Seduced by death: doctors, patients, and the Dutch cure.

• Author: Hendin, Herbert
• Position: Assen, Netherlands

In the Dutch city of Assen in the spring of 1993, a court of three judges acquitted a psychiatrist who had assisted in the suicide of his patient, a physically healthy fifty year old woman who had lost her two sons and who had been recently divorced from her husband. The court ruled that the psychiatrist, Dr. Boudewijn Chabot, was justified in his actions because his patient was competent to make the decision to die freely, her suffering was irremediable, and the doctor met the Dutch criterion for force majeure, meaning that he found it necessary to put the welfare of his patient above the law, which formally prohibits assisted suicide and euthanasia.(1)

The Assen case is joining the handful of internationally known Dutch cases of assisted suicide and euthanasia, each referred to by the name of the city where it was tried. The court's decision established a milestone extending Dutch toleration for assisted suicide and euthanasia into the treatment of suicidal patients who are not physically ill.

I have been involved with research into the problem of suicide and the treatment of suicidal patients all of my professional life. My studies have been psychosocial and psychodynamic in nature and have focused on the meaning and motivation for suicide in cultures and subcultures ranging from Scandinavia to Harlem and on particular groups such as college students, Vietnam veterans, and older persons.(2) I have become more directly involved with the question of assisted suicide and euthanasia since I began serving as executive director of the American Suicide Foundation, an organization that funds research and education designed to prevent suicide. Founded six years ago by scientists and lay people who were primarily occupied with the problem of suicide in general and the rise in youth suicide in particular, the foundation did not perceive euthanasia as an initial concern.

In the past few years public activism for assisted suicide and euthanasia--spurred by Jack Kevorkian, Timothy Quill, and Derek Humphry--has aroused our attention. While acknowledging that there are cases where helping a terminally ill patient to die in the final weeks of his or her illness may be humane and a physician would be justified in providing such help, the only consensus we have had is that the hasty and unreflective efforts that were being undertaken in several states to legalize assisted suicide and euthanasia were the worst possible answers to a problem that needs to be addressed.

Although both assisted suicide and euthanasia have been put forward as an expression of the individual's "right to die," some advocates have drawn a distinction between assisted suicide, where, as in the Assen case, the doctor prescribes or provides medication and informs the patient how much is needed to end life, and euthanasia, in which the doctor induces death, usually by injection with drugs. Assisted suicide has been seen as protecting against medical abuse by giving the patient control over his death. Advocates also see it as a first step, more likely to be accepted than euthanasia. Opponents see little protection in assisted suicide because by use of their influence or powers of coercion physicians or relatives can achieve the same result without direct action.

In the past ten years in this country the argument for medically assisted suicide has centered on the personal suffering of the terminally ill and has been seen as an extension of the right to refuse to be sustained on life support systems or to request not to be resuscitated. Advocates of euthanasia see no essential difference between a doctor's withdrawing futile treatment and his becoming a more direct participant in inducing death.

Assisted suicide and euthanasia are not yet advocated in this country for patients regarded as purely psychiatric. But the Assen case seemed to justify the concerns here as in the Netherlands of a "slippery slope" that moves society inexorably from assisted suicide to euthanasia, from euthanasia for the terminally ill to patients who are chronically ill, from physical suffering to mental suffering, from voluntary requests for euthanasia to killing at the discretion of the physician.

The rationale for such extensions has been that to deny the right to die with assistance to the chronically ill, who will have longer to suffer than the terminally ill, or to those who experience psychological pain not associated with physical disease is a form of discrimination. Involuntary euthanasia has been justified as necessitated by the need to make decisions for patients not competent to choose for themselves.

News accounts of the Assen case made me wonder about Chabot's willingness to assist in his patient's suicide. I was pleased when, before I left for the Netherlands on an already planned trip to look at euthanasia and assisted suicide in medical and psychiatric cases as well as the question of involuntary euthanasia, I received a letter from Chabot agreeing to my request to discuss the case. In addition, Rene Diekstra, who pioneered the acceptance of assisted suicide in the Netherlands, and Herbert Cohen, one of the most prominent practitioners of euthanasia in the country, had already agreed to discuss their work with me.

