Medical aid in dying debated in NY, extended in the Netherlands

 Here are two related stories, one from the NYT about a debate on whether to allow medical aid in dying in New York State. The other is from Fox News, about the medically assisted death of a physically healthy young woman afflicted with a frightful psychiatric disorder.

In New York, there's a debate about whether to become the 11th state to legalize medical aid in dying.  Some of the opponents worry about a slippery slope, leading to the Netherlands, where mental illnesses can qualify candidates for such aid.

Here's the NYT on the debate in NY:

Doctor-Assisted Death Is Legal in 10 States. Could New York Be No. 11? Activists have renewed attention on legislation related to the emotional issue of so-called medical aid in dying that has long languished in Albany.

"New York is one of 19 states where lawmakers are considering bills that would legalize medical aid in dying, a practice that is legal in 10 states and Washington, D.C.

"The bill in New York would allow mentally competent, terminally ill adults with no more than six months to live to request prescriptions from their doctors for life-ending medication. The patients would have to be able to ingest the medication on their own, and only the person seeking to die could request the prescription.

...

"Opponents worry that some patients might choose to end their lives based on an inaccurate prognosis or after being pressured to do so. And while the current bill is restricted to terminally ill people, they worry that lawmakers could expand eligibility for medical aid in dying after any initial legislation is passed."

*************

Here's Fox News on the Netherlands:

Physically healthy Dutch woman dies by assisted suicide at age 29. Zoraya ter Beek died by assisted suicide in the Netherlands last week.  By Kendall Tietz Fox News,  June 1, 2024

"29-year-old Zoraya ter Beek's life was terminated last week after waiting three years for final approval for her euthanasia, which is legal in the Netherlands if the patient is deemed to be experiencing "unbearable suffering with no prospect of improvement."

...

"she tried various things to treat her mental illness, including 33 rounds of electroconvulsive therapy, in which electric currents jolt the brain. But, after her last treatment in August 2020, her psychiatrist told her, "There’s nothing more we can do for you. It’s never going to get any better."

...

"My whole friends and my support system, we really did it together," she had told The Free Press. Ter Beek reportedly saw herself as an ambassador for the Dutch euthanasia program and believed there is proper protocol in place to prevent abuse of the system. 

"We’ve had this law for more than 20 years," she had told the outlet. "There are really strict rules, and it’s really safe."

Medical aid in dying, together, in the Netherlands

The Guardian has the story:

Duo euthanasia: former Dutch prime minister dies hand in hand with his wife. Dries and Eugenie van Agt, both 93, died as number of couples in Netherlands choosing joint end to life grows. by Senay Boztas  

"A Catholic former Dutch prime minister, Dries van Agt, has died by euthanasia, hand in hand with his wife Eugenie. They were both 93.

"Their deaths last Monday are seen as part of a growing trend in the Netherlands for “duo euthanasia”.

"Although still rare, euthanasia of couples was first noted in a review of all cases in 2020, when 26 people were granted euthanasia at the same time as their partners. The numbers grew to 32 the following year and 58 in 2022.

...

"Elke Swart, spokesperson for the Expertisecentrum Euthanasie, which grants the euthanasia wish of about 1,000 people a year in the Netherlands, said any couple’s requests for assisted death were tested against strict requirements individually rather than together.

“Interest in this is growing, but it is still rare,” she said. “It is pure chance that two people are suffering unbearably with no prospect of relief at the same time … and that they both wish for euthanasia.”

Netherlands to broaden euthanasia rules to cover children of all ages

Read more

"Euthanasia and assisted suicide have been legal in the Netherlands since 2002 for six conditions, including unbearable suffering, no prospect of relief and a long-held, independent wish for death.

"A second specialist must confirm the wish, and most cases are carried out by the family doctor at home."

Regulating legal prostitution isn't easy, even in Amsterdam

 The NYT has the story:

Amsterdam Tries to Dim the Glare on Its Red-Light District. The mayor wants to improve the neighborhood for residents, but sex workers oppose measures recently put in place. Now the city is looking to set up legal prostitution elsewhere.  By Claire Moses

"It has been a goal sought after by Amsterdam for years: dissuading rowdy, brawling tourists from overtaking the red-light district.

