For eighteen years, euthanasia has been widespread in the Netherlands. Many Dutch claim that the practice is often involuntary, that the consent of the person to be killed is often not requested, and that the definition of what is permissible as "euthanasia" is broadening daily. They also think the United States is particularly vulnerable to widespread Dutch-style killing of the old and infirm.
(Amsterdam) On August 8, it was announced that Final Exit, by Derek Humphry, had risen to No. 1 on the New York Times bestseller list. Humphry is executive director of the Hemlock Society, a Eugene, Oregon-based group that promotes euthanasia, and his new book, as is now well known, is a how-to manual for suicide.
That we are in the midst of the greatest push yet for euthanasia is clear not only from the uproar over Final Exit but also from a series of other widely publicized incidents. Retired Michigan pathologist Jack Kevorkian set up a device in a van in Portland, Oregon, that an Alzheimers victim used to kill herself. (Dr. Kevorkian will soon attempt to make it onto the bestseller lists with his new book Prescription: Medicide.)
A Missouri judge ruled that a comatose womans parents could have her feeding tube removed. ("Woman in Coma Wins Right to Die, " ran the bizarre headline in Denvers Rocky Mountain News.) A Colorado man gave his mother a gun which she used to end her life before liver cancer could — only to find out at the autopsy that his mother had been misdiagnosed and merely had a liver inflammation. A "right to die bill has appeared in Illinois, and in November Washington state voters will have a chance to make theirs the first state to legalize euthanasia.
The latest round of controversy began last March when Rochester, New York, doctor Timothy E. Quill admitted in the New England Journal of Medicine that he had prescribed sleeping pills to an ill patient who he knew would use them to kill herself. Assisting in a suicide is a felony in Quills jurisdiction, and the publication of the article was clearly intended to stir debate.
But even before a Rochester grand jury decided on July 26 not to indict Dr. Quill, a spokesman for the National Right to Life Committee in Washington expressed fears that the debate would soon be over: "What is left to argue here is whether it will be possible in this society to preserve the lives of those who dont want to be killed."
What would happen in a United States with legalized euthanasia? The answer may lie in the experience of the Netherlands, where it has been widely practiced for nearly two decades now.
Euthanasia in the Netherlands
"Active" euthanasia, the active killing of a patient at his request by a physician, is illegal in the Netherlands. The Dutch criminal code provides for 12 years imprisonment for anyone who "takes the life of another at his or her explicit and serious request."
Nevertheless, an activist judiciary has rendered the statute essentially meaningless. In 1973, a doctor who had put her terminally ill mother to death with morphine received a suspended sentence of a week in jail, plus a years probation. The court went even further to find that, under the proper conditions, active euthanasia would have been acceptable and legal. The conditions it specified were that (1) the patient be incurably ill, (2) the patient be experiencing unbearable suffering, (3) the patient request the termination of his life, and (4) the patients physician perform the euthanasia.
The following year, the Royal Dutch Medical Association (KNMG) issued a provisional statement urging that:
legally euthanasia should remain a crime, but that if a physician, after having considered all the aspects of the case, shortens the life of a patient who is incurably ill and in the process of dying the court will have to judge whether there was a conflict of duties which could justify the act of the physician.
These two developments pushed euthanasia into the limelight of public policy debate.
In all court cases between 1973 and 1984, two conditions were listed as essential to euthanasias legality. First, the patient must make the request freely. He must take the initiative, asking specifically for euthanasia rather than merely wishing aloud that he were dead, something many of us do on occasion without the expectation that someone will subsequently plunge a lethal syringe into our arm.
Second, the patient must consider his condition to be unbearable. One commentator notes that this means, "A more objective medical check of this experience is necessary to avoid extremely subjective requests."
In the words of Eugene P. R. Sutorius, attorney for the Dutch Society for Voluntary Euthanasia, "Euthanasia is only acceptable if it is the keystone of a well-cared-for dying process." Another commentator writes that it means that "euthanasia should not become an answer to failing care, fear, and loneliness. " In practice, however, the term "unbearable" is so vague that it would be virtually impossible to prove that any doctor who claimed it applied had actually violated the requirement.
