This page also includes Dr Hendin's letter to MJA & response

 

bulletEuthanasia consultants or facilitators?

Few euthanasia consultants in the Netherlands act as independent evaluators of the patient's situation As the Netherlands alone has long practised legally sanctioned assisted suicide and euthanasia, its experience is of great interest to the rest of the world. Of particular significance have been the Dutch government-sponsored studies conducted by van der Maas and his colleagues in 19901 and 1995.2,3 Those studies relied on data collected from a stratified sample of physicians selected because their practices were likely to involve them in end-of-life decisions.

In each of the studies, more than 6000 physicians were surveyed and over 400 were interviewed. Informative data were collected. However, the investigators' analysis of their data has been criticised for emphasising procedural problems in the Dutch system while ignoring more basic substantive flaws, such as whether patients were offered treatment alternatives that might have made euthanasia seem unnecessary.4-6 The same might be said of the article in this issue of the Journal by Onwuteaka-Philipsen et al7, which draws on the individual interviews with physicians conducted in 1995 to discuss the use of consultants, a requirement in the Netherlands in intended cases of assisted suicide and euthanasia.

The purpose of consultation is to confirm that the attending physician has followed established guidelines regarding the voluntary, well-considered nature of the patient's decision, the presence of suffering that must be unbearable and hopeless, and the absence of any alternative treatment.

In a substantial number of cases, however, a consultation is not obtained. Most of these cases involve violation of another Dutch guideline: although all cases of assisted suicide and euthanasia must be reported to the authorities, most (59%) are not.2 Only a minority of unreported cases involve consultants.3 In the most flagrant violation of Dutch guidelines, consultants are not called: between 900 and 1000 patients' lives are ended without their explicit consent each year.1,2 In the 1995 study, 21% of these patients were competent; in the 1990 study, 37% were competent. A consultant was virtually never called when the lives of competent patients were ended without their explicit consent.1

Onwuteaka-Philipsen et al report that 42% of the interviewed physicians had at some time served as a consultant in an assisted suicide or euthanasia case. More general practitioners than specialists had done so (49% v. 30%). The authors note that, of the physicians who had been a consultant more than once, 50% had previously been consulted by the same physician. In 24% of these cases, the treating physician and the consultant had previously acted as consultants for each other. Recognising that such "pairs" may compromise the independence of the consultants, the authors appropriately suggest appointing independent consultants.

The Dutch cases I have reviewed warrant the need for concern. The consultant basically functioned in a pro forma way, asking questions to confirm that the patient wished to go forward with euthanasia.8 The current article indicates that physicians did not actually see the patients in 12% of consultations. This probably reflects the view frequently expressed to me by Dutch physicians that the consultations were for the purpose of meeting legal requirements.

The authors point out that most Dutch physicians do not have much experience in consulting in assisted suicide and euthanasia cases. Only 27% of Dutch physicians who have served as consultants have done so more than three times, and only 3% more than 10 times. The authors state that "consultants need to have knowledge relevant to euthanasia and assisted suicide, such as the possibilities of palliative care. Gaining experience as a consultant seems to be important for a physician to become comfortable in this role."

No one should assume that experience as a consultant in euthanasia cases would make physicians knowledgeable about palliative care. My own experience with a few physicians in the Netherlands who had performed or been consultants in dozens of euthanasia cases was that they were surprisingly uninvolved in palliative care. Nor did they show sensitivity to the ambivalence that accompanies most requests to die, clearly evident in some of the cases we discussed.8 They seemed to be facilitators of the process rather than independent evaluators of the patient's situation who might be able to relieve suffering so that euthanasia seemed less necessary to the patient. One physician described his role as easing the doubts of physicians who were uncertain whether to go forward with euthanasia. He and the other consultants were certainly knowledgeable in what the authors refer to as the "medicotechnical" aspects of euthanasia -- they could end life quickly and efficiently.

The Dutch have been widely criticised for their failure to provide adequate palliative care or hospice care for terminally ill patients.9,10 In recent testimony before the British House of Lords, Zbigniew Zylicz, one of the few palliative care experts in the Netherlands, emphasised Dutch deficiencies in palliative care, attributing them partly to the easier alternative of euthanasia. He saw the lack of hospice care in the Netherlands and the fact that there are only 70 palliative care beds in the country as reflections of this easier option.11

The conclusion in the Dutch studies that physicians in the Netherlands essentially practise euthanasia when there is no other alternative has been challenged.6,9,12,13 As neither the attending doctors, nor the consultants, nor the physician-interviewers in the government-sponsored studies were trained in palliative care, they were not in a position to make such a determination. Dr Zylicz, who has devoted his professional life to relieving the suffering of terminally ill patients and to training individual physicians in palliative care, finds his task complicated by the attitude of a medical establishment that insists on regarding euthanasia as a form of palliative care.14,15 This attitude encourages physicians to find euthanasia, which is far less demanding and challenging than what is ordinarily regarded as palliative care, a suitable alternative.

