November 5, 2013 | Posted By Marleen Eijkholt, PhD

Last week, Dutch newspapers report about a Dutch physician who committed suicide after he had been suspended from his job, pending examination of his involvement in a Euthanasia case. The Dutch Inspection for Health Care (the Inspection or the IGZ), an institution that oversees quality in health care  with administrative powers or powers to bring cases to the Public Prosecution, had received reports about the physician’s inappropriate behaviour and the police had questioned him intensely. The reports awakened fear on Dutch soil, on both physicians and on the public’s side. It seemed hard to imagine that a Dutch physician would act inappropriately in the system that is firm from the inside, but so vulnerable for the outside. Why and how would someone pose a threat to the process?

Euthanasia and physician assisted suicide (PAS) legislation in the Netherlands or in Belgium regularly sparks controversial headlines in international newspapers: Headlines report on the increase in cases of Euthanasia or PAS: “Mobile death squads to kill sick and elderly in their own homes leads to surge in suicide rates in the Netherlands”, extension of grounds for requests: such as failed gender reassignment, and the possibilities of accessing euthanasia interventions. They seek to create fear about death squads and a vulnerable (elderly) population that is pressured into Euthanasia or that is euthanized involuntarily. Hardly any attention is paid to the process around Euthanasia.

Dutch newspapers, on the contrary, are much less concerned about the practice. Euthanasia or PAS are hardly a matter of controversial news. The public has accepted (and requested) the practice and Euthanasia is mostly dealt with the realm of public trust. Dutch individuals request the freedom to access such practice and generally believe in the process surrounding it. This process relies on a series of criteria that allow for Euthanasia, these criteria are called ‘criteria for carefulness’. Fear of the public is not so much an issue. Those who are not in favour of the practice accept that differences in opinion exist and that it is contained within a framework that they do not have to access. If newspapers report on Euthanasia, like last week, news tends to be big, even if they focus on the process.

The National Association for Primary Care Physicians (NAPCP or LVH) demanded transparency from the Inspection about what had happened. Concerned about the process in which Euthanasia is embedded, such a serious incident would threaten public trust and the reporting system. In response, the Inspection initially reported not wanting to provide details about the case due to violation of privacy of both the patient and the physician. Public pressure prevailed in the end however, and the Inspection revealed what had happened.

At this stage, I believe it’s useful to clarify the process of Euthanasia under Dutch legislation. I alluded to its dimensions in an earlier post, but here I will state them more formally.

Dutch legislation contains two clauses that exempt physicians from criminal prosecution in cases of Euthanasia or PAS. In cases where a physician administers a drug that brings about the death of another person/ hastens the death of another person, six criteria govern decisions when a physician is exempted from criminal charges. Exemption can be granted if all of the following 6 criteria are fulfilled. There needs to be: 1. Request from a patient with capacity for his/her Euthanasia 2. This request was voluntary and considerate 3. No prospect of recovery from the patient’s condition 4. Unbearable suffering of the patient, 5. No other reasonable solutions for the situation. 6. Physician that concurs with criteria 1-4, 7. Reports this death by Euthanasia to the coroner.

The Inspection published their case file, which showed that the physician had administered 1 gram of morphine to the patient, about 100 times the allowed dosage. Additionally it noted that the case was brought by the resident who had witnessed the process, who had challenged the physician but was dismissed, and then had reported it to her supervisor who brought it to the Inspection. Everything from the resident’s statement was revealed including controversial quotes from the physician. The physician’s statements were also revealed including that he had acted on a cry for ‘help me’ of the patient and that he had known the patient for 21 years. He suggested that there had not been enough time to go through all the administrative procedures for Euthanasia.

All through the reporting of this case, the deceased patient’s family was furious with the inspection and the publication of the entire file. Their husband and father had been suffering; he was terminally ill and was in his last days on earth. He had had a really stressful time due to his breathing difficulties, while he wanted to be at home. They widow emphasized that the physician had acted compassionately. Their loved one had gone in peace. They suggested that publication of the entire file was an unacceptable breach of privacy, only to justify the Inspection’s course of action, rather than to provide clarity around the process.

Several questions arise from this case description: 1. What was the role of the resident in this process, did she show moral courage in reporting on this case or did she violate the trust between her and the physician? 2. What is the role for privacy in this case: both the patient and the physician are deceased, but information about the case is still sensitive for the family of the physician and the patient. Would this violation of privacy be justified in the light of public trust and who do we owe this public trust?? However, the ultimate question, in my opinion, is: Would transparency and emphasis on the process create more or less public trust for the system? 

The Alden March Bioethics Institute offers a Master of Science in Bioethics, a Doctorate of Professional Studies in Bioethics, and Graduate Certificates in Clinical Ethics and Clinical Ethics Consultation. For more information on AMBI's online graduate programs, please visit our website.

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