an interview with bert keizer   introduction  
photo of bert keizer

Bold Type: Is there no law about euthanasia in Holland?

Bert Keizer: There is. It's against the law to help a person kill her or himself. However, there is jurisprudence which has grown over the past 26 years, and in this way a set of rules evolved under which physician-assisted suicide is allowed, the above law in those cases being overruled. Do not press me for sound legal reasoning, I haven't any to offer. In the courts there's no difference between physician-assisted suicide (patient takes overdose which doctor provides) and euthanasia (doctor gives lethal injection).

BT: What are the conditions that must exist for physician-assisted suicide to be allowed?

Keizer: The patient must be suffering from an objectively diagnosed disease and that suffering must be unbearable and without any prospect of improvement. The death wish must be durable and persistent--if a patient puts in a request on a Tuesday and is helped to die on a Wednesday, then this would be almost impossible to get away with. The death wish must not be uttered in the course of a psychiatric disease, such as, of course, a depression. In doubt, a psychiatrist must certify this. The death wish must also be put in writing by the patient, and signed in the presence of witnesses. (The patient also states that she or he allows the doctor to divulge medical information afterwards to the police.) The doctor must keep written records of all conversations about this subject and a second opinion must be given by a doctor not involved in the case in any capacity, preferably a doctor who doesn't even work in the same hospital. This doctor checks all the above.

BT: What are some of the problems with the law as it stands?

Keizer: Some of the conditions are hopelessly subjective. What is unbearable? There's nothing here about terminating the life or stopping medical support in cases of coma, severely handicapped newborn, etc. Holland is the classic example of the slippery slope: as the debate has gone on, more and more categories applied the rules to themselves. Thus we moved on from the terminally ill to the horribly ill to the mentally ill and now there is a clamour for a death-pill to be marketed which would enable elderly people who feel that their lives are over, to die peacefully at their own appointed hour without having to wait endlessly for Godot.

BT: Do many doctors provide euthanasia to their patients when requested to do so?

Keizer: Believe me, doctors still dislike having to take part in euthanasia and Dancing With Mr. D should make it clear why. A recent survey by the Dutch Euthanasia Society shows that doctors on the whole are very reluctant to get involved with euthanasia.

BT: What effect do the rules have on the execution--pardon the pun--of physician-assisted suicide?

Keizer: The point is this: there are reasonably strict rules for appendectomy. You cannot mess around. If you have a set of criteria for allowable euthanasia, then doctors cannot fool around. You wouldn't believe how messy the ongoings are in cases where doctors just don't know how to go about things. Openness implies control: you have to account for what you did, because everybody is watching you, just the way they are when you are in the operating room removing an appendix. Doing it on the sly, in secret, leads inevitably to shoddy performance. In Holland the effort at openness only partially succeeded: a thorough, recent survey showed that only 50 to 60% of cases are duly recorded, and this is despite a lenient legal climate. Still, the percentage of openly recorded cases in the USA is zero.

BT: Are patients ever euthanized without their consent?

Keizer: In the Dutch statistics you'll find a number of cases, around 1000 each year, in which the patients' lives are shortened without their express consent. Opponents wouldn't put it like this, they would say each year 1000 people are being killed by their physicians. It sounds rather terrible, but in fact these staggering numbers represent a very ordinary occurrence, in tens of thousands of cases, in all hospitals around the entire globe, also in the USA, also and expressly so in the English hospices where morphine practically rains down from the bloody ceilings and oozes through the walls.

Let me explain:

In the terminal stages of an illness you often give morphine injections against pain, dypnea, sleeplessness, fear and other discomforts. Often you have discussed this in advance with your patient and in all cases you notify the relatives of what you are doing. Morphine means eating less, drinking less, coughing less, and moving less. In short you more or less cause a number of complications which will hasten a patient's end. If you start this at the right moment, the patient will die after one to two or four days. Often you will increase the dose intermittently. Now just how would you characterize this use of morphine depends on where you are: talking to a journalist from Reader's Digest you would say, or should say, that you only meant to ease the pain, and the thought that the medication hastened her death never even crossed your mind.

Writing for The New York Times you would say that you realized it would hasten her end but that that was certainly not your purpose.

Talking to your wife that evening you would say: I don't know whether she had more pain this morning, but, Jesus, I was so relieved when she died 3 hours after I doubled the dosage.

No, this is not physician-assisted suicide, this is good palliative care, I would say. No, say the opponents, this is killing people off.

BT: How do you answer these critics?

Keizer: It's almost impossible to argue against this kind of criticism. Opponents of euthanasia usually have a parade of crummy performances of euthanasia in their files, from which they conclude it should never be done. These can easily be countered with some shockingly devastating deathbeds where euthanasia was withheld. From which one cannot conclude that it should always be done.

A truly adult conversation on this topic is only possible when we realize that the same deathbed in the case of Mr. A and Doctor B ends in physician-assisted suicide, and in the case of Mrs. C and Doctor D does not, and that BOTH are good deathbeds.

BT: Physician-assisted suicide is currently under debate in the United States Supreme Court. What are some of the differences you see between medicine in Holland and in the United States that may affect this decision?

Keizer: A striking difference between us and the States is, for instance, the malpractice circus. I am particularly vulnerable, attending so many deathbeds, yet I don't even have any insurance against legal fees for litigation against me. Another striking difference between our countries is the availability of health care, or the access to health care. In Holland everybody is insured. No joke. This means that having a diseased relative is never a financial problem, even if transplant surgery is considered. What I'm driving at is that in Holland medical bills will never be a reason for a patient to ask for her death. I understand this is not always the case in the States. These are considerations that I am vaguely aware of and which should keep me from talking too assuredly about what should be done in the USA.

BT: Do you fear death?

Keizer: Yes. People would say to me that you're dealing with it every day, but that doesn't lessen my own fear of what may happen to me.

--Larry Weissman

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Photo Credit: Roger Fokke.
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