...

"Now the city is pushing a more drastic move: setting up a location for legal prostitution in another neighborhood to spread out demand — an idea that has set off mixed reactions from the industry.

...

"Last year, Amsterdam saw about 20 million visitors, according to figures provided by the city. It has about 900,000 residents and is on track to have 30 million annual tourists by 2030

...

"Prostitution is legal in the Netherlands, but it is not allowed everywhere or without a permit. It is illegal to practice sex work at home, in a hotel room or in the street, for example. It is unclear how many sex workers are active in Amsterdam, and experts are wary of estimates. The red-light district has about 250 active windows.

"The local government is planning to decide on a final location early next year. But the erotic center, which would not be funded by the city, is still far from becoming a reality. Some people are adamantly opposed, and the city cannot force sex workers to move to an erotic center.

...

"Even before it was made legal, prostitution was associated with the red-light district for hundreds of years because of its original proximity to the port of Amsterdam. The commercial nature of the neighborhood and of its window prostitution, which has helped make it such an international draw, originated in the late 1960s, Mr. Verlaan said."

Medical aid in dying: access for children, and for mental illness

Two recent articles discuss whether there should be categorical limits on medical aid in dying (MAID).  In the Netherlands, the law now permits euthanasia for children in certain horrific situations, and in Canada, a debate continues about the status of patients with mental illness.

 From The Conversation:

Dutch government to expand euthanasia law to include children aged one to 12 – an ethicist’s view  by Dominic Wilkinson

"Ernst Kuipers, the Dutch health minister, recently announced that regulations were being modified to allow doctors to actively end the lives of children aged one to 12 years who were terminally ill and suffering unbearably.

"Previously, assisted dying was an option in the Netherlands in rare cases in younger children (under one year) and in some older teenagers who requested voluntary euthanasia. Until now, Belgium was the only country in the world to allow assisted dying in children under 12.

...

"Dutch paediatricians and parents had reported that in a small number of cases, children and families were experiencing distressing suffering at the end of life despite being provided with palliative care.

"That included, for example, children with untreatable brain tumours who developed relentless vomiting, screaming, and seizures in their dying phase. Or children with epilepsy resistant to all treatment with tens to hundreds of seizures a day.

"The study recommended improvements in access to palliative care for children, as well as altering regulation to provide the option of assisted dying in these extreme cases.

"It has been suggested that five to ten children a year might be eligible for this option in the Netherlands.

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From the NYT, an opinion piece:

Medical Assistance in Dying Should Not Exclude Mental Illness By Clancy Martin

"I am a Canadian, where eligible adults have had the legal right to request medical assistance in dying (MAID) since June 2016. Acceptance of MAID has been spreading, and it is now legal in almost a dozen countries and 10 U.S. states and Washington, D.C. To my mind, this is moral progress: When a person is in unbearable physical agony, suffering from a terminal disease, and death is near, surely it is compassionate to help end the pain, if the person so chooses.

"But a debate has arisen in Canada because the law was written to include those living with severe, incurable mental illness. This part of the law was meant to take effect this year but was recently postponed until 2024."

Ambivalence on recreational cannabis in Amsterdam

 The Guardian has the story:

Amsterdam considers banning ‘cannabis tourists’ from its coffee shops. Fed up with stoned visitors and worried by hard-drug criminality, the mayor wants to clean up the city. But will it work? by Senay Boztas

Here's one bit that suggests that ambivalence is widespread, and baked into current regulations.

"In April, in a 13-page policy proposal, the mayor asked for the council’s support to temporarily enforce the residents-only law, largely because of concerns about the “criminal back door” of the coffee shops. Smoking and possessing weed for personal consumption are “tolerated”, but commercial growing is not – so coffee shops must buy from criminals. An influential 2019 report on the capital’s “dark side” suggested revisiting the residents-only rule to help tackle this “urban jungle”.

Opt out organ donation in England and the Netherlands

 

Jansen, N. E., Williment, C., Haase-Kromwijk, B. J. J. M., & Gardiner, D. (2022). Changing to an Opt Out System for Organ Donation—Reflections From England and Netherlands. Transplant International, 133.

