The Netherlands is about to become the first nation in modern times to formally legalize euthanasia. The mainstream media stories about legalization frequently assert with a straight face that euthanasia will be governed by strict guidelines to prevent abuse. Well we've been hearing that little ditty for decades about Dutch euthanasia, and as Ira Gershwin once put it, "It ain't necessarily so." Indeed, the vaunted guidelines do not even rise to the level of paper tigers.
The newly enacted killing regulations are virtually identical to those that have governed Dutch euthanasia for many years under which euthanasia remained technically illegal but was not prosecuted so long as doctors followed the guidelines. (The only substantial difference between the former decriminalized regime and legalized euthanasia is that doctors will no longer have to notify coroners after they kill a patient.) Not only have the guidelines failed to protect vulnerable and devalued patients but they have been violated so often that they might as well not exist at all.
Here are the guidelines followed by a brief recitation describing how each has been violated in actual practice over the last 27 years:
When ending a life a physician must be convinced that the patient's request was voluntary, well-considered, and lasting. Study after study of Dutch euthanasia practice have shown that Dutch doctors routinely kill patients who have not asked to be poisoned. (The favored method of killing in the Netherlands is an overdose of barbiturates followed by a lethal dose of curare.) In the Netherlands this practice is known as "termination without request or consent," and is not even formally considered euthanasia in the statistics compiled by the government.
The evidence of decades demonstrates that such involuntary euthanasia is rampant. Indeed, in its 1997 ruling refusing to create a constitutional right to assisted suicide (Washington v. Glucksberg) the United States Supreme Court quoted a 1991 Dutch government study finding that in 1990 doctors committed "more than 1000 cases of euthanasia without an explicit request" and "an additional 4,941 cases where physicians administered lethal morphine overdoses without the patients' explicit consent." That means in 1990, nearly 6,000 of approximately 130,000 people who died in the Netherlands that year were involuntarily euthanized --approximately 4 percent of all Dutch deaths. So much for "choice."
The physician must be convinced the patient was facing unremitting and unbearable suffering. Notice that this guideline does not require that the patient be dying or, for that matter, even be actually ill. Indeed, there have been several documented cases of euthanasia based on depression or suicidal ideation. For example, a Dutch documentary reported on the euthanasia of a young woman in remission from anorexia. Worried that her eating disorder would return, she asked her doctor to kill her. He did and the authorities refused to prosecute.
The most infamous case of this sort involved a physically healthy woman who had become obsessed about being buried between her two dead children. She bought a cemetery plot, had her children buried one on each side of her planned grave, and then asked a psychiatrist named Boutdewijn Chabot to assist her suicide. He met with her four times over approximately five weeks and never attempted treatment. He then assisted her suicide. The Dutch Supreme Court refused to punish him, ruling that suffering is suffering and it does not matter whether it is physical or emotional, to justify euthanasia.
Another documented euthanasia that violated this and other guidelines was depicted in a Dutch documentary played in this country in the PBS program the Health Quarterly, in 1993. Henk Dykma had asymptomatic HIV infection. Fearing future afflictions that might befall him, Henk asked his doctor to kill him. The film shows the doctor telling Henk that he might live for years at his current state of seemingly healthful living. When Henk still proclaims a desire to die, the doctor speaks with a colleague but never consults a psychiatrist or psychologist. He then helps kill Henk on July 28, a date, we are told, which had symbolic importance for the patient.
This killing, like those of the anorexic young woman and the bereaved mother, was clearly not a matter of last resort, as the guidelines claim to require. Henk and his doctor did not explore all other options available to him before ending his life. Indeed, psychiatric treatment, which might have alleviated Henk's obvious anxiety about being HIV-positive, was never even discussed or attempted. Nor was Henk advised of the steps that could be taken to alleviate his suffering should he fall ill. The doctor didn't even wait until Henk had actual symptoms of AIDS. There is a word for that level of care --abandonment --and it demonstrates the utter hollowness of the Dutch protective guidelines.
The physician must have informed the patient about their situation and prospects. This guideline presumes that the physicians involved will have sufficient expertise to adequately inform the patient about their condition and options for treatment or palliation. But the Dutch medical system is unlike ours. It is primarily made up of general practitioners, rather than specialists, who may not have the training, expertise, or desire to know the many treatment alternatives that may be available. Moreover, there are few hospices in the Netherlands, meaning that the many compassionate and dignified methods of alleviating suffering in the dying may never be discussed with patients who ask to be killed.
