Medicinal Murder

The forty-five-year-old twin brothers had not contracted a terminal illness. Nor were Marc and Eddy Verbessem in physical pain. Both had been born deaf and were progressively losing their eyesight. As the Telegraph reported, “The pair told doctors that they were unable to bear the thought of not being able to see each other again,” and so wanted to die.

When their own doctor wouldn’t kill them, they found their executioner in Dr. David Dufour, who told a television newscast: “They had a cup of coffee in the hall, it went well and [they had] a rich conversation. Then the separation from their parents and brother was very serene and beautiful. At the last there was a little wave of their hands and then they were gone.”

In a morally sane society, Dufour would lose his license to practice medicine and be tried for homicide. But having legalized euthanasia, Belgium no longer fits that description. The twins were not the first joint euthanasia killings reported in the country. In 2011, Belgian media extolled the joint deaths of an elderly couple, who were lethally injected with the apparent knowledge and support of their local community. They even made their final arrangements at the local mortuary before submitting to their terminations.

The couple’s demise was celebrated by a Belgian bioethicist, who said, “It is an important signal to break a taboo.” He added in terms as calm and chilling as those of the doctor who killed the twins, “This can be viewed as a normal way of dying and viewed as such by the community at large . . . . Non-terminal partners, as we call them, also have the option of dying together. It is legally possible. There are no legal difficulties. It is only less well known. People think that euthanasia can only be applied to terminal cancer patients. But the group is a lot bigger. And this is a beautiful example that allows us to provide a dignified death to this couple, thanks to euthanasia.” Most societies see joint suicides by elderly couples as tragic. For some in Belgium, they are beautiful.

In a separate case early this year, a Belgian psychiatrist euthanized Ann G., a forty-four-year-old woman with severe anorexia who had only a few months earlier publicly accused her previous psychiatrist of persuading her into sexual relations. Bioedge, an Australian blog that serves as an international clearinghouse for stories involving bioethics, reported that as early as 2007 Ann G. had told a journalist of her wish to commit suicide. Several months before her death, she appeared on a TV program and alleged that her former psychiatrist had sexually abused her and other patients. (The psychiatrist later admitted his guilt.) “Going public,” Bioedge reported, “gave Ann a brief respite from ‘the cancer in her head.’ However, she was bitterly disappointed that the man who had victimised her was not severely disciplined. Then, overseen by a new psychiatrist, she exercised her option.”

The news gets much worse in Belgium. Currently, the government is agitating to allow minors to consent to euthanasia if, as the ruling Socialist party leader Thierry Giet advocates, the child is “capable of discernment or affected by an incurable illness or suffering that we cannot alleviate.” Alzheimer’s patients will also soon be allowed to consent to euthanasia.

And that isn’t the worst of it. In my first published article against euthanasia—“The Whispers of Strangers,” published in Newsweek in June 1993—I worried that if assisted suicide were ever normalized, one day “organ harvesting” could be added to euthanasia “as a plum to society.” In Belgium it now has.

The joining of voluntary euthanasia and organ harvesting came to light in a 2008 letter published in the medical journal Transplant International, reporting that a totally paralyzed woman first asked for euthanasia—permission granted—and then asked to donate her organs after her heart stopped. These procedures were deemed ethical simply because they had been performed. “This case of two separate requests . . . demonstrates that organ harvesting after euthanasia may be considered and accepted from ethical, legal, and practical viewpoints” in countries where euthanasia is legal, doctors claim in the letter. Moreover, “this possibility may increase the number of transplantable organs and may also provide some comfort to the donor and his (her) family.”

Since this first case, other killings followed by organ harvesting have been reported—including at least one case involving a patient with a severe mental illness. As reported in Applied Cardiopulmonary Pathophysiology in 2011, four patients (three disabled and one mentally ill) were euthanized and their lungs harvested. The authors seem to hope for more opportunities to study the efficiency and efficacy of harvesting organs from euthanized patients. “Euthanasia donors accounted for 2.8% of all donors and 23.5% of all DCD [donors after cardiac death],” they noted in their conclusion. Lungs taken from these donors “resulted in excellent immediate graft function and good early outcome comparable to other DCD.”

They did worry that one lung condition called BOS (bronchiolitis obliterans syndrome) needed to be studied for its effect on the long-term survival of those who received the lungs. The reason is chilling. “A difference may be expected as the quality of the pulmonary graft from a euthanasia donor may be superior compared to any other brain-dead and cardiac-dead donor,” the authors observed. “In contrast to these donors, euthanasia donors do not experience an agonal phase before circulatory arrest as seen in donors dying from hypoxemia or from cardiogenic or hypovolemic shock” and other effects that lead to lung inflammation and thus to neurogenic edema that is “a known risk factor for later development of BOS.” That is not the only problem, though. They add that, “on the other hand, a possible toxic effect on human lung tissue of a lethal dose of barbiturates given at the time of euthanasia is not yet known.”