Courts have added a third condition since 1984: that a physician must consult a colleague in order to confirm the correctness of his diagnosis and prognosis, to verify the correct medical performance of euthanasia, and to assure that all legal requirements are met. The KNMG has reformulated its position to include all three conditions. Many court cases have also cited as requirements the presence of an incurable disease or the demand that the patients death not inflict unnecessary suffering on others.
No official statistics on the overall incidence of euthanasia in the Netherlands exist. A controversial 60 Minutes broadcast in 1986 said that as many as one-sixth of all deaths in the Netherlands could be from euthanasia, about 20,000 people per year. Dr. Sven Danner of the Amsterdam Medical Center, which treats 75 percent of Netherlands AIDS patients, reports that one in eight AIDS patients receives euthanasia, but there is no reason to believe that this percentage would apply to people with other illnesses.
One survey in the northern Netherlands, if extrapolated, would indicate 5,000 euthanasia deaths annually. This includes only those killed by their own family doctor, not those killed in hospitals. A 1988 article in Issues in Law & Medicine citing an estimate of the Central Medical Inspection of National Health, said that euthanasia
is being carried out at least 6,000 times per year in general medical practice [huisartsen is the term used; it refers to a family doctors practice in his own home, which is still common in the Netherlands]. If one adds to that the hospitals, nursing homes, and medical specialists, then we are talking about as many as 10,000 to 12,000 cases of euthanasia per year.
Most of the authorities I spoke with threw their hands up in the air when I asked them how many acts of euthanasia were committed yearly, although Dr. Pieter Admiraal, an anesthesiologist at the de Graaf hospital in Delft who himself carries out euthanasia, proffered a guess. Cancer, he says, accounts for about 80 percent of euthanasias, and about 10 percent of cancer patients are euthanized. This would give a national figure of 3,000.
The CombatantsThe Netherlands is not without opposition to euthanasia. The Netherlands Patients Organization works to alert sick people and their families that in many hospitals people are being killed without their consent or knowledge, without even the knowledge of their families. The Hiding Place Foundation has recently printed a "life declaration, " a small document to be carried on ones person stating that the undersigned does not wish to be euthanized. A group of physicians has broken off from the KNMG to form the Dutch Physicians league, loudly alleging that certain doctors dispose of patients almost on whim.
These opponents are a disparate lot. One with whom I spoke was a fiercely traditional, pro-family, anti-Communist general practitioner. Another, not a doctor, who has written extensively on the subject, is a self-proclaimed lesbian. Most are Christians, but all are united by the belief that euthanasia as now practiced is unnecessary and will lead to an ever-expanding definition of what is allowable.
Prominent among the opposition physicians is Dr. Karel F. Gunning, a general practitioner in Rotterdam who advises the government on the medical problems of German concentration camp survivors. Gunning doesnt question the sincerity of the pro-euthanists. "I dont think theres a lot to gain [monetarily or in other concrete ways] by supporting euthanasia, so those who say they believe in it really do." But, Gunning adds, "it is enormously dangerous to think that doctors, who arent the most conscientious people in the world, should have the right to kill — and kill unchallenged."
Amsterdam dermatologist Dr. Isaac van der Sluis also fears giving too much power to doctors. "In France," he says, "they dont trust the state or even lesser authorities. But here, as in the U.S., people are idealists. They want to be able to trust the government and doctors to do the right thing."
Of the Netherlands anti-euthanists, the best-known in the U.S. is Dr. Richard Fenigsen, a cardiologist. He is also the most disliked by the pro-euthanists, who say they are considering a libel suit against him for allegedly fabricating material concerning euthanasia abuses. In Fenigsens defense, it must be said that after an article by him appeared in the Hastings Center Report, the most prestigious American journal of medical ethics, angry letters from important pro-euthanists questioning Fenigsens veracity flooded the journal. The editors of the Report countered: "In our tenure as editors, no manuscript has been subjected to more sustained scrutiny."
The Christian Democratic Party (CDP), which has a majority of seats in parliament, is the most strongly anti-euthanasia of the major parties. "In a case of life and death we must be very careful," says party spokesman Jan Schinkelshoek. "The core of the argument is that people are the creation of God and do not have the right to determine about their own living, about ending it. We are the first country in the world moving this way. And maybe we dont know what we are doing."