Although the Dutch courts have ruled that unrelievable suffering must be present for a physician to be justified in carrying out euthanasia, it is increasingly accepted in the Netherlands and elsewhere that suffering can be considered unrelievable if patients simply exercise their right to refuse treatment for it. A prominent Dutch investigator sees a shift away from unrelievable suffering towards patient choice as the natural progression of a liberal society's increasing emphasis on autonomy.16

The problem with this position is that it ignores what actually happens when a suffering patient is confronted with a physician who does not know how to relieve that suffering except by euthanasia. If the only alternatives are continued suffering and an early death, patients are not likely to feel they have a choice.

Study in the United States has shown that the more physicians know about palliative care, the less they favour legalisation of assisted suicide and euthanasia; the less they know, the more they favour it.17 Caring for people at the end of life is challenging, not only taking considerable skill but also requiring a great deal emotionally of physicians. Medical schools and residency training programs have only begun to prepare physicians to meet this challenge. If they succeed, the question of "euthanasia consultants" may become irrelevant.

Herbert Hendin
Professor of Psychiatry, New York Medical College, and
Medical Director, American Foundation for Suicide Prevention, New York, USA

  1. van der Maas PJ, Van Delden JJM, Pijnenborg L. Euthanasia and other medical decisions concerning the end of life. New York: Elsevier Science Inc, 1992.
  2. van der Maas PJ, van der Wal G, Haverkate I, et al. Euthanasia, physician-assisted suicide, and other medical practices involving the end of life in the Netherlands, 1990-1995. N Engl J Med 1996; 335: 1699-1705.
  3. van der Wal G, van der Maas PJ, Bosma JM, et al. Evaluation of the notification procedure for physician-assisted death in the Netherlands. N Engl J Med 1996; 335: 1706-1711.
  4. Hendin H. Seduced by death: doctors, patients, and the Dutch cure. Issues Law Med 1994; 20: 123-168.
  5. Keown J. Euthanasia in the Netherlands. In: Keown J, editor. Euthanasia examined: ethical, clinical, and legal perspectives. Cambridge: Cambridge University Press, 1995.
  6. Hendin H, Rutenfrans C, Zylicz Z. Physician-assisted suicide and euthanasia in the Netherlands: lessons from the Dutch. JAMA 1997; 277: 1720-1722.
  7. Onwuteaka-Philipsen BD, van der Wal G, Kostense PJ, van der Maas PJ. Consultants in cases of intended euthanasia or assisted suicide in the Netherlands. Med J Aust 1999; 170: 360-363.
  8. Hendin H. Seduced by death: doctors, patients and assisted suicide. New York: W W Norton & Company, 1998.
  9. Zylicz Z. Euthanasia [letter]. Lancet 1991; 338: 1150.
  10. Dorrepaal KL, Aaronson NK, Van Dam F. Pain experience and pain management among hospitalized cancer patients. Cancer 1989; 63: 593-598.
  11. Matthews H. Better palliative care could cut euthanasia [news]. BMJ 1998; 317: 1613.
  12. Gomez C. Regulating death: euthanasia and the case of the Netherlands. New York: Free Press, 1991.
  13. Jochemsen H, Keown J. Voluntary euthanasia: under control? Further empirical evidence from the Netherlands. J Med Ethics 1999; 25: 16-21.
  14. Admiraal PV. A physician's responsibility to help a patient die. In: Misbin RI, editor. Euthanasia: the good of the patient, the good of society. Frederick, Md: University Publishing Group, 1992.
  15. Borst-Eilers E. Euthanasia in the Netherlands: brief historical review and present situation. In: Misbin RI, editor. Euthanasia: the good of the patient, the good of society. Frederick, Md: University Publishing Group, 1992.
  16. Van Delden JJM. Slippery slopes in flat countries -- a response. J Med Ethics 1999; 25: 22-24.
  17. Portenoy RK, Coyle N, Kash KM, et al. Determinants of the willingness to endorse assisted suicide: a survey of physicians, nurses and social workers. Psychosomatics 1997; 38: 277-287.
bulletSource http://www.mja.com.au/public/issues/apr19/hendin/hendin.html
bulletUsed with permission: First published on the Internet by The Medical Journal of Australia  1999 Medical Journal of Australia.

bullet 

To the Editor

On the basis of their survey of physicians in Oregon who received requests for assistance with suicide, Ganzini et al. conclude that despite "substantive palliative interventions," some patients do not change their minds about assisted suicide. The authors' data do not warrant such a conclusion. 

