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by Karel F. Gunning
If today we accept the intentional killing of a patient as a solution for one problem, then tomorrow we will find a hundred problems for which killing must be accepted as a solution. During World War II, euthanasia was considered to be a solution for over 100,000 German patients who were killed as unwanted by doctors under Nazi Germany.

In the Netherlands, a government-installed committee headed by the former Attorney General, Mr. Remmelink, investigated the extent of euthanasia practiced in 1990 (1). The conclusion of the excellent Remmelink Report (see summary in Table) was that, on a total annual mortality of nearly 130,000, a lethal drug was given in  only  2,300 cases (1.8% of all deaths). As the Dutch government defines euthanasia as "ending a patient's life at his own explicit request"   there remain many other cases of killing the patient which we would call euthanasia, and which are not called euthanasia, but which are called "  normal medical practice"   by the Dutch government. There are 400 cases of assisted suicide and 1000 cases where a lethal drug was given without request. Then there were over 11,000 cases where life saving treatment was omitted with the explicit intention of shortening a patient's life, while only 4,000 cases at the latter's request. And in nearly 5,000 cases pain treatment was intensified with the implicit intention of shortening life. Together in almost 20,000 cases (15.4% of all deaths) the patient died after a doctor' s decision to hasten death, in almost 11,000 cases at the patient' s own request.

A change in the law since 1994 makes it possible today for a doctor to end a patient's life without being prosecuted, provided he follows some guidelines: he must consult a colleague (not necessarily a specialist in palliative care); he must write a report answering some 50 questions, and so on. This report is given to the public prosecutor who decides whether to prosecute or not. But this decision is made on the basis of the report. Its author is the doctor himself. According to Dutch law, one cannot be expected to accuse oneself. The chief witness -- the patient -- is dead at this point. In most cases, the doctor can report as he likes. This means that our patients are no longer protected.

In 1996, a report similar to the Remmelink Report was produced over the year 1995
(2). Comparing the two reports (see table), we find that the number of cases where the patient died after a doctor's decision to hasten death, had increased from almost 20,000 (over 15% of total deaths) to almost 27,000 (nearly 20% of total deaths) of which over 13,000 were done at the patient's request. Of the cases which should have been reported according to the guidelines of the new law, only 41% were actually reported. In fact, the new law protects the doctor, not the patient.

What About The 'slippery Slope

The first case of euthanasia in Holland where a doctor killed her mother allegedly at the latter's request, was in 1975. This doctor was sentenced to a two weeks prison term on probation. Twenty years later we got down to 27,000 cases of intentional killing per year. It shows that not only had the numbers increased, but that the mentality toward euthanasia is going down the slippery slope. Of course, if treatment is refrained from or if a high dose of medication is given without the intention to kill but for the patient's benefit, this is regarded as very good medical practice.

The situation in which euthanasia can be practiced with impunity is also increasing. First, only in cases of unbearable and uncontrollable suffering near the end of life, can euthanasia at the patient's request exempt a doctor from prosecution. Today, the handicapped, new borns, comatose patients, and even completely healthy but depressed people have been euthanized without punishment by the courts. Some Dutch doctors, hearing about the British successes with palliative care, answered that they did not need to study it, as they could apply euthanasia instead.

What this change in mentality means in practice, is shown by a few examples. An internist, called to see a lady with lung cancer who breathed with great distress, told her that he could help her, but that he would prefer to admit her to his hospital. The patient refused, as she feared to be euthanized. But the doctor told her that he would be on duty during the weekend and would admit her himself. She did go on Saturday. On Sunday night, she was breathing normally. On Monday morning the doctor was off duty. In the afternoon, he came back to the hospital but the patient was dead. A colleague had come in that morning and said, "  We need that bed for another case. It makes no difference for her whether she dies today or after a fort night!   So, the patient was euthanized against her explicit will.

