July 15th 2017

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Articles from this issue:

COVER STORIES Liberal discontents take internal struggle to Shakespearean heights

NATIONAL AFFAIRS Cardinal Pell charged: the process is the punishment

EUTHANASIA What Boudewijn Chabot can teach Victoria

INTERNATIONAL AFFAIRS Taiwan's 'friends' make the Beijing cut

FREEDOM OF CONSCIENCE NT abortion law oppressive towards health professionals

HEALTH Gardasil(R) and the man upon the stair, Part I

AFRICAN AFFAIRS Special force deals with scourge of poaching

MUSIC Andrea Keller: transpositions of death and grief

CINEMA Cars 3: On ageing without rusting

BOOK REVIEW Biggest democracy makes big strides

BOOK REVIEW A refinement of the Industrial Revolution


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What Boudewijn Chabot can teach Victoria

by Paul Russell

News Weekly, July 15, 2017

Dr Boudewijn Chabot is a retired Dutch psychiatrist and psychotherapist. In 1993 he was charged with having assisted in the suicide of a healthy 50-year-old Dutch woman, Hilly Bosscher, in 1991.

At that time acts of euthanasia and assisted suicide were not legal but allowed under certain circumstances via court precedents stretching back to 1973 and the Postma case. The Termination of Life on Request and Assisted Suicide (Review Procedures) Act would not become law until 2002.

Chabot was tried and acquitted in a lower court. The prosecution appealed to the Supreme Court, where a guilty verdict was returned but no punishment was applied.

Following the Supreme Court decision in November 1993 the Royal Dutch Medical Association (KNMG) amended its 1984 guidelines to include the possibility that there may be cases where “it is merciful, such as if a patient has serious psychiatric problems and has no prospect of improvement”.

The Chabot case opened the door to euthanasia and assisted suicide for psychiatric reasons. This is a classic case of “bracket creep” or incremental extension. The recent interim report of the Victorian Ministerial Advisory Panel notes that in its consultations there are those who have argued for a “starting point” that is much broader in application than parameters suggested by the earlier parliamentary committee report.

One way or another, such extension is inevitable.

But Chabot offers us another consideration both in the 1993 case and his recent lament about the application of the Dutch law published in NRC Handelsblad on June 16, 2017.

Chabot is severe in his criticisms of developments in the application of the Dutch law in recent years. He’s not at all concerned about the skyrocketing numbers of deaths (“In the last ten years, the number of euthanasia reports has increased from two thousand to six thousand per year.”) but rather the changes that have seen the “due care criteria” morph in ways that suggest that euthanasia and assisted suicide “on demand” is now the prevailing paradigm.

The Victorian Parliamentary Committee suggested a framework for assisted suicide and euthanasia with certain qualifying criteria. They included:

  • Is at the end of their life (final weeks or months of life).
  • Is suffering from a serious and incurable condition that is causing enduring and unbearable suffering that cannot be relieved in a manner the person deems tolerable (so similar to the Dutch Due Care criteria #2 & #3).

The Interim Report of the Victorian Ministerial Advisory Panel suggested the possibility that “final weeks or months of life” could be determined formally as a prognosis of either six or 12 months to live. At no time has there been any suggestion that a person who “qualifies” need have first exhausted any reasonable treatment options. That stands to reason in as much as no one can be forced to accept any treatment offered. But I wonder if the public sees it that way.

Chabot laments: “Once upon a time, moving to a nursing home or receiving treatment with some medication was still considered a ‘reasonable alternative’ for euthanasia. At least it had to be tried. Many doctors now accept that a patient can refuse a reasonable alternative and that this does not create a barrier for euthanasia. That brake has now also disappeared.”

That description would seem to be the starting point in the proposed Victorian regime. Any thought in the mind of the public that a death by assisted suicide or euthanasia would be a “last resort” option only, cannot be sustained.

The same applies to the role of the psychiatrist. Chabot is concerned that a majority of the notified cases of euthanasia for psychiatric reasons were “executed” by the Dutch End-of-Life Clinic:

“What happens to doctors for whom a deadly injection becomes a monthly routine? They are surely well intended, but do they also realise how they are fanning a smouldering fire that can become a blaze because they fuel the death wish of vulnerable people who are still trying to live with their disabilities?

“The End of Life Clinic is now actively recruiting psychiatrists. It justifies this by pointing to the long waiting list. Their task: relieving the unbearable and unrelievable suffering from psychiatric patients through euthanasia. Every time the clinic is in the news, a wave of depressed patients whose treatments are allegedly exhausted but many of whom have never been properly treated report to the clinic.

“The newly recruited psychiatrists won’t need to enter into a treatment relation with the patient.”

Will the same be said of the Victorian regime? Will the role of psychiatry be reduced to a “diagnosis-prescription” type business where the therapeutic role of the profession is ignored or, at least, only given lip service?

The Victoria branch of the Royal Australian and New Zealand College of Psychiatrists (RANZCP) noted concerns in their submission to the Victorian Ministerial Advisory Panel:

“The [Victorian] branch also notes that, due to the often rapidly changing manifestations of mental illness, proper assessments are best undertaken by clinicians with the benefit of extended interactions over a significant period of time with the individual in question. As such, the views of psychiatrists and/or other mental health professionals with established therapeutic relationships with individuals seeking voluntary assisted dying [sic] should be sought wherever possible.”

Yet the thrust in terms of the law proposed for Victoria seems likely to only require a psychiatric evaluation for the sake of concerns about capacity and not necessarily about suicidal ideation or the presence of psychiatric illness (though that may be implied).

This raises serious questions about the mechanism that supposedly “protects” people who are vulnerable. If neither of the two assessing doctors suspects a psychiatric issue, nothing more is done.

“In psychiatry, an essential limitation disappeared when the existence of a treatment relationship was no longer required,” said Chabot.

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