Physicians in favor of post-euthanasia organ harvesting have become so emboldened by the seeming acceptance of their agenda that they hold symposia proselytizing for the program to be expanded wherever euthanasia is legal. These symposia specifically target patients with neuromuscular disabilities as best suited to the joint procedure since, unlike cancer patients, they provide “good organs” when they die.

By joining euthanasia with organ donation, Belgium crossed a very dangerous bridge: The country gave society the chance to benefit from mercy killing. But the acceptance of joint killing and harvesting sends a cruel message to disabled and mentally ill people that their deaths could have greater value than their lives. Bromides about “choice” and the voluntary nature of “the process” are mere rationalization.

In the Netherlands, euthanasia was decriminalized in certain cases after a 1973 court ruling that a doctor who followed protective guidelines would not be prosecuted. The doctor could euthanize his patient only if unbearable suffering could be alleviated in no other way, the patient had made repeated requests for euthanasia, a second doctor had confirmed the opinion of the first, and the doctor reported the euthanasia to the coroner. This system continued until 2002, when lethally injecting or assisting the suicides of qualified patients was formally legalized.

From its supposedly restricted and limited beginnings, since 1973 the practice of physician-administered death to those who ask for it has steadily expanded—from the terminally ill, to more seriously chronically ill, to people with serious disabilities, to those suffering from existential anguish or mental illness. Euthanizing the profoundly depressed became legal after the Dutch Supreme Court ruled that a psychiatrist did not break the law when he assisted in the suicide of a chronically grieving patient who wanted to die so she could be buried between her two dead children.

Abuses of the system have been repeatedly reported, with the offenders facing few or no legal or professional consequences when they violate legal guidelines. For example, doctors sometimes euthanize patients who have not asked to die, a practice known as “termination without request or consent.” Such cases are rarely prosecuted or meaningfully punished, with a few weeks’ suspended sentence a typical sanction in the rare convictions. Infanticide is a regular practice in some Dutch hospitals. The Lancet twice reported that about 8 percent of all infants who die in the Netherlands each year—perhaps eighty to ninety cases—are euthanized. Another study found a similar infanticide rate in Flanders, Belgium.

Infanticide remains against the law in the Netherlands, and euthanizing babies is technically murder. But, as in cases of non-voluntary euthanasia, few doctors are prosecuted for euthanizing babies, and, as far as I know, none of those convicted has ever faced professional discipline or anything more than a brief suspended sentence. In fact, infanticide became so acceptable that in 2004, a pediatrics professor at the University Medical Center Groningen published a bureaucratic checklist designed to help doctors determine which terminally ill or severely disabled infants could be euthanized ethically. The Groningen Protocol, as it is known, was ratified by the Dutch National Association of Pediatricians and even published respectfully in the New England Journal of Medicine.

Dutch law enforcement and society are utterly indifferent to these legal violations. The legal guidelines supposedly restricting the practice of euthanasia are ignored with general impunity. Indeed, one can reasonably say the guidelines exist more to give the appearance of control than to provide meaningful preventive barriers.

But these facts are old news. More recent events demonstrate that the practice of euthanasia has grown ever more radical. For example, euthanasia inflicted upon the mentally ill has recently become far more common. A 2012 Dutch News story reported that thirteen patients with mental illness had been euthanized in 2011, along with forty-nine patients with early dementia.

Dutch euthanasia authorities explicitly approve such cases through oversight boards called regional committees that review and discuss cases of euthanasia that test the boundaries. For example, the euthanasia death of a woman hospitalized for severe depression was specifically approved in the Regional Committees Annual Report of 2010. She had suffered intermittently from depression since 1980, and since 2005 she had spent most of her time in the hospital. When a final round of treatment failed, the committee held that her mental suffering constituted suitable grounds to be killed. Though she was lucid, she used a wheelchair, had a poor appetite, and slept badly.

The committee report said that “her thinking was not abnormal, nor did she have serious cognitive problems” and that “her mood was depressive, but not psychotic.” The patient

was emotionally unstable, crying all the time and constantly talking about how miserable she felt and how empty, hopeless and unbearable her life was. She had had enough of phasing in new medication and then phasing it out again. She no longer enjoyed anything, she had no energy or feelings left and she had not laughed for four years. She had considered suicide, but did not know how to go about it. She stated that she could no longer cope with reality, since she no longer felt part of it.

Since her suffering “was unbearable, with no prospect of improvement,” the committee decided that the doctor “had acted in accordance with the statutory due care criteria.”