The anti-euthanists are clearly the underdogs. The Democratic and labor parties are pro-euthanasia, and so is even a major element of the CDP. "The establishment" seems clearly on the side of expanded euthanasia. Says Gunning, "The only way we [publish]is [in] advertisements or our own publication. Then the question is, Will people believe you or the official papers?"
The mainstream media, he says, are overwhelmingly pro-euthanasia. "Some Protestant and Catholic newspapers are against it, but all the leading papers are on the wrong side."
Indeed, euthanasia is so accepted and supported by the establishment that one prosecutor in Alkmaar openly works for judicial widening of the scope of euthanasia laws. For one who is responsible for prosecuting crimes to work to decriminalize them would in the United States constitute a clear conflict of interest, but such is the mood in the Netherlands that he has encountered little criticism.
A leading advocate of euthanasia is Mrs. Pit M. Bakker, president of the 45,000-strong Dutch Society for Voluntary Euthanasia. A piece of the organizations literature shows a bear climbing into a comfortable-looking coffin complete with fluffy pillow and a caption reading, "You should give me the right to die as a gentleman. " Says Bakker of the anti-euthanists, "They are always saying, Im afraid, Im afraid. But you cant live in fear. The world is changing. " Mrs. Bakker notes that euthanasia was common in Roman times. She thinks statutory legalization "will give security to doctors and patients because theyll know their rights and it will take away those behind-the-curtain cases."
But the one person most identified with the cause of Netherlands euthanasia is the aforementioned Dr. Admiraal. He is in such great demand, between his telephone and his beeper, that a reporter who wants to speak to him for 30 minutes is advised to schedule at least a few hours in his office. A man of 61 with a beard and large belly, he looks a bit like Burl Ives with glasses. Certainly he does not fit the description of a man who has been killing patients for almost two decades now.
"Killing" is his word. In explaining why he wrote a how-to booklet on euthanasia, which appeared in 1977, he told me, "Its not so simple to kill somebody the honest way." Admiraal began administering euthanasia in the early 1970s and only later became involved with pro-euthanasia organizations. A new edition of this how-to guide was published in 1980 by the Dutch Euthanasia Society and sent to all practicing physicians in the Netherlands. It was also translated into English. "Now," he says, "the world knows me as the first strong advocate of euthanasia."
Dr. Admiraal specifically rejects the hospice system that began in the United Kingdom and has subsequently been adopted in the United States. Hospices are institutions designed to allow dying people to live out their lives as comfortably as possible. Ideally, they are both cheaper and homier than hospitals. Admiraal calls euthanasia "the ultimate act of care for the dying." He warns, "Dont speak of the Dutch experiment. After fifteen years, its no longer an experiment. " Unlike Bakker, he is not pushing for statutory legalization. "I can live with the rules of today. Its very, very clean. "
His protocol involves the consultation of two doctors, a nurse, and a pastor. After the act, the prosecutor is informed. The prosecutor can then contact the police. Formerly, the police were routinely contacted but that is no longer the case.
While Mrs. Bakker appears content to keep her crusade within national boundaries, Dr. Admiraal sees himself as an internationalist. He has come eight times to preach the cause to the U.S., which he feels is somewhat reactionary. "I never see pro-lifers except in America, " he says. "I think pro-lifers must be very afraid of dying. They are young and a little bit blind."
A third pro-euthanist, one with a slightly different angle on the subject, is Eugene Sutorius. He sees modern medicine and its ever-growing ability to sustain life as something of a culprit in making euthanasia necessary. "I think euthanasia shows we cant cope with technology," he says. "I wonder if this isnt a transient phenomenon. One of the roots of [modern-day euthanasia] is that physicians treat too long."
How Strong Is Popular Support?Dutch polling data seem to indicate a high level of support for euthanasia, though the numbers vary widely. A 1986 poll has been interpreted to show that 76 percent favor the practice. One poll conducted by questionnaire through a variety of newspapers in 1986 showed that 33 percent of the Dutch are sympathetic to the idea of active euthanasia, that 43 percent want to take action in the case of comatose patients, and that 27 percent think that they might request euthanasia for a senile member of the family. It is notable that neither of the last two categories involves the patients consent.
Some Dutch carry a will requiring active euthanasia to be performed on them "in case of bodily injury or mental disturbance of which no recovery to reasonable and dignified existence is to be expected. " Recently, these wills have begun to be replaced by small plastic cards. In 1981, the number of people carrying such cards was reported to be 30,000, but they have yet to catch on, numbering perhaps 45,000 today.
