GESTIÓN EN SALUD PÚBLICA: BioEdge: Dutch doctor acquitted of unlawful euthanasia

domingo, 15 de septiembre de 2019

BioEdge: Dutch doctor acquitted of unlawful euthanasia

BioEdge: Dutch doctor acquitted of unlawful euthanasia

Bioedge

Dutch doctor acquitted of unlawful euthanasia

by Michael Cook | 15 Sep 2019 |

In a landmark case, a Dutch doctor who euthanised a severely demented patient while she was struggling has been acquitted of unlawful euthanasia.

The case, which happened in 2016, has been widely reported because it was the first in the history of the controversial Dutch euthanasia law to trigger criminal charges.

The deceased woman, a victim of Alzheimer’s disease, had indicated in an advance directive that she wanted to die through euthanasia. But a year before her death, she added a new clause: “I want to make use of the legal right to undergo euthanasia whenever I think the time is right for this… Trusting that at the time when the quality of my life has become so poor, I would like for my request for euthanasia to be honoured.”

The prosecution basically argued that the woman’s consent was conditional upon her perception of her quality of life – and that there was no moment of unequivocal consent.

Victims of dementia in the Netherlands who have advance directive are being euthanised. What made this case exceptional is this: when the time came, the woman, though clearly demented, appeared not to consent. In fact, the doctor secretly slipped a sedative in the patient’s coffee because she would have refused to take it. Then the doctor administered the lethal injection, but forcibly, for the patient suddenly began resisting so strongly that the doctor needed the help of her relatives to hold her down.

How could this possibly be deemed voluntary?

The court framed the issue as follows: “Does the physician have a duty to verify the current desire for life or death of an incapacitated, deeply demented patient in order to speak of a voluntary, well-considered request for euthanasia?”

Its answer was No. “The doctor did not have to verify the current wish to die. The patient was deeply demented and completely incapacitated. The use of pre-medication was discussed with the family and doctors and was not negligent in this case. The proven fact is not punishable and the doctor is relieved of all legal proceedings.”

Unfortunately, this leaves many questions unanswered. Within the limits of her dementia, the woman had a reasonable quality of life.

In a detailed study of the case in the Journal of Medical Ethics, it was reported that “She regularly told her caregivers that she wanted to die. But when she was asked whether she wanted to die, several times she answered, ‘But not just now, it’s not so bad yet!’ Mrs A’s geriatrician thought that her inconsistent wishes reflected a loss of insight into her illness.”

No doubt she lacked insight, but she also appeared to be happy enough in her state. In any case she was euthanised after only seven weeks’ residence in the nursing home, which hardly seems enough for a woman in her condition to settle in.

Furthermore, her relatives and her doctors only honoured part of her advance directive. She had stated, “I absolutely do not want to be placed in an institution for elderly dementia patients.” She missed her husband and felt miserable without him after his daily visits. The doctors interpreted that misery as “unbearable suffering” which was a trigger for the euthanasia clause in her advance directive. But perhaps she was suffering because they had ignored the other clause about not living in a nursing home.

The implications of the judgement remain to be worked out in practice, but it appears that a demented person cannot revoke an advance directive composed in better times; he effectively delegates the moment of euthanasia to the discretion of a doctor.

Michael Cook is editor of BioEdge

Conscientious objection to procedures like abortion and euthanasia often features in BioEdge. There is a growing consensus that CO has no place in modern medicine. It’s often argued nowadays that a doctor’s duty is to carry out the wishes of patients, regardless of whether they agree with them or not.

I stumbled across an interesting hypothetical on the American Medical Association Journal of Ethics which makes me question this consensus. In it, three bioethicists analyse a situation involving a difficult patient with deep Christian convictions. He is refusing post-operative pain medication because he believes that he needs to suffer in order to atone for his life as an alcoholic. What should the physician do?

The bioethicists conclude that he should neither acquiesce nor refer the patient to another doctor who will acquiesce. Instead, the physician should “refuse to offer this course of action, regardless of the religious rationale for such a request”.

They go on to assert that “Indeed, as part of their professional commitment to the patient’s health, physicians have some obligation to respectfully challenge patients' refusals of medical care that the physician believes is needed. A sincere discussion—even a respectful debate—in no way denigrates [his] religious beliefs.”

Indeed, this makes good sense. But, viewed from another angle, the bioethicists are advising the physician to conscientiously object to a course of action determined by a lucid patient after serious consideration. They even counsel him to argue (respectfully) with the patient to convince him that he is wrong.

If this is so obviously the case, why is it wrong for a doctor to refuse to perform an abortion? I’m having trouble reconciling the ethical reasoning of the two situations. Can anyone help?