Countries around the world are making it easier to choose the time and manner of your death. But doctors in the world’s euthanasia capital are starting to worry about the consequences.
Last year a Dutch doctor called Bert Keizer was summoned to the house of a man dying of lung cancer, in order to end his life. When Keizer and the nurse who was to assist him arrived, they found around 35 people gathered around the dying man’s bed. “They were drinking and guffawing and crying,” Keizer told me when I met him in Amsterdam recently. “It was boisterous. And I thought: ‘How am I going to cleave the waters?’
But the man knew exactly what to do. Suddenly he said, ‘OK, guys!’ and everyone understood. Everyone fell silent. The very small children were taken out of the room and I gave him his injection. I could have kissed him, because I wouldn’t have known how to break up the party.”
Keizer is one of around 60 physicians on the books of the Levenseindekliniek, or End of Life Clinic, which matches doctors willing to perform euthanasia with patients seeking an end to their lives, and which was responsible for the euthanasia of some 750 people in 2017. For Keizer, who was a philosopher before studying medicine, the advent of widespread access to euthanasia represents a new era.
“For the first time in history,” he told me, “we have developed a space where people move towards death while we are touching them and they are in our midst. That’s completely different from killing yourself when your wife’s out shopping and the kids are at school and you hang yourself in the library – which is the most horrible way of doing it, because the wound never heals. The fact that you are a person means that you are linked to other people. And we have found a bearable way of severing that link, not by a natural death, but by a self-willed ending. It’s a very special thing.”
This “special thing” has in fact become normal. Everyone in the Netherlands seems to have known someone who has been euthanised, and the kind of choreographed farewell that Keizer describes is far from unusual. Certainly, the idea that we humans have a variety of deaths to choose from is more familiar in the Netherlands than anywhere else. But the long-term consequences of this idea are only just becoming discernible.
Euthanasia has been legal in the Netherlands for long enough to show what can happen after the practice beds in. And as an end-of-life specialist in a nation that has for decades been the standard bearer of libertarian reform, Keizer may be a witness to the future that awaits us all.
In 2002, the parliament in the Hague legalised euthanasia for patients experiencing “unbearable suffering with no prospect of improvement”. Since then, euthanasia and its close relation, assisted dying, in which one person facilitates the suicide of another, have been embraced by Belgium and Canada, while public opinion in many countries where it isn’t on the national statute, such as Britain, the US and New Zealand, has swung heavily in favour.
The momentum of euthanasia appears unstoppable; after Colombia, in 2015, and the Australian state of Victoria, in 2017, Spain may be the next big jurisdiction to legalise physician-assisted death, while one in six Americans (the majority of them in California) live in states where it is legal. In Switzerland, which has the world’s oldest assisted dying laws, foreigners are also able to obtain euthanasia.
If western society continues to follow the Dutch, Belgian and Canadian examples, there is every chance that in a few decades’ time euthanasia will be one widely available option from a menu of possible deaths, including an “end of life” poison pill available on demand to anyone who finds life unbearable. For many greying baby boomers – veterans of earlier struggles to legalise abortion and contraception – a civilised death at a time of their choosing is a right that the state should provide and regulate. As this generation enters its final years, the precept that life is precious irrespective of one’s medical condition is being called into question as never before.
As the world’s pioneer, the Netherlands has also discovered that although legalising euthanasia might resolve one ethical conundrum, it opens a can of others – most importantly, where the limits of the practice should be drawn. In the past few years a small but influential group of academics and jurists have raised the alarm over what is generally referred to, a little archly, as the “slippery slope” – the idea that a measure introduced to provide relief to late-stage cancer patients has expanded to include people who might otherwise live for many years, from sufferers of muscle-wasting diseases such as multiple sclerosis to sexagenarians with dementia and even mentally ill young people.
Perhaps the most prominent of these sceptics is Theo Boer, who teaches ethics at the Theological University of Kampen. Between 2005 and 2014, Boer was a member of one of the five regional boards that were set up to review every act of euthanasia and hand cases over to prosecutors if irregularities are detected. (Each review board is composed of a lawyer, a doctor and an ethicist.)
Recent government figures suggest that doubts over the direction of Dutch euthanasia are having an effect on the willingness of doctors to perform the procedure. In November, the health ministry revealed that in the first nine months of 2018 the number of cases was down 9% compared to the same period in 2017, the first drop since 2006. In a related sign of a more hostile legal environment, shortly afterwards the judiciary announced the first prosecution of a doctor for malpractice while administering euthanasia.
It is too early to say if euthanasia in the Netherlands has reached a high-water mark – and too early to say if the other countries that are currently making it easier to have an assisted death will also hesitate if the practice comes to be seen as too widespread. But it is significant that in addition to the passionate advocacy of Bert Keizer – who positively welcomes the “slippery slope” – Boer’s more critical views are being solicited by foreign parliamentarians and ethicists who are considering legal changes in their own countries. As Boer explained to me, “when I’m showing the statistics to people in Portugal or Iceland or wherever, I say: ‘Look closely at the Netherlands because this is where your country may be 20 years from now.’”
“The process of bringing in euthanasia legislation began with a desire to deal with the most heartbreaking cases – really terrible forms of death,” Boer said. “But there have been important changes in the way the law is applied. We have put in motion something that we have now discovered has more consequences than we ever imagined.”
Bert Keizer carried out his first euthanasia in 1984. Back then, when he was working as a doctor in a care home, ending the life of a desperately ill person at their request was illegal, even if prosecutions were rare. When a retired shoemaker called Antonius Albertus, who was dying of lung cancer, asked to be put out of his misery, Keizer found that two sides of himself – the law-abiding doctor and the altruist – were at odds.