The same paradigm exists now in the Netherlands for euthanizing the elderly because they are “tired of life” or for non-life-threatening conditions, even existential suffering. Thus, the 2010 report quoted above also approved the euthanasia of an elderly woman who was losing her eyesight and experiencing other typical effects of aging. The woman, who was in her eighties, “could no longer do the things that made life worthwhile to her,” such as “reading, philosophising, debating, politics, art and so on.” The report explained that she “had always been very independent and had considered this her greatest asset” but was deteriorating physically.

The doctors had talked with her about withholding food and fluids, but the patient thought the period of dependence this would require of her “the most dreadful thing that could happen to her, and she rejected this alternative. She considered it a blessing that she could end her life with the help of euthanasia and would not have to become dependent. The unbearable nature of her suffering was due to her loss of the ability to live a meaningful life.”

Certainly, everyone will empathize with the distress a once-vigorous person feels as she experiences debilitation. But often this kind of depression is treatable with proper geriatric psychiatric interventions. Yet there was no indication in the report that psychiatric treatment was even attempted. Despite this, the committee approved the woman’s euthanasia as “in accordance with the statutory due care criteria.”

In a better world, mental health professionals would push back against killing those suffering existential anguish or certified mental illnesses, no matter how severe. But the Dutch psychiatric journal Tijdschrift voor Psychiatrie took the opposite tack, instead celebrating changes that have made it safe for psychiatrists to become a “midwife of death” for their patients and calling euthanasia “an emancipation of the psychiatric patient and psychiatry itself.”

According to the article, psychiatrists would be wrong to refuse to kill a patient merely based on personal beliefs: “Categorical rejection of help [to die] in psychiatry represents a failure [to respect] the autonomy of psychiatric patients.” And so the last line of defense against the suicides of mentally ill and deeply depressed people—a dedicated mental health professional fighting for the life of every patient—has surrendered to the euthanasia imperative.

The Royal Dutch Medical Association (KNMG) also has condemned doctors who refuse to euthanize legally qualified patients because they have conscientious objections. The KNMG’s position paper The Role of the Physician in the Voluntary Termination of Life, published in 2011, admits that “most physicians find it difficult to perform euthanasia or assisted suicide,” but still insists that a doctor who “is not prepared to consider a euthanasia request from patients . . . must then put the patient in touch with a colleague who does not have fundamental objections to euthanasia and assisted suicide. If a physician cannot or does not wish to honor a patient’s request for euthanasia or assisted suicidehe must give the patient a timely and clear explanation of why, and furthermore must then refer or transfer the patient to another physician in good time.”

Though the doctor has “no legal obligation to refer patients, there is a moral and professional duty” to help patients find a doctor who will help them die. In other words, the KNMG holds that every Dutch physician is ethically required to be complicit in legal euthanasia, either by doing the deed or referring to a colleague willing to kill.

The same paper explains that when patients do not qualify for euthanasia, a doctor may legally refer them to how-to-commit-suicide literature, and then discuss the literature with them, in order to help them kill themselves. If the patient decides to deny himself food and water, the doctor must supervise his care and “alleviate the suffering by arranging effective palliative care.”

To review: According to the KNMG, it is unprofessional for a doctor to refuse to participate in euthanasia—either by doing the deed or referring so the deed can be done—when a legally qualified patient asks for euthanasia. But it is perfectly acceptable for a physician to teach patients how to commit suicide if they don’t qualify for euthanasia under the law. That is an example of why it is called the culture of death.

In the last decade, Switzerland has become Jack Kevorkian as a country. During the 1990s, about 130 disabled, depressed, and/or terminally ill people traveled from all over the United States to Kevorkian’s home state of Michigan to commit suicide with his help. (The suicide trips ended when the doctor was imprisoned in 2000 for murder after videotaping himself lethally injecting a man suffering from Lou Gehrig’s Disease and taking it to 60 Minutes for broadcasting.) But now, Kevorkianism is back in the form of “suicide tourism,” the flow of people traveling to Switzerland to be killed at the country’s legal suicide clinics.

Assisted suicide was legalized in Switzerland in 1942. Unlike the situation in the Netherlands and Belgium, in Switzerland anyone can participate as long the reason for helping is not a “selfish motive.” For decades, the Swiss law made barely a ripple. But then, with the emergence of an international euthanasia movement, enterprising ideologues opened new facilities, creating a growth industry. In 2011 the nation’s two primary assisted suicide facilities helped a staggering 560 people to kill themselves (up from 350 in 2006). That’s nearly two suicides each day.

Swiss suicide clinics do not restrict their services to the terminally ill. Many of their customers are disabled or depressed. For example, the parents of Daniel James made headlines when they flew their son from the United Kingdom to Switzerland to commit suicide after he was paralyzed from injuries sustained while playing rugby.

There have also been joint suicides in Swiss clinics, most notably the famous English conductor Sir Edward Downes and his wife Joan, who flew together to Switzerland to die at the assisted suicide facility run by the advocacy group Dignities—a decision endorsed in the media by their children. (Joan had been diagnosed with cancer, and Sir Edward was almost blind.)

