Response to the study uncovering euthanasia deaths based on loneliness in the Netherlands

Alex Schadenberg
Executive Director, Euthanasia Prevention Coalition

Diane Meier from the Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, published an editorial in JAMA concerning the study: Euthanasia and Physician-Assisted Suicide in Patients With Multiple Geriatric Syndromes. In her editorial, Meier argues that the extension of euthanasia, in the Netherlands, to people who are not terminally ill but who live with multiple geriatric syndromes is proof that a slippery slope exists in the legalization of euthanasia.

Article: Dutch study uncovers euthanasia deaths based on loneliness (Link).

Meier writes:

countries where PAD has been legal for considerably longer than the US have revised their original laws to remove prognostic requirements, eliminate psychiatric exclusions, broadly define unbearable suffering (to include such conditions as geriatric syndromes and existential distress), and reduce reporting requirements. For example, in the Netherlands, physicians must now follow only vague due care criteria before administering euthanasia or physician-assisted suicide (EAS). Only 75% of EAS cases are reported to regional euthanasia committees as required by law, and nonreporting is rarely punished, and EAS in children, people with mental illness, and dementia further illustrates the impossibility of limiting the practice and safeguarding vulnerable patients once it is permissible. The study by van den Berg et al points to expansion of EAS to another, potentially very large, group of eligible patients: those with multiple geriatric syndromes.

Meier challenges the accuracy of the data in the study. She writes:

Between 2013 and 2019, a total of 1605 occurrences of EAS in people with multiple geriatric syndromes were recorded in the Netherlands, accounting for 4% of all EAS cases in that period. We can assume this number is an underestimate given the level of failure to report. We know little about the 53 cases described by the regional euthanasia committees as representative. Seventy-seven percent were women and older than 90 years, and approximately 1 in 10 was described as having gloomy or depressive feelings. No information on cognitive or functional capacity is given, no psychiatric evaluation is described for any patient, no information on family or physician efforts to identify remediable issues or to provide support and encouragement is given, and the possibility that perceived or actual burdens on caregivers motivated the requests is not considered.

Meier examines the social harm caused by legalizing euthanasia (PAD):

As with any public policy, however, potential benefits must be weighed against societal harms. The expansion of eligibility criteria and the failure of the initial regulatory constraints to contain PAD to a narrowly defined and small group of patients demonstrated by the study underscore real societal harms in the Netherlands and the potential for such harms in the US. Once access to PAD becomes legal, when does a right become an obligation, especially when families are strained and society denies patients and families the resources needed to receive safe and reliable care? The more than 50 000 nursing home deaths from COVID-19 have exposed the lack of investment and years of underfunding in the care and safety of our most vulnerable adults.

Meier focuses on euthanasia based on depression, loneliness and social isolation.

Requests for PAD may result from many modifiable stressors. Depression is frequently a concomitant component of requests for a hastened death and is routinely underdiagnosed and undertreated despite the availability of effective therapies. Pain is underrecognized and undertreated in people of all ages but is especially prevalent among the oldest old and was reported in 41 of 53 of the cases in the series reported by van den Berg et al. Regulations on PAD assume that practitioners have both the training and the time to carefully explore the meaning of the request with patients and families, to understand the sources of the despair, to offer and try alternative approaches to reduce suffering, to be present during that suffering, and to provide encouragement and validation to the patient regarding the value and meaning of their continued life. Most do not. The epidemic of loneliness and social isolation among older persons further threatens society’s ability to surround its citizens with care, attention, and human support.

Meier completes her editorial by urging a caring response, not killing.

Patient despair and suffering should be met with human connection and support to relieve suffering and improve quality of life, not a rush to put an end to things to reduce collective distress at the confrontation with finitude. David Barnard wrote, “The sting of illness and death is the specter of broken relationships and the loss of the world. Over and against this threat stand the efforts of caregivers and companions to embrace the sufferer and continuously reaffirm his or her capacity for relationship.” Meaningful and committed human connection—not 2 g of secobarbital—is the right prescription.

The Netherlands euthanasia law has not changed the language of the law, but the interpretation of the law is constantly expanding. This is the real slippery slope. Another example of the slippery slope is the recent decision by the Netherlands Health Minister to permit child euthanasia without changing the law.