I was living in comfortable retirement with my wife, Mathilde, when, at the age of 71, she received a diagnosis of Waldenstrom’s disease. The chief danger of this rare cancer of the bone marrow is that it impedes and eventually destroys the production of vital components of the blood supply.
It was held at bay by periodic bouts of chemotherapy, sometimes for a few months, once for several years. And for a long time, we lived our lives under this regime, citizens of the realm of the chronically ill, with monthly visits to the cancer hospital for checks and tests, always wary of the disease. But this soon became a routine, and for long spells we did not feel seriously threatened, taking a quick holiday when another round of chemotherapy was in the offing. Apart from fatigue and the common effects of advancing age, Mathilde did not suffer very much.
Then, after seven years, the cancer suddenly turned aggressive and the treatment no longer worked. The disease had soon wrought havoc among the leukocytes, the white blood cells that guard against infection, and all of Mathilde’s resistance had gone. It was just a matter of time — a couple of weeks or maybe months — before she would die from influenza or some other common infection. At the hospital, they gave her a blood transfusion and told her to report next week; and then they gave her another blood transfusion and told her to report again a week later. And if she had not fallen ill and refused further treatment, they would no doubt have continued in this way.
But we live in the Netherlands, and here is where our story becomes a little different. When people become as ill as my wife, with no prospect of cure and only pain and exhaustion in the offing, it is quite legal to end one’s life by voluntary euthanasia.
For all her quiet ways, Mathilde was a strong-willed person, cherishing her independence and her freedom, and determined to live her life as she wanted. When euthanasia first became a public issue in the early 1970s, she became a strong supporter of the cause. We joined the Dutch Association for Voluntary Euthanasia, signed petitions and wrote letters to members of Parliament demanding such a law. When, as a first step, our courts set out conditions that made euthanasia acceptable, Mathilde, then only in her 40s, made sure we filled out the forms with the association stating that we wanted to receive euthanasia when the time came.
In 2001, euthanasia finally was fully legalized. Those who wanted it had to ensure the cooperation of their family doctor. We made sure all the doctors who joined our village medical practice knew our wishes, and we always asked whether they would administer euthanasia. As an added precaution, Mathilde continued to carry a thick wad of forms and declarations in her handbag wherever she went, in case of an accident.
All the doctors agreed to our request. They were from a younger generation; it is older doctors, mainly, who are reluctant to administer euthanasia. A few refuse on grounds of principle, others because they just do not wish to become involved. But more than 80 percent of all Dutch family doctors, according to a recent large study, report that they have performed euthanasia at least once, and among the willing doctors the average rate is once every two or three years.
Euthanasia is by now widely accepted here. It is supported by the vast majority of the population, of the medical profession and of the political parties. The costs for it are borne by our compulsory health insurance, and suicide clauses voiding life insurance policies have been set aside. Still, it is an onerous task for the attending physician, and it also demands paperwork and careful planning. Demands for euthanasia are not made lightly and are more often denied than granted, largely because of insufficient forethought.
But in Mathilde’s case, forethought had not been lacking.
When it was clear that Mathilde’s life was coming to its end, we went at once to see our doctor and reminded him of his earlier promise to administer euthanasia. I asked him how it was done. In the past, he told us, the patient drank a deadly potion, demonstrating for the last time the exercise of free will. But that is an uncertain method: Sometimes the patient throws up and survives in worse shape than before. More certain is the active method, where the doctor prepares two syringes. The first injection induces a deep coma; the second is a muscle relaxant that stops the heart. The whole process is over in a couple of minutes.
We still had a couple of weeks, perhaps a month or two, before things came to that. We informed our children, all adult now, our relatives and close friends, and then we settled down to wait.
There were three possible places for Mathilde’s death: the hospital, a local hospice and at home, in her own bed. She chose the last option and began her preparations, taking off her wedding ring of more than 50 years and issuing firm instructions: I should be present when she died; if euthanasia were used, I must be at her bedside and our children nearby, in the house but not in the bedroom.
And contrary to what is common here, she wanted her body to be taken away before nightfall, not lying in state for several days for friends and relatives to pay their last respects, a custom Mathilde and I both disliked.
In all these matters I accepted her wishes without argument, as I was wont to do, for I knew how much she disliked tiresome explanations and discussions.
All her life, Mathilde had slept soundly, falling asleep like a contented child, and until her very last days she continued to do so. I slept at her side, not so soundly, with instructions about what to do should she die in her sleep (a vain hope): Close her eyes, prop up her chin (”Otherwise, my mouth will fall open and I shall look silly”) and only then call the doctor.
