Seduced by death

Author: Herbert Hendin. Seduced by death. Physicians and patients facing assisted suicide and euthanasia.
Published in: Barcelona: Planeta, February 2009. 350 pp. degree scroll original: Seduced by Death. Translation: Margarita Gesta.

The discussion on euthanasia usually revolves around borderline cases. But the law is made for the generality, and that is why it is necessary to pay attention to the results of the few countries that have legalized it. This is what Dr. Herbert Hendin did when he studied the Dutch experience on the ground, and where he spoke with its main promoters. Hendin is Full Professor of Psychiatry at the New York Medical College and an authority on suicide prevention. We offer a selection of paragraphs from his book Seduced by Death, which has just been translated by publishing house Planeta.

My experience with seriously ill people with suicidal tendencies made me fear that they would become victims in a status where assisted suicide and euthanasia were legal. This was my fear when I started studying euthanasia, and what I saw in the Netherlands confirmed that this fear was justified.

However, I thought that, as in the Netherlands attendance health care is guaranteed for all, euthanasia was placed there in a context where patients would have a better alternative to palliative care than we have in the United States. But I realised that this was not true, and that the acceptance of euthanasia was leading precisely to the neglect of development palliative care. Euthanasia, which had been proposed as a necessary solution for a few extreme cases, had become an almost routine way of treating anxiety, depression and pain in seriously or terminally ill patients. What I saw afterwards in the Netherlands and the United States convinced me that the legalisation of euthanasia should be avoided because palliative care would be neglected and worsen.

This may seem surprising, but it is equally surprising that euthanasia, contrary to what its promoters hope, increases the power of doctors, not that of patients. This is because doctors can propose euthanasia (which has a great influence on the patient's decision), they can ignore the patient's ambivalence, they can stop proposing alternatives, and they can kill patients who had not been killed order.

Impossible to regulate

It was equally important for me to realise that it is impossible to regulate euthanasia. I drew this conclusion from the Dutch government reports, from talking to the researchers who did them, and from the cases they presented to me. The fact that legal recognition creates a cultural climate that favours disobedience to any rules and regulations is well illustrated by the fact that 25 percent of doctors admit to having given life-shortening drugs without the consent of patients. Counselling has become a mere formality. Patients are not offered alternatives. And since in most cases the authorities are not informed, regulation is impossible.

(...) It is surprising how much misinformation there is on these issues, even among doctors. Advocates of euthanasia have muddied the waters to such an extent that several doctors told me that they had practised euthanasia, when in fact they had agreed to withdraw treatment from a dying patient.

Moreover, few doctors know that it is possible to eliminate all pain with adequate palliative care, if sedation is included where necessary. When they realise this, most doctors prefer these methods (...).

Those who are most adamant in their opinion are people, including doctors, who have had the traumatic experience of the painful death of a family member or loved one; they have become convinced that the legalisation of euthanasia is the only way to prevent the suffering they saw.

An example of this is euthanasia advocate Dr. Marcia Angell, editor of the New England Journal of Medicine, who published the story of her father's death as an argument for the legalisation of assisted suicide. (...)

Family members often feel guilty after a suicide. Blaming society for not allowing assisted suicide is one way of dealing with this feeling.

The social change that could help people on Angell's father's status would be for doctors and family members to talk more openly with those who are dying. It is B that, when this happens, patients stop being in a hurry to die, feel grateful for the time they have left and do not feel that they are dying alone and abandoned.

Even more assertive are those who have assisted in the suicide of a friend, family member or patient. Many feel the need to justify what they did by proclaiming not only that it was well done, but that society as a whole should recognise it by legalising assisted suicide. (...)

Other options

The acceptance of euthanasia has led to the neglect of the development of palliative care.

However, most people are more flexible. When they say they are in favour of assisted suicide, what they mean is that they want the doctor to do everything possible to eliminate suffering. And when they realise that there are other options than suffering or going to a quick death, they change their minds. When they realise what happens when assisted suicide and euthanasia are put on internship, they are even more convinced.

But people are very misinformed, because of the advocates of euthanasia. For example, assisted suicide is proposed as an alternative to euthanasia practised directly by a doctor, as public opinion is more reluctant to accept the latter. But both proponents and opponents of euthanasia agree agreement that once assisted suicide is allowed for those who can commit suicide, it will be impossible (legally, medically and morally) to prevent the development of euthanasia carried out directly by a doctor.

The medical and legal problems facing doctors and patients in Oregon, where assisted suicide is permitted by law, are enormous. Doctors do not know which drugs to use, or whether they will be effective, or what side effects they will have. The lethal dose of barbiturates (which, based on Dutch experience, is recommended by the Hemlock Society) in 25 percent of cases does not result in death even three to four hours after it is administered. Those of us who work with people who have attempted suicide see cases where, after ingesting even more than the lethal dose, the patient goes into a coma for several days. Some die, others live with unpredictable results.

In the Netherlands, when a prolonged coma occurs after an assisted suicide attempt, the doctor administers a lethal injection. In the United States, family and friends cannot bear the uncertainty of a prolonged coma and feel compelled to suffocate the patient with a plastic bag. This is what happened to Jane, the only patient described in Timothy Quill's second book to be given a lethal dose of drugs. Jane's friends told Quill, some months later, that they had to use a plastic bag to end her life. The same thing happened to George Delury, who admitted that he had to use a plastic bag because his wife did not die with the lethal dose he had prepared for her. Of course, if there is a doctor present, he or she will probably use lethal injection; in either case one starts with assisted suicide and ends with euthanasia.

