Euthanasia: looking beyond the death wish
The interpretation and boundaries of the Euthanasia Act are the subject of ongoing debate. It seems that public opinion in the Netherlands has, for some time now, been calling for a more liberal application of the Euthanasia Act.
The number of cases of euthanasia as a percentage of overall annual mortality has more than doubled over the last five years, in spite of better care. It appears that euthanasia is increasingly becoming an autonomous decision of the patient rather than a last resort for physicians.
Under the auspices of the Julius Center of the University Medical Center (UMC) Utrecht, family doctor cum researcher Pauline Kouwenhoven conducted research for eight years, receiving her PhD in December for a dissertation on the knowledge and opinions of health care professionals and the public about end-of-life decisions.
The findings of the widely distributed questionnaires and interview review show that there is wide support for the Euthanasia Act among the respondents. However, all parties have reservations when it comes to euthanasia in cases of mental suffering. These reservations have now decreased among the public (Third evaluation of the Euthanasia Act, 2016), but not among physicians. Kouwenhoven says, "The shift towards euthanasia as an autonomous decision of the patient is in line with autonomy being viewed as a right. It is, however, important that physicians and patients continue to engage in dialogue and discuss a death wish in a wider context, which entails more than just testing it against the Euthanasia Act.
The assessment and management of (unbearable) suffering by the physician remains crucial, as it is in normal medical practice. Patients tend to rely on their physicians' judgment, with physicians and patients arriving at a satisfactory approach in joint consultation. This should definitely continue to apply to an important and difficult decision such as opting for euthanasia too. Euthanasia is an emergency measure. In most cases, physicians can support terminal patients very effectively in a different way.
The key conclusions from the dissertation entitled "Knowledge and opinions of health care professionals and the public about end-of-life decisions":
1. The Euthanasia Act is widely supported, particularly when it comes to physical suffering. Both professionals and the public have reservations when it comes to mental suffering. Advanced dementia is an exception, as people find this a horror scenario. Euthanasia in cases of dementia is a horror scenario to physicians.
2. The basis for euthanasia seems to be shifting from a conflict of duties of the physician towards patient autonomy. This shift appears to be particularly in line with autonomy being viewed as a right (freedom of external interference). However, patients and citizens seem to benefit more from an approach based on autonomy as an ideal (freedom of development and development by clarifying wishes and desires). Assessment and management of (unbearable) suffering by the physician is crucial here.
3. It is remarkable that the importance attached to autonomy in the request for euthanasia or assisted suicide is barely reflected in the execution. Assisted suicide as an alternative to euthanasia is often not discussed with the patient and is, paradoxically, predominantly a decision made by the physician.
The principal recommendations from the dissertation:
1. Good communication between all parties involved remains essential for a proper understanding of the possibilities and impossibilities of termination of life upon request.
2. It is of great importance to find/restore the balance between the physician's professional responsibility and the patient's personal autonomy in the euthanasia process.
3. (The preference for) assisted suicide as opposed to euthanasia could be discussed and put into effect more often and this could underline the patient's autonomy.