Abortion, the suicide pill and euthanasia. In the Netherlands, life and death are both individual choices. That may be the image the Netherlands has abroad but euthanasia is not, in practice, carried out on any major scale. Dutch doctors are often reticent.
Take the case of a woman in her eighties. She is perfectly healthy, able to take care of herself and not in need of assistance. Despite this, she made a request for euthanasia to her family doctor saying “enough is enough”. The doctor refused point blank, since there was no question of unbearable suffering.
There are plans to open an assisted suicide or 'life's-end' clinic in the Netherlands in 2012. The clinic intended is for people who are eligible for euthanasia but can’t find a doctor willing to assist them. The clinic would have the capacity for a thousand patients per year, for people with incurable diseases, psychiatric patients and those in the early stages of dementia. The NVVE (Dutch Right-to-Die Association) is behind the push for the clinic.
The KNMG (Royal Dutch Medical Society) is not in favour. It is worried about the prospect of “conveyor belt work” with unacceptable pressure on doctors to carry out euthanasia. Dying will be made too easy, it warns, with patients passing away within three days of entering the clinic.
The Dutch Voluntary Euthanasia Act, which dates from 2001, contains a large number of rules and conditions. Euthanasia is only permitted at the explicit request of the patient. The children of a mother with advanced dementia asking for her life to be ended will be turned down. There has to be unbearable suffering. In other words, the patient must be in such physical pain that death can be regarded as a release. Many terminal cancer patients in the Netherlands elect for euthanasia.
Mental suffering is also included - for psychiatric patients who have no prospect of a cure or people who fear gradual mental deterioration if they develop dementia. These people can file a statement to that effect. Last year 25 people with dementia (a fraction of the total number) received a euthanasia injection.
Around 8,500 requests for euthanasia were submitted in 2010. One third of these were approved, one third were rejected and one third of the patients died before the decision was made.
Gert van Dijk is an ethicist who checks that the rules are observed in euthanasia cases. He says euthanasia requests are problematic for many doctors. They prefer to avoid them if they can:
“If it’s a terminal cancer patient who is dying in a highly unpleasant way, doctors don’t have so much of a problem. They can appreciate that people don’t want to die that way. But there are people who don’t want to go on living because of dementia or a mental illness. Many doctors have issues about helping them, since these people often still have good life expectancy.”
Petra de Jong is the director of the NVVE, which lobbies for the recognition of the choice for voluntary death. As a lung specialist she helped a number of people with euthanasia, some of them in the time it was still a criminal offence. She was interviewed by the police a few times but never charged. She never felt any need for guilt either:
“As a doctor you have to put yourself in the place of the patient, more or less feel what the patient is feeling and what he’s afraid of. It’s part of the job. For example, I’ve had patients who were afraid they would choke to death. As a lung specialist I know those symptoms. You want people to be able to die in a dignified way. That’s comforting – for the patient and for the doctor.”
Dr De Jong is pleased with the Dutch euthanasia act, since it has allowed more openness about the subject. However, she complains that - for many doctors - unbearable suffering always means physical suffering. People with severe depression or dementia are often excluded:
“Doctors have a problem with it. Although mental suffering can be much worse than physical pain. With cancer you generally know there will be an end and that a number of measures can be taken for the intervening period. Mental suffering for which there is no treatment can sometimes continue for as long as 40 years. That’s a terrible thing.”
Ethicist Gert van Dijk says there are other options for doctors. Doctors cannot be prosecuted for supplying patients with information about how to stop eating and drinking, for instance, in order to die by wasting away. The doctor is, however, required to support the patient until the end.
Three thousand Dutch people die each year by wasting way and it’s expected the numbers will increase. The physicians’ professional association KNMG is currently drawing up guidelines for doctors.