Tuesday, November 8, 2011

More bad news on euthanasia from the Netherlands

For those who have continued to insist that there is no such thing as a slippery slope in the Netherlands in its practice of euthanasia, today's news is sobering. A woman with advanced dementia received lawful euthanasia, in a case regarded as a further watershed in euthanasia practice. Read it below in translation as well as a critical article by a Dutch correspondent below it. These two articles are pertinent in the context of the Steph Key Bill in South Australia, which allows euthanasia, but is promoted as merely a protection for doctors who perform it, and not bestowing a right to euthanasia by those who want it.

In Dutch euthanasia law doctors who practice euthanasia must report each euthanasia case, after the act, to a regional assessment committee. The core task of such a committee is to decide whether a doctor has acted with due care, that is, followed all the required guidelines.

These Dutch guidelines are that the doctor:
  • is convinced that the patient request was voluntary and well considered;
  • this convinced of the presence of the patient’s unbearable suffering with no relief in sight;
  • has informed the patient about their health situation and about their prospects;
  • has come to the conclusion with the patient that for this situation there is no other reasonable solution ;
  • has consulted with at least one other independent doctor, who has seen the patient and gave his judgement in writing about the above mentioned requirements for due care;
  • has carried out the ending of life or assistance in suicide in a medically careful way.
The question for any society, perhaps especially rich Western societies, is how it chooses to address suffering. The ‘unbearable’ suffering described in this case involves a fear of going into a nursing home and loss of independence. Fears of becoming a nursing home inmate can be well founded. Few people who have seen their own elderly family members live in such places would want to live there themselves, for good reasons. Are there really no other ways in which such fears can be addressed in a practice of better care? Or do we like to talk about compassion in discussing euthanasia legislation but are too lazy to actually practice it?

Any developments in euthanasia in the Netherlands do travel to other jurisdictions. This country has now taken yet another step closer towards a culture of death where prohibitions even of killing those who can not express their own wishes on euthanasia have now officially fallen. The article’s expressed expectations of many further requests for euthanasia in similar cases, within the mentioned context of a growing and large contingent of people who have dementia, in a society which is practising cost-cutting measures in health care and disability support, can only diminish the inherent dignity of human worth. Where life is not worth much it will be more easily disposed of. 

What kind of future will this lead to? There is an urgent need to look at accepting dependence and vulnerability as inalienable parts of what it is to be human. Losing independence in itself is no loss of dignity. It is the way in which we help others, and in the ways in which we are helped by them, that dignified and worthwhile lives are lived. 

It is clear that nothing stands in the way of performing euthanasia on other people who might be perceived as suffering unbearably and who are cognitively not capable of expressing their wishes. Who's next? Already euthanasia for people with a mental illness is openly discussed by the Dutch as a 'right' that they should have. People with intellectual disability too perhaps? And people with acquired brain injury, autism or some other condition?

The following is a translation of an article that appeared in the Dutch newspaper De Volkskrant, by Maud Effting − 09/11/11 

For the first time euthanasia has been applied in Holland to a patient with advanced dementia. The 64-year-old woman had indicated for some time that she wanted this, though she could no longer express her wish to die clearly and her mental capacity and reduced significantly. Nevertheless her euthanasia was approved (after its performance) by the official euthanasia assessment committee.

The woman died in March of this year. This case can have far-reaching consequences for the practice of euthanasia in the Netherlands. This means that patients who lose their mental capacity can still have euthanasia under certain circumstances, so says GP Constance de Vries from Munstergeleen. She was involved in the case as a 'SCEN'-doctor, who is a consultant as a second medical opinion in euthanasia requests.
The law requires that the doctor has to be convinced that the patient's request is voluntarily and carefully considered. In this case the patient had made it clear to her GP from the beginning that she wanted euthanasia when the time came that she had to go to a nursing home. The prospect of losing her independence and no longer be able to recognise her children was said to be a nightmare for her.

She had put these wishes in writing in a euthanasia declaration at a time when she was still clear minded. After that she had regularly repeated her wishes to her GP, with whom she had a close relationship. Her husband and children supported her decision.

Up to this time euthanasia in the Netherlands had only be applied to people who were in the beginning stages of dementia. Doctors only dared act on requests of patients with whom it was still possible to have a conversation.

 Remembering shreds of her motivation

In the last months of her life the 64-year-old patient could only remember shreds of her motivation (in asking for euthanasia). All the doctors said it was clear that she was suffering: she was confused, angry, and cried a lot. In every conversation with the doctor she said that she would rather die than go to a nursing home.

The GP consulted a number of other doctors. One SCEN doctor judged the case negatively. He agreed that she suffered unbearably but decided that he could not check whether her request was voluntary and well considered. The second SCEN doctor did agree that euthanasia was possible. Because of the sensitivity of this case, it has been considered by all five of the regional euthanasia assessment committees. In August they judged that the GP had acted with due care.

The committee found that, through many discussions with the patient, he had been able to form a clear picture of what the patient considered to be unbearable suffering. This was confirmed by her written euthanasia declaration. In addition, be it in unclear terms, she persistently signalled her wish to die till the last. 

