ETHICS * ETHIQUE
About 2000 Dutch patients choose euthanasia annually, forum told Shirley Won T he Netherlands is not an easy place to practise euthanasia despite the widely held North American view that so-called "mercy killings" are commonplace, says a leading advocate for a Dutch right-to-die group. "People seem to think that in the Netherlands you can just walk up to the door of a doctor's office and say here I am . .. and he will help you," said Jeane TrompMeesters, coordinator of the Members Aid Service (MAS) of the Dutch Society for Voluntary Euthanasia. "That is definitely not the case." In Holland, euthanasia is widely defined as the termination of a patient's life by a physician acting at the patient's request under strict conditions. The MAS is a volunteer group that counsels terminally ill patients, at their request, on such matters as discussing euthanasia with a doctor. Speaking to reporters before a recent forum in Toronto, TrompMeesters said reports that 20 000 Dutch are dying annually through euthanasia are grossly exaggerated. She said the latest research indicates that the correct figure is probably closer to 2000 people. To be eligible for euthanasia, Dutch patients must be in the end stage of a terminal illness and be Shirley Won Toronto.
mentally competent. They also must find a doctor willing to help them die. Euthanasia, she noted, is still illegal in the Netherlands under a century-old law that provides a maximum penalty of 12 years' imprisonment. However, a pattern of jurisprudence has developed since a 1973 court case and this has allowed doctors to administer lethal drug doses to patients, but only if strict guidelines are
followed.
The doctor must ask a pharmacist in person for the necessary drugs. That landmark case involved a Dutch physician who was given a suspended sentence for performing euthanasia on her dying mother by giving her a fatal dose of morphine. The decision also set
down certain rules for euthanasia that have since been refined. "If a doctor follows all those rules, he will most likely not be prosecuted," Tromp-Meesters said before speaking to a public forum sponsored by a Canadianbased group, Dying With Dignity. is a freelance writer living in The rules require the patient
NOVEMBER 15, 1991
to ask the doctor for euthanasia in person and more than once. The doctor must keep a diary of the case, must inform the patient about his medical status and prognosis and of any alternative treatment available. Tromp-Meesters said the doctor must be convinced that the patient understands the situation clearly and is asking for euthanasia of his own free will. Once all these conditions are met, the doctor must then consult at least one colleague to make sure an alternative treatment has not been over-
looked. If convinced that all possible medical avenues have been explored, Tromp-Meesters said the doctor should inform the patient's relatives of the patient's decision to receive euthanasia to give them time to get used to the idea, say their farewells and handle any unfinished business. Should a patient become unconscious and a relative asks for euthanasia on his behalf, such a decision would only be possible if the patient had a living will written when he was still mentally capable. This medical directive can ask that medication be administered mercifully to alleviate suffering, even though it may shorten the patient's life. "If there is no living will, there is no question of euthanasia because nobody knows whether that person would have CAN MED ASSOCJ 1991; 145 (10)
1341
I
opted for euthanasia," she said. To perform euthanasia, either at home or in hospital, TrompMeesters said the doctor must ask a pharmacist in person for the necessary drugs. Later, the physician must hand over to local authorities a report of the death by euthanasia and the empty prescription boxes. Tromp-Meesters told the public forum that patients often ask whether their life insurance companies will honour claims if death is caused by euthanasia. She said Dutch firms have been honouring claims as long as the policy was purchased at least 6 months to 2 years beforehand, depending on company practice. Dutch patients "6most likely" have to be in pain or physically ill to be eligible for euthanasia, but Tromp-Meesters favours changes to the eligibility rules. For example, she noted that some elderly people may not be in pain but have various age-related ailments that make life miserable. Because doctors can be held accountable for deeds or misdeeds by a disciplinary board, they are the only ones allowed to help people die. "They are being controlled by their colleagues and we THE 8 tIOLUK NITROGIYCERIN
NITE%QNGs SR
DV TAGE rilE 24 110U1 K AIAN
(o.u)m tl. liet
t. d dw,It,..g.l
Prescribing Information Nitroglycerin sustained rel . nti anginal agent Therapeutic clas g SR re f Indications:
three p ewit Ntro
oattas
feel that control," said TrompMeesters. "It's kind of a safeguard against misbehaving doctors." A physician is also needed because patients can react to drugs in different ways and a doctor would be better able to respond if the drugs did not work, she added. Drug injection is a common method of performing euthanasia. Before administering the drugs, a Dutch physician must ask the patient if euthanasia is indeed what he wants, and when he wants to receive the drugs. Once the patient gives the go-ahead, he will receive a first injection that puts him into a deep sleep; a second injection will stop his breathing. The most popular way of receiving euthanasia, she said, is for the doctor to hand over the lethal drugs to the patient, who will take them himself if he isn't too weak or tired. The doctor should be on call in case something goes wrong, she added. The latter method of dying is, technically, still a suicide, but in the Netherlands it is considered euthanasia because a doctor is involved and all rules for euthanasia were followed. Tromp-Meesters said it is not industry workers continuously exposed to nitrates, chest pain, acute myocardial infarction and even withsudden dary
laches
drawa
or symbent
v
k
ness
a recumbent Dosition. may be due to ;overdosaue.
