HEALTH

Killing Them Softly

HEALTH
Jan 12, 2014 at 11:53 PM ET

The doctor who’s preparing to kill his patient is wearing a Looney Tunes tie.

It is festive and patterned with miniature Bugs Bunnies, and he’s sporting crimson corduroys to match. In all, it’s an ensemble more suited for a rum and eggnog than the needle he holds in his hands.

Standing beneath fluorescent lights, Dr. Marc Van Hoey and his colleague are arranging the implements of death. They fill three syringes, label each with a Sharpie and place them on a sterile silver tray.

Bedridden and tucked beneath his sheets, an 83-year-old man awaits their lethal cocktail. He appears relaxed and surprisingly upbeat. On his chart “12/18: Euthanasia Day” has been written in curling script, and according to the nurse, it’s the first time he has smiled in weeks.

A few months earlier, his eldest daughter had found him hanging from a rope. He was in the throes of stomach cancer and was unable to walk. His wife had died a few years before, and he intended to join her, but he wound up at Antwerp’s Nottebohm nursing home instead. He grew angry and threatened to leap from the window. He wanted death so desperately that it infected his dreams.

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“When he woke up this morning he thought he was already dead,” remarks his nurse.

Despite the man’s apparent good cheer, the room is cast in a palpable gloom. His children and grandchildren stand huddled around his bed, and with the moment nearing, Van Hoey asks his patient if he would like his family to stay. “I don’t care,” he replies with a sarcastic quip. “I will be the first to leave.”

The man’s arm is limp and extended outwards over the edge of the bed. A catheter has already been taped to his forearm, and its tubing lodged tightly into a vein. “Are you ready?” the doctors ask. With a “yes” they begin the five-minute process.

Time slows as the doctors make their first injection, like a roller coaster nearing a drop. It is benzodiazepine, a sedative that weighs heavily on the patient’s eyelids and in moments has put him to sleep. He appears motionless, though raspy breaths are still resounding from his lungs. Next comes a noxious dose of anaesthetic—Thiopenal, a coma-inducing barbiturate that hits the body hard. The man rattles the room with a single, gut-wrenching gasp for air, and instantly ceases all movement. At this point, his mind has passed into blackness, and the doctors administer their final blow: Norcuron, a muscle relaxant used to stop the heart.

The family whimpers and cheeks grow wet with tears, their dry-humored patriarch gone suddenly stiff and white. His granddaughter fumbles nervously with a raggedy stuffed animal.

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“He was so peaceful,” one of his daughters says, hoping to dissolve some of tension in the room. “He was so happy. We are so lucky that he could go in this way.”

The nurse leads the family down the hall, and the doctors leave to fill out paperwork and wash their hands.

 “That was emotional,” Van Hoey says to his colleague, peeling back his latex gloves.

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For someone so frequently confronted with pain and suffering, Van Hoey is an inordinately lively man—though an upbeat attitude must be a necessary means of recourse. At 52, he is currently one of Belgium’s leading physicians when it comes to dealing out death, with somewhere close to 120 patients (he has lost track) under his belt so far. To put that number into perspective, it’s a body count that falls just shy of the notorious Jack Kevorkian’s.

Tall, with shortly cropped hair and wire-rimmed glasses, Van Hoey is the president of Right to Die Flanders (RWS), a euthanasia advocacy group for Belgium’s Flemish-speaking population. It is one of many organizations around the world aiming to protect an individual’s right “to self-determination at the end of their lives.”

Aside from his penchant for mercy killing, Van Hoey is cultured and quirky: He’s a lover of opera who rides his bike to work and eats his burgers with a knife and fork. When he moves his hands, the diamond on his pinky ring glitters.

By the time euthanasia was officially legalized in Belgium in 2002, Van Hoey had already been exposed to many cases of “assisted dying” through his experience in palliative care, an area of medicine focused on the relief of suffering and pain. At the time, the act was considered a clandestine pact between patient, doctor and family, and was often reported as “cardiac arrest.”

In the early ’90s Van Hoey started his own practice and began working in hospitals with geriatrics, whom he calls “quite fun.” It was there that he learned how to cope with dying people and their families while growing passionate about what he calls “patient wishes.”

His first experience with euthanasia was nearly a decade ago, though it’s preserved in his mind as clearly as the day he did it. The patient was a woman in her 70s with severe pulmonary disease. She came to hospital on oxygen and a host of medicines, and was ready to trade them for death.

“I leaned over her and asked, ‘Do you really want it to stop?’” he recalls. At the prick of the needle she delivered her last words: “Thank you very much.” Even today, Van Hoey still carries her gratitude with him.

“If this is what people really want, and we can help them in that way, then I think that’s part of medicine,” he says.

