Non-Voluntary and Involuntary Euthanasia in the Netherlands: Dutch Perspectives

By Cohen-Almagor, Raphael | Issues in Law & Medicine, Spring 2003 | Go to article overview

Non-Voluntary and Involuntary Euthanasia in the Netherlands: Dutch Perspectives


Cohen-Almagor, Raphael, Issues in Law & Medicine


Abstract: During the summer of 1999, twenty-eight interviews with some of the leading authorities on euthanasia policy were conducted in the Netherlands. They were asked about cases of non-voluntary (when patients are incompetent) and involuntary euthanasia (when patients are competent and made no request to die). This study reports the main findings, showing that most respondents are quite complacent with regard to breaches of the guideline that require the patient's consent as a prerequisite to performance of euthanasia.

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In November 1990, the Dutch Ministry of Justice and the Royal Dutch Medical Association set out Guidelines for the performance of euthanasia based on the criteria established in court decisions relating to the conditions under which a doctor can successfully invoke the defense of necessity. The substantive requirements are as follows:

1. The request for euthanasia or physician-assisted suicide must be made by the patient and must be free and voluntary

2. The patient's request must be well considered, durable and consistent.

The patient's situation must entail unbearable suffering with no prospect of improvement and no alternative to end the suffering. (1) The patient need not be terminally ill to satisfy this requirement and the suffering need not necessarily be physical.

3. Euthanasia must be a last resort. (2)

The procedural requirements are as follows:

* No doctor is required to perform euthanasia, but those opposed on principle must make this position known to the patient early on and help the patient to get in touch with a colleague who has no such moral objections.

* Doctors taking part in euthanasia should preferably and whenever possible have patients administer the fatal drug themselves, rather than have a doctor apply an injection or intravenous drip. (3)

* A doctor must perform the euthanasia.

* Before the doctor assists the patient, the doctor must consult a second independent doctor who has no professional or family relationship with either the patient or doctor. Since the 1991 Chabot case, (4) patients with a psychiatric disorder must be examined by at least two other doctors, one of whom must be a psychiatrist.

* The doctor must keep a full written record of the case.

* The death must be reported to the prosecutorial authorities as a case of euthanasia or physician-assisted suicide, and not as a case of death by natural causes. (5)

In 1990, the Dutch government appointed a commission to investigate the medical practice of euthanasia. The Commission, headed by Professor Jan Remmelink, Solicitor General to the Supreme Court, was asked to conduct a comprehensive nation-wide study of "medical decisions concerning the end of life (MDEL)." The following broad forms of MDEL were studied:

* Non-treatment decisions: withholding or withdrawing treatment in situations where treatment would probably have prolonged life;

* Alleviation of pain and symptoms: administering opioids in such dosages that the patient's life could be shortened;

* Euthanasia and related MDEL: the prescription, supply or administration of drugs with the explicit intention of shortening life, including euthanasia at the patient's request, assisted suicide, and life termination without explicit and persistent request. (6)

The study was repeated in 1995, making it possible to assess for the first time whether there were harmful effects over time that might have been caused by the availability of voluntary euthanasia in the Netherlands. It is still difficult to make valid comparisons with other countries because of legal and cultural differences, and also because similar comprehensive studies are quite rare. (7)

The two Dutch studies were said to give the best estimate of all forms of MDEL (i.e., all treatment decisions with the possibility of shortening life) in the Netherlands as approximately 39% of all deaths in 1990, and 43% in 1995. …

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