Whose Right to Die?

America should think again before pressing ahead with the legalization of physician-assisted suicide and voluntary euthanasia

The 1996 data show small increases in the numbers of requests for physician-assisted suicide and euthanasia since 1990, but the overall changes are undramatic. The new research does indicate, however, that problems identified by the Remmelink Report have by no means been eliminated.

First, the update found that beyond the roughly 3,600 cases of physician-assisted suicide and euthanasia reported in a given year, there are about 1,000 instances of nonvoluntary euthanasia. Most frequently, patients who were no longer competent were given euthanasia even though they could not have freely, explicitly, and repeatedly requested it. Before becoming unconscious or mentally incompetent about half these patients did discuss or express a wish for euthanasia; nevertheless, they were unable to reaffirm their wishes when the euthanasia was performed. Similarly, a study of nursing-home patients found that in only 41 percent of physician-assisted suicide and euthanasia cases did doctors adhere to all the guidelines. Although most of the violations were minor (usually deviations in the notification procedure), in 15 percent of cases the patient did not initiate the request for physician-assisted suicide or euthanasia; in 15 percent there was no consultation with a second physician; in seven percent no more than one day elapsed between the first request and the actual physician-assisted suicide or euthanasia, violating the guideline calling for repeated requests; and in nine percent interventions other than physician-assisted suicide or euthanasia could have been tried to relieve the patient's suffering.

Second, euthanasia of newborns has been acknowledged. The reported cases have involved babies suffering from well-recognized fatal or severely disabling defects, though the babies were not in fact dying. Precisely how many cases have occurred is not known. One estimate is that ten to fifteen such cases occur each year. Whether ethically justified or not, providing euthanasia to newborns (upon parental request) is not voluntary euthanasia and does constitute a kind of "mercy killing."

The Netherlands studies fail to demonstrate that permitting physician-assisted suicide and euthanasia will not lead to the nonvoluntary euthanasia of children, the demented, the mentally ill, the old, and others. Indeed, the persistence of abuse and the violation of safeguards, despite publicity and condemnation, suggest that the feared consequences of legalization are exactly its inherent consequences.

Third, the Boudewijn Chabot case raises a warning flag. Chabot, a psychiatrist, participated in the suicide of a depressed fifty-year-old woman in 1991. Her first son had committed suicide a few years earlier. Then her father had died. Under the stress her marriage dissolved. In May of 1991 her second son died of cancer, and less than three months later the woman reached Chabot through the Dutch Voluntary Euthanasia Society, seeking someone to help her end her life. She refused antidepressants and additional psychotherapy. She was never seen by another physician in consultation. When Chabot discussed the case with seven colleagues, at least two suggested that he not assist in the suicide. The Dutch Supreme Court ultimately opted not to penalize Chabot, reaffirming the permissibility of providing assisted suicide and euthanasia on grounds of mental suffering alone. The Amsterdam Medical Disciplinary College did reprimand him, however.

A statement by Else Borst-Eilers, the Dutch Minister of Health, raises concerns about how euthanasia will come to be viewed once it is routine: "There are situations in which the best way to heal the patient is to help him die peacefully, and the doctor who in such a situation grants the patient's request acts as the healer par excellence." The logic of understanding voluntary euthanasia as "healing" begins to justify using euthanasia for children, the incompetent, the mentally ill, and others who are suffering or who we imagine are suffering in some fashion. As we have seen, there is a very strong tendency among people who are healthy to extrapolate from the suffering of others in ways that those who are in fact suffering would not countenance.

Many in favor of legalization urge caution in applying the experience of the Netherlands to the United States, citing the many significant geographic, cultural, and political differences between the countries. The differences suggest, though, that the kinds of departures from agreed-upon procedures that have occurred in the Netherlands are likely to be even more commonplace in America. Whatever the emerging cultural, ethnic, and religious diversity of the Netherlands, it pales in comparison to the raucous diversity of the United States. And the Dutch have relative income equality, whereas income inequality in the United States is among the greatest in the developed world. Such diversity and inequality make it harder to share norms and to enforce them. The Dutch are also a law-abiding people who view government social supports, interventions, and regulations as legitimate. America is a land founded on opposition to government, where candidates for office campaign against government legitimacy. If the law-abiding Dutch violate their own euthanasia safeguards, what can we expect of Americans?

In the Netherlands physician-assisted suicide and euthanasia are provided in the context of universal and comprehensive health care. The United States has yet to provide such coverage, and leaves tens of millions effectively without health care. Paul van der Maas, the professor of public health who conducted the two Netherlands studies, has said that in the absence of health-care coverage he would be loath to permit euthanasia in the Netherlands, fearing that pressure might be brought to bear on patients and doctors to save money rather than to help patients.

Presented by

Ezekiel J. Emanuel is an oncologist, a bioethicist, and a vice provost of the University of Pennsylvania. He is the author or editor of 10 books, including Brothers Emanuel and Reinventing American Health Care.

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