Abstract: Recently England and Netherlands have changed their consent system from Opt In to Opt Out. The reflections shared in this paper give insight and may be helpful for other nation considering likewise. Strong support in England for the change in legislation led to Opt Out being introduced without requiring a vote in parliament in 2019. In Netherlands the bill passed by the smallest possible majority in 2018. Both countries implemented a public campaign to raise awareness. In England registration on the Donor Register is voluntary. Registration was required in Netherlands for all residents 18 years and older. For those not already on the register, letters were sent by the Dutch Government to ask individuals to register. If people did not respond they would be legally registered as having “no objection.” After implementation of Opt Out in England 42.3% is registered Opt In, 3.6% Opt Out, and 54.1% has no registration. In contrast in Netherlands the whole population is registered with 45% Opt In, 31% Opt Out and 24% “No Objection.” It is too soon to draw conclusions about the impact on the consent rate and number of resulting organ donors. However, the first signs are positive."

...

"There had been many failed attempts to introduce Opt Out legislation to England over the last 30 years but was achieved on 20th May 2020. In October 2017 the Prime Minister stated her intention to shift “the balance of presumption in favour of organ donation” and “introduce an opt out system for donation.”

"Fortuitously a parliamentarian from the opposition party had successfully had his name drawn from a legislation ballot (a system which allows a few “Private Members Bills” to be considered by parliament from a randomly chosen subset of legislation suggestions), for a new Opt Out Bill. This led to an unusual alignment of opposing political parties, working together on a new policy. Due to this cross party support, the Bill progressed through Parliament and never had to be put to a vote.

"England’s Opt Out legislation built on the positive experience in Wales and Parliament was further reassured by the response to a public consultation on the draft Bill, which asked how Opt Out should be introduced. The Government usually expects between 200 and 500 responses; over 17,000 responses were received. The responses were supportive and gave a strong steer for the issues needing to be addressed.

"The main issues raised by the public were: the need for autonomy and individual choice; the role of the family; the need to respect faith and beliefs through the donation process. The government worked closely with NHSBT to identify ways to ensure that these issues were addressed. Ministerial commitments also secured additional resources such as increased recurrent funding.

"The final inspiration came from two young people—Max Johnson and Keira Ball. When the Bill was introduced, Max Johnson, a 9 year old boy, was in desperate need of a heart transplant. The UK media—particularly the Mirror newspaper—campaigned for the introduction of Opt Out legislation. Max’s life was saved through the gift of donation by Keira Ball, also aged nine, who tragically lost her life in a road traffic collision. The Opt Out legislation is known as Max and Keira’s Law, in their honour.

"Netherlands

"On the 1st of July 2020 the Opt Out system for organ donation was implemented in Netherlands. Changing the organ donation law from an Opt In consent system into an Opt Out system had not been easy. It took more than 12 years of political discussion to reach the milestone of a majority.

"In 2012 a member of the House of Representatives prepared a Bill to change the consent system into an “Active Donor Registration.” On the 16th of September 2016 the Bill was passed by the smallest possible majority in the House of Representatives, 75 members voted in favour of the Bill and 74 members against. On the 16th of February 2018 the vote in the Senate again ended in a close call, 38 senators voted in favour of the Bill and 36 members against. The Bill could only pass after a required amendment to develop a “Quality Standard Donation,” which describes the role of the doctor and the family in the donation conversation, based on the different outcomes of the Donor Register.

"The Active Donor Registration means that Dutch residents without a registration in the Donor Register, 7 million, will be asked by letter to register their donation preferences (same options as in the Opt In system). If they do not respond to a first and second letter, they will receive a third and final letter with the confirmation that they will be registered as having “No Objection” to organ and tissue donation. Under the new legislation “No Objection” would legally be considered the same as a registration of “Yes, I want to be an organ donor.” Registrations can be changed 24 h a day via the Internet. It could therefore be argued that while the change in law was to introduce Opt Out, it has similarities to a model of mandated choice for organ and tissue donation (6).

School choice in Amsterdam: a counterfactual analysis

 Forthcoming in the JPE (It looks like the refereeing process worked its magic on this paper, whose first version was distributed in 2015...):

Haan, Monique De, Pieter Gautier, Hessel Oosterbeek, and Bas Van der Klaauw. "The performance of school assignment mechanisms in practice." 

