The two have not yet made arrangements for themselves. “I don’t think I’m old enough yet; I’ll start thinking about it only when I’m over 70”, says Houtepen. “And I certainly wouldn’t rule euthanasia out.” It’s early days for Metsemakers too. “But if I were to become a vegetable, the people close to me know I’d want nature to run its course rather than to be kept alive at all costs. Which is different to a well-considered choice to end one’s life.” And in the case of dementia? “That’s a different
story altogether”, they say in unison. Metsemakers: “I wouldn’t know what to do about that. Where does the border lie between liveable and not? What constitutes a decent existence? You can’t answer such questions now.” In the Netherlands, euthanasia is lawful in the case of dementia. There must be a living will; that is, an updated declaration of the patient’s wishes should he or she no longer be able to give informed consent. In addition, a number of legal requirements must be met. For instance, the doctor must assess whether a euthanasia request has been made voluntarily and with due consideration. The problem is that, in the case of patients unable to give informed consent, this is often impossible. According to the KNMG, this is why the law should include an extra requirement: there has to be a minimum level of communication. If this is not the case, people who are unable to give informed consent - even if they have a living will - may not be euthanised. Demented end of life Doesn’t all this leave people with severe dementia out in the cold? There can still be a certain threshold, says Houtepen, who is also a member of a euthanasia review committee. Doctors should not be burdened with expectations about ending the lives of dementia patients who have not carefully considered what the procedure means for the doctor. “The KNMG rightly emphasises how stressful and often inconceivable it is for doctors to give lethal injections to patients who don’t know exactly what’s happening and are unable to confirm what their wishes are. In view of this human threshold, it’s not strange to ask those who so fear the suffering their dementia will cause to spend some lucid moments carefully considering and consulting with their doctor about how they wish to die. You ought to take into account what you’re asking of the doctor; after all, a doctor is not just a vet with a syringe.”
Metsemakers, who also works as a GP, would be enormously uncomfortable euthanising a patient on the basis of a living will only. “I’d wonder about its status. How independently was it written? Was it drawn up on a good or a bad day? You have to be sure to weigh up all the considerations well in advance with the patient and the family. Then at least you have a back story.” Early on, Metsemakers would also consult a SCEN doctor, whose job is to provide advice on euthanasia requests. “Ultimately, I’d perform the euthanasia - but I wouldn’t find it easy.” Slippery slope According to Houtepen, the strict standpoint of the KNMG may lead doctors to push euthanasia decisions along too quickly. “If euthanasia is impossible in the case of late dementia, this has an impact on the early stage”, he explains. “Imagine that an early-stage dementia patient comes to the doctor with a living will, for when he’s no longer lucid later. ‘Will you do the procedure then, doctor?’ This places the doctor in a position where he’s forced to say: ‘Not if you’re unable to give informed consent. So make sure you don’t miss your chance.’ This can be seen as pressuring the patient: better euthanasia soon rather than an uncertain future. It puts the doctor in an almost impossible position.” As Metsemakers sees it, this was not the KNMG’s intended objective. “The euthanasia law was more broadly formulated than doctors initially perceived. They thought it was designed
for somatic patients with a terminal illness. Now the discussion is shifting to patients who say their cognitive faculties are fading or they’ve simply had enough of life. Doctors are struggling with this shift; they’re reluctant, and wonder how this fits in with the law. No one wants to go back to the early phase of the euthanasia legislation, when the prosecutor would drop by for a visit.” Still, he wonders what lies in the future for doctors. “Is this a slippery slope?” Suicide law But doctors can also be restrained, according to Houtepen. “Particularly when it comes to advanced dementia, most doctors have a basic attitude of: is euthanasia really necessary?” Doctors should bring up the topic early instead of waiting until there’s an immediate need. “If an early-stage dementia patient says he absolutely does not want to go to a nursing
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