Awareness of euthanasia in the Netherlands seem high. The only American visitor to the Netherlands that I discussed it with thought — Im not kidding -that it concerned therapy to keep people youthful-looking. But the Dutch all knew what I was talking about, though they hadnt necessarily given it much thought. One said he approved of it, "if somebody was sick and said he wanted to die."
How about a comatose patient? "Ah, thats a very tough issue." So tough, in fact, he would not give me an answer. What if euthanasia were requested years earlier in the event of a hypothetical situation? To this, he related the story of a friends father who had asked to be killed if he reached a certain level of debilitation, When he actually reached that level, however, he changed his mind, declaring vociferously that he had no wish to die.
A young woman whose own father had been killed by euthanasia saw it as an answer only if death was imminent and the person was in great pain, circumstances she said applied to her father. As to comatose patients, she allowed that "if theyve been comatose a long time and there is little hope of recovery, thats okay."
Who Commits Euthanasia?It is difficult to gauge how many Dutch doctors perform euthanasia. One survey taken in 1985 and 1986 found that 48 percent said they had received at least one request for death. Of these, 37 percent said they had complied. Thus, 18 percent of the doctors responding had performed euthanasia. But another survey indicated that 81 percent of the family doctors polled had done it. Dr. Gunning, however, says, "Quite a number of doctors really dont like it after all. Some say they support it but they refuse to practice it."
Performance of euthanasia remains limited to doctors, although a physician can request the help of a nurse. A few years ago, three nurses at the Free University Hospital of Amsterdam killed several comatose patients without any form of consent. At trial they were found guilty only of acting without the guidance of a doctor.
The KNMG, together with the Dutch nurses union, issued a joint paper in March 1987 that not only explicitly advocates euthanasia but also clearly delineates the respective tasks and the collaboration of both medical and nursing professions at bedside of the future victim. While nursing personnel are clearly excluded from performing the actual killing, total collaboration is nonetheless called for, and it is considered normal conduct for nursing personnel to be involved in decisions.
The Netherlands Pharmaceutical Society offers doctors a booklet of combinations that Dr. Admiraal recommends for euthanasia. Typically, the patient will be given an injection of a strong dose of barbiturates that causes unconsciousness within three to five seconds. This is followed by a drug resembling curare (arrow poison), which causes death in ten to twenty minutes by paralyzing the respiratory muscles.
The Dutch physician is not allowed to attribute the death to "natural causes" on the death certificate In theory, either the physician or the coroner must report to the police that the killing has taken place. The police then report to the district attorney, who decides whether to prosecute. This decision is based on prior case law and the conditions listed previously. If prosecution occurs, the Lower Court, comprising three judges, tries the case and, upon conviction, pronounces sentence. If convicted, the defendant can appeal first to the Court of Appeals and then to the Supreme Court.
In practice, the use of this procedure is extremely rare. An average of only eleven euthanasia cases a year prompt public prosecutors even to make inquiries. In the few cases that have been brought to trial, the court has sometimes declared the doctor guilty but has not imposed punishment. In each such case however, the higher court has overturned the guilty verdict on appeal on the grounds that the doctor acted out of "higher necessity." In every case but one, punishment imposed by a lower court has been reversed on a technicality by a higher court. The only case in which a conviction has been upheld was the 1973 case that started the euthanasia boom.
A recent movie here tells the true story of a Dutch soldier trapped behind enemy lines in the Korean War. Upon discovering that his unit has been overrun by Communist soldiers he makes an even more horrifying discovery. One of his fellow soldiers has been horribly injured, clearly beyond recovery. In his torment, the wounded man begs his comrade to shoot him. Reluctantly, the healthy soldier does so. This is the image the Netherlands euthanists like to present of their craft: "He was in horrible pain and about to die anyway and so, with great reluctance, I helped him to accomplish that which he could not do himself."
This may once have been the typical situation, but critics charge that in more and more instances, Netherlands euthanasia is neither voluntary nor restricted to cases of impending death.
Is Euthanasia "Necessary"?Dutch euthanasia opponents aver that one need not adopt a "pro-life" philosophical outlook to find that voluntary euthanasia is still a needless practice, that an understanding doctor and improved conditions can almost always prevent requests for death.
