The Netherlands Debates the Legal Limits of Euthanasia : The Controversy

Dr. Pieter Admiraal, an anesthesiologist who practices in a suburb south of this Dutch city, has been performing euthanasia for so long that his preferred technique--a shot of powerful barbiturate followed by a dose of deadly curare--has been adopted by some American states for use in executions.

Even today, 15 years or so after Admiraal first practiced euthanasia while treating intractable terminal cancer pain, the proposition that a patient will ask to be killed, and that Admiraal will agree, remains somewhat breathtaking--even to this doctor.

“It is,” he says of the choice to be killed, “the most important decision you can make in your life. It’s the last decision, yet normally, you will never make it. You always, in your life, make decisions to live on.

“It’s what you did the moment we offered you surgery. All that time you said, ‘Yes, yes, of course. I want to live.’ It’s normal. You want to live on in the circumstances of that moment. But then suddenly, you say to me, ‘Please, I prefer to die.’ In a way, it’s unbelievable.”

Political Hot Potato

What Admiraal is sometimes called upon to do--”euthanatize” a patient--has become one of the most prominent issues in Dutch politics. The Royal Dutch Medical Assn. has endorsed euthanasia on demand--as long as it is performed by physicians--for anyone who competently wants it, including minors without parental consent. Euthanasia is even appropriate, according to a medical association position paper and a bill pending in the Dutch Parliament, in certain psychiatric cases where the depth of the mental affliction portends a terminal outcome.

And possibly within the next few days--certainly by the end of the summer--the administration of Prime Minister Ruud Lubbers is expected to propose legislation to formally legalize euthanasia in the Netherlands, essentially absorbing into statute law, practices that are now permitted by the courts. A liberal minority party, D66, already has a more permissive bill pending.

The proposal--promised months ago by Lubbers but delayed by politics--is certain to rekindle one of this nation’s fiercest and most emotionally wrenching debates. The Netherlands is already the only country where euthanasia is legally sanctioned. Formally codifying euthanasia would make the Netherlands the first country to formally promulgate, in statute law, a policy most other nations perceive as the stuff of books like “1984.”

It is such a touchy political issue that, through a spokesman, Lubbers declined to be interviewed on it.

What will happen to the legislation is uncertain, but the fight is certain to be divisive. Formal debate in Parliament will begin in the fall. Most observers believe the centrist Christian Democratic Party, which shares power in a coalition with the moderate Liberal Party, will continue to bow to the demands of religious leaders who oppose formal legalization and resist any attempt to broaden the latitude of court-sanctioned euthanasia.

The Dutch right-to-life movement is a two-issue organization, opposing abortion and euthanasia. And though the Roman Catholic Church here has a somewhat more liberal view of abortion and euthanasia than the church elsewhere, it remains opposed--even though a spokesman conceded an unknown but probably large number of Dutch Catholic physicians offer euthanasia services.

Forced to Resign

But just as the issue has been readied to resurface in Parliament--the last time euthanasia was intensively scrutinized was more than a year ago--the Dutch euthanasia movement has committed an act of what might be perceived as attempted suicide.

Three weeks ago, more than half of the board of directors of the Dutch Assn. for Voluntary Euthanasia was forced to resign after a battle between radicals demanding complete, immediate legalization of all forms of euthanasia, and a more moderate element that believed it was useless to press for more than the existing de facto system. The radicals won.

While the association has sought, with some success, to minimize Dutch press coverage of the split, Jean Tromp Meesters, a top association official, conceded that the organization had done the wrong thing at the wrong time.

“I don’t think there is any hope we will get a really liberal euthanasia law,” she said. “The people who are in charge (of the association) now say that you have to ask loudly for what you want. That you have to (demand) it. Well, we will see.”

The dissension even among pro-euthanasia forces is a reminder of the ambivalence that lingers just below the surface in the Netherlands.

Opinion polls taken as recently as 1985 indicate that the Dutch overwhelmingly support the practice--67% favor it, including 69% of Roman Catholics. And while the number of euthanasias performed annually in this nation of 14.5 million people is subject to debate--estimates range from a few dozen to about 6,000--a significant number of Dutch people choose to die each year and their physicians agree to kill them.

Age Limit

“It really started in the Netherlands as early as the end of the 1960s when you saw development in our country of the right of self-determination,” said Hank Leenen, a health law professor at the University of Amsterdam and member of the State Committee on Euthanasia, which, in the early 1980s, advocated the elimination of most legal barriers to euthanasia on demand.

“It is one of the most prominent issues in Dutch political life,” said Jan Schinkelshoek, spokesman in Parliament for the Christian Democratic Party. “But if you look at the polls more narrowly, you see on the one hand the tendency to say, ‘People should be allowed to decide on their own lives,’ but on the other hand a stronger opinion saying, ‘We should be very careful.’ ”

But there is widespread doubt that the Netherlands will remain unique much longer.

