| The definition of euthanasia
The generally acknowledged Dutch definition of euthanasia is readingas follows: "Intentional life-terminating action at explicit request of the person concerned, carried out by another than the person concerned".
The Vatican definition of euthanasia is reading: "Intentional life-terminating action or omission of treatment to put an end to all suffering". According to the Vatican the patient is not allowed asking for euthanasia, so the Vatican definition does not speak about the voluntariness of the person concerned and subsequently about his explicit request.
With regard to the definition some elements are important:
- There must be no doubt about the voluntariness of the patient's request for life- terminating action. Even in a country with a moderated jurisprudence like Holland the physician has to keep strictly to this condition.
- The word "intentional" implies the distinction between primarily intended shortening of life to alleviate suffering and primarily intended relief of suffering in the course of which life-shortening may occur as a not-intended side-effect. This distinction may be subtile, in practice the intention of the life-terminating action is nearly always clear
- The life-terminating action is carried out by another person than the patient concerned.
The following situations are not covered by the term euthanasia:
- Withholding medical action because of the patient's refusal, even if withholding will result in the not intentional death of the patient.
- Primarily intended alleviating of the patient's suffering with the possible side-effect that the patient's life will be shortened.
- Withholding or withdrawal of meaningless medical action.
Abandoning extraordinary or disproportional means is not the same as euthanasia or suicide. Rather it will bring to expression the acceptance of the human condition at the moment the patient is staring death in the face. The legalization of euthanasia
April 1st 2002 "the Termination of life on request and assisted suicide (review) Act" came into force. The Act implies that a physician performing euthanasia may make an appeal to a special punishment-exemption ground. That is only possible if the physician has complied with the conditions of carefulness formulated in the Act and has reported the case to the municipal coroner. Other forms of life terminating action at request and assisted suicide &endash; for instance euthanasia not performed in complete agreement with the due care criteria or practised by a non-physician &endash; will remain punishable like formerly. Practically one may say that euthanasia has been legalized under conditions. James Kennedy remarks about the social and cultural factors promoting the Dutch euthanasia policy: "Life in Holland is estimated on the base of considerations of quality of life. The more people are claiming quality of life the more the last therapeutical and palliative stalks of straw, which one can catch, will disappear from one's view". But what must be understood by quality of life? The present legalization may be seen as the formalization of the development round the problem of euthanasia which was completed less or more towards the end of the eighties. Legalization was never the central goal of the euthanasia-movement (James Kennedy). The central goal was making euthanasia debatable in open discussion, the honest attitude of the caregivers and the emancipation of the patient. In the Netherlands the ideal of the debatability indicated the direction of the euthanasia discussion and provided the framework in which in a relatively simple way consensus could be reached about much of the issue. This situation is rather peculiar for the Netherlands and not just like this applicable to the situation in other countries. According to the government other main arguments for legalizing euthanasia are:
1. The assumption that there is a broad social support for accepting euthanasia at explicit request of the patient concerned. Anyway, it is questionable whether this allegation is correct, because the aspects and the possibilities of palliative care have got relatively little attention.
2. The alleged legitimate request of the patient for euthanasia is getting the physician into a difficult criminal position. Different opinion about the interpretation of the conditions of carefulness, the fact that the physician is regarded as a suspected person and the fact that the physician has to turn himself in to the public prosecutor may bring about feelings of uncertainty and insecurity to the physician.
Now increasing legal protection has arised because according to the Euthanasia Act euthanasia has become not punishable, if the physician has complied with the due care conditions and with the duty to report the case. That the law has come into force does not mean that the discussion about life terminating action has finished. Euthanasia is not considered as a normal medical action and remains one of the most difficult problems a physician may be faced with. Both advocates and opponents of euthanasia have come with good, valid arguments. Charging with heresy from both sides does not facilitate the discussion. Listening to the arguments of the other party and trying to understand their reasons is preferable.
