Euthanasia in the Netherlands

The Dutch Euthanasia legislation actually only provides a special provision of exemption from punishment in certain circumstances.
  • The legislation: requires that due care be used by the physician, requires that the doctor believe the suffering to be lasting and unbearable, permits 16 to 18 year olds to be killed without parental approval, permits 12 to 16 yr olds to be killed if a parent or guardian agrees.
  • National character traits, key court rulings, lack of palliative care training and Royal Dutch Medical Association approval, led to this legal decision
  • In 1990, over 3700 people were euthanaised.
The Dutch Euthanasia legislation only provides a special provision of exemption from punishment in certain circumstances.

The legislation: requires that due care be used by the physician, that the doctor believe the suffering to be lasting and unbearable, permits 16 to 18 year olds to be killed without parental approval, permits 12 to 16 yr olds to be killed if a parent or guardian agrees.

National character traits, key court rulings, lack of palliative care training and Royal Dutch Medical Association approval, led to this legal decision. In 1990, over 3700 people were euthanaised.

Euthanasia in the Netherlands is widely accepted by the medical establishment, the government and the Dutch people themselves.
The average Dutch citizen takes for granted that as they get older and face illness, euthanasia is available to escape any pain and suffering.


It is considered an integral part of palliative care and the normal way to deal with serious and terminal illness.

The average Dutch citizen takes for granted that as they get older and face illness, Euthanasia is available to escape any pain and suffering.

Suicide among those over 50, has fallen by a third, because medically assisted suicide is available for those assessed as suffering depression and 'assisted' suicides are not included in statistics of suicide.

An Independent Overview
The Netherlands experience with Euthanasia has been widely studied. We have drawn on the study published in 2002, by Herbert Hendin, M.D., Professor, Department of Psychiatry and Behavioral Sciences, New York Medical College. He was one of three independent foreign observers permitted to investigate all aspects of Euthanasia in the Netherlands.

The Dutch embraced Euthanasia through a combination of their national character traits, pivotal court rulings and the approval of the Royal Dutch Medical Association.
There is little compromise on ideas and viewpoints. People don’t argue, they simply separate into like-minded groups and organizations.

Dutch Social History
A unique feature of Dutch culture is operating in compartments. There is little compromise on ideas and viewpoints. People don’t argue, they simply separate into like-minded groups and organizations.

The populace are generally secular and indifferent to moral and philosophical issues.

Thus there was little debate in the medical world. Assisted suicide and Euthanasia were approached on a purely pragmatic basis. Catholic and Protestant doctors who opposed, were intellectually confined to their own organizations, through the indifference of the majority.

The Dutch medical establishment views any differences on Euthanasia as based not, on medical grounds but purely religious in nature.

This approach is echoed in the wider Dutch non-religious community.

How Euthanasia Became Accepted
In 1984, the case of a doctor who assisted in the suicide of a 95-year old woman reached the Dutch Supreme Court. The Court took a narrow view, asking whether from an objective medical perspective, the Euthanasia could be regarded as an action justified by medical necessity.

The prosecutor was thus obliged to seek the advice of the Royal Dutch Medical Association, who supported the doctor’s action. The doctor was duly acquitted, the Medical Association then asked the Minister of Justice to change the law and permit Euthanasia.
A consensus on guidelines was reached and provided doctors kept to the rules, they could practice Assisted Suicide and Euthanasia, without fear of prosecution.


A consensus on guidelines was reached and provided doctors kept to the rules, they could practice Assisted Suicide and Euthanasia, without fear of prosecution.

Overseas Concerns Lead to Two Studies
In 1990, international concerns about 'wild Euthanasia' prompted the Dutch government and the Royal Dutch Medical Association to sponsor a study of the practice Assisted Suicide and Euthanasia. This was followed by a second study in 1995.

