Euthanasia: Normal Medical Practice?

Abstract

Since the 1973 Leeuwarden trial of a doctor who killed a patient requesting euthanasia, public debate on euthanasia in the Netherlands has become come more intense. Despite the fact that, legally, active euthanasia is a criminal offense, physicians are quite open about practicing it. For example, in 1983 several general practitioners published case reports in influential Dutch medical journals.[1] However, the overall incidence of active euthanasia in medical practice was unknown; estimates varied between 2,000 and 20,000 cases a year. In the 1970s and 1980s a pattern of jurisprudence developed that reflected a considerable judicial lenience toward physicians practicing euthanasia under strict conditions.[2] At least three conditions have been repeatedly referred to in court decisions and bills: (1) the patient's voluntary and persistent request; (2) the hopeless situation of the patient; (3) consultation of a colleague. Early in 1989 two legislative proposals were submitted to Parliament pertaining to the practice of euthanasia but could not be discussed, as shortly afterwards the Cabinet resigned. In November 1989 the government (a coalition of the Christian Democratic Party and the Socialist Party) announced its intention to suspend political debate on legislation in order to obtain an empirical understanding of the frequency and nature of euthanasia in medical practice. In January 1990 a new committee consisting of three lawyers and three physicians was established by the Ministers of Justice and Public Health to investigate medical practices regarding decisions at the end of life. In September 1991 the committee published its report, followed by new legislative proposals issued by the government on 8 November 1991 and scheduled to be discussed in Parliament about May 1992. These developments suggest that the current debate in the Netherlands has shifted from the level of medical-ethical arguments, justifying or opposing euthanasia within the doctor-patient relationship, to the socioethical and political problem of whatever and how to regulate or legalize the actual practice of euthanasia, given newly accumulated empirical data. Medical-ethical viewpoints regarding euthanasia in clinical practice have been moved to the background. In this contribution, we will discuss the present state of the debate, first through analysis of research into the practice of euthanasia and then through a moral evaluation of its political and legal implications. Research into the Practice of Euthanasia In the fall of 1991 the results of two empirical studies on euthanasia were published. Van der Wal and his associates reported on the results of an exploratory, descriptive, retrospective study of morbidity, age, and sex of patients whose family doctors helped them to die; the study also tried to assess the level of suffering these patients experienced.[3] More influential was the report of the Committe on the Study of Medical Practice concerning Euthanasia (also called the Remmelink Committee after its president, attorney general of the Supreme Court J. Remmelink). The task of this committee was not to advise the government about legalizing euthanasia, but to investigate the current practice in the Netherlands.[4] Some 130,000 people die in the Netherlands each year. In some 49,000 of these instances physicians have to decide whether to continue life support, withhold treatment, increase the dose of morphine to provide adequate pain relief, even at a potentially lethal level, assist in suicide, or actually kill the patient. Although the committee was asked to investigate only the medical practice of terminating life, it decided to look into the whole field, that is, all situations in which physicians make decisions that aim (also) at ending suffering by hastening the end of the patient's life or in which the probability of a hastening of the end of life must be taken into account. …