Every morning, Mathilde would take her temperature. One day she ran a fever, and soon she became very ill indeed. First she contracted influenza but miraculously recovered; then there followed cystitis. She kept to her bed, and when another blood transfusion was due, she refused to go. She had given up. She no longer slept well and no longer wanted food or drink. The time had come to act.
The law lists four major conditions for euthanasia. It must be administered by a doctor; the patient must earnestly desire it, a resolve taken after due deliberation, and freely; there must be no prospect of recovery and, in the words of the law, the patient must be suffering unbearably. The attending physician must confirm that these conditions are met and write a report to this effect.
As a rule, the family doctor who has known the patient for years is the best judge of her condition and of the earnestness and independence of her request. But he must also consult another doctor, an outsider, for an independent assessment; that doctor must also put his views in writing. Afterward, both reports are submitted to a monitoring committee, which may ask for further explanation and can refer problematic cases to the Inspector of Health and the Public Prosecutor. But their annual reports show that the monitoring committees do this only very rarely — in 2010, at the rate of one in every 300 reported cases.
We called for the consulting doctor, who spent the better part of an hour with Mathilde. Afterward, he called our family doctor and said he was not sure she was suffering enough.
What is unbearable suffering? It is an impossible question. The monitoring committees have given up trying to define it and adopted the view that the patient’s own judgment is decisive, provided the acting doctor is convinced of its earnestness and sincerity. For Mathilde, the prospect of being at the mercy of random infections while permanently dependent on blood transfusions was intolerable. We wrote a letter to this effect and heard no more of it.
On a Sunday morning not long afterward, we decided that the time had come. The logistics dictated a tight schedule. The doctor had to order the drugs, which meant a day’s delay. On Tuesday, he would be available at the earliest in the afternoon, after his morning rounds. Afterward, we would have to wait for a visit from the coroner, since Mathilde would have died an unnatural death, and only after that could the undertaker take the body away.
We set the date for Tuesday at 3 p.m. Our children assembled in the sitting room and I was in the bedroom, with the doctor and a nurse. Mathilde had had a bad night, distraught and unable to sleep, and the doctor had come to give her morphine.
But now she was awake and fully conscious of her condition. To the nurse she said, “I am ready” and to me, “I am not afraid.” I sat on one side of the bed and took her hand, and the doctor, at the other side, gave her the first injection.
She immediately fell asleep, snoring loudly. The doctor gave her a second injection, and the snoring stopped. She had died. It was all over in a couple of minutes.
What about emotions? Was there no grief, no anguish, was it all a matter of procedures and logistics?
Oh, yes, I felt plenty of grief in those terrible weeks. I had loved my wife more than anything else in the world, day by day, for over 50 years, and to know that she would shortly die was breaking my heart. But at the supreme moment, did our eyes meet in a last loving look? Were we united by a sense of extraordinary belonging and togetherness?
Nothing of the kind. By this time Mathilde was very ill and running a fever. Events demanded her utmost concentration, and quite understandably she had no time for me. And I, who had been crying for weeks, who had burst into tears at my appointment with the dentist when that kind man asked me in all innocence how I was, at this ultimate moment I felt nothing beyond the constant numbing grief of the last weeks.
I saw the doctor out, and one of our daughters went to dress her mother as she had wanted.
Then my children left, the nurse withdrew and I sat alone in the living room. The coroner, who had been alerted by the doctor, called to say that he was held up in traffic. When he arrived he stomped up the stairs and down again, and gave me a sheaf of legal papers. “Do not read them,” he said. “Just hand them to the undertaker.” I called the undertaker and told him we were ready.
And then, as I sat there by myself, all the formalities completed, I began to wonder whether I was right in not taking a last look at my wife in death. I reflected that many people derive comfort and solace from the practice, and I also recalled a passage from the memoirs of some British author who had also lost his wife in old age and in illness, like me. When he went to view her body, he reported that she had in death quite miraculously regained the radiance of her youth.
Three times I went upstairs to take a look. Mathilde was lying there peacefully, quite cold, even colder than the room, so it seemed. She looked no younger than she was when she died. Again I felt no particular emotion. The British author must have been a fool.
It was already dark when the undertaker’s men arrived. It did not take them long to take Mathilde away.
The day was over, and all her wishes had been fulfilled.
Cramer is a retired professor of econometrics who lives in Amsterdam. He occasionally writes memoirs, short stories and opinion pieces in Dutch.