Fenigsen notes that, in his entire career of over thirty-five years, he has received only one request for euthanasia, made in a brief moment of despair. During six years of follow-up, the patient never made the request again. (The representativeness of his experience may be questioned since, as a cardiologist and not a general practitioner, he might not be in a position to get many requests.)
According to one doctor, J. H. Segers, the results of a 1984 survey indicate that "a request for ... euthanasia often disappears when there is good supportive care and a good combating of the symptoms of the disease in the present discussion about euthanasia, too little attention is being given to the improvement of care as an alternative to life termination."
A project undertaken in a Rotterdam nursing home provides evidence for this, according to Segers. By employing additional personnel and taking other steps, it was possible to devote extra care to patients whose death was near. Of 500 patients who died, only six or seven requested a fatal injection, and in most of these cases, they dropped the request after a conversation.
In 1985, Dr. Admiraal was tried for ending the life of a young girl with multiple sclerosis who, though suffering, could have been expected to live indefinitely. This, he says, was after he had repeatedly tried to get her to go to a nursing home. The charges were dismissed because the act of euthanasia fell within the criteria developed by the High Court, namely that the disability, although not fatal, was incurable. Downs syndrome and spina bifida cases represent similar situations.
The KNMG guidelines appear conservative when compared to legislative proposals or judicial decisions, but they still do not require a terminal illness, an impending death, or a written request — safeguards that would increase the possibility of objective verification. The 1987 proposal put forth by the governments general health council would allow the termination of people who are (1) not terminally ill, (2) not incompetent, and (3) less than 16 years old — without parental knowledge or consent. Yet even these proposals are limited compared to what actually goes on in the homes and hospitals of the Netherlands.
How Voluntary Is "Voluntary"?Some Dutch supporters of euthanasia are adamant that the act is always voluntary, or at least should be, and that actions to the contrary are abuses of an otherwise valid system. The right to terminate ones own life is considered simply the flip side of the right to keep ones life — an aspect of individual autonomy.
"The right of self-determination is one of our highest goals," says Mrs. Bakker. But, as noted, many Dutch favor euthanizing comatose patients. A majority of the State Commission on Euthanasia also supports involuntary euthanasia for persons who have irreversibly lost consciousness. Admiraal says, "Theres no possibility of euthanasia for demented patients because they cannot voluntarily ask for it."
But both the Dutch Society for Voluntary Euthanasia and Admiraal support disconnecting the feeding tubes of comatose patients in some circumstances, a practice Admiraal defends on both economic and humanitarian grounds. "I think comas wont be accepted by nursing homes today, because theres not enough room as it is," he says. "If theyre in a coma, theres no consciousness, so its not cruel."
After the Amsterdam University Hospital nurses were arrested, the victims parents thanked them at an emotionally charged televised ceremony, providing additional evidence that what Fenigsen calls "crypthanasia" is not shunned as an "abuse but widely accepted, openly supported, and praised as a charitable deed.
As a result of such actions, the Dutch Patients Association placed an advertisement in the press saying that in many hospitals patients are being killed without their or their families will or knowledge. They advised the families to inquire about every step in their relatives treatment and, when in doubt, to consult a reliable expert outside the hospital.
A "request" for euthanasia can be defended quite loosely, to say the least. In the spring of 1985, a doctor came under suspicion of killing at least twenty patients at a nursing home in the Hague. He eventually confessed to five, explaining that his actions had been justified because the patients had, as much as four years earlier, made such remarks as, "I do not want to become a vegetable."
At some point thereafter, he would send the patient to the sick bay where, regardless of the patients medical condition, he would administer a huge amount of sedatives. He would then kill the now-comatose patient with a large dose of insulin. The doctor was arrested and put into jail. He was eventually convicted of killing three patients and received an unconditional one-year prison sentence, though the prosecutor requested eight years. The KNMG and others criticized the judgment as too harsh, with the president of the KNMG declaring, "I fear that this judgment can lead to euthanasia practice again being drawn into the sphere of secrecy."
They feared too soon. A higher court oven-Wed the verdict on technical grounds (the collection of evidence against the doctor was considered irregular), after which a civil court granted him $150,000 in damages against the Netherlands for having spent several months in jail. (He was, however, disciplined by the medical authorities, who imposed a fine but allowed him to keep his license.) This doctor is the only one in the Netherlands ever to serve jail time for his euthanasia activities. As Dr. Admiraal notes, in principle "the courts are never against you" if you commit euthanasia.
