Euthanasia in Holland

Author: Julie Grimstad

EUTHANASIA IN HOLLAND An interview with a Dutch PRO-LIFE physician by Julie Grimstad, copyright 1991

AS I WRITE, voters in Washington State are being asked to consider Initiative 119, a measure that would legally allow physicians to actively kill patients who request "physician-aid-in-dying." The "aid" given would probably be in the form of a lethal injection or an overdose of pills.

Initiative 119 is sponsored by Washington Citizens for Death with Dignity, a coalition of pro-euthanasia groups including the American Civil Liberties Union of Washington, Americans for Democratic Action of Washington, several AIDS-related advocasy groups, the Unitarian Universalist Association, and, of course, Hemlock of Washington, a lobbying arm of the National Hemlock Society.

According to a report in the May 18, 1990 issue of American Medical News, Derek Humphry, executive director of the National Hemlock Society, has said that the society hopes to see similar proposals pass during the next three years in California (where an "aid-in-dying" initiative effort failed in 1988), Oregon and Florida. On previous occasions, Humphry has expressed the hope that America will follow the lead of Holland, where euthanasia has become a common way of death.

What can Americans learn from Holland's experience with euthanasia? In search of the answer to this question, I turned to Dr. Richard Fenigsen, a Dutch cardiologist who renounced his membership in the Royal Dutch Society of Medicine on June 24, 1984, the day the Society's board endorsed euthanasia. Dr. Fenigsen retired from his work (retirement is mandatory in Holland at age 65) at Willem-Alexander Hospital in 's-Hertogenbosch, The Netherlands, on February 1, 1990, but remains active in the field of medical humanities and medical ethics, both in Holland and in the United States. In addition to numerous papers and two books pertaining to cardiological subjects and internal disease, he has authored an essay on the ethical and intellectual costs of modernization in medicine (1964), and eight papers and a book (1987) on subjects pertaining to the philosophy of medicine, euthanasia and medical ethics.

In June, Dr. Fenigsen responded to my many questions with answers which I hope will alert American citizens to the perils inherent in accepting the notion that doctors should be allowed to kill their patients on request.

What is the current status of euthanasia in The Netherlands?

Active euthanasia is accepted by 76% of the Dutch public, by the largest professional medical association (The Royal Dutch Society of Medicine), the health authorities, and the judiciary. The law prohibiting euthanasia (article 293 of the Dutch Penal Code) is still on the books, but doctors who practice active euthanasia are not prosecuted if they conform to the so-called rules of careful conduct. Sometimes euthanasia is performed by nurses without the involvement of a physician; a recent study showed that this occurs in 18% of all cases. These independently acting nurses risk prosecution and sentences of up to four months of suspended arrest.

Can you give a realistic estimate of the number of people who die by active euthanasia in Holland each year?

The number of patients who die by active euthanasia is not known because, in the great majority of cases, doctors who perform euthanasia do not state it as the cause of death on the death certificates. From a questionnaire run among general practitioners it was estimated that these doctors carry out active euthanasia in 5000 cases every year. This number does not include euthanasia performed in hospitals. From a recent questionnaire among the general public, an estimated 18,400 cases of active euthanasia per year was obtained. This number, if correct, would mean that every sixth death in Holland is due to active euthanasia.

Is euthanasia only practiced in the cases of terminal illness and are patients with AIDS and Alzheimer's-type dementia candidates for euthanasia?

People who die by active euthanasia are not necessarily terminally ill. Chronic disability and suffering, which the patient finds intolerable, are now generally accepted as sufficient reasons for euthanasia.

Patients with AIDS are, indeed, considered to be candidates for euthanasia. The Center for AIDS Treatment in Amsterdam revealed that 11.2% of all deaths of patients with AIDS in Holland were due to active euthanasia.

To my knowledge, euthanasia is not performed at present in cases of Alzheimer's disease or other dementia. This situation, however, may change in the future as there is a certain public pressure toward allowing euthanasia for "persons who are unable to make decisions and/or express their will," and the Royal Dutch Society of Medicine appointed a committee to work out guidelines for euthanasia on demented and mentally retarded persons.

Is euthanasia always voluntary at present?

Involuntary euthanasia has been practiced along with voluntary from the very beginning. The practice of involuntary euthanasia was studied in great detail by H. W. A. Hilhorst (1983), and recently the Medicolegal Group at the Limburg University, led by F. van Wijmen, has attempted a quantitative assessment of the practice. Of 299 doctors questioned, 123 (41.1%) declared that they have performed euthanasia "without request of the patient." Seven doctors stated that they have performed involuntary euthanasia in more than fifteen cases each.

Those who advocate legalizing euthanasia in the United States say there won't be abuses. What do you say to that?