It is not encouraging to learn that in more than half of the 142 cases in Oregon for which physicians provided information about interventions, including 18 of the 29 cases in which patients were given prescriptions for lethal medication and 9 of the 17 cases in which the patients died from taking the prescribed medication, there was not even one palliative intervention. In less than half the cases (68), at least one of the following measures was recommended: control of pain or other symptoms, referral to a hospice program, consultation (with a chaplain, social worker, palliative-care or mental health professional, or colleague), or a trial of antidepressant medication. 

Oregon law does not require that physicians who provide assistance with suicide be knowledgeable about palliative care or even that they consult with someone who is. (1,2,3) In only 13 percent of the 142 cases was a palliative-care consultation recommended. The most frequently recommended consultation was with a colleague (reported for 28 percent of the 142 cases) -- a referral that is required under the Oregon law to determine a patient's eligibility for assistance with suicide but that is not necessarily a substantive palliative intervention. 

Without an assessment of the pain-control measures used by the physicians, one cannot know whether the care provided was adequate. Nor can one view a referral to a hospice program as a substantive palliative intervention without knowing what care the hospice program provided. 

The study by Ganzini et al. does not inspire confidence in Oregon's approach to the treatment of depression in elderly persons who are ill -- a group at high risk for suicide. Physicians both underdiagnose and undertreat depression in this population. (4) Although two thirds of patients requesting assistance with suicide have been shown to be depressed, (5) only 20 percent of such patients in Oregon were reported by physicians to have symptoms of depression. 

In almost half the cases in which any interventions were made, the patients changed their minds about
requesting assistance with suicide. How many more would have changed their minds had they received
adequate assessment and treatment? 

Herbert Hendin, M.D. 
New York Medical College 
New York, NY 10028

References 

1. Oregon Death with Dignity Act, Rev. Stat. 127.800-97. Return to Text 

2. Hendin H, Foley K, White M. Physician-assisted suicide: reflections on Oregon's first case. Issues Law Med 1998;14:243:70. Return to Text 

3. Foley K, Hendin H. The Oregon report: don't ask, don't tell. Hastings Cent Rep 1999;29:37-42.
Return to Text 

4. Oquendo MA, Malone KM, Ellis SP, Sackeim HA, Mann JJ. Inadequacy of antidepressant treatment for patients with major depression who are at risk for suicidal behavior. Am J Psychiatry 1999;156:190-4. Return to Text 

5. Chochinov HM, Wilson KG, Enns M, et al. Desire for death in the terminally ill. Am J Psychiatry
1995;152:1185-91.

Source http://www.nejm.org/content/2000/0343/0002/0150.asp#tref-2-5

bulletTo the Editor:

The article by Meier et al. (April 23 issue) (1) on physician-assisted suicide and euthanasia in the United States contains somewhat misleading information about the Oregon law on assisted suicide. The authors say that the majority of patients to whom physicians gave prescriptions to assist them in suicide would have met the criteria of the Oregon law's regulatory safeguards for this practice. They list such criteria as the patient's age and prognosis, the presence of a repeated request, the physician's belief that the request reflected the patient's wishes, consultation with another physician, and the presence of a group of clinical symptoms such as severe discomfort, pain, dependence on others, and being bedridden.

The Oregon law, unlike Dutch law, does not regard suffering as a requirement for assisted suicide and refers to no clinical symptoms. That the patient must be over 18 years of age and have a terminal illness with a prognosis of less than six months' survival are statutory requirements of the law, not safeguards. A repeated request is such a safeguard, but only half the patients receiving prescriptions in the survey by Meier et al. met that requirement. Obtaining a second opinion is another safeguard, but fewer than 1 percent of physicians who assisted in suicide obtained such an opinion.

Euthanasia is prohibited by the Oregon law, so none of the 4.7 percent of physicians who gave lethal injections were in compliance with the law. In all cases of assisted suicide or euthanasia, physicians said that they "believed that the request reflected the patient's wishes." This safeguard presumably refers to the stipulation in the Oregon law that the patient's decision be voluntary and uncoerced. The survey did not determine, however, what efforts the physician made to find out whether this was so. Simple belief is not enough.