The 1990 study estimated assisted deaths at 4,813 (3.7% of all deaths in that year). The 1995 study estimated 6,368 deaths (4.7% of all deaths). However, investigators discovered that 60% of all assisted deaths were not being reported and the safeguards, or guidelines, were being routinely ignored. Busy doctors were not prepared to carry out all the required 'safeguard' procedures. Doctors admitted that involuntary Euthanasia is widespread and largely unreported. Those doctors carrying out involuntary euthanasia do not consult with colleagues.

Assisted Suicide
Dutch doctors have traditionally received minimum training in care for the dying and in palliative care. Dutch citizens were aware that if they became terminally ill, they could expect to suffer.
Dutch doctors have traditionally received minimum training in care for the dying and in palliative care. Dutch citizens were aware that if they became terminally ill, they could expect to suffer. Patients that become depressed can request Assisted Suicide. Dr Hendrin observed that this psychological suffering was taken as given. Relatively few doctors sought psychological assistance for their patients.

Faced with the fearful prospect of severe pain, the Dutch regard Euthanasia as a merciful alternative.

A Polish expert on palliative care who runs one of the ten hospices in the country, also provides training courses for doctors. He observed that most Dutch doctors are unable to effectively treat pain, through lack of training and skills.

The tendency when faced with situations beyond their competence is to euthanise the patient. He also notes that doctors who specialise in administering Euthanasia, are uninterested in learning about palliative care.

Grassroot Changes
Concern about the lack of palliative care facilities, led the Dutch Government in 1996 to launch a five-year plan designating six institutions as centres and developing thirty units in nursing homes. Specialists in palliative care associated with the ten hospices, report much demand for training courses for doctors and nurses.
There is a growing awareness among the medical profession of their deficiencies in palliative care skills


There is a growing awareness among the medical profession of their deficiencies in palliative care skills - and the need to provide a viable alternative to Assisted Suicide and Euthanasia.

Dutch Penal Code
Dutch Euthanasia legislation which was passed on April 10, 2001 and went into effect on April 10, 2002 offered special provision on exemption from punishment for a physician provided she/he complies with two conditions:

  1. He must practice due care as set forth in a separate law, the Termination of life on request and Assisted Suicide (Review) Act
  2. He must report the cause of death to the municipal coroner in accordance with the relevant provisions of the Burial and Cremation Act.
The due care criteria, in order for a physician to be exempt from criminal liability, stipulate that the attending physician:
  • must be convinced that the patient has made a voluntary and well-considered request to die;
  • must be convinced that the patient's is facing interminable and unendurable suffering;
  • has informed the patient about his situation and his prospects;
  • together with the patient, must be convinced that there is no other reasonable solution;
  • has consulted at least one other independent doctor of the patient;
  • has seen and given his written assessment of the due care requirements as referred to in points 1 to 4;
  • has helped the patient to die with due medical care.
Minors
Children of 16 and 17 can, in principle, make their own decision. Their parents must, however, be involved in the decision-making process regarding the ending of their life although their agreement or approval is not strictly necessary.
Dutch doctors have traditionally received minimum training in care for the dying and in palliative care. Dutch citizens were aware that if they became terminally ill, they could expect to suffer.
For children aged 12 to 16, the approval of parents or guardian is required.

Declaration of Will
Persons aged 16 years and older can, in effect, make a written statement years before they may actually be in a position where it becomes a critical issue, based on views that may have changed in the meantime. The declaration has the same status as a concrete request for Euthanasia. (1)

Since 1981, guidelines have been interpreted by the Dutch courts and Royal Dutch Medical Association (KNMG) in ever-broadening terms. One example is the interpretation of the "unbearable pain" requirement reflected in the Hague Court of Appeal's 1986 decision. The court ruled that the pain guideline was not limited to physical pain, and that "psychic suffering" or "the potential disfigurement of personality" could also be grounds for Euthanasia. (2)

The main argument in favour of Euthanasia in Holland has always been the need for more patient autonomy -- that patients have the right to make their own end-of-life decisions. Yet, over the past 20 years, Dutch Euthanasia practice has ultimately given doctors, not patients, more and more power. The question of whether a patient should live or die is often decided exclusively by a doctor or a team of physicians.(3)
Using 'life-terminating treatment' frees doctors from following the established euthanasia guidelines and reporting the death as Euthanasia to local authorities.


