Correspondence

Euthanasia and Physician-Assisted Suicide in the Netherlands

N Engl J Med 1997; 336:1385-1387May 8, 1997

Article

To the Editor:

In their articles on physician-assisted death in the Netherlands (Nov. 28 issue), van der Maas et al.1 and van der Wal et al.2 omit some information that has been of particular concern to international observers and is contained in their fuller Dutch report.3

The 1990 study documented that 50 percent of Dutch physicians suggest euthanasia to patients.4 Neither the physicians nor the study investigators seem to recognize how much the voluntariness of the process is compromised by such a suggestion. A frightened and suffering patient is inclined to listen to a suggestion made by the doctor, even when the doctor is telling the patient that his or her life is not worth living. Criticism of this practice by the Dutch has been so great5 that American advocates of euthanasia have recommended incorporating a provision into their proposed statutes for legalization of assisted suicide that would prevent the practice. Given the concern of those outside the Netherlands, it is surprising that the investigators make no reference to it in the English report of their current work. The Dutch version reveals, however, that the practice has continued and even increased somewhat.

The investigators minimize the number of patients put to death who have not requested it by omitting from this category cases in which patients were given pain medication without discussion of the doctors' explicit intention to use the medication to end their lives; these cases are instead treated as deaths secondary to pain medication. These deaths have increased by 40 percent — from 1350 deaths (1 percent of all deaths in the Netherlands) in 1990 to more than 1900 (1.4 percent) in 1995 — a comparison the investigators choose not to make. In over 80 percent of these cases, the patient made no explicit request for death. Since researchers around the world consider these cases to be nonvoluntary or involuntary euthanasia (if the patients were competent), they will view these data as reflecting a striking increase in the number of patients whose lives were terminated without their request and as a refutation of the investigators' claim that there has been no increase and perhaps a slight decrease in the number of such patients.

Herbert Hendin, M.D.
American Foundation for Suicide Prevention, New York, NY 10005

5 References

1. 1

   van der Maas PJ, van der Wal G, Haverkate I, 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;335:1699-1705
   Full Text | Web of Science | Medline

2. 2

   van der Wal G, van der Maas PJ, Bosma JM, et al. Evaluation of the notification procedure for physician-assisted death in the Netherlands.N Engl J Med 1996;335:1706-11.
   

3. 3

   van der Wal G, van der Maas PJ. Euthanasie en andere medische beslissingen rond het levenseinde. The Hague, the Netherlands: Staatsuitgeverij, 1996.
   

4. 4

   van der Maas PJ, van Delden JJM, Pijnenborg L. Euthanasia and other medical decisions concerning the end of life. New York: Elsevier, 1992.
   

5. 5

   Euthanasia in the Netherlands: sliding down the slippery slope? In: Keown J, ed. Euthanasia examined: ethical, clinical, and legal perspectives. New York: Cambridge University Press, 1995:261-96.
   

To the Editor:

The report by van der Maas et al. presents the data in a misleading manner, which makes the situation appear more favorable than it is.

Some of the data are presented as the percentage of change, which emphasizes the magnitude of change, whereas other data are presented as absolute numbers, giving an impression of minimal change. Thus, we are told of a 37 percent increase in the number of requests for euthanasia from 1990 to 1995. But the change in the incidence of euthanasia is given in absolute percentages (2.4 percent in 1995 vs. 1.7 percent in 1990), which of course seems to be a trivial increase, whereas the actual increase is 41 percent, or more than an additional 1000 patients whose lives were terminated. The influence of such framing of data on their interpretation has been well documented.1,2

The authors also report data on life expectancy as if these estimates were straightforward facts. The inability of physicians to predict life expectancy for critically ill patients is well known. Categorical statements, such as the statement that patients whose lives were deliberately terminated had “only a few hours or days to live,” are not reassuring.

