National Catholic Reporter
April 11, 1997
As assisted suicide and euthanasia
issues simmer, look at Holland
By MICHAEL J. FARRELL
As a race we have always worked harder at making life good than making
death happy. Death unsettles us individually and communally. One
manifestation of our nervousness is the expanding debate about assisted
suicide and euthanasia.
As the complex and emotional arguments ebb and flow in this country, we
would do well to take a look at the Netherlands, "the only country where
euthanasia is accepted practice," as Herbert Hendin writes in Seduced by
Death: Doctors, Patients and the Dutch Cure (Norton, 256 pages, $27.50).
Hendin, a psychiatrist, has for much of his professional career studied
and treated people who wanted to end their lives. In 1990 he became
executive director of the American Suicide Foundation, which aims to prevent
suicide, assisted suicide and euthanasia. He took over just in time for the
currently burgeoning debate fueled by Dr. Jack Kevorkian and others.
While Seduced by Death contains scattered flights of theory, its
power to persuade derives from the stark, lived experience in Holland. But
also in America, which brings the issues seriously close to home. Such as
the story of Tim -- presumably not his real name -- a hard-driving young
executive halted by leukemia, with a 25 percent chance of survival. Since
Tim, the career track aside, wasn't having much of a life, his insistent
pursuit of suicide was in its own way logical.
But if Tim should be allowed legal suicide, should everybody? And if
allowing it is good, would insisting on it not be preferable? There is no
context on earth in which the term "slippery slope" seems as appropriate as
Tim died eventually. But first he took the treatment previously rejected.
This allowed him time for unfinished business. "Two days before he died,"
writes Hendin, "Tim talked about what he would have missed without the
opportunity for a loving parting." But for every Tim there is a
counter-story in which suicide might seem a good idea. "In the rush to
legislate," suggests Hendin, "advocates have failed to understand the
problem they are claiming to solve."
Search for answers
The author's own search for a solution took him to Holland in 1993. He
learned that even in Holland the legalities are murky. The law still
provides punishment for euthanasia and assisted suicide, but the same code
stipulates exceptions to the law. By now these "special circumstances" have
pretty much become the rule: "In a series of cases over the last 20 years,
the Dutch courts have ruled that force majeure is such a special
circumstance; euthanasia is thus permitted when a doctor faces an
unresolvable conflict between the law, which makes euthanasia illegal, and
his responsibility to help a patient whose irremediable suffering makes
A cozy coexistence has evolved between the Dutch courts and the medical
authorities who follow agreed guidelines for assisted suicide or euthanasia:
(1) voluntariness -- the patient must freely, and repeatedly, ask for it;
(2) unbearable suffering -- which cannot be relieved by other means; (3)
consultation -- a second opinion.
These guidelines, it turns out, are ideal circumstances for the "slippery
It is hard to be sure how far down the slope the Dutch are, according to
Hendin. The best guide is the celebrated Remmelink Report, published in
1991, the work of a government commission headed by Attorney General Jan
Remmelink of the Dutch Supreme Court.
The report found assisted suicide uncommon: about 400 cases a year. There
were, by contrast, about 2,300 cases of straightforward euthanasia, or about
2 percent of all Dutch deaths. Over 50 percent of Dutch physicians admitted
to practicing euthanasia, mostly for cancer patients. Only 60 percent of
doctors kept a written record of their cases.
More startling was how quickly physicians had slipped down the slope to
involuntary euthanasia, unilaterally terminating the lives of competent
patients, as distinct from those who were "out of it." Remmelink reported
more than 1,000 cases of death caused or hastened without any request from
the patient. In over 5,000 cases, giving pain medication or withdrawing or
withholding treatment was done to shorten life.
So-called "demented" patients are in an even more precarious situation.
Chairman of the Royal Dutch Medical Association Joost Schudel announced
unambiguously, "The doctor decides." Here the doctor's guiding principle
should be, according to Schudel: If I were in the patient's position, what
would I want for myself? This endearing concept is flimsy ground to build an
ethics on. Friends or relatives were not to be given any say in this big
decision. Medical Association guidelines also indicated that physicians
should not treat demented patients for infectious diseases. The author
quotes another Dutch euthanasia advocate: "Pneumonia is an old person's best
Perhaps the most scary aspect is how readily Dutch physicians have grown
into the role of God. "There is a certain paternalism built into our
system," one conceded. This same doctor railed against the legislation
demanding that doctors report all lives terminated without the patient's
request -- only those asking for it are entitled to Dutch euthanasia.
This requirement of mental competency for euthanasia is particularly
awkward for Alzheimer's patients. At the onset of the disease, patients who
decide they don't want to live with it interminably must ask for -- and
receive -- euthanasia. They may not ask for it now and get it later when
competency deserts them; in this way they are likely to be deprived of
months or years of good-quality life.
Dr. Herbert Cohen is one of the best-known practitioners in the
Netherlands, with between 50 and 100 deaths to his credit.
