by Dr. Jos Welie
In the past half-a-year, two members of my family passed away. That’s not unusual given the large size of my extended family. Neither is it unusual that both had cancer, which remains the most common cause of death (60%) in my native country, The Netherlands. What is unusual is that both died as a result of euthanasia. Granted, two cases do not amount to meaningful statistics. But it is startling nevertheless that all of the recent deaths in my family were the result of euthanasia. This suggests euthanasia is no longer an exceptional event, practiced only in those extremely rare situations when the patient’s suffering defies all medical attempts at relief and has become absolutely unbearable; rather, it has become a routine intervention in The Netherlands.
Indeed, already one out of every four Dutch cancer patients dies as a result of physician assistance in suicide (PAS) or euthanasia (with euthanasia being the preferred route involving more than 90% of the cases). As is true in Oregon where research has shown that pain and other sources of physical suffering are not the primary reason for patients to request PAS, psycho-social reasons appear to be the main drivers of the Dutch PAS/euthanasia practice. Here again, the two recent deaths in my own family are good examples.
One patient was single with no children, both parents had already passed away and relations with her siblings were somewhat strained. Due to the cancer, the patient had lost her ability to communicate, which she experienced as a grave burden. Her cancer had become incurable but as far as I know she had not yet entered the dying phase when she elected to undergo euthanasia. This is definitely true for the second member in my family. She had been diagnosed with lung cancer only weeks ago after two primary care physicians had failed to diagnose the cause of her persistent cough, prescribing antibiotics instead. Once diagnosed correctly, the lung cancer turned out to be incurable. The patient received a permanent chest tube to relieve fluid from her lungs and facilitate breathing, and was then admitted to hospice. The hospice team managed to control her pain and the patient indicated feeling much better at the hospice site. Three days later, she celebrated her birthday with the members of her immediate family attending. The next day, she had some more visitors to whom she mentioned feeling tired but otherwise OK. The next evening, euthanasia was performed.
What exactly motivated these patients to request euthanasia is not known to me. But Dutch law requires that the patient’s suffering is beyond relief and that it is experienced by the patient as unbearable. No doubt, the fact that the second patient went from living an active life to being terminally ill in a matter of weeks must have been weighing heavily on her; but such devastating diagnoses usually motivate health care professionals to assist their patients in readjusting their lives, not ending them.
Then again, ever since The Netherlands legalized PAS and euthanasia, it has been gradually expanding the conditions under which PAS/euthanasia can be performed. Last month the Ministers of Health and of Justice of the Dutch Government sent a letter to Parliament, announcing the Government wants to make it possible for people who consider their lives complete to undergo PAS/euthanasia, even if this sense of life no longer being worth living is not due to medical conditions or physical disabilities. Remarkably, the Dutch government in doing so went against the advice of its own advisory commission, which had concluded in its final report of February 4, 2016 that there was no need to relax the legal criteria for PAS/euthanasia.
In their letter, the Ministers make clear what situations they have in mind. It concerns people:
- whose suffering is not due to medical conditions
- who generally will be elderly (but not exclusively so)
- who suffer from situations such as
- loss of a beloved partner
- loss of meaningful contacts with friends
- loss of independence
- reduced mobility
- tiredness and apathy (not due to a medical condition)
- loss of personal dignity
- who consider life to have become too burdensome or pointless
- and who are competent to make the decision in favor of PAS/euthanasia autonomously
The Ministers emphasize the importance of autonomy, arguing that this principle trumps the principle of the inviolability of human life. This suggests that the Ministers have adopted a classic libertarian moral stance: The government should not stand in the way of the free choices of individuals, whatever those choices may be, as long as these choices do not unduly harm third persons. But as is true of virtually all advocates of PAS/euthanasia, the Ministers in the same letter invoke a second justification that is fundamentally different and even at odds with the aforementioned libertarian defense. The Ministers next argue that it is out of compassion for the suffering of others that health professionals and likewise the government should facilitate PAS/euthanasia for people who no longer want to go on living.
Whereas the libertarian argument hinges on the presupposition that it is not up to me to assess what you want to do with your life (indeed, some libertarians have argued that it is simply impossible for me to evaluate your personal preferences), this compassion-based argument presumes that I can actually sense your suffering. For “com-passion” literally means “suffering with (another person).” It is because I myself have found that your suffering has rendered your life no longer worth living that I can compassionately conclude that PAS/euthanasia is justified. In other words, the person performing the PAS/euthanasia must him/herself reach a judgment on whether the life of that other person is still worth living independent of that other person’s autonomous request for PAS/euthanasia.
Indeed, the ministers go on to insist that the health care professionals involved must carefully evaluate the request to determine whether the requester’s reasons are sound. They mention, by way of example, that if somebody has just lost his much beloved partner due to a car accident, that loss does not render life unworthy of further living, regardless whether the suffering person himself insists that he does not want to go on living without his partner. Thus, the Dutch government will have to make a list of situations that render life pointless, and if - and only if - a person requesting PAS/euthanasia falls within one of those situations will his/her request be met. The decisive factor, hence, is not whether an autonomous person judges his own life meaningless, but whether society also judges that person’s life to have become meaningless. And that latter judgement is most disconcerting.
Many US states as well as the District of Columbia are considering to decriminalize physician assistance in suicide, thereby following the five states that have already done so. Almost always, The Netherlands is invoked by advocates of such decriminalization as proof that the practice can be regulated tightly and restricted to only those cases where physicians have exhausted all means of relieving unbearable pain, dyspnea, chronic tiredness and other severe symptoms. Critics of the Dutch approach have long warned about a gradual expansion of the Dutch practice to include psychiatric patients, neonates, teenagers, incompetent adults (based on a previously issued living will), and now anybody who considers it pointless to go on living.
Advisory Committee on Completed Life (2016). Final report (available only in Dutch). Feb. 24, 2016. The Hague (NL): Government of the Netherlands. On-line at https://www.rijksoverheid.nl/onderwerpen/levenseinde-en-euthanasie/docum...
Government of the Netherlands (2016). Response to the final report of the Advisory Committee on Completed Life (available only in Dutch). Oct. 12, 2016. The Hague (NL): Government of the Netherlands. On-line at https://www.rijksoverheid.nl/documenten/kamerstukken/2016/10/12/kabinets...