The measure would add a provision to the existing Dutch Criminal Code so that euthanasia and assisted suicide "would not be treated as a criminal offence if carried out by a physician and certain criteria of due care have been fulfilled." [Dutch Ministry of Justice Press Release, 11/28/00. Hereafter cited as MOJ Press Release.]

• "be convinced that the patient’s request was voluntary and well-considered";
• "be convinced that the patient was facing unremitting and unbearable suffering";
• "have advised the patient concerning the latter’s situation and prospects";
• "have reached the firm conclusion together with the patient that there was no reasonable alternative solution to the patient’s situation";
• "have consulted at least one other independent physician, who has examined the patient and has formed a judgment concerning the requirements of due care as set out above";
• "have carried out the termination of life in a medically appropriate manner." [MOJ Press Release]

     Patients who qualify for an induced death need not be terminally ill.

     Under the new law, the regional review committee is obligated to report a euthanasia or assisted suicide death to the Public Prosecution Service only if the committee thinks that the doctor did not comply with the criteria of due care. If the committee feels that the doctor acted appropriately, then the "case is closed," and no report to the Prosecution Service is required. [MOJ Press Release; CNN.com, 11/28/00]

     Under both the existing and new law reporting requirements, doctors are not obligated to report patient killings until after the patient is dead.

     Moreover, by eliminating the prosecutorial review of all cases, the government hopes to lessen doctors’ fears of possible prosecutions and encourage more doctors to actually report induced deaths. Reporting noncompliance is a major problem for the government. A Dutch study, published in 1996, found that the majority of Dutch doctors (59%) do not report voluntary euthanasia and assisted-suicide deaths, and cases of involuntary euthanasia (without patients’ knowledge or consent) are rarely if ever reported. [van der Wal et al., "Evaluation of the Notification Procedure for Physician-Assisted Death in the Netherlands," New England Journal of Medicine (NEJM), 11/28/96:1706-1707]

     It is not surprising that Dutch physicians do not report involuntary euthanasia cases. Such deaths are a blatant violation of the very first euthanasia guideline and should be prosecuted as a criminal act under both the existing and new law guideline scheme. Given the fact that Dutch physicians have rarely been prosecuted for guideline violations and that no doctor has ever been imprisoned or substantially penalized for noncompliance, it would seem that physicians’ fears of legal ramifications are misplaced.

     In a more recent Dutch study, researchers found that 55% of the Dutch doctors interviewed in 1995 indicated that "they had ended a patient's life without his or her explicit request" or "they had never done so but that they could conceive of a situation in which they would." [van der Maas et al., "Euthanasia, Physician-Assisted Suicide, and Other Medical Practices Involving the End of Life in the Netherlands, 1990-1995," NEJM, 11/28/96:1701]

     Yet, according to Health Minister Els Borst, who drafted the new law, "Doctors should not be treated as criminals." "[The law] will create security for doctors and patients alike," he explained. "Something as serious as ending one’s life deserves openness." [AP, 11/29/00]

     Just how "open" euthanasia and assisted suicide practice will be is questionable. Like Oregon’s assisted suicide law, the new Dutch measure mandates that annual reports be published. In Oregon, those reports are issued by the state Health Division, and the data has been sketchy and incomplete due in large part to physician non-reporting and inflated privacy concerns.

     According to the new Dutch law, the regional review committees are supposed to "publish annual reports which provide as much information as possible—whilst preserving anonymity—concerning the way in which they have tested actual cases against the criteria of due care." [MOJ Press Release] But, like in Oregon, if Dutch doctors do not report the deaths, including the involuntary euthanasia cases, and if privacy concerns outweigh justice for vulnerable patients, the committee reports will be skewed and not a true picture of Dutch medicalized killing.

     Generally, it has been the contention of the government and medical establishment that minors should also have the right to request euthanasia. Children with terminal illnesses, proponents argue, are often more mature than many adults, and they deserve the right to have their suffering ended.

