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The Doctor and Euthanasia

In these modern times the physicians find themselves in a difficult position regarding Euthanasia. Many of them would like to heal and provide (terminal) palliative care on the one hand and on the other to help them to die with dignity. Outdated moral views, rooted in the Dutch Euthanasia Act of 1886 (!) and the guidelines of the Royal Dutch Society of Medicine, maintain this situation.

Even with the current Dutch Euthanasia Act from 2001, it is difficult for the doctor to decide on Euthanasia or assisted suicide due to certain subjective due care requirements (especially unbearable and hopeless suffering). Also: the threat that the Regional Review Committee Euthanasia (checks whether the doctor accurately has followed the legal requirements) may assess the doctor’s euthanasia report negatively, the threat of having to appear before the Medical Disciplinary Board, or of prosecution by the Public Prosecutor and of problems with the family of the euthanasia applicant make doctors nervous. Changes to the End-of-Life Management are necessary to achieve adequate assistance in the event of helping to die (for whatever reason). To substantiate this, several interviews were conducted with all kind of doctors, especially general practitioners and a SCEN doctor[1].

Summary

The doctors find themselves not able to determine for someone else (the patient) whether the patient suffers unbearable (only pain behavior can be determined, not the degree of pain); and hopeless[2] (except medically if there is no treatment available anymore) or whether the patient finds another solution other than euthanasia reasonable. Only the person concerned can do that.

Most important interview results

1. It would be better if the doctor does not have to be involved in the decision-making about euthanasia and assisted suicide. Provided that everything is done carefully, the Proposal End-of-Life Management route is a good option to relieve doctors from their dilemmas, especially with respect to the due care requirements for unbearable and/or hopeless suffering. This can be done by limiting the role of the doctor to, in particular (if requested by the patient) the diagnosis of physical and/or psychiatric and/or psychological suffering and, if desired by the patient, treatment and/or palliation.

2. With regard to the academic training those involved felt:

. Their training regarding conversation techniques was mainly focused on: 1. the (differential) diagnostic process, 2. ‘bad news conversations’, 3. learning to deal with the patient’s emotions and with ‘difficult or aggressive’ patients. There was no training regarding the determination of unbearable suffering or the other due care requirements. However, the doctors considered learning to communicate essential.

2.2. General ethics had been discussed in the training. However, there had been insufficient ethical discussions about Euthanasia and assisted suicide, not or very little about the ethical background of euthanasia legislation or the reasonableness or feasibility of the due care requirements themselves or about the patient’s right of self-determination with regard to assisted suicide, euthanasia or at the end of a completed life. The subjects were more in determining the doctor’s own position; how the doctor can act carefully within the legal due care requirements; and how the doctor would be protected from prosecution after euthanasia or assistance suicide.

2.3. The academic training provided little or no psychological insights to prepare the doctor to assess the degree of somatic and/or psychiatric and/or psychological suffering. That is to say: to determine whether the suffering is unbearable and hopeless, and whether no other reasonable solution than euthanasia is possible. Insofar as medically hopeless is concerned, the doctor can give an estimation of the remaining survival time. A doctor cannot determine hopeless in the sense of a ‘life without meaning’. The training also did not provide any criteria to determine the suffering or with regard to being able to apply the due care criteria of hopelessness, unbearability and the ‘reasonableness of a solution other than euthanasia’.

2.4. The doctors found it impossible to properly define criteria for the application of the due care requirement ‘Unbearable suffering and to assess this. Suffering in itself is a subjective experience: the pain thresholds of patients and doctors mutually differ. So, if the doctors’ frame of reference with his own pain experiences is different from the patient’s how can the doctor determine the pain of the patient?

3. All doctors agree that the doctor faces major dilemmas when a patient requests euthanasia or assisted suicide. If the competent patient has to live, this is usually accompanied by unbearable suffering and there is a risk of horrific suicide with often serious consequences for loved ones and other collateral damage. Nevertheless, the doctor must comply with the Euthanasia Act. Although it does not happen often, a negative assessment of the doctor’s euthanasia report by the Regional Euthanasia Review Committee carries the risk of having to appear before the Medical Disciplinary Board and/or be prosecuted by the public prosecutor. The recent suicide of a general practitioner in North Holland and the long-term prosecution of a nursing home doctor in The Hague have shocked the medical profession. In addition, problems may arise with the patient’s relatives. These risks strongly undermine the (often existing) willingness among (young) doctors to actually perform euthanasia or assisted suicide. In 2020, nine out of ten doctors did not want to perform euthanasia.

4. Particularly in the case of psychiatric or psychological disorders, doctors found it difficult to determine hopelessness and to draw up a prognosis. The requirement to establish that no reasonable solution other than euthanasia is possible is sometimes problematic. if the patient has psychotic episodes. With every psychiatric or psychological disorder, the patient’s assessment of his or her own quality of life and his or her decision-making capacity should also be central.

5. When doctors talk about euthanasia or assisted suicide, they often immediately think of the extremes that can occur. Mainly out of distrust about the actions of family members, not out of confidence in acting with integrity and care. That thinking pattern seems to have been learned during academic medical training. This applies, for example, to the purchase of an End-of-Life drug: doctors immediately thought of possible abuse instead of careful and honest use.

6. The Sanctity of Life (the sanctity of ‘life in general’) often seems to take precedence over the importance of the Quality of Life (the quality of each individual life). This rather conservative principle is ingrained in medical training and can lead to preserving life ‘at all costs’. The individual quality of life, especially in the case of a request for euthanasia or assisted suicide, should prevail.

Recommendation

The results of the interviews should be confirmed or not confirmed by more extensive objective research. If the above proves to be correct in general, both the legislator and the Royal Dutch Society of Medicine (with its guideline on Euthanasia) require the doctor to apply due care requirements for which de doctor is not qualified. If the KNMG and the legislator knowingly adhere to the Due Diligence Requirements of Unbearable, Hopeless, Reasonable then this is unethical. This in principle also applies to a doctor who realizes that he cannot apply these two Due Care Requirements himself, but still claims to be able to do so and to act accordingly (e.g. when rejecting Euthanasia). It is important to know what the judge would think of this reasoning. If the judge agrees that the current Euthanasia Act is unethical, it will have to be radically changed.

Wim van Dijk, psychologist, June 2022, Den Bosch.

[1] A SCEN doctor is the second assessor of the Euthanasia request and is qualified with three days of training and a number of hours of self-study.

[2] In the sense of considering the rest of life as meaningless.