Dutch doctors blackmailed and pressured in euthanasia requests.

Alex Schadenberg
Executive Director - Euthanasia Prevention Coalition

This week I wrote an article titled: Dutch doctors pressured in euthanasia requests based on the abstract of a study and and an article in the Medical Bag. 

This follow-up article reports on the full study - Pressure in dealing with requests for euthanasia or assisted suicide. Experience of general practitioners.

The study interviewed 22 General Practitioners (GPs) and did indepth interviews with 15 GPs. The indepth interviews concerned 36 euthanasia deaths whereby the GP felt pressured. The study concluded that:

GPs experienced in dealing with EAS requests were revealed: (1) emotional blackmail, (2) control and direction by others, (3) doubts about fulfilling the criteria, (4) counterpressure by patient’s relatives, (5) time pressure around referred patients and (6) organisational pressure.

According to the study 11 of the 15 GP's had done euthanasia many times, while the other four had done it once. The study described incidences of emotional blackmail:

GPs experienced pressure in cases where they felt emotionally blackmailed to perform EAS as if it were the patients’ right. This may be patient’s threatening to commit suicide: ‘If you do not help me this week I will have to jump’ (Case 2.3); family members threatening to murder the patient: ‘Well, will I have to do it myself then, will I have to put a pillow over her head? And then you will be the guilty one’ (Case 9.1); or jointly by patient and family: The patients says: ‘I want it [euthanasia] now, or else I will hang myself from the bridge,’ to which the partner of the patient reacts by saying: ‘he will do it for real’ (Case 6.2). 

These examples show how euthanasia can be a form of suicide by doctor, whereby the doctor reacts to suicide ideation with lethal injection. 

Under the heading, control and direction by others, the study states:

For example, in the case where the GP was still in the process of willingness to discuss euthanasia in due time and the patient suddenly said: ‘I have made up my mind, I want it [euthanasia] after my birthday, because I still want to celebrate my birthday.’ At this point, this GP started ‘feeling pressure, because she [the patient] very much took over control’ (Case 5.1). ... Another GP described his unpleasant feeling when the patient who was about to receive euthanasia opened the door himself and led the GP into the living room which was full of people as if it was a birthday party: ‘Everybody had a glass of wine in his hands, while I was preparing the euthanatica’ (Case 13.3).

Case 13.3 shows a person who was not dying, opened the door to let the doctor into a room full of people who were having a "euthanasia party."

The study comments on circumstances when the GP had doubts about the death fulfilling the criteria.

GPs reported also to experience pressure, in case they had doubts about fulfilling the legal criteria for EAS. One GP provided the example of a patient who was suffering from increasing dependency and loss of control: ‘I needed multiple meetings and time for myself to feel this [type of suffering] was enough for euthanasia.’ Looking back she felt forced to make a decision in a situation which to her felt as ‘too soon’ (Case 11.2). Another GP told about how she questioned herself whether the request for euthanasia of a patient with metastatic colon cancer was perhaps grounded in fear and ‘Can unbearable fear be a ground for euthanasia?’ She sighed: ‘In the acute moment you are actually on your own [to decide]’ (Case 6.3). 

These instances show how decisions are made to approve euthanasia in questionable circumstances.

The study then comments on counterpressure by patient’s relatives.

One GP counteracted this pressure by encouraging the patient to explicitly state to her partner: ‘I am dying, not you, and I am the one making this decision’ (Case 4.1). Another GP decided ultimately to not grant the EAS request because she did not want to ‘give your [the patients] wife a unacceptable problem and huge grief to [his] children,’ but was left with the feeling ‘we could have saved him [the patient] from dreadful weeks’ (Case 5.3).

Physicians should never euthanize a patient when the spouse is opposed. The death tranfers the pain from the person who is dying to the person who survives and the survivor is forced to live with the emotional and psychological pain, related to the euthanasia death. Last year I published this article: Grief and Suffering associated with death by euthanasia. 

Under the title: time pressure and referred patients, the study states:

There are cases where the GP feels pressured by the circumstances of a referred patient, with whom he/she lacks time to develop a trusting relationship. ... While the patient felt ‘I have already talked this through and I want it [euthanasia] now,’ the GP found herself at the beginning of the decision-making process because this patient was just referred to her. Another GP described a patient who had ‘moved’ to one of his colleagues because they did not bond very well. Unfortunately, this colleague was not able to work around the moment the euthanasia was planned to be performed. The GP told: ‘Then I took back the euthanasia case of this patient, and I experienced it as a very annoying euthanasia.…I rather had not performed this euthanasia’ (Case 4.3). The GP felt he had no other option than to continue the euthanasia process his colleague already started

The last area, the study examines, is organisational pressure. The study reports:

Many GPs made reference in general terms to the difficulty of combining a euthanasia case with the daily work in their GP practice. All the arrangements to be made with regard to the pharmacy and the planning of consultations with other patients are referred to as ‘organizational hassle.’ ... Euthanasia may also interfere with a GP’s family life, as explained by a GP who became very introvert and not very nice around the time cases took place, even to the extent that his wife had told him, ‘I do not want you to do that anymore.’

The concern that this study uncovers is that some euthanasia deaths are done based on pressure by the patient or by the family. In other words, these doctors are agreeing to kill a patient because they feel pressured to do the act.

This study purports to be the first study to explore the content of the pressure experienced by GP's concerning euthanasia requests, but a much larger Netherlands study interviewed 800 GP's in 2011 

I was recently contacted by a man living with quadriplegia who felt pressured by medical staff to "ask" for euthanasia. Candice Lewis and Roger Foley were also pressured to "request" euthanasia. The common denominator is that the person who is being pressured to death is living with a significant disability.
 
The studies concerning doctors being pressured to do euthanasia, likely share the same common denominator, that being the patient is significantly disabled and in this case, the family wants euthanasia.
 
This survey helps explains the incidence of euthanasia without request in the Netherlands. According to a study published in the New England Journal of Medicine in 2017, there were 431 terminations of life without request in the Netherlands in 2015.
 
It is natural that once euthanasia is legal, promoted, and normalized, that physicians will be pressured to do the act. It is also normal that once euthanasia is legal, that those physicians who do euthanasia will start to view certain life experiences as being "better off dead."

Euthanasia is the killing of patients, usually on request. Society should always care for people and not kill.