Study Finds Disturbing Trend in Assisted Deaths

A new analysis of doctor-assisted death in the Netherlands--considered a model by some advocates of assisted suicide in the United States--suggests that caregivers there have increasingly taken the next troubling step: Ending patients’ lives without their permission.

The assessment contradicts Dutch government data publicized last year and widely interpreted as evidence that assisted suicide, which is not criminal in the Netherlands under certain conditions, can be humanely applied. It confirms the fears of U.S. opponents of the practice, which remains illegal in most states pending a decision from the Supreme Court, expected this summer.

Made public today as a commentary in the Journal of the American Medical Assn., the article is a “warning light” that “raises important questions that we as an ethical and humane society cannot afford to ignore,” said Karen Orloff Kaplan, executive director of the New York-based Choice in Dying, which takes no position on physician-assisted suicide. “The Dutch experience tells us that we have to go very carefully.”

But a Dutch researcher involved in the original studies disputed the new analysis, saying it was “flawed” and “without basis.” Dr. Johannes van Delden, a physician and ethicist at Utrecht University, said in an interview: “It makes it seem that in the Netherlands we are killing off people we don’t like, which is absurd.” He and others point out that two of the three authors of the article are recognized opponents of physician-assisted suicide.

Nevertheless, the article addresses a crucial question: Does allowing doctors to fulfill a terminally sick person’s expressed wish to die put them on a slippery slope leading to willy-nilly euthanasia of patients? Dutch government researchers estimated that the number of euthanasia cases lacking explicit patient consent was 1030 (0.8%) in 1990 and 948 (0.7%) in 1995.

Advocates hailed such findings when they appeared last November in the New England Journal of Medicine. “They confirm that physicians in that country provide assisted death in a careful, responsible manner,” said Compassion in Dying, a Seattle-based group whose legal challenge to Washington state’s laws against of physician-assisted suicide is one of the two cases before the Supreme Court.

“Are the Dutch on a slippery slope?,” the New England Journal’s executive editor Marcia Angell asked at the time. “It appears not.”

The AMA journal article reaches a starkly different conclusion--even though it uses the same Dutch research data. The conflicting conclusions result from different interpretations of deaths following high doses of opiate drugs used to treat pain. In 1990, an estimated 1,350 people died that way in the Netherlands; in 1995, that number rose to 1,896. The earlier Dutch reports did not count such deaths as cases of euthanasia or assisted suicide.

But the authors of the new study, using an estimate from the Dutch researchers that 80% of the 1995 opiate-induced deaths occurred without the patients’ explicit consent, conclude that there has been a “striking increase in the number of cases terminated without request.”

“The care of terminally ill people in the Netherlands is worse than what we provide, and it’s worse because they have euthanasia,” said the article’s lead author, Dr. Herbert Hendin of the American Foundation for Suicide Prevention, which opposes the practice. Hendin said he visited the Netherlands four times between 1993 and 1996 researching his book “Seduced by Death.”

Coauthor Chris Rutenfrans, a criminologist in the Department of Justice in The Hague, said that their analysis shows that nearly half of all doctor-assisted deaths in the Netherlands in 1995 (2,844 out of 6,368) were not voluntary. “In too many cases,” he said, “it’s the physician who decides.”

He said the Dutch researchers slanted their reports to fit their agenda. “They are very much in favor of euthanasia and tried to hide as much as possible the negative consequences that are very clear in their reports.”

Van Delden defended the research. He said that the new analysis has merely seized on a linguistic glitch. By definition, he said, euthanasia implies consent, so the researchers didn’t classify opiate-induced deaths as such. But he concedes that the opiate-induced deaths are significant to understanding the whole picture.

“I think these cases should be treated as very close to euthanasia,” he said. “What bothers me is that these people are making their point by incriminating our integrity.”

The AMA staunchly opposes physician-assisted suicide. But, said Linda Emanuel, vice president of ethics for the association, the article was not published to promote the AMA’s position.

She said the two lessons of the Dutch experience were that there has been no apparent explosion of euthanasia cases in recent years and yet “the openness that some people have said would improve methods has not significantly reduced untoward events,” including “patients given euthanasia without full consent.”