When the law is not respected

(...) There is the impression that in physician-assisted suicide the patient is protected because his or her participation is active. But (...) assisted suicide also has its dangers and drawbacks. Unlike euthanasia, it is often used with people who are not yet close to death. They are also more likely to be patients who are suffering from depression as a consequence of an illness and who, if treated properly, would want to live.

Proponents of euthanasia have exaggerated the issue number of doctors who practice euthanasia, and say that it should be legalised so that it can be regulated. The argument does not seem very convincing: should the law be changed simply because it is not respected, and what makes us think that those who do not respect the law now will respect the rules that are then proposed? The Dutch experience tells us rather that legalisation creates a climate favourable to disobedience of the rules. In any case, the law will never allow doctors to end a patient's life without his or her consent, but doctors who already do so now will feel even freer to do so when euthanasia is allowed.

It is not only a religious civil service examination

Part of the misinformation created is to make people believe that civil service examination euthanasia is a Catholic Church or religious right thing. Voters in Oregon were told: are you going to allow the Catholic Church to dictate how you die?

association It is unknown that the American Medical Association (AMA) is probably the most important organisation opposing legalisation. In fact, the AMA's report against legalisation (also endorsed by the association American Nurses Association, the association American Psychiatric Association and many other medical associations) was the most cited document by the Supreme Court in its recent decision on assisted suicide and euthanasia. Many other associations and groups submitted briefs to the Supreme Court opposing the legalisation of assisted suicide.

(...) Among doctors, those most opposed to legalisation are palliative care specialists, those caring for elderly patients and psychiatrists with experience of suicidal patients. In other words, the doctors with the most knowledge and experience in caring for patients requesting assisted suicide are precisely those who, in general, are most opposed to its legalisation: they know that legalisation is an uninformed response to challenge to help such patients.

Supporters of legalisation say that they too are in favour of palliative care, but they seem to be much more in favour of assisted suicide and euthanasia. Their assertion, in their report to the Supreme Court, that withdrawing treatment is tantamount to assisted suicide only serves to confuse doctors and relatives, creating doubt when a patient asks for treatment to be withdrawn. Equally damaging is his comment that the sedation sometimes required at the end of life is akin to torture. Fortunately, the Supreme Court rejected both arguments. Doctors who oppose assisted suicide and euthanasia are the ones who are moving palliative care forward. They know that assisted suicide and euthanasia are bad medicine. Bad for doctors, bad for patients and bad for society.

Euthanasia without consent

The internship of euthanasia in the Netherlands has moved from the terminally ill to the chronically ill, from physical to mental illness and from voluntary to involuntary euthanasia.

The Remmelink study [an official 1990 study on the internship of euthanasia in the Netherlands] uses an even cruder expression, "termination of the patient without his or her explicit request", to refer to euthanasia performed without the patient's consent whether the patient is competent to decide or only partially competent or simply incompetent.

The study reveals that in more than 1,000 cases the doctor admitted to causing or hastening the patient's death without the patient's request. In 30 per cent of these cases, the reason given was the inability to treat the pain effectively. In the remaining 70 per cent, the reasons given varied from "lacked quality of life" to "treatment was withdrawn, but the patient did not die". The Remmelink Commission did not consider this to be a moral problem, as the suffering of these patients was "unbearable" and in any case they would normally have died soon. Twenty-seven percent of the doctors indicated that they had terminated a patient's life without request; another 32 percent said they would do so if necessary.

(...) I was curious to know how Eugene Sutorius [a famous lawyer defending doctors in euthanasia cases] would react when I told him that thousands of lucid and non-lucid patients were being put to death without their consent. When I told him about it, he said that there were times when doctors felt they had to act because patients or families could not. He knew of one case where a doctor had ended the life of a nun a few days before she had died a natural death because she was in great pain and the doctor knew that the nun's religious convictions did not allow her to ask for euthanasia. Sutorius found no argument, however, when I asked him why the nun had not been allowed to die the way she wanted to. (...)

"The doctor decides".

In the case of a patient who cannot decide for himself, who should decide whether he should live or die? Professor Joost Schudel, director of the KNMG [Royal Dutch Medical Society] subcommittee on medical decisions for the termination of life, which deals with end-of-life decisions for patients who are not mentally competent, stated unambiguously: "The doctor decides.

Professor Schudel explained to me that the criterion President that the doctor should follow with such patients is to ask himself whether he would agree to live if he were in their place. I asked him if the relatives could decide that the patient should stay alive, and Schudel repeated that no, "the doctor decides", adding that the Netherlands is not the United States, where patients have a greater say in medical decisions. It seems that in the Dutch context the relationship between patient and doctor is reaching a new dimension in which the doctor's wishes are assumed to be identical to those of the patient.

In demented patients

(...) In a way, the Dutch are kind of stuck when it comes to dementia patients. According to their definition, euthanasia is only possible for lucid patients, so they cannot approve it for demented people. Patients who feel the first symptoms of Alzheimer's disease but fear that their disease will worsen can, while they are still lucid, ask for euthanasia and receive it. But they cannot leave order to be euthanised when they lose their lucidity. These patients will therefore have to end their lives months or years earlier than they would have wished. A Dutch psychiatrist who feared the burden that his own dementia might one day place on his family told me that this is precisely what he intended to do.

The KNMG has somewhat modified this position by stating that if serious dementia is accompanied by severe physical pain, and if the patient has order in advance of death if he or she becomes insane, then his or her wish can be fulfilled.

(...) Like most doctors, Herbert Cohen was against the new legislation requiring that all cases in which a life has been ended without the patient's request should be report . He thought it was a silly idea, considering that it was an illegal internship . "You can't expect someone to turn themselves in after committing a crime," he said. He also said that "the doctor has an influence on death in almost all non-traumatic cases. Death is an orchestrated event".

(Paragraphs reproduced with permission).