The Dutch define Euthanasia in a very limited way: "Euthanasia is understood [as] an action which aims at taking the life of another at the latter's expressed request. It concerns an action of which death is the purpose and the result." (4) (Emphasis added.) This definition applies only to voluntary euthanasia and excludes what the rest of the world refers to as non-voluntary or involuntary euthanasia, the killing of a patient without the patient's knowledge or consent. The Dutch call this 'life-terminating treatment'.

Some physicians use this distinction between Euthanasia and 'life-terminating treatment' to avoid having a patient's death classified as Euthanasia thus freeing doctors from following the established Euthanasia guidelines and reporting the death to local authorities.

One such example was discussed during the December 1990 Institute for Bioethics conference in Maastricht, Holland. A physician from The Netherlands Cancer Institute told of approximately 30 cases a year where doctors ended patients' lives after the patients intentionally had been put into a coma by means of a morphine injection.

The Cancer Institute physician then stated that these deaths were not considered Euthanasia because they were not voluntary, and that to have discussed the plan to end these patients' lives with the patients would have been 'rude' since they all knew they had incurable conditions. (5)

For the sake of clarity in this fact sheet, the direct and intentional termination of a patient's life, performed without the patient's consent, will be termed 'involuntary Euthanasia'.

THE FACTS
Despite long-standing, court-approved euthanasia guidelines developed to protect patients, abuse has become an accepted norm.

The Remmelink Report-- On September 10, 1991, the results of the first, official Government study of the practice of Dutch Euthanasia were released. The two volume report (6) - popularly referred to as the Remmelink Report (after Professor J. Remmelink, M.J., attorney general of the High Council of the Netherlands, who headed the study committee)- documents the prevalence of involuntary euthanasia in Holland, as well as the fact that, to a large degree, doctors have taken over end-of-life decision making regarding Euthanasia.

The data indicate that, despite long-standing, court-approved, Euthanasia guidelines developed to protect patients, abuse has become an accepted norm. According to the Remmelink Report, in 1990:
  • 2,300 people died as the result of doctors killing them upon request (active, voluntary euthanasia).(7)
  • 400 people died as a result of doctors providing them with the means to kill themselves (physician-assisted suicide).(8)
  • 1,040 people (an average of 3 per day) died from involuntary Euthanasia, meaning that doctors actively killed these patients without the patients' knowledge or consent.(9)
    • 14% of these patients were fully competent. (10)
    • 72% had never given any indication that they would want their lives terminated. (11)
    • In 8% of the cases, doctors performed involuntary Euthanasia despite the fact that they believed alternative options were still possible. (12)
  • In addition, 8,100 patients died as a result of doctors deliberately giving them overdoses of pain medication, not for the primary purpose of controlling pain, but to hasten the patient's death. (13) In 61% of these cases (4,941 patients), the intentional overdose was given without the patient's consent.(14)
  • According to the Remmelink Report, Dutch physicians deliberately and intentionally ended the lives of 11,840 people by lethal overdoses or injections - a figure which accounts for 9.1% of the annual overall death rate of 130,000 per year. The majority of all Euthanasia deaths in Holland are involuntary deaths.
  • The Remmelink Report figures cited here do not include thousands of other cases, also reported in the study, in which life-sustaining treatment was withheld or withdrawn without the patient's consent and with the intention of causing the patient's death. (15) Nor do the figures include cases of involuntary Euthanasia performed on disabled newborns, children with life-threatening conditions, or psychiatric patients. (16)
  • The most frequently cited reasons given for ending the lives of patients without their knowledge or consent were: "low quality of life," "no prospect for improvement," and "the family couldn't take it anymore."(17)
  • In 45% of cases involving hospitalized patients who were involuntarily euthanized, the patients' families had no knowledge that their loved ones' lives were deliberately terminated by doctors. (18)
  • According to the 1990 census, the population of Holland is approximately 15 million. That is only half the population of California. To get some idea of how the Remmelink Report statistics would apply to the U.S., those figures would have to be multiplied 16.6 times (based on the 1990 U.S. census population of approximately 250 million).
To avoid additional paperwork and scrutiny, doctors deliberately falsify patients' death certificates, stating that the deaths occurred from natural causes.
Falsified Death Certificates
In the overwhelming majority of Dutch Euthanasia cases, doctors - in order to avoid additional paperwork and scrutiny from local authorities - deliberately falsify patients' death certificates, stating that the deaths occurred from natural causes. (19)