Derek Humphry, head of the Santa Monica-based Hemlock Society, which advocates the right to suicide and access to assistance in committing suicide, said a proposed California ballot referendum to permit “physician-assisted suicide” may mean the controversy will surface here next.

Other places the issue could emerge, Humphry said, are Australia and Great Britain. But ethics expert Alexander Capron, a professor of law, medicine and public policy at USC, was cautious: “The Dutch are a very tolerant people. They understand the ways things like this can go on in ways Americans never would.”

And even outspoken and internationally known proponents of euthanasia on demand, like Admiraal and Eugene Sutorius, an attorney specializing in euthanasia law, concede there are potentially enormous dangers in establishing euthanasia as a routine practice in Western society.

Range of Development

These profound risks probably will not emerge today or tomorrow, say Admiraal, Sutorius and other experts questioned by The Times, but 30 or 40 years from now. By then, Sutorius predicted, a range of medical developments--from greater use of genetic manipulation to growing demand for donor organs that could be transplanted after a euthanasia death--raise questions potentially more troubling than anything in the euthanasia debate thus far. Spectacular medical achievements will produce a growing number of survivors in comas or with other disabilities.

At that time, the Netherlands and every other Western country will face the steady graying of the world’s population. In the United States, estimates are that by 2025, the number of people 100 or older will increase from 25,000 to 400,000. But medicine will probably not be able to cope with the debilitating effects of aging and more of the aged will require greater amounts of costly medical care.

Inevitably, choices will have to be made.

“Treating everyone in the next 30 or 40 years will not be possible,” Sutorius said, “and then the first questions (will) arise. For the first time in history, already, there is not enough money to give everyone good treatment. I fear that, if there is reason to be afraid (of what could happen), it will start in mental institutions. (Society) will start asking, ‘Why have that burden? Why have all those psychiatric patients and mongoloid patients, for instance, and the elderly?’ ”

“We can estimate that by 2020 or 2030, there will be the highest (proportion) of old people and the smallest amount of young people the world has ever known,” Admiraal said. “We know already about the ratio of Alzheimer’s disease in such an old population. We realize there will be demented patients by the tens of thousands. So I’m a little bit afraid. I really think that (by then), we may accept that for purely economic reasons, they can stop life after a period of three years of complete dementia, for instance. I can imagine that. I don’t know if you can stop it. I don’t believe we can prevent it.”

Two even more troubling, potential problems are making euthanasia available to minors and forcing parents to permit euthanasia on their deformed children. No proposal being debated in the Netherlands would permit the killing of retarded or handicapped youngsters, but the Royal Dutch Medical Assn. and other euthanasia advocates do believe children and teen-agers should have the right to choose euthanasia--even without parental consent. The association specifically has advocated elimination of age limits from any euthanasia legalization bill.

“Sometimes a 15-year-old child can have a mature judgment; sometimes parents can have an immature judgment,” concluded a medical association white paper late last year. Dr. Theo van Berkestijn, the association’s executive director, said the organization had concluded that “the most important thing is that (the physician) keep the trust of the child.”

He said the issue of euthanasia in children is particularly relevant because children often cannot understand the reasons they must endure suffering--in terminal cancer, for instance. “When some doctors (argue) that Hippocrates would say, ‘You have to prolong life,’ ” Van Berkestijn said recalling the author of the Hippocratic Oath, “I say that if Hippocrates had known the possibilities (for life-prolongation in modern medicine), would he instead have said, ‘You have never to prolong suffering?’ ”

To Baroness Adrienne van Till, an attorney who was the founder of the now-defunct Foundation for Voluntary Euthanasia, talk about terminal cancer is one thing, but discussion of euthanasia for people with psychiatric disorders is quite another.

Mental Patients

“If you make a law that somebody can get help to die simply because he is lonely or psychotic,” she said, “then that, of course, is quite uncontrollable.” But the direction of the Dutch debate is clearly toward consideration--eventually--of just such a concept. Admiraal said he believes euthanasia could be appropriate for some incurable neurotics or psychotics--even patients with a history of serious suicide attempts who persuade their physicians that they have a legitimate and strong will to destroy themselves.

Such a development could have catastrophic effects, Van Till and other observers agree. “In the very short run,” she said bluntly, “there would be a hell of a lot of abuse.”

To Admiraal, perhaps the only insurance against future abuse is a strong legalized system today. Changing the law and establishing such a system now, he said, would give it several decades to mature and perhaps withstand any pleas for nightmarish deviation that might come later.

