Death With Dignity, Or Door to Abuse?
Popular Dutch Euthanasia Law Continues to Draw Condemnation
By Keith B. Richburg
Washington Post Foreign Service
Sunday, January 4, 2004; Page A01
AMSTERDAM -- For Nelleke Jorissen-Dumee, the Netherlands' right-to-die law means death with dignity. She recalls her mother Maria's fight with cancer, and how five years ago the sick woman chose the day to end her life.
The family brought 20 red roses and played Maria's favorite songs, including Fats Domino singing "Blueberry Hill." They lit 64 candles, one for each year of her life. Then after a final glass of wine, she lay in her daughter's arms while a doctor administered two gently lethal injections.
"For us, it was quite a beautiful experience," Jorissen-Dumee said. Following her mother's example, she now keeps a copy of her own euthanasia request, specifying the conditions under which she would want her life to be ended.
A year and a half after the Netherlands became the first country to legalize euthanasia and doctor-assisted suicide, an estimated 2,000 to 3,000 lives end that way here each year. The law appears to enjoy support among the Dutch public and doctors, many of whom for years carried out such procedures in secret.
But to other citizens it does not seem right. Christian groups condemn euthanasia as counter to their faith. Activist opponents are urging counterparts in the United States to block passage of a similar law in the United States, though they see little hope of undoing it in their own country, where privileges granted by law are rarely rolled back.
Opponents argue that, moral objections aside, euthanasia in practice is often not a black-and-white decision. The patient may be of unsound mind, relatives at the bedside may disagree on how to proceed and morphine given to relieve pain may also hasten death, without anyone having made a clear decision to end the patient's life.
For euthanasia to be legally conducted, the doctor must determine that the patient's suffering is what the law describes as "unbearable" and "lasting," with no prospect of improvement. The doctor must give all "due care" beforehand, and determine, in consultation with the patient, that "there is no reasonable alternative."
Children aged 12 to 16 need their parents' consent, and youths aged 16 to 18 must involve their parents in the decision but do not need parental approval. There is no requirement that the patient's condition be terminal, or that the suffering be physical.
"I'm very pleased that it is in the law, because now you know what you can do and you know what you can't do," said Nico Mensing van Charante, a family doctor for 27 years. When he began practicing medicine, most doctors had a "criminal period," he recalled. "There was no law, but we did euthanasia."
Mensing van Charante said he was called on to perform euthanasia about every two years. He prefers the term physician-assisted suicide because "for me, it's important, because it symbolizes another time the will of the patient." The patient takes a barbiturate and usually is dead in about a half-hour. But Mensing van Charante said, "I always have all the injections with me, just in case it is not going okay."
Opponents of euthanasia argue that the new law encourages people to end their lives when confronted with suffering, and creates an atmosphere in which doctors feel free to make decisions for death that in many cases go unreported, though failure to report remains counter to the law.
"You should never aim to kill a person -- that's the bottom line," said Bert P. Dorenbos, chairman of the Dutch anti-euthanasia group Cry For Life.
Dorenbos said he has closely followed the case of Terri Schiavo, a Florida woman who has been in a persistent vegetative state for 13 years and whose husband won a court order to have her feeding tubes removed, only to have it overturned by Gov. Jeb Bush and the state legislature.
Dorenbos e-mailed leaders of U.S. groups opposing the tubes' removal, warning them that if Schiavo is allowed to die, her case will quickly open the door to legal euthanasia. He cited the 1990 case of a Dutch woman in a coma, Ineke Stinissen, who was allowed to die at her husband's request, with food and fluids withheld. Dorenbos said that case "shifted the debate" and led to legalization here.
Rob Jonquiere, a physician who runs a pro-euthanasia group -- The Right to Die, Netherlands -- said the lesson to be learned from the Schiavo case was that, if she had filled out a right-to-die request form of the type that is freely available in the Netherlands, her wishes would be known.
"It's still a difficult decision," he said. "But if she had a piece of paper saying, 'I don't want to be in a vegetative state,' then her husband would have a stronger case."