     When the new euthanasia law was originally proposed, it contained a provision allowing minors 12 and over to request and obtain an assisted death, even if their parents objected. Because of intense criticism both nationally and internationally, that provision was amended. As passed by the Lower House, the measure now stipulates that children age 12 through 15 can still be euthanized or assisted in suicide, but the consent of at least one parent or guardian is required. Minors 16 or 17 years-old can decide to have their lives ended without parental consent. [MOJ Press Release; Time Europe, 11/28/00]

     One of the most dangerous provisions of the new law is the sanctioning of advance directives authorizing euthanasia and assisted suicide. The law expressly validates written declarations—signed by patients long before the onset of incompetence—regarding their "termination of life" wishes. These declarations would give doctors the right to decide whether patients’ lives should be terminated if they become unable to make decisions for themselves. [MOJ. Press Release; AP, 11/28/00]

     Not surprisingly, reactions to the Lower House’s passage of the euthanasia bill has been strong and varied. German Justice Minister Chert Dauber-Melvin is highly critical of the bill’s passage. "Germany will never legalize euthanasia," the minister said. "I see this law as breaching a taboo." Germany is especially sensitive to the euthanasia mentality, given Hitler’s systematic extermination of children and adults considered physically or mentally disabled. "Everyone has the right to die naturally," explained the minister, who is a patron of Germany’s hospice programs. "It is not a doctor’s job to judge whose life is worth saving and whose is not." [Reuters, 11/30/00]

     As observed in a Wall Street Journal Europe editorial, "there is a slippery slope here." "If we someday find ourselves as callous toward human life as were the ancient Romans, it may be remembered that it all began in the name of compassion with a people who tended toward ‘progressive’ ideas, the Dutch." [Editorial, WSJ Europe, 12/1/00]

      On November 7, 2000, Maine voters joined ranks with those in Washington State, California, and Michigan by defeating a ballot measure that would have legalized assisted suicide.

     The measure, the Maine Death with Dignity Act (MDWDA), was placed on the ballot as Question 1: "Should a terminally ill adult who is of sound mind be allowed to ask for and receive a doctor’s help to die?" The voters responded: 51% no, 49% yes.

      The MDWDA’s defeat was essentially a rejection of Oregon’s way of dealing with end-of-life difficulties—sanctioned killing. Oregon is the only state which has legalized assisted suicide, despite similar attempts in approximately 15 other states—most often in state legislatures—since Oregon embraced the practice. Maine was one of those states. In fact, its legislature soundly rejected assisted-suicide bills four times, the last time being earlier thisyear before the MDWDA was placed on the ballot.

     The progressive decline in support for the MDWDA was a direct indication of just how effective the No on 1’s efforts were in educating Maine voters about the dangers and abuses inherent in assisted-suicide practice. In August 2000, polls showed that 71% of Mainers supported the MDWDA. [Portland Press Herald, 8/24/00] By the end of September, support dropped to 67%. [Bangor Daily News, 9/27/00] In mid-October, support tumbled to only 54%, with a further decline by the end of October to 52%. [Press Herald, 10/18/00 & 10/30/00] When voters actually cast their votes on November 7, support was down to 49%.

     "The more we tell the truth about Question 1," said No on 1 spokesperson Dr. Laurel Coleman, "the less people like the proposed law." [No on 1 Press Release, 10/24/00]

     "The gut reaction is to like the idea of ‘death with dignity,’" explained IAETF’s Rita Marker. "But as people begin to take a closer look within the context of health care today—managed care, the need to save money, how cost-effectiveness will play a part—opinion starts to change." [Wall Street Journal, 11/10/00]

……….

     Between 1994 and 1998, support among America’s cancer specialists for physician-assisted suicide declined more than 50% and support for euthanasia plummeted by almost 75%, according to a recent survey published in the Annals of Internal Medicine.

      The study—conducted in 1998 by researchers from Maryland, Colorado, Massachusetts, New York, Texas, and Tennessee—surveyed 3,299 members of the American Society of Clinical Oncology (ASCO) regarding their attitudes and practices with respect to assisted suicide and euthanasia. It is the largest study ever conducted on the subject.

     When the findings were compared to a similar study conducted by Dr. Emanuel in 1994, researchers discovered that "support for euthanasia and physician-assisted suicide has decreased substantially." Using the same "prototypical case of the terminally ill patients with unremitting pain," they found that support for assisted suicide dropped by half, from 45.5% in 1994 to 22.5% in the current study. Euthanasia support fell by nearly 75%, from 22.7% in 1994 to only 6.5% in the new survey.

