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In his opinion piece Dr Chabot expresses regret for assisting in a woman’s suicide a decade before assisted suicide and euthanasia were decriminalised in the Netherlands. 

He makes several references suggesting the existence of bracket creep (a slippery slope) and a lack of adequate oversight. In practice the legal criteria have been extended, without Parliament debating and voting on an official extension of the law. 

He argues that in non-terminal cases doctors are not necessary to achieve a ‘good death’. Instead, he advocates a return to suicide – that people cause their own deaths, or be assisted sometimes by relatives.  

The fact that Chabot advocates suicide as preferable to euthanasia, after 15 years of euthanasia legislation, is a reason for New Zealand NOT to change our criminal law to legalise voluntary euthanasia and physician-assisted suicide! Why should a doctor be involved anyway? Why not a lawyer, social worker, or a newly-created profession? Why are advocates not campaigning for the decriminalisation of assisted suicide performed by relatives?

(Highlighting below is ours.)

 

Boudewijn Chabot: I will not assist suicide anymore

 

Published in the Dutch newspaper, Trouw, 20 May 2017

Translated from Dutch into English by Petrus Simons, Ph.D.

 

Our euthanasia law has now been in force for 15 years. It does not make sense to fiddle around with it. However, since it is now possible to buy lethal pills on Internet, doctors must review their role, according to B. Chabot.

These are turbulent times for ‘completed’ lives. There are two proposals to extend the law on euthanasia. Cabinet minister Schippers’s (VVD, (Liberal Party)) one stipulates that you are only entitled to euthanasia if you are suffering. Pia Dijkstra’s (D66, Democrats 66) does not require this.

One wonders whether these proposals to change the law are necessary, for in 2016 nearly 250 elderly people, whose lives were ‘completed’, were euthanised, i.e. under the existing law. They had physical problems, were lonely and had lost loved ones. The review committee marked all these cases as having been done ‘carefully’.

I became concerned when I learnt that in 2016 euthanasia was performed three times on demented elderly who had ‘lost it’ completely. They had directed many years earlier, in writing, that they wanted this. People do sign contracts, and regret doing so, sometimes already a year later. Now I hear you thinking that demented people cannot regret anything.

 

 

Lethal Injection

 

Since euthanasia means death, you would expect doctors to be circumspect when confronted with a written advance directive, even when it was renewed year after year. However, one doctor euthanised a severely demented woman whilst she resisted. The review committee judged that as being careless.

This judgment does not put me at ease. I suspect that doctors of the End-of-Life-Clinic would first administer a sedative to a demented woman, after which she could not possibly resist. Problem solved.

When the euthanasia bill was going through the lower house of parliament (Tweede Kamer) in 2002, euthanasia of advanced cases of dementia was not even discussed. What was discussed was ‘completed life’, because at that time the Supreme Council (Hoge Raad; highest Court) had to deal with the case of Mr. Brongersma, a very old man who believed that his life had been completed. Cabinet minister Korthals promised solemnly at the time that the bill was not meant for elderly such as Brongersma. Nevertheless, in 2016 it happened 250 times. I am afraid that it will also be done to severely demented people.

During the past ten years, the number of notifications of euthanasia, usual cases of cancer, has tripled from around 2,000 to 6,000. Apparently, euthanasia is requested more often, is administered by doctors more often and is almost always approved by the review committee. This points to a widely supported change in culture with regard to the dying of people suffering from a deadly disease.      

Within the river of euthanasia vulnerable groups have entered major rapids. That is worrying. The number of notifications of psychiatric patients has increased strongly. Let me take another difficult group, patients with dementia. Amongst them euthanasia has risen tenfold. Compared to 2007 the frequency of euthanasia is three times higher, but for dementia ten times. It is not yet a waterfall? Or is it?

 

 

Lethal Potion

 

I should watch what I am saying, because the Supreme Council’s decision in my case of 1994 opened the way to euthanasia for patients who are suffering on account of their life with heart, soul and mind. Let me tell this story once more. Ten years prior to the euthanasia law I administered a lethal potion to a 50-year old healthy social worker.

