Maybe it was finding that a European conference on euthanasia and assisted suicide was held during a stretch of grey, foreboding weather in early June of this year in the chilly, southern Holland town of Maastricht.

Normally, Maastricht is better known for giving its name to a treaty for the European Economic Community, but this somber conference dealing with mercy-killing may well change that.

For many years now there have been intermittent stories coming out of the Netherlands about the growing acceptance of euthanasia.  Often one would hear about hospitals setting up euthanasia protocols, elderly patients afraid of their own doctors, people being killed in nursing homes, and many other anecdotes.  But there seemed to be a shortage of hard facts and numbers to be able to actually deal with the truth of the Dutch reality.  This conference was to lay out the facts according to the sponsors who included the Dutch Ministries of Health and Justice and the Royal Dutch Medical Society among others.  The reality is as bad as you’ve heard.

Setting the stage

The Dutch have long been known for their tolerance towards drugs, prostitution and alternative lifestyles.  From a distance, it seemed that anything was possible.  For example, the question of abortion seemed to be a closed concern and even mercy-killing supposedly was quietly being practiced.

In 1973 a doctor gave a lethal injection to her aged mother, who had requested it.  In the subsequent court cases, the motive of compassion was the doctor’s main defense.  The Dutch Supreme Court accepted this and gave the doctor a suspended sentence.

In the same year the Royal Dutch Medical Association made it their official opinion that there could be extreme circumstances where a doctor might justifiably “shorten the life” of a terminally ill patient.

In the next eleven years, fourteen cases came before the courts and were dealt with lightly.  Gradually, case law built up, and in 1984 the pivotal Alkemaar case was decided.  In this case, an elderly woman, Mrs. B., was killed at her request by her doctor.  The doctor’s defense was that he was faced with conflict of interest in that he had to break the law to fulfill a higher good – that of mercy in releasing his patient from a cruel and lingering death.

This is the defense of force majeure wherein a physician had to act in a way that broke the law from necessity.  Basically, the Supreme Court accepted this defense.  As J. Legemaate, the legal counsel for the Royal Dutch Association put is, “Effectively with this decision, the ethical debate of euthanasia had been settled by the courts and the way was open to work on process and procedure.”

The laying out of the process was not long in coming.  Three months after the Alkemaar decision, in November 1984, the doctors’ group came out with guidelines as to when mercy-killing would be acceptable.  With very little revision, these have subsequently been adopted by the courts and have now been incorporated into law as of June 1 this year.  Though on paper euthanasia is still against the law, it has been effectively legalized.

Dutch euthanasia guidelines

For an act of euthanasia to be legally acceptable the Royal Dutch Medical Association has set up the following criteria:

  • There must be a voluntary and continuing request for it.
  • The patient must do so with fully informed consent.
  • There must be hopeless and intolerable suffering.
  • All other alternatives must be rejected and this the only alternative left.
  • Another physician must be consulted.

These guidelines were accepted by the courts by 1987, but there still remained the problem that, for the most part, mercy-killings were still dome underground and the doctors were reporting them as natural deaths.  Since about 42% of deaths in the Netherlands take place in the home (as compared to Canada where over 80% die in hospitals or nursing homes) this was very difficult to monitor.

The Dutch government, facing both opposition party pressure to change the law and a growing practice of euthanasia that the courts could not contain, decided to tackle the problem by setting up a government commission to get the actual facts and some hard numbers as to what was the real situation.  In September 1991 the so-called Remmelink Report (named after its chairman) presented its results.

The Remmelink Report:  Hard numbers, soft definitions

The government promised both immunity from prosecution and anonymity to any doctor who would participate.  Ninety-two percent of those who were asked did so and the interviews were usually several hours in length.  Seven thousand death certificates were examined and all death certificates in a six-month period were scrutinized.  Both sides of the debate consider the Report a solid piece of work.