t
onic aWf#e*ut niae RtablE~c
anO wnittrhS ederei ntrnalpesead I~feni, SR is asontraIrdceli yton -diosno., SR M er Data hesaf sW ly phas myocadanrtin(eprpduincr Nitr kKno
cal adfbrtr~foig r ing whic ett saleYaey h unstable are use of NitrongSincnetvher failure requires carefu clinical aII ii monitoring. Nitrate dependence may occur in patients with chronic use. To avoid possible withdrawal effects, the administration of Nitrong SR should gradually be reduced over 4-6 weeks. In 1342
CAN MED ASSOC J 1991; 145 (10)
;|=9~ y:Su
always easy to find a Dutch doctor who will perform euthanasia. "One-third of the physicians will not apply euthanasia," she estimated. "One-third are willing to do it under the proper circumstances. And one-third are hesitant, afraid, anxious, and will try to postpone it or will try to withdraw and let the patient down at the very end." Tromp-Meesters said legalization of euthanasia has been a hot political topic in the Netherlands but politicians have so far managed to postpone voting when such bills are put before Parliament. In Canada, however, Chris Axworthy, the New Democratic Party member of Parliament for Saskatoon-Clark's Crossing, introduced a private member's bill in June that would regulate and permit euthanasia and protect doctors from criminal sanctions if they help a patient die. Axworthy, who spoke at the Toronto forum, said his bill is meant to bring euthanasia "out of the closet," increase public debate about the issue, and open the government's mind to the possibility of changes to the Criminal Code.reduced or the use of the product discontinued. Less frequently, postural hypotension, an increase in heart rate, faintness, flushing, dizziness, nausea and vomiting have been reported. Symptoms and treatment of overdosage: Symptoms of overdosage related to vasodilation, including cutaneous he, nausea, dizziness and h teno.-Methemio a is also posTreatment sible. t saa ortive. ~~~~~~~~j an t:Rec enTda da efore and fore j 2i $
es ofw and
VAN& imltWpUAM1fWJ 1975, 90(5)6
Vial)
uig mntornvatuon available
eWL1dTrdmr may be treated with concomitant administration of mild analgesics. If headache is unresponsive to such treatment, the dose of Nitrong SR should be
(
RORER PHARMA
RH6NE POULENC-RORER CANADA INC. MONTREAL, QUEBEC
LE 15 NOVEMBRE 1991
About 2000 Dutch patients choose euthanasia annually, forum told Shirley Won T he Netherlands is not an easy place to practise euthanasia despite the widely held North American view that so-called "mercy killings" are commonplace, says a leading advocate for a Dutch right-to-die group. "People seem to think that in the Netherlands you can just walk up to the door of a doctor's office and say here I am . .. and he will help you," said Jeane TrompMeesters, coordinator of the Members Aid Service (MAS) of the Dutch Society for Voluntary Euthanasia. "That is definitely not the case." In Holland, euthanasia is widely defined as the termination of a patient's life by a physician acting at the patient's request under strict conditions. The MAS is a volunteer group that counsels terminally ill patients, at their request, on such matters as discussing euthanasia with a doctor. Speaking to reporters before a recent forum in Toronto, TrompMeesters said reports that 20 000 Dutch are dying annually through euthanasia are grossly exaggerated. She said the latest research indicates that the correct figure is probably closer to 2000 people. To be eligible for euthanasia, Dutch patients must be in the end stage of a terminal illness and be Shirley Won Toronto.
mentally competent. They also must find a doctor willing to help them die. Euthanasia, she noted, is still illegal in the Netherlands under a century-old law that provides a maximum penalty of 12 years' imprisonment. However, a pattern of jurisprudence has developed since a 1973 court case and this has allowed doctors to administer lethal drug doses to patients, but only if strict guidelines are
followed.
