An outsider's view of Dutch euthanasia policy and practice.

• Author: Cohen-Almagor, Raphael

ABSTRACT: This article provides a critical analysis of Dutch euthanasia policy and practice. The research benefited from twenty-eight interviews conducted in the Netherlands during the summer of 1999 with some of the leading figures who dictate the decision-making process and take an active part in the debates. The discussion begins with a review of the two major Dutch reports on euthanasia and the conflicting views and interpretations offered by the literature. Next, I provide some data about the interviews, and then analysis indicating that the Dutch Guidelines on the policy and practice of euthanasia do not provide ample mechanisms against abuse. I argue that the Dutch Guidelines are insufficient, do not provide adequate control over the practice of euthanasia, and that the entire policy should be revised and made more coherent and more comprehensive.

The Dutch experience has influenced the debate on euthanasia and death with dignity around the globe, especially with regard to whether physician-assisted suicide and euthanasia should be legitimized or legalized. Review of the literature reveals complex and often contradictory views about this experience. Some claim the Netherlands offers a model for the world to follow; others believe the Netherlands represents danger rather than promise, that the Dutch experience is the definitive answer why we should not make active euthanasia and physician-assisted suicide part of our lives.

Given these contradictory views, fieldwork is essential to develop a fully informed opinion. 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 leading figures in euthanasia policy and practice. This article reports the main findings of my interviews and provides detailed accounts of the way in which some of the Netherlands' leading experts perceive the policy and practice of euthanasia in their country. These accounts are quite fascinating.

The discussion begins with a review of the two major Dutch reports on euthanasia and the conflicting views and interpretations offered by the literature. Next, I provide some data about the interviews, and then analysis indicating that the Dutch Guidelines on the policy and practice of euthanasia do not provide ample mechanisms against abuse. Virtually every guideline has been breached or violated. This finding reiterates Hendin's finding.(1) I conclude by recommending that the Netherlands amend its policy and remedy its troubling practice. The findings should compel us to conduct further investigation and research. The Netherlands should overhaul its policy and procedures to prevent potential abuse.

Background

Since November 1990, prosecution is unlikely if a doctor complies with the Guidelines on euthanasia and physician assisted suicide set out in the non-prosecution agreement between the Dutch Ministry of Justice and the Royal Dutch Medical Association. These Guidelines are based on the criteria set out in court decisions relating to when a doctor can successfully invoke the defense of necessity

The substantive requirements are as follows:

* The request for euthanasia or physician-assisted suicide must be made by the patient and must be free and voluntary.

* The patient's request must be well considered, durable and consistent.

* The patient's situation must entail unbearable suffering with no prospect of improvement and no alternative to the end of suffering.(2) The patient need not be terminally ill to satisfy this requirement and the suffering need not necessarily be physical.

* Euthanasia must be a last resort.(3)

The procedural requirements are as follows:

* No doctor is required to perform euthanasia but if he/she is opposed on principle the doctor must make his/her position known to the patient early on and help the patient get in touch with a colleague who has no such moral objections.

* Doctors taking part in euthanasia should preferably and whenever possible have patients administer the fatal drug to themselves, rather than have a doctor apply an injection or intravenous drip.(4)

* A doctor must perform the euthanasia.

* Before the doctor assists the patient, the doctor must consult a second independent doctor who has no professional or family relationship with either the patient or doctor. Since the 1991 Chabot case,(5) if the patient has a psychiatric disorder the doctor must cause the patient to be examined by at least two other doctors, one of whom must be a psychiatrist.

* The doctor must keep a full written record of the case.

