Coercion and Involuntary Euthanasia

Research undertaken in the Netherlands and Oregon in the USA show how patients are coerced to accept euthanasia and/or assisted suicide as 'medical treatment'. Coercion can come from physicians, family or due to a lack of adequate palliative care.
  • The guidelines established by the Dutch for the practice of assisted suicide and euthanasia have been consistently violated and cannot be enforced.
  • Palliative care and hospice in the Netherlands has been a casualty of the practice of ethanasia and assisted suicide.
  • Doctors in Oregon are not required to be knowledgeable about how to relieve either physical or emotional suffering in terminally ill patients.
  • Quote: "It could have taken another week before she died. I just needed this bed."
  • Many physicians choose the option of euthanasia rather than train in palliative care, because it is easier for them.
  • Dutch doctors who have undergone training in palliative care have publicly expressed their regrets over having previously euthanised patients due to their lack of knowledge.
Many terminal patients enduring pain do not wish to terminate their lives. Most of those who do, can do so without a doctor's involvement.

Those opposed to the legalisation of euthanasia and asisted suicide (EAS) warn that the pressures upon people with disabilities to choose to end their lives, and the insidious appropriation by others of the right to make that choice for them (i.e., medical professionals and the Courts) are already way too common in our society.

These pressures are increasing and will continue to grow as managed health care and limitations upon health care resources cause increased "rationing" of health care services and health care funding.

The world's largest and most effective euthanasia propaganda group owes its foundation and growth to one man, Derek Humphry, who has been involved in the questionable suicides of two of his wives.iii Hemlock leaders admit that they seek to legalise euthanasia for not just the terminally ill, but on a "quality of life" basis. This would include the disabled and those with "incurable" illnesses that are not terminal. 1

The Netherlands
Dr Herbert Hendin, professor of psychiatry at New York Medical College and medical director of the American Foundation for Suicide Prevention, was one of a few foreign researchers who had the opportunity to extensively study the situation in the Netherlands, discuss specific cases with leading Dutch practitioners and interview Dutch government-sponsored euthanasia researchers about their work.

Thay all independently concluded that guidelines established by the Dutch for the practice of assisted suicide and euthanasia were consistently violated and could not be enforced.

According to the guidelines, a competent patient who has unrelievable suffering makes a voluntary request to a physician. The physician, before going forward, must consult with another physician and must report the case to the authorities.

The Dutch government, concerned over accusations that the practice of euthanasia was being abused, undertook studies in 1990, 1995 and in 2001. Physicians were guaranteed anonymity and immunity for what they revealed in regard to violations of the guidelines.

It quickly became apparent that half of Dutch doctors had no hesitation in suggesting their patients consider euthanasia, which compromised the voluntariness of the process. In addition, fifty percent of cases were not reported.

Even more alarming was the fact that a quarter of the physicians said that they "terminated the lives of patients without an explicit request" from the patient, and another third of the physicians said that they could conceive of doing so.

Dr Hendon illustrated this with a case he had discovered, involving a Dutch nun who was dying painfully of cancer.
"Her physician felt her religion prevented her from agreeing to euthanasia so he felt both justified and compassionate in ending her life without telling her he was doing so.

Practicing assisted suicide and euthanasia appears to encourage physicians to think they know best who should live and who should die, an attitude that leads them to make such decisions without consulting patients--a practice that has no legal sanction in the Netherlands or anywhere else." 2
In another instance a physician ended the life of a patient with breast cancer because, he said, "It could have taken another week before she died. I just needed this bed."

Dr Hendon says that other studies conducted in the Netherlands have indicated how voluntariness is compromised, alternatives not presented and the criterion of unrelievable suffering bypassed. He gives some examples to illustrate how this occurs:
  • A wife, who no longer wished to care for her sick, elderly husband, gave him a choice between euthanasia and admission to a home for the chronically ill. The man, afraid of being left to the mercy of strangers in an unfamiliar place, chose to have his life ended; the doctor although aware of the coercion, ended the man's life.
  • A healthy 50-year-old woman, who lost her son recently to cancer, refused treatment for her depression and said she would accept only help in dying. Her psychiatrist assisted in her suicide within four months of her son's death. He told me he had seen her for a number of sessions when she told him that if he did not help her she would kill herself without him. At that point, he did. He seemed on the one hand to be succumbing to emotional blackmail and on the other to be ignoring the fact that even without treatment, experience has shown that time alone was likely to have affected her wish to die.
  • Another Dutch physician, who was filmed ending the life of a patient recently diagnosed with amyotrophic lateral sclerosis, says of the patient, "I can give him the finest wheelchair there is, but in the end it is only a stopgap. He is going to die, and he knows it." That death may be years away but a physician with this attitude may not be able to present alternatives to this patient. 3
Palliative care suffers
Palliative care in the Netherlands has been a casualty of the practice of ethanasia and assisted suicide and hospice care is not as well developed as in other countries.

In testimony given before the British House of Lords, Zbigniew Zylicz, one of the few palliative care experts in the Netherlands, attributed Dutch deficiencies in palliative care to the easier alternative of euthanasia.

Although the Dutch government has attempted to stimulate palliative care at six major medical centres throughout the Netherlands, established more than 100 hospices and provide for training professionals caring for terminally ill patients, many physicians choose the easier option of euthanasia rather than train in palliative care.