The doctor must ask a pharmacist in person for the necessary drugs. That landmark case involved a Dutch physician who was given a suspended sentence for performing euthanasia on her dying mother by giving her a fatal dose of morphine. The decision also set
down certain rules for euthanasia that have since been refined. "If a doctor follows all those rules, he will most likely not be prosecuted," Tromp-Meesters said before speaking to a public forum sponsored by a Canadianbased group, Dying With Dignity. is a freelance writer living in The rules require the patient
NOVEMBER 15, 1991
to ask the doctor for euthanasia in person and more than once. The doctor must keep a diary of the case, must inform the patient about his medical status and prognosis and of any alternative treatment available. Tromp-Meesters said the doctor must be convinced that the patient understands the situation clearly and is asking for euthanasia of his own free will. Once all these conditions are met, the doctor must then consult at least one colleague to make sure an alternative treatment has not been over-
looked. If convinced that all possible medical avenues have been explored, Tromp-Meesters said the doctor should inform the patient's relatives of the patient's decision to receive euthanasia to give them time to get used to the idea, say their farewells and handle any unfinished business. Should a patient become unconscious and a relative asks for euthanasia on his behalf, such a decision would only be possible if the patient had a living will written when he was still mentally capable. This medical directive can ask that medication be administered mercifully to alleviate suffering, even though it may shorten the patient's life. "If there is no living will, there is no question of euthanasia because nobody knows whether that person would have CAN MED ASSOCJ 1991; 145 (10)
1341
I
opted for euthanasia," she said. To perform euthanasia, either at home or in hospital, TrompMeesters said the doctor must ask a pharmacist in person for the necessary drugs. Later, the physician must hand over to local authorities a report of the death by euthanasia and the empty prescription boxes. Tromp-Meesters told the public forum that patients often ask whether their life insurance companies will honour claims if death is caused by euthanasia. She said Dutch firms have been honouring claims as long as the policy was purchased at least 6 months to 2 years beforehand, depending on company practice. Dutch patients "6most likely" have to be in pain or physically ill to be eligible for euthanasia, but Tromp-Meesters favours changes to the eligibility rules. For example, she noted that some elderly people may not be in pain but have various age-related ailments that make life miserable. Because doctors can be held accountable for deeds or misdeeds by a disciplinary board, they are the only ones allowed to help people die. "They are being controlled by their colleagues and we THE 8 tIOLUK NITROGIYCERIN
NITE%QNGs SR
DV TAGE rilE 24 110U1 K AIAN
(o.u)m tl. liet
t. d dw,It,..g.l
Prescribing Information Nitroglycerin sustained rel . nti anginal agent Therapeutic clas g SR re f Indications:
three p ewit Ntro
oattas
feel that control," said TrompMeesters. "It's kind of a safeguard against misbehaving doctors." A physician is also needed because patients can react to drugs in different ways and a doctor would be better able to respond if the drugs did not work, she added. Drug injection is a common method of performing euthanasia. Before administering the drugs, a Dutch physician must ask the patient if euthanasia is indeed what he wants, and when he wants to receive the drugs. Once the patient gives the go-ahead, he will receive a first injection that puts him into a deep sleep; a second injection will stop his breathing. The most popular way of receiving euthanasia, she said, is for the doctor to hand over the lethal drugs to the patient, who will take them himself if he isn't too weak or tired. The doctor should be on call in case something goes wrong, she added. The latter method of dying is, technically, still a suicide, but in the Netherlands it is considered euthanasia because a doctor is involved and all rules for euthanasia were followed. Tromp-Meesters said it is not industry workers continuously exposed to nitrates, chest pain, acute myocardial infarction and even withsudden dary
laches
drawa
or symbent
v
k
ness
a recumbent Dosition. may be due to ;overdosaue.
t
onic aWf#e*ut niae RtablE~c
anO wnittrhS ederei ntrnalpesead I~feni, SR is asontraIrdceli yton -diosno., SR M er Data hesaf sW ly phas myocadanrtin(eprpduincr Nitr kKno
cal adfbrtr~foig r ing whic ett saleYaey h unstable are use of NitrongSincnetvher failure requires carefu clinical aII ii monitoring. Nitrate dependence may occur in patients with chronic use. To avoid possible withdrawal effects, the administration of Nitrong SR should gradually be reduced over 4-6 weeks. In 1342
CAN MED ASSOC J 1991; 145 (10)
;|=9~ y:Su
always easy to find a Dutch doctor who will perform euthanasia. "One-third of the physicians will not apply euthanasia," she estimated. "One-third are willing to do it under the proper circumstances. And one-third are hesitant, afraid, anxious, and will try to postpone it or will try to withdraw and let the patient down at the very end." Tromp-Meesters said legalization of euthanasia has been a hot political topic in the Netherlands but politicians have so far managed to postpone voting when such bills are put before Parliament. In Canada, however, Chris Axworthy, the New Democratic Party member of Parliament for Saskatoon-Clark's Crossing, introduced a private member's bill in June that would regulate and permit euthanasia and protect doctors from criminal sanctions if they help a patient die. Axworthy, who spoke at the Toronto forum, said his bill is meant to bring euthanasia "out of the closet," increase public debate about the issue, and open the government's mind to the possibility of changes to the Criminal Code.reduced or the use of the product discontinued. Less frequently, postural hypotension, an increase in heart rate, faintness, flushing, dizziness, nausea and vomiting have been reported. Symptoms and treatment of overdosage: Symptoms of overdosage related to vasodilation, including cutaneous he, nausea, dizziness and h teno.-Methemio a is also posTreatment sible. t saa ortive. ~~~~~~~~j an t:Rec enTda da efore and fore j 2i $
es ofw and
VAN& imltWpUAM1fWJ 1975, 90(5)6
Vial)
uig mntornvatuon available
eWL1dTrdmr may be treated with concomitant administration of mild analgesics. If headache is unresponsive to such treatment, the dose of Nitrong SR should be
(
RORER PHARMA
RH6NE POULENC-RORER CANADA INC. MONTREAL, QUEBEC
LE 15 NOVEMBRE 1991