Moreover the discussion has to be turned to the today social and cultural attitude in which the euthanasia practice is flourishing rather than to absolutism in the exceptional case euthanasia being not or hardly evitable. The euthanasia debate deals with more than only the question whether one is for or against. Freedom of conscience
Formulating an euthanasia will (or declaration) by the patient does not imply for him or her that the whole procedure will be settled. A euthanasia will does not lead necessarily to an automatic agreement with regard to the concrete terminal situation. Often the patient has not any idea about "compliance with the conditions of carefulness". It will not always be clear to him what will be the physician's interpretation of the terms "unbearable suffering" and "reasonable therapeutic alternative". Besides the patient often does not realize he is saddling the physician with a complicated procedure or even a matter of conscience.
The patient has no absolute right to euthanasia and the physician has no absolute duty to perform it. However, many patients and their relatives are thinking differently about this subject: requesting becomes claiming, the asserted right of the patient becomes the duty of the physician.
A remarkable comment came from the United States: " It is unimaginable that the Dutch justify euthanasia based upon the right of self-determination but at the same time are thinking that an other person &endash; the physician &endash; has to perform the lethal act".
The physician has the right to appeal to conscientious objections or other ponderous reasons against performing euthanasia. He has to make known these objections to the patient in time. Needless wavering about the readiness of the physician to perform euthanasia so long that the patient can no longer express his will or can look around for another physician is seen as unsporting and silly. Strictly, a physician refusing euthanasia on principal grounds is not obliged to refer the patient. But in the Dutch culture of openness he is expected to inform the patient about physicians or institutions where the patient can get by with his request and to hand over the medical history of the patient. Decrease or explosion?
The following numbers of cases of euthanasia were reported to the municipal coroners during the last years.
In 1994 1400 cases.
In 1996 1650 cases
In this year the second official state inquiry took place. It revealed that the 1650 reported cases corresponded with 41% of the estimated total number of performed euthanasia.
In 1998 2400 cases
In 2000 2150 cases
In 2001 2050 cases In 2002 the third official state inquiry started to the practice of euthanasia.
At the moment one can only guess about the reasons of the decrease of the reported number of euthanasia. Nevertheless an explosion of the number of euthanasia is not to be expected. Readiness to report
Decriminalization of euthanasia is considered being a means to raise the percentage of the number of reported euthanasia above 41 per cent (1996). By ending the punishableness of euthanasia all impediments to the physician to report euthanasia should be put away. Decriminalization should increase "the transparency of the euthanasia problem".
In the cases reported to the public prosecutor (41%) the physician mostly complied with the conditions of carefulness. In 55% of the not reported cases of euthanasia (59%), fear of judicial consequences plays a part, in 30% there is no compliance with the conditions of carefulness and in 12% the physician has the opinion that reporting means a violation of the patient-doctor relationship. By decriminalization of euthanasia one could expect an increase of reporting if not reporting was caused by fear of judicial consequences. In other cases the willingness to report will not increase probably. The so called transparancy will be limited anyhow. A physician concerning himself with questionable practices will not report a case of euthanasia. One may be in doubt whether the new law will join the social reality.
Euthanasia requires an intensive guidance of the patient and his family and an adequate technique. A physician who wants to be indemnified against criminal prosecution, has to submit on behalf of the public prosecutor a precise, completely documented protocol. Many physicians shrink from the time-consuming procedure, so that because of this reason a part of the cases of euthanasia are not reported officially and some death certifications are not filled in correctly.. The conditions of carefulness
Euthanasia seems to be less complicated than terminal care. Nevertheless in the Netherlands the physician has no walk-over, if he will comply with the conditions of carefulness. These due-care conditions are:
1. The request of euthanasia must be expressed by the patient himself. The physician has to verify that the request has been done voluntarily and without pressure. The request has to be expressed repeatedly and must be recorded ( in writing, by video or by tape-recorder).
