Sanctioned euthanasia: lessons from abroad

For patients, does Dutch example imply power or pressure?

If Jack Kevorkian were in the Netherlands, he probably wouldn't be nearly so notorious as he is in the United States. There, helping people take their own lives - which the Michigan pathologist admits to having done some 120 times in this country - is officially sanctioned.

But does the Dutch experience with physician-assisted suicide and euthanasia provide any lessons for a country grappling with the ethical and legal issues surrounding Dr. Kevorkian?

Both sides in the debate cite the record there to buttress their case.

Supporters of carefully prescribed laws allowing assisted suicide, like the one here in Oregon, say there has been no rush to hasten death in the Netherlands. Between 2 percent and 3 percent of the cases involve an active role by doctors - usually within a few weeks of when patients are expected to die.

And while helping someone take his or her own life remains technically illegal there, guidelines and reporting procedures approved by legislators and upheld by Dutch courts have satisfied prosecutors and the public. Opinion polls show high support, and only rarely have doctors been charged in such cases.

In fact, Oregon's landmark law is far more restrictive than Dutch practice. It applies only to mentally competent adults who declare their intentions in writing, are diagnosed as terminally ill, and take the prescribed drug themselves orally after a waiting period. Oregon prohibits "lethal injec- tion, mercy killing, or active euthanasia."

But the recent broadcast of a video showing Kevorkian injecting a man with a lethal dose of a drug has galvanized opposition to such procedures, even though the man and his family had requested it.

Failure to prosecute Kevorkian, they say, would mean a "slippery slope," posing special dangers for vulnerable patients.

"At greatest risk are the poor, elderly, disabled, disadvantaged, and others without access to good medical care - for whom the 'choice to die' could become the 'duty to die,' " warns C. Everett Koop, the former US surgeon general.

Others note the difficulty of determining a patient's mental condition. Dutch courts have ruled that a patient's mental state could constitute "unbearable suffering" under the guidelines for assisted suicide.

"Assisted suicide and euthanasia ... become easy ways of dealing with anxiety and depression," says Herbert Hendin, a professor of psychiatry at New York Medical College who has studied the experiences of Dutch doctors, patients, and families.

Sanction for assisted suicide "increases the power and control of doctors, not patients," he told a House judiciary subcommittee in July. "The doctor can suggest assisted suicide or euthanasia, which has a powerful impact on patients' decisions, can ignore patient ambivalence, not present suitable alternatives, and even end the lives of patients who have not requested it."

Dr. Hendin cites Dutch studies showing that approximately 1,000 of some 5,000 cases in which death is hastened each year involve no explicit consent of the patient. Some researchers put the percentage of involuntary euthanasia in the Netherlands (including the withholding of medical treatment) as high as 50 percent. Dutch officials say these are mostly cases of infants with severe deformities or older patients who expressed to family a desire to be euthanized.

Others who track the issue say the Netherlands simply acknowledges and at least tries to regulate a practice that inevitably occurs. They liken it to abortion in that it will take place with or without legal status.

"Independent surveys have shown that thousands of doctors [in the US] quietly help people die when they know that this is the patient's repeated, desperate wish," says Faye Girsh, executive director of the Hemlock Society, the Denver-based 27,000-member group promoting "death with dignity." "This is a practice that must be legalized and regulated."

Some people liken physician-assisted suicide to abortion in that it will take place with or without legal status.