On Netherlands and ethics, or lack thereof

Responding to a post by a Catholic pro-lifer (“Disciple”): Netherlands and bioethics, or lack thereof, which illustrates both the particular problem about trying to oppose abortion as a Catholic, and the general problem all pro-lifers have that their movement is based on lies: while they claim to be “against abortion”, they neither support any effective means of preventing abortion, nor do they actually believe their oft-repeated claim that abortion=murder.

Disciple claimed repeatedly that s/he believes “Abortion is MURDER. And that is all there is to it.” (cite, cite)

The only successful way of preventing abortions – if you believe pro-lifers, of “preventing murders” – is to provide both free access to contraception, and educate/encourage young people to use contraception whenever they have sex. Both are essential. Pro-lifers support neither. (Pro-lifers were actively against allowing the US once more to provide funding to overseas family planning clinics, which prevent abortions, and actively against allowing low-income women to claim contraception on Medicaid, which would prevent abortions.)

The global good example of preventing abortions is the Netherlands. This isn’t a flash-in-the-pan good example, and it’s no secret how it was achieved:

People in the Netherlands consider unplanned pregnancy to be a large problem that society and decision-makers should and do seriously address. The abortion rate fluctuates between 5 to 7/1000 women of reproductive age, the lowest abortion rate in the world. Between 1965 and 1975, a shift from a largely agricultural society to an industrial society, rapid economic growth and the establishment of a welfare state, a reduced influence of the church in public and personal life, introduction of mass media, and a rapid increase in the educational level of both men and women brought about a rapid change in traditional values and family relations in the Netherlands. These changes and the introduction of modern contraception effected a breakthrough in family planning and sexual morality. Factors facilitating the rapid transition to a contraceptive society in the Netherlands were a voluntary family planning movement, fear of overpopulation, role of general practitioners in providing family planning services, and inclusion of family planning in the national public health insurance system. Acceptance of contraception preceded liberalization of abortion. Society accepts abortion as only a last resort. The sexual sterilization rate is higher than that in other European countries (25% vs. 0-23%). Special family planning programs in the Netherlands target groups at risk of unwanted pregnancy, particularly teenage pregnancy. Almost all secondary schools and about 50% of primary schools address sexuality and contraception. Sex education has largely been integrated in general health education programs. The mass media address adolescent sexuality and preventive behavior. Very large scale, nonmoralistic, public education campaigns that are positive towards teenage sexual behavior appear to be successful. Teens have wide access to contraceptive services through general practitioners who maintain confidentiality and do not require a vaginal exam and through subsidized family planning clinics. (1994)

What has this meant, in real terms?

In 2002, the total number of abortions in the Netherlands was 34,168. (This includes just over 4000 abortions performed on non-residents, women travelling to the Netherlands to obtain an abortion or on illegal immigrants.) The abortion rate per 1000 women ages 15-44 resident in the Netherlands was 8.7.

In 2002, the total number of abortions reported in the United States was 948,712: it’s estimated that as many as 347,000 were not reported, and the abortion rates for non-residents, which I presume includes all illegal immigrants, are strikingly higher. But the abortion rate per 1000 for women ages 15-44 legally resident in the United States was 20.5.

One presumes, if you genuinely regard abortion as MURDER, you won’t cavil at preventing it among women who aren’t actually legally resident.

In 2002, in the Netherlands, the abortion ratio (abortions per 1000 live births) is 169.1. In the United States, it is 315.5. The abortion rate – considering abortions as percentage of pregnancies (excluding fetal deaths/miscarriages) in the Netherlands in 2002 is 14.5%. In the United States, it is 24%.

How many abortions would have been prevented, in the United States in 2002, if the United States had adopted the same educational/health system as in the Netherlands and only 14.5% of the pregnancies in that year had ended in abortion, instead of 24%? The historical statistics for the Netherlands and the United States are here: you can play around with the statistics for yourself.

But I make it, at lowest, 440,000. Four hundred and forty thousand. 440,000. That’s how many, at minimum, abortions could be prevented, in the United States, each year, if the US would use the Netherlands model.