     Equally significant are the findings that (1) doctors who had received better training in end-of-life care were less likely to engage in assisted suicide or euthanasia, and (2) physicians who were unable to obtain adequate care for their cancer patients were more likely to favor both practices. [E.J. Emanuel et al., "Attitudes and Practices of U.S. Oncologists regarding Euthanasia and Physician-Assisted Suicide," Annals of Internal Medicine, 10/1/00:527-532]

     "These study results underscore the need for physician education of optimal pain and palliative care practices," explained researcher Dr. Robert J. Mayer from the Dana-Farber Cancer Institute "Physicians who are better informed about end-of-life issues feel less need to use euthanasia and physician-assisted suicide." [ASCO Press Release, 10/2/00]

     While 60% of terminally ill patients in a recent study indicated support for euthanasia and assisted suicide in a hypothetical case, only 10% said that they had seriously considered the induced-death practices for themselves. The study—published in the 11/15/00 issue of the Journal of the American Medical Association (JAMA) as one of a series of articles and commentaries on end-of-life care—presents the first research to actually track over a period of time terminally ill patients’ attitudes and desires regarding euthanasia and assisted suicide.

     Between March 1996 and July 1997, researchers surveyed 988 terminally ill patients and 893 patient-designated primary caregivers. The data revealed that psychological factors, such as depression and the patients’ sense that they were no longer appreciated, were the most significant factors associated with patients’ considering and planning euthanasia or assisted suicide deaths. Those who reported that they had more pain or required substantial care were also more likely to consider having their lives ended, and their caregivers were more likely to support a decision for euthanasia or assisted suicide. In contrast, the majority (89.6%) of terminally ill patients who did not personally consider either practice were less likely to have depressive symptoms and more likely to feel appreciated, be 65 or over, African American, and religious.

     Researchers also noted, "While a majority [60.2%] of those surveyed find euthanasia acceptable for terminally ill patients with unremitting pain, less than a third support it when the patient desires it because of fear of being a burden on the family." Furthermore, the study’s authors observed that there appears to be "a tension between attitudes and practices, between the reason people find euthanasia and PAS [assisted suicide] acceptable—predominantly pain—and the main factor motivating interest in euthanasia or PAS—patient depression."

     In addition, researchers found that the patients’ personal considerations of euthanasia and assisted suicide were significantly unstable. More than 50% of the patients who initially expressed interest in ending their lives later changed their minds, and some of those who had not considered these induced-death practices at the initial interview began to do so. "Depressive symptoms and dyspnea were associated with this instability," researchers wrote. "This suggests that when physicians are confronted by a patient’s request for euthanasia or PAS, they should attend to the possibility of depression and other psychological stressors," they concluded. [E.J. Emanuel, D.L. Fairclough, & L.L. Emanuel, "Attitudes and Desires Related to Euthanasia and Physician-Assisted Suicide Among Terminally Ill Patients and Their Caregivers," JAMA, 11/15/00:2460-2468]

Editor’s notes:

1. Two of the three co-authors of this study were the husband and wife team Drs. Ezekiel Emanuel and Linda Emanuel. Ezekiel Emanuel was also lead author of the study (reported on page 5) showing a dramatic drop in support for assisted suicide and euthanasia among cancer specialists trained in end-of-life care. Apparently upset by both studies’ published findings, euthanasia and suicide guru Derek Humphry wrote to fellow right-to-diers, "Thus we should not let academics like the Emmanuels [sic] make a reputation out of trumpeting that hastened death is no longer necessary so long as there is palliative care, and groups like Hemlock etc. are now superfluous. They apparently give little or no consideration to quality of life, which is uppermost in most of our minds." [D. Humphry, right-to-die e-mail list, 11/15/00]

2. Regarding the researchers’ recommendation that physicians should take steps to determine if patients who request euthanasia or assisted suicide are depressed or are under other "psychological stressors," it is interesting to note that during the first two years under Oregon’s permissive assisted-suicide law, less than 35% (15 out of 43) of the patients who received lethal prescriptions were referred for a psychiatric or psychological consultation. [Oregon Health Division, "Oregon’s Death with Dignity Act: The Second Year’s Experience," Table 2, 2/23/00]