This is the author’s accepted manuscript without copyediting, formatting, or final corrections. It will be published in its final form in an upcoming issue of Journal of Political Economy, published by The University of Chicago Press. Include the DOI when citing or quoting: https://doi.org/10.1086/721230  Copyright 2022 The University of Chicago Press.

Abstract: "We use a unique combination of register and survey data from Amsterdam to investigate the performance of school assignment mechanisms in practice. We find that Deferred Acceptance (DA) results in higher mean welfare than the adaptive Boston mechanism. This is due to students making strategic mistakes. The welfare gain o fa switch from actual Boston to DA is over 90 percent of the welfare difference be-tween actual Boston and optimal (proxy) Boston. Disadvantaged and lower ability students would benefit most from such a switch."

"We contribute to the existing literature by complementing register data of the actual choices of secondary-school students in Amsterdam with survey information from the same students. Students’ actual choices reveal their behavior under the Amsterdam version of the Boston mechanism, where students apply in the first round to one school and ties are broken by lotteries. The survey asks students to rank schools according to their true preferences. For each of the ranked schools, the survey asks students to give preference points that reflect the valuation of these schools relative to the valuation of their most-preferred school. The data enable us to (i) quantify the welfare differences between Boston and DA without making strong assumptions about beliefs and choice behavior,(ii) identify the students who are revealed-strategic under the manipulable mechanism,(iii) identify which students make mistakes in their application choices, separately for students who are revealed-strategic and those who are not, (iv) investigate what type of students are hurt (the most) by making suboptimal choices under the Boston mechanism, and (v) quantify the welfare gain of Boston without mistakes (optimal Boston) relative to actual Boston and DA."

Selection of Dutch doctors by lottery

 Here's a recent article describing the once and future Dutch selection of medical students by lottery. (I believe that residency positions may also have or have had selection by lottery.)

Rationales for a Lottery Among the Qualified to Select Medical Trainees: Decades of Dutch Experience by Olle ten Cate, J Grad Med Educ (2021) 13 (5): 612–615. https://doi.org/10.4300/JGME-D-21-00789.1

"The Dutch Lottery for Medical School Selection

"A lottery, as a method to determine who will be admitted to medical school or residency, may sound an absurd proposition to many. A lottery appears to devalue motivation, disregard high effort and talent, and randomly block freedom of career choice. However, The Netherlands has decades of experience with this method. The Dutch government applied a lottery system nationally for admission to all medical schools in 1972. This system was abandoned in 2017 after an appeal but will now be reinstalled in 2023 as a legitimate procedure for the selection of students.

"Until 1972, the admission to Dutch medical schools, which have a 6-year program not preceded by baccalaureate education, was freely accessible for applicants with the proper secondary schooling (note that the Dutch government pays for most of medical education). When applicants increased in number and their costs became substantial, the Dutch government introduced a numerus fixus, a restricted total number of positions, derived from predictions of future physician need. After years of debate, politicians settled on a “weighted lottery” system for admissions. The average score on a national final secondary examination determined the weighting. Students with an outstanding score would triple their chances compared to those with a just-pass score. Declined candidates could reenter the lottery for 2 subsequent years. For decades schools and the public were generally satisfied with this procedure to determine the one-third of all applicants (on average across decades) for whom there was space at a Dutch medical school. The lottery procedure was smoothly conducted by a government agency, until 1996. That year an outstanding high school graduate was turned down 3 times and appealed the decision. Political and societal anger arose and led to a gradual replacement of the lottery, initially with a local qualitative selection process in parallel with a national weighted lottery. In 2 decades, the national lottery system was abandoned altogether; legislation prohibited medical schools from using a lottery as of 2017. Surprisingly, in 2020, a parliamentary majority voted to allow schools to use a lottery system, and thus reinstalled lottery processes as a legitimate method of selection. The law is effective in 2023."

*************

Related:

Lottery Admissions System in the Netherlands, FL Meijler, J Vreeken - Science, 1975 - science.org

The weighted lottery in the admission to ‘restricted’ university studies in the Netherlands,      

Ben Wilbrink

The use of lottery systems in school admissions

C Stasz, C Von Stolk, R Europe, C Rand, TW Sutton - 2007 - researchgate.net

International adoptions temporarily halted in the Netherlands

 The decision by the Netherlands to indefinitely ban international adoptions has generated some controversy.  

The NY Times has the story:

Netherlands Halts Adoptions From Abroad After Exposing Past Abuses.  An inquiry found systemic abuses like child trafficking, lack of record-keeping and government complicity until 1998. Practices have since improved, the government said, but not enough.   by  Claire Moses

"The Netherlands has temporarily halted all adoptions from abroad after an investigation found that the government had failed to act on known abuses, including child theft and trafficking, between 1967 and 1998.

“Adoptees deserve recognition for mistakes that were made in the past,” Sander Dekker, the minister for legal protection, said on Monday, as the results of the investigative report were made public

...

"The government formed an independent commission in 2018 to look into international abuses after a lawsuit showed that the Dutch government had been involved in an illegal adoption from Brazil in 1980, and pointed to the possibility of more such cases. Experts said they knew of no other Western country that had stopped international adoptions.

"In its report, the commission said it had found systematic wrongdoing, including pressuring poor women to give up their babies, falsifying documents, engaging in fraud and corruption, and, in effect, buying and selling children. In some cases, the Dutch government was aware of misdeeds in adoptions from Bangladesh, Brazil, Colombia, Indonesia and Sri Lanka, but did nothing about them and allowed them to continue, the report said.

"“The intercountry adoption system itself served as a kind of ‘child-laundering’ mechanism, as children who were put up for adoption under suspect circumstances could be transformed into legitimately adopted children,” the commission reported. It described the creation of an adoption market and the conversion of children into “tradable goods,” a system that could be “categorized as an abuse.”

"The government froze new applications for international adoptions, though pending adoptions can be completed, Mr. Dekker said.

...

“We need a permanent stop,” to adoptions from abroad, Mr. Westra said.

"Many others disagreed.

"Sander Vlek, the chairman of the National Organization for Adoptive Parents and the father of two adopted children from South Africa, said the decision to suspend international adoptions was made hastily, without input from Parliament or scientific research about contemporary adoptions.

“This severely disadvantages children for whom parents will no longer be available,” he said.

...

"Another group, the Dutch Adoption Foundation, said in a statement that the years of misdeeds were “painful and sad,” but warned that a ban could push adoptions into a black market. The foundation urged Parliament not to agree to the suspension in international adoptions.

"The foundation said it was “unpleasantly surprised” about the “draconian” decision. “This affects the children who gain most from adoption,” it said."

HT: Stephanie Wang

Medically assisted dying, at any age, in the Netherlands

 The NY Times has the story:

Netherlands to Allow Doctors to Help End Lives of Terminally Ill Children--Hugo de Jonge, the Dutch health minister, said that “incurably ill” children ages 1 to 12 should be able to die with the help of a doctor.  By Maria Cramer and Claire Moses

"The Dutch government announced plans this week to allow doctors to end the lives of terminally ill children who are under 13 years old, a decision that is bound to inflame the debate over physician-assisted death.

"The Netherlands already allows doctors to facilitate the deaths of people who are over 12 or less than a year old as long as parents have given their consent.

"In a letter to parliament on Tuesday, the Dutch health minister, Hugo de Jonge, proposed expanding the law to include children between the ages of 1 and 12 who are dying and suffering.

“In a small number of cases, palliative care isn’t sufficient,” Mr. de Jonge wrote. “Because of that, some children suffer unnecessarily without any hope of improvement.”

...

"Three other European countries — Luxembourg, Belgium and Switzerland — allow physician-assisted death, though the laws differ in each country. Belgium allows children to die with the help of a doctor, but in Luxembourg, the law is restricted to adults with an incurable medical condition.

"Canada, parts of Australia and Colombia have also legalized physician-assisted death for adults in certain cases.

...

"Eight states and Washington, D.C., have laws that allow mentally competent adults with a terminal illness and six months or less to live to obtain prescription medication that will hasten their deaths, according to Death With Dignity, an Oregon-based nonprofit that supports such laws."