In reference to Dutch euthanasia guidelines and the requirement that physicians report all euthanasia and assisted-suicide deaths to local prosecutors, a government health inspector recently told the New York Times:

"In the end the system depends on the integrity of the physician, of what and how he reports. If the family doctor does not report a case of voluntary Euthanasia or an Assisted Suicide, there is nothing to control." (20)

Inadequate Pain Control and Comfort Care
In 1988, the British Medical Association released the findings of a study on Dutch Euthanasia conducted at the request of British right-to-die advocates. The study found that, in spite of the fact that medical care is provided to everyone in Holland, palliative care (comfort care) programs, with adequate pain control techniques and knowledge, were poorly developed. (21)
Where Euthanasia is an accepted medical solution, there is little incentive to develop programs which provide modern, available, and effective pain control for patients.


Where Euthanasia is an accepted medical solution to patients' pain and suffering, there is little incentive to develop programs which provide modern, available, and effective pain control for patients. As of mid-1990, only two hospice programs were in operation in all of Holland, and the services they provided were very limited. (22)

Broadening Interpretations of Euthanasia Guidelines
In July 1992, the Dutch Pediatric Association announced that it was issuing formal guidelines for killing severely handicapped newborns. Dr. Zier Versluys, chairman of the association's Working Group on Neonatal Ethics, said that "Both for the parents and the children, an early death is better than life."

Dr. Versluys also indicated that Euthanasia is an integral part of good medical practice in relation to newborn babies. (23) Doctors would judge if a baby's "quality of life" is such that the baby should be killed.

A 2/15/93 statement released by the Dutch Justice Ministry proposed extending the court-approved, Euthanasia guidelines to formally include "active medical intervention to cut short life without an express request." (Emphasis added.) Liesbeth Rensman, a spokesperson for the Ministry, said that this would be the first step toward the official sanctioning of Euthanasia for those who cannot ask for it, particularly psychiatric patients and handicapped newborns.(24)
A 4/21/93 landmark Dutch court decision affirmed Euthanasia for psychiatric reasons (i.e. mental anguish).


A 21/4/93, landmark Dutch court decision affirmed Euthanasia for psychiatric reasons. The court found that psychiatrist Dr. Boudewijn Chabot was medically justified and followed established Euthanasia guidelines in helping his physically healthy but depressed, patient commit suicide. The patient, 50-year-old Hilly Bosscher, said she wanted to die after the deaths of her two children and the subsequent breakup of her marriage.(25)

Euthanasia 'Fallout'
The effects of Euthanasia policy and practice have been felt in all segments of Dutch society:
  • Some Dutch doctors provide "self-help programs" for adolescents to end their lives. (26)


  • General practitioners wishing to admit elderly patients to hospitals have sometimes been advised to give the patients lethal injections instead. (27)
  • Cost containment is one of the main aims of Dutch health care policy. (28)
  • Euthanasia training has been part of both medical and nursing school curricula. (29)
  • Euthanasia has been administered to people with diabetes, rheumatism, multiple sclerosis, AIDS, bronchitis, and accident victims. (30)
  • In 1990, the Dutch Patients' Association, a disability rights organization, developed wallet-size cards which state that if the signer is admitted to a hospital "no treatment be administered with the intention to terminate life." Many in Holland see the card as a necessity to help prevent involuntary Euthanasia being performed on those who do not want their lives ended, especially those whose lives are considered low in quality. (31)
"They [the elderly] are afraid that at a certain moment, on the basis of age, a treatment will be considered no longer economically viable, and an early end to their lives will be made."
In 1993, the Dutch senior citizens' group, the Protestant Christian Elderly Society, surveyed 2,066 seniors on general health care issues. The Survey did not address the Euthanasia issue in any way, yet ten percent of the elderly respondents clearly indicated that, because of the Dutch Euthanasia policy, they are afraid that their lives could be terminated without their request. According to the Elderly Society director, Hans Homans. "They are afraid that at a certain moment, on the basis of age, a treatment will be considered no longer economically viable, and an early end to their lives will be made." (32)

The Irony of History
During World War ll, Holland was the only occupied country whose doctors refused to participate in the German Euthanasia program. Dutch physicians openly defied an order to treat only those patients who had a good chance of full recovery. They recognized that to comply with the order would have been the first step away from their duty to care for all patients. The German officer who gave that order was later executed for war crimes. Remarkably, during the entire German occupation of Holland, Dutch doctors never recommended nor participated in one Euthanasia death. (33) Commenting on this fact in his essay "The Humane Holocaust," highly respected British journalist Malcolm Muggeridge wrote that it took only a few decades "to transform a war crime into an act of compassion." (34)

The Dutch experience clearly indicates that, where voluntary Euthanasia and Assisted Suicide are accepted practice, a significant number of patients end up having no choice at all.


Implications of the Dutch Euthanasia Experience
Right-to-die advocates often argue that euthanasia and assisted suicide are "choice issues." The Dutch experience clearly indicates that, where voluntary euthanasia and assisted suicide are accepted practice, a significant number of patients end up having no choice at all.

Euthanasia does not remain a "right" only for the terminally-ill, competent adult who requests it, no matter how many safeguards are established. As a "right," it inevitably is applied to those who are chronically ill, disabled, elderly, mentally ill, mentally retarded, and depressed-- the rationale being that such individuals should have the same "right" to end their suffering as anyone else, even if they do not or cannot voluntarily request death.

Euthanasia, by its very nature, is an abuse and the ultimate abandonment of patients.

In actual practice, euthanasia only gives doctors greater power and a license to kill.
Once the power to kill is bestowed on physicians, the inherent nature of the doctor/patient relationship is adversely affected.


Once the power to kill is bestowed on physicians, the inherent nature of the doctor/patient relationship is adversely affected. A patient can no longer be sure what role the doctor will play--healer or killer.

Unlike Holland, where medical care is automatically provided for everyone, in the U.S. millions of people cannot afford medical treatment. If euthanasia and assisted-suicide were to become accepted in the U.S., death would be the only "medical option" many could afford.

Even with health care reform in the U.S., many people would still not have long-standing relationships with their doctors. Large numbers of Americans would belong to health maintenance organizations (HMOs) and managed care programs, and they often would not even know the physicians who end up treating them.
- For some, the "bottom line" would be, "Dead patients cost less than live ones." Giving doctors the legal power to kill their patients is dangerous public policy.

Given those circumstances, doctors would be ill-equipped to recognize if a patient's euthanasia request was the result of depression or the sometimes subtle pressures placed on the patient to "get out of the way." Also, given the current push for health care cost containment in the U.S., medical groups and facilities many be tempted to view patients in terms of their treatment costs instead of their innate value as human beings. For some, the "bottom line" would be, "Dead patients cost less than live ones."

Giving doctors the legal power to kill their patients is dangerous public policy.

The Dutch experience in effect
The Dutch reports contain abundant evidence that doctors kill more patients without their explicit request than with their explicit request, and that euthanasia is not restricted by the so-called “strict medical guidelines” provided by the Dutch courts.