Studies show that the less physicians know about palliative care, the more they favor assisted suicide or euthanasia; the more they know, the less they favor it.

A number of the doctors who have undergone the training in palliative care have publicly expressed their regrets over having previously euthanised patients because they had not known of any viable option.

Oregon
Dr Hendon compared what he learned in the Netherlands with Oregon, the only American state to legalise assisted suicide.
"In Oregon, when a terminally ill patient makes a request for assisted suicide, physicians are required to point out that palliative care and hospice care are feasible alternatives. They are not required, however, to be knowledgeable about how to relieve either physical or emotional suffering in terminally ill patients.

Without such knowledge, the physician cannot present feasible alternatives. Nor are physicians who lack this knowledge required to refer any patient requesting assisted suicide for consultation with a physician knowledgeable about palliative care.

The inadequacy of palliative care consultation in Oregon was underscored by a survey of Oregon physicians who received the first 142 requests for assisted suicide since the law went into effect. In only 13% of cases was a palliative care consultation recommended, and we do not know how many of these recommendations were actually implemented."
Dr Hendon uses two cases to show how compromised the offer of palliative care can become.

The first patient, referred to by her physician as "Helen," was the first known case of physician-assisted suicide in the state and received much publicity from the Compassion in Dying Federation, an advocacy organisation for physician-assisted suicide.
Helen, an Oregon woman in her mid-80s, had metastatic breast cancer and was in a home-hospice program. Her physician had not been willing to assist in her suicide for reasons that were not specified and a second physician refused on the grounds that she was depressed.

Helen called Compassion in Dying and was referred to a physician who would assist her. After her death, a Compassion in Dying press conference featured a taped interview said to have been made with Helen two days before her death. In it, the physician tells her that it is important she understand that there are other choices she could make that he will list for her--which he does in only three sentences covering hospice support, chemotherapy and hormonal therapy.

Doctor: There is, of course, all sorts of hospice support that is available to you. There is, of course, chemotherapy that is available that may or may not have any effect, not in curing your cancer, but perhaps in lengthening your life to some extent. And there is also available a hormone which you were offered before by the oncologist, tamoxifen, which is not really chemotherapy but would have some possibility of slowing or stopping the course of the disease for some period of time.

Helen: Yes, I don't want to take that.

Doctor: All right, OK, that's pretty much what you need to understand.
A diagnosis of depression is not usually regarded as a sufficient reason for a referral to a licensed psychiatrist or psychologist, yet studies have shown that non-psychiatric physicians are not reliably able to diagnose depression, let alone to determine whether the depression is impairing judgment.

Patients who desire an early death during a serious or terminal illness are usually suffering from a treatable depressive condition.

Case two was Joan Lucas, a woman with amyotrophic lateral sclerosis, who had attempted suicide. Hendon states:
"Lucas survived her attempt and was assisted in suicide 18 days later by a physician who gave interviews about the case to an Oregon newspaper on condition of anonymity. He stated that after talking with attorneys and agreeing to help aid Lucas in her death, he asked her to undergo a psychological examination.

"It was an option for us to get a psychological or psychiatric evaluation," he told the newspaper. "I elected to get a psychological evaluation because I wished to cover my ass. I didn't want there to be any problems."

The doctor and the family found a cooperative psychologist who asked Lucas to take the Minnesota Multiphasic Personality Inventory (MMPI). Because it was difficult for Joan to travel to the psychologist's office, her children read the true-false questions to her at home. The family found the questions funny, and Joan's daughter described the family as "cracking up over them."

Based on these test results, the psychologist concluded that whatever depression Joan had was directly related to her terminal illness--a completely normal response. His opinion is suspect, the more so because while he was willing to give an opinion that would facilitate ending Joan's life, he did not feel it was necessary to see her first.
Hendon points out that although Oregon doctors may not have known the patient for longer than 15 days, they are expected to:
  • inform patients that alternatives are possible without being required to be knowledgeable enough to present those alternatives in a meaningful way, or to consult with someone who is
  • evaluate patient decision-making capacity and judgment without a requirement for psychiatric expertise or consultation
  • make decisions about voluntariness without having to see those close to the patient who may be exerting avariety of pressures, from subtle to coercive
A disability perspective
People with disabilities are among society's most likely candidates for ending their lives. As the experience in the Netherlands demonstrates, there is also little doubt that legalising assisted suicide generates strong pressures upon individuals and families to utilise that option, and leads very quickly to coercion and involuntary euthanasia.

The so-called "slippery slope" already operates in regard to individuals with disabilities and decisions to discontinue life-support systems and "Do Not Resuscitate" orders. It is likely to expand dramatically if physician-assisted suicide were to become legal.

Not only would the lives of people with any disability deemed too difficult to live with be at risk, but persons with disabilities who are poor or members of racial minorities as well as the elderly are likely to be in the most jeopardy of all.

For many people with disabilities, society has frequently made it clear that it believes they would be better off dead, or better that they had not been born. But it is more often the discrimination, prejudice, and barriers that they encounter, and the restrictions and lack of options that this society has imposed, rather than their disabilities or their physical pain, that cause people with disabilities' lives to be unsatisfactory and painful.

References:
  1. Hemlock Quarterly, 10/84
  2. Herbert Hendin, M.D., The Case Against Physician-Assisted Suicide: For the Right to End-of-Life Care Psychiatric Times February 2004 Vol. XXI Issue 2
  3. Ibid