I pointed out to Disciple (and noticed that s/he had responded when I clicked on a tag, thanks to WordPress’s sorting system). Disciple’s key interest in the Netherlands is not their success in preventing what Disciple claimed s/he regards as “MURDER”, because Disciple, like most pro-lifers, really doesn’t think preventing abortion is that important. (Given Disciple’s repeated adjuration to me that it’s important to think of abortion as MURDER, I can only conclude that Disciple doesn’t regard murder as that important a sin, since preventing what Disciple claims to think of as 440,000 murders a year is something to be dismissed with contempt.)

Disciple’s key interest is, s/he claims, in the issue of what happens when babies are born with a hopeless prognosis who experience what parents and medical experts deem to be unbearable suffering. The most common cause of this is a baby born with Spina bifida cystica – where a section of the spinal cord and the nerves that stem from the cord are exposed and visible on the outside of the body. It’s possible to keep babies born this way alive for some time with extreme medical care: but they don’t live long and all their lives, all they experience is extreme suffering. (See spina bifidia)

(In a country with a universal healthcare system and where pregnancies tend to be planned, the incidence of spina bifidia can be quite low: the likelihood has been shown to be strongly reduced if a woman takes folic acid supplements for several weeks before and after the date of conception.)

In the Netherlands, it has been legal since 1985 for an adult with a terminal disease to decide for themselves when they want to die and to demand medical assistance in dying painlessly at the time of their choice. (You can argue this one way or another: the United States in 2005 had a suicide rate of 11.1 per 100,000 adults, and the Netherlands in 2004 had a suicide rate of 9.4 per 100,000 adults. WHO. I personally feel that if a person is going to die, and knows their death is going to be agonising and protracted, then it’s absolutely their right to decide to finish it early or to fight it out to the end – their choice. What else can it mean to be human: that you can think about even your own death?)

The topic being discussed by medical professionals, which Disciple dismisses rather glibly, is whether it ought to be legal for parents/care-givers to make that decision and to ask a doctor to provide the same painless assistance that an adult should ask for.

And my instant knee-jerk reaction is: No. It ought not to be legal. An adult can make that choice: I’m willing to accept that it’s possible an older child could make that choice – why should a fifteen-year-old have to die in agony because they haven’t yet reached their 16th birthday, when the instant they do they can ask for the help to die painlessly? But it’s not right for anyone else to make that choice for a child.

And then I thought about spina bifida babies. They’re going to die – ordinarily they are kept alive only by extreme medical intervention. If the intervention is withdrawn, they die. While they are alive, they experience only pain. Is it right to keep a baby alive for as long as medically possible while all his/her live s/he will know only pain?

As this article from March 2005 makes clear, it is accepted by most doctors that there are going to be times when the right thing to do is to withdraw treatment. The question is, when? Under what circumstances? The question must be discussed, and discussed publicly. (See this Radio Netherlands discussion for an example of the other side, a more thoughtful piece than any of the kneejerk OMGDEATHBAD items than Disciple linked to.)

Dutch paediatric neurosurgeon Rob de Jong (whom Disciple does not cite) argues that it is not possible to tell whether a newborn infant’s suffering is “unbearable”, and that it is possible for the diagnosis of Spina bifida cystica to be mistaken. (Deliberate termination of life of newborns with spina bifida, a critical reappraisal)

The argument about mistaken diagnosis I believe to be a red herring: he offers some few examples and they tend to be on the level of “the doctor said she might live 20 years so she might as well die now” rather than the discussed situation in the Groningen Protocol for Euthanasia in Newborns: that the diagnosis is certain and confirmed by at least one other independent doctor.

The argument that it’s not possible to tell if a newborn infant is experiencing unbearable pain I believe to be a reformatting of the old argument that babies don’t feel pain – a myth centuries old. It used to be standard practice to operate on newborn babies without anaesthesia. (One of the key differences between a fetus and a baby is, in fact, that a fetus cannot feel pain: low oxygen levels in the brain mean the fetus is effectively “asleep” until the first breath, regardless of how well-developed the nervous system is. cite)

But the key problem with the kneejerk reaction against parents/caregivers and doctors deciding about the death of newborns, is that it’s not a thoughtful reaction.

