Dispositions Re Euthanasia Among Dutch Physicians: An Interpretation (part 2)
1. The ‘conscientious objector’ disposition
1.1 Summary: Physicians with this disposition approach the care of their patients with the resolve not to manage a patient’s death by means of euthanasia under any circumstances.
1.2 Metaphor: An individual who appeals for ‘conscientious objector’ status rather than to bear arms must make the case that to take up arms would essentially be to occasion his/her own existential death. Being classified a ‘conscientious objector’ is not popular in a time of national crisis. The government cannot protect the individual from criticism, ridicule, even harm. Physicians who, regarding euthanasia, are analogous to ‘conscientious objectors’ are convinced that performing euthanasia would essentially be to occasion their own existential and professional death. It would not be accurate to use the ‘conscientious objector’ metaphor in reference to all Dutch physicians (from 1968 to the present) who have determined never to perform euthanasia. Other considerations leading to such a resolve have included concerns about public image, economic consequences, or convenience. Some Dutch physicians claim to be categorically opposed to euthanasia in an effort to keep their practice decisions private. However, I do think the majority of Dutch physicians who have determined never to perform euthanasia are analogous to ‘conscientious objectors’.
1.3 Commentary: Each of the Dutch physicians involved in this study -- regardless of his/her disposition about euthanasia -- acknowledges that s/he crosses the threshold from ‘managing life/recovery’ to ‘managing the death/dying process’ with some patients. It is the exception for a Dutch physician not to acknowledge crossing this threshold. Management deliberations and decisions for patients on either side of this threshold are clearly distinguishable. Within the ‘managing the death/dying process’ paradigm, all deliberations and decisions are measured against the goal of avoiding an undignified or humiliating death. ‘Conscientious objector’ physicians in Holland are no exception regarding crossing this threshold in patient care. However, they would limit such patients to terminally ill patients who have somatic illnesses and who are experiencing great pain/suffering from their illnesses. These physicians are prepared to direct management decisions regarding all end-of-life options other than euthanasia toward relieving the patient and toward achieving a ‘good death’. These decisions may knowingly hasten the patient’s death. These physicians are hesitant to say that such decisions are made primarily to hasten the patient’s death. They are very sensitive to the burdens being borne by these patients’ family/friends and are often active in providing hospice care. Political activity for these ‘conscientious objector’ physicians may take three forms. First, they may be active in the Dutch Association of Physicians, a ‘pro-life’ professional organization that formed in 1973 when @1500 KNMG members withdrew after the 30,000 member KNMG took favorable positions regarding abortion and euthanasia. (KNMG is the professional organization in Holland that corresponds to the AMA in the United States.) Second, they may be active in the ‘Pro-Life Platform’. This organization provides leadership for several smaller opposition groups for political activism, public education writings, medical education proposals (e.g., palliative care education for physicians), and professional societies. Third, they may be active in one of three small political parties that represent Christian constituencies in support of a ‘pro-life’ agenda. These parties have held 3-5 seats in the 150-seat Dutch Parliament since the early-1970s. Among the Dutch physicians in this study, two are politically active at the local and national levels. One has initiated an advance directives alternative to the Dutch Voluntary Euthanasia Society’s declaration card. Many physicians who are ‘conscientious objectors’ regarding euthanasia would account for their disposition by reference to their religious (esp., Calvinistic) convictions.
1.4 Distribution: Among the Dutch physicians in this study, 17% (4/24) have identified themselves with the ‘conscientious objector’ disposition. One is a general practitioner and three are long-term care hospital physicians. Prior to the late-1960s, the vast majority of Dutch physicians would have described themselves as categorically opposed to euthanasia. The national discussion of euthanasia was fueled by J.H. van den Berg’s 1969 Medical Power and Medical Ethics. The first signs of consensus in support of euthanasia in Holland were evident by 1973 -- e.g., a series of court cases and favorable position statements from the KNMG. By 1973, perhaps 30% of Dutch physicians would have expressed categorical opposition to euthanasia. By 1984, perhaps 15%. Several national surveys since the late-1980s have found 5-10% of Dutch physicians to be categorically opposed to euthanasia. Most of the Dutch physicians with whom I am acquainted expect this 5-10% to remain constant in the years ahead.
1.1 Summary: Physicians with this disposition approach the care of their patients with the resolve not to manage a patient’s death by means of euthanasia under any circumstances.
1.2 Metaphor: An individual who appeals for ‘conscientious objector’ status rather than to bear arms must make the case that to take up arms would essentially be to occasion his/her own existential death. Being classified a ‘conscientious objector’ is not popular in a time of national crisis. The government cannot protect the individual from criticism, ridicule, even harm. Physicians who, regarding euthanasia, are analogous to ‘conscientious objectors’ are convinced that performing euthanasia would essentially be to occasion their own existential and professional death. It would not be accurate to use the ‘conscientious objector’ metaphor in reference to all Dutch physicians (from 1968 to the present) who have determined never to perform euthanasia. Other considerations leading to such a resolve have included concerns about public image, economic consequences, or convenience. Some Dutch physicians claim to be categorically opposed to euthanasia in an effort to keep their practice decisions private. However, I do think the majority of Dutch physicians who have determined never to perform euthanasia are analogous to ‘conscientious objectors’.
1.3 Commentary: Each of the Dutch physicians involved in this study -- regardless of his/her disposition about euthanasia -- acknowledges that s/he crosses the threshold from ‘managing life/recovery’ to ‘managing the death/dying process’ with some patients. It is the exception for a Dutch physician not to acknowledge crossing this threshold. Management deliberations and decisions for patients on either side of this threshold are clearly distinguishable. Within the ‘managing the death/dying process’ paradigm, all deliberations and decisions are measured against the goal of avoiding an undignified or humiliating death. ‘Conscientious objector’ physicians in Holland are no exception regarding crossing this threshold in patient care. However, they would limit such patients to terminally ill patients who have somatic illnesses and who are experiencing great pain/suffering from their illnesses. These physicians are prepared to direct management decisions regarding all end-of-life options other than euthanasia toward relieving the patient and toward achieving a ‘good death’. These decisions may knowingly hasten the patient’s death. These physicians are hesitant to say that such decisions are made primarily to hasten the patient’s death. They are very sensitive to the burdens being borne by these patients’ family/friends and are often active in providing hospice care. Political activity for these ‘conscientious objector’ physicians may take three forms. First, they may be active in the Dutch Association of Physicians, a ‘pro-life’ professional organization that formed in 1973 when @1500 KNMG members withdrew after the 30,000 member KNMG took favorable positions regarding abortion and euthanasia. (KNMG is the professional organization in Holland that corresponds to the AMA in the United States.) Second, they may be active in the ‘Pro-Life Platform’. This organization provides leadership for several smaller opposition groups for political activism, public education writings, medical education proposals (e.g., palliative care education for physicians), and professional societies. Third, they may be active in one of three small political parties that represent Christian constituencies in support of a ‘pro-life’ agenda. These parties have held 3-5 seats in the 150-seat Dutch Parliament since the early-1970s. Among the Dutch physicians in this study, two are politically active at the local and national levels. One has initiated an advance directives alternative to the Dutch Voluntary Euthanasia Society’s declaration card. Many physicians who are ‘conscientious objectors’ regarding euthanasia would account for their disposition by reference to their religious (esp., Calvinistic) convictions.
1.4 Distribution: Among the Dutch physicians in this study, 17% (4/24) have identified themselves with the ‘conscientious objector’ disposition. One is a general practitioner and three are long-term care hospital physicians. Prior to the late-1960s, the vast majority of Dutch physicians would have described themselves as categorically opposed to euthanasia. The national discussion of euthanasia was fueled by J.H. van den Berg’s 1969 Medical Power and Medical Ethics. The first signs of consensus in support of euthanasia in Holland were evident by 1973 -- e.g., a series of court cases and favorable position statements from the KNMG. By 1973, perhaps 30% of Dutch physicians would have expressed categorical opposition to euthanasia. By 1984, perhaps 15%. Several national surveys since the late-1980s have found 5-10% of Dutch physicians to be categorically opposed to euthanasia. Most of the Dutch physicians with whom I am acquainted expect this 5-10% to remain constant in the years ahead.