When is a problem not a problem?

Refusing to dispense drugs to kill patients with psychiatric illness

Levenseinde Kliniek complains about uncooperative Dutch pharmacists

Sean Murphy*

Full Text

In April, 2014, a complaint was made in the Netherlands that some Dutch pharmacists were refusing to provide euthanasia drugs.  The complaint led members of the Dutch Parliament from the green party, GroenLinks, to ask for a debate with health minister, and members of other Dutch political parties let it be known that they were also concerned.1 

 According to the news reports, over half the physicians at "the independent euthanasia clinic" had been refused lethal drugs, and 23 percent of 53 pharmacists surveyed reported that they sometimes refused to fill euthanasia prescriptions.  It was argued that pharmacists should not be able to refuse drugs needed to kill patients if two physicians had approved the euthanasia request.2  However, while the law in the Netherlands permits physicians to provide euthanasia, it does not mention pharmacists.

Note that excitement among GroenLinks party members and other politicians and the subject of the news reports was the experience of physicians at a single "independent euthanasia clinic," which the English language report did not identify.  It was, in fact, the Levenseinde Kliniek (End of Life Clinic)(LK) in Amsterdam.1,2 The facility has an interesting history.  It begins with what seems to be the reluctance of many Dutch physicians to personally kill patients.

Statistics indicate that a maximum of 9% to 12% of all Dutch physicians have been directly involved in reported euthanasia cases each year (Appendix "A"), though the proportion of general practitioners who personally kill patients is much higher: 28% in 2010.  It must be emphasized that, while these figures are approximate, they are approximate maximums.  Official statistics are not compiled in a way that makes it possible to determine whether ten patients have been killed by ten physicians, or by only one.

Taking a different perspective, the statistics suggest that at least 88 to 91% of Dutch physicians (or at least 72% of general practitioners) do not kill patients themselves.  This likely explains the complaint by Dr. Petra de Jong of Right to Die-Nl that "many general practitioners, either for moral reasons or perhaps because of uncertainty about the law," refuse to perform euthanasia.3  Moreover, though the Royal Dutch Medical Association claims that physicians who refuse to kill patients themselves are obliged to refer patients to someone who will,4 it seems (according to Dr. de Jong) that many will not do so.5  For these reasons, in 2012, Right to Die NL formed mobile teams to provide euthanasia for patients at home.  The Levenseinde Kliniek (End of Life Clinic) in Amsterdam was established to provide the teams with a base of operations.   

Eric van Wijlick, a policy adviser for the Royal Dutch Medical Association, expressed uneasiness about the mobile teams when Levenseinde Kliniek was established.  He did not care for the practice of separating the provision of euthanasia from ongoing care by a general practitioner.  If a physician refuses euthanasia, he said,  it is usually for a good reason, such as failing to meet legal criteria for the procedure.  In contrast, those running Levenseinde Kliniek believe that everyone over 70 years old should be allowed to have euthanasia if they are tired of living.3

Van Wijlick's misgivings seem justified in light of some of practices of the mobile teams.   In April, 2014 - as GroenLinks and others were fretting about uncooperative pharmacists -  government officials criticized a Levenseinde Kliniek physician who lethally injected an elderly woman with psychiatric problems because he did not talk to her enough.  Four months later, Levenseinde Kliniek was reprimanded by euthanasia monitoring officials for killing a stroke victim in her 80's.  She was said to be  "suffering unbearably" because she did not want to live in a nursing home.6

This information provides a broader context for the evaluation of the "problem" attributed to pharmacists who refused to fill prescriptions for LK physicians.  In most cases, refusals were based on pharmacists'  religious beliefs or involved patients with dementia, psychiatric illness, or who simply consider their lives complete and wish to die.1  In other words, the objecting pharmacists appear to have been acting upon the same kinds of concerns that led Dutch authorities to reprimand the facility.

The Royal Dutch Pharmacists Association (Koninklijke Nederlandse Maatschappij ter bevordering der Pharmacie, KNMP) defended pharmacists who were unwilling to dispense lethal medications for euthanasia: "A pharmacy is not a shop where deadly drugs are just handed over."1

Speaking for the Association, Annemieke Horikx complained about the attitude of some physicians:

 They say, "Get me the medication and be quick about it". That's no way to request medication. These are matters of life and death we're dealing with. We also hear from pharmacists that the doctors concerned are unknown to them.1

Unfortunately, the KNMP accepted the characterization of Levenseinde Kliniek's difficulties in getting lethal drugs as a problem to be solved, and offered a solution.  This is a classic example of getting the wrong answer by beginning with the wrong premise.  There was a conflict, to be sure, but, as official criticism of Levenseinde Kliniek indicates, it is by no means clear that the refusal of some pharmacists to supply some LK physicians was problematic.  It may, in fact, have been more in keeping with the law and medical ethics than the conduct of the LK physicians.

In any case, the KNMP proposed that Dutch law should be amended to recognize the role of pharmacists in euthanasia, and added that objecting pharmacists should refer physicians to a pharmacy willing to dispense euthanasia drugs.1  Faced with the "problem" of  pharmacists who refuse to dispense drugs to kill patients with psychiatric problems or dementia, or elderly people who dislike nursing homes, the "solution" proposed by the KNMP is to force the objectors to find a colleague willing to do so.

 From the perspective of freedom of conscience, this cure is as bad as the disease.

The Dutch officials who reprimanded Levenseinde Kliniek might even say it is worse.

Appendix "A"

Netherlands: Termination of Life on Request and Assisted Suicide (Review Procedures) Act

Euthanasia and assisted suicide were legalized in the Netherlands in 2002.  The following statistics refer only to reported euthanasia and assisted suicide cases.

Note that there is no way to determine from the statistics provided how many times a physician acted as a consultant in different euthanasia cases throughout the year.  A single physician involved in three cases will appear here as three physicians.  Thus, the statistics here indicate the maximum number of physicians involved in reported cases each year, not the actual number of physicians participating.

Click to enlarge

Click to enlarge

Notes

1.  DutchNews.nl, 16 April, 2014  "Pharmacists sometimes refuse to give doctors euthanasia drugs." (Accessed 2014-10-24) 

2.  nrc.nl nieuws, 16 April, 2014.  "Apothekers weigeren soms middelen voor euthanasie te leveren." (Accessed 2014-10-24)

3.  Jolly D., "Push for the Right to Die Grows in the Netherlands."  New York Times, 2 April, 2012.  (Accessed 2014-07-15)

4. Royal Dutch Medical Association, The Role of the Physician in the Voluntary Termination of Life (30 August, 2011), p. 40 (Accessed 2012-07-12)

5.  Brumfield, B. "Dutch euthanasia clinic offers mobile service." CNN, 9 March, 2012 (Accessed 2014-07-15)

6.  DutchNews.nl "Euthanasia clinic reprimanded for death of stroke victim." 27 August, 2014.  (Accessed 2014-11-05)