Shimon M. Glick, M.D.
Ben Gurion University of the Negev, Beer Sheva, Israel 84105

2 References

1. 1

   Forrow L, Taylor WC, Arnold RM. Absolutely relative: how research results are summarized can affect treatment decisions. Am J Med 1992;92:121-124
   CrossRef | Web of Science | Medline

2. 2

   Naylor CD, Chen E, Strauss B. Measured enthusiasm: does the method of reporting trial results alter perceptions of therapeutic effectiveness? Ann Intern Med 1992;117:916-921
   Web of Science | Medline

To the Editor:

Dutch physicians still do not report the majority of cases of euthanasia and assisted suicide, as required by law. The required safeguard of consultation with another physician occurred in 94 percent of reported cases but in only 11 percent of unreported cases. Without independent consultation by physicians knowledgeable about palliative care, there can be no assurance that physician-assisted death occurs only as a voluntary measure of last resort.1 In the absence of such consultation, I find it difficult to concur with Dr. Angell's conclusion in her accompanying editorial, “As far as we can tell, Dutch physicians continue to practice physician-assisted dying . . . under compelling circumstances.”2

Franklin G. Miller, Ph.D.
University of Virginia, Charlottesville, VA 22908

2 References

1. 1

   Miller FG, Quill TE, Brody H, Fletcher JC, Gostin LO, Meier DE. Regulating physician-assisted death. N Engl J Med 1994;331:119-123
   Full Text | Web of Science | Medline

2. 2

   Angell M. Euthanasia in the Netherlands -- good news or bad? N Engl J Med 1996;335:1076-1078
   Full Text

To the Editor:

In 1991, a Dutch psychiatrist gave a lethal dose of barbiturates to a severely depressed 50-year-old woman at her request.1 Although physically healthy, the woman had recently gone through a bitter divorce, and her two children had died. The Dutch Supreme Court found the doctor guilty but exempted him from any penalty, ruling that in matters of assisted death, there is no distinction between mental and physical suffering.

In March 1993, a Dutch gynecologist gave a lethal injection to a three-day-old girl born with multiple handicaps, including spina bifida, hydrocephalus, and leg deformities.2 This physician was cleared of murder charges because he had obtained the consent of the parents and followed official guidelines for euthanasia in adults.3 It has also been reported that a growing number of older Dutch children with cancers and degenerative diseases are having their lives ended through euthanasia.4

In July 1994, a Dutch nurse gave a lethal injection to a friend with AIDS at the friend's request.5 Under Dutch law, only a physician can perform euthanasia. The nurse was found guilty of this violation, but she was given only a two-month suspended sentence.

These events indicate that in addition to the involuntary euthanasia mentioned by Dr. Angell, there are other disturbing trends in the Dutch practice of physician-assisted death.

(The opinions contained herein are the private views of the author and are not to be construed as official or as reflecting the views of the Department of the Army or the Department of Defense.)

Kenneth J. Simcic, M.D.
William Beaumont Army Medical Center, El Paso, TX 79920-5001

5 References

1. 1

   Spanjer M. Mental suffering as justification for euthanasia in Netherlands. Lancet 1994;343:1630-1630
   CrossRef | Web of Science | Medline

2. 2

   Spanjer M. Terminating life of severely handicapped Dutch baby. Lancet 1995;345:975-975
   CrossRef | Web of Science | Medline

3. 3

   Infants' euthanasia sets off new Dutch debate. American Medical News. January 1, 1996.
   

4. 4

   Orlowski JP, Smith ML, Van Zwienen J. Pediatric euthanasia. Am J Dis Child 1992;146:1440-1446
   Web of Science | Medline

5. 5

   Spanjer M. Nurses cannot assist suicide in Netherlands. Lancet 1995;345:849-849
   CrossRef | Web of Science | Medline

Author/Editor Response

The authors reply:

To the Editor: Hendin misrepresents the facts. The 1990 study report did not document that 50 percent of Dutch physicians suggest euthanasia to patients. Of all cases of euthanasia, physician-assisted suicide, and the ending of life without an explicit request, the physician had initiated the discussion in 21 percent.1,2 For euthanasia and physician-assisted suicide only, this figure was 12 percent (data not included in the report). Contrary to Hendin's suggestion, we did not present comparable figures in our Dutch 1995 report. (For the 1995 study, the comparable figure for euthanasia and physician-assisted suicide was 15 percent.) Taking the initiative to create an opportunity for patients to discuss their wishes concerning the end of life is very different from “telling the patient that his or her life is not worth living.”

