IN AUSTRALIA AND THE
NETHERLANDS
Three comprehensive studies have been made of medical practice at
the end of life. Two in the Netherlands five years apart allow comparisons
to be made over that period. The third, in Australia, allow comparisons
to be made between a country that permits voluntary euthanasia in some
circumstances and one that does not. (The short time that voluntary euthanasia
was legal in the Northern Territory was outside the study period.) See
Fact Sheet 21 for a one page summary of
the third study.
In January 1990, the Dutch government set up a commission to investigate
the medical practice of euthanasia, defined as "a life-ending act by someone
other than the patient at his or her request". The Remmelink Commission,
named after its Chairman, the Dutch attorney general, initiated a nation-wide
study on euthanasia and other medical decisions concerning the end of life
(MDEL). The study was carried out by the Department of Public Health and
Social Medicine at Erasmus University, Rotterdam, in collaboration with
the Dutch Central Bureau of Statistics, The Hague. The results of the study
were reported in the Lancet in September 1991 (1).
This detailed study of MDEL was the first of its type and intense international
debate on the interpretation and significance of the results followed.
The Dutch repeated their study in 1995 and included among their objectives
the evaluation of changes in MDEL over the five year period. The results
were reported in the New England Journal of Medicine in November 1996 (2).
Government funds were made available in Australia through the National
Health and Medical Research Council for a similar study of MDEL. The studies
were carried out by the Centre for Human Bioethics and the Department of
Mathematics at Monash University, Melbourne, and by the School of Community
Medicine at the University of New South Wales, Sydney. The results were
reported in the Medical Journal of Australia in February 1997 (3).
Three broad types of MDEL were identified in the first Dutch study,
and these were used in the later studies:
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Non-treatment decisions (NTD), the withholding or withdrawal of treatment
in situations where treatment would probably have prolonged life.
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Alleviation of pain and symptoms (APS) with opioids in such dosages that
the patient's life may be shortened.
-
Euthanasia and related MDELs, the prescription, supply or administration
of drugs with the explicit intention of shortening life, ie euthanasia
at the patient's request (VE), assisted suicide (PAS), and life terminating
acts without an explicit and persistent request (LAWER).
The categories NTD and APS embrace actions that are legal and an accepted
part of sound medical practice provided the doctor does not "intend" the
death of the patient. For this reason doctors usually do not acknowledge
any such intention unless anonymity or freedom from prosecution is assured.
The categories VE, PAS and LAWER are all illegal. In the Netherlands, however,
doctors are not prosecuted in VE and PAS cases provided they have followed
established guidelines which include reporting their actions to the authorities.
The incidence of the various types of MDEL as revealed
in the studies is summarised in the table at the end
of this paper.
In the Netherlands
The studies gave the best estimate of all forms of MDEL as around 39%
of all deaths in 1990 and 43% in 1995. There was an increase in VE and
PAS from 1.9% to 2.6%, and a slight decrease in LAWER from 0.8% to 0.7%,
the majority of which were cases where the patient had earlier expressed
a wish for death to be hastened. In almost all cases the patient was no
longer competent and death was hastened by a few hours or days.
A number of factors may have contributed to the 0.7% increase in VE
and PAS over the 5 years period. Mortality rates increased as a consequence
of the ageing of the population. The proportion of deaths from cancer increased
as a consequence of a decrease in deaths from heart disease. Life-prolonging
techniques became increasingly available and there were possibly generational
and cultural changes in patient's attitudes.
The report concludes:
Safe Ground or Slippery Slope?
A major issue in the debate about euthanasia is whether some form
of acceptance of euthanasia or assisted suicide when it is explicitly requested
by a greatly suffering, terminally ill, competent patient is the first
step on a slippery slope that will lead to an unintended and undesirable
increase in the number of cases of less careful end-of-life decision making
and to the gradual social acceptance of euthanasia performed for morally
unacceptable reasons. Obviously, our data provide no conclusive evidence
in either direction. Five years may be too short a period in which to observe
important cultural changes, our results may be valid only in the context
of Dutch culture and the Dutch health care system, in which virtually all
of the population is insured for health care costs and economic motives
have not yet entered the realm of end-of-life decision making.