I, myself, had a discussion with a colleague about administering morphine. I maintained that large does are needed to kill a patient. At first he denied this, but suddenly said, "You are right. I remember a case of an old man who could die any day. His son came to see me. He was booked for a holiday and did not want to come home for his father's funeral. He wanted the funeral to be over with before he left. So I went to see the old man and gave him a huge dose of morphine. In the evening I came back to declare death, but the patient was happily sitting on the edge of his bed. At last, he had gotten enough morphine to kill his pain."   My colleague told this story as if it were the most normal thing to do: to kill a patient in order to please the family.

Two Ethical Systems

Nowadays, there are two competing ethical systems. The oldest, which I call humanitarian, is the ethics of the Universal Declaration: the Hippocratic Oath formulated in 400 B.C. by Hippocrates who was no Christian. He believed that the doctor was a powerful man who could decide on life or death. As the patient could not know whether a white powder was meant to kill or cure him, he had to simply trust his doctor. That is why Hippocrates made doctors swear that they would never use their knowledge and experience to kill, either before or after birth; not even at the patient's own request. In this humanitarian ethic, the well being of the individual is central.

The other ethic I call utilitarian because it is not for the patient's well being, but the well being of others which prevails. The doctor judges the quality and the sense of a patient's life whether he is a burden or useful to society, etc. This way of thinking was described in a very clear editorial in California Medicine, September of 1970. It said that medical ethics had been based so far on the notion that all men's lives had equal value, but that this could no longer be maintained as over population was threatening us and we were no longer prepared to accept every quality of life. Choices would have to be made on the basis of medical evaluation. Intentional killing was still abhorrent, so one had to begin with abortion and then go on to voluntary euthanasia. But in the end, we would have death control as well as birth control, and we doctors should prepare ourselves for this new task.

Many people think that legalizing euthanasia will make them autonomous. But, in fact, it is the doctor who is made free to do as he thinks right. In the end, it is not the patient, but the doctor who decides when life should be ended. Is this what we really want?  Respect for human life will diminish: violence will increase.

Here is another option. Instead of killing the patient, we can kill the pain. Britain is far ahead of us in dealing with the symptoms of terminal diseases: pain, vomiting, constipation, shortness of breath, itching, fear of the future, loneliness, and so on. Today, we can help these patients effectively.

The big question is, Will the United Nations maintain the humanitarian ethic of the Universal Declaration on Human Rights which recognizes each man's right to life?  Or, Will we accept the utilitarian ethic of death with its elimination of unwanted people?  We cannot at the same time defend people's right to life and allow them to be killed. We need a clear strategy to make sure that our children inherit the kind of world the U.N. has promised to build.

K.F. Gunning, MD - President
World Federation of Doctors Who
Respect Human Life


1       P.J. van der Maas, J.J.M. van Delden & L. Pijnenborg. 1991.Medische beslissingen rond het levenseinde. SDU - Den Haag.

2       G.van der Wal & P.J. van der Maas. 1996. Euthanasie en andere medische beslissingen rond het levenseinde. SDU - Den Haag

Summary of Report 1990 (1) and Report 1995 (2)
Year 1990   1995
Total number of deaths 128,824   135,675
Lethal drugs given (total) 3,736 2.9 %   4,613 3.4 %
Of which assisted suicide 386 0.3 %   407 0.3 %
At the patient's request 2,319 1.8 %   3,207 2.4 %
Without the patient's request 1,031 0.8 %   950 0.7 %
Death intended 3,736 2.9 %   4,613 3.4 %
Intensifying pain-treatment (total) 24,219 18.8 %   26,050 19.2 %
Death not intended 19,324 15.0 %   22,115 16.3 %
Partly intended to hasten death 4,895 3.8 %   3,935 2.9 %
At patient's explicit request 4,122 3.2 %   4,447 3.3 %
Without the patient's request 20,097 15.6 %   21,573 15.9 %
Non-treatment decisions (total) 23,060 17.9 %   27,406 20.2 %
Death not intended 11,852 9.2 %   9,361 6.9 %
Explicit intention to hasten death 11,208 8.7 % 18,045 13,3 %
At patient's explicit request 3,994 3.1 %   5,155 3.8 %
Without patient's explicit request 19,066 14.8 %   22,251 16.4 %
Total decisions around end of life 50,885 39.5 %   58,069 42.8 %
Total decisions intended to hasten death 19,839 15.4 %   26,592 19.6 %
Total decisions at patient's request 10,821 8.4 %   13,296 9.8 %
Total decisions without patient's request 40,064 31.1 %   44,773 33.0 %
Reported cases of life-ending 484 18 %   1,463 41 %