A good example of this phenomenon is illustrated in the memoir Dancing with Mr. D, written by a Dutch nursing-home doctor named Bert Keizer. Keizer writes about a patient who had been tentatively diagnosed with lung cancer. A relative tells Keizer that the man wants to be given a lethal injection, a request later confirmed by the patient. Keizer quickly agrees to perform the killing. Demonstrating the utter uselessness of "protective guidelines," Keizer never tells his patient about treatment options that may be available or how the pain and other symptoms of cancer can be palliated effectively. He never checks to see if the man has been pressured into wanting a hastened death or is depressed. Indeed, Keizer doesn't even take the time to confirm the diagnosis with certainty or to prepare a prognosis about the expected course of the disease. When a colleague asks, why rush, and points out that the man isn't suffering terribly, Keizer snaps:
Is it for us to answer this question? All I know is that he wants to die more or less upright and that he doesn't want to crawl to his grave the way a dog crawls howling to the side walk after he's been hit by a car. The next day, he lethally injects his patient, telling his colleagues as he walks to the man's room to do the deed, "If anyone so much as whispers cortisone [a palliative agent] or 'uncertain diagnosis,' I'll hit him."
The physician must have reached the firm conclusion with the patient that there was no other reasonable alternative solution. The cases already described illustrate the hollowness of this guideline. Another prime example of its uselessness is the killing by Dr. Henk Prins of a three-day old infant born with spina bifida and limb anomalies. (Yes, euthanasia has entered Dutch pediatric wards. A 1997 study in the British medical journal, The Lancet, revealed that about 8 percent of all infants who die in the Netherlands are killed by doctors.)
Spina bifida is a condition in which there is an opening at the spine that may cause disability or death. Prins --a gynecologist, not a pediatrician or expert in spina bifida --killed the child at the request of her parents, because, he later testified, the baby screamed in agony when touched. No wonder the baby was in pain! Prins never closed the wound in her back. In other words, the doctor killed his patient without first attempting proper medical treatment. Yet, rather than punishing Prins, the trial judge praised him for his "integrity and courage," wishing him well in any further legal proceedings he might face.
The physician must have consulted at least one independent physician, who has examined the patient and formed a judgment about the above points. The idea of independent physicians acting as a check and balance to prevent abuses sounds good. But in practice, it offers little actual protection. Proof of this is found in a Dutch euthanasia documentary --played in the USA on the ABC television program Prime Time Live. It is the euthanasia of Cees van Wendel, a patient disabled by ALS (Lou Gehrig's disease). As depicted in the film, the driving force behind the euthanasia appears to be the man's wife, Antoinette, who does all of the talking for her husband (who is able to communicate). This also proves true during the second opinion consultation, which is cursory and perfunctory. Suicide expert, the New York psychiatrist Dr. Herbert Hendin, in his book about Dutch euthanasia Seduced by Death, describes the "consultation," such as it was:
The consultant, who practices on the same block as the doctor, also makes no attempt to communicate with Cees alone, and he too permits the wife to answer all the questions put to Cees. When the consultant asks the pro forma question if Cees is sure he wants to go ahead, Antoinette answers for him. The consultant seems uncomfortable, asks a few more questions, and leaves. The consultation takes practically no time at all. Dutch euthanasia is a human-rights disaster. Not only does the practice devalue the lives of the most defenseless people, but once killing became an acceptable answer to one problem, it soon became a solution to one hundred. Indeed, in their nearly 30 years of euthanasia practice, Dutch doctors have gone from killing terminally ill patients who ask for it, to chronically ill patients who ask for it, to disabled patients who ask for it, to depressed patients who ask for it, to babies who cannot by definition ask for it, to thousands of patients without request or consent. Now, the last slight remaining impediment to killing by doctors --its technically illegal status --has been dismantled. And as an additional plum to depravity, teenagers beginning at the age of 16 will be able to receive euthanasia without parental consent.
The theologian and philosopher, Richard John Neuhaus, was once asked "Do you believe there is a euthanasia "slippery slope?" His answer hit the mark: "Yes, like I believe that there is a Hudson River." We ignore the lessons of the Netherlands at our own peril.