“I believe (the possibility of eventual societal pressure to accept euthanasia) is very real and I am very scared about that,” Tromp Meesters said. “I fear that it is too early for a really liberal euthanasia law and it might be too early always.”

Nevertheless, Tromp Meesters repeated a line of reasoning that runs throughout the Dutch euthanasia debate: It is allowed here now and it has become a part of the social fabric, like it or not.

“I advocate changing the laws,” she said, “because I have experienced how unspeakably horrifying it is for people to be so ill and pleading with the doctor, ‘Let me die in peace!’ and not be heard.”

Even Admiraal concedes such doubts haunt him. But, like many other experts, he sees no way to retreat from what has developed, much less escape the future. He also has little use for suggestions that the Dutch people have forgotten, too quickly, the lessons of Nazi Germany where euthanasia became an accepted means of removing large numbers of undesirables. The Nazi legacy is so strong, Admiraal said, that there was even a conference of Dutch euthanasia doctors to consider dropping the word euthanasia from their medical vocabulary.

“Euthanasia has been mixed up by what Hitler did,” Admiraal said. “In the end, we decided not to (change). It’s a Greek word. It says exactly what it means: good death . We accepted it.”

Though it is widely believed elsewhere that the Netherlands has already legalized euthanasia, the situation is far more complex. Under existing Dutch law, assisting suicide or providing euthanasia is a serious crime. But in 1973, Dutch courts took up the case of a doctor who gave a lethal dose of drugs to an elderly friend in a nursing home, even though the physician was not the patient’s personal doctor.

Judges eventually upheld the physician’s actions. Euthanasia is even institutionalized to the point that reported euthanasias must be investigated and referred eventually to a committee of the five Dutch equivalents of local U.S. federal prosecutors. Harry Avvens, the public prosecutor who heads the committee, said cases of possible improper euthanasia referred to it have increased from about 12 last year to about two dozen so far in 1987.

But prosecutions are infrequent.

Under a legal doctrine called force majeur --meaning, roughly, that a patient’s deteriorating condition gave the physician no choice but to comply with a euthanasia request--a doctor is generally not prosecuted if he or she can prove several conditions: that the patient voluntarily asked to die and repeated the request over weeks or months, that the patient was known to the doctor and continuously under his or her care, that the doctor consulted with a colleague who also questioned the patient, and that both physicians agreed that no pressure was exerted on the patient, by family or friends, to accept death.

Meanwhile, Dutch courts have steadily expanded the circumstances in which a doctor may avoid prosecution if he kills--with case law now permiting euthanasia for patients with such non-terminal afflictions as multiple sclerosis or simply the physical ravages of old age.

Existing legal strictures on euthanasia rule out many cases. A comatose person, for instance, is often unable to make a request to die. And although the Dutch Assn. for Voluntary Euthanasia and individual doctors get frequent requests from abroad to accept foreign patients for death, those requests are virtually never granted.

Though there has been speculation about AIDS patients from the United States flocking to the Netherlands, such a trend has not developed, experts here agreed, and significant numbers of foreign AIDS patients probably never will be accommodated.

Despite these elaborate de facto safeguards, there can always be doubt. “The margin between murder and assisting (a patient to die by euthanasia) is a very small one,” Avvens said.

Recording the Deaths

Most cases are recorded as “natural” deaths, with no reference to performance of euthanasia, doctors agreed. Signing death certificates for “unnatural” death, Admiraal and other doctors said, is a virtual guarantee of an immediate police investigation. It all leaves many Dutch doctors uncertain how to proceed, said the medical association’s Van Berkestijn.

Dutch euthanasia experts and the medical association carefully distinguish between passive euthanasia--deciding not to continue life-sustaining treatment and letting a patient die on his or her own as a result--and active euthanasia, in which the doctor takes direct steps to kill the patient. There is a broad consensus that the Dutch debate focuses on active euthanasia. Passive euthanasia is simply a part of routine care in terminal cases.

Admiraal said he began to realize the necessity for active euthanasia at some point after he began offering pain control treatment to cancer patients nearly 20 years ago. As he became familiar with pain control, Admiraal said, he realized that the real terminal suffering of cancer is driven not so much by pain but by a combination of devastating physical and emotional developments.

“Euthanasia is not done because of pain,” he said. “You can always treat pain. But there is severe dehydration, uncontrolled itching and fatigue. I think that’s one of the most terrible things. These patients are completely exhausted. They have loss of all strength. Some of them can’t turn around in their beds. They become incontinent. All these factors make a kind of suffering from which they only want to escape.

“And of course you are suffering because you have a mind. You are thinking about what is happening to you. You have fears and anxiety and sorrow. In the end, it gives a complete loss of human dignity. You cannot stop that feeling with medical treatment.”