenen is certain that the Netherlands does not have more euthanasia cases than other countries. The problem is that there is no way to prove this because little data is available in regard to what is taking place in other parts of the world. (4) Leenen concluded his answer by saying that Callahan is speculating, "imagining fiction" without any hard data. On a personal level, it seems to Leenen that Callahan does not trust human intentions. After all, most people have respect for other people, and most physicians are not criminals. Physicians act in a bona fide manner to fulfill the wishes of their patients.

Rob Houtepen, an ethicist from Maastricht, argued that there is no general climate of death and that there are no shortcuts to performing euthanasia, as Callahan alleges. He acknowledges that there is a need to be on guard, but "there is no room for alarm." Yes, there is a need to improve the notification procedure, but if the Guidelines are followed, then there is no danger of abuse. At the present time, Houtepen admits, the Guidelines are insufficiently followed. Houtepen ended his defense by saying that the 1990 and 1995 reports do not indicate a slippery slope.

Interestingly, later in the interview, Houtepen suggested that hospital physicians thrive on action. In their quest to cure, they always seek something else to do, something to explore. This is their culture. Consequently, euthanasia is not a popular practice in hospitals, and there is no need to worry about physicians' conduct. "Relatively speaking," Houtepen elucidated, "the weak point are the GPs." In hospitals and nursing homes, there are mechanisms of social control. The nursing staff works in teams, and there are usually people around, whereas GPs act more or less alone. It is worth noting that, as the data show, most of the euthanasia cases are performed by GPs. (5)

Ron Berghmans, another ethicist from Maastricht, attempted in his answer to counterbalance the "culture of death" notion by pointing out that there are many cases in which euthanasia was requested but not performed. (6) In general, the spirit of medicine and health care is to help people and not to kill them. Berghmans explained that the Dutch climate is different from other countries insofar as patients feel that they have the right to request a quick death, to determine the moment of death, and to receive full compliance by their doctors. Consequently, patients can put a lot of pressure on doctors to comply with euthanasia requests. There is no insistence on continuing life by all means, and the emphasis is put on the meaning and quality of life. Furthermore, there are open discussions about what constitutes useful treatment. Euthanasia, physician-assisted suicide (PAS) and painkillers are all considered as legitimate mechanisms to prevent unnecessary suffering.

Egbert Schroten, Director of the Center for Bioethics and Health Law at Utrecht University, thought that the notion of a culture of death is an exaggeration, claiming that it is much more difficult to control passive euthanasia. Sometimes doctors switch machines sooner than required, "but...