* The death must be reported to the prosecutorial authorities as a case of euthanasia or physician-assisted suicide (PAS), and not as a case of death by natural causes.(6)

In 1990, the Dutch government appointed a commission to investigate the medical practice of euthanasia. The Commission, headed by Professor Jan Remmelink, Solicitor General to the Supreme Court, was asked to set up an inquiry research team to conduct a comprehensive nation-wide study of"medical decisions concerning the end of life" (MDEL). The following broad forms of MDEL were studied:

* Non-treatment decisions: withholding or withdrawing treatment in situations where treatment would probably have prolonged life;

* Alleviation of pain and symptoms: administering opioids in such dosages that the patient's life could be shortened;

* Euthanasia and related MDEL: the prescription, supply or administration of drugs with the explicit intention of shortening life, including euthanasia at the patient's request, assisted suicide, and life termination without explicit and persistent request.(7)

The study was repeated in 1995, making it possible to assess for the first time whether there were harmful effects over time that might have been caused by the availability of voluntary euthanasia in the Netherlands. It was difficult to make valid comparisons with other countries, not only because of legal differences but also because similar studies have not been done.(8)

The two Dutch studies were said to give the best estimate of all forms of MDEL (i.e., all treatment decisions with the possibility of shortening life) in the Netherlands as around 39% of all deaths in 1990, and 43% in 1995. In the third category of MDEL, the studies gave the best estimate of voluntary euthanasia as 2300 persons each year (1.9% of all deaths) in 1990,(9) and 3250 persons each year (2.4%) in 1995. The estimate for physician-assisted suicide was about 0.3% in 1990 and in 1995. There were 8900 explicit requests for euthanasia or assisted suicide in the Netherlands in 1990, and 9700 in 1995. Less than 40% were proceeded with. The most worrisome data is concerned with the hastening of death without the explicit request of patients. There were 1000 cases (0.8%) without explicit and persistent request in 1990, and 900 cases (0.7%) in 1995.(10)

In 1990, 30% of the general practitioners (GPs) interviewed said they had performed a life-terminating act at some time without explicit request (compared with 25% of specialists and 10% of nursing home physicians).(11) Performing a life-terminating act without explicit request occurred, on the average, with older patients than did euthanasia or physician-assisted suicide.(12) There were still treatment alternatives in 8% of cases in which a life-terminating act was performed without explicit request of the patient. The physician did not use these alternatives because the patient had indicated she/he no longer wanted it, because it "only would prolong suffering," or because the expected gain was not enough to make the treatment worthwhile.(13) It should be noted that the level of consultation was significantly lower in life-termination acts without the patient's explicit request compared with euthanasia or physician-assisted suicide. A colleague was consulted in 48% of the cases (compared with 84% in euthanasia and assisted suicide cases).(14) Relatives were consulted in 72% of the cases (compared with 94% in euthanasia and assisted suicide cases). In 68% of the cases, the physician felt no need for consultation because the situation was clear.(15) Van der Maas and colleagues note that this should be considered in light of the very brief period by which life was shortened.(16)

About a quarter of the one thousand patients had earlier expressed a wish for voluntary euthanasia.(17) The patient was no longer competent in almost all of those cases. In 67% of cases in this group death was hastened by a few hours or days; in 21% of cases the patients' lives were shortened by one to four weeks; in 7% of cases by one to six months, and in 1% of cases by more than half a year.(18) A small number of cases (approximately fifteen) involved babies who were suffering from a serious congenital disorder and were barely viable; the doctor decided, in consultation with the parents, to hasten the end of life.(19)

The Remmelink Commission regarded these cases of involuntary termination of life as "providing assistance to the dying." They were justified because the patients' suffering was unbearable, standard medical practice failed to help and, in any event, death would have occurred within a week.(20) The Commission added that actively ending life when the vital functions have started failing is indisputably normal medical practice: "It deserves recommendation that the reporting procedures in place ... will in the future also cover the active termination of life by a doctor in the framework of help-in-dying without an explicit request by the patient," except if it concerns a situation where there is "the beginning of irreversible, interrelated failure of vital functions." In this last case "natural death would very quickly occur even if the doctor did not actively intervene.... "The recommendation goes on to say that this is not the case with patients whose vital functions are still...