The main author of the Report, P. Van der Maas, spoke in Maastricht.  The authors had decided that their definition of euthanasia would be a very strict and narrow one.

As defined by them. Euthanasia is a doctor killing his patient at her voluntary request.  Withdrawing treatment or killing incompetent patients or assisting in suicide do not figure in this.  As was pointed out repeatedly by many questioners, this is a very narrow definition.

Normally in Canada, and in most of the rest of the world, we have a much broader definition.  As well, the intention of the doctor, more of less ignored in the Report, is of vital importance especially when evaluating the ethics of withdrawing or withholding treatment.

Still, in using these definitions the Report came up with some interesting figures.  To understand them takes a bit of digging.

The Netherlands has approximately 15 million people (roughly half the population of Canada). Each year there are 129,000 deaths from all causes.  According to Remmelink, there were 2.3000 cases of assisted suicide (which he admitted are almost impossible to separate from euthanasia).  But, surprisingly, there were also 1,000 cases that had a strange name – Life-terminating Acts Without Explicit Request (LAWER).  Here no consent had been sought or given, but the patients were still killed.

Throughout the entire conference there was a definite move to avoid discussion about these cases.  These were seen as unfortunate but necessary side-effects or deaths of people who “generally” were known to the doctor and who had “talked about it before” or patients that “were obviously suffering but not competent enough to ask for relief,” etc.

If these cases are added together – 3,700 – it is slightly over 3% of all deaths.  The problem is that this is not the whole story.

What the numbers really say

As several commentators have pointed out there are other strange numbers in the Remmelink Report.  There were a surprisingly high number of morphine overdoses – 22,500 per year.  Of these, 36% (8,100) were done with the expressed and stated purpose and intention of shortening life and 3,159 were involuntary.

As well, there were 13,506 cases of withholding or withdrawing treatment with the intention of shortening the patient’s life.  Of these, 8,750 were without consent.

This amounts to 25,306 or 19.4% of all deaths of which 11,909 were involuntary.  If you exclude heart attacks, strokes and accidents from the larger picture, this means that almost 50% of Dutch deaths are being caused by their doctors.

What about safety guidelines?

Repeatedly at the conference, speakers claimed that euthanasia was firmly contained in the Netherlands, and that they would not be embarking on the slippery slope to all-out mercy-killing.  Researchers tend to deny this, however.

Let’s examine how these guidelines work in practice.

  • How durable was the euthanasia request? There were documented instances where the requests were only written minutes or hours apart.  Very few are written.
  • How voluntary are the requests? If the social attitude towards mercy-killing is changing it prompted even a definite proponent of euthanasia, Professor Borst-Eilers to state, “If I am honest I must admit I cannot judge whether the fact that euthanasia is openly talked about does not bring about a kind of feeling that it’s something you’re allowed to do.”  Doctors admit to suggesting mercy-killing to patients, as do family members.
  • How informed is the patient’s consent? Pain can obviously warp judgment.  Dutch government studies have admitted that between 54% and 80% of cancer patients are treated inappropriately for pain. Drugs can cloud the thinking process as well.  Indeed, being a patient always puts a person in a somewhat powerless position as anyone who has been one knows.

Mercy-killing is also being done on handicapped newborns.  G. Van der Laan of the Nurses’ Association has admitted to promoting this along with the Dutch Pediatric Association (1992).  Mrs. Van der Laan would also like to have nurses allowed the right to euthanize patients.  Many speakers casually admitted that the incompetent elderly are “granted relief from a futile existence” or, in plainspeak, killed.

The LAWER cases (that is, killing without request) show this.  In 14% of the cases the patients wee totally competent and, in a further 11%, partially competent.  Clearly, powerlessness is a dire reality in the patient-doctor relationship in the Netherlands.

If one looks at the question of intolerable suffering the situation is even cloudier.  Don’t imagine that the Dutch mean only physical pain in this regard.  Pain as a single primary motive ranks very low (between 5% and 17%) in the reasons for euthanasia requests.  Instead, suffering, meaningless life and loss of dignity are rated far higher as reasons for such requests.