The Netherlands leading specialist in pediatric oncology, Professor P. A. Voute, revealed that since the early 1980s it had been his practice, at times on his own initiative, to provide some of his patients with doses of poison, enabling them to commit suicide if they wished. An opinion poll showed that 70 percent of the public approved of Voutes actions.
Yet even when a patient makes so clear a statement as, "Please kill me; Im dying to go," it might not be so voluntary as it appears. Fenigsen writes:
For 20 years, the population of Holland has been subjected to all-intrusive propaganda in favor of death. The highest team of praise have been applied to the request to die: This act is "brave," "wise," and "progressive." All efforts are made to convince people that that is what they ought to do, what society expects of them, what is best for themselves and their families.
"The Netherlands: A verdant land of windmills, dikes, and legalized murder."
Under Admiraals protocol, the "family has no rights at all; in fact, it cant even stop a request for euthanasia." Admiraal says, "Even if your wife wanted to stop it she couldnt." Yet euthanasia opponents say that, outside of Admiraals de Graaf hospital, involuntary euthanasia does occur at familial request. According to one hospital director with terminal patients, Dr. J. Michels, euthanasia requests from his patients are extremely rare; most requests come from the family.
Van der Sluis quotes a general practitioner who said: "There are different kinds of families. Some will do almost anything to help the sick man, nursing him at home, often going to incredible lengths, but there are also families that want to make a clean sweep."
Van der Sluis describes one general practitioner explaining how he was persuaded by the patients wife:
You know, doctor, my husband is looking all the time at my fathers picture on the wall,and he thinks my father would not have approved his leaving me alone But I told him: What nonsense. He would have said that you certainly earned your rest. And I took away that picture.
Such hearsay hardly constitutes a patient request for euthanasia, but the doctor killed the man nonetheless and claimed to have been quite proud of it, says van der Sluis. He said it gave him "a liberating certainty and a feeling of elation that I had done such a radical thing all on my own."
Clearly the definition of "voluntary" is affected by the amount of initiative a doctor takes. According to van der Sluis, one terminally ill woman reported that, after an especially painful night, her doctor asked her, "Shall I give you "an injection now?" After a moment of silent bewilderment on her part, he addded, "All right, Ill be back within an hour. Then you must have made your decision. Either an injection or the hospital. "
Much of the evidence of involuntary euthanasia is anecdotal, for obvious reasons. But polls confirm that many people in the Netherlands believe involuntary euthanasia is common. One poll of the elderly found that those living independently favored euthanasia at dramatically higher rates than residents of nursing homes. Of those living independently, 47 percent opposed euthanasia, as compared to 97 percent of nursing home residents. The former clearly feel they have less risk of being involuntarily killed. Of elderly people opposed to euthanasia, 60 percent of nursing home residents expressed fear that they would be involuntarily euthanized, while 24 percent of those living independently expressed that fear.
One inquiry among hospital patients showed that many fear their own families may ask for euthanasia without consulting them. A group of people with severe disabilities stated in their letter to the Parliamentary Committees for Health Care and Justice:
We feel our lives threatened.... We realize that we cost the community a lot .... Many people think we are useless .... Often we notice that we are being talked into desiring death.... We will find it extremely dangerous and frightening if the new medical legislation includes euthanasia.
Is Euthanasia for the Patient or Society?
The euthanasia proponents I talked to all insisted that, as Mrs. Bakker put it "the patient must ask the doctor [to be euthanized]. It must not be allowed merely because the family thinks it is best or the doctor thinks the world is better off. It must be a possibility for those who want to die, and for no other reason." Sutorius goes even further to state that it is a "dangerous threat to society the moment physicians themselves withhold treatment on non-medical grounds, citing societal needs, etc."
But, according to Dr. Gunning, there are two branches of ethics regarding euthanasia. One is "humanitarian," and says euthanasia is to be performed solely for the alleged benefit of the euthanized. The other is utilitarian, and says that the needs of society should be considered in the decision. Dr. Gunning says "There are people who exploit the humanitarian views of the public" to support their own utilitarian purposes.