Doctors are very reticent with euthanasia in case of dementia. Last year euthanasia was applied 21 times with patients with dementia. Before that time this hardly ever happened. The expectation is that the number of requests will increase significantly. The number of Dutch patients with dementia is estimated to reach 500,000 in 2050.

Her husbands and children supported her decision.

A second article on this euthanasia topic was published in the same edition of the newspaper which is also reproduced here in translation.

Marie-Jose Calkhoven − 03/11/11, 14:34

Contrary to suggestions of de Dutch Society for Voluntary Euthanasia (NVVE), made in its advertisements, euthanasia is not a right that can be demanded, says therapist and author Marie-Jose Calkhoven.
The NVVE is engaged in a national campaign for self-determination declarations. The television advertisements which can be seen and heard on regional television revolve around a do-not-resuscitate pendant, a non-medical-treatment declaration and a euthanasia declaration.

The fact that the NVVE campaign is contributing to awareness about dilemmas during dying is sensible. At this time where technology allows many life-saving procedures, it is good to weigh up carefully where are an individual's boundaries for medical intervention. Unfortunately there are significant concerns about the way in which the NVVE is conducting its campaign. In particular the advertisement about the euthanasia declaration is a low point. In it a teenage girl tells of her grandfather who chose for euthanasia. “Perhaps it sounds strange “, she adds , “ but when the time comes, that's what I want to do.” After which a male voice-over adds the global message :” With an NVVE self-determination declaration doctors and loved ones know what you want, because dying with dignity, that is completely normal isn’t it!” ("doodnormaal")

What is wrong with this advertisement? First the tone. The lobby-like way in which death through euthanasia is promoted, is eerie. euthanasia is recommended as if it is the latest iPhone, which you must absolutely have. Through this approach the NVVE creates the image of euthanasia as an ‘individual (consumer) right.’ This suggestion is not a contribution to a correct and realistic understanding of euthanasia law, which was developed to protect doctors, not to give citizens rights.

 When a doctor supports a self-chosen death within a strict framework of law for guidelines, he will be immune from criminal prosecution. In other words people may request a doctor to perform euthanasia, but it is not a right that can be demanded, and therefore should not be sold as such. There are too many people who assume that everything is fine with their euthanasia declaration, while its practice appears imperfect. To receive a deadly injection is a complicated matter, including when by your own request.

Human decline

 A second problem lies in the connection made between the terms ‘euthanasia’ and ‘dying with dignity.’ Through this connection it is suggested that other forms of dying would necessarily negatively affect human dignity. It is clear that the NVVE has difficulty with human experiences of decline. In many of its publications illness, dementia, wheelchair dependency, and loss of independence are mentioned alongside a ‘diminished quality of life.’  

In this sense the NVVE does not only strive for a ‘good death’, but also contributes significantly to a negative image construction of ageing, illness, and disability. The natural processes of human decline and dying process are painted as undignified, where the only way for release from them is in an early death by means of euthanasia. The NVVE thus contributes in large measure to the medicalisation of death and further dependency on medical intervention.

A third critique concerns the campaign as a whole, where the NVVE makes no distinction between self-determination declarations within the framework of medical interventions (like the do-not-resuscitate pendant and no treatment declaration) and a declaration about euthanasia. That is disappointing and also confusing. It appears as if all these instruments exist in equal classes, which is not so. Medical self-determination declarations put boundaries around interventions which a doctor may lawfully apply under life-threatening situations. The declaration releases the doctor of his duty to act in a life-saving manner and therefore lets death more easily arrive.

The declaration for euthanasia on the other hand encourages medical intervention and makes the doctor co-responsible for the arrival of death. By making active euthanasia equal to the refusal of medical treatment, the NVVE normalises and propagandises a choice for euthanasia, while it is especially important not to do so. The killing of a human being is no sinecure, including when surrounded by protocols and self-determination declarations. Therefore it has to remain an exception and no common right which can be demanded.

It would be a good thing for the NVVE if it would promote euthanasia less as a normal death, but instead try everything in preventing any necessity for requesting euthanasia.

Do-not-resuscitate pendants and a declaration not to treat can contribute to this, as can good care. In this way euthanasia can remain available where really necessary, and not as a normal means to obtain a ‘death with dignity.’

Proliving provides the translation of this article without endorsing all of its views. Do-not-resuscitate pendants as a form of advanced directive for example are a complex area fraught with difficulty. Nor does Proliving endorse a concept of euthanasia ‘where necessary only.’ This article is interesting however in offering some dissenting and cautionary views in the Netherlands which has been encultured to support euthanasia and its ongoing ‘progress’ down the slippery slope. Not only people with dementia are on this slope. There is a strong and growing Dutch movement for euthanasia for people aged over 70 who feel they have ‘completed life.’

To act on a person’s wishes to die by euthanasia because of a fear of going to a nursing home and of losing one’s independence is an indictment of an uncaring society. Why do people not want to go into a nursing home? Because in no small measure the care received in such places is undignified, and places one at risk of illness and early death. But for some reason we do not put the spotlight on better care and find it easier to reach for ways to deliver death as deliverance from human-created suffering. The lazy society’s way to practicing ‘compassion.’ A society which cannot accept dependence and vulnerability as normal parts of human life will never be a civil one. People with disabilities will be especially at risk.