At breakfast one morning, I sat across from Dr. H. Cohen who admitted to doing 7-8 mercy-killings a year on older adolescents, arthritis sufferers, and asthma sufferers among others.  He could not see that it was his place to the validity of the reasons for the request.  As Time Magazine reported recently, a Dutch doctor was cleared of charges of killing a depressed woman at her request because, “Intolerable psychological suffering is no different from intolerable physical suffering.”

  • Were alternatives to euthanasia offered? Though many speakers talked about good pain control being available, government studies, as mentioned above, do not bear this out.  In addition, there are only three hospices in all of the Netherlands, (the lowest available rate in Europe) with only 62 beds in total.  Taking into account the social isolation of the sick and elderly and a social culture that promotes mercy-killing, few valid alternatives would seem to be presented.

Lastly, there is the question of consulting with another physician before killing the patient.  Less than half of doctors did so or even felt that there was any true value in such a consultation.

To sum up, the guidelines are more honoured in their being ignored than followed and the legal counsel for the doctors admits that it would be practically impossible to being a case successfully before the courts even if such rules are flouted.

There is obviously no real control.  As G. Annas, an ethicist and euthanasia advocate admits, (when referring to the Time case) “If you’re worried about the slippery slope, this…is as far down as you can get.”

How to calm a conscience

Nobody likes to talk about killing people.  When the term mercy-killing was uttered a rustle of displeasure would be heard throughout the audience.  Here follows a list of preferred terms to use when killing patients with or without their consent.  All were used at the conference: granting relief, alleviating distress, initiating the dying process, aiding personal self-determination, supervising final autonomy decisions, terminating biological life, unrequested life terminations, life-terminating acts without explicit request, activating euthanaticums (giving poisons), non-treatment decisions, conservative treatment, responsive care for the dying, and many other euphemisms.  But above all – do not say killing!

The probable future

As R.A. de Moor pointed out in a brilliant presentation, the push for mercy-killing will continue to grow because of increasing secularization of Dutch society, acceptance of mercy-killing as an option, legalization of euthanasia, an aging population and degenerative and disabling illnesses such as AIDS, etc.

Increasingly, health care providers will see killing of their patients as part of good health care where to respect the person may well mean killing her with or without her request.

An export product

Though most speakers insisted that the Netherlands is a unique case and that its model could not be exported to other countries, this is a very naïve and dishonest view.  Other countries are looking to the Netherlands as an example and pro-euthanasia groups (of which there were many members present at the Maastricht conference) want to import the model.  The Dutch are rightfully seen as a civilized and intelligent people who have handled their challenges with gritty determination.  Their effective legalization of euthanasia is seen as the route to go by many pro-mercy-killing pushers.

However, this year, the British House of Lords’ Select Committee on Medical Ethics came out against euthanasia and assisted suicide.  One of their main reasons for doing so was their trip to Holland where the dangers of legalizing euthanasia were obvious.  It would appear that enthusiasm for the Dutch model is not universal.

No goodbyes

Leaving the conference, one has several haunting thoughts.  First, the participants did not generally worry about the morality of killing or suicide.  Process and due procedure were what mattered and ethics were consigned to only a mild worry.

Secondly, nobody was overtly ashamed about what they were doing and promoting – killing patients – if one overlooks the language gymnastics.

Thirdly, the terms and methods used to bring in euthanasia are eerily similar to how abortion was brought into Canada.

Lastly, all the pieces seem to be in place here for the same process.  We don’t have to wonder at what the future will look like with euthanasia.  Just buy a ticket to the Netherlands or read their reports.  The future is now.

There is no saying goodbye to the Dutch practice of euthanasia/mercy-killing.  There is only the hard work necessary to make sure that the grey clouds of Maastricht do not come to hover over Canada.