Euthanasia in the Netherlands University of Haifa ( May 2005 )

Euthanasia in the Euthanasia in the NetherlandsNetherlands

University of HaifaUniversity of Haifa

( (May 2005May 2005))

Raphael Cohen-AlmagorRaphael Cohen-Almagor

Preliminaries: Comparative Preliminaries: Comparative LawLaw

Preliminaries: Comparative Preliminaries: Comparative LawLaw

Part A: BackgroundPart A: Background

1. The Three Research Reports of 1. The Three Research Reports of 1990, 1995 and 2003 and Their 1990, 1995 and 2003 and Their InterpretationsInterpretations

2. The Practice of Euthanasia and the 2. The Practice of Euthanasia and the Legal FrameworkLegal Framework

Part B: FieldworkPart B: Fieldwork

3. The Methodology3. The Methodology

Phase I: The InterviewsPhase I: The Interviews

4. Why the Netherlands?4. Why the Netherlands?5. Views on the Practice of 5. Views on the Practice of

Euthanasia Euthanasia

66 . .Worrisome DataWorrisome Data

““Some of the most worrisome data in Some of the most worrisome data in the two Dutch studies are concerned the two Dutch studies are concerned with the hastening of death without with the hastening of death without the explicit request of patients. There the explicit request of patients. There were 1000 cases (0.8%) without were 1000 cases (0.8%) without explicit and persistent request in explicit and persistent request in 1990, and 900 cases (0.7%) in 1995. 1990, and 900 cases (0.7%) in 1995. What is your opinion?”What is your opinion?”

77 . .The Remmelink Contention The Remmelink Contention and the British Criticismand the British Criticism

The Remmelink Commission held that actively ending The Remmelink Commission held that actively ending life when the vital functions have started failing is life when the vital functions have started failing is indisputably normal medical practice. Is this correct? indisputably normal medical practice. Is this correct?

What is your opinion?What is your opinion?

In its memorandum before the House of Lords, the BMA In its memorandum before the House of Lords, the BMA held that in regard to Holland, “all seem to agree that held that in regard to Holland, “all seem to agree that the so-called rules of careful conduct (official guidelines the so-called rules of careful conduct (official guidelines for euthanasia) are disregarded in some cases. Breaches for euthanasia) are disregarded in some cases. Breaches of rules range from the practice of involuntary of rules range from the practice of involuntary euthanasia to failure to consult another practitioner euthanasia to failure to consult another practitioner before carrying out euthanasia and to certifying the before carrying out euthanasia and to certifying the cause of death as natural.”cause of death as natural.”

I asked my interviewees: Do you agree?I asked my interviewees: Do you agree?

8. Should Physicians Suggest 8. Should Physicians Suggest Euthanasia to Their Patients?Euthanasia to Their Patients?

99 . .Breaches of the GuidelinesBreaches of the Guidelines

The physician practicing euthanasia The physician practicing euthanasia is required to consult a colleague in is required to consult a colleague in regard to the hopeless condition of regard to the hopeless condition of the patient. Who decides who the the patient. Who decides who the second doctor will be? second doctor will be?

What happens in small rural villages What happens in small rural villages where it might be difficult to find an where it might be difficult to find an independent colleague to consultindependent colleague to consult. .

Lack of ReportingLack of Reporting Record-keeping and written requests of Record-keeping and written requests of

euthanasia cases have improved euthanasia cases have improved considerably since 1990; there are now considerably since 1990; there are now written requests in about 60% and written written requests in about 60% and written record-keeping in some 85% of all cases of record-keeping in some 85% of all cases of euthanasia. The reporting rate for euthanasia. The reporting rate for euthanasia was 18% in 1990, and by 1995 it euthanasia was 18% in 1990, and by 1995 it had risen to 41%. The trend is reassuring, had risen to 41%. The trend is reassuring, but a situation in which less than half of all but a situation in which less than half of all cases are reported is unacceptable from the cases are reported is unacceptable from the point of view of effective control.point of view of effective control.

What do you think? What do you think? How can the reporting rate be improved?How can the reporting rate be improved?

1010 . .On Palliative Care and the On Palliative Care and the Dutch CultureDutch Culture

It has been argued that the policy It has been argued that the policy and practice of euthanasia is the and practice of euthanasia is the result of undeveloped palliative result of undeveloped palliative care. What do you think? care. What do you think?

I also mentioned the fact that there I also mentioned the fact that there are only a few hospices in the are only a few hospices in the Netherlands.Netherlands.

Culture of DeathCulture of Death Daniel Callahan Daniel Callahan

argues that there is argues that there is aa “ “culture of culture of deathdeath” ” in thein the Netherlands.Netherlands.

What do you think? What do you think?

