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Assessing physician compliance with the rules for euthanasia and assisted suicide
By JAMA
Aug 10, 2005 - 1:04:00 PM
Physicians in the Netherlands rely on careful patient evaluations and official practice guidelines when considering patient requests for euthanasia and physician-assisted suicide (EAS), according to a study in the August 8/22 issue of the Archives of Internal Medicine, one of the JAMA/Archives journals.
In Oregon, Belgium and the Netherlands physicians are permitted to perform euthanasia or physician-assisted suicide if specific official requirements are met, according to background information in the article. Because of the complexity of an EAS request and decision, several types of situations can arise: the request can be granted and EAS performed, patients can die of natural causes before the performance of EAS or before the decision is made, the patient can withdraw the request or the request can be refused.
Marijke C. Jansen-van der Weide, M.Sc., of VU University Medical Center, Amsterdam, the Netherlands, and colleagues surveyed all general practitioners in 18 of 22 Dutch general practice districts. Physicians received a written questionnaire in which they were asked about the number of requests for EAS they had received in the last 12 months and how they had dealt with those requests. In addition, physicians were asked to describe in detail the most explicit request for EAS received in the last 18 months, including patient symptoms, the extent to which the patient's situation met the official requirements for accepted practice and the decision-making process.
A total of 3,614 general practitioners responded to the questionnaire (60 percent response rate). Forty-four percent of all explicit requests for EAS resulted in the granting and performance of EAS, the researchers report. The patient died before the performance of the request in 13 percent of cases, or before the final decision was made in 13 percent of cases. The patient withdrew the request in 13 percent of cases and the physician refused the request 12 percent of the time. The most frequent reasons for requesting EAS were "pointless suffering," "loss of dignity" and "weakness." The patients' situation met the official requirements for accepted practice best in requests that were granted and least in refused requests. Refusal of requests were associated with a lesser degree of competence, and less unbearable and hopeless suffering.
"The complexity of EAS decision making is reflected in the fact that besides granting and refusing a request, three other situations could be distinguished," the authors conclude. "The decisions physicians make, the reasons they have for their decisions, and the way they arrive at their decisions seem to be based on patient evaluations. Physicians report compliance with the official requirements for accepted practice."
In an editorial accompanying the article, Susan M. Wolf, J.D., of the University of Minnesota Law School, writes, "The ultimate question remains-if you permit physicians to take life deliberately by assisting suicide or performing euthanasia, can you control the practice? � Determining the answers will require detailed study in each health system and culture permitting assisted suicide or euthanasia. The Dutch have struggled mightily for more than two decades to devise a system to oversee physician-assisted suicide and euthanasia and keep both practices within agreed bounds. It is not clear that they have succeeded. Yet even if they were to succeed, that system might not work in the United States. The Dutch have universal health care coverage, long-standing relationships between physician and patient, and a far more homogenous society."
"Virtually all agree that it is irresponsible to permit assisted suicide and euthanasia without safeguards," Wolf concludes. "There must be limits and an effective way to police them. Yet it remains unclear that we know how to restrain these practices and assure physician reporting. The Dutch should be commended for wrestling with this problem. But even they may not have the answer to this immensely difficult question."
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