Euthanasia in the Netherlands

de Wachter, Maurice A. M., The Hastings Center Report

The growing debate about physician aid-in-dying has often invoked the Netherlands as a case study and has drawn somewhat indiscriminately on the Dutch experience to support arguements both for and against physician-assisted suicide and, especially, euthanasia. In December 1990 the Insititute for Bioethics in Maastricht assembled a group of seven Dutch and seven international experts for a two-day conference to examine the practice of euthanasia in the Netherlands. The conference was explicity intended to promote better understanding of the Dutch situation and to foster a critical yet constructive dialogue concerning these practices. Thus in addition to papers outlining the current state of law and practice, presentations addressed the social and ethical dimensions of physician aid-in-dying. Given its topic and goals, the conference quite naturally took the form of scrutinizing, debating, and justifying the practices of Dutch physicians in caring for patients at the end of life.

In his opening remarks Dr. L.B.J. Stuyt, president of the conference, noted that a central concern was the "wide divergence in the definition of term" that hampers mutual understanding and must be clarified. To lay the foundation for our further discussions, then, I examined the current Dutch definition of euthanasia.

What Are We Talking About?

Although |euthanasia' has been performed and publicly debated in the Netherlands for several decades, here as elsewhere the word is still used for many different practices of helping patients in their last moments of life. The Dutch debate has developed a growing consensus by focusing on competent patients who request that a doctor either assist them to take their own life (assisted suicide) or actively end life for them (euthanasia).

The definition of euthanasia widely accepted in the Netherlands is: the active termination of a patient's life at his or her request, by a physician. Although euthanasia is technically illegal, physicians who adhere to three important conditions recognized by the courts and endorsed by the State Commission on Euthanasia in 1985[1] are in practice not subject to criminal sanctions.

Voluntariness. The patient's request must be persistent, conscious and freely made. In the Netherlands "voluntary euthanasia" is a tautology and "involuntary euthanasia" a contradiction in terms.

Unbearable suffering. The patient's suffering, including but not limited to physical pain, cannot be relieved by any other means; both physician and patient must consider the patient's condition to be beyond recovery or amelioration.

Consultation. The attending physician must consult with a colleague regarding the patient's condition and the genuineness and appropriateness of the request for euthanasia.

Dutch law independently requires that physicians accurately report the cause of death and though not specifically directed toward the practice of euthanasia, this provision figures importantly as a safeguard. The extent to which it is actually adhered to has, however, been the focus of considerable debate and was recently addressed in two independent surveys of Dutch physicians.[2]

It is important to stress that several medical practices at the end of life are not considered euthanasia under this definition: respecting tha patient's refusal of treatment (whether before or after treatment has begun), abstaining from medically futile treatment, and giving needed pain medication in doses that may hasten death.

Just as it is incorrect to state that euthanasia is legal (it is specifically prohibited by Article 293 of the Dutch Penal Code), it is an oversimplification to state that euthanasia is accepted in the Netherlands. Certainly both debate and practice are more open and developed in the Netherlands than in other Western countries, but Dutch society recognizes that many serious question remain.

Moreover, in working toward a comprehensive ethical and legal framework to guide practice we must remember that definitions are not morally neutral. They are not just innocent tools that allow us to described reality. Rather, they shape our perception of reality - they select, they emphasize, they embody biases. Definitions constantly need refining if they are to aid our understanding and help ground law and policy.

Facts and Figures

If, as is often said, good ethics depend on good facts, it is important to know as much as we can about the actual practices of Dutch physicians. Dr. E. Borst-Eilers, chair of the Health Council and former medