Safeguards for the mentally ill and the demented are slipping away
If there is anyone who could be called a patron saint of Dutch euthanasia, it is the psychiatrist Boudewijn Chabot. In 1991 he gave one of his patients, Mrs B, a lethal dose of medication. After accompanying her until she died he reported himself to the police and was subsequently tried. In 1993, the Supreme Court declare that he was guilty of assisting a suicide, but did not punish him and allowed him to keep practicing medicine.
Physically, there was nothing wrong with Mrs B. Nor did she have depression. But her personal life was tragic and Dr Chabot felt that she in a state of existential distress that she should be allowed to die. It was a landmark case in the steady advance towards legalisation in 2002.
That was 25 years ago. Now Dr Chabot looks back and is horrified. Writing in one of the leading Dutch newspapers, NRC Handelsblad, he says that legal safeguards for euthanasia are slowly eroding away and that the law no longer protects people with psychiatric condition and dementia.
The Dutch are complacent about their famous law, he says. But there is no room for complacency.
Under current legislation, euthanasia is only legal if a doctor believes that three conditions have been met: (1) the request must be voluntary and deliberate; (2) there must be unbearable suffering with no hope of improvement; and (3) there must no reasonable alternative to euthanasia.
However, as euthanasia has sunk its roots deeper and deeper into Dutch medicine, the second and third conditions have shrivelled up. Patients define what is unbearable and they define what is a reasonable alternative. Unhappiness can be unbearable and a nursing home may not be a reasonable alternative. So, as one ethicist has observed, requirements (2) and (3) “add little to the requirement of a voluntary and thoughtful request”. Autonomy has trumped medicine. As a result, the number of euthanasia cases roughly tripled between 2007 and 2016, from 2000 to 6000.
In itself, this does not bother Dr Chabot. After all, he is the Grand Old Man of Dutch euthanasia. He says that he is prepared to accept tens of thousands of euthanasia cases. But he is aghast at the rapid rise in the number of people with psychiatric illness or dementia who have been euthanised:
What does worry me is the increase in the number of times euthanasia was performed on dementia patients, from 12 in 2009 to 141 in 2016, and on chronic psychiatric patients, from 0 to 60. That number is small, one might object. But note the rapid increase of brain diseases such as dementia and chronic psychiatric diseases. More than one hundred thousand patients suffer from these diseases, and their disease can almost never be completely cured.
One sign of the changing times is the rapid expansion of the services of the End of Life Clinic Foundation (Stichting Levenseindekliniek). This organisation offers euthanasia to patients whose own doctors have refused. They never offer to treat the underlying illness, whether it is physical or mental.
By 2015, a quarter of euthanasia cases on demented patients were performed by these doctors; in 2016 it had risen to one third. By 2015, doctors of the End of Life Clinic performed 60 percent of euthanasia cases in chronic psychiatric patients, by 2016 that had increased to 75 percent (46 out of 60 people).
Last year, Dr Chabot points out, doctors from the End of Life Clinic each performed about one euthanasia every month. “What happens to doctors for whom a deadly injection becomes a monthly routine?” he asks.
Now the End of Life Clinic is recruiting psychiatrists to service the mentally ill and demented. One obvious problem is that there is a shortage of good psychiatric help in the Netherland – which tends to take a long time have an effect, in any case – because of budget cuts.
Without a therapeutic relationship, by far most psychiatrists cannot reliably determine whether a death wish is a serious, enduring desire. Even within a therapeutic relationship, it remains difficult. But a psychiatrist of the clinic can do so without a therapeutic relationship, with less than ten ‘in-depth’ conversations? Well …
Dr Chabot is deeply sceptical about euthanasia for the demented: “we are dealing with a morally problematic act: how do you kill someone who does not understand that he will be killed?”.
How? It turns out that sometimes a relative or doctor secretly laces their food or drink with a sedative to make it easier to give them a lethal injection. In one notorious case last year, the sedative didn’t work and relatives pinned the terrified woman to the bed while the doctor gave the lethal injection. Dr Chabot was astonished to discover that “surreptitious administration of medication has previously occurred, but has never been mentioned in an annual report.”
Isn’t anyone paying attention to these developments, Dr Chabot asks.
The euthanasia practice is running amok because the legal requirements which doctors can reasonably apply in the context of physically ill people, are being declared equally applicable without limitation in the context of vulnerable patients with incurable brain diseases. In psychiatry, an essential limitation disappeared when the existence of a treatment relationship was no longer required. In the case of dementia, such a restriction disappeared by making the written advance request equivalent to an actual oral request. And lastly, it really went off the tracks when the review committee concealed that incapacitated people were surreptitiously killed.
After surveying the wreckage of the euthanasia law, Dr Chabot concludes bitterly,
I don’t see how we can get the genie back in the bottle. It would already mean a lot if we’d acknowledge he’s out.
Michael Cook is editor of BioEdge. Dr Chabot’s original article in NRC Handelsblad was translated by Professor Trudo Lemmens, of the University of Toronto Faculty of Law. Excerpts have been republished from his blog with permission.
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