Hilly Bosscher had lost her youngest son to cancer and her eldest to suicide by shooting himself. She had had enough. She promised herself that she would lie in between their graves as soon as possible, although she was not lonely, but surrounded by loved ones.

Her attempt with medicines she had saved up had failed. She was just as capable of making decisions as I was. Her death wish had existed for five years. During twenty conversations, she explained to me why she refused to mourn. When I had understood her reasons for this from her life story, I did not want to leave her to her own devices. I gave her a bitter drink with the words “I hope you will pour this down the toilet’. However, she did drink it and passed away in the arms of her friend. The court decided to put this case before the Supreme Council. Its judgment: ‘guilty but not punishable’.

Although the verdict was a relief, I did not feel at ease. My patient had told me that she did not want to burden me, but rather wanted to collect a lethal medicine. She did not know which medicines were effective, nor how she could get them. I did not know that either. I could have left her to her own devices, but I would then have blamed myself. To explain this I published a book, entitled: ‘Zelf Beschikt’ (My own will) containing her letters and my records of the conversations.      

 

 

Sensible People

 

Although it had been a long road to the Supreme Council, the critique I received, after the book was published, from sensible people such as Hans Achterhuis, Willem Jan Otten and Rudi van den Hoofdakker, weighed more heavily on me.

Van den Hoofdakker thought that I should have sought compulsory hospitalisation and treatment. This elicited from Dries van Dantzig, another level-headed psychiatrist, the question how you could force somebody to mourn and whether you should want to force it. None of the criticists answered that question.

Back to my dilemma; had I chosen the lesser of two evils? With what I know now, I would not do it again. So, what should be done? Let me explain.

Only when all was over, did I found it possible to reflect properly. Should somebody who is able to explain so clearly her wish to die, be allowed to die well? I began to realise that I would not have facilitated euthanasia had I known that she could die without pain and surrounded by loved ones, as this is considered a good death, according to research. That led to the fundamental question whether a doctor is always necessary if one wants to die in such manner? Nobody had any idea, there were only rumours.

I wanted to thoroughly research the indispensability of a doctor when dying well. It took me ten years. In my thesis, I stated that since 2000 a self-chosen death appears to happen with dignity without the presence of a doctor and that it happens regularly. Other researchers have confirmed that this is not a rare event.

Nobody knew that road, at least nobody talked about it. So as to break that silence I described it as: ‘a self-chosen death in consultation with people that are near to them, without medical assistance’, in short ’the autonomous route’ or ‘self-euthanasia’, to distinguish it from doctor’s euthanasia.

 

 

The Big Bad Disease

 

With journalist Stella Braam I wrote ‘Uitweg’ (A Way of Escape) to explain how this is possible. Its thirteenth edition will be published next month. For those who are too tired to read a whole book, there is a film on DVD: ‘Eyewitnesses of dying under own management’ (Ooggetuigen van sterven in eigen regie). In it loved ones of the deceased tell how they assisted with the preparation, remaining present during the act and how they managed the aftermath with the Justice system.

Should I be worried in any way? Dementia is the big bad disease of our time. Thousands of elderly people are so diagnosed every year. Moreover, the care for them has seriously diminished and the quality of life enjoyed by many of them is less than, for example, in the project ‘Experimental Garden Dementia’ of Anne-Mei Thé.

Ever more written advance directives are handed to GPs, who cannot promise anything, but are exasperated by the authors saying: “It is allowed, doctor!” And the doctor’s explanation: ‘I cannot promise that’, falls on deaf ears, as I heard from my GP friends. Patients ask: “Doctor, please don’t leave me in the lurch!’ Ever more GPs will say: “I will never do it in case of dementia, please go to the End-of-Life-Clinic.”

Let us consider that we are approaching ten thousand notifications of cancer and a multiple of the 150 demented people who were euthanised in 2016. Most doctors have had enough. They want to apply the brakes, but do not know how to do this without abandoning their patients. They are, therefore, in a situation similar to the one I faced at the time.