The narrow definition of “euthanasia” in the Dutch report masks the real numbers of physician- assisted deaths, the majority of which have not been shown to be at the request of the patient. The so-called “strict medical guidelines” are clearly not strictly followed or enforced.

A Summary for the US Congressional Subcommittee on the Constitution Suicide, Assisted Suicide and Euthanasia by Herbert Hendin, M.D. Lessons From the Dutch Experience

Sources
1. www.justitie.nl/english
2.. Carlos Gomez, Regulating Death (New York: Free Press, 1991), p.32. Hereafter cited as Regulating Death.
3. H. Jochemsen, trans., "Report of the Royal Dutch Society of Medicine on 'Life-Terminating Actions with Incompetent Patients, Part 1: Severely Handicapped Newborns.'" Issues in Law & Medicine, vol. 7, no.3 (1991), p. 366.
4. From KNMG Euthanasia Guidelines as quoted in Regulating Death, p. 40.
5. Alexander Morgan Capron, "Euthanasia in the Netherlands--American Observations," Hastings Center Report (March, April 1992), p. 31.
6. Medical Decisions About the End of Life, I. Report of the Committee to Study the Medical Practice Concerning Euthanasia. II. The Study for the Committee on Medical Practice Concerning Euthanasia (2 vols.), The Hague, September 19, 1991. Hereafter cited as Report I and Report II, respectively.
7. Report I, p. 13.
8. Ibid.
9. Ibid.,p. 15.
10. Report II, p.49, table 6.4.
11. Ibid., p.50, table 6.6.
12. Ibid., table 6.5.
13. Ibid., p. 58, table 7.2.
14. Ibid., p. 72.
15. Ibid.
16. Report I, pp. 17-18.
17. Report II, p. 52, table 6.7.
18. Ibid., table 6.8.
19. I.J. Keown, "The Law and Practice of Euthanasia in The Netherlands," The Law Quarterly Review (January 1992), pp. 67-68.
20. Marlise Simons, "Dutch Move to Enact Law Making Euthanasia Easier," New York Times, 2/9/93, p.A1.
21. Euthanasia: Report of the Working Party to Review the British Medical Association's Guidance on Euthanasia, British Medical Association, May 5, 1988, p. 49, no. 195.
22. Rita L. Marker, Deadly Compassion -The Death of Ann Humphry and the Truth About Euthanasia (New York; William Morrow and Company, 1993), p. 157. Hereafter cited as Deadly Compassion.
23. Abner Katzman, "Dutch debate mercy killing of babies," Contra Costa Times, 7/30/92, p. 3B.
24. "Critics fear euthanasia soon needn't be requested," Vancouver Sun, 2/17/93, p. Al0. Also, "Dutch may broaden rules to permit involuntary euthanasia," Contra Costa Times, 2/17/93, p. 4B.
25. New York Times, 4/5/93. p.A3, and Washington Times, 4/22/93, p.A2.
26. "It's Almost Over -- More Letters on Debbie," Letter to the editor by G.B. Humphrey, M.D., Ph.D., University Hospital, Groningen, The Netherlands, Journal of the American Medical Association, vol. 260, no. 6 (8/12/88), p. 788.
27."Involuntary Euthanasia in Holland," Wall Street Journal, 9/29/87, p.3.
28. "Restructuring Health Care", The Lancet (1/28/89), p.209.
29."The Member's Aid Service of the Dutch Association for Voluntary Euthanasia," Euthanasia Review, vol. 1, no. 3 (Fall 1986), p.153.
30. "Suicide on Prescription," Sunday Observer (London, England), 4/30/89, p. 22.
31. Deadly Compassion, p. 156.
32. "Elderly Dutch afraid of euthanasia policy," Canberra Times (Australia), 6/11/93.
33. Leo Alexander, "Medical Science Under Dictatorship," New England Journal of Medicine, vol.241 (July 14, 1949), p.45.
34. Nancy Gibbs, "Love and Let Die," Time Magazine (March 19, 1990), p.67.