Dutch perspectives on palliative care in the Netherlands

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

Johannes van Delden (39) estimated that the fact that the Netherlands does not have many hospices should not be taken as an indication that "we don't have palliative care." Rather, "we organize things differently." (40) Van Delden, who co-authored the 1990 comprehensive research project, asserted that doctors know how to deal with pain, GPs do receive adequate education and training in this sphere, and, in any event, palliative care involves more than just ameliorating pain. It also involves providing psychological support for the patient. While acknowledging that there is room for improvement in this area, Van Delden argued that euthanasia has actually paved the way for calling more attention to palliative care. He emphasized that euthanasia does not exclude palliative care, but the reverse, and adamantly objected to the accusation that lack of palliative care has resulted in greater acceptance of euthanasia. Van Delden noted the problem that sometimes patients refuse to receive palliative care and expressed his uncertainty about whether doctors should comply with euthanasia requests under such circumstances. (41)

George Beusmans, a GP who practices euthanasia, substantiated Van Delden's arguments, (42) testifying that he received education on palliative care and contending that this aspect does not present a major problem. He considers himself to be qualified in evaluating suffering and in providing proper medication and palliative care. But pain is not the primary issue in question. People that request euthanasia suffer not only from physical pain, but also from anguish, dependence on others, and anxiety regarding the unknown. They ask for help because they have lost the sense of purpose in waiting and see no good reason for prolonging their situation.

Govert den Hartogh, a philosopher who is a member in the Amsterdam regional committee that reviews all reported euthanasia cases in the region, provided the most extensive answer, claiming that the flip side of the fact that GPs are involved in euthanasia is that they are not fully aware of palliative care. (43) While acknowledging that palliative care cannot serve as a complete substitute for euthanasia, Den Hartogh insists that euthanasia should be used only as the last resort. The doctor should first try to alleviate suffering by other means and resort to euthanasia only when all those other means have failed. At the same time, Den Hartogh does not think that Dutch doctors are less knowledgeable about palliative care than doctors in other countries. Furthermore, Den Hartogh holds that while palliative care is available to patients in hospitals, many patients still choose to leave the hospital and return home to die by requesting euthanasia. This can be seen as an indication that euthanasia is in fact performed on many occasions after palliative care has been tried.

In his comments on the first draft of this study, Den Hartogh elaborated on his answer, arguing that it is false to think that palliative care can provide a viable alternative to euthanasia in all cases. There are many instances in which no pain relief can be given, except by sedating the patient into unconsciousness. Furthermore, we need to take into account the many other forms of suffering besides pain, which can be part of the process of dying, and for which relief may be unavailable or insufficient. Den Hartogh rejects the suggestion that palliative care is neglected because the Netherlands has euthanasia as an alternative. It is essential in this respect to see palliative care as an integral part of medical care for the dying, whether it is given in an institutional setting or (as the Dutch generally prefer) at home. It is nowadays a normal practice for a GP who is responsible for the treatment of cancer patients to act in constant consultation with a hospital's pain-relief team. Of course, there is more to palliative care than pain relief. (44)