Dutch doctors adopt guidelines on mercy killing of newborns
BMJ 2005; 331 doi: https://doi.org/10.1136/bmj.331.7509.126-a (Published 14 July 2005) Cite this as: BMJ 2005;331:126
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The exchange between Drs Dodd and Webb tended to obscure the
undeniable impact of acceptance of euthanasia by a society on the value
that it places on human life. Dr Webb introduced abortion into the
equation and I for one would not disagree with him that abortion is
another facet of the same phenomenom.
The decriminalisation of abortion has the effect of determining the
value of a human life using criteria other than just its intrinsic value.
I believe the decriminalisation of euthanasia would also do the same. With
the former, the effects can easily be seen all over the world. The
presence of "defects" can lead to the value of a developing fetus to
diminish so much that abortion is the acceptable, and to some, the only
logical answer. Because life does not depend on an intrinsic value, but on
other external factors, a life can be brought into this world, not for its
own sake, but as a tool for curing another. I do not refer to cloning but
to the Law Lords decision regarding saviour siblings.
What is happenning in the Netherlands can be seen as a gradual
desensitisation of both the profession and the Society to physicians
killing their patients. Whether one welcomes it or condemns it does not
alter the relationship between the acceptance of euthanasia by the Dutch
and its seemingly inevitable spread in that society. As doctors, we have
to decide whether that is something we wish to see in our local community.
Competing interests:
None declared
Competing interests: No competing interests
Dr Dodds refers to my letter as "angry" and suggests that it "misses
the point". I concede that the tone was angry but not that I missed the
point. He claims NOT to have called the Dutch doctors involved Nazis but
only to have "reminded" them of what happened "at their doorstep". Let
readers judge whether or not accusing any of the doctors involved of being
"calculting murderers regardless of their reasons or justifcation", and
then "reminding" them of what the Nazis did as equivalent to suggesting
that they are no better than the Nazis were. I know nothing of him, and
he may well be a kind and compassionate Doctor and gentleman, who is truly
concerned about the excesses of and the potential for abuses in medicine.
My point --- which he seems to have missed -- is that the language he uses
appears to leave no room for the possibility that the same is true of the
doctors he accuses of being murderers. What if they are right and he is
wrong?. What if the doctors are well meaning and in fact, with proper
protection and oversight, massive human suffering cam be avoided? I can
respect that he sees abortion in the UK as a "bloody and dispiriting"
experience; but so is forcing a woman to give birth to an umwanted child,
which may in fact be the product of rape, incest, mental illness, or just
plain tragic judgement borne out of tragic human circumstance.
A few years ago my colleagues and I conducted and published a study
in the U.S. showing the tremendous variation from one hospital to the next
in the number of extremely premature deliveries of nonviable fetuses
(under 22 weeks gestation with mortality rate of 100%) that were being
classified as "live births", as opposed to miscarriages. The legal
definition for "live birth" in the the State where the study was conducted
was any product of conception showing "any sign of life". Every doctor or
nurse we spoke to admitted that this was meaningless. One nurse when
asked about this definition and how it could be that virtually none of
their 22 week "products of conception" were deemed to have shown any
"signs of life" (and thus regarded as a "live birth") responded thusly:
"if you don't look for such signs you don't see them". The point? Every
day thousands upon thousands of doctors and nurses are making life and
death decisions about thousands and thousands of suffering patients based
on hopelessly complicated factors, including their own biases and moral
beliefs. That a few Dutch doctors are trying to protect themselves and
inject some transparency into this situation just could be a good thing.
And I stand by my original point: leaping to the conclusion that they are
evil "murderers regardless of justification or reasons", and will
inevitably become genocidal maniacs is not science and not rational but
ideological. Pardon my angry tone, and perhaps I assume too much about Dr
Dodds. But here in the States we are living in hell, under an ideological
regime guided in part by certain, so-called "right to life" principles;
that really have everything to do with the disregard for human suffering
and frailty, and everything to do with their so called "God" -- who it
purports tells them to prohibit abotions, keep the Terry Schiavo's of the
world alive at all costs and, coincidently, send young women and men off
to get killed and mamimed in a war that it manufactured and orchestrated.
I'll take my chances with the Dutch doctors.
Competing interests:
None declared
Competing interests: No competing interests
Neonatologist Bellieni states above: “… in the future they may become
so neurologically impaired that their self- awareness will almost be non
existent, and also in this case the word suffering is a misnomer.” On the
one hand, we can never know the extent of another person’s suffering,
especially when that other person is not capable of describing it, for
instance because he is a neonate or because he is neurologically impaired.
On the other hand, isn’t life itself commensurate with self-awareness?
This is the same impasse that complicated the Terri Schiavo case.
The dilemma arises in the first place because paediatricians are
trying to set up guidelines for making a decision that is not theirs to
make. In the Terri Schiavo case, judges ruled that the decision was up to
her legal guardian.
Competing interests:
None declared
Competing interests: No competing interests
I am surprised at the outrage the Groningen Protocol has caused in
newspapers all around the world. Dr Verhagen is right; Euthanasia has been
carried out all over the world for years. Now when the dutch present a
protocol so that it protects the doctors, there is an uproar.