Culture of deathCulture of death

I intentionally I intentionally refrained from refrained from explaining the term explaining the term “culture of death.” I “culture of death.” I wanted to see wanted to see whether the whether the interviewees have interviewees have different ideas on different ideas on what would constitute what would constitute such a culturesuch a culture..

11. On Legislation 11. On Legislation and the and the Chabot Chabot CaseCase

IIPhase IIPhase Interviewees’ General Interviewees’ General CommentsComments

PreliminariesPreliminariesGeneral CommentsGeneral Comments

Phase III: UpdatesPhase III: Updates

PreliminariesPreliminariesOn the New ActOn the New ActOn the Work of the Regional On the Work of the Regional

CommitteesCommitteesFurther ConcernsFurther Concerns

Suggestions for ImprovementSuggestions for Improvement

Physician-assisted suicide, not Physician-assisted suicide, not euthanasia, to ensure better control euthanasia, to ensure better control that at least in the Netherlands is that at least in the Netherlands is lacking.lacking.

Guideline 1Guideline 1

The physician should not suggest The physician should not suggest assisted suicide to the patient. assisted suicide to the patient. Instead, it is the patient who should Instead, it is the patient who should have the option to ask for such have the option to ask for such assistance.assistance.


The request for physician-assisted suicide The request for physician-assisted suicide of an adult, competent patient who suffers of an adult, competent patient who suffers from an intractable, incurable and from an intractable, incurable and irreversible disease must be voluntary. The irreversible disease must be voluntary. The decision is that of the patient who asks to decision is that of the patient who asks to die without pressure, because life appears die without pressure, because life appears to be the worst alternative in the current to be the worst alternative in the current situation. The patient should state this wish situation. The patient should state this wish repeatedly over a period of time. repeatedly over a period of time.

These requirements appear in the abolished These requirements appear in the abolished Northern Territory law in Australia, the Northern Territory law in Australia, the Oregon Oregon Death with Dignity ActDeath with Dignity Act, as well as in , as well as in the Dutch and Belgian Guidelines. the Dutch and Belgian Guidelines.


At times, the patient’s decision might be At times, the patient’s decision might be influenced by severe pain. The role of influenced by severe pain. The role of palliative care can be crucialpalliative care can be crucial. .

The Belgian law as well as the Oregon The Belgian law as well as the Oregon Death with Dignity Act Death with Dignity Act require the require the attending physician to inform the patient attending physician to inform the patient of all feasible alternatives, including of all feasible alternatives, including comfort care, hospice care and pain comfort care, hospice care and pain control. control.


A psychiatrist’s assessment can confirm A psychiatrist’s assessment can confirm whether the patient is able to make a whether the patient is able to make a decision of such ultimate significance to decision of such ultimate significance to the patient’s life and whether the decision the patient’s life and whether the decision is truly that of the patient, expressed is truly that of the patient, expressed consistently and of his/her own free will. consistently and of his/her own free will.

TheThe Northern TerritoryNorthern Territory Rights of Terminally Rights of Terminally Ill ActIll Act required that the patient meet with required that the patient meet with a qualified psychiatrist to confirm that the a qualified psychiatrist to confirm that the patient was not clinically depressedpatient was not clinically depressed..


The patient must be informed of the The patient must be informed of the situation and the prognosis for situation and the prognosis for recovery or escalation of the disease, recovery or escalation of the disease, with the suffering that it may involve. with the suffering that it may involve. There must be an exchange of There must be an exchange of information between doctors and information between doctors and patients.patients.

The Belgian law and the Oregon The Belgian law and the Oregon Death with Dignity Act Death with Dignity Act require thisrequire this..

Guideline 5

It must be ensured that the patient’s decision is not a result of familial and environmental pressures.

It is the task of social workers to examine patients’ motives and to see to what extent they are affected by various external pressures.


The decision-making process should The decision-making process should include a second opinion in order to include a second opinion in order to verify the diagnosis and minimize the verify the diagnosis and minimize the chances of misdiagnosis, as well as chances of misdiagnosis, as well as to allow the discovery of other to allow the discovery of other medical options. medical options.

A specialist, who is not dependent on A specialist, who is not dependent on the first doctor, either professionally the first doctor, either professionally or otherwise, should provide the or otherwise, should provide the second opinion. second opinion.


It is advisable for the identity of the It is advisable for the identity of the consultant to be determined by a consultant to be determined by a small committee of specialists (like small committee of specialists (like the Dutch SCEN), who will review the the Dutch SCEN), who will review the requests for physician-assisted requests for physician-assisted suicide. suicide.


