In the Netherlands, a doctor will not be prosecuted for assisting a patient to die either through euthanasia or assisted suicide (EAS) if certain conditions are met, among which are the following: The patient’s request for aid-in-dying must be voluntary and well-informed, without coercion from others, and uninfluenced by psychological illness or drugs; their suffering should be unbearable and hopeless, with no prospect for improvement and without reasonable alternatives; and an independent physician should be consulted, who should concur with the aforementioned conditions. Supporters aver that these guidelines have made physician-assisted death safe and have avoided the “slippery slope” that detractors and fear-mongers fulminate about.
A commentary (preview available here) in last week’s JAMA gives cause to question the rosy picture some paint of the Netherlands experience. The commentary refers to a study that appeared in the April 2016 JAMA Psychiatry. The study describes the practice of EAS for psychiatric disorders in the Netherlands, reviewing 66 patient reports filed by physicians from 2011 to 2014. Surprisingly, only 49 of the 66 patients experienced depression. Thirty-four had at least one prior suicide attempt. Six had substance abuse, two a diagnosis of autism. Thirty-four had personality disorders; 13 had never had a psychiatric hospitalization; 37 described social isolation or loneliness. Thirty-seven of the patients had refused some recommended treatment. In eight cases, the involved psychiatrist believed that the criteria for EAS had not been met. Eighteen cases involved physicians who had not cared for the patients before the EAS request; most had met the patients through mobile euthanasia clinics. (As Paul Appelbaum writes in an accompanying editorial [preview available here], “One might wonder whether a clinic intended to make assisted death more available will have a lower threshold for approving requests.”) In 16 patient cases, three independent physician reviewers could not agree among themselves as to whether the patient was making a competent request, or whether there was treatment that offered some prospect of improvement.
The description of some of the patients is compelling. The study reports that a “woman in her 70s without health problems … and her husband had decided some years before that they would not live without each other. She experienced life without her husband, who had died 1 year earlier, as a ‘living hell’ and ‘meaningless.’ A consultant reported that this woman ‘did not feel depressed at all. She ate, drank, and slept well. She followed the news and undertook activities.’ ” About patients who reported social isolation or loneliness: ” ‘The patient indicated that she had had a life without love and therefore had no right to exist’ . . . and ‘The patient was an utterly lonely man whose life had been a failure.’ ” A Dutch regional euthanasia review committee found one case that did not meet due care criteria: “. . .a woman … in her 80s with chronic depression who sought help from the End-of-Life Clinic. The clinic physician met with her 2 times (the first time was 3 weeks before her death), and the patient was not alone on both occasions, with family members present. The physician was not a psychiatrist, did not consult psychiatrists, was unaware of the Dutch Psychiatric Association Guidelines, and yet ‘had not a single doubt’ about the patient’s prognosis.”
These stories are tragedies. I do not deny that the patients in this study were truly suffering. But is EAS really an appropriate way to treat the suffering, by killing the sufferer? If someone fails in an “illegal” suicide attempt, can they just go to the doctor and have it done legally? Is EAS to be the new solution for loneliness, social isolation, and grief? Is it not a slippery slope to go from “Doctors must not kill,” to “Doctors can kill in the case of terminal illness,” to “Doctors can kill people who don’t have a terminal illness but just want to be dead”?