Dr Paulina Taboada
Profesor Centro de Bioetica
Pontificia Universidad Catolica de Chile
Alameda 340 Correo Central 1
The Lancet published recently the results of a survey studying the rate of euthanasia, physician assisted suicide, and other end-of-life decisions in The Netherlands in 2001 (Onwuteaka-Phillipsen, B. et al.: Euthanasia and other end-of-life decisions in the Netherlands in 1990, 1995, and 2001, The Lancet, published online June 17, 2003: http://www.thelancet.com). Perhaps one of the main interests of this article is the fact that the authors replicated the interviews and death-certificate studies they had already done in 1990 and 1995 (cf. Van der Maas, PJ, et al.: Euthanasia, physician assisted suicide, and other medical practices involving the end of life in The Netherlands, 1990 – 1995. N Engl J Med 1996; 335: 1699 – 705). The use of identical methodology permits the comparison of the empirical data available regarding Dutch physician’s attitudes before and after the legalization of Euthanasia in this country in 2000.
A first remarkable result is that the death-certificate studies showed that the rate of euthanasia has increased from 1.7% of all deaths in 1990 to 2.4% in 1995, and further to 2.6% in 2001 (Table 1). It is striking to learn that 57% of the Dutch physicians had performed euthanasia or assisted suicide during their working career and that the proportion of those physicians who would never perform euthanasia is consistently falling down: 4% in 1990, 3% in 1995, and 1% in 2001 (Table 2). On the other hand, empirical data show (p < 0.0001) that physicians have become less permissive towards euthanasia over the years (Cf. Table 4). Commenting on these apparently contradictory results, the authors say (p. 4) that "there seems to be a slightly increasing anxiety among physicians that economic measures are going to affect end-of-life decision making." This fear suggests that voluntary euthanasia cannot be said to be "under control" in The Netherlands after its legalization (Cf. Jochemsen, H. & Keown J. "Voluntary Euthanasia under Control? Further Empirical Evidence from the Netherlands". Journal of Medical Ethics 1999; 25: 16 – 21).
A further significant result of the present study is the fact that, as compared with the results obtained in 1990, a lower proportion of physicians (only a third) thought that euthanasia could be avoided by providing adequate palliative care. This datum reminds of a warning Dr. Zylicz made some years ago preventing Dutch physicians from the danger of becoming less creative in solving their patient’s needs and problems if they wanted to include euthanasia among their ‘therapeutic tools’. (Cf. Zylicz, Z. & Janssens, M.J.: "Options in Palliative Care: Dealing with Those Who want to Die." Bailliere’s Clinical Anaestesiology 1998, 12; 1: 121 – 131).
In this context, a further empirical datum revealed by the study is worth mentioning here, namely, the increase in the alleviation of symptoms preceding death observed in 2001 as compared with the previous results (Table 1). With regard to this point, the authors state that (p. 4) "in addition to a growing interest in palliative care at the end of life, reports in which the life-shortening potential of opioids is limited and evidence that the quality of terminal care is commonly less than optimum may have contributed to a diminished reluctance to use opioids in palliative care for terminal patients." Nevertheless, if in spite of having learned better ways to alleviate symptoms at the end of life most Dutch physicians still think that euthanasia cannot be avoided by providing adequate palliative care, the question about the reasons for euthanasia requests raises. Unfortunately, this study does not inquire into the reasons for the euthanasia requests, in contradistinction to the Remmelick Report (1991). So, if we look at the data provided by the Remmelick Commission, we realize that 56 % of the patients asking for euthanasia in The Netherlands between August and December 1990 did so because of a sense of "lack of dignity" and 47% because of "untreatable pain". Both data are striking. The former, because the sense of "lack of dignity" has never been listed among the conditions for ‘justified euthanasia’ in The Netherlands. And the latter, because the same Report reveled that in 17% of the cases in which euthanasia was actually performed the attending physicians thought that there were still therapeutic alternatives, but the patients had rejected them. In fact, the Report also shows that 35% of the physicians rejected voluntary euthanasia requests because they thought there were still unemployed therapeutic alternatives.
These empirical evidences confront us with various underlying difficult theoretical questions, as for instance the question whether it is conceptually adequate to define euthanasia as "the administration of drugs with the explicit intention of ending the patient’s life on his or her explicit request" as the authors of the article do (p. 2) and the question about how to understand the dignity of the human person in the face of evident limitations and unavoidable death. I shall deal with these questions in the coming months.
Dr. Paulina Taboada, MD, PhD
Palliative Care and Bioethic