Examination of Witnesses (Questions 1600
- 1620)
FRIDAY 17 DECEMBER 2004
MR JACOB
KOHNSTAMM and DR
ROB JONQUIERE
Q1600 Chairman: These figures that
we have been given, which come to about 1,000, 0.7 per cent of
the total—do these derive, as far as you understand from
the coroners' certificates and investigations, in unnatural death?
Dr Jonquiere: No, they derive from the research
by van der Wal and van der Maas, which is a repeated survey performed
by doctors interviewing colleagues with, before that, a statement
by the prosecuting office that all information given in the case
of this research would not be a reason for prosecution. There
was such an enormous response to this research—which I believe
is statistically famous internationally—that van der Wal
has said that the numbers he received from a certain number of
doctors could be extrapolated to the whole population. That is
the reason why The Netherlands can produce figures about how many
times euthanasia is performed and what percentage of that euthanasia
is or is not reported, and how many times termination of life
without request is performed. That is on the basis of research.
Only a part of these cases are reported, I admit, but still the
cases are reported.
Mr Kohnstamm: So it is not the coroner's business,
but it is research business.
Q1601 Chairman: I do not completely
understand, particularly in view of what the government people
told us yesterday, what has happened to the information the coroner
gets about unnatural deaths and what use, if any, is made of that.
Dr Jonquiere: It depends on what he finds out.
If the coroner finds out that the unnatural death is because of
a criminal act, he will certainly report that to the prosecutor.
Q1602 Chairman: Yes, but what happens
to his record? Does the coroner's decision in relation to any
unnatural death go into the central government data?
Dr Jonquiere: I think it goes into the prosecuting
office.
Q1603 Chairman: You have responsibility
for the data now?
Mr Kohnstamm: Yes!
Dr Jonquiere: He is defending it.
Mr Kohnstamm: That is correct. It is first the
prosecutor's office, and then there is the Holland-wide CBS—the
centre for statistics. The Remmelink 900 or 1,000 cannot be seen
in the prosecutor's office or in the CBS office, because it is
research—where doctors were interviewed by doctors, talking
in depth about how life ended.
Q1604 Chairman: I understand that
perfectly. The professor's research has figures, but I am still
puzzled about the other way in which figures are collected that
go into the central archive. They would not be of no use. They
are done for a purpose.
Mr Kohnstamm: Once there is a reported unnatural
death, the public prosecutor will then proceed and do whatever
is necessary.
Q1605 Chairman: If he thinks it right
to do so, but when—
Mr Kohnstamm: There are some cases where the
chief of the public prosecutors reported that there was an unnatural
death reported and they decided, for several reasons, in I think
three or four cases in the last couple of years, that they had
cases which they would not prosecute. Those are the only figures
that come to my mind.
Lord Joffe: My Lord Chairman, I think
that I can clear that up with a question.
Chairman: I am very happy to hear that.
Q1606 Lord Joffe: Would the case
be that all these 1,000 cases are reported by the doctors concerned
as natural death, so that there is no evidence on the certificate
that these were unnatural?
Dr Jonquiere: I do not think all the cases are
not reported. I am afraid that many of those are not reported
because doctors do not want to be in danger of being prosecuted—which
is understandable. Because of all the discussions, however, we
have discovered that, more and more, doctors are reporting those
cases. Some of them are very brave in reporting them, and even
go to court to defend their case. Then they find out that the
defence of necessity is applicable in such cases—and in
the majority of cases. Unfortunately, we do not yet have 100 per
cent reporting on euthanasia. You will not have the 100 per cent
on the involuntary euthanasia being reported.
Lord Joffe: Are you saying that, of the
1,000 cases, most of the doctors would write, "involuntary
euthanasia"?
Q1607 Lord Patel: No. As I understand
it, these 1,000 cases are not real cases; they are anecdotal,
identified through an interview process, on the basis of a research
project. They were never on any death certificate?
Mr Kohnstamm: No, and this afternoon you may—if
I may advise you—ask van der Wal to go over the 900 cases.
These 900 cases are not 900 cases as such. They are, for example,
in neonatology, severely handicapped newborn babies—problems
that are mainly in the medical sphere.
Chairman: You may rest assured that we
will ask the professor about it. What I was concerned about was
the other source of information. Yesterday at the government office,
I understood from what the lady in the health department told
us—and I may have misunderstood—that there were two
sources of information. There was the research information that
the professor has, which we will hear about later, and also returns
to the government through the coroner in respect of all deaths.
Q1608 Baroness Finlay of Llandaff:
Could I ask two short, completely unrelated questions? First,
do you have a protocol for the doctors of what to do, what dose
to use, and which drug you recommend?
Mr Kohnstamm: Yes.