3. The mental assessment rate is even lower in the Netherlands where only 3% of all those euthanized or assisted in suicide receive professional mental health evaluations. According to Dr. Linda Ganzini, director of geriatric psychiatry at the Veteran’s Affairs Medical Center in Portland, OR, "[S]tudies of dying cancer patients reveal that between 59-100% of patients wanting hastened death have major depressive disorder." "Depressed people," she explained, "often focus on the worst possible outcomes and are impaired by apathy, pessimism, and low self-esteem." "The experience of palliative care psychiatrists is that depression treatment is effective in terminally ill patients," Ganzini wrote. [L. Ganzini, "Commentary: Assessment of Clinical Depression in Patients Who Request Physician-Assisted Death," Journal of Pain & Symptom Management, June 2000, pp. 474-478]

    A study of 69 of Jack Kevorkian’s assisted-suicide deaths from 1990 to 1998 revealed that only 25% involved people with a terminal condition, meaning they had less than six months to live. Of the 69 people whose lives Kevorkian claimed, five were found to have no "anatomical disease" whatsoever upon autopsy.

    These findings, which were published as a letter in the New England Journal of Medicine, were the result of a two-year clinical analysis, conducted by psychologists from the University of South Florida, of data from the Oakland County, Michigan, medical examiner’s office . Since autopsy procedures can vary among counties, Kevorkian-related deaths outside of Oakland County were excluded from the study. Kevorkian has claimed to have participated in about 130 deaths.

    Researchers found that in 72% of the cases the individual had experienced a recent decline in health, a factor which could have precipitated their desire to die. Seventy-one percent (71%) were women’ and most of the 69 were either divorced, widowed, or had never married. Thirty-five percent (35%) were experiencing pain, and 13% exhibited symptoms of depression. "Altogether," researchers concluded, "our findings underscore the vulnerability of women and groups of men (i.e., those not married and those coping with serious illness) to physician-assisted suicide and euthanasia…." [L. Roscoe, L.J. Dragovic, D. Cohen, "Dr. Jack Kevorkian and Cases of Euthanasia is Oakland County, Michigan, 1990-1998," NEJM, 12/7/00]

     Euthanasia activists in Australia have announced plans to set up a secret laboratory to test the effectiveness of common weeds to kill patients. Leading this project is Dr. Philip Nitschke, the doctor responsible for the deaths of 4 patients under the now defunct Northern Territory law legalizing euthanasia. After that law was overturned by Australia’s national parliament, Nitschke began holding how-to euthanasia clinics throughout the country. He is also developing a suicide tent designed to remove oxygen from the air to cause one or more individuals to suffocate to death.

     Reportedly, Nitschke and his fellow activists have raised A$40,000 (Australian dollars) and they expect another A$60,000 from foreign sources. If the underground lab is established, suicidal patients would be able to send in plant samples to be tested for lethal effects.

     Hemlock, the weed responsible for Socrates’ death in 399 bc, will be one of the first plants tested. As Nitschke has pointed out, it is not illegal to grow hemlock, and it is a common weed all across Australia.

     Nitschke also said that he didn’t believe people would use the lab to establish the best substances to use to murder someone or to commit suicide because of depression or any non-medical reason. He said that if a person wanted to murder someone, they wouldn’t want to wait for the lab to suggest a "peaceful way" to do it. [South China Morning Post, 10/24/00; Herald Sun, 10/23/00; Courier Mail, 9/28/00] (See "News Notes" in this Update for more on Nitschke.)

     According to a recent survey conducted by researchers from the Free University Brussels and Ghent University, more than one in ten deaths in Belgium are the result of doctors actively ending patients’ lives. Euthanasia is illegal in Belgium, though the country’s parliament has been debating a proposal to legalize the practice. (See Update, 2000, No. 1, p. 8.)

     Researchers studied deaths in Belgium’s northern region which occurred during the first four months of 1998. After extrapolating the data from those deaths to estimate likely causes of death for an entire year, they found that more than three in every 100 deaths patients had been given lethal injections without the patient’s’ request or permission. In 5.8% of the cases treatment was withheld expressly for the purpose of ending the patient’s life. [BBC News, 11/24/00; CNN.com, 11/24/00]

     Britain’s top anesthetists have called for certified brain-dead organ donors to be given painkilling drugs to insure that the patient does not experience pain when the organs are harvested. An editorial that appeared in Anaesthesia, the journal of the Royal College of Anaesthetists, said that anesthetics should routinely be given to a beating-heart, brainstem-dead patient during surgery to remove the person’s heart, lung, liver, and pancreas.

