After spending a total of about 30 hours with his patient, Dr Boudewijn Chabot, a Dutch psychiatrist, had to face the facts. She was sane, healthy and determined to die.
The woman, a 50-year-old former social worker, had only one wish - 'to lie in between the graves of her two sons'. The first had committed suicide five years before, the second died of cancer four-and-a-half years later. Both were in their early twenties. Their mother was unable to accept her loss and lived every day wanting to die. Where did Dr Chabot's responsibility lie?
Faced with the choice of consigning her to a possible lonely death or helping her to commit suicide, he chose the latter.
The events became a test case that was decided in a historic Dutch Supreme Court ruling last week and have sparked a national debate on the limits of euthanasia and the ethics of doctors helping a healthy person to commit suicide. Euthanasia, defined as a doctor 'intentionally taking the life of a person upon his or her explicit request', and assisted suicide, in which patients perform the final act themselves, has been accepted for more than 10 years in the Netherlands. Strict guidelines stipulate that the patient must be 'suffering unacceptably' without any prospect of relief and has a voluntary, well considered and 'durable' wish to die. If these guidelines are followed, the courts will judge the doctor to have acted in an emergency and dismiss charges.
Dr Chabot, now 53, originally trained as a GP before specialising in psychiatry. It was not until he had spent more than 12 years in psychiatric practice that he decided to see patients who had contacted the Dutch Society for Voluntary Euthanasia (NVVE), desperately wanting to die. He has said that he got in touch with the NVVE in order to 'offer my services in difficult cases'. It had been reported that the organisation was unable to find psychiatrists who did not utterly oppose the patient's wish to die.
Dr Chabot found that patients in his practice often had hidden suicidal desires. Talking about the longing to die is therefore part of his daily work. He says his role has always been to help people to live while at the same time taking their death wish seriously.
Chabot was put in contact with his patient through the NVVE in the summer of 1991. Two months of intensive consultations followed, during which he tried to find a way into her 'closed world of suicide'. She had planned to take her own life since the death of her second son earlier that year and had bought a plot of four graves, two for her sons, one for herself and another for her estranged husband. A suicide attempt the night of her second son's death failed.
Yet Dr Chabot found her neither hysterical nor pathetic. In the book he has written about the events, Zelf Beschikt (Chosen Fate), he describes her as a 'very down-to-earth person' whose 'contact with reality was never disturbed'. 'The only thing that interests her is how to join her two boys.'
Dr Chabot could find no evidence of psychosis. There was no personality disorder, nor symptoms of depression that would have responded to drugs. He had to accept that she was competent, her feelings appropriate. She appeared to belong to a small minority of people whose grieving has been blocked. For her, life was meaningless without her sons. In her last letter to Dr Chabot she wrote: 'I do not want to become a different person from when I was a mother and happy.' She had lost everything and would never get it back.
Dr Chabot asked her to try anti-depressants, but she refused both medication and entrance into a therapeutic community. Dr Chabot believed that with or without his help, she was close to death. As his conviction grew that her wish to die was genuine, he sought opinions from six other physicians: four psychiatrists, a psychologist and a GP. All were convinced that her determination to die was well considered.
Even at the 11th hour he was offered a way out. All his patient required was effective pills which he could have provided with several prescriptions. No one would have needed to know of Dr Chabot's role.
But Dr Chabot believes doctors should be accountable. Speaking to Rotterdam's NRC Handelsblad, one of the Netherlands' leading opinion-forming newspapers last year, he asked, what sort of psychiatrist would I be if I helped someone to die with a bundle of prescriptions, then washed my hands in innocence towards the outside world?
So in the late summer of 1991, at the home where his patient lived alone in the little town of Ruinen, Dr Chabot administered a drink and some yoghurt-type dessert spiked with the lethal dose. Five minutes later, his patient fell into a deep sleep from which she never awoke. With her sons' favourite Bach music playing, her death was witnessed by a sister, brother-in-law and woman friend. Dr Chabot promptly reported the facts to the local coroner. He was prepared to defend his decision to offer 'physician-assisted suicide', though this remains illegal in the Netherlands, carrying a three-year jail sentence unless guidelines are followed.
The case was so unusual that it was considered a matter for the local court. The local and appeal courts dismissed charges against Dr Chabot, but the Ministry of Justice chose to take a test case to the Supreme Court. At the heart of the case lay the concern that Dr Chabot's patient was not physically, terminally ill. Neither was it felt possible to judge if someone is 'suffering unacceptably' when the source of the suffering is mental rather than physical.
But last November the Royal Dutch Medical Association (KNMG) published guidance on assisted suicide for psychiatric patients, in addition to those laid down in 1984. These accept that there may be cases where it is merciful, such as if a patient has serious psychiatric problems and has no prospect of improvement.
Last week the highest Dutch legal authority, the Supreme Court, came to the highly unusual but pragmatic conclusion that Dr Chabot was guilty but would not be punished, and is still allowed to practise. His failure to insist that a second doctor should examined his patient meant the court refused to accept that he had acted in an emergency, the normal defence. But, it added, there were special reasons why it would not punish Dr Chabot. These related to the previous judgment of the appeal court, which accepted that Dr Chabot had acted reliably in consulting with colleagues and attempting to persuade his patient to reject suicide.
The case has set precedents. A patient need not be in a 'terminal phase' of life, or suffering physically for euthanasia to be considered. These have been welcomed by the NVVE and KNMG.
Meanwhile, the public seems to have an insatiable appetite for the details of his case, with Dr Chabot interviewed on television, radio and in the press. There is precious little criticism and virtually no outright condemnation of his actions. That may be hardly surprising in a country where 78 per cent of people recently questioned in a poll agreed with euthanasia for the incurably ill.
It was left to the tiny, fundamentalist Protestant GPV party to express fear and shock at the result, saying it was the 'next step to legalising euthanasia and assisted suicide'. The main religious party, the Christian Democrat Appeal, did not criticise Dr Chabot's actions but said the case highlighted the difficulty of establishing whether a patient's free will to make up his or her mind has been influenced by their illness.
There has been no response from the churches, even though recent research shows that 43 per cent of the Dutch still regularly attend church.
By far the strongest criticism of Dr Chabot's actions has come from the Amsterdam psychiatrist Dr Frank Koerselman. He believes that Dr Chabot should never have drawn a conclusion of such far-reaching consequences in so short a time (less than two months). 'Under the facade of almost superhuman compassion I found a deathly form of professional naivety,' he said. For him, it is not a doctor's job to kill people. The idea of a well-considered suicide is a myth.
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