********

The first link above is to this Gallup Poll report:

MAY 31, 2018,  Americans' Strong Support for Euthanasia Persists  BY MEGAN BRENAN

"72% say doctors should be able to help terminally ill patients die

"Fewer, 65%, express support when the question includes "commit suicide"

"54% think doctor-assisted suicide is morally acceptable"

Netherlands now has opt out deceased donor registration

The Netherlands Times has the story:

NEW DONOR REGISTRY OPT-OUT RULE TAKES EFFECT TODAY
By Janene Pieters on Wednesday, 1 July 2020

"The Netherlands' new organ donation law takes effect today. From now on Dutch adults who haven't told the Donor Register their wishes for their organs after death will automatically be registered as "no objection to organ donation", instead of automatically being registered as a non-donor. This means their organs can go to a patient after their death, though their next of kin will first be consulted.

"According to the government, almost 7 million Netherlands residents have not registered their wishes with the Donor Register yet. They will be sent a letter, prompting them to do so. Residents of Noord-Holland will be the first to receive this letter in September and October. A second letter will be sent six weeks later. If no response is received after the two letters, the person will be registered as "no objection to organ donation".

"Of those who have registered their wishes with the Donor Register, 53 percent are registered as organ donors. About 36 percent are non-donors, and 11 percent decided to leave this decision up to their families. "

**************

In the U.S., almost 50% of drivers are registered donors, close to the Netherlands rate. But it looks like the 36 percent "non donors" have given a definite "no" to donation. It will be interesting to see how the deceased donor transplantation rate evolves in the Netherlands.

Parents in Dutch surrogacy (proposal: as many as four...)

An English language idiom refers to "Dutch uncles," but now there is something new in Dutch parentage, aimed at regularizing parental rights in surrogacy.

Here's the story from a blog for expatriate residents of the Netherlands:

Agreement reached: Dutch children can have four parents

"According to RTL Nieuws, which viewed a draft letter to parliament, the coalition parties have finally reached an agreement, after months of negotiations, on surrogacy and how to arrange custody for families that have more than two parents. The Council of Ministers will discuss the proposal on Friday.

Four parents possible in the Netherlands

Soon, Dutch children will be allowed to have four legally recognised parents. However, not all parents will be afforded the same rights. Non-biological parents will only be granted “partial custody”, meaning that they have more input than at present and can, for example, attend the child’s doctor’s appointments and be involved in choosing the school the child will go to, amongst other things. But should the official parents (the biological ones) die, the child will still become an orphan.

...

"At this moment in time, if a child is born via surrogacy, a judge determines who the parents are after birth. The government wants the parents to be registered before birth in the future. Before conception, agreements will need to be made, which will then be looked at by a judge to decide whether all conditions for surrogacy are met. One of these being that the surrogate mother and at least one of the to-be parents have the Dutch nationality and live in the Netherlands.

Moreover, a surrogacy register will be introduced to enable children born from surrogacy to find out whom their biological parents are, as their birth certificate will only contain the names of the “adoptive” parents. The surrogate mother is also allowed to terminate the surrogacy agreement via a judge up until the birth and shortly thereafter.

Commercial surrogacy in the Netherlands is illegal. Providing surrogate mothers with extra compensation on top of compensation for actual incurred costs is punishable. This measure has been taken to prevent “child-buying”.

Frequencies of medically assisted death, in jurisdictions where it is legal

From the Lancet:
Regulation of assisted suicide limits the number of assisted deaths
Gian Domenico Borasio, Ralf J Jox, Claudia Gamondi
Published:February 20, 2019
DOI:https://doi.org/10.1016/S0140-6736(18)32554-6

"Several countries and US states have recently legalised euthanasia, assisted suicide, or both, including Canada and California, USA. In 2017, more than 13 000 patients died through either method of assisted death in countries where these practices are permitted. Euthanasia and assisted suicide have been legal in the Netherlands and Belgium since 2002, whereas assisted suicide has been legal in Switzerland since 1918 and in Oregon, USA, since 1997.

