Dr. David Amies: When it comes to assisted dying, Canada has much to learn from the Netherlands

In his first blog post of 2017, Dr. David Amies takes a closer look at medical aid in dying in the Netherlands and reflects on what Canada might take away from the Dutch approach.

For Dying With Dignity Canada, this new year is unlikely to be as heady as last year. In June 2016, we welcomed Bill C-14, warts and all. Flawed as it was, it did at least allow several people to find their way out of intolerable medical situations at a time and place of their own choosing. To date, about 750 people have done so.

The crude death rate for Canada is 8.5 persons per 1,000 people. Just over 280,000 people die from all causes each year, therefore 0.53 per cent of all deaths in 2016 could be attributed to medical aid in dying. Doubtless, this rate will increase over time. But even so, it hardly represents the flood forecast by the opponents of medically-assisted death. Dutch workers in the field claim that they have seen no sign of the dreaded “slippery slope.”

Major differences

An interesting article appeared in the Canadian Medical Association Journal that compared the history of the development of medical aid in dying (MAID) in the Netherlands with Canada's.

MAID in the Netherlands has been led by doctors since its inception. There is now a nationwide system of expert consultants who deliver it and an official euthanasia review committee to ensure that it is done properly and in full compliance with Dutch law. In Canada, MAID law arose from the Carter case, which removed the prohibition against assisted suicide. National guidelines were instituted which appear to have caused uncertainty among many health professionals on how to proceed.

By contrast, discussions concerning MAID began in the Netherlands in 1984 because the medical profession wanted to protect oncologists (cancer physicians) who were unofficially assisting patients to die. By 2002, euthanasia law rules and regulations had been worked out, largely by doctors, with a focus on ethics and medical science, which resulted in its widespread acceptance. At first, only 20 to 30 per cent of Dutch doctors were in favour. Now 90 per cent are. There are built-in safeguards for doctors who practice MAID and obey the rules. Hence, they face no legal repercussions. Dutch law requires that the patients are fully informed, aware and able to communicate and in the grip of unbearable and hopeless suffering. Doctors must consult a colleague and follow a prescribed protocol for ending life. There must also be an absence of reasonable alternatives for the patient and doctor. About two-thirds of all applications are turned down.

The Dutch have assembled a cadre of specially trained specialists, known as the "support and consultation on euthanasia in the Netherlands consultants (SCEN)”—a cumbersome title which is perhaps a little snappier in Dutch! ­They are available across the country at short notice. All the information surrounding each case is sent to a regional Euthanasia Review Committee (ERC), which determines that the rules and regulations are followed. These committees comprise of doctors, lawyers and ethicists, and they hold monthly meetings to review cases. Occasionally, physicians are asked to provide additional information.

In 1991, there were 1,800 MAID cases in the Netherlands or 2.9 per cent of all deaths from any cause. In 2015, there were 5,516 cases or 3.9 per cent of all deaths. Common diagnoses include dementia, psychiatric illness and other ailments. Forty per cent of all deaths in the Netherlands occur in hospital whereas the corresponding number in Canada 66 per cent.

Now it must be expressed that the Netherlands and Canada differ in many ways. The population of the former is around 18 million—nearly 50 per cent of the latter—and that country could be tucked away into every province of Canada, apart from Prince Edward Island, at least twice. Canada’s governance is blessed—or perhaps, bedevilled?—with 14 separate governments, each of which guards its reach and authority very jealously. Inevitably, this introduces complications that are not present in a unitary state such as the Netherlands.

It is also worthy of note that the Dutch do not insist that a patient seeking MAID be within sight of death and suffering from a physical rather than a mental illness. They do not insist on a waiting period and it also looks as if they respect a request for MAID formulated in an advanced care directive. Perhaps Canada will modify its overly prescriptive laws in due course.

Dr. David Amies is a retired doctor in Lethbridge, Alta., and a member of DWD Canada's Physicians Advisory Council.

(Photo: Red tulip fields in the Netherlands, Public Domain)

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