 

 

Dying under Own Management

 

The major difference with that time is that we have learnt that we can manage our own death with a bit of effort and help from those close to us. Counsellors (volunteers who accompany along this route) will give all needed information. Ninety percent of people who choose self-euthanasia by medicines, order a barbiturate over the Internet. It is the same means used by a doctor who administers euthanasia. It is doubtless effective,

The Chinese supplier has been trustworthy for many years. Supply from a European country is impossible as a result of the prohibition of selling opiates. Similarly, testing a sample is prohibited. Given that dozens of people who have taken it have died, the supplier must provide the correct thing. Most keep it for the time when dementia troubles one’s spirit.

My thesis has put a new fact on the table in the euthanasia debate: except in the terminal phase of cancer or in case of a terrible muscular disease, doctors are not indispensable for dying in a dignified manner. That provides room to deal pleasantly with somebody who presents with early dementia and who turns up with an advanced directive. The conversation might proceed as follows:

Would you euthanise me when I cannot recognise my daughter anymore?

When you call your daughter Sara, just as your late beloved one, but you become calm when your daughter sits next to you for an hour? In that case you still recognise her.

Anyway, I mean when I start to urinate in a corner of the room, just like my old dog, then, surely, I am not human anymore!

You would be a human being who has lost the way in life, but not a dog.

All right, not a dog, but not the type of human anymore, which I used to be.

If you are confused, you will remain a human to me and I would not kill you. But I realise that you would not like to experience the process of dementia that is ahead of you. That means that you yourself should take the difficult decision at a time of your choosing that you want to die.

You don’t want to help me!

I would not help you by killing you, but rather by pointing out to you how you could kill yourself.

 

 

Inheritance   

 

Last year October ex-CDA (Christian Democratic Appeal) member of parliament Frans Jozef van der Heijden and his wife took their own life in the presence of their children. The prosecutor’s office knows that it happened by means of a barbiturate, but took no action, as usual.

Meanwhile euthanasia is regularly mentioned in the media. Yet, all politicians find it too difficult to deal with. Already in 2008 Albert Heringa used the information in my book to help his mother Moek to carry out her own death. The Court of Den Bosch, which is going to deal with his case, may prepare a road which follows societal developments without moving ahead of it.

Doubtless, this will be followed by an appeal to the Supreme Council to identify the boundary between what is punishable assistance and what is not in the case of a self-chosen ending of life in the family circle,

One of the European basic rights is the right to a private and family life. According to the European Court for Human Rights that basic right encompasses choosing death within the family circle. Since a member of a family is not a doctor, other terms for that situation will be required than for euthanasia by doctors. This does not detract from the fact that self-euthanasia has been acknowledged as legitimate by the highest European judge. 

It goes without saying that after a self-chosen death it should be indisputably clear that the deceased was in charge with respect to the decision to die and its execution. There should be no sign of a chasing after the inheritance by the heirs. This could be established in the way done by Heringa: by filming conversations in which the person wishing to die explains why she wants to die and which also shows that she takes the medicines independently. It is now already practice not to prosecute the next-of- kin who can show this at the post-mortem examination.

 

 

Good Death

 

The acceleration in the numbers of patients sufferig from dementia and other complicated diseases which are coming to GPs will teach them to watch their moral boundaries, not by blunt refusal but rather by remaining in conversation. A doctor faced with the dilemma that he neither wants to provide euthanasia nor wishes to abandon his patient, may point the family towards the autonomous route. Already in 2011 was this confirmed by the KNMG (Royal Dutch Medical Association).

The main road will be the road to a good death via the GP. It is not necessary to change the law. Should the main road be blocked, then, there is an effective and humane alternative. What are still lacking are juridical beacons as to how the Dutch practice of the autonomous route might be fitted into the right to a private life as is provided in the European basic human right. That basic right also encompasses the choice of choosing the moment of death in the family circle.

Beacons are necesary to mark the space within which autonomy about the end without doctor’s assistance may be done well. Dying under own management and in conversation with close ones will not go away, even if the trial against Heringa were to fail setting those beacons.

 

 

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