Dispositions Re Euthanasia Among Dutch Physicians: An Interpretation (part 3)
2. The ‘backed against the wall’ disposition
2.1 Summary: Physicians with this disposition intend and expect not to manage a patient’s death by euthanasia, even though the patient and his/her family/friends as well as a majority of professional peers would judge the case to satisfy the professional and legal criteria prerequisite for doing so. However, they may judge the circumstances peculiar to some cases to be exceptional enough to result in the decision to override their reservations and to perform euthanasia.
2.2 Metaphor: KNMG position statements as late as 1984 recommended that physicians who seriously consider (and, in some cases, perform) euthanasia view themselves as ‘backed against the wall’ by the patient’s unbearable and unmanageable suffering. This metaphor suggests that the physician has been cornered by extreme circumstances and only has morally unsettling choices by which to respond.
2.3 Commentary: The Dutch physicians in this study with this disposition all acknowledge that they cross the threshold from ‘managing life/recovery’ to ‘managing death/dying process’ with some patients. They would limit such patients to patients whose suffering is associated with a somatic condition and are usually considered terminally ill. The suffering these patients experience cannot be made bearable by standard pain management and has reduced them to an undignified/humiliating state. These physicians find themselves ‘backed against the wall’ by competent and persistent requests for euthanasia from such patients. The most frequently referenced example among the Dutch physicians in this study is the patient with bowel obstruction due to a large abdominal tumor who is experiencing terrible pain and who is repeatedly vomiting fecal waste. In such extreme cases and once passive or indirect methods for hastening the dying process (e.g., withholding/withdrawing life-sustaining interventions) have failed, these physicians are prepared to experience considerable moral dissonance in agreeing to perform euthanasia. The critical question for these physicians is, “Are there compelling reasons to provide euthanasia?” They often suspect that depression lies behind the longing for death and expect proper pain management to make the patient’s pain bearable with very rare exception. Several of these physicians are active in providing hospice care. Though not often politically active themselves, these physicians hold a disposition about euthanasia that corresponds most closely with the Christian Democratic Party. Until the 1993 elections, CDA had been in the Parliament’s governing coalition throughout the 20th century and, now as the strongest minority party, intends to keep euthanasia on the Dutch penal code.
2.1 Summary: Physicians with this disposition intend and expect not to manage a patient’s death by euthanasia, even though the patient and his/her family/friends as well as a majority of professional peers would judge the case to satisfy the professional and legal criteria prerequisite for doing so. However, they may judge the circumstances peculiar to some cases to be exceptional enough to result in the decision to override their reservations and to perform euthanasia.
2.2 Metaphor: KNMG position statements as late as 1984 recommended that physicians who seriously consider (and, in some cases, perform) euthanasia view themselves as ‘backed against the wall’ by the patient’s unbearable and unmanageable suffering. This metaphor suggests that the physician has been cornered by extreme circumstances and only has morally unsettling choices by which to respond.
2.3 Commentary: The Dutch physicians in this study with this disposition all acknowledge that they cross the threshold from ‘managing life/recovery’ to ‘managing death/dying process’ with some patients. They would limit such patients to patients whose suffering is associated with a somatic condition and are usually considered terminally ill. The suffering these patients experience cannot be made bearable by standard pain management and has reduced them to an undignified/humiliating state. These physicians find themselves ‘backed against the wall’ by competent and persistent requests for euthanasia from such patients. The most frequently referenced example among the Dutch physicians in this study is the patient with bowel obstruction due to a large abdominal tumor who is experiencing terrible pain and who is repeatedly vomiting fecal waste. In such extreme cases and once passive or indirect methods for hastening the dying process (e.g., withholding/withdrawing life-sustaining interventions) have failed, these physicians are prepared to experience considerable moral dissonance in agreeing to perform euthanasia. The critical question for these physicians is, “Are there compelling reasons to provide euthanasia?” They often suspect that depression lies behind the longing for death and expect proper pain management to make the patient’s pain bearable with very rare exception. Several of these physicians are active in providing hospice care. Though not often politically active themselves, these physicians hold a disposition about euthanasia that corresponds most closely with the Christian Democratic Party. Until the 1993 elections, CDA had been in the Parliament’s governing coalition throughout the 20th century and, now as the strongest minority party, intends to keep euthanasia on the Dutch penal code.
2.4 Distribution: Among the Dutch physicians in this study, 46% (11/24) have identified themselves with the ‘backed against the wall’ disposition. It is my impression that by 1973 perhaps 60% of Dutch physicians were prepared to admit that, when ‘backed against the wall’, they would consider it ethically justifiable to provide euthanasia. This majority continued for a decade. However, it is my impression that by 1993 the percentage had dropped to @35% of Dutch physicians as the percentage of Dutch physicians with a ‘peripheral vision’ disposition (introduced below) grew. This percentage seems to have remained constant to the present time. Some of the Dutch physicians in this study predict that the percentage will drop a bit in the next ten years; but others predict that the percentage will rise somewhat.
