PHYSICIAN-ASSISTED DYING IN THE NETHERLANDS
By Ron L.P. Berghmans & Guy A.M. Widdershoven
(EACME Newsletter, July 2007)
Introduction
The Dutch Termination of Life on Request and Assisted Suicide (Review Procedures) Act (Wtl) came into force in 2002. This Act makes it compulsory for physicians to report the administering of euthanasia or assisting in suicide to the municipal forensic pathologist. One of five regional euthanasia review committees (RT’s) – consisting of a physician, ethicist and a lawyer - subsequently determines whether the legally-established requirements of due care have been complied with.
These requirements are: a voluntary and well-considered request of the patient; unbearable suffering without prospect of improvement; having informed the patient about his situation and prospects; no more reasonable alternatives; having consulted at least one other, independent physician; and having terminated the patient’s life or provided assistance with suicide with due medical care and attention.
The RT’s only forward cases to the legal prosecutor when the requirements for careful practice have not been met. In May 2007, the results of the first evaluation of the Wtl were published. Research has been carried out in connection with this evaluation so as to provide insight into practical developments in medical decision-making at the end of life and into the efficacy and side effects of the Wtl. In order to achieve
this objective, a number of sub-studies have been carried out. A distinction has been made between a legal evaluation of the Act, and a practical investigation that concentrates more on studying medical decisions and terminal care in practice. Most of the practical investigation is comparable to previous nation-wide investigations that were conducted in 2001, 1995 and 1990 by the research group of Van der Maas and Van der Wal and reported in medical journals.
Results of the evaluation
The results of the present evaluation can be summarized as follows. In 2005, of all deaths in the Netherlands, 1.7% were the result of euthanasia and 0.1% were the result of physician-assisted suicide. The absolute numbers decreased significantly: in 2005 there were more than 2300 cases of euthanasia and 100 cases of assisted suicide, while in 2001 there were 3500 and 300 cases respectively. Of all deaths, 0.4% were the result of the ending of life without an explicit request by the patient. Continuous deep sedation (‘palliative sedation’ or ‘terminal sedation’) was used in conjunction with possible hastening of death in 7.1% of all deaths in 2005 and significantly increased from 5.6% in 2001. The study shows that doctors are reporting cases of euthanasia more often: the proportion of cases that were reported rose very substantially from 54 to 80 per cent. The reason for not reporting euthanasia is nearly always that the doctor believes his action did not fall under the euthanasia law. Doctors hardly ever omit to make a report because they think they have not met the requirements of due care, or because they have objections on grounds of principle. It appears that doctors nearly always comply with the due care requirements.
The number of express requests for euthanasia or assisted suicide fell from 9700 in 2001 to 8400 in 2005. The number of cases of palliative sedation rose from 8500 to 9600. The increase in the use of palliative sedation probably explains in part the decrease in the number of cases of euthanasia and assisted suicide.
The authors of the evaluation report conclude that these findings represent a significant reversal of the trends in end-of-life decision making that were found between 1990 and 2001. They give three possible explanations for these trends. Firstly, the increase in the age group of people 80 years of age or older, which is the age group for which euthanasia and assisted suicide are not very common. Secondly, Dutch physicians have been found to consider high-quality end-of-life care as an alternative to euthanasia or assisted suicide, at least in some cases. In the study it was found that euthanasia and assisted suicide to some extent were replaced by continuous deep sedation. The types of suffering that prompt requests for euthanasia overlap with those that prompt requests for sedation, although the emphasis is more on existential suffering and physical deterioration in euthanasia and more on physical suffering in sedation. Thirdly, the authors think the attitudes of physicians towards opioids and their more accurate understanding of the effects of the drugs may have contributed to a decrease in the frequency of euthanasia.
Continuity
All in all, the ‘standard euthanasia case’ has not changed: it concerns a family physician who terminates the life on the request of a patient under 80 years of age who suffers from cancer in a progressed stage. This case is assessed by the review committee and generally this committee takes the view that the requirements for careful practice have been met by the physician. No further legal action follows. Given that the number of reported cases has risen significantly, the system seems to work well. Does this imply that the Dutch euthanasia debate has come to a close? This conclusion would be too hastened. There are three areas of debate we will briefly address: active life termination in cases of dementia, being ‘tired of life’ as a reason for assistance in dying, and the shift from euthanasia towards continuous deep sedation.
Dementia
A new element in the 2002 euthanasia law is article 2.2 concerning an incompetent patient who has written, when he was still competent, an advance directive requesting the active ending of life under certain circumstances. The law stipulates that a physician may act according to that written request if the patient becomes incompetent, as long as he fulfils all other rules of due care in a corresponding way.
This provision has stirred debate in relation to patients suffering from Alzheimer’s disease. Can euthanasia ever be an option for a patient suffering from Alzheimer’s who has made a written request before he became incompetent? To give a brief answer (which is in line with the position taken by the Dutch government): no, because it is impossible to assess whether the conditions of due care have been met. Particularly the assessment of the unbearability and hopelessness of the patient’s suffering is difficult, if not impossible (but also the other conditions give rise to problems). One recommendation that appears from the evaluation study is that better information should be provided on the possibilities and limitations of euthanasia advance directives. It appears that there are still misunderstandings about this among both doctors and the general public.