Euthanasia- "defined as gentle,painless death", is not just the end
of suffering for the dying but also the living, who slowly die each minute
of the day watching their loved ones suffer. Yet, can one deny a miracle?
Can you stop parents who see their own flesh and bloodtrying to survive,
from hoping?
Does the Groningen Protocol guide in the situation of parents
refusing to let go? What does one do then? Is'nt it all about informed
consent?
How is this different from a termination for fetal abnormality? Yes,
one can detach oneself as a professional, but is the decision easier
because you don't actually see the baby trying to live? What goes through
the mind of a parent who has to make this decision? I can't imagine it
being any easier when there is a struggle for life.
What is the answer? What is right and what is wrong? If the lord
giveth and the lord taketh away, then who are we? Where do we stand as
mere mortals?
Competing interests:
None declared
Competing interests: No competing interests
After suffering hypocalcaemia, hypoglycaemia, hypoxia, jaundice,
transfusions, heart failure, major congenital heart surgery at the age of
7
days, we told that our son's future was bleak and his quality of life
poor.
We were also taken into a little room where the frankness was spelt
out
he would never walk or talk; possibility of brain damage and developmental
problems.
My son, despite his short life and a syndrome had a good quality of
life and
did all those things - walked, talked and had limited damage if none at
all, he
had moderate learning difficulties. He may not have lived long, but he
taught
me things about caring for the sick, crippled and retarded is logical - it
showed me "compassion, courage and faith". He was special, "unique" and
many doctors have learnt from him.
I live with the same rare syndrome, and dependent on which doctor
speaks
to me - I have been labelled as having things that I do not have or that
individuals with this syndrome die at birth! They make automatic
assumptions like learning difficulties, psychiatric problems,
communication
problems etc etc. I don't have any such thing!
I have a full active life, have a job, have a degree but would I have
another
child with the same syndrome the answer is no but would I end my life nor
anybody else's life with the same syndrome the answer is no. However, we
were always aware of the possibility of having to switch off a life
support
machine and any risks of further surgery might bring.
I do believe that I have a responsiiblity in not passing certain
genes on to
others that it is morally wrong to knowlingly pass a gene on such as
22q11.2.
Competing interests:
None declared
Competing interests: No competing interests
Dr Webb's angry response to my letter misses the point. I am not an
idealogue but after 35 years in clinical practice in a wide variety of
settings I wish that I had spoken out more publicly about the present and
potential abuses in medicine.
I do not know if he is a physician or not or whether he has ever been
in practice whereas I have seen how limited change extends without
planning way beyond the original intentions. I have worked in a unit where
abortions were carried out and ,contrary to general opinion, it is a
bloody and dispiriting business. What started in the UK as limited
terminations ( and what an accurate description that is) for therapeutic
reasons has moved on to essentially abortion on demand and its use as a
contraceptive. I have little doubt that limited killing of newborns will
extend gradually to the termination of other handicapped children and then
adults especially when medical people feel justifiesd and unafraid of
legal retribution.
Whatever our disagreements, he should read some history of the second
World War and in particular what the Nazi policy was towards Jews,
gypsies, handicapped children and others with medical support in many
caaes. I was not calling the Dutch Doctors Nazis but asking if they had
forgotten what happened on their doorstep within living memory and about
which we must constantly be on guard.
Competing interests:
None declared
Competing interests: No competing interests
Recently Verhagen and Sauer described euthanasia as a measure against
neonatal suffering (1,2) due to some causes, among which they cite a bad
prognosis or the possibility of a low quality of life. But newborns don’t
suffer for these reasons. Suffering is the gap between what we expect from
life and what we actually get (3), and newborns suffer from insulation and
from endless painful procedures; but they cannot suffer from having no
chance of survival or a poor prognosis as they have no self-awareness; and
the struggle against pain has been won by good analgesic drugs. Moreover,
in the future they may become so neurologically impaired that their self-
awareness will almost be non existent, and also in this case the word
suffering is a misnomer. We have good analgesic drugs and only a bad
treatment of pain provokes suffering; moreover, a bad prognosis is not a
reason for suffering if the subject cannot be aware of it. Neonatal
euthanasia does not cure newborns’ suffering. It is more appropriate to
say that it "helps" adults(parents, caregivers)... but we cannot accept
the idea that somebody may be killed to cope with the needs of somebody
else.
1. Verhagen E, Sauer PJJ: The Groningen Protocol — Euthanasia in
Severely Ill Newborns. N Engl J Med 2005 352:959-962
2. Sheldon T: Killing or caring? BMJ 2005;330(7491):560
3. Schopenhauer A: On the basis of morality, trans. Payne EFJ.
Indianapolis: Bobbs-Merrill, 1965:196
Competing interests:
None declared
Competing interests: No competing interests
The protocols are described as being a great step
forward...because...
"The protocol, which the Groningen doctors agreed with the public
prosecution service, enables doctors to report their actions without being
prosecuted."
Translation: It permits doctors to kill and not worry about being
prosecuted.