2. The suffering must be perspectiveless and experienced as unbearable by the patient himself. A better term seems to be untreatable suffering. But, what kind of suffering is covered by the term perspectiveless and unbearable? Many people are suffering from their life, whereas there exist a social and not a medical problem.
3. Diagnosis and prognosis have to be as certain as possible. The patient must be completely informed about the diagnosis and the prognosis of his disease and about the eventual therapeutic alternatives. The alternatives have to be tried out reasonably, preferably following a palliative consultation.
4. The decision of euthanasia must be taken by the physician in attendance after consultation of at least one colleague-expert, not involved in the treatment.
5. The life-terminating action has to take place lege artis that is according to the standard of medical-technical and professional acting. Physicians who are requested to perform euthanasia may ask for support to a special consultancy office called SCEN (Support and Consultation in the case of Euthanasia in the Netherlands). The consultants of SCEN have got the opinion that nearly all physicians, intensively concerned with their terminal patient, put much time, free time and energy in the assistance of the patient and are ready to give personally the needed care until the end. Often these consultations are leading to more intensive palliative treatment and sometimes to another outcome than euthanasia.
Sometimes a consultant can be carried away in a proces that seems to have only one goal: ending the patients life and no longer trying to alleviate suffering. If the consultation- asking physician in attendance already promised to perform euthansia or even fixed the time, it is not easy for the consultant physician to come with objections or with alternative treatment. When the consultation has been asked in an earlier stage euthanasia is easier to avoid.
The SCEN consultation is comparable with the so called "ex ante", the beforehand check, suggested by the United Nations Committee for the Human Rights. "Better a euthanasia counsellor than a euthanasia examinator". The slippery slope
The argumantation of the government in favour of decriminalization of euthanasia passes completely by the dangers of decriminalization.
- Euthanasia without compliance with all conditions of carefulness.
- Life-termination of people considering life ready, thus finished.
- Claimed euthanasia.
- Habituation, indifference, routinely acting and uncarefulness.
Many elderly people are lonely, resulting from pesonal or collective individualism and a number of other social reasons. Together with the decreasing professional help many elderly aged fear they will be physically and economically a burden to their family and care-givers.
There may be a danger that the new Act will be stretched up to patients
- developping dementia
- who do not like living any longer: ready with living, tiredness of life.
- not being in the terminal phase.
- with perspectiveless coma without a euthanasia will.
- with a poignant terminal proces so that physicians are urged to shorten the dying proces actively.
- with unbearable, perspectiveless suffering without a euthanasia will. The case of the senator
An 86 years old man, formerly a member of the Senate, did not suffer from physical nor psychiatric disease. He was "ready with living". He suffered unbearably from the fact that his life had become aimless, useless and perspectiveless in his view. His physician assisted his suicide, was acquitted in the first instance but was convicted later by the supreme court.
This case has led to a number of questions and considerations:
- Is euthanasia because of being "ready with living" exceeding the legal limit or is it a logical extending of the already legalized today situation?
- When unbearable suffering from one's existence is considered being an acceptable reason for euthanasia may we give it a place on the slippery slope together with other social unbearable suffering such as the loss of the job, a broken love, or the death of the partner?
- Subjectively experienced unbearability of suffering is difficult to estimate. Does it deserve the same or a different approach if compared with medically objectivated suffering?
- What about existential suffering from loneliness, emptiness and a subjectively meaningless life which is not yet actual now, but is expected as a problem eventually for many years?
- May we expect a social development, sanctioned by jurisprudence and by the law, with the tendency that the total range of human suffering - provided that it is interpreted as unbearable and perspectiveless by the patient concerned &endash; may end into a request to the medical profession to (help) terminate the existence?
- May we expect the scenario in which physicians are only permitted to refuse euthanasia if they appeal to their individual freedom of conscience? Society deserves a better answer to citizens experiencing their life or suffering as meaningless, than giving them the legally rooted assisted ending of life.