Belying such belief, and perhaps most disturbing in the survey, is the fact that, in 79 percent of cases, physicians who gave lethal injections to patients had received no direct request from the patients to do so. Meier has written elsewhere that the likelihood that such practices would increase with legalization (2) and the fact that these practices cannot be regulated have led her to cease to favor legalization of assisted suicide or euthanasia. (3)

Herbert Hendin, M.D.
American Foundation for Suicide Prevention
New York, NY 10005

References

1. Meier DE, Emmons C-A, Wallenstein S, Quill T, Morrison RS, Cassel CK. A national survey of physician-assisted suicide and euthanasia in the United States. N Engl J Med 1998;338:1193-201.
Return to Text

2. Hendin H. Seduced by death: doctors, patients, and assisted suicide. New York: W.W. Norton, 1998. Return to Text

3. Meier D. A change of heart on assisted suicide. New York Times. April 24, 1998.
Return to Text

bulletTo the Editor:

According to the survey by Meier et al., 97 percent of those who received prescriptions for a lethal dose of medication were men. This rate contrasts with that of the group who received a lethal injection, of which only 57 percent were men. For lethal injection, the request was more likely to be somewhat indirect or made by a family member, and the doctor-patient relationship was, in some cases, of very short duration. Although statistical probabilities are not reported, the differences based on sex are likely to be statistically significant and, at least for feminists, clinically significant; they should give us pause as we debate legalizing assisted suicide. How do the authors interpret these findings?

Susan Dorr Goold, M.D.
University of Michigan
Ann Arbor, MI 48109-0376

bulletThe authors reply:

To the Editor:

Contrary to Hendin's assertion, nowhere in our article did we claim that Oregon's Death with Dignity Act (1) requires evidence of suffering by a patient as a safeguard. We did list (as a footnote to Table 4) that the law requires that a patient be an adult with a terminal illness and a life expectancy of less than six months, that the request be made by the patient, and that the request be voluntary. Our data suggest that the majority of patients who received a prescription for a lethal dose of medication met these requirements. Our national survey was conducted before the passage of the Oregon legislation; at that time, physician-assisted suicide was illegal in all 50 states. The fact that procedural safeguards (such as getting a second opinion) were not followed is not surprising. Since lethal injections are not permitted under the Oregon law, it is not appropriate to assess the conformity of the use of lethal injection with the legislation.

We do not know the reasons for the disparity between men and women in the proportions of patients receiving prescriptions for a lethal dose of medication (a weighted 97 percent were men). The survey contained data on only 36 patients who received such a prescription for whom sex was reported. The raw (unweighted) numbers show that two thirds (24 patients) were men. The weighted proportions are considerably more lopsided because the seven prescriptions written by general internists or family practitioners (groups of physicians whose responses were weighted more heavily to reflect their preponderance in the population of U.S. physicians) were all written for men. Given the low prevalence of such prescriptions in our study, it is uncertain whether the sex differences found were in fact true differences or whether they were an artifact of the statistical weighting necessary to analyze the survey. The raw data suggest that both assistance with suicide from a physician and euthanasia are more commonly requested and received by men, with men making up 60 to 66 percent of the patients described. Most, (2,3,4) but not all, (5) previous surveys have found a similar sex distribution. Possible explanations for this disparity are that women are less inclined to seek to hasten their own deaths, that they are uncomfortable asking their physicians (most of whom are men) for help, or some other factor or combination of factors.

Diane E. Meier, M.D.
R. Sean Morrison, M.D.
Sylvan Wallenstein, Ph.D.
Mount Sinai School of Medicine
New York, NY 10029

References

1. Oregon Death with Dignity Act, Or. Laws ch. 3 (initiative measure no. 16), 1995. Return to Text

2. Back AL, Wallace JI, Starks HE, Pearlman RA. Physician-assisted suicide and euthanasia in Washington state: patient requests and physician responses. JAMA 1996;275:919-25. Return to Text

3. Pijnenborg L, van der Maas PJ, van Delden JJM, Looman CWN. Life-terminating acts without explicit request of patient. Lancet 1993;341:1196-9.
Return to Text

4. van der Wal G, van der Maas PJ, Bosma JM, et al. Evaluation of the notification procedure for physician-assisted death in the Netherlands. N Engl J Med 1996;335:1706-11. Return to Text

5. van der Maas PJ, van der Wal G, Haverkate I, et al. Euthanasia, physician-assisted suicide, and other medical practices involving the end of life in the Netherlands, 1990-1995. N Engl J Med 1996;335:1699-705. Return to Text

OTHER NEJM ARTICLES ON OREGON AND EUTHANASIA

http://www.nejm.org/content/2000/0342/0008/0598.asp

http://www.nejm.org/content/2000/0342/0008/0583.asp

 

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