Euthanasia in the NetherlandsEuthanasia in the Netherlands

University of HaifaUniversity of Haifa

) ) 25 May25 May 20052005((

Raphael CohenRaphael Cohen--AlmagorAlmagor

Preliminaries: Comparative LawPreliminaries: Comparative Law

Preliminaries: Comparative LawPreliminaries: Comparative Law

Part A: BackgroundPart A: Background

�� 1. The Three Research Reports of 1990, 1. The Three Research Reports of 1990,

1995 and 2003 and Their Interpretations1995 and 2003 and Their Interpretations

�� 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 IPhase I : :The InterviewsThe Interviews

�� 4. Why the Netherlands?4. Why the Netherlands?

�� 5. Views on the Practice of Euthanasia 5. Views on the Practice of Euthanasia

6. Worrisome Data6. Worrisome Data

�� ““Some of the most worrisome data in the Some of the most worrisome data in the

two Dutch studies are concerned with the two Dutch studies are concerned with the

hastening of death without the explicit hastening of death without the explicit

request of patients. There were 1000 request of patients. There were 1000

cases (0.8%) without explicit and cases (0.8%) without explicit and

persistent request in 1990, and 900 cases persistent request in 1990, and 900 cases

(0.7%) in 1995. What is your opinion?(0.7%) in 1995. What is your opinion?””

�� 8. Should Physicians Suggest Euthanasia 8. Should Physicians Suggest Euthanasia

to Their Patients?to Their Patients?

9. Breaches of the Guidelines9. Breaches of the Guidelines

�� The physician practicing euthanasia is The physician practicing euthanasia is

required to consult a colleague in regard required to consult a colleague in regard

to the hopeless condition of the patient. to the hopeless condition of the patient.

Who decides who the second doctor will Who decides who the second doctor will

be? 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

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

10. On Palliative Care and the Dutch 10. On Palliative Care and the Dutch

CultureCulture

�� It has been argued that the policy and It has been argued that the policy and

practice of euthanasia is the result of practice of euthanasia is the result of

undeveloped palliative care. What do you undeveloped palliative care. What do you

think? think?

�� I also mentioned the fact that there are I also mentioned the fact that there are

only a few hospices in the Netherlands.only a few hospices in the Netherlands.

Culture of DeathCulture of Death

�� Daniel Callahan Daniel Callahan argues that there is aargues that there is a ““culture of deathculture of death ” ”in in thethe Netherlands.Netherlands.

What do you think? What do you think?

Culture of deathCulture of death

I intentionally refrained I intentionally refrained

from explaining the term from explaining the term

““culture of death.culture of death.”” I I

wanted to see whether wanted to see whether

the interviewees have the interviewees have

different ideas on what different ideas on what

would constitute such a would constitute such a

cultureculture..

IIIIPhasePhase

IntervieweesInterviewees’’ General CommentsGeneral Comments

�� PreliminariesPreliminaries

�� General CommentsGeneral Comments

Phase III: UpdatesPhase III: Updates

�� PreliminariesPreliminaries

�� On the New ActOn the New Act

�� On the Work of the Regional CommitteesOn the Work of the Regional Committees

�� Further ConcernsFurther Concerns

Suggestions for ImprovementSuggestions for Improvement

PhysicianPhysician--assisted suicide, not 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.

Guideline 2Guideline 2

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

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

Guideline 3Guideline 3

�� At times, the patientAt times, the patient’’s decision might be s decision might be

influenced by severe pain. The role of palliative influenced by severe pain. The role of palliative

care can be crucialcare can be crucial . .

�� The Belgian law as well as the Oregon The Belgian law as well as the Oregon Death Death with Dignity Act with Dignity Act require the attending physician require the attending physician

to inform the patient of all feasible alternatives, to inform the patient of all feasible alternatives,

including comfort care, hospice care and pain including comfort care, hospice care and pain

control. control.

Guideline 4Guideline 4

�� The patient must be informed of the The patient must be informed of the

situation and the prognosis for recovery or situation and the prognosis for recovery or

escalation of the disease, with the escalation of the disease, with the

suffering that it may involve. There must suffering that it may involve. There must

be an exchange of information between be an exchange of information between

doctors and patients.doctors and patients.

�� The Belgian law and the The Belgian law and the OregonOregon Death Death with Dignity Actwith 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.

Guideline 6Guideline 6

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

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

Guideline 7Guideline 7

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 physicianrequests for physician--assisted assisted

suicide. suicide.

Guideline 8Guideline 8

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

Guideline 9Guideline 9

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..

Guideline 10Guideline 10

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

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

Guideline 12Guideline 12

�� Doctors may not demand a Doctors may not demand a special feespecial fee

for the performance of assisted suicide. for the performance of assisted suicide.

The motive for physicianThe motive for physician--assisted suicide assisted suicide

is humane, so there must be no financial is humane, so there must be no financial

incentive and no special payment that incentive and no special payment that

might cause commercialization and might cause commercialization and

promotion of such procedures.promotion of such procedures.

Guideline 13Guideline 13

�� There must be extensive documentation in the There must be extensive documentation in the patientpatient’’s medical file, including the following: 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 patientattempted treatments; the patient’’s reasons for s reasons for seeking physicianseeking physician--assisted suicide; the patientassisted suicide; the patient’’s 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 physicianthe patient; the physician’’s offer to the patient to s offer to the patient to rescind his or her request; documentation of rescind his or her request; documentation of discussions with the patientdiscussions with the patient’’s loved ones; and a s loved ones; and a psychological report confirming the patientpsychological report confirming the patient’’s s condition. condition.

Guideline 14Guideline 14�� Pharmacists should Pharmacists should

also be required to also be required to

report all report all

prescriptions for lethal prescriptions for lethal

medication, thus medication, thus

providing a further providing a further

check on physicianscheck on physicians’’

reporting.reporting.

Guideline 15Guideline 15

• 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.

Guideline 16Guideline 16

�� The local medical association should The local medical association should

establish a committee, whose role will be establish a committee, whose role will be

not only to investigate the underlying facts not only to investigate the underlying facts

that were reported but also to investigate that were reported but also to investigate

whether there are whether there are ““mercymercy”” cases that were cases that were

not reported and/or that did not comply not reported and/or that did not comply

with the with the GuidelinesGuidelines..

Guideline 17Guideline 17

�� Licensing sanctions will be taken to punish those health Licensing sanctions will be taken to punish those health

care professionals who violated the care professionals who violated the GuidelinesGuidelines, failed to , failed to

consult or to file reports, engaged in involuntary consult or to file reports, engaged in involuntary

euthanasia without the patienteuthanasia without the patient’’s consent or with s consent or with

patients lacking proper decisionpatients lacking proper decision--making capacity. making capacity.

�� Physicians who failed to comply with the above Physicians who failed to comply with the above

GuidelinesGuidelines will be charged and procedures to sanction will be charged and procedures to sanction

them will be brought by the Disciplinary Tribunal of them will be brought by the Disciplinary Tribunal of

the Medical Association. Sanctions should be the Medical Association. Sanctions should be

significant.significant.

Thank youThank you