Cases in which the physicians who responded said they had alleviated pain and symptoms with opioids but with the explicit intention of hastening the patient's death have in both studies been reported as a separate group of decisions, representing a boundary area between physician-assisted death and other end-of-life decisions.2-4 Thus, contrary to Hendin's claims, these deaths were not treated as secondary to pain medication.

We certainly do not want to imply that the increase in euthanasia in the Netherlands between 1990 and 1995 is trivial, as Glick suggests. As we stated, we think the increase is real and not due to sampling error. We mentioned the 37 percent increase in requests for euthanasia or physician-assisted suicide at a later time in the disease (i.e., if suffering were to become unbearable), as compared with a 9 percent increase in explicit requests for euthanasia or physician-assisted suicide in the near future. From Table 1 of our article,4 it can be directly inferred that 36 to 38 percent of the explicit requests for physician-assisted death in the near future were acceded to in 1995, as compared with 27 to 32 percent in 1990.

Physicians' estimates of life expectancy in critically ill patients are fairly accurate.5 In our studies, we have found estimates of life expectancy that were consistently different for the different types of end-of-life decisions made by patients. This finding supports the view that these differences in estimates are meaningful.2-4

We agree with Miller that the majority of cases of euthanasia and assisted suicide are still not reported, despite the increase from 18 to 41 percent in the notification rate between 1990 and 1995. On the basis of the results of our study, the Dutch government recently proposed a substantial revision of the notification procedure. We expect that this revision will lead to a sizable increase in the percentage of cases reported.6

The 11 percent of unreported cases in which a colleague had been consulted refers to “consultation in the context of the reporting procedure.” Table 2 of our article6 shows that the decision had been discussed with colleagues in 58 percent of unreported cases (which is still far from the desirable 100 percent).

Simcic lists a number of cases that have been brought to court, which means that they do not represent standard practice in the Netherlands. To judge the considerations and rulings of the court in these cases, it is advisable to study them in more detail than Simcic's presentation allows.

Paul J. van der Maas, M.D., Ph.D.
Erasmus University, 3000 DR Rotterdam, the Netherlands

Gerrit van der Wal, M.D., Ph.D.
Vrije Universiteit, 1081 BT Amsterdam, the Netherlands

6 References

1. 1

   van der Maas PJ, van Delden JJM, Pijnenborg L. Medische beslissingen rond het levenseinde. The Hague, the Netherlands: Staatsuitgeverij, 1991.
   

2. 2

   van der Maas PJ, van Delden JJM, Pijnenborg L. Euthanasia and other medical decisions concerning the end of life. Health Policy 1992;22:1-262
   Web of Science

3. 3

   van der Maas PJ, van Delden JJM, Pijnenborg L, Looman CWN. Euthanasia and other medical decisions concerning the end of life. Lancet 1991;338:669-674
   CrossRef | Web of Science | Medline

4. 4

   van der Maas PJ, van der Wal G, Haverkate I, 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;335:1699-1705
   Full Text | Web of Science | Medline

5. 5

   Knaus WA, Harrell FE Jr, Lynn J, et al. The SUPPORT prognostic model: objective estimates of survival for seriously ill hospitalized adults. Ann Intern Med 1995;122:191-203
   Web of Science | Medline

6. 6

   van der Wal G, van der Maas PJ, Bosma JM, et al. Evaluation of the notification procedure for physician-assisted death in the Netherlands.N Engl J Med 1996;335:1706-11.
   

Citing Articles (1)

Citing Articles

1. 1

   Judith A. C. Rietjens, Johan Bilsen, Susanne Fischer, Agnes van der Heide, Paul J. van der Maas, Guido Miccinessi, Michael Norup, Bregje D. Onwuteaka-Philipsen, Astrid M. Vrakking, Gerrit van der Wal. (2007) Using Drugs to End Life without an Explicit Request of the Patient. Death Studies 31:3, 205-221
   CrossRef