Examination of Witnesses (Questions 1680
- 1699)
FRIDAY 17 DECEMBER 2004
PROFESSOR GERRIT
VAN DER
WAL, DR
BREGJE ONWUTEAKA-PHILIPSEN
and DR AGNES
VAN DER
HEIDE
Q1680 Chairman: To support the request.
So you have not found cases at all in which the advance directive
has been the only basis for the request?
Dr Onwuteaka-Philipsen: No.
Q1681 Lord Carlile of Berriew: By
a competent person. What about non-competent persons?
Dr Onwuteaka-Philipsen: By non-competent persons,
we have not found it at all.
Professor van der Wal: One.
Dr Onwuteaka-Philipsen: One, yes. That is true.
Q1682 Lord Carlile of Berriew: Is
that the sort of case where you think the doctor may be reluctant
to report, because he lacks confidence in the robustness of an
advance directive as a basis for euthanasia?
Professor van der Wal: That might very well
be, but I do not think that cases happen frequently.
Q1683 Lord Joffe: There are two sets
of numbers that we have been talking about. One is the 3,800 cases
of voluntary euthanasia—and I think that we have been addressing
most of our remarks so far to those. There are also the famous,
or infamous, 1,000 cases. Is there any evidence to suggest that
there is any link between the introduction of euthanasia and that
number? Is there any evidence to support that?
Professor van der Wal: We do not know whether
these life-ending cases without request existed before we started
our studies. Probably, yes. We found them the first time—the
famous 1,000 Remmelink cases—but they remain stable over
all those years. Maybe they have decreased a little. So, as far
as we can see, there is no association between the development
in jurisprudence and law and life-ending cases without a request.
Dr van der Heide: Perhaps I may add the European
dimension because, in our European study, one of the most important
findings was that life-ending without a request occurred in all
countries we studied. Whereas euthanasia appeared to be a typically
Dutch phenomenon, life-ending without a request occurred in every
country and also in almost similar frequencies. You could therefore
conclude from that that there must be a reason why life-ending
without a request occurs anywhere. I do not think that it relates
to the Dutch system or the Dutch liberal attitude towards euthanasia.
Q1684 Lord Taverne: We were told
that there were some figures which suggested that in Flanders
life-ending without consent was three times as high as The Netherlands,
or five times as high, and the same is true of Australia. Is this
correct?
Professor van der Wal: Yes.
Q1685 Lord Taverne: And that generally
the studies of comparison showed that this was a much more frequent
occurrence in countries which do not have a euthanasia law than
in those which do?
Dr van der Heide: In our six-country study which
we did in 2001, the percentage in Belgium was the highest. It
was 1½ per cent of all deaths, whereas in The Netherlands
it was 0.7 per cent, and in Italy it was the lowest, at around
0.2 per cent.
Q1686 Lord Carlile of Berriew: Was
it not 0.06?
Dr van der Heide: In The Netherlands?
Q1687 Baroness Finlay of Llandaff:
In Italy.
Dr van der Heide: Yes, 0.06.
Q1688 Chairman: That is per head
of the population, or percentage of deaths?
Dr van der Heide: Percentage of deaths.
Q1689 Lord Joffe: Could I clear up
something about which I am still confused? When we were at the
Department of Health yesterday and asked a question about whether
the doctor would record something about what I understood would
be the cases of involuntary euthanasia, the lady who was presenting
on euthanasia said, "Yes, they would put at the bottom of
the death certificate `euthanasia without consent'". We thought
that maybe she had been confused or that we had confused her,
but I wondered what your reaction would be to that—from
your death certificate studies.
Professor van der Wal: I have not seen those
death certificates, but my guess would be that this is not reported
on the death certificate. No, that must be a misunderstanding.
Q1690 Lord Joffe: It would seem strange,
because they would immediately be prosecuted.
Professor van der Wal: No. One could do that,
because our Statistics Netherlands is free of prosecution.
Q1691 Baroness Thomas of Walliswood:
You would not know who had done it.
Professor van der Wal: No.
Chairman: It would be anonymous.
Q1692 Lord Joffe: But you have not
come across it?
Professor van der Wal: No.
Q1693 Chairman: It is quite clear
now that the basic figure, the 3,800, is derived in two different
ways. One is from the paper study of death certificates with the
questionnaire and, secondly, from the study that proceeded by
way of interview of physicians.
Professor van der Wal: Yes.
Q1694 Earl of Arran: When you are
deciding which are the appropriate questions to put into your
questionnaire, do you consult amongst other departments as to
whether they also have suggestions to make, before you take the
final decision within your own department?
Professor van der Wal: What do you mean by "other
departments"? Other disciplines?
Q1695 Earl of Arran: Yes, other disciplines,
or other departments associated with euthanasia, as to whether
they might have appropriate questions which could throw light
upon the answers to your questionnaire—or do you decide
here yourselves?
Professor van der Wal: No, there are hundreds
of people who have commented on the drafts.
Q1696 Earl of Arran: Putting in suggestions
to you the whole time as to what should be the data of the questionnaire?
Professor van der Wal: Yes, but at a certain
moment we would stick to certain questions and we would not want
to change it any more. Otherwise, we could not make comparisons
between the replicated surveys.
Q1697 Chairman: You have to keep
a reasonable framework that is constant from one study to the
other, if you are going to compare the studies?
Professor van der Wal: Yes.
Q1698 Chairman: For example, the
doctors' association commented on the questionnaire on the lines
you have said—about the shortening of life. Shortening of
life might include what was not strictly speaking euthanasia,
but was the giving of a pain-relieving drug which the doctor knew
would in fact, in addition to relieving pain, be likely to shorten
life. They felt that possibly inflated the number of cases in
which it was found by you that euthanasia had occurred and which
were not reported. They obviously had an interest in considering
that percentage. I suppose that is possible, from the way you
have described it?
Professor van der Wal: Yes, that is right.
Q1699 Lord Joffe: Coming back to
the 1,000 or 900 cases, do you have any research into what were
the reasons? Also, how concerned are you that these cases are
there?
Professor van der Wal: First of all, we are
not labelling those cases as involuntary euthanasia. We say that
they are cases without request. It is not ruled out that some
cases are involuntary but, as far as we can see, that is mostly
not the case. Roughly speaking, in about half of all those cases
there has been some kind of discussion before the patient became
incompetent; because most of the patients are incompetent—that
is to say, no longer capable of making a request. We do not know
whether they would have done it, but they are not capable of it.
Before they became incapable or incompetent, there has been some
kind of discussion about ending life—but not an explicit
request for euthanasia. As I have said, almost all patients—and,
in our last study, 100 per cent of all patients—were incompetent
at the moment of that decision. It is about patients who are mostly
very ill, dying, and seen to be suffering very much, by vomiting
their stools, having very bad bedsores, severe dyspnoea, and suchlike.
As we also know from qualitative studies, doctors feel that they
have their back against the wall; that the family and nurses are
asking him or her to end this suffering and this unbearable state
of life; and then they decide to hasten the end of life. Whether
or not this is very explicit is not that clear. For example, we
found that the drugs used in these kinds of cases are mostly opioids,
as used for intense pain and symptom treatment, and not neuromuscular
relaxants as used in euthanasia. So there are some differences.
Are we disappointed or what do we think about it? We are neutral
researchers, but we do not like these cases—I do not like
these cases. We hoped that they would decrease in number, but
it has not happened.
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