In Holland, has "a right to die" become "a duty to die"?
When DR BEN ZYLICZ examined the 50-year-old woman at the clinic where he worked in Holland, he knew immediately that she did not have long to live. Cancer had spread beyond her breast to her bones, liver and lungs.
Carefully, the Polish-born oncologist explained to the woman that he could reduce her pain with drugs, and he offered her a hospital room. Zylicz sensed, however, that she was fearful of Holland's policy allowing doctors to end the lives of the terminally ill.
"I am a Catholic," she said. "My religious beliefs would never allow me to accept euthanasia."
Zylicz assured the woman that he would take care of her, and finally she agreed to be admitted to the hospital. After 24 hours of morphine treatment, she was free of pain. Though she knew death was close, the woman was at ease, able to see her husband and family.
Later, however, a nurse phoned Zylicz at home with distressing news. After he left the hospital, another doctor had entered the patient's hospital room and asked her husband and sister to leave. He then ordered an increase in her morphine dosage, but refused to confirm the order in writing. Within minutes she was dead.
Zylicz demanded an explanation.
"It could have taken another week before she died," his colleague told him. "I needed the bed."
Around the world, people are wrestling with the question of humane death — especially in the face of painful terminal illnesses. The dilemma has become more complicated in recent years, as advanced medical technology has enabled doctors to keep patients alive much longer in even the most extreme cases. Of course, patients have the right to refuse medical treatment at any time; requesting lethal injections, however, is another matter.
Last April, the Australian parliament overturned the Northern Territory's Rights of the Terminally Ill Act, which had made voluntary euthanasia legal in the territory for nine months — but the states remain free to legalise the practice. As the debate continues, advocates of assisted suicide and euthanasia find a role model in Holland, the only country that permits both practices. Its policy, says America's Jack Kevorkian, is a "remarkable triumph of common sense."
A closer look reveals the truth about the practice of euthanasia in Holland.
The Royal Dutch Medical Association officially endorsed euthanasia in 1984, and issued strict guidelines on how to perform it: the patient's condition must be one of unbearable suffering that cannot be relieved, and the patient must freely request to die. When a patient does ask, the doctor should not proceed without consulting an independent physician. Then each case must be reported as an "unnatural death" to local officials. Doctors who do not comply with the guidelines can be imprisoned for up to 12 years.
Approved by parliament, the guidelines were meant to protect and empower terminally ill patients. But evidence suggests that they empower doctors instead.
Though Dutch patients are supposed to decide for themselves, they are sometimes influenced by doctors.
"If doctors judge someone's quality of life to be low," says K. J. P. Haasnoot, a general practitioner in Baarn, "they ask, 'Why should we add to the suffering?'"
A survey commissioned by the Dutch government estimated that only 3600 people died in 1995 as a result of assisted suicide or euthanasia. But this only included cases where the patient requested death. The survey did not count as euthanasia or physician-assisted suicide the 900 cases in which patients' lives were ended without their request, and nearly 1900 deaths in which doctors increased painkilling drugs with the explicit intention of hastening death.
A 64-year-old woman, told in 1988 she had advanced ovarian cancer, wished to die at home. When she woke one morning covered in what looked like red pinpricks, her husband took her to the hospital and then left. Returning to the hospital the next day to take his wife home, he took a short walk while he waited for the doctor to attend to his wife. When the husband returned to his wife's room, she was unresponsive. Three hours later she died — from lethal drugs the doctor had injected into her intravenous drip.
The husband believes a doctor proposed the injection and his wife was swayed.
"She always thought doctors knew best," the husband said. "It wasn't euthanasia — it was murder."
But there was no investigation because he did not want the doctor prosecuted.
"Because euthanasia is politically correct, prosecutors are often unwilling to press charges," says Dutch criminologist Chris Rutenfrans.
Since 1981 only 20 doctors have come before the courts. Nine were convicted. Of those, six received suspended sentences, and three got no punishment at all.
