Correspondence

Physician-Assisted Death and Pharmacy Practice in the Netherlands

N Engl J Med 1997; 337:1091-1092October 9, 1997

Article

To the Editor:

Although the opinions of pharmacists on euthanasia and physician-assisted suicide have been examined,1 there is little information about their practices. Between April and September 1994, we surveyed attitudes and practices with respect to euthanasia and physician-assisted suicide in community and hospital pharmacies in the Netherlands. Under Dutch legislation euthanasia and physician-assisted suicide are technically crimes, but through an amendment to the Burial Act physicians are granted immunity from prosecution if they adhere to certain conditions.2 The Royal Dutch Pharmaceutical Association has issued guidelines for pharmacists who receive requests to dispense drugs for euthanasia or physician-assisted suicide. The guidelines, however, have no legal status.

Anonymous questionnaires were sent twice to a random sample of 50 percent (n = 755) of all community pharmacies and to all 101 hospital pharmacies in the Netherlands. The response rates were 52 percent and 51 percent, respectively. The second mailing yielded 12 percent of all responses. A comparison of the responses obtained from the first and second mailings and a comparison of the respondents from community pharmacies with all Dutch community pharmacists with respect to age, sex, province, and size of the community did not show significant differences.

Most of the respondents from the community pharmacies agreed with the concept of euthanasia (94 percent) and physician-assisted suicide (91 percent) and would dispense drugs for these purposes (95 percent). Furthermore, 44 percent responded that these activities should remain subject to criminal law. A majority (71 percent) of the hospitals had official guidelines for dealing with requests; in 8 percent these activities were officially not allowed.

Data on practical experiences with euthanasia and physician-assisted suicide in community and hospital pharmacies are given in Table 1Table 1Explicit Requests by Physicians to Dispense Drugs for Euthanasia or Physician-Assisted Suicide in Community Pharmacies (1991–1993) and Hospital Pharmacies (1993) in the Netherlands.. When the data were extrapolated to all pharmacies, there were 1691 instances in which drugs were dispensed for euthanasia and physician-assisted suicide per year. This number is substantially lower than the number of cases reported by van der Maas et al. (2700 cases in 19903 and 3600 cases in 19952).

Although we cannot rule out response and recall bias, the main reason for the difference in values may be that physicians often do not inform a pharmacist — for example, when they have not notified the coroner about a case of euthanasia. This happens in approximately 59 percent of the cases of physician-assisted death in the Netherlands.4 The choice of drugs for euthanasia generally followed published guidelines that recommend the combination of a barbiturate and a muscle relaxant given parenterally and a barbiturate mixture given orally.5 The combination of a benzodiazepine and a muscle relaxant, which was also often prescribed, is problematic. The dose of benzodiazepine needed to induce a narcotic state varies considerably among patients.5

In conclusion, most of the respondents to our survey were supportive of euthanasia and physician-assisted suicide and were prepared to fill prescriptions written for these purposes.

Anthonius de Boer, M.D., Ph.D.
Hong Sang Lau, Pharm.D.
Arijan Porsius, Pharm.D., Ph.D.
University of Utrecht, 3508 TB Utrecht, the Netherlands

5 References

1. 1

   Rupp MT, Isenhower HL. Pharmacists' attitudes toward physician-assisted suicide. Am J Hosp Pharm 1994;51:69-74
   Medline

2. 2

   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

3. 3

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

4. 4

   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;335:1706-1711
   Full Text | Web of Science | Medline

5. 5

   Admiraal PV. Toepassing van euthanatica. Ned Tijdschr Geneeskd 1995;139:265-268
   Medline

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