Physician-assisted death in the Netherlands: impact on long-term care.

• Author: Fenigsen, Richard

Active euthanasia has been practiced in the Netherlands for twenty-three years, a time probably much too short to expose all the changes euthanasia brings about in society, but long enough to reveal some of the consequences. Indeed, the practice of euthanasia has perceptibly affected the position of the individual in relation to society, society's very nature and purpose, the law, the government, the judicial system, the family, the expectations of older persons and the prospects of newborn infants, the practice of medicine, and the care of persons with disabilities.

It is important to realize that among the industrialized nations Holland has developed one of the best, and arguably the best, health care system and an excellent system of care for older persons and people with disabilities. Practically all residents have health insurance that covers all essential expenses, including the costs of a prolonged or terminal illness. Money matters play no role in a patient's decisions concerning medical treatment. A high percentage of physicians practice family medicine, which makes health care eminently accessible. There are no crowded emergency rooms. Nursing homes and institutions for mentally retarded persons are modern, well equipped, and manned by skilled and dedicated workers.

Now in the country where so much has been and still is being done to secure good and lifelong care for everybody, the lives of many people are deliberately put to an end, and this happens sometimes upon the request of the person in question and sometimes without his or her request, consent, or knowledge.

The figures presented in Tables 1 and 2 are taken or computed from the Report of the Dutch Governmental Committee on Euthanasia and pertain to the year 1990, when the government-ordered survey of the practice was conducted.

Table 1 Euthanasia by Omission in the Netherlands(1) Withdrawing or Withholding of Nonfutile Number of Deaths Medical Treatment with Intention to Terminate Life Caused in 1990 With Patient's Consent 4,756 Without Patient's Consent 8,750 Total 13,506 Table 2 Active Euthanasia in Holland: Number of Cases in 1990(2) Physician- Morphine Overdose Assisted Active Intended to Suicide Euthanasia Terminate Life Total With Patient's Consent 400 2,300 3,159 5,859 Without Patient's Consent -- 1,000 4,941 5,941 Total 400 3,300 8,100 11,800 For a country of Holland's size, the total of 11,800 cases of active euthanasia a year is a large number. Holland's population is fifteen million. If the United States practiced active euthanasia to the extent it is being done in Holland, this would amount to more than 190,000 cases a year.

The figures further show that euthanasia performed without the patient's request, consent, or knowledge occurs more often than euthanasia upon a patient's request.

Seventy-six percent of adult patients who underwent nonvoluntary euthanasia suffered from various forms of cancer; others had heart or lung disease, stroke or other neurological disorder, or mental illness.(3) Twenty-five percent of patients who underwent nonvoluntary active euthanasia were fully competent.(4)

The Report of the Governmental Committee confirmed that the lives of newborn babies with disabilities and of gravely ill children are also terminated,(5) but no exact figures pertaining to these groups were obtained. However, an estimate of euthanasia on newborn babies and infants up to three months after birth was published by the Royal Dutch Society of Medicine in 1988. Annually, three hundred babies disabled due to extreme prematurity, birth trauma, spina bifida, or Down syndrome are starved and dehydrated to death or denied lifesaving surgery; ten babies with disabilities receive lethal injections each year.(6)

A Committee of the Royal Dutch Society of Medicine stated that termination of life of a newborn is justified if the child almost certainly would have an unliveable life.(7) However, the question should be asked, What kind of life is "unliveable," not for the parents, the doctor, or the ethicist, but for the child involved? In practice, the lives of children with Down syndrome are terminated, although it is well known that people with this disability enjoy their lives. These lives clearly are not unliveable but simply unwanted by the parents and unacceptable for others.

There may be disagreements between the persons who decide, but if the doctor and the parents agree on euthanasia, the life of the child will be terminated.(8)

According to the Royal Society's Committee, when the life of a disabled newborn is terminated, this should be done by refraining from lifesaving medical interventions and depriving the child of food and water; only when this is done and the child does not die, a lethal injection is justified. Again, the practice in some cases departs from the official advice, and doctors proceed directly to administering the lethal injections.

The individual cases become known when published in professional journals,(9) when somebody opposed to the termination of the child's life calls in help from outside the hospital, or when the perpetrator or the authorities put the case to trial in order to establish a legal precedent.

The justifications and the circumstances of euthanasia on newborns and children are illustrated by the following published case histories:

1. A baby born with Down syndrome vomited all nourishment and was admitted to one of the country's leading centers for pediatric surgery, the Sophia Hospital in Rotterdam. It was found that the child had an inborn defect of the digestive tract, duodenal atresia, which made it impossible for food to pass from the stomach to the intestines. In these cases, surgery to remove the obstruction is feasible and lifesaving. However, the parents and the pediatric surgeon, Professor Molenaar, decided to refrain from surgery and let the child die. The family physician, who could not reconcile himself with putting the child to death, called the district attorney. The latter warned the Council for Children's Protection, but this body decided not to intervene. No surgery was done and the child died.(10) A court, and then the Supreme Court, exonerated the surgeon.(11) The family physician was harshly criticized because by calling the DA he broke his oath of confidentiality.12

   The case provoked a broad discussion, which took an unexpected turn: Many debaters condemned Professor Molenaar's course of action.(13) The Minister of Welfare, Health, and Culture declared that medical treatment should never be refused on the grounds of mental handicap.(14) There was no doubt that the case was just one example of a more widespread practice. Indeed, a team of anesthetists at a teaching hospital decided never to provide anesthesia for cardiac surgery in children with Down syndrome; and there were reports of three children with this syndrome who were denied vitally important surgery for their inborn cardiac defects.(15) The parents persevered and finally found hospitals that accepted the children for surgery.

2. A girl born prematurely, in the thirty-second week, recovered from an infection, but there was a suspicion of intracranial bleeding. This was followed by accumulation of intracranial fluid. The parents refused to allow the insertion of a drainage tube or shunt. On the thirtieth day after birth the child was killed by the pediatrician with injections of a morphine-like drug and potassium chloride.(16)

3. After consulting several specialists and getting the approval of the parents, Dr. Henk Prins, an obstetrician, killed a girl born with spina bifida and hydrocephalus. The Minister of justice decided to put Dr. Prins on trial, expecting a verdict that would establish a legal precedent.(17)

4. Danny had spina bifida and hydrocephalus but was in fair general condition. No drainage tube to relieve the hydrocephalus was inserted. Once Danny seemed to...