Dignitas was also instrumental in bringing a case to the Swiss Supreme Court to legalize assisted suicide for the mentally ill. The court complied, ruling, “It must be recognized that an incurable, permanent, serious mental disorder can cause similar suffering as a physical disorder, making life unbearable to the patient in the long term.” Once the ideological premises of assisted suicide are accepted, ultimately there is no way to stop its expansion.

Swiss law does not permit actual euthanasia, that is, when the lethal act is performed by someone other than the person who dies. But that soon may change, thanks to a court ruling that refused to penalize a doctor who inserted a lethal drip into a paralyzed patient’s vein. According to media reports about the case, the court ruled that since the patient wished to die, “the doctor in this case had a medical and moral duty to break the law.”

Advocacy groups have wielded suicide tourism as a cudgel to shatter the public’s resistance to legalizing assisted suicide—just as the line of people flying to Michigan in the 1990s helped to soften up America. England has been particularly targeted for the argument that people should be able to kill themselves at home, surrounded by family, rather than having to fly to Switzerland to do it. Polling shows that this argument resonates with many Europeans, indicating that at least some people now view suicide as a necessity in circumstances involving serious illness or disability.

The English media have energetically exploited tourism suicides in the same way the American media did deaths facilitated by Kevorkian. Just as in 1998, when 60 Minutes played Kevorkian’s video of his murder of Thomas Youk, the BBC aired a video of an assisted suicide that took place in a Swiss clinic—complete with narration by a famous euthanasia advocate.

Airing the actual suicide violated World Health Organization media guidelines. As the WHO’s “Preventing Suicide: A Resource for Media Professionals” states: “Television . . . influences suicidal behavior. [One study] showed an increase in suicide up to ten days after television news reports of cases of suicide. As in the printed media, highly publicized stories that appear in multiple programs on multiple channels seem to carry the greatest impact—all the more so if they involve celebrities.” To prevent one suicide from leading to others, the WHO instructs the media to avoid glorifying or sensationalizing suicide, publishing photographs or suicide notes, and reporting details on the methods used.

Thus the BBC did precisely what it isn’t supposed to according to suicide prevention guidelines. I don’t think there is much doubt that media sensationalism in England has both promoted suicide tourism and concomitantly boosted the potency of assisted suicide advocacy there—which is probably the point.

What conclusions can we draw from the European euthanasia experience that might be of use in the United States as we grapple with these issues? First, once assisted suicide or euthanasia is legalized, it will not long remain a limited enterprise. This is not a “slippery slope” alarmist projection but a conclusion abundantly demonstrated by facts on the ground in Belgium, the Netherlands, and Switzerland. There is no gainsaying that once euthanasia gains widespread public and medical professional support, the supposedly strict guidelines designed to prevent “abuses” become, at most, low hurdles easily circumvented or ignored.

Second, legalizing euthanasia changes culture. Not only do the categories of people eligible for euthanasia expand, but the rest of society generally ceases to think that it matters. This desensitizing, in turn, affects how people perceive the moral value of the seriously ill, disabled, and elderly—and perhaps how they view themselves.

Third, euthanasia corrupts medical ethics by mutating the role of doctors into purveyors of death rather than consistent enablers of life. The hospice movement seeks to improve life by maximizing the patient’s health, comfort, and inclusion in the human community until his natural death. In contrast, euthanasia intentionally cuts short the patient’s life through lethal means. To put it another way, hospice is about living, euthanasia is about dying.

Fourth, once a person is deemed the member of a killable caste, it becomes easier to reduce his worth to that of a mere natural resource that can be exploited for the benefit of society.

Finally, I think widespread popular acceptance of euthanasia in Europe—recent polls show strong support, including in relatively conservative countries like Poland—is a symptom of cultural nihilism. Consider: A hundred years ago, when people really did die in agony, there was little call for legalizing euthanasia. Yet today, when most pain can be significantly alleviated if not eliminated, we see calls for so-called “death with dignity.” Clearly, more is going on than just a desire to eliminate suffering.

What is the antidote? Love. We all age. We fall ill. We grow weak. We become disabled. Life can get very hard. Euthanasia raises the fundamental question of whether our culture will retain the moral capacity to sustain a culture of care for those who have entered life’s most difficult stages. On that question, it seems to me, hangs the moral future of Western civilization. For as the Canadian journalist Andrew Coyne has cogently warned: “A society that believes in nothing can offer no argument even against death. A culture that has lost its faith in life cannot comprehend why it should be endured.”

Wesley J. Smith is a senior fellow at the Discovery Institute’s Center on Human Exceptionalism. He also consults for the Patients Rights Council and the Center for Bioethics and Culture.