I have certain reservations about the term "abuses" as applied to euthanasia. Anyway, a number of documented cases have been published in Holland in which euthanasia turned out to be the result of criminal scheming, coersion of the patient by a spouse, coersion by the doctor, a nurse's error, a doctor's negligence, or was carried out by a doctor out of impatience or in an outburst of anger. Occurances such as these are an unavoidable corollary of euthanasia because the availability of unpunished killing attracts lowly motivated people, and because the medical profession, entrusted with carrying out euthanasia, has its share of intellectual mediocrities and emotionally unbalanced members.

Much more important is the widespread practice of involuntary euthanasia which, as the Dutch experience has shown, unavoidably accompanies voluntary euthanasia. Involuntary euthanasia - the medical killing of sick people without their knowledge - is a terrible abuse of trust, of individual freedoms, of the right of choice, and of the fundamental human right: the right to life.

Finally, euthanasia in its "voluntary" form is an abuse of all those who submit their requests while weakened by disease, under the influence of drugs, in a moment of transient depression, indoctrinated by the incessant propaganda of death in the media, and under the awesome pressure of social expectation that they quit the scene. Euthanasia, even "voluntary," is also an abuse of the doctor's calling, of human thinking and feeling, and of the highest values of our civilization. That's why I am somewhat reluctant to discuss in length the "abuses of euthanasia." Euthanasia, any euthanasia, is itself a terrible abuse.

"Right to die" organizations claim that, in America, we treat people "forever" without regard to their quality of life or the hopelessness of their condition. Can you comment on this?

It is our sad destiny to suffer and die. It is wrong to shun this truth, and to accuse instead those who bring relief as best they can. In a hospital, the sick person may be taken aback when confronted with all those machines and with an organization which seems so impersonal, but this organization is conceived to serve the patient, functions for the patient, and is manned by caring people. The hospital machinery are but tools; they do not dictate what need and will be done. The essential thing for a patient in any medical situation is to be in good hands. A good doctor has not only the professional skills, but also a life experience, a human understanding, and common sense. Fortunately, most doctors fit this description. They may finally not succeed, but they will certainly do their best to help, and not to harm; they will try not to let the patient die even a week to soon, but they will refrain from acts that are senseless or inflict unnecessary suffering. The patient may and should ask questions, and he may refuse any treatment proposed. Little is gained by spreading fear of doctors and hospitals.

I reject the term "quality of life." This is a flawed concept based on several false assumptions: that joy, physical well-being, self- fulfillment, friendship and respect of peers, reciprocated love and sense of belonging can all be expressed in a single dimension that can be measured; that this is an objective assessment, that is, applicable to all, cognizable by all, and allowing one person to determine the quality of life of another; and that some lives, namely those of "low quality," are not worth being lived. The concept of "quality of life" has little to do with life, and much to do with death. It is used to make arbitrary and wrongful decisions on behalf of other persons, to hasten their deaths without asking them whether they cherish their lives and what they themselves wish.

Do you think that allowing euthanasia will deter the search for better methods of pain control and treatment of disease?

To some extent it is true that the acceptance of euthanasia tends to diminish the efforts towards optimal pain contol. Indeed, the new perfected forms of palliative care are now making quick advances in Great Britain and Canada, but are non-existent in Holland, where euthanasia is practiced instead. It is also true, that the practice of euthanasia adversely influences the care of patients in general because, by offering "the easy solution," euthanasia inhibits the doctor's motivation to undertake the most difficult and not always successful tasks, and the motivation to do the utmost in investigating and treating severely ill patients.

We read that it is primarily evangelicals and a few Catholics who oppose euthanasia in Holland. Does the Catholic Church speak out on this issue?

38% of Holland's population belong to the Protestant churches, and about 40% to the Catholic Church. Largely as a consequence of the twenty years' pro-euthanasia campaign in the media, a great majority of Protestant churches (the Synod of the Hervormde Kerk) officially endorsed euthanasia in 1972. There are small Protestant groups opposed to euthanasia: the Dutch Patients' Association (NPV), the Shelter Association (Schuilplaats), the Lindeboom Institute for Medical Ethics in Ede, and the newspaper Reformatorisch Dagblad. The pro-life Dutch Physicians' Association (NAV), with a membership of 1200, is non-denominational. The Catholic bishops issued, several years ago, a pastoral letter condemning euthanasia. A very well edited small-circulation Catholic newspaper, Katholiek Nieuwsblad, consistently opposes euthanasia. I am not aware of the existence of any other organized Catholic anti-euthanasia groups.

Can you suggest ways in which anti-euthanasia groups and individuals in America can prevent legalization of euthanasia here?

I admire the excellent work being done by the American anti-euthanasia groups - your ability to analyze the subject, find the proper language, reach the public, and get things done. I regret we haven't had similar organizations in Holland. A good deal of your work qualifies for the national media, and I realize that to gain access to these may be difficult, but it is certainly worth the effort because it would greatly increase the impact of your work on the public. In Holland, we lost the battle in defense of human life (I hope, temporarily) because the media have been monopolized by the advocates of euthanasia.

Julie Grimstad is executive director of the Center for the Rights of the Terminally Ill, Inc., a patient advocacy, educational and legislative action organization headquartered in Fargo, North Dakota.

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