He says Dutch television offers "constant performances of someone suffering" and who is therefore a good candiadate for euthanasia, but at the same time time there is much talk in the country about the "tremendous cost to society" of an aging population. "Im sure some people do it for purely humanitarian reasons," he says, "but others Im sure do it for purely demographic reasons."
Obviously, what Dr. Gunning calls "utilitarian" euthanasia is another word for "involuntary." And the subject leads the question of child euthanasia. The KNMG thinks teen agers and even younger children should have the right to choose to be killed, even without parental consent, and has advocated the elimination of age limits from any euthanasia legalization bill.
"Sometimes a 15-year-old child can have a mature judgment; sometimes parents can have an immature judgment," concluded a KNMG white paper released in 1986. Dr. Theo van Berkestijn, then-director of the association, said the organization had concluded that "the most important thing is that [the physician) keep the trust of the child."
But what of children far below the age of 15, in whom mature judgment is objectively impossible? The inability of such small children to speak for themselves appears to put them in the legal position of comatose adults. Thus, in 1975, the Commission on Medical Ethics of the Health Council advised that, for newborns, both active and passive euthanasia should be permissible under certain conditions.
Euthanasia opponents Catharina Dessaur and Chris Rutenfrans cited the example of one doctor relating to another the incident of a child born with Downs syndrome who had blockage of the duodenum. The physician decided simply to allow the child to starve to death, believing that starvation would cause death in two days.
In fact, the child withered away over a period of two horrible weeks. Blockage of the duodenum occurs fairly frequently in newborns and an operation to remove the blockage almost always proves successful (mortality is about 3 percent), yet the doctors only regret was that he didnt actively euthanize the child with a hypodermic. In the spring of 1988, the KNMG published the first part of a report called "Terminating Life in Incompetent Patients," which stated that about 300 newborn babies have their lives ended every year, though usually they are just allowed to die.
Interestingly, even though both Bakker and Admiraal will state forcefully that they always oppose involuntary euthanasia, they say they support euthanizing severely defective newborns. Thus, in the same conversation in which Dr. Admiraal told me, "Theres no room for involuntary euthanasia," I asked him about euthanizing newborns and he stated flatly, "Thats involuntary euthanasia. Most of these babies have severe neurological problems and if theres no possibility [Of correcting them, doctors] will decide with the parents what to do. In that case, we can stop the life of the baby."
Said Admiraal, "I think its quite normal for society to ask for euthanasia of newborns and for allowing the death of [people in] comas." The Dutch Voluntary Euthanasia Society also supports the euthanization of newborns.
Thus, despite the talk of euthanasia being voluntary, van der Sluis says, "Euthanasia doctors will kill you with your consent if they can get it, and without your consent if they cannot."
Down the Slippery Slope
If the original purpose of euthanasia was to provide terminal patients with a chance of checking out early, then abuses have already been institutionalized in the form of euthanizing non-terminal patients, newborns, and those in comas.
Mrs. Bakkers reaction to questions of abuse seems particularly disconcerting. She says her organization opposes abuses, but this appears to be with nothing more than an occasional verbal disclaimer. "Were not going to spend energy to work against murder," she says. "We have justice and police to do that... As soon as euthanasia is [statutorily] legalized, we believe illegal things will be far easier to detect."
In fact, it may be that a euthanasia statute would make illegal euthanasia easier to deal with in the same way abolishing laws against shoplifting would make that crime easier to deal with namely because it wouldnt be a crime anymore. letter after letter to the Hastings Center Report objecting to the Fenigsen article relied on semantics, saying, in briefest form, that since "involuntary euthanasia" is a contradiction in terms, there is therefore no involuntary euthanasia in the Netherlands.
More specifically, they said the instances Fenigsen cited as being euthanasia abuses were not euthanasia because euthanasia is by definition "a deliberate life-ending action by another person than the concerned person at the enduring request of the latter," to quote from one letter signed by twenty-five prominent pro-euthanists.
Another letter mentioned "the 1985 definition of the State Commission on Euthanasia that euthanasia refers to all actions aimed at deliberately terminating a persons life at his or her explicit and voluntary request. Consequently, it is impossible for people who do not want euthanasia to be maneuvered or forced into it." Yes, of course it is impossible — if thats how strictly you define euthanasia. But call it what you will, says Fenigsen, people are putting others to death who did not explicitly ask for it, and they are doing so because they feel they can get away with it.
