Under Oregon law, he probably would have asked a doctor's help
in taking his own life. Because he was mentally competent and
did not meet the clinical criteria for a diagnosis of depression,
he would have qualified for assisted suicide and would surely
have found a doctor who would agree to his request.
Since the Oregon law, which uses guidelines like those in effect
in the Netherlands that do not require an independently referred
doctor for a second opinion, Tim would have been referred by a
physician supportive of assisted suicide to a colleague who was
equally supportive. The evaluation would very likely have been
pro forma. He could have been put to death in an unrecognized
state of terror, unable to give himself the chance of getting
well or of dying in the dignified way he did (Hendin 1994b).
Although the Oregon law requires counseling if the patient's doctor
determines that he or she has a mental disorder or has his or
her judgment impaired by depression, studies indicate that most
doctors are not qualified to make such a determination (Conwell
and Caine 1991). Nor should psychiatrists and psychologists be
sanguine at being reduced to the role, advocated in most legalization
proposals, of simply determining if a patient is competent to
make a decision regarding euthanasia. It was
the fact that I was not the arbiter of this case that permitted
the patient I described with acute myelocytic leukemia to talk
freely about his fears of death and eventually to change his mind
about wanting assisted suicide.
In the Netherlands, where there is legal sanction
for assisted suicide and euthanasia, instances of inappropriately
hastening death are common. Even in a film intended to promote
euthanasia, Appointment
with Death (K.A. Productions, 1993), that I was shown at the Dutch
Voluntary Euthanasia Society, I saw an example. A young man, seemingly
in his mid-30s, was diagnosed as HIV-positive. He had no physical
symptoms, but had seen others suffer with them and wanted his
physician's assistance in dying. The doctor compassionately explained
to him that he might live for some years symptom-free. Over time
the young man repeated his request for euthanasia and eventually
his doctor acceded to it. The young man was clearly depressed
and overwhelmed by the news of his situation. The doctor kept
establishing that the young man was persistent in his request,
but did not address the terror that underlay it. I was convinced
that with a psychologically sensitive physician looking for more
than repeated requests to die, more likely in a culture not so
medically accepting of euthanasia, this young man would not have
needed to be put to death.
Suicide in the Netherlands
The Dutch experience illustrates how social sanctions promote
a culture that transforms suicide into assisted suicide and euthanasia
and encourages patients and doctors to see assisted suicide and
euthanasia-intended as an unfortunate necessity in exceptional
cases-as almost a routine way of dealing with serious or terminal
illness and more recently even with grief.
The Dutch like to point out that they have a relatively low suicide
rate and that since the acceptance of euthanasia that rate has
not increased, but dropped. But many of the cases of euthanasia
are likely to be people who would have ended their own lives if
euthanasia were not available to them. This was certainly one
of the justifications given by Dutch doctors for providing such
help. If any significant percentage of the euthanasia cases were
to be included among the suicides, the Dutch figure would rise
considerably.
In fact, the figures suggest that the drop in the Dutch suicide
rate from a peak of 16.6 in 1983 to 12.8 in 1992 (in absolute
numbers from 1,886 to 1,587) may well be due to the availability
of euthanasia. More significant than the drop is the fact that
it has taken place in the older age groups. In the 50 to 59 age
group, the rate dropped from a peak of 21.5 in 1984 to 14 in 1992.
Among those age 60 to 69 the rate dropped from a peak of 23.2
in 1982 to 14.5 in 1992. Among those age 70 and older the rate
dropped from a peak of 31.3 in 1983 to 19.9 in 1992. These are
remarkable drops of about 33 percent in these three groups. Of
the 1,886 suicides in 1983, 940 were in the three older age groups.
Of the 1,587 suicides in 1992, 672 were in the three older age
groups. The drop of 268 suicides in the three older age groups
was primarily responsible for the drop in the Dutch suicide rate.
Comparing the five years of 1980 to 1984 with the 1988 to 1992
years provides statistically significant evidence of a drop in
the older age groups that is not due to chance. These are the
age groups containing the highest numbers of euthanasia cases
(86 percent of the men and 76 percent of the women) and the greatest
number of suicides.
The period of the last decade is the period of growing Dutch acceptance
of euthanasia. It seems plausible that the remarkable drop in
the older age groups is due to the fact that older suicidal patients
are now asking to receive euthanasia.Among an older population,
physical illness of all types is common, and many who have trouble
coping with physical illness become suicidal. In a culture accepting
of euthanasia, their distress may be accepted as a legitimate
reason for euthanasia. It may be more than metaphorical to describe
euthanasia as the Dutch cure for suicide.