As the authors of the Groningen Protocol (Eduard Verhagen and Pieter J.J. Sauer) point out:

Given that the national survey indicated that such procedures are performed in 15 to 20 newborns per year [in the Netherlands], the fact that an average of three cases were reported annually suggests that most cases are simply not being reported. We believe that all cases must be reported if the country is to prevent uncontrolled and unjustified euthanasia and if we are to discuss the issue publicly and thus further develop norms regarding euthanasia in newborns. With that aim, we developed a protocol in 2002, in close collaboration with a district attorney. The protocol contains general guidelines and specific requirements related to the decision about euthanasia and its implementation. Five medical requirements must be fulfilled; other criteria are supportive, designed to clarify the decision and facilitate assessment (see Table 2). Following the protocol does not guarantee that the physician will not be prosecuted. Since implementing this protocol, our group has reported four cases in which we performed a deliberate life-ending procedure in a newborn. None have resulted in prosecution.

Dilemmas regarding end-of-life decisions for newborns with a very poor quality of life and presumably unbearable suffering and no hope of improvement are shared by physicians throughout the world. In the Netherlands, obligatory reporting with the aid of a protocol and subsequent assessment of euthanasia in newborns help us to clarify the decision-making process. This approach suits our legal and social culture, but it is unclear to what extent it would be transferable to other countries.

Doctors and parents all over the world are facing this: a wanted and loved child is dying, a baby in pain – in agony. The choice is between keeping the baby alive in pain, terminating treatment and letting the baby die “naturally”, and acting to give the baby an immediate and painless death.

What do you do? I don’t know. I don’t know what I would do. It’s one of those situations where there is never going to be a right answer, because under those circumstances, there are no right answers. But I do think the right thing to do with decisions like this is not to lie about them. Not to do them covertly and pretend you’re not. Not to refuse to do them with Pharisaical indifference to suffering. Not to do them openly because the healthcare provided is expensive and the baby’s parents are too poor to afford it. (Yes, I am thinking about Sun Hudson.)

For each baby – for each set of parents – for each doctor – each circumstance will be different. The existance of a published protocol with guidelines that a doctor may follow will not increase or change the likelihood of a baby being born with spina bifidia who cannot live, or parents who decide that their baby’s suffering is unbearable even for the short life that medical intervention can give. All it will do is provide doctors with a means of considering if they can justly respond to the parents request: their own ethical decision remains theirs to make, and following the protocol is no guarantee that a court will not decide that euthanasia was a criminal act.

But – to go back to Disciple and the other pro-lifers who refuse to consider the Netherlands success in preventing abortions by education, public health campaigns, and freely-accessible contraception: the numbers are indicative. In the past 12 years, in the Netherlands, 22 infants have been reported killed according to this protocol. I use “killed” rather than the euphemism because I do believe in facing it: twenty-two babies born to a protracted and agonizing death were killed painlessly by a doctor, rather than live the weeks or months before a “natural death”. Is this wrong? For each baby, for each set of parents, for each set of doctors who all had to make the decision, the only honest answer I can give is: I don’t like it, but I don’t know. I don’t believe in the kneejerk OMGDEATHBAD!

I believe in preventing death, in fighting death, in opposing just letting people die when they could be saved. That’s why I’m against the pro-life belief that it’s OK to let 70,000 women a year die without access to safe legal abortion: why I’m against the Republican/conservative belief that it’s OK to let 22,000 people in the US each year die because they didn’t have health insurance. But a prolonged life of nothing but pain, ending in an inevitable death: is that worth struggling to preserve? In the US, just as in the Netherlands, there will be instances where doctors decide that the parents are right, that it’s better for their baby to die soon rather than be kept alive: the difference is only that in the Netherlands it is legal to talk about it with specific examples of actual decisions and the medical reasoning that led to the doctors supporting the parents’ decision: in the US it is not. (It is legal to discuss letting patients die due to their extreme lack of money, oddly enough.)

22 babies killed in the Netherlands; Disciple thinks that’s worth dismissing their entire healthcare system, which, if adopted by the US, has the potential of preventing 440,000 abortions each year. Nine murders and far more instances of attempted murder, arson, bombings, and acid attacks by pro-lifers against abortion providers in the United States (cite): Disciple is still a determined supporter of the pro-life movement.

When pro-lifers such as Disciple claim they believe “Abortion is MURDER”, it is worth considering that they do not regard MURDER all that seriously, and they actively prefer not to contemplate any changes to US healthcare that would prevent what they claim they regard as mass murder.

What kind of ethics can they lay claim to, if they don’t even care about preventing murder?