"Strict", "scrupulous" and "rigid". These are some of the words that have been used to describe the regulation of physician-assisted suicide (PAS) in the Netherlands. But how closely are doctors actually monitored?
A new study by researchers from the National Institutes of Health (NIH) suggests that the Dutch euthanasia review committees (RTE) struggle to judge whether doctors have correctly applied PAS criteria, and are ultimately dependent on the transparency with which physicians report cases of PAS.
The study, authored by David Miller and Dr Scott Kim from the NIH's bioethics department, analyses 33 cases from 2012-2016 in which the RTE committees deemed that doctors had failed to meet due care criteria.
The results are revealing. In light of the "open-ended" and "evolving" nature of the Dutch criteria for PAS, the RTE committees focus primarily on whether doctors have followed procedural regulations, rather than whether the patient was actually eligible for euthanasia.
"Evaluating patient's [euthanasia] requests requires complicated judgements in implementing criteria that are intentionally open-ended, evolving and fraught with acknowledged interpretive difficulties. Our review suggests that the Dutch review system's primary mode of handling this difficult is a trust-based system that focuses on the procedural thoroughness and professionalism of physicians". The study found that out of 33 cases reviewed, 22 failed to meet only the procedural due care criteria (i.e., due medical care and consulting an independent physician). "These criteria are more clearly operationalised than other criteria", the authors observe.
In seven of the cases, the committee deemed that the consulting physician was not sufficiently independent from the PAS physician. In 14 of the cases, physicians were found not to have followed "due medical care". The authors write that "this criterion was most commonly not met because physicians incorrectly used drugs, dosing regimens (too low), rout of administration (intramuscular instead of intravenous) or order of administration of EAS drugs (eg, paralytic before sedative)."
Even when substantive criteria were at issue, the authors write that " the RTE's focus was generally not on whether the physician made a 'correct' judgement, but on whether the physician followed a thorough process (ie, whether the physicians should have consulted specialists or evaluated the patient further, but not whether the patient should have received EAS)".
In six of the cases, the RTE found that the PAS physician had not been thorough enough in applying the "unbearable suffering" criterion.