     If these patients are not sedated, it is common for there to be disturbing and dramatic responses from the donor’s body. "Nurses get really, really upset," explained Philip Keep, a consultant anesthetist from the Norfolk and Norwich hospital. "You stick the knife in and the pulse and blood pressure shoot up," he said "If you don’t give anything at all, the patient will start moving and wriggling around and it’s impossible to do the operation."

     British High Court Judge Dame Elizabeth Butler-Sloss has ruled that the right-to-life provision in Britain’s newly enacted Human Rights Act does not affect a doctor’s right to withhold or withdraw tube feeding from patients thought to be in a permanent vegetative state (PVS).

     The new Human Rights Act incorporates the provisions of the European Convention on Human Rights into British law. The cases before the British High Court purportedly involved two articles from the Act—Article 2, stating "Everyone’s right to life shall be protected by law," and Article 3, banning "inhuman and degrading treatment."

     The cases in question involved two women referred to only by their initials. Mrs. M, 49, reportedly has been PVS for three years as a result of an anesthesia accident that occurred during surgery. Ms. H, 36 and an epileptic, has been only "near-PVS" (she responds to external stimuli) since last January when she went into cardiac arrest.

     The families of both women want their feeding stopped. John Grace, the lawyer arguing for the withdrawal of tube-feeding on behalf of the two hospital trusts caring for the women, described PVS in court as "a twilight zone of suspended animation where death commences whilst life continues. A living death."

     Initially it was reported that the Official Solicitor representing the two women was expected to argue that withholding their tube-feeding would violate their right to life. However, during the hearing, Official Solicitor Ben Emmerson agreed with the opposing lawyer, John Grace, that the existing nutrition and hydration guidelines established seven years ago by the House of Lords—allowing the starvation and dehydration of Tony Bland, a young man brain-damaged during a soccer riot—were compatible with Article 2 of the Human Rights Act.

     Judge Butler-Sloss agreed and so ruled. [British Medical Journal, 10/14/00; London Times, 10/2/00; Ananova, 10/6/00, 10/5/00]

     The city of Zurich has issued a directive sanctioning assisted suicide for elderly people in residence homes. The man behind this new directive is Robert Neukomm, head of the Zurich Health Department, which maintains control of elderly residence homes in the city.

     According to a message sent over the right-to-die e-mail list by a Swiss EXIT board member, there are guidelines regulating assisted suicide practice in the residence homes:

1. The elderly person no longer has a private home, and the person’s room in the residence is considered his or her "private sphere."
2. The person must be competent and state a wish to die on several occasions.
3. Nurses and resident home staff are not allowed to participate in the death, but they are allowed to be present.
4. If the competence of the patient is questionable, the case should be referred to an ethics committee for final determination.
5. A physician is not to be involved in the assisted suicide; the assistance is to be provided by EXIT or other such group. (That way the policy of no physician-assisted suicide is officially maintained.)
6. All other options, including palliative care are to be exhausted.
7. Assisted suicide is not allowed in hospitals. [Dr. Harri Wettstein, right-to-die e-mail list, 10/30/00]

     Neukomm issued the new assisted-suicide directive even though he has admitted that such suicide decisions are often the result of severe depression.

     Dr. Albert Wettstein, head of a group of municipal doctors, said "Only 1.1% of the residents...have expressed the wish to commit suicide." His fear now is that the new directive will encourage suicides and will be a "first step" toward active euthanasia—which is officially illegal in Switzerland. [Zenit News Agency, 10/29/00]

……

……

     But the PRPA provision that has been most controversial is the prohibition against using federally controlled drugs to intentionally end patients’ lives—a practice allowed under Oregon’s assisted suicide law. If the PRPA passes Oregon doctors could no longer prescribe lethal doses of barbiturates, the drugs of choice for assisted suicides.

……

     "We are writing to you, a leader of a democracy, to ask that you, as president, demand that Dr. Kevorkian be given a pardon and released from prison," Nitschke et al. wrote. "We… beg you to exercise your authority and have Dr. Kevorkian restored to his rightful place in society—as a leader and a hero of reform." [AAP, 11/27/00]