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On Dec. 12 the Belgian Senate voted 50-17 to lift all age restrictions on euthanasia, making it the first country in the world to do so. The tiny multilingual kingdom continues to push the envelope when it comes to acceptable criteria for doctor-aided deaths, and in turn has set an entirely new precedent for end-of-life care.

Today only Belgium, Luxemburg, the Netherlands and Colombia allow physicians to actively facilitate the death of a patient, while Switzerland and several U.S. states permit the more indirect method of “assisted suicide.” In these cases, the patient is prescribed something lethal they must ingest or inject themselves. In May, Vermont became the fourth state to legalize this technique, following Washington and Montana, which passed similar laws in 2008, and Oregon in 1994.

As with most jurisdictions where euthanasia is legalized, the practice has grown increasing common in Belgium, with the number of documented cases rising steadily each year. In 2012, the death count clocked in at more than 1,400 people, a 25 percent increase from 2011. Since then, public support for the law has also grown. According to a recent poll, a full three-fourths of Belgians approve of the practice, including its expansion to terminally ill children.

The unprecedented move caused its fair share of moral panic on the world’s editorial pages, but at least in Belgium, the legislation passed with a surprising bipartisan majority.

Though the original debate in 2002 was divided along religious lines, Jean-Jacques De Gucht, a Flemish senator for the liberal party, believes his country has come a long way since then. “It’s not about atheism, agnosticism and religion anymore,” he says. “It’s about coping with the end of life and setting a legal framework for the patient and the doctor.”

De Gucht is quick to note that the need for regulations regarding euthanasia was important because it was already happening anyway. The theory was that a legal framework for the practice would help prevent abuse and the prosecution of doctors who were just listening to their patient’s pleas. The same goes for the recent extension to minors.

“Until recently, doctors were performing an illegal act when they assisted minors who asked for help during a terminal phase,” De Gucht says.  “Now the legal safeguards are there to make sure everything is done by the book.”

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Still, critics argue that such protections just aren’t strong enough. They speak about the “slippery slope” that allowing such legislation has inevitable induced, making it easy for just about anyone to be euthanized. Recent high-profile cases involving a transgender person with a botched sex change, deaf middle-aged twins who were going blind and a woman with anorexia are often sited as troubling examples.

Wim Distelmans, the acting physician in the first two cases, also happens to be the co-chairman of the federal commission charged with monitoring possible abuses of the law. In 11 years, not a single violation has been reported to prosecutors.

The most significant concern, however, is whether or not it is even safe to grant a group of people the exclusive right to end a human life. We’re talking about doctors, that class of professionals bound to the Hippocratic Oath and its mantra to do no harm. Physicians are supposed to save lives, not take them, as custom would have it, though Van Hoey would argue that’s too narrow a description of their role.

“Of course, we are not educated or trained to really kill a person,” he says. “But what you tell yourself is that you are doing what the person themselves has asked in so far as the law allows.” He fields questions about ethics and malpractice with a similar tactful pivot, maintaining that the right to die empowers the patient, not the physician.

“People see Belgium as killing country. That’s crazy!” he says, tossing up his arms in protest. “It’s not an eradication program.”

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Though euthanasia can be easy to perform on principle, the emotional learning curve is a bit more arduous for many physicians. It takes nerve to watch a dying breath, let alone be its catalyst. With so many lives relinquished at his hands, one has to wonder how Van Hoey endures it.

Last year, he was featured in the Dutch documentary End Credit, where he aided in the death of a 34-year-old patient. Her name was Eva, and she succumbed to severe, chronic depression. For 10 years she had sought every possible treatment in vain, including electroshock therapy. And so, on a quiet day in August, Van Hoey delivered her coup de grâce.

“The bond between a patient and doctor gets so strong by the time the euthanasia takes place that it’s hard,” he said in an interview shortly after the film’s release. “It’s so personal and intimate and beautiful.”

Van Hoey was especially stirred watching himself inject her onscreen, slipping a fatal needle into an otherwise vibrant young woman. “It was very strange for me,” he says. “You can see the emotion in my face.”

Sentiments aside, Van Hoey is resolved in his ways and wholly committed to what he believes is as an act of compassion. At times he is even asked to come to the aid of fellow doctors who are too squeamish to do the deed.

Last year, Van Hoey euthanized the mother of a fellow physician who felt unable to do it himself.

“She began to talk about how she didn’t see the sense of life anymore,” Walter De Roeck remembers over tea in a hotel cafe.

Weeks before, his 82-year-old mother had received diagnoses of depression and onset dementia. “Her spirit was away,” he says, as if part of her had passed already. “You could see it in her way of speaking.” As her doctor, De Roeck changed her antidepressants several times to see if things would improve. Nothing worked.

