More than 85 percent of doctors in the Netherlands say they would consider helping a patient die, but just one in three say they would consider it if a patient were suffering from advanced-stage dementia or debilitating mental illness, according to a new study published in the Journal of Medical Ethics.
The findings are based on interviews with more than 1,500 physicians in the Netherlands, which in 2002 became the first country to legalize euthanasia and physician-assisted suicide in specific circumstances. Under the Termination of Life Request and Assisted Suicide (Review Procedures) Act, Dutch physicians are not prosecuted for euthanasia (administering lethal drugs to a patient) or physician-assisted suicide (providing a patient with lethal drugs), as long as they follow certain criteria for due care.
Specifically, Dutch law states that euthanasia and assisted suicide (EAS) are legal when there is “the presence of unbearable suffering without the prospect of improvement” and “a voluntary and well-considered request”; “the patient is informed about the situation and prognosis”; there is “the absence of reasonable treatment alternatives”; there has been “consultation with a second physician”; and “EAS is performed with due medical care and attention.”
Although euthanasia or assisted suicide for those whose suffering is psychiatric or psychological in nature is legal in the Netherlands, it only represents a fraction of the numbers of patients who are helped to die in this way. And while there is no “right to euthanasia” (meaning that physicians may turn down patient requests), the freedom of a doctor to refuse the request on personal grounds has been widely debated, following some highly publicized cases.
In this latest study, researchers led by Dr. Eva Elizabeth Bolt of the VU University Medical Center in Amsterdam, the Netherlands, set out to establish what Dutch doctors thought of euthanasia and assisted suicide, and under what circumstances they would engage in either practice.
“The main question debated is whether [euthanasia and physician-assisted death] is legally and ethically acceptable in patients with these conditions and, if so, whether physicians should be willing to provide it,” the researchers explain.
To reach their conclusions, the team surveyed 2,269 randomly selected Dutch general practitioners and specialists in the fields of elderly care, cardiology, respiratory medicine, intensive care, neurology and internal medicine between October 2011 and June 2012.
The doctors were asked whether they had ever helped a patient to die and for what reasons: cancer, another form of severe physical illness, mental illness, early or advanced dementia, or tired of living with or without severe physical illness. Doctors who had not helped a patient to die were asked if they would consider it and under what circumstances they would do so.
Cause of suffering ‘a decisive factor’ for euthanasia, physician-assisted suicide
Of the 1,456 doctors who completed the survey, 77 percent had been asked at least once for help to die — rising to more than 90 percent among general practitioners — and 86 percent said they would consider assisting a patient’s death. In fact, the majority of respondents (60 percent) had actually helped a patient to die, almost half of whom had done so within the past 12 months.
Doctors’ attitudes toward euthanasia and assisted suicide were found to vary by condition: The vast majority said they would consider helping a patient die if they had cancer (85 percent) or another physical disease (92 percent), but only 34 percent would consider it for someone with a mental illness. Interestingly, only 1 in 3 doctors said they would consider euthanasia or assisted suicide for a patient in the late stages of dementia, even if the patient held an advance written directive for euthanasia.
Around one in four (27 percent) doctors said they would be prepared to help someone ‘tired of living’ to die if they had a severe medical condition, but fewer than one in five (18 percent) would do so if the patient had no other medical grounds for suffering. Only a few of the respondents (7 percent) had actually helped a patient who did not have cancer or another severe physical illness to die, whereas over half (56 percent) had helped a cancer patient to die, and around a third (31 percent) had assisted someone with another physical disease.
Based on their findings, the researchers say it is clear that the cause of suffering in a patient is a “decisive factor” for doctors when it comes to patient requests for euthanasia or physician-assisted suicide. However, the results also reveal that physicians are more responsive to patients who are suffering due to a physical disease, as opposed to a psychiatric condition, even when the degrees of suffering are equal.
“Most Dutch physicians can conceive of performing [euthanasia or physician-assisted suicide] in patients suffering from cancer or another physical disease. However, in patients suffering from psychiatric disease, dementia or being tired of living, opinions differ,” the researchers write. “To prevent disagreement and disappointment, it is important that a patient with a future wish for [euthanasia or physician-assisted suicide] discusses this with their physician in time and that the physician is clear about their standpoint on the matter.”
The great debate
Rapid and dramatic developments in medicine and technology have given us the power to save more lives than was ever possible in the past. Medicine has put at our disposal the means to cure or to reduce the suffering of people afflicted with diseases that were once fatal or painful. At the same time, however, medical technology has given us the power to sustain the lives (or, some would say, prolong the deaths) of patients whose physical and mental capabilities cannot be restored, whose degenerating conditions cannot be reversed, and whose pain cannot be eliminated. As medicine struggles to pull more and more people away from the edge of death, the plea that tortured, deteriorated lives be mercifully ended grows louder and more frequent.
Whether or not we as a society should pass laws sanctioning euthanasia and/or assisted suicide has generated intense moral and political controversy. Since 1992, efforts to decriminalize or legalize the practice have failed in California, Michigan, Maine, and most recently, in Massachkusetts. Currently, four states (Oregon, Washington, Vermont and Montana) allow some form of physician-assisted suicide while 46 states have deemed it illegal.
Supporters of legislation legalizing assisted suicide argue that all persons have a moral right to choose freely what they will do with their lives as long as they inflict no harm on others. This right of free choice includes the right to end one’s life when we choose. For most people, the right to end one’s life is a right they can easily exercise. However, there are many who want to die, but whose disease, handicap, or condition renders them unable to end their lives in a dignified manner. When such people ask for assistance in exercising their right to die, their wishes should be respected.
Furthermore, it is argued, we ourselves have an obligation to relieve the suffering of our fellow human beings and to respect their dignity. Lying in our hospitals today are people afflicted with excruciatingly painful and terminal conditions and diseases that have left them permanently incapable of functioning in any dignified human fashion. They can only look forward to lives filled with yet more suffering, degradation, and deterioration. When such people beg for a merciful end to their pain and indignity, it is cruel and inhumane to refuse their pleas. Compassion demands that we comply and cooperate.
Opponents of physician-assisted death claim that decriminalizing or legalizing any form of the practice will lead to a “slippery slope” effect in which the acceptance of certain practices, such as physician-assisted suicide, will invariably lead to the acceptance or practice of concepts which are currently deemed unacceptable, such as non-voluntary or even involuntary euthanasia of ‘undesirable’ individuals. However, the same nihilistic arguments could be — and have been — made against other laws and constitutionally-protected rights and interests. The legalization of abortion, for instance, did not pave the way for the acceptance of infanticide or racial genocide (as some predicted it would), nor did the recognition of self-defense as a legitimate exception to criminal homicide lead to the acceptance of murder.
Furthermore, studies in the Netherlands refute the idea that legalizing assisted suicide will create a ‘slippery slope’ — in fact, just the opposite is true. After the passage of The Dutch Euthanasia Act, rates of euthanasia and physician-assisted suicide actually dropped. Researchers say the decrease may have resulted from the increased use of other end-of-life care interventions, such as palliative sedation. Similar findings have also been reported in Oregon after the decriminalization of assisted suicide. Interestingly, anecdotal evidence suggests that simply having the option to end one’s life — and to take control of the dying process — might just give people the strength they need to continue holding on in the face of unimaginable suffering.