Valid Instructions
Jonquiere said about 95,000 of his group's 100,000 members have filled out euthanasia request forms. But he said any written declaration was legally valid, even the single sentence that was handwritten by Maria Dumee-Allart before her death and that her daughter still keeps. It says only: "Dear Doctors, With this note I want to let you know that my situation is hopeless and I decided I want to have euthanasia as soon as possible."
Jorissen-Dumee, 49, a college administrator, signed her own euthanasia request form in 1999. Her statement declares that she will want her life to end when she is completely dependent on others, when she can no longer recognize her husband and children, or when she is no longer living "in dignity."
"If I'm more than eight weeks in a coma, I want to die," she said.
There is some dispute about the number of mercy killings performed in the Netherlands, but both sides agree there has been no surge in reported cases since the law took effect in April 2002.
According to Cry For Life, there were 1,882 reported euthanasia cases in 2002, compared with 2,054 in 2001 and 2,123 in 2000. The group uses figures first published by the Health Ministry and supplied by regional euthanasia committees that usually lump together euthanasia and the tiny number of doctor-assisted suicides.
On the opposite side of the debate, The Right To Die, Netherlands, showed 3,800 reported cases of euthanasia and doctor-assisted suicides in 2001, a figure it said was virtually unchanged from 3,600 euthanasia and doctor-aided suicides in 1995. It has no figures after 2001 but says that anecdotal evidence suggests that the numbers have held generally steady.
Legalizing euthanasia was supposed to encourage doctors to be more honest in reporting it. But even supporters concede that has not happened. Family doctor Mensing van Charante, who occasionally lectures in other countries on the Dutch euthanasia experience, estimates that about half the physicians in his country continue to conduct euthanasia in secret. That's because reporting it requires filing extensive paperwork and getting a second opinion.
In any case, the numbers may not be complete because euthanasia is strictly defined as the "active termination of life on request," and does not include what is known here as "terminal sedation" -- a terminally ill patient who is in severe pain is given painkilling morphine in quantities that relieve the pain but also hasten death. Under Dutch law, that leaves room for ambiguity about whether death was intended.
"It is considered to be a natural death," said Jonquiere, of the pro-euthanasia group. "It doesn't need to be reported."
He added, "We don't know how many doctors do that," but said some physicians were "misusing terminal sedation."
Henk Reitsema, 34, a former social worker at a Christian service agency, is convinced that his grandfather died from such an overdose in a nursing home eight years ago. By Reitsema's account, his grandfather was partially paralyzed on his left side as the result of a stroke and was in pain from thrombosis in his leg. But the World War II veteran was mentally fit, Reitsema said.
A doctor in the nursing home gave the 80-year-old man what Reitsema called a lethal dose of morphine that swelled the sick man's tongue and left him gasping for fluids. He died shortly afterward.
By Reitsema's account, the doctor said he was acting on the old man's final wish, a cry of "please help me." But for Reitsema, the cry from the man, whom he remembers as having a survivor's determination, was simply a request for pain relief. "It's unfathomable that he would have made a determination for his own death," Reitsema said.
A Wife's Consent
The doctor who administered the morphine had the consent of the patient's wife, according to Reitsema, and lawyers later told him that that fact would make a lawsuit futile. But Reitsema argues that the elderly woman trusted the word of doctors but would never have knowingly agreed to a treatment that would kill.
A doctor at the nursing home in the city of Groningen said there was no intention to take the life of Reitsema's grandfather and that the facility never gave lethal doses of morphine. High-level sedation was used "only to relieve pain and suffering" of patients "who are going to die in a few days anyway," said the doctor, who spoke on condition he not be identified. He acknowledged that morphine given this way might hasten death.
He said fluids were withheld only when patients could not drink without assistance, and when giving fluids artificially might prolong suffering.
The doctor said that family members were consulted by the attending physician, whose name he would not disclose. "My colleague -- I know him very well -- did a lot of talking with the relatives," he said, adding that "there was a conflict between the doctor and some relatives," but in this case, the elder Reitsema's wife, who had legal responsibility, was consulted and "she agreed with our policy."
When the Dutch bill became law last year, Reitsema was one of about 60 protesters who attended a silent vigil in the capital, The Hague.
"I find it mind-boggling that there was so little formal debate," he said. "It was the most explicit legalization of euthanasia in history." He added, "Killing shouldn't be a treatment."
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