Critics say euthanasia supporters selectively prosecute cases only to extend the limits on what is acceptable. In June 1994, for example, the Dutch supreme court ruled on a case in which Haarlem psychiatrist Boudewijn Chabot had assisted the suicide of a 50-year-old woman. She was not terminally ill or in physical pain, but she was depressed. Not one of the doctors who rendered "second opinions" saw her in person. Nevertheless, the court accepted for the first time what was previously a crime: helping a physically fit patient to die.
Dr Herbert Hendin, medical director of the American Foundation for Suicide Prevention, has studied euthanasia in the Netherlands. He notes that
"what was intended as a solution for exceptional cases has become a routine way of dealing with terminal cases. The Netherlands has moved from euthanasia for the terminally ill to euthanasia for the chronically ill, from euthanasia for physical illness to euthanasia for psychological distress, and from voluntary to involuntary euthanasia."
Duty to die
Already, Holland's euthanasia guidelines offer scant protection to the mentally ill and newborn babies. Researchers from the Centre for Bioethics and Health Law at the University of Utrecht found that more than 40 per cent of all mentally handicapped patients who died in 1995 did so after a doctor's decision to withdraw treatment, increase painkilling drugs or give lethal injections.
In that same year, doctors were charged with killing two handicapped newborns. The courts ruled that the doctors had no option but to kill. The Dutch government survey reports that doctors now kill about 15 non-viable newborns each year.
In some cases, a patient's "right to die" has subtly become a duty to die.
"I frequently see people pressured towards euthanasia by exhausted and impatient relatives," says Amsterdam psychiatrist Frank Koerselman. He tells of a woman whose relatives gathered in Amsterdam for her planned euthanasia. One relative came from overseas. When the patient expressed last-minute doubts, the family said, "You can't have her come all this way for nothing." Instead of ensuring that the patient's true wishes were observed, the doctor carried out the euthanasia.
In Holland, the key alternative to euthanasia — palliative care — is largely unavailable. Originating in England 30 years ago, this philosophy of total care for the terminally ill and their families offers spiritual comfort and the control of physical and mental pain, without seeking to either hasten or postpone death. Today almost all communities in the United Kingdom and many in Europe and North America provide such care, often in facilities known as hospices.
Dr Robert Twycross, a leading authority on palliative care at Oxford University, recalls a cancer patient who drank excessively to escape the pain and mental distress caused by his illness, and finally demanded to be put to death. After pain treatment, he changed his mind, saying, "It wasn't me speaking. It was the alcohol."
"Depression often overlaps and complicates terminal illness," says Twycross. "As the patient comes out of depression, the demand for euthanasia evaporates."
Australia has about 360 hospice and palliative care services, used by more than 20,000 people every year. In the United States, some 3000 hospices were used by 450,000 people in 1996. But Holland has no more than half a dozen independent hospices with up to 36 beds.
"Unfortunately, the Dutch discovered euthanasia before they discovered palliative care," says Zylicz.
Ineke Verloop learned in October 1996 that neither surgery nor chemotherapy was likely to cure her cancers of the throat and stomach. But the two options available to her — a hospital or a nursing home — did not appeal to the 65-year-old widow, who feared her own wishes would not be respected there.
I'm not afraid of death, Verloop thought, but I don't want someone else to decide how I should die. She seriously considered euthanasia. Like most Dutch people, she knew little about options in palliative care. Then an acquaintance told her about Hospice Rozenheuvel.
Five weeks later, Verloop was sitting in the Rozenheuvel sun lounge. She considered herself blessed.
"When I came here, I could hardly walk or talk, and I hadn't eaten for a month," she recalled. "After ten days, I chat, walk and feel relaxed. I know I'm not leaving here alive, but I feel like a human being."
Verloop died peacefully a few weeks later. She had been cared for by a doctor with a special sense of mission — Ben Zylicz.
Five years before, soon after his patient was euthanised by another doctor, Zylicz quit his hospital post to dedicate himself to an alternative.
"As a doctor, I saw lives taken for reasons that had little to do with healing," he says. "Now I am able to help patients in a humane and caring way. I only hope that others — both doctors and patients — will have that chance."