Citizens' opinions on new forms of euthanasia. A report from the Netherlands

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Abstract

Euthanasia strictu sensu is about ending a patient's life at his or her explicit request. However, there are many cases of ending someone's life that are related to euthanasia in its classical form but do not neatly fit into the strict definition. Dutch citizens were asked to judge all kinds of `euthanasia' and appeared to be able to do this in a highly balanced way. They do not use just one or two criteria to judge various cases of euthanasia, they seem to evaluate each new case on its own merits and they do so in a very thoughtful and sophisticated way, using a refined combination of criteria.

Introduction

Public debate on euthanasia in the Netherlands has made a rather intriguing U-turn over the years. It started with a much discussed pamphlet by J.H. van den Berg, entitled Medical Power and Medical Ethics (1969) [1]. Van den Berg discussed a number of tragic cases of, in his phraseology, victims of medical power. Had they but lived 100 or even 50 years ago, they would have been allowed to die in peace. These days, however, they are being kept alive, simply because their doctor is able to keep them alive regardless their best interests. Van den Berg's cases include a senile woman suffering from Alzheimer's disease; a newly born baby whose mother had been given thalidomide and who consequently did not have arms or legs; and a hydrocephalic, severely retarded young man who could not do anything other than lie in bed and whose life was prolonged by a drain from his brain. Van den Berg suggested that all these victims of medical power should be granted a dignified death. Following Van den Berg's publication Dutch opinion leaders discussed the (moral and other) pros and cons of different varieties of medical mercy killing: active killing, passive or indirect killing, death in the patient's best interest, at the patient's request, voluntary and involuntary euthanasia. Gradually, the debate narrowed down to one particular form of euthanasia, probably due to the fact that this particular form had been submitted to legal judgment in several famous court cases. Henceforth, euthanasia was defined as ending a patient's life at his or her explicit request (in 1985 this definition became official when the state committee on euthanasia chose to use it in their final report) [2].

Recently, however, public debate turned back to the tragic cases in Van den Berg's little book. This U-turn was preceded by empirical research (first and foremost two large scale research projects commissioned by the government 3, 4, 5) which had shown that the number of cases that would qualify as clear cut euthanasia (in the official definition) was much smaller than might have been expected. Medical practice seemed to involve a large number of other decisions regarding the end(ing) of life, many of them much more ambivalent than straightforward euthanasia (administering ever growing doses of morphine for instance), and some of them dealing with patients who could not be considered fully competent. The Royal Dutch Medical Association (KNMG) published four widely discussed reports on end-of-life decision making with regard to incompetent or less competent patients: severely handicapped newborn infants, irreversibly comatose patients, senile patients in the last stages of Alzheimer's disease, and psychiatric patients [6]. In 1996 two physicians were prosecuted (but not convicted) for having terminated a severely handicapped infant's life. A well known retired law professor (and former member of the Dutch Supreme Court) argued that old people should be given the right to ask their doctor for lethal medications, so as to prevent the last stages of old age (dementia, nursing homes, increasing invalidity). In short: the debate was broadened considerably. These days a number of new or rediscovered issues are being discussed that were not on the public agenda during the 1980's when the debate was structured around the official state committee's definition of euthanasia.

Until recently public opinion research took (almost) no notice of these new developments. Over the years an impressive number of opinion polls have been held to find out how Dutch citizens feel about euthanasia strictu sensu. The number of citizens who approve of euthanasia at the patient's explicit request grew from 40% in 1966 to over 60% (in some polls almost 80%) in 1993. Likewise the number of opponents decreased steadily (21% in 1986, 17% in 1989, 12% in 1994) 7, 8, 9, 10. Few opinion researchers took the trouble of asking their respondents how they felt about other forms of euthanasia; see for an exception the study undertaken by Veenhoven and Hentenaar [11]. It seems both interesting and important to remedy this deficiency. What do ordinary Dutch citizens think of medical killing that does not qualify as euthanasia in the old Dutch definition? After a long period of public debate in which the importance of the patient's explicit request was emphasized time and again, citizens might disapprove of any form of medically induced death which is not grounded in such a request. On the other hand, several pessimistic observers of Dutch euthanasia policy have predicted that people are bound to lose every sense of distinction, once the norm of the holiness of human life is infringed upon. It might be that the semi-legalization of euthanasia in the Netherlands has resulted in a certain loss of moral standards: people might have come to think that every kind of medically authorized death is morally permissible. Are Dutch citizens still able to distinguish between different kinds of medical decisions regarding the end of life?

In this article we present the results of a public opinion research on several forms of end-of-life decision making. We will try to find out whether ordinary Dutch citizens are able to distinguish between different sorts of euthanasia and if they are, what kind of distinctions they make. Henceforth we will refer to different forms of medical mercy killing as `euthanasia'; ending a patient's life at his or her own explicit request will be referred to as `euthanasia strictu sensu', as `euthanasia in the traditional Dutch definition' or some similar formulation.

Section snippets

Methods

In May 1995 we mailed a questionnaire to a random sample of 2000 households in the Dutch population; the sample was provided by the Postal Office. In an accompanying letter, we described the procedure for drawing a sample within the household: the questionnaire was supposed to be filled in by a person 18 years of age or older, more specifically the person whose birthday would be first follow the receipt of the questionnaire. One week after sending the questionnaire a reminder was sent. A total

The classical case of euthanasia

Our first sketch presented the case of Mr. Bootsma, an example of euthanasia in the classical, strict sense. We presented this case as follows:

Mr. Bootsma has an incurable muscular disease. He cannot walk, talking is getting harder. The disease will paralyse him more and more and chances are big that he will suffocate eventually. Bootsma told his wife and his doctor several times that he does not want it to come this far. He wants the doctor to help him die. After consulting another doctor,

Multiple criteria in evaluating euthanasia

Dutch citizens apparently are able to judge all kinds of examples – presented as invented cases but modeled on reality – of `euthanasia' and the first impression is that they are able to do so in a more or less sophisticated way: not all cases we presented to our respondents were the same, and not all opinions were the same. Moreover it does not seem possible to attribute differences in opinion to one or two specific criteria. To name but a few examples. The public discussion on euthanasia

Conclusion

Our explorative factor analysis of public opinion suggests that people evaluate euthanasia situations one by one and they do this from different perspectives and on the basis of a diversity of norms and values. Does a doctor have the right to terminate human life? Do we have to do with a physical or mental illness? Is there an explicit request? Is the patient old or not? How hopeless exactly is the situation? Are we dealing with a very special case, for instance a mongoloid baby for whom the

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