- The jurisprudence in individual, difficult cases leads to legally fixed criteria and conditions, which in their generality will aplogize more than we like to do properly. So the new Act may lead us into the wrong direction. The limits of palliative care.
Nearly everybody knows inside his circle of acquaintancies the spectre of patients suffering terribly, more and longer than necessary or acceptable. The request of euthanasia is often prompted by fear of such untreatable and perspectiveless suffering. So the social base under the acceptance of euthanasia, assuming that the physician will comply with the conditions of carefulness, has become broader. The problem of euthanasia can not be denied nor neglected nor concealed and no more the question why some patients are requesting euthanasia when good palliative care is still available.
The mentality of most of the Dutch people is sensible, fair and reasonable. They experience euthanasia and e.g. abortion too as situations to be considered profoundly. If anyway possible these situations are to be avoided and the decisions must not be taken rashly. But they can not bear looking on mother who is terribly suffering. Than they will insist to put an end to that suffering. They will not hesitate at the very moment to point the legal possibilities. Mostly intensive palliative care can alleviate suffering sufficiently. But in spite of all allegations not every kind of suffering can be treated in an adequate and dignified way.
Some examples:
- Nearly always pain is treatable in an adequate way but pain and other symptoms of some patients can only be treated by bringing them in complete unconsciousness. This includes among others withdrawing and withholding of hydration and nutrition by the normal way. In this way the difference between this form of treatment and euthanasia can be subtile. When this process is taking much time, than an exhausting process is brought about, which can not be meant by the patient as "dying in dignity", apart from the feelings of the family.
- Such situations can be worsened when because of diseases or by the way of infusions the patient has become overhydrated so that it is taking more time to the patient coming to hypovolemia and uremia, both of them being favourable conditions to realize a good death.
- Terminal anxiety is sometimes difficult to treat without making the patient unconscious.
- Ulcerative carcinoma and its symptoms like stench are very difficult to treat.
- If the patient is gasping for breath and rattling with open mouth during several days , even when the patient is unconscious and not aware of his terminal respiratory distress, there may exist an unworthy situation.
- A physician may unexpectedly and unpleasantly be surprised and even browbeated by unworthy situations in terminal illness without time to comprehensive deliberation.
The physician is responsible for releaving the patient's suffering. He needs further development and refinement of palliative care so that his possibilities of terminal care do not get exhausted.
Moreover patients needing terminal medical care also need emotional, social and sometimes religious care. Distance and commitment
Mostly patients are dependent from medical power, sometimes they are its victims. We need new ethics for leading this relation in good channels. Every life is meaningful, not every prolongation is meaningful nor has additional value: sometimes a life may be considered as completed. It could imply that the physician only has to prolong human life if that is meaningful. What kind of life could be prolonged should be indicated by a wise committee.
The physician and other care-givers may be expected demonstrating commitment with the sick, but professionally they must be able to consider a situation at a distance especially when in our society one is seeking for the perfect life with the maximum happiness. At the other side living with a handicap or an incurable disease is a tall order. Enhancing its acceptation and acceptibility is a great challenge. But may this be laid upon the shoulders of the handicapped person only?
Physicians have to listen very well to the patients. Commitment implies also a plea to break through the traditional silence of physicians at the sickbed. They have to come nearer to the patients starting deliberation with the sick about sickness and with the dying about death.
In spite of the emphasis on "autonomy" people are not able to survive without the help of other people. Epilogue
I like to end with five theses I presented at the occasion of a congress on terminal care in 1992.
1. Euthanasia is not a really good death, at best the least bad one.
2. Euthanasia means always killing, even if it is practised from mercy or despair or at request.
3. It is debatable whether ending otherman's life may be justified anyway. At best it may be disculpated.
4. A physicican practising euthanasia according to his and the patient's deepest conscience &endash; provided he has complied with all conditions of carefulness &endash; does not be punished.
5. If the problem of unbearable suffering will not be resolved, there will not be a good alternative for euthanasia. Arnhem June 30th 2002 | 