“She wanted it stopped,” he says. “For six months straight she kept saying, ‘I don’t want to be in a situation where I can’t recognize anyone anymore.’”

Understandably, De Roeck was deeply conflicted. “As a professional I could understand her desire,” he says. “But as her child, as her son, it was not so easy emotionally. Your mother dies and she’s gone. She can’t come back anymore.” In time, De Roeck realized how firm she was in her decision and gradually came to accept it. It was then that he asked Van Hoey to step in as her physician.

“So for those last days I was just her son,” he says.

De Roeck took his mother on a long walk the day before her injection, and that evening his sister and her children joined them for a final family meal. A last supper, or “pre-funeral” of sorts, has become something of a newfangled tradition among families whose loved ones have elected to die. The De Roecks ate their mother’s favorite Flemish dish—eel in a green herb sauce—and toasted her with wine and champagne. Her appointment was set for 10 a.m. the next morning, and she planned to die in the very place she lived: smack in the middle of the living room.

Dr. Van Hoey arrived shortly after breakfast, and prepared the syringes as the family anxiously stood by. When the time came, De Roeck’s mother lay down, and her children and grandchildren gathered round to watch the needle take her. It took only five minutes.

Dipping a bag of tea into porcelain cup, De Roeck reasons with his mother’s choice. “It’s an individual decision, a personal decision,” he says. “You can’t decide things like that for another person. For me, maybe she could have lived for some time more, but that is for me. And I am not her, and she is not me, you understand?”

Of course, throwing in life’s towel can be easier for some patients than for others. Among the most challenging end-of-life cases are those with diagnoses of Alzheimer’s and other forms of cognitive atrophy. One of the requirements for euthanasia is that patients must be fully competent at the time of their request, as determined by a psychologist. As the law stands today, someone in the final stages of a cerebral disease cannot be euthanized because his or her mental faculties are not in full form. Instead, people are forced to die preemptively—before the disease has even begun to ravage their minds.

Julien, a veterinarian living in an Antwerp suburb, has just been diagnosed with Alzheimer’s at the age of 56. It began last year when he noticed he was having difficulty with numbers. He couldn’t keep score playing tennis, and he often felt disoriented in time. In February of 2013 he received the official verdict. “I knew what it meant,” he says, anxiously rubbing his fingers around the rim of a water glass. “The most important thing I remembered was that there is no cure. That is my biggest problem.”

Julien’s wife, Marie, is also well aware of the slowly mounting misery they are now condemned to. As a physical therapist, she often works in nursing homes surrounded by the severely demented—human houseplants in need of constant care. “It’s a disease that doesn’t happen often with people his age,” she says, pulling on the skin of her cheeks as we sit at the dining room table. “He is a very intelligent man,” she continues. “For me it is very hard to know that my husband could end up like that. Like the people I see every day.”

Unsure of what to do, the couple contacted Van Hoey for advice. The three of them deliberated over Julien’s case, and Van Hoey suggested they begin an agonizing discussion: Julien needed to think about how far he was willing to go.

Still coming to terms with his diagnosis, Julien has yet to set his expiration date, though the possibility of a quick exit remains comforting. Years ago, he watched his own mother lose a protracted battle to intestinal cancer.

“He told me that he wanted to go to his veterinarian’s office and get the medicine that would make it stop,” Marie says as Julien’s eyes grow doleful.

“If it gets really bad I will make the decision,” he murmurs. And for a moment his spirits appear to lift. “But right now I am still playing tennis.”

A week ago, the beloved “Belgian Bolt,” a 95-year-old track-and-field athlete named Emiel Pauwels, ended his life after being diagnosed with terminal intestinal cancer. Pauwels became famous last year after an epic, last-second sprint to win the 65-meter-dash at the Veterans Games. Not keen on cancer’s plodding pace, Pauwels decided to pull out early while life was still good. He took a final victory lap in his hometown of Bruges, throwing a party where he downed several glasses of celebratory champagne. Some 100 guests showed up.

“It is the best party of my life,” Pauwels announced to a local paper, his enthusiasm heightened by the ticking clock. It’s the kind of thing Van Hoey sees all the time.

Driving in his compact, Euro-style sedan, Van Hoey muses on the importance of living well—“I love partying!”—and dying that way, too. A symphony reverberates against the windows, his favorite classical station turned on high. “In my 26 years of being a doctor, I’ve seen a lot of dying,” he says, making his way toward an appointment at a nearby nursing home. “Many people spend so much time suffering. You can see it in their faces. But when you see people before euthanasia, they are happy. Almost all of them die happily.”