"Its requirements include a clear diagnosis and prognosis; that the
newborn baby must be suffering hopelessly and unbearably with no prospect
for future treatment; that both parents must give their informed consent;
that the decision must be confirmed by a second independent doctor; and
that the death and treatment must be reported to the local coroner."
Translation: Well, we can treat Spina bifida patients, but we will
ignore the fact. The prognosis of Spina bifida does not depend on the size
or the height of the meningomyelocoel, but we will ignore that. And the
presence of hydrocephalus does not correlate with IQ, but we will ignore
that...the "second indpendent doctor" will not be independent, but a
physician friendly to killing, so we will ignore that part, and "the
treatment" will be reported to the local coroner...but since less than 30
percent of adult euthanasia is being reported, we will ignore that also.
Indeed, there are many adults who had such disabilities treated, and
are alive today thanks to treatment. Were their opinions sought on whether
they thought they should be dead instead of alive? Or are these decisions
based not on the idea of suffering of the child, but on the idea that
caring for such a child would inconvenience the parents? Inquiring minds
want to know...
Last week, I was watching a Tellie show on evolution...there was a
fossil of Homo erectus found that had evidence of an injury that had
healed, implying that someone had to care and feed for the injured
person...the narrator remarked that this showed a major indication of
evolution, since it showed compassion...
Caring for the sick and crippled and retarded is not "logical". It
costs money. It keeps people from doing more important things. But the
retarded teach us the lessons of courage, compassion and faith.
And despite the claim of Eduard Verhagen, who told the BMJ at the
time, "It is time to be honest; all over the world doctors end lives
discreetly, out of compassion", the dirty little secret is that human
beings, since the time of homo erectus, have NOT always ended lives, but
much more often we see those "meaninless" people assisted in their daily
living: helped, cared for, and loved....and that it is such compassion
that make us fully human.
Competing interests:
None declared
Competing interests: No competing interests
George Dodds' response to the report that Dutch doctors have adopted
guidelines regarding the mercy killing of hopelessly suffering newborns is
ludicrous and employs an old trick that ideologues seem never to tire of:
assume the inherent evil in those whose opinion with whom you disagree,
then extend their arguments into absurdity using your own projected
extremism. So Dutch doctors acknowledge the reality of euthanasia for
newborns and desire a structure for more accountability and less secrecy:
"naturally", of course, they will eventually become Frankensteinian
Hitlers who will look for every reason to kill off all undesirables.
Likewise for "abortionists", I’m sure. Let's turn the tables, using the
same logic: "naturally", if we allow those who oppose euthanasia in any
form to "win" we will all eventually be hooked to breathing and feeding
machines forever, while our brains and our bodies rot and any savings that
we hope to leave to our children evaporate. As for abortion: if right-to-
lifers have it their way contraception will be equivalent to negating
potential human life, be banned, and all women who use it will be regarded
as murderers. And why would they stop there? All women of childbearing
age will no doubt be regarded as potential aborters/murderers; and those
that don't bear some expected number of children will have to prove that
they are either sexually inactive or infertile.
Competing interests:
None declared
Competing interests: No competing interests
Neonatal euthanasia: an Italian point of view
Dr De Leeuw demonstrated (1) that a considerable number of European
neonatologists, confess to having made certain types of “end-of-life
decisions”. So, Dr Verhagen says the truth with "It is time to be honest;
all over the world doctors end lives discreetly, out of compassion"
(2).This highlights the problem: nowadays the neonatal intensive care is
potentially inhuman although a paramount outcome of the modern medicine.
Day by day we are dealing with death. In a lot of cases a decision must be
taken and to stop or to start treatment... can become a terrible decision
for someone else. Nevertheless, for example, in the Italian legal and
political situation it often happens that only one doctor is responsible
for the patient, especially with paediatric patients, however this kind of
ethical decision cannot be made by one doctor alone.
I firmly believe that the Groningen protocol (3) from Verhagen and Sauer,
and the following Dutch paediatricians' decision to adopt it as national
guidelines, has the power to “motivate physicians to adhere to the highest
standards of decision making and to reduce hidden euthanasia…” (4).
Moreover it offers the possibility of triggering discussions about one of
the most critical problems in modern intensive care, although, as the
authors state, the Netherlands’ model is not to be considered as the most
appropriate for others countries (3). Finally, it has the merit of placing
more importance on the parents’ role as despite not being the final word,
they are still the ones most closely involved in the care and emotional
life of their children.
References:
1. De Leeuw R,Cuttini M, Nadai M, Berbik I, Hansen G, Kucinskas A et al.
Treatment choices for extremely preterm infants: An international
perspective. J Pediatr 2000;137:608-15
2. Sheldon T. Killing or caring? BMJ 2005;330:560
3. Verhagen E, Sauer PJJ. The Groningen protocol-euthanasia in severely
ill newborns. N Engl J Med 2005;352:959-62
4. Verhagen E, Sauer PJJ. Euthanasia in Severely Ill Newborns. N Engl J
Med 2005;352:2353-2355
Competing interests:
None declared
Competing interests: No competing interests