That the role of the doctor in determining whether a patient chooses assisted suicide would be a concern was underlined by the well-known case of assisted suicide in this country--that of Diane and her physician, Dr. Timothy Quill.

Quill, an associate professor at the University of Rochester School of Medicine, made a seemingly reasonable case for assisting in the suicide of Diane, who had been his patient for eight years and whose situation he described in the New England Journal of Medicine(3) and in a subsequent book, Death and Dignity: Making Choices and Taking Charge.(4) Quill, Diane's internist, tells us that Diane came from an alcoholic family and suffered from depression and alcoholism through much of her adult life. At the time of her death, she was a recovered alcoholic who had recently been diagnosed with acute leukemia. Her chances of surviving painful chemotherapy and radiation were assessed to be one in four. Diane told Quill that "she talked to a psychologist she had seen in the past"(5) and implied that the psychologist supported her decision to end her life. After Quill helped her to implement her decision, he published an account of what transpired in an attempt to persuade the medical community of the need for legal sanction for his actions.(6)

Quill's account aroused considerable controversy among physicians who responded with letters to the New England Journal of Medicine for or against ending the life of a terminally ill patient.(7) It was left to psychiatrists, most notably Dr. Patricia Wesley of Yale, whose insightful analysis of Diane's case in Issues in Law & Medicine(8) parallels my concerns, to challenge both Quill's role in Diane's decision and his account of their interaction, in which he appears as simply a compassionate figure responding in a disinterested way to her needs.

Quill tells us that, after the suspicion of leukemia was confirmed by bone marrow biopsy, the hospital oncologist, believing that delay was dangerous, "broke the news to Diane"(9) and began plans to begin chemotherapy. When Quill saw her shortly thereafter, "she was enraged at his (the oncologist's) presumption that she would want treatment and was devastated by the finality of the diagnosis."(10) She informed Quill that she wanted no treatment and wished to go home to be with her family. Instead of exploring with her what transpired with the oncologist or the inadvisability of a hasty decision made in anger, Quill tells us that "together we lamented her tragedy and the unfairness of life."(11)

Diane justifies her refusal of treatment and her desire for assistance with suicide by her need to be in control and by her conviction that she would die during the treatment for leukemia. Quill never questions her insistence on total control, an impossible demand in the face of serious illness, or sees this as potentially an aspect of depression, not simply a reasonable response. But characteristically it is suicidal people who are most afflicted by the need to control and to make demands on life that life cannot fulfill. Determining the time, place, and circumstances of death is the most dramatic of such demands. Depression, anxiety, and the wish to die are often the first reactions to the prospect of serious illness and possible death. Exploring and treating this demoralizing triad can change the decision whether to live with illness. That Diane appeared composed after deciding to end her life is not surprising. Those who are suicidal with or without physical illness often appear less depressed after deciding to end their lives. Coping with the uncertainties of life and death is what agitates and depresses them.

Diane's insistence that treatment would fail, which she had no way of knowing, is also not challenged by Quill. As Wesley points out:

It is frighteningly naive to assume that when our guide to medical practice is 'doing what the patient wants,' we will escape the imposition of the physician's values on the clinical encounter. Personal values can be sequestered in the question not asked, or the gentle challenge not posed, when both should have been.(12)

It is not surprising, given Quill's responses, that Diane went one step further than refusing treatment to ask for his help in dying. Although he initially tells her he cannot take part in her suicide, he tells us and appears to have conveyed to her that her "request made perfect sense."(13) Quill responded to Diane's wish for assisted suicide by referring her to the Hemlock Society, describing it as "helpful"(14) and implicitly, if unwittingly, giving her the message, as Wesley notes, that he agreed "if you cannot be fully independent, you are better off dead."(15) Wesley adds: "In making...