Could there be a worse place in the world to be a doctor than the Netherlands? Not because of the standard of its health care; it has one of the highest life expectancies in the world and one of the lowest infant mortality rates. But because the professional association of Dutch physicians has decreed that euthanasia is an integral part of a doctor's job.
This became clear earlier this month when the national association, the Royal Dutch Medical Association (KNMG), issued a report, "The role of the physician in the voluntary termination of life". It is a long document whose carefully phrased distinctions, detached reasoning and urbane tone mask its chilling message: that the Dutch medical profession has capitulated to the culture of death.
Although the KNMG's policies do not have the force of law, they are very influential and help to frame legislation. What it proposes is far more radical than anything suggested by its counterparts in English-speaking countries. The thrust of this report is that there is a professional obligation always to deal sympathetically with requests for euthanasia. Even if doctors are morally opposed, they must refer patients who want to die to a willing colleague.
Ten years after legalisation in the Netherlands, euthanasia for the terminally ill has become commonplace. Some elderly people are so afraid of being killed by doctors that they carry please-do-not-euthanse-me cards. About 2,400 people officially die through euthanasia every year -- although the real number may be significantly higher because doctors often fail to dol the paperwork required by the government.
Now public debate has moved on to euthanasia for those who are weary of life but not ill and euthanasia for people with dementia and psychiatric conditions.
A group called Uit Vrije Wil ("By Free Choice") claims that those over 70 who feel that they have "completed life" and wish to die a "dignified death" should be able to get professional assistance. This is currently illegal in the Netherlands, because patients have to have a terminal illness or unbearable suffering. But the KNMG does not appear to be opposed to the movement in principle - and this colours its recommendations for how doctors should approach requests for death.
As for people with dementia and other psychiatric conditions, the KNMG insists that they are already covered by the current law. There is a chilling paragraph in the report which argues that the notion of unbearable suffering can be expanded much further than most Dutch doctors realise:
"The current statutory framework and the concept of suffering are broader than their interpretation and application by many physicians to date. Vulnerability - extending to such dimensions as loss of function, loneliness and loss of autonomy - should be part of the equation physicians use to assess requests for euthanasia. The result of this non-linear sum of medical and non-medical problems, which are usually not in themselves life-threatening or fatal, can lead to lasting and unbearable suffering within the meaning of the Euthanasia Law."
The implication of this is that the burdens of old age alone are sufficient to request euthanasia. "An accumulation of geriatric afflictions, including loss of function, that result in progressive deterioration may also qualify as unbearable and lasting suffering" for which euthanasia is a solution, says the report.
What if a patient does not have unbearable suffering but still wants to die? In this case, he cannot legally resort to euthanasia, but he can decide to stop eating and drinking.
"Refused this assistance by his physician, a patient with a strong wish to die may decide for himself to deny food and drink. In that case, the patient is making a conscious choice to hasten death. Studies indicate that there are some 2,500 such cases each year. These studies further show that the conscious denial of food and drink, when combined with effective palliative care, can offer a dignified death. The KNMG endorses this view."
Not only that. A doctor must respect a decision by a patient to starve himself to death and "is obligated, in such cases, to supervise the patient and to alleviate the suffering by arranging effective palliative care."
In other countries, a request to die is treated as a cry for help, a temporary derangement of one's instinctive desire to continue living. Doctors try to dissuade them. Dutch doctors are obliged to think differently:
"A patient should always be deemed competent unless there is evidence to the contrary. The wish to die does not, in itself, indicate a patient is suffering from depression."
What about a patient who is not suffering unbearably and who still wants to kill himself with lethal drugs like Nembutal? It is illegal for a doctor to encourage a patient to commit suicide or offer any assistance, the KNMG states. However, "There is no punishment for physicians and other persons if they provide information about suicide. Physicians are also legally permitted to refer patients to information that is available on the Internet or to publications sold by book vendors, or provide these on loan, and to discuss this information with patients."
So, if there is no unbearable suffering and a patient wants to commit suicide with stockpiled drugs, a Dutch doctor can give guidance without being liable for punishment.
The upshot of all this is that the peak professional body for doctors in the Netherlands is urging its members to help patients to die upon request. This is a complete reversal of the traditional life-saving role of doctors.
What about Dutch doctors who do not want to participate in euthanasia? They do exist, the KNMG acknowledges: "There will continue to be plenty of physicians who are either unwilling or morally indisposed to be able and willing to make full use of the statutory freedom, to which society is laying an increasingly vocal claim as integral to its right to self-determination."
The language of the KNMG's report oozes oleaginous sympathy for these moral fringe dwellers. "A request for euthanasia is one of the most intrusive and onerous demands that a patient can make of a physician. Most physicians find it difficult to perform euthanasia or assisted suicide. This is all the more true if that wish is not prompted by a terminal illness."
However, the message of the report is clear: cooperation is mandatory. If a doctor does not want to cooperate directly, "there is a moral and professional duty to provide patients with timely assistance in finding a physician (for example, within the practice) who does not have fundamental objections to euthanasia and assisted suicide."
This also extends to patients who want to die who are not even eligible for legal euthanasia. If they want to starve themselves to death, "the physician is obligated, in such cases, to supervise the patient and to alleviate the suffering by arranging effective palliative care." If patients want to kill themselves with drugs, "Physicians have a professional duty to engage a patient in discussion" about the pros and cons of the methods.
What lies ahead for the practice of medicine in the Netherlands? The report observers that there are already 1 million elderly with "multimorbidity" and in ten years' time there will be 1.5 million - 10 percent of the population. All of these will be eligible for euthanasia if their suffering feels interminable and their life seems meaningless. The peak body of Dutch doctors seems to be preparing for an avalanche of elderly anguish by forcing its members to honour nearly any request to die. If this is not a repudiation of all that doctors stand for, what is?