A new nation-wide survey of euthanasia was commissioned in 2001 by the Dutch Ministers of Health and Justice, and the report on this study, a book of 272 pages, was published in the fall of 2003. (1) The study was led by the same investigators as the previous government-ordered surveys of euthanasia (1990 (2) and 1995 (3)), and arranged to obtain partly comparable data. This time, however, the main purpose was to assess the effectiveness of review and verification procedure (toetsing procedure). (4) The practice of euthanasia was studied to the extent necessary to evaluate this procedure.
Several issues that had not been covered in previous studies were included this time: euthanasia on children and minors ages 1-16, physician-assisted suicide of healthy persons "tired of life," euthanasia of demented older persons who had previously signed a declaration, the use of terminal sedation, the possible influence of palliative care on the demand for euthanasia, and opinions of patients' families and the general public.
Questionnaires were mailed to doctors who had issued 7,440 death certificates; 5,618 responses were obtained. Oral interviews were conducted with 410 physicians of various specialities, 63 pediatricians (pediatric oncologists, pediatric neurologists, and intensive care pediatricians), and 87 family members of patients who had died by euthanasia. Questionnaires were addressed to the general public, and answered by 1,390 persons.
As in the two previous studies, national estimates (see Table 1) were obtained by weighted extrapolation of numbers found in the studied samples.
The total number of patients who died by lethal overdose of painkillers (regardless of doctors' intentions) was estimated at 28,216. (9) Potentially effective life-prolonging treatment of 28,075 persons was withheld or withdrawn; in 18,249 cases this was done with the explicitly stated intention to cause death. (10) Seventy-one percent of family physicians stated that they had performed euthanasia or assisted suicide some time in the past, and 38% did so in the last two years. (11) Eleven percent of interviewed doctors declared that they would never perform euthanasia or assist a patient in committing suicide; (12) some of them (one percent) would also never refer a patient who requests euthanasia to a colleague willing to carry it out. (13)
Similar to the previous studies, out of 9,700 direct and explicit requests for euthanasia or assistance in suicide, about 5,900 were not granted, which often has been interpreted as proof that such requests are cautiously considered and in the majority of cases rejected. It turned out, however, that in many cases the reason for not granting the requests was different: in 2,832 cases (48%) euthanasia was not carried out because the patients died before it could be done. (14) The finding tends to support the opinion of critics who maintain that euthanasia, however it is judged from a moral point of view, is simply unnecessary.
Some escalation of euthanasia has occurred in the nursing homes. In 1995, 54% of nursing home physicians received requests by residents to provide euthanasia "when the right time comes"; in 2001 this figure rose to 86%. Seventy percent of physicians received direct requests for euthanasia or assistance in suicide. Thirty-six percent of nursing home doctors (in 1995 only 21%) stated that they had performed euthanasia or assisted suicides. (15)
Compared with the number of cases of active euthanasia, assisted suicide remains a very infrequent practice in the Netherlands. According to the authors of the report, "the argument that assisted suicide is [an act] more respectful of patient autonomy and responsibility, often weighs less with doctors, and presumably also the patients, than the better control achieved when the doctor injects a lethal drug." (16)
The number of cases of involuntary active euthanasia …