The Continuing Threat of Euthanasia
International Conference 1997
Schreeuw om Leven  Ruitersweg 35-37, 1211 KT  Hilversum, The Netherlands
phone +31 35 624-4352, fax +31 35 624-9141, e-mail info@schreeuwomleven.nl, internet www.schreeuwomleven.nl


by Karel F. Gunning M.D.

Before I speak about doctors who perform euthanasia, I want to make clear that in my opinion almost all of them do it out of compassion, being convinced that it is the best way to help a patient. I disagree, as I think that adequate palliative care is a far better way to help. But whatever our own position, we have to admit that euthanasia in the Netherlands is completely out of control. If you define euthanasia, as the Dutch Physicians" League does, as "Consciously causing a patient's death,"  then it occurred in some 20,000 cases in the Netherlands in one year. Of a total annual mortality of 129,000, this amounts to over 15 percent of all deaths.

Yet the government-installed Remmelink Committee, which issued a report on the practice of euthanasia in the Netherlands in the year 1991, speaks of 2,300 cases of euthanasia, that is 1.8 percent of all deaths! They used another definition of euthanasia, to wit "life-ending treatment at the patient's explicit request." 

Using our own definition we have to include, besides the 2,300 cases called euthanasia by the Committee, the 400 cases of assisted suicide and the 1,000 cases of ending a patient's life without his request, also mentioned in the report. That makes together nearly 4,000 cases. But the report speaks also of cases where high doses of medicine for pain and symptom control were given or where treatment was omitted with the implied or explicit intention to hasten the patient's death. And these cases are called "  normal medical practice"  . That is most frightening. Refraining from treatment which burdens the patient and cannot prevent his death is, of course, very good medical practice. But if it is done with the intention to end life, then it is not medical practice at all, but consciously causing a patient's death, which we call euthanasia. On the basis of the numbers given in the Remmelink report the Dutch Physicians"   League had estimated the number of these cases at 16,000. Together, the League estimated the number of cases where the doctor had the intention (implied or explicit) to end the patient's life at nearly 20,000 per year, that is over 15 percent of all deaths. These are huge numbers.

Now these conclusions and estimates of the Physicians"   League have been hotly contested. But in a recent letter to the editor of Medisch Contact (MC, April 29,1994), the official organ of the Royal Dutch Medical Association, the investigators of the Remmelink Committee themselves say that abstaining from treatment was done with the explicit intention to hasten the end of life in 11,000 cases. And high doses for pain and symptom control were given with the implied or explicit intention to hasten the end of a patient's life in 6,500 cases. So, according to their estimates there must have been over 21,000 cases where the doctor had the intention (implied or explicit) to end the patient's life, which is over 16.4 percent of all deaths, even more than the estimates of the Physicians"   League.
I mention these facts as a warning, because they show that we have no reason at all to tell the world to follow our example. They show how rapidly the Netherlands has slipped down the slippery slope. They show that, once you accept killing as a solution for one problem, you soon find a hundred problems for which killing can be regarded as a solution. First you kill at the patient's request, then without request, a comatose patient or a handicapped newborn baby, then you help a healthy but depressed person to commit suicide, etc.

Just recently a change in the "  Act on the Disposal of the Dead"   has been accepted by the Dutch Parliament. It requires that in the event of the termination of life on request or without explicit request on the part of the patient, or assisting a patient to take his or her own life, the consulting physician must notify the municipal coroner and provide him with a reasone and full written report on the basis of a questionnaire of some 50 points to be dealt with. This report is given to the Public Prosecutor, who must decide either to prosecute or to dismiss the case. But the author of the report is the euthanazing doctor himself, and as the patient is dead and the doctor cannot be expected to co-operate in his own condemnation, we can safely predict that no doctor will be prosecuted. Moreover, if one doctor would be punished, the medical profession would boycott the notification procedure. Already now the number of notifications is far too slow, some 1,400 last year, whereas, according to the Remmelink Committee the annual number should be some 4,000. This means that not yet half of the cases are reported.