"In assisted suicide, patients take the lethal drug themselves, whereas doctors administer the drug in euthanasia. In 2012, this appeared to be a main reason for the higher frequency of assisted deaths in the Netherlands and Belgium, compared with Oregon and Switzerland. Yet data from the past 5 years suggest that the lack of legislation in Switzerland could also explain the higher frequency of assisted suicide, particularly since an increasing number of patients without terminal illness obtain permission for assisted suicide in Switzerland. By contrast, the lower frequency in Oregon might be explained by the requirement of a maximum life expectancy of 6 months and by the requirement that patients obtain a lethal dose from the pharmacy for auto-administration. On average, 36% of these patients in Oregon end up not using the lethal drug and die of their illness"

Medically assisted death

The Guardian and the BBC bring us up to date on death with dignity in the Netherlands.

Here are some excerpts from the Guardian's long read:

Death on demand: has euthanasia gone too far?
Countries around the world are making it easier to choose the time and manner of your death. But doctors in the world’s euthanasia capital are starting to worry about the consequences
By Christopher de Bellaigue

"Keizer is one of around 60 physicians on the books of the Levenseindekliniek, or End of Life Clinic, which matches doctors willing to perform euthanasia with patients seeking an end to their lives, and which was responsible for the euthanasia of some 750 people in 2017. For Keizer, who was a philosopher before studying medicine, the advent of widespread access to euthanasia represents a new era. “For the first time in history,” he told me, “we have developed a space where people move towards death while we are touching them and they are in our midst. That’s completely different from killing yourself when your wife’s out shopping and the kids are at school and you hang yourself in the library – which is the most horrible way of doing it, because the wound never heals.
...
"Euthanasia has been legal in the Netherlands for long enough to show what can happen after the practice beds in.
...
"In 2002, the parliament in the Hague legalised euthanasia for patients experiencing “unbearable suffering with no prospect of improvement”. Since then, euthanasia and its close relation, assisted dying, in which one person facilitates the suicide of another, have been embraced by Belgium and Canada, while public opinion in many countries where it isn’t on the national statute, such as Britain, the US and New Zealand, has swung heavily in favour.

"The momentum of euthanasia appears unstoppable; after Colombia, in 2015, and the Australian state of Victoria, in 2017, Spain may be the next big jurisdiction to legalise physician-assisted death, while one in six Americans (the majority of them in California) live in states where it is legal. In Switzerland, which has the world’s oldest assisted dying laws, foreigners are also able to obtain euthanasia.
...
"Euthanasia is counted as a basic health service, covered by the monthly premium that every citizen pays to his or her insurance company. But doctors are within their rights not to carry it out. Unique among medical procedures, a successful euthanasia isn’t something you can assess with your patient after the event. A small minority of doctors refuse to perform it for this reason, and others because of religious qualms. Some simply cannot get their heads around the idea that they must kill people they came into medicine in order to save.
...
"At any meeting organised by the NVVE [Dutch Voluntary Euthanasia Society], you will look in vain for poor people, pious Christians or members of the Netherlands’ sizeable Muslim minority. Borne along by the ultra-rational spirit of Dutch libertarianism (the spirit that made the Netherlands a pioneer in reforming laws on drugs, sex and pornography), the Dutch euthanasia scene also exudes a strong whiff of upper-middle class entitlement.

"Over coffee I was introduced to Steven Pleiter, the director of the Levenseindekliniek. We went outside and basked in the early October sun as he described the “shift in mindset” he is trying to achieve. Choosing his words with care, Pleiter said he hoped that in future doctors will feel more confident accommodating demands for “the most complex varieties of euthanasia, like psychiatric illnesses and dementia” – not through a change in the law, he added, but through a kind of “acceptance … that grows and grows over the years”. When I asked him if he understood the scruples of those doctors who refuse to perform euthanasia because they entered their profession in order to save lives, he replied: “If the situation is unbearable and there is no prospect of improvement, and euthanasia is an option, it would be almost unethical [of a doctor] not to help that person.”
...
"Even those who have grave worries about the slippery slope concede that consensual euthanasia for terminal illness can be a beautiful thing, and that the principle of death at a time of one’s choosing can fit into a framework of care. The question for any country contemplating euthanasia legislation is whether the practice must inevitably expand – in which case, as Agnes van der Heide recognises, death will eventually “get a different meaning, be appreciated differently”. In the Netherlands many people would argue that – for all the current wobbles – that process is now irreversible."
*******

And here's a link and a figure from the BBC story, which concentrates on the difficult case of dementia--difficult because even the clearest directive from a patient with early stage dementia who wants to end his or her life as the disease progresses can often not be confirmed by the patient once dementia is fully established.

