Stuart J. Youngner & Gerrit K. Kimsma, editors
Physician-Assisted Death in Perspective:
Assessing the Dutch Experience
(New York: Cambridge University Press, 2012) 403 pages
(ISBN: 978-1-107-00756-7; hardcover)
(Library of Congress call number: R726.P484 2011)
(Medical call number: WB65P578 2012)
23 academics and physicians with first-hand experience
with 'euthanasia' and 'physician-assisted suicide' in the Netherlands
offer their perspectives and analyses of how these life-ending decisions
are achieved and reported in Holland.
Several chapters at the beginning trace the unusual pathways
by which Holland has finally arrived at its present practices.
Usually court decisions have led to regulations that make exceptions
to the laws against helping patients to die.
The decision to bring life to an end must be chosen by the patient
and only physicians are permitted to help their patients die
in these prescribed ways defined in Dutch law.
Usually the life-ending decision is carried forward by the family doctor,
after careful consultation with a euthanasia consultant,
who is trained in the process for making the decision to end life
and in the proper methods for reporting such deaths.
Because "unbearable suffering" is required by Dutch law of 2002,
there has been considerable discussion about exactly what qualifies
as conscious suffering that cannot be relieved by any medical methods.
Some advocates of the right-to-die argue that the normal losses of old age
are sufficient losses of dignity to qualify as "unbearable suffering".
And because patients must be suffering,
they no longer qualify if they become comatose.
Also, Alzheimer's patients do not qualify
for 'euthanasia' or 'physician-assisted suicide'
because it is questionable whether they are suffering unbearably.
And they can no longer give informed consent for a life-ending decision.
This is a peculiarity of Dutch law
that might be avoided by other countries.
Instead of requiring "unbearable suffering",
would it be sufficient to determine that meaningful life is over?
Reporting of 'euthanasia' and 'physician-assisted suicide'
continues to improve each year.
And as of 2011, about 2% of all deaths in Holland
were being achieved by these defined and reported methods.
Another 2% are achieved by patients forgoing food and water.
This method of choosing death does not fall under the Dutch law
and therefore does not require consultation and reporting.
Also, an even larger number of death are achieved
as a normal part of medical practice,
which would be found in any countries with advance medical care.
These include providing pain-medications at the end of life,
knowing that the pain-killers might shorten the process of dying.
Terminal sedation is becoming more popular:
The doctor decides to keep the patient continuously unconscious
until death comes as a part of the natural process of dying.
And, of course, whenever life-supports are in use,
it is completely within normal medical practice
to discontinue all forms of medical treatment and life-supports.
Such life-ending medical decisions often include
discontinuing artificial nutrition and hydration,
but these doctor-initiated decisions are not counted
in the 2% of Dutch deaths (mentioned above)
caused when patients themselves decide to give up food and water.
In Dutch medical practice at the end of life,
it seems important to distinguish between drugs that cause immediate death
and drugs that shorten the process of dying.
Certain drugs are recommended for achieving 'euthanasia'.
These do not have any other medical uses.
And the doctor's report of 'euthanasia'
will specify that gentle poison was used.
Other drugs--most notably morphine--
are widely used in order to relieve pain and suffering
in all sorts of medical patients, not just those expected to die.
However, morphine also suppresses vital functions,
which will sometimes lead to the death of the patient.
When the death results from the use of morphine,
this is not 'euthanasia' or 'physician-assisted suicide'.
The death-certificate will say "from natural causes".
And no report to the Regional Review Committee will be required.
And some attempts to discover the frequency
of each kind of life-ending decision
have focused on exactly what drugs were used
at the end of life--and in what quantities.
Dutch doctors strongly defend their right to practice terminal care
within the standards of normal medical practice,
as defined by their medical societies.
Thus, the practice of increasing everyday drugs to relieve suffering
is reported as death from palliative care
rather than death from 'euthanasia'.
This even extends to the use of drugs
to keep the patient completely and continuously unconscious
until natural death occurs.
Such 'terminal sedation' is much more common than 'euthanasia'.
But the lack of required reporting
means that the exact frequency of such life-ending decisions is not known.
The Dutch system for making life-ending decisions
involves just the patient and his or her doctors.
Others might be involved in rather informal ways,
such as family members and nurses,
but the official decision is made by the patient and his/her physician.
When 'euthanasia' or 'physician-assisted suicide' is being chosen,
at least one other physician must be consulted and approve.
This book provides an excellent over-view of how
'euthanasia' and 'physician-assisted suicide' are achieved in Holland.
Other life-ending decisions are much more common,
but they do not require any special consultation and/or reporting.
In the future, Holland might continue to lead the way
toward more liberal and transparent life-ending decisions.
Other methods of choosing death
besides 'euthanasia' and 'physician-assisted suicide'
will become more widely acknowledged and discussed.
Other methods of dying are already accepted parts of terminal care,
which fall under the medical ethics of the doctors.
But other methods (such as sleeping pills or giving up food and water)
are chosen by the patients themselves when they are ready to die.
Will Dutch law be the first to recognize officially
the difference between 'voluntary death' and 'irrational suicide'?
If you would like to read other books favoring the right-to-die,
search the Internet for this expression: "Books on the Right-to-Die".
James Leonard Park, advocate of the right-to-die with careful safeguards.