Treating the Whole Patient  Dutch in Denial Back to main article

Dr. Zbigniew Zylicz once dreamed of becoming a medical missionary in a developing country. That all changed when the Polish doctor married a Dutch woman and settled in Holland. “It turned out I was needed more here,” he says: “I’m doing missionary work here, I think.”

Dr. Zbigniew Zylicz is a pioneer in pain management for terminally ill patients in the Netherlands. “Finally, we are being listened to,” he says. Photo by John Bookser Feister

Zylicz is medical director of Hospice Rozenheuvel in the Netherlands, one of only three hospice centers in a nation that has accepted the practice of euthanasia without ever actually legalizing it. The center is three years old.

An oncologist with a Ph.D. in pharmacology, he is devoting his career to palliative care, the practice of pain management.

The soft-spoken physician sees most of his patients in their homes: He makes about 500 house calls per year in an area about a 20-km. (12-mile) radius from his 10-bed center. He tells St. Anthony Messenger that Americans should avoid legalizing physician-assisted suicide: “The societal price you will pay for this is enormous: It’s a slippery slope.”

Although euthanasia was never envisioned when the Dutch government first agreed in 1984 not to prosecute doctors for assisting in suicides, euthanasia is now common. In fact, says Zylicz, doctors in the Netherlands perform euthanasia so frequently now that they scarcely know what to do for a terminally ill patient who does not request it. Dutch doctors have lost the ability—the creativity and experience—to solve difficult pain-management problems, he says. “They are losing the art of medicine—the basis of our profession!”

He also warns that once suicide is allowable, it soon will become expected. “The law [allowing assisted suicide] makes a difference because it is immediately experienced as a right. That’s a big difference....There is a pressure on doctors to do euthanasia, even if they don’t want to.”

A 1991 Dutch government study confirms Dr. Zylicz’s assertions. It found 2,280 cases of euthanasia each year, two percent of all Dutch deaths. What started as assisted suicide soon progressed to euthanasia—it seems that those who wish to die voluntarily would rather have the doctor do the killing. Over half of physicians surveyed admitted to practicing euthanasia.

Often it is the doctor and not the patient who makes the decision for euthanasia in the Netherlands. “The [Dutch government] report revealed that in over 1,000 cases, physicians admitted they actively caused or hastened death without any request from the patient,” writes Herbert Hendin, M.D., in the 1997 book Seduced by Death: Doctors, Patients and the Dutch Cure. “Uncontrollable pain was cited in 30 percent of cases; the remaining 70 percent were killed with a variety of different justifications ranging from ‘low quality of life’ to ‘all treatment was withdrawn but the patient did not die.’ The investigation found thousands of other cases where painkilling medication was given with the primary intention of shortening life and without the consultation of fully competent patients.” Some people in the Netherlands, out of fear, are carrying cards that instruct doctors not to euthanize them. Others are carrying cards asking to be euthanized.

“The societal price you will pay for this is enormous: It’s a slippery slope.”

Treating the Whole Patient

Both Doctors Hendin and Zylicz were featured speakers at The Catholic University of America conference on euthanasia (see adjoining article). Dr. Zylicz recounted from his own experience that many times it is the Dutch family or physician who requests death for an older person, and often not for dignified reasons, he says. For example, one family requested euthanasia for an elderly parent who, though terminally ill, was to be discharged from the hospital to die at home. With some probing, Dr. Zylicz learned that the grown children had already removed and divided up the household furniture and didn’t want the old man to find out.

Time and time again, it is pain and depression that lead a person to request death, he reports. When those symptoms are managed, he says, people don’t ask to die. One can use his or her final time to prepare for death.

Dr. Zylicz’s is a careful approach to medicine, looking to treat the whole patient instead of merely a set of symptoms. A patient’s life story, he says, has a profound effect on the request for death. “If a patient comes to us and says, ‘My husband died three years ago,’ it’s going to be very important to know how he died. Because how he died influences her idea of how she wants to die or doesn’t want to die.”

Most doctors seek merely a diagnosis, he observes. “But what’s needed in this case is more of a spiritual examination. You need to have a lot of time, a lot of patience. And you need to invest a lot of energy to developing a good relationship.” Then, what he calls “soul wounds”—often from the distant past—will come forward. He recalls a patient who had experienced a stillbirth 50 years ago and began talking about it as she was dying of cancer. “These wounds tend to open at the end of life. If you recognize this, you can help these people to cope,” he explains.

Dutch in Denial

What Dr. Zylicz finds most significant about what’s happening in the Netherlands today is that people are pretending nothing is happening, that life is not becoming less valued and medical care is not diminishing: “People keep denying the slippery slope even as it is more and more obvious.”

Yet there is growing interest in Dr. Zylicz’s ideas: Twenty Dutch hospices are in the planning stages. He offers a three-month training in palliative care that now has a waiting list of interested doctors. He sees it as a dramatic change: “Finally we are being listened to!” he says. What was once merely a theoretical discussion about pain management versus euthanasia in the Netherlands now has solid clinical evidence, thanks to his and other doctors’ efforts. “Three or four years ago I would write an article for a medical journal and wait two years before somebody would print it. Now the journals are waiting two years before I can write something!” There is also talk of setting up professorships in palliative care at several universities. That would be a first in the Netherlands.

His dream is to see palliative care become omnipresent in Dutch medicine. Instead of a network of hospice centers, which he thinks would drain medical talent from the hospitals, he hopes to place well-trained doctors throughout the existing health-care system. “My idea for the coming five years is to start strong education and training programs at the universities, so that all doctors, nursing-home and general practitioners would be trained in palliative care.” He envisions 50 or 60 pain-management experts, highly specialized in helping general practitioners to solve difficult pain problems.