Wanting to die at 'five to midnight' - before dementia takes over

Dutch marijuana: where a legal market must purchase from an illegal black market

 The Dutch (legal) market for marijuana seems as confused as the legal American markets in (now) 30 states, but in different ways.
The NY Times has the story:
Solving the Dutch Pot Paradox: Legal to Buy, but Not to Grow
By CHRISTOPHER F. SCHUETZE

"While licensed coffee shops have the right to sell small amounts of recreational cannabis and hash to buyers older than 18, they have to rely on the black market to acquire their wares in bulk.

“Right now, you are allowed to buy the milk, but you can’t know anything about the cow,”...
...
"Last month, the national police union, Politie Bond, released a stinging report warning of the growth of organized crime in the country, fueled by the drug trade.

“The Netherlands fulfills many characteristics of a narco-state. Detectives see a parallel economy emerging,” the report stated, noting that while crime over all had decreased, those producing and trafficking drugs were becoming ever more sophisticated.
*********

The situation in the U.S. is at least as conflicted.  After a long history as a popular illegal drug, thirty states and Washington D.C. have legalized marijuana in some forms and for at least some uses. But marijuana is still a banned Schedule I drug under Federal law, even though marijuana (spelled “Marihuana” in Schedule I) seems no longer to fit the legal definition of a Schedule I drug.
(See Title 21 Code of Federal Regulations, Part 1308 — Schedules Of Controlled Substances, https://www.deadiversion.usdoj.gov/21cfr/cfr/2108cfrt.htm )


See, earlier,

Saturday, December 9, 2017

The gray market for marijuana in Holland

The gray market for marijuana in Holland

The combination of a legal market and an illegal one makes for a gray market, which seems to be the situation of marijuana sellers in the Netherlands. (Not so different from legal marijuana sellers in some American states, who still run afoul of federal laws...)

The Guardian has the story:
Netherlands coffee shop case highlights 'paradox' of cannabis laws

"With 3,000 customers a day, a restaurant, ample parking and turnover of €26m (£23m) a year, Checkpoint cafe, the largest cannabis-selling coffee shop in the Netherlands, was a fabulous commercial success.

"That was until it was closed down in 2009 for testing to the limits what the Dutch describe as their gedogenbeleid (tolerance policy) under which prosecutors turn a blind eye to the breaking of certain laws, including in the business of selling cannabis.

"The latest and most likely final appeal hearing of criminal charges against the cafe’s owner, Meddie Willemsen, has highlighted what the president of a court in Den Bosch described as “paradoxes” in the Dutch approach to so-called soft drugs.

"Licensed coffee shops are allowed to sell cannabis from their premises, but can keep only 500g on site at any time. Production of the drug is illegal.

"When Checkpoint was at its peak, Willemsen, 66, was regularly keeping about 200kg of cannabis on his large premises in Terneuzen, near the Belgian border. The size of the enterprise could have led to fairly reasonable assumptions that those providing the drugs would be large criminal gangs.

"Prosecutors were informed by the court that while Checkpoint cafe was certainly criminal, local authorities had effectively aided it at times and turned a blind eye for long enough that punishment of the owner would be inappropriate.

"The court heard the illegal activity was necessary for a cafe of Checkpoint’s size. The president ruled: “That is punishable. But at the same time not to be avoided when you run a well-functioning coffee shop.”
...
"The president of the court in Den Bosch said the story of Checkpoint cafe highlighted the absurdity of the law in the Netherlands, where selling cannabis at the front of the shop is legal, under strict criteria, but production and sourcing of it at the back is illegal. “Here lies a task for the legislator,” the president said.

"In 2012, the Dutch government changed the law to criminalise sales by coffee shops to customers who cannot prove they live in the Netherlands. There is a dispensation for people in Amsterdam, on the grounds that the practice is part of the attraction for tourists visiting the city.