Assisted Suicide and Euthanasia:
Lessons from the Dutch Experience
Herbert Hendin. M.D.
Most people assume that seriously or terminally ill people who wish to end their lives are different than those who are otherwise suicidal. But the first reaction of many patients to the diagnosis of serious illness and possible death is terror, depression, and a wish to die. Such patients are not significantly different than patients who react to other crises in their lives with the desire to end the crisis by ending their lives.
Suicidal patients are also prone to make conditions on life: I won't live ..."without my husband,"..."if I lose my looks, power, prestige or health," or "if I am going to die soon." They are afflicted by the need to make demands on life that cannot be fulfilled.
Determining the time, place, and circumstances of their death is the most dramatic expression of their need for control. The request for assisted suicide is also usually made with as much ambivalence as are most suicide attempts. If the doctor does not recognize the ambivalence as well as the anxiety and depression that underlie patients' requests for death, the patient may become trapped by that request and die in a state of unrecognized terror.
I have just completed a study of assisted suicide and euthanasia in the Netherlands where both are accepted practices. In the past decade by making assisted suicide and euthanasia easily available to those over 50 the Dutch have reduced the suicide rate in this segment of their population.
Among an older population physical illness of all types is common, and many who have trouble coping with physical illness became suicidal. In a culture accepting of euthanasia their distress is accepted as a good reason for dying. It may be more than ironic to describe euthanasia as the Dutch cure for suicide.
Should we consider legalization of assisted suicide an extension of the patients' rights movement? That it is often the doctor and not the patient who determines the choice for death was underlined by the documentation of "involuntary euthanasia" in the Remmelink report - the Dutch government's commissioned study of the problem.
The report revealed that in over 1,000 cases, of the 130,000 deaths in the Netherlands each year, physicians admitted they actively caused or hastened death without any request from the patient. In about 5,000 cases physicians made decisions that might or were intended to end the lives of competent patients without consulting them.
I was given as an example of a case where this was necessary--a doctor who had terminated the life of a nun who was dying in great pain but whose religious convictions did nnot permit her to ask for death. Even when the patient requests or consents to euthanasia, in cases presented to me in the Netherlands and cases I have reviewed in this country, assisted suicide and euthanasia were usually the result of an interaction in which the needs and character of family, friends, and doctor play as big and often bigger role than those of the patient.
A study of euthanasia done in Dutch hospitals concluded that in most cases families, doctors, and nurses were involved in pressuring patients to request euthanasia.
A Dutch medical journal described a wife who no longer wished to care for her sick husband; she gave him a choice between euthanasia and admission to a home for the chronically ill. The man, afraid of being left to the mercy of strangers in an unfamiliar place, chose to be killed. The doctor, although aware of the coercion, ended the man's life.
The Remmelink report revealed that more than half of Dutch physicians considered it appropriate to introduce the subject of euthanasia to their patients. They seemed not to recognize that the doctor was also telling the patient that his or her life was not worth living, a message that would have a powerful effect on the patient's outlook and decision.
Patients who request euthanasia are usually asking in the strongest way they know for mental and physical relief from suffering. When that request is made to a caring, sensitive, and knowledgeable physician who can address their fear, relieve their suffering, and assure them that he or she will remain with them to the end, most patients no longer want to die and are grateful for the time remaining to them.
But in the Netherlands social sanction has encouraged patients and doctors to see assisted suicide and euthanasia--intended as an unfortunate necessity in exceptional cases--as almost a routine way of dealing with serious or terminal illness. The public has the illusion that legalizing assisted suicide and euthanasia will give them greater autonomy. If the Dutch experience teaches us anything it is that euthanasia enhances the power and control of doctors who can suggest it, not give patients obvious alternatives, ignore patients' ambivalence, and even put to death patients who have not requested it.