Legalising euthanasia leads to a fall in trust between doctors, nurses and patients

by Dr David Richmond, retired geriatrician
8 November 2015
Clause 8 of the 8 dangers of legal euthanasia pamphlet expresses concern about the adverse effect that legal euthanasia will have on doctor-patient relationships.

In response, the Voluntary Euthanasia Society writes: “This is not true. Probably the opposite is true. In the Netherlands for instance, 85% of the population supports voluntary euthanasia. In 2008 a report showed that 88% of respondents in Belgium and 91% in the Netherlands trust their doctors – one of the highest rankings in Europe. It is the view of those supporting voluntary euthanasia that patients are more likely to trust their doctors because they remain with, and work with them to achieve a peaceful death instead of walking away and saying ‘I can’t help you’.”

Before proceeding further, I would make the point that pro-euthanasia activists will stop at nothing to further their case: even, as in this statement, to the extent of portraying all those health professionals who are opposed to legalising euthanasia as uncaring incompetents who are fully prepared to “walk away” from their patients and leave them to suffer. If there was not already concern in the minds of some people about their doctor, this kind of denigration would hardly reassure them.

In my professional career as a physician, which spanned some 42 years, not a single person expressed concern to me that a loved one under some doctor’s care had been subjected to euthanasia. In the last six months I have been asked for my opinion about a doctor’s actions in respect of a patient on three occasions. That is quite remarkable. In two cases it was clearly not euthanasia although in the third case, one would have needed more information to make a judgement, he says. It shows that levels of concern about the trustworthiness of doctors are rising quite quickly.

Oregon resident Kathryn Judson [2. Judson, K. (2011, February 15). I was afraid to leave my husband alone. Hawaii Free Press.] in a letter to the Hawaii Free press told about her horror on hearing her husband’s doctor suggest that he ought to think about applying for “assisted suicide”-apparently on the grounds that she, Kathryn, needed respite from caring for him. She wrote: “We got a different doctor and David lived another five years or so. But after that nightmare in the first doctor’s office, and encounters with a ‘death with dignity’ inclined nurse, I was afraid to leave my husband with doctors and nurses for fear they’d morph from care providers to enemies ….It’s not a good thing wondering who you can trust in a hospital or clinic”.

And it’s not just doctor-patient relationships that suffer. Doctor-to doctor relationships can be also be severely strained. Dr. Ben Zylicz [3. Zylicz B. see: Eaads, B. (1998). A Licence To Kill. Retrieved from ] , a Polish born oncologist working in Holland, offered hospital admission to one of his patients who had widespread metastatic cancer. His intention was to improve her anti pain medication. She was hesitant because she was afraid of being euthanased. “I am a Catholic” she said. “My religious beliefs would never allow me to accept euthanasia.” Dr Zylicz reassured her that he would protect her. She was admitted and within 24 hours was pain free. Later that day, a nurse phoned Dr. Zylicz with the information that after he had left the hospital another physician had entered the patient’s room and substantially increased her dose of IV morphine, without prescribing it formally. Within minutes the patient was dead. Zylicz demanded an explanation of his colleague. “It could have taken another week for her to die” his colleague said. “I needed her bed.”

Proponents of legalising euthanasia often refer to a study by Ganzini L and others (2001) [4. Ganzini, L., Nelson, H. D., Lee, M.A. et al. (2001). Oregon physicians’ attitudes about and experiences with end-of-life care since passage of the Oregon Death with Dignity Act. JAMA, 285(18), 2363 -2369. Retrieved from ] that is interpreted to show that with the legalisation of Oregon’s Death with Dignity Act more patients terminated their professional relationship with a doctor who opposed the provisions of the new Act than left from practices where the doctor supported the new Act. What the study actually shows is that these figures, respectively 3.86% and 1.4%, were not statistically different and were similar for patients leaving practices where the doctor was neutral on the issue!

Another source of comfort for pro-euthanasia advocates is the GfK Trust Index. [5. See: ] It involves pollsters in 25 countries asking on average 1145 people questions designed to discover how much a range of 20 professionals including doctors, in those countries are trusted. The results are ranked in a bar graph by % trust. It is not known how the respondents are selected, a key issue without which it is difficult to interpret the results.. New Zealand was not surveyed. In the case of responses in the range “I completely / generally trust my doctor / physician”, India topped the rankings with a 97% score. South Africa and Canada followed with scores of 95%, just ahead of Belgium and Indonesia on 93%. The Netherlands was ranked 14th equal at 88%, alongside Germany, Spain and the USA, and one percentage point ahead of Kenya. The average for all countries surveyed was 89%. On the list of 20 professions surveyed, Belgian doctors were placed sixth and Dutch doctors eighth on their respective lists. Fire fighters, para medics, nurses and pharmacists in both countries were ranked higher than doctors. One has to ask however, how well do these results reflect the real world with its divergent cultural norms, living conditions and health service funding?