Nevertheless, in our view, these data do not support the idea that
physicians in the Netherlands are moving down a slippery slope. As in 1990,
a large majority of Dutch physicians consider euthanasia an exceptional
but accepted part of medical practice. The number of requests for it has
increased, but most of the requests are not granted. Physician-assisted
death nowadays does not involve patients whose illnesses are less severe,
as can be seen from our estimates of the amount of time by which life was
shortened [by 24 hours at most in 33% of cases and in a further 58%
by at most one week]. Finally, there are no signs that the decision
making has become less careful. Indeed, the increased frequency of consultation
and better documentation of cases can be considered to indicate better
decision making. The large majority of Dutch physicians are prepared to
invest substantial time in participating in studies of this type and to
make information on this difficult area of their practices public. As a
result, further developments in end-of-life decision making can be monitored
closely.
The two Netherlands studies provide persuasive evidence that Dutch medical
decision making at end of life continues to be of a very high standard
and that predictions of a slippery slope due to acceptance of voluntary
euthanasia as a part of medical practice have not so far been born out
in practice.
And in Australia?
The Australian study shows important differences. The high incidence
of non-voluntary euthanasia (LAWER) (3.5% compared with 0.7% in the Netherlands)
is of particular concern.
In addition there is the matter of medical decision making without the
consent of the patient. The study revealed that 30% of all Australian deaths
were preceded by an action or omission explicitly intended to end the patient's
life. In only 4% was the decision taken in response to an explicit request
from the patient. Do so many Australians really want their doctor to make
this sort of decision on their behalf? Do these percentages mean that doctors
(and patients) are inhibited by the illegality of voluntary euthanasia
from openly discussing any treatment that might hasten death?
Those opposed to voluntary euthanasia have argued that the Netherlands
studies underestimate the number of euthanasia cases because they do not
include NTD and APS cases where there is an explicit intention to hasten
death. In Australia, 36.5% of all deaths involved a medical decision either
explicitly or partly intended to hasten death or not prolong life. The
corresponding figure in the Netherlands was 19.5%.
The authors of the Australian study state:
Our study shows that Australia had a significantly higher rate of
intentional ending of life without the patient's consent, both through
the administration of drugs and by withholding or withdrawing treatment
than the Netherlands ...
and they conclude:
Australian law has not prevented doctors from practising euthanasia
or making medical decisions explicitly intended to hasten death without
the patient's request.
Significance of the Australian Study
There is no alternative to presenting results in a statistical form
on the basis of defined categories. There is thus scope for endless argument
on how the categories have been defined, how the studies have been carried
out and how the data have been interpreted.
In assessing the various claims and counter claims, it is important
to recognise that the studies have been carried out at established secular
universities. They have been carried out in a glare of publicity by academics,
many with international reputations, and the results submitted to referees
before publication in the scientific literature. Following publication,
there have been follow-up articles in the literature commenting on various
aspects and the opportunity for the various authors to reply.
It is clear that the situation in Australia is less satisfactory than
in the Netherlands, where there is more emphasis on the careful regulation
and monitoring of medical end-of- life decision-making. The case is strengthened
for law reform to permit voluntary euthanasia under appropriate safeguards.
References:
-
van der Maas PJ, van Delden JJM, Pijnenborg L, Looman CWN. Euthanasia and
other medical decisions concerning the end of life. Lancet 1991; 338: 669-74
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van der Maas PJ, van der Wal G, Haverkate I, de Graffe CLM, Bosma, JM,
Willems DL. Euthanasia, physician-aided suicide, and other medical practices
involving the end of life in the Netherlands, 1990-1995. N Engl J Med 1996;
335: 1699-1705
-
Kuhse H, Singer P, Baume P, Clark M, Rickard M. End-of-life decisions in
Australian medical practice. Med J Aust 1997; 166: 191-6
PERCENTAGE OF ALL DEATHS
Netherlands(90) Netherlands(95) Australia(95/96)
VE 1.7% 2.4% 1.7%
PAS 0.2% 0.2% 0.1%
LAWER 0.8% 0.7% 3.5%
2.7% 3.3% 5.3%
APS 18.8% 19.1% 30.9%
NTD 17.9% 20.2% 28.6%
Total MDEL 39.4% 42.6% 64.8%
This article was written for the SAVES newsletter, The VE Bulletin,
Vol 14 No 2, July 1997
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