One gets the idea that Mrs. Bakker just isnt very concerned about abuses, whether because she doesnt really believe they have been happening or will happen or simply because she thinks even addressing the subject distracts from the good fight. Certainly her attitude is reflected in her concern over what a new euthanasia statute would look like. "If too tight, it will be ignored and if too wide the right-wing Christian party will not accept it." It is telling that this concern over having too wide a law had nothing to do with the possibility of allowing involuntary euthanasia, only in getting it passed.
Even pro-euthanists occasionally concede theyre headed down the slippery slope. "We can estimate that by 2020 or 2030 there will be the highest [proportion] of old people and the smallest amount of young people the world has ever known," Admiraal told the Los Angeles Times. Regarding Alzheimers disease, "We realize there will be demented patients by the tens of thousands. So Im a little bit afraid. I really think that [by then] we may accept that, for purely economic reasons, they can stop life after a period of three years of complete dementia, for instance. I can imagine that.... I dont believe we can prevent it."
That the Netherlands should be in the forefront of euthanasia today is ironic, considering the resistance of Dutch doctors to German attempts at euthanasia during World War II. Even after 100 Dutch physicians were sent to concentration camps, the medical profession would not give in.
Thus, wrote the late Dr. Leo Alexander, a member of the Office of the Chief Counsel for War Crimes in Nuremberg, "it came about that not a single euthanasia or sterilization was recommended or participated in by any Dutch physician. " Today, it is the German physicians who have taken the lead in actively rejecting euthanasia.
There are mixed opinions in the Netherlands on whether euthanasia is gaining ground elsewhere. Fenigsen, writing in the Wall Street Journal, stated that
the Standpoint on Euthanasia proposed by the Dutch Royal Society of Medicine was unanimously rejected by the Committee on Medical Ethics of the European Community and this body expressed "hope that this strong reaction will induce the Dutch colleagues to reconsider their move and return to the happy communion of utmost respect for human life."
Nevertheless, Dr. Philippe Schepens, a Dutch physician residing in Ostende, Belgium, has written that "it is extremely important to know what is happening there because from the Netherlands it is slowly spreading across the borders. In Sweden, Belgium, and England there are already signs of complacency towards the idea of killing certain patients." But van der Sluis says that, among other nations, the U.S. could be the closest to following the Netherlands model.
Can It Happen Here?
An American commentator, Patrick G. Derr, notes:
German medicine required fewer than 20 years to make the transformation [to where widespread euthanasia of "undesirables" was accepted]. In America, the pressures which exist or can be reasonably anticipated seem much less, and the abuses of medical killing which can be reasonably anticipated seem likely to be correspondingly milder. Still, it is worth remembering that the engine which drove the early moral transformation of German medicine was not the ideology of racial discrimination, but medical economics.
"Back off, sonny! I dont feel like going yet!"
The significance of the doctors Hippocratic Oath, Margaret Mead noted, was that
for the first time in our tradition there was a complete separation between killing and curing. Throughout the primitive world the doctor and the sorcerer tended to be the same person. He with power to kill had power to cure, including specially the undoing of his own killing activities. He who had power to cure would necessarily also be able to kill.
With the Greeks, the distinction was made clear. One profession, the followers of Asclephis, were able to be dedicated completely to life under all circumstances, regardless of rank, age, or intellect-the life of a slave, the fife of the Emperor, the life of a foreign man, the life of a defective child.... This is a priceless possession which we cannot afford to tarnish, but society always is attempting to make the physician into a killer — to kill the defective child at birth, to leave the sleeping pills beside the bed of the cancer patient ...
In the Netherlands, society appears to be succeeding. Last year, the practice of euthanasia took another Great Leap Forward. A doctor was cited by the Dutch Medical Disciplinary Board for "breach of trust" in misleading a patient into supposing that he was being given a lethal dose of drugs when the doctor knew otherwise. This prompted one commentator in the Times of London to suggest that the doctor was in effect found guilty of "not... unlawfully killing his patient."
An American scholar has written, "A right to die, once accepted, too easily becomes a duty to die, or an excuse to kill." Will it soon be a duty to kill?
Read Michael Fumentos additional work on euthanasia.