"There is a certain satisfaction in being involved in the terminal phase
of life," he explained. "There is a special warmth and intimacy and harmony.
It is true for them as well; it improves relations among the family. My
absolution is the Christmas cards I receive." Sometimes, going to a
euthanasia, he has brought flowers.
He is not as cavalier about death as his words might suggest. "The idea
that each case gets easier and easier is just rubbish," he tells Hendin.
"The price of any dubious act is doubt. ... I don't sleep for a week after."
He added that he never drives when about to perform euthanasia, being so
focused that he fears an accident.
Most physicians, he said, prefer euthanasia to assisted suicide, which is
less tidy. Drugs often take several hours, with relatives phoning, thinking
the person is dead. "You have to be present or available on the phone, ready
to terminate the life if something goes wrong."
Public opinion in Holland supports assisted suicide and euthanasia,
Hendin writes. This includes most lawyers, judges and prosecutors. In a few
short years euthanasia has grown to acceptance as a fact of life. Professor
Rene Diekstra, one of the fathers of Dutch euthanasia, was nevertheless
worried that "there would be a backlash when the public eventually realized
what was actually happening. He also thought it possible that world opinion
would force the Netherlands to regulate the procedures more carefully."
Case after case bring home to the reader the ambiguity -- at the very
least -- that surrounds the issue, and the seemingly ever-steepening
slippery slope. Netty Boomsma's was a troubled life. Undesirable parents.
Husband who beat her. Her first son, whom she loved best, shot himself after
a failed love affair. Her other son died on schedule from an incurable
Netty wanted suicide because she wanted to be with her children. She had
no interest in the alternatives, such as bereavement therapy, that the
doctors still feel obliged to suggest. Writes Hendin: "Netty needed someone
who could tell her in a firm but kind way that she had never really lived
for herself and that it was not too late to try. She could always kill
herself, but she ought to give life a chance first."
What is ultimately striking about Netty's story, sad though it is, is the
extraordinary lengths to which our advanced civilization will go to meet
needs that as a race we had to shrug off and walk over since the world
began. The world, alas, is and always was full of grief like Netty's, from
ancient Egyptian slaves to dead Tutsis in Rwanda, but we seldom could afford
the luxury of the options that were afforded Netty. The Dutch system
pampered her with advice and offers of assistance before it killed her. Hers
was the psychological equivalent of the monumentally expensive tubes and
machines that some very old people are hooked up to in hospitals in the
wealthy West. It's ironic that death, one way or the other, becomes the
culmination of such lavish attention.
The slope gets very slippery. Hendin writes that a major step in
normalizing euthanasia as a part of everyday life was the Dutch television
showing in the fall of 1994 of "Death on Request." Cees van Wendel, a
patient with amyotrophic lateral sclerosis, was put to death on his own
request. Part of this program was shown here on "Prime Time Live," where Sam
Donaldson described it as "a story of courage and love."
Hendin saw it differently. He writes of the seeming contradiction between
the film's message -- that we all want release from illness, especially the
patient -- and the obvious eagerness of the patient's wife that he die. She
intercepted all questions asked of Cees and answered on his behalf. She
appeared "repulsed" by her husband's illness, never touching him during
their on-camera conversation.
"From the beginning, the loneliness and isolation of the husband haunt
the film," writes Hendin. In this book the old, sick man seems to represent
the old and infirm everywhere, getting shouted out of the debate by every
side. Alive and human and feeling and no doubt fearing, he is nevertheless
depersonalized as if he were already dead. In a culture that has scant care
for old age, that voice needs desperately to be heard.
Can of worms
Meanwhile, back in Salem, Oregon, the law allowing assisted suicide has
been put on hold following a March 13 appeal by the National Right to Life
Committee, according to Catholic News Service. Reservations seem to be
growing about the measure, the Oregon Death with Dignity Act, narrowly
approved by voters in 1994.
Dr. James Boehnlein, a representative of the Oregon Psychiatric
Association, said assisting suicide would make members liable to ethics
charges. "None of our training prepares us to decide if a patient is
competent to commit suicide," he said. And Dr. Larry Lewman, Oregon's chief
medical examiner, has turned from supporter of assisted suicide to opponent:
"This is a potentially unworkable can of worms that has been dumped into
your laps," he told the Oregon House subcommittee. And Rep. George Eighmey,
who supports the measure, said the legislature should make sure that "the
right to die never becomes duty to die."
And in New York, Cardinal John O'Connor said in a TV interview that an
unspecified insurance company had told the staff of one Catholic hospital,
"You are keeping your people alive too long. If you continue to do this, we
will cut off your insurance."
Not only are hospitals pressured to shorten life, so are patients, he
said. Assisted suicide "sounds wonderful, sounds compassionate," he said,
when patients are told about "the fear of suffering" and "what a drain on
society they would be [by] taking up another [hospital] bed."
O'Connor said, "We are at the mercy of insurers."
Michael Farrell is NCR's
National Catholic Reporter, April 11, 1997