Looking to the future, with the possibility to diagnose dementia with more certainty at an early stage, there might be an increase in the number of requests for euthanasia or assisted suicide from patients who consider the future loss of self a condition of such indignity that life would not be worth living. In the Netherlands, the official interpretation of the law does not leave room for this. Whereas euthanasia is legally problematic in late dementia, the situation for early dementia seems to be more open. Over the past years, several cases of euthanasia in early Alzheimer’s have been reported to the review committees. In the reported cases, patients declared that the prospect of becoming more demented was very disturbing for them, for instance because they had experienced great distress when a relative (for instance a parent) had gone through this process. For the physicians this was convincing as an instance of unbearable suffering. The cases reported thus far have been approved by the review committees. Yet, the discussion about suffering in (early as well as late) dementia is not fully closed. Further societal debate about end of life decision making in cases of dementia is to be expected.
Tired of life
Recently, the Nederlandse Vereniging voor een Vrijwillig Levenseinde (NVVE, the Dutch Euthanasia Society) argued for the introduction of a so-called dignity criterion. The ‘irreversible loss of personal dignity’ in the view of the NVVE could replace in some cases the now accepted criterion of unbearable and hopeless suffering. Particularly cases of ‘having completed life’ (klaar met leven) in which there is no illness and which because of that fall outside the domain of medicine, would apply. This proposal has met with criticism from different sides. It seems hard to fit this into the Dutch practice of euthanasia, which is centered on the physician. Many physicians are clearly against non-medical criteria. Others have argued that the distinction between medical and non-medical criteria is artificial, given that many elderly people have complaints of a physical nature, and that the patient’s view on his life may very well be a subject for discussion with the (family) physician. Several opponents of the ‘tired of life’ criterion think that opening the way to assisted suicide by non-medical volunteers (as in Switzerland) would not be good social policy. On the other hand, proponents of non-medicalization of assisted suicide argue forcefully for the right to self-determination of people who see no interest in continued living.
Deep sedation
As mentioned, a shift has taken place away from euthanasia towards continuous deep sedation as a (partial) alternative. Sedation was most common in the subgroups in which euthanasia and assisted suicide were also most common: patient under 80 years of age, men, patients with cancer, and patients attended by general practitioners. The use of deep sedation near the end of life is often preceded by a discussion of the option of euthanasia.
The shift towards deep sedation does not mean that in the end all requests for euthanasia can be dealt with by applying deep sedation. In the first place, deep sedation is only clearly indicated when life expectancy is less than two weeks. Although in many cases of euthanasia life expectancy is short, this is not always the case. Secondly, for patients who desire to continue to be conscious during the terminal stage of their life, deep sedation is not a serious option. Although deep sedation may in general be regarded as ethically less problematic than euthanasia, it is not always an alternative.
The debate continues
The new Dutch coalition government, consisting of two Christian democrat parties and the social democrats, has decided for the coming four years not to make changes regarding any sensitive bioethical issue, be it euthanasia or the creation of embryos for research purposes. This does by no means imply that the societal debate on these important topics will be silenced. The debate will continue, and needs to be continually informed by good empirical research, as it has been since the 1990s.
Ron Berghmans and Guy Widdershoven work at the department of Health, Ethics and Society, Faculty of Health, Medicine and Life Sciences of Maastricht University, the Netherlands
r.berghmans@zw.unimaas.nl
-
Onwuteaka-Philipsen, B.D., Gevers, J.K.M, Heide, A. van der et al., Evaluatie Wet toetsing levensbeëindiging op verzoek en hulp bij zelfdoding. Den Haag: ZonMw, mei 2007 and Heide, A. van der, Onwuteaka-Philipsen, B.D., Rurup, M.L. et al., End-of-life practices in the Netherlands under the Euthanasia Act. New England Journal of Medicine, 356, 2007, 1957-65.
-
Delden, J.J.M. van, The unfeasibility of requests for euthanasia in advance directives. Journal of Medical Ethics, 30, 2004, 447-452.
-
Gevers, S., Dementia and the law. European Journal of Health Law, 13, 2006, 209-217.
-
Hertogh, C.M.P.M., de Boer, M.E., Dröes, R.M., Eefsting, J.A., Would we rather lose our life than lose our self? Lessons from the Dutch debate on euthanasia in dementia. American Journal of Bioethics, 7, 2007, 4, 48-56, and: Health Council of the Netherlands, Dementia. The Hague: Health Council of the Netherlands, 2002; publication no. 2002/04E (www.gr.nl).
-
Rientjens, J.A., Heide, van der, A., Vrakking, A.M., et al., Physician reports of terminal sedation without hydration or nutrition for patients nearing death in the Netherlands. Annals of Internal Medicine, 141, 2004, 178-185.
No comments:
Post a Comment