But what is really terrifying is that the Dutch government considers the administration of an overdose of drugs or the omission of life-supporting treatment both with the explicit or implied intention to end the patient's life as "  normal medical treatment,"  which therefore does not have to be reported to the coroner. The annual number of these cases was estimated at 16,000, that is some 80 percent of all cases of consciously causing a patient's death. The new Act makes the patient defenseless in the hands of a powerful doctor. At the same time it is disquieting that in most cases "unbearable suffering"   is put forward as the reason for ending a patient's life. Does it mean that great numbers of Dutch doctors do not know how to treat suffering?   Another government-sponsored committee, investigating the treatment of pain in the Netherlands in the late eighties, reported that in over half of the cases of cancer with pain, the treatment had been insufficient, so that these patients were suffering unnecessarily.

So that is where the Dutch Physicians League feels the greatest need. Many countries in the world have followed the British example of training doctors and nurses as specialists in Palliative Care, treating all the physical symptoms of a terminal disease and helping the patient to deal with the mental and spiritual problems he experiences, treating the whole person including his family. Why do we not help our Dutch patients the same way?   Why does the Dutch government hesitate to train sufficient specialists in Palliative Care so that the terminal patient can live comfortably till the day he dies?   The Act requires that the euthanazing doctor consults at least one colleague. Why does the Act not specify that a specialist in Palliative Care must be consulted" 

In September 1970 an editorial in California Medicine, the official publication of the California Medical Association, stated that besides birth control we would also adopt death control, because those with an inferior quality of life would have to be eliminated. In 1970 this sounded absurd. Today we have almost reached that point in the Netherlands. It is the consequence of a kind of thinking which I like to call utilitarian ethics, as it may take in consideration a patient's quality of life, weighing a patient's costs against his usefulness to society, judging the sense of his or her life, etc. It is the opposite of the old Hippocratic ethics, which I like to call humanitarian ethics, where the patient is the centre of all medical care.

We will soon have to choose between humanitarian or utilitarian ethics, as they are incompatible. Do we want our children to inherit a world where doctors decide who may live and who not?  Or do we want a world where there is place for everyone, healthy or disabled, young or old, clever or less clever?  We still can choose. The decision is ours.

So far I have been speaking of the Netherlands. In my opinion the Netherlands are not alone. We are facing a worldwide strategy to get euthanasia accepted. They have used the Netherlands as a pilot country, and the moment euthanasia was accepted, the propaganda started in many other countries, using the Netherlands as an example to be followed: Australia, Germany, England, Canada, U.S.A., even Japan, etc. I was invited to come and tell the reality of the Netherlands in Australia, England and Canada, and fortunately in all three countries proposals to legalize euthanasia were rejected. In Oregon, U.S.A., the bill permitting euthanasia was declared unconstitutional, and in the Northern Territories of Australia the opposition to the Euthanasia Bill may soon defeat it after all.

But we must not be complacent. It will be a continuous battle to restore respect for human life. The most important will be to establish good hospice care throughout the world. And secondly we must show the world that we have  to  choose  between   humanitarian  and utilitarian ethics. HOW to do it is another question we might be able to discuss today. When we could find enough money, we might start a huge information program, which itself might induce people to support us financially, But there must be many ways, if we plan it all together. That is what I hope this conference may bring.

K.F. Gunning  President
World Federation of Doctors Who Respect Human Life;
Nederlands Artsenverbond - Dutch Physicians"   League

Dutch Euthanasia - Worldwide Threat
International Conference 1995
Schreeuw om Leven  Ruitersweg 35-37, 1211 KT  Hilversum, The Netherlands
phone +31 35 624-4352, fax +31 35 624-9141, e-mail schreeuw@solcon.nl, internet www.schreeuwomleven.nl



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