Dr Jonquiere: As an organisation, we do not
have it. However, the pharmacists' organisation and, from the
beginning of the 1970s, Dr Admiraal, an anaesthesiologist, have
advised in this regard. This society has a protocol, of what we
call the gold standard of what to use when euthanasia is performed.
Q1609 Baroness Finlay of Llandaff:
What do they recommend?
Dr Jonquiere: In euthanasia—the injecting?
Q1610 Baroness Finlay of Llandaff:
Yes.
Dr Jonquiere: First, to cause a deep comatose
situation by barbiturate or something like that.
Q1611 Baroness Finlay of Llandaff:
I wondered what the drug was and the dose that they recommend.
Mr Kohnstamm: Shall we try to get this information
to you?
Dr Jonquiere: It is Nesdonal or something that
is used in anaesthesiology. After this deep comatose situation
is caused, then we give secondly a curare-like substance to paralyse
the breathing muscles. Then the patient dies within a short period.
That is considered to be the gold standard.
Q1612 Baroness Finlay of Llandaff:
So the patient dies of asphyxia?
Dr Jonquiere: Yes.
Q1613 Baroness Finlay of Llandaff:
Having had the coma induced.
Dr Jonquiere: Yes.
Baroness Finlay of Llandaff: Has there
been any research doing EEG monitoring to be sure that the patient
does not regain consciousness before they die? With a short-acting
intravenous barbiturate, you could have the patient's induction
time very short but, because they are completely paralysed, even
if they regained consciousness you would not know—because
there would be absolutely no movement. They would not be tearing,
as you would have with a caesarean section, because you are not
using a surgical knife and causing new pain.
Lord Patel: But he is not answering whether
they are long-acting or short-acting barbiturates.
Baroness Finlay of Llandaff: No, but
we all know that, if you have induced liver enzymes, even long-acting
barbiturates have a remarkably short time of action.
Chairman: You say "we all know",
but—
Baroness Finlay of Llandaff: I am sorry!
Lord Patel: She was looking at me at the time.
Q1614 Chairman: I can understand
that.
Dr Jonquiere: I do not know the research on
that. As far as I know, the organisation has asked doctors to
report on their experience with this medication. On the basis
of that report, it is seen as the gold standard—which is
so golden that, if the review committee gets a report from a doctor
who performs euthanasia and who does not use these barbiturates
and curare-like substance, it will certainly ask, "Why did
you use potassium chloride?", or whatever.
Baroness Finlay of Llandaff: Could I
ask a completely separate and unrelated question? Why did you
call it the "right to die"? We are all going to die.
What I do not understand is why you did not call it the "right
to euthanasia" or the "right to stop living".
Chairman: It is not even a right to do
that, is it?
Q1615 Baroness Finlay of Llandaff:
No, but a right to euthanasia is what you are arguing for. We
all have the right, in fact. Nobody has the right not to die.
Mr Kohnstamm: As far as the society is concerned,
it is called NVVE—the Dutch society for voluntary euthanasia.
So there you have your answer. We are not talking about right
to die. In the international sphere, yes; but in the Dutch sphere,
we stick to the words "euthanasia and assisted suicide",
because euthanasia and assisted suicide would always be voluntary.
Q1616 Baroness Finlay of Llandaff:
This is clarity of Dutch thinking, which other people have not
adopted.
Dr Jonquiere: The French talk—if I translate
it into English—of the "right to die in dignity".
Internationally, maybe the "in dignity" is left out
of "right to die"; but that is the meaning of the right-to-die
societies.
Q1617 Baroness Finlay of Llandaff:
I wondered what you were campaigning for next, having achieved
what you have achieved.
Dr Jonquiere: Do you have another afternoon?
Q1618 Earl of Arran: In all the research
that you have done into public opinion in this country, to what
extent have you done research amongst the young about euthanasia?
One day, "our problem" will also be their problem. Have
you done much, and what is their opinion?
Mr Kohnstamm: The research that we as a society
have been doing is mainly research amongst our members, and I
must admit that the general age of our members is pretty high.
Q1619 Earl of Arran: I understand
that, but do you know what the answer is amongst the research
done in the country?
Mr Kohnstamm: That is the government or other
organisations which have dealt with these sorts of interviews.
Generally speaking, the support amongst younger and older people
is more or less the same. You see it growing the older the age,
where people are more affected by this discussion.
Q1620 Chairman: The time seems to
have passed very quickly today, and I fear that we are going to
have to stop.
Dr Jonquiere: We have done a survey or poll
in The Netherlands, asking this question and we have it translated
into English. We could photocopy these results and leave it for
you to read. There is also an indication as to the difference
between the age groups.
Mr Kohnstamm: I am told that you have an interview
quite soon after this one. We have therefore ordered a Dutch lunch,
and we will leave you with your discussion—perhaps preparing
for whatever comes next.
Chairman: That is very kind. We are very
happy to have you stay with us, but you may have something else
to do. Thank you very much.
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