Dutch perspectives on palliative care in the Netherlands

Issues in Law & Medicine, Fall, 2002 by Raphael Cohen-Almagor

On November 28, 2000, the Dutch Lower House of parliament, by a vote of 104 for and forty against, approved the legalization of euthanasia. On April 10, 2001 the Dutch Upper House of parliament voted to legalize euthanasia, making the Netherlands the first and at that time only country in the world to legalize euthanasia. Forty-six members of the seventy-five-seat Senate voted for the Termination of Life on Request and Assistance with Suicide Act; twenty-eight voted against; one member was not present. The new legislation makes it legal to end a patient's life, subject to the following criteria: the patient must be suffering unbearable and unremitting pain, with no prospect of improvement. The patient must make a sustained, informed and voluntary request for help to die. All other medical options must have been previously exhausted. A second medical opinion must be sought to confirm diagnosis and prognosis. The termination of life must then be carried out with medically appropriate care and attention. The physician is obliged to report the death to the municipal pathologist, specifying whether the cause of death was euthanasia or assisted suicide. (14)

Physicians will be immune from prosecution for helping a patient to die, as long as they follow this set of Guidelines. They will still report cases of voluntary euthanasia to the coroner and a regional panel, who can recommend prosecution leading to a prison sentence of up to twelve years if the Guidelines have not been followed. The new Act changed the emphasis on who should prove guilt or innocence if the code of practice is breached. Previously, the onus was squarely on the doctors to prove that they had followed the Guidelines and were therefore innocent of any offence. But the new law shifts the responsibility for proving guilt to the regional panels. (15) Time will tell to what an extent the new law will improve the situation.

The concern of this article lies with the practice of palliative care. The World Health Organization defines palliative care as the "active, total care of patients whose disease is not responsive to curative treatment," maintaining control of pain, of other symptoms, and of psychological, social, and spiritual problems, is paramount. (16) Impediments to adequate pain treatment include health care providers' fear of inducing physical or psychological addiction, misconceptions about pain tolerance, and assessment biases. (17) Herbert Hendin testified that his experience with a few Dutch physicians who had performed or been consultants in dozens of euthanasia cases indicated that they were uninvolved in palliative care. (18) Zbigniew Zylicz, one of the few palliative care experts in the Netherlands, regards the lack of hospice care and the fact that there are only seventy palliative care beds in the country as reflections of having the easier option of euthanasia. He argues that palliative care is virtually unknown in the Netherlands and that people mistakenly equate palliative care with the use of morphine or other drugs, not understanding that it involves much more than the use of painkillers. (19) The aim of this study was to determine what leading authorities in the euthanasia field in the Netherlands think about this issue, i.e., whether they think their country has a developed practice of palliative care.