Some time prior to the performance of Some time prior to the performance of physician-assisted suicide, a doctor and a physician-assisted suicide, a doctor and a psychiatrist are required to visit and psychiatrist are required to visit and examine the patient so as to verify that examine the patient so as to verify that this is the genuine wish of a person of this is the genuine wish of a person of sound mind who is not being coerced or sound mind who is not being coerced or influenced by a third party. The influenced by a third party. The conversation between the doctors and the conversation between the doctors and the patient should be held without the patient should be held without the presence of family members in the room in presence of family members in the room in order to avoid familial pressure. A date for order to avoid familial pressure. A date for the procedure is then agreed upon.the procedure is then agreed upon.


The patient can rescind at any time and in any The patient can rescind at any time and in any manner. manner.

This provision was granted under the abolished This provision was granted under the abolished Australian Northern Territory ActAustralian Northern Territory Act and under theand under the OregonOregon Death with Dignity Act.Death with Dignity Act.

The Belgian Euthanasia Law holds that patients The Belgian Euthanasia Law holds that patients can withdraw or adjust their euthanasia can withdraw or adjust their euthanasia declaration at any timedeclaration at any time..


Physician-assisted suicide may be Physician-assisted suicide may be performed only by a doctor and in the performed only by a doctor and in the presence of another doctor. presence of another doctor.

The decision-making team should include at The decision-making team should include at least two doctors and a lawyer, who will least two doctors and a lawyer, who will examine the legal aspects involved. examine the legal aspects involved. Insisting on this protocol would serve as a Insisting on this protocol would serve as a safety valve against possible abuse. safety valve against possible abuse. Perhaps a public representative should also Perhaps a public representative should also be present during the entire procedure, be present during the entire procedure, including the decision-making process and including the decision-making process and the performance of the act. the performance of the act.

Guideline 11

Physician-assisted suicide may be conducted in one of three ways, all of them discussed openly and decided upon by the physician and the patient together: (1) oral medication; (2) self-administered, lethal intravenous infusion; (3) self-administered lethal injection. Oral medication may be difficult or impossible for many patients to ingest because of nausea or other side effects of their illnesses. In the event that oral medication is provided and the dying process is lingering on for long hours, the physician is allowed to administer a lethal injection.


Doctors may not demand a Doctors may not demand a special special feefee for the performance of assisted for the performance of assisted suicide. The motive for physician-suicide. The motive for physician-assisted suicide is humane, so there assisted suicide is humane, so there must be no financial incentive and no must be no financial incentive and no special payment that might cause special payment that might cause commercialization and promotion of commercialization and promotion of such procedures.such procedures.

Guideline 13Guideline 13 There must be extensive documentation in the There must be extensive documentation in the

patient’s medical file, including the following: patient’s medical file, including the following: diagnosis and prognosis of the disease by the diagnosis and prognosis of the disease by the attending and the consulting physicians; attending and the consulting physicians; attempted treatments; the patient’s reasons for attempted treatments; the patient’s reasons for seeking physician-assisted suicide; the patient’s seeking physician-assisted suicide; the patient’s request in writing or documented on a video request in writing or documented on a video recording; documentation of conversations with recording; documentation of conversations with the patient; the physician’s offer to the patient to the patient; the physician’s offer to the patient to rescind his or her request; documentation of rescind his or her request; documentation of discussions with the patient’s loved ones; and a discussions with the patient’s loved ones; and a psychological report confirming the patient’s psychological report confirming the patient’s condition. condition.

Guideline 14Guideline 14 Pharmacists should Pharmacists should

also be required to also be required to report all report all prescriptions for prescriptions for lethal medication, lethal medication, thus providing a thus providing a further check on further check on physicians’ physicians’ reporting.reporting.


• Doctors must not be coerced into taking actions that contradict their conscience or their understanding of their role.

• This was provided under the Northern Territory Act.


The local medical association should The local medical association should establish a committee, whose role establish a committee, whose role will be not only to investigate the will be not only to investigate the underlying facts that were reported underlying facts that were reported but also to investigate whether there but also to investigate whether there are “mercy” cases that were not are “mercy” cases that were not reported and/or that did not comply reported and/or that did not comply with the with the GuidelinesGuidelines..


Licensing sanctions will be taken to punish Licensing sanctions will be taken to punish those health care professionals who violated those health care professionals who violated the the GuidelinesGuidelines, failed to consult or to file , failed to consult or to file reports, engaged in involuntary euthanasia reports, engaged in involuntary euthanasia without the patient’s consent or with patients without the patient’s consent or with patients lacking proper decision-making capacity. lacking proper decision-making capacity.

Physicians who failed to comply with the Physicians who failed to comply with the above above GuidelinesGuidelines will be charged and will be charged and procedures to sanction them will be brought procedures to sanction them will be brought by the Disciplinary Tribunal of the Medical by the Disciplinary Tribunal of the Medical Association. Sanctions should be significant.Association. Sanctions should be significant.

Thank youThank you

Documents

Euthanasia in the Netherlands University of Haifa ( May 2005 )