Memorandum by Associate Professor B D
Onwuteaka-Philipsen and Professor G van der Wal
1. INTRODUCTION
The decade of experiences with the safeguarding
of EAS in the Netherlands, makes it possible to examine the feasibility
of public oversight and legal control over EAS. In this submission
we want to present results of our studies on euthanasia and other
end-of-life decisions and the euthanasia review procedure in the
Netherlands. This submission is built up in the following way:
— a description of the authors
and their work;
— short description of the Dutch
Euthanasia Review procedure;
— a summary of key results of
our studies that are relevant to the Assisted Dying for the Terminally
Ill Bill;
— a summary of key conclusions
of our study that are relevant to the Assisted Dying for the Terminally
Ill Bill; and
— an appendix with that relevant
papers that were published in the Lancet in 2003.
2. THE AUTHORS
G. van der Wal is professor of Social Medicine
and head of the department of Occupational and Public Health of
the VU University Medical Center in Amsterdam. BD Onwuteaka-Philipsen
is associate professor at this department. Both have been doing
research on the topic of end-of-life care for over a decade. They
have been, together with professor PJ van der Maas en Dr A van
der Heide of the Erasmus Medical Center in Rotterdam, responsible
for the two nationwide studies on the incidence and characteristics
of euthanasia and end-of-life decisions and the evaluation of
the euthanasia review procedure, that were conducted in 1995 and
2001 (Professor van der Maas was supervisor of the Remmelink study
in 1990). They also have been, again with their to colleagues
from Rotterdam, the coordinator of an international study (in
six European countries and Australia) on end-of-life decisions
(the EURELD study). Besides research on euthanasia and other end-of-life
decisions, professor van der Wal is also conducting research on
palliative care. One of the few Dutch centres for development
and research of palliative care is located at his department,
under his supervision.
3. THE (CHANGES
IN) THE
DUTCH NOTIFICATION
PROCEDURE
In the notification procedure (and in our research),
euthanasia is defined as the administration of drugs with the
explicit intention of ending the patient's life on his or her
explicit request. Physician-assisted suicide is defined as the
prescription or supply of drugs with the explicit intention to
enable the patient to end his or her own life. The notification
procedure changed several times, but in all notification procedures
the central question for review was and is whether the requirements
for prudent practice have been met. In the first notification
procedure, which started in 1991 and was legally enacted in 1994,
the physicians had to report cases to the public prosecutor (through
the medical examiner). The initial review was carried out by the
public prosecutor, and the final review by the Assembly of Prosecutors
General and the Minister of Justice. In this procedure euthanasia
and physician-assisted suicide were punishable, but physicians
could expect not to be prosecuted if the requirements for prudent
practice were met. In November of 1998 the procedure was changed.
Physicians had to report to one of five Regional Review Committees
(RRCs) (through the medical examiner). These RRCs, consisting
of a lawyer, an ethicist and a physician, reviewed reported cases
and advised the Assembly of Prosecutors General. The latter still
made the ultimate decision on whether or not to prosecute and
the legal status of euthanasia and physician-assisted suicide
was similar to the previous procedure. Since the beginning of
April 2002, a new law on euthanasia was enacted. All cases are
still reviewed by the RRCs, but only those cases in which they
consider that the requirements for prudent practice are not met,
are subsequently reviewed by the Assembly of Prosecutors General.
In this procedure euthanasia and physician-assisted suicide are
legal provided that the requirements for prudent practice are
met.
4. KEY RESULTS
(a) Results concerning incidence and characteristics
of euthanasia and other end-of-life decisions.
In the EURELD study it was found that in 2001
physician-assisted death (administration of drugs with the explicit
intention of hastening death) occurred in all countries studied:
in about 1 per cent or less of all deaths in Denmark, Italy, Sweden
and Switzerland, in 1.82 per cent of all deaths in Belgium, and
3.40 per cent of all deaths in the Netherlands. In the Netherlands
this is most frequently on the explicit request of the patient
(ie euthanasia or physician-assisted suicide).
In the Netherlands, death-certificate studies
showed the rate of euthanasia increased from 1.7 per cent of all
deaths in 1990 to 2.4 per cent in 1995 and 2.6 per cent in 2001,
while the rate of physician-assisted suicide remained stable (0,2
per cent in all three years).
The frequency of ending of life without the patient's
explicit request remained virtually unchanged during all years
(respectively 0.8 per cent, 0.7 per cent and 0.7 per cent of all
deaths)
In 1990, 1995 and 2001, in the Netherlands, almost
10.000 explicit requests for euthanasia were done to physicians.
In all years about one third of these requests resulted in euthanasia
or physician-assisted suicide. While in 2001 3 per cent of all
requests was based on a psychiatric disorder and 4 per cent was
based on being tired of life, virtually all requests that resulted
in euthanasia or physician-assisted suicide were based on a physical
illness.
(b) Results concerning the evaluation of
the Euthanasia review procedures.
In 1996 the notification procedure that (unofficially)
started in 1991 was evaluated. The notification rate increased
from 18 per cent in 1990 to 41 per cent in 1995, and the substantive
requirements for prudent practice were generally met in reported
as well as non-reported cases. Most physicians seemed willing
to have their cases reviewed, and even more so if the procedure
would be amended in such a way that they would not feel criminalized
and there would be less uncertainty about prosecution. These results
contributed to the development of the new notification procedure
that was enacted in 1998.
The notification procedure that was enacted in
1998, was evaluated in 2001. The notification had increased to
54 per cent. Especially general practitioners contributed to this.
There is an association between the introduction of professionalised
consultation and notification. In general, reporting physicians
have no negative experiences with the euthanasia review procedure.
The experience of reporting physicians were more positive than
with the previous notification procedure. Of all Dutch physicians
most were of the opinion that the new notification procedure is
better than the previous notification procedure in achieving it's
goals. While in 1990, 25 per cent of Dutch physicians said that
they had become more permissive concerning euthanasia and physician-assisted
suicide, this percentage decreased to 18 per cent in 1995 and
12 per cent in 2001. The large majority of the general public
(91 per cent) consider it important that control takes place over
the practice of euthanasia and physician-assisted suicide.
5. KEY CONCLUSIONS
Euthanasia and physician-assisted suicide occur
everywhere, albeit in different frequencies. Therefore in every
country it seems opportune to consider whether or not to create
ways of reviewing these practices. Two important issues in this
consideration are whether creating a review procedure would lead
to entering a slippery slope and whether it is actually practically
possible to gain public oversight and legal control through a
review procedure.
After 1995, the rate of euthanasia and explicit
requests by patients for physicians' assistance in dying in the
Netherlands seems to have stabilized, the rate of physician-assisted
death without the patient's explicit request has not increased
since 1990 and physicians do not seem to have become more permissive
towards euthanasia. Therefore, it seems that the start of and
developments in the review procedure did not result in a slippery
slope in the practice of euthanasia.
The results from the evaluation of the two review
procedures indicate that it is possible, at least to some extent,
to reach public oversight and legal control. The changes in the
procedures have turned out to lead to higher notification. However,
still half of all physicians do not report their cases of euthanasia
or physician-assisted suicide yet. Therefore the perfect procedure
has not been found yet. In light of the fact that the majority
of the general public consider it important that public oversight
takes place and the majority of physicians have positive attitudes
towards review, at least for the Netherlands the aim should be
to have a review procedure and keep working on it's further improvement.
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