Although strictly speaking not addressing the point of this discussion, a paper by G K Kimsa (2010)
[6. Kimsa, G. K. (2010). Death by request in the Netherlands: facts, the legal context and effects on physicians, patients and families. Mental Health Care and Philosophy, 13, 355-361.] is sometimes appealed to as demonstrating that a special relationship develops between doctors and patients who have requested euthanasia of them. Kimsa’s paper is based on a study of 10 terminal patients in the Netherlands by American anthropologist Frances Norwood. [7. Norwood, F. (2009). The maintenance of life. Preventing social death through euthanasia talk and end-of-life care – lessons from the Netherlands. Durham, North Carolina: Carolina Academic Press.] The relationship of which he writes is based on Aristotelian notions of ‘reciprocal love’ and implies a “closeness and high level of emotional involvement and compassion”. Kimsa writes: “to respond to unbearable suffering and breaking a fundamental law (Thou shalt not kill) is only possible when there is a relation (sic) that makes it possible. Being able to end the life of a patient implies the existence of a physician-patient relationship that has different qualities and which is a “deeper relationship than in normal medicine with its focus on healing.…“. Such relationships are necessary to enable doctors to be able to “assess the unbearable sufferings of patients and in the end come to a joint conclusion that this suffering has been enough.”

There is something very wrong in this. Such a relationship between doctor and patient is exactly what is not needed. As the final sentence of the previous paragraph shows, this sort of emotional tangle between doctor and patient almost inevitably leads to a situation where emotions cloud judgement and doctor and patient are no longer able to bring objectivity to the evaluation and agree that euthanasia may not be the right answer. No matter how fraught the situation, someone in the relationship must retain objectivity.

A diametrically opposite take on doctor-patient relationships where euthanasia is legal is that of Benoit Beuselinck a Belgian oncologist. . In late 2013 he made the following observations to international media [8. Beuselinck, B. Quoted in: Graham, H., & Pritchard, J. (2013, October). Voluntary euthanasia and assisted dying in Australia. A response to Giddings and McKim. University of Tasmania.]. “For me and several of my colleagues, the euthanasia law has been bad for Belgium. The patients are finding less humanity, (and) the doctors have more difficulties in their daily work. In my practice it occurred that some family members thought we were euthanizing a patient without her demand. Another patient refused to go to a hospice because he thought that palliative care would automatically lead to euthanasia. A colleague even received a false demand for euthanasia written by a son on behalf of his father.”

The Dutch are fond of presenting what could be taken as best practice and then generalising it to make it appear that it is the norm. Hence when Dr. Rob Jonquiere visited New Zealand on behalf of the Voluntary Euthanasia Society in 2015, he spoke at length about the relationship he developed over four years with the first applicant along the lines recommended by Kimsa before he could do it. But he failed to mention that that was not the norm: there are many cases such as that described by Hendin [9. Hendin, H. (1998) Seduced by death. (pp. 50 – 55). WW Norton New York and London.] in the documentary Death on Request [10. Ibid, (pp.127-128)]. Despite this film, shot in real time with the assistance of a real patient and his wife to showcase euthanasia in the Netherlands, the patient is isolated from his wife and his doctor, emotions coming a poor second to management. For reasons that we do not know, the wife can hardly wait to be rid of her disabled husband. The doctor is prevented from communicating with the patient: the wife answers for him. Similarly the second consultant’s assessment is managed by the wife. She doesn’t trust anybody. The doctor is obviously uncomfortable but goes ahead with the euthanasia anyway. This is a very different kettle of fish from that described by Kimsa et al. and Jonquiere But events of this type could be recounted many times over in today’s Netherlands and in Belgium.

A documentary aimed at featuring euthanasia in Belgium in a positive light was released in January 2015 [11. Fiano, C. (2015, January 29). Documentary shows Belgian doctor euthanizing a depressed, suicidal woman. Retrieved from ]. Dr. Van Hoey, president of Right to Die Flanders is depicted euthanizing a healthy young woman who has had long-standing depression. He points out with satisfaction that in Belgium, all a patient, even a mentally ill patient has to do is write down his/her name, date and that s/he wants euthanasia. Then a doctor will happily euthanize him / her. The only element of trust seems to be in the certainty that a doctor will accede to a request for euthanasia. The rapid increase in numbers of psychiatric patients being euthanized without proper evaluation in the Netherlands and Belgium is what triggered this recent observation by from Prof. Boudewijn Chabot, the ‘father’ of euthanasia in Holland: “The Netherlands euthanasia law has derailed [12. Chabot, B. (2014, January 15). Reported in NRC Handelsblad newspaper. Retrieved from] .” In our opinion the euthanasia law has also derailed doctor-patient relationships and will continue to do so until one day the world will recognise that much of what is happening in the Low Countries is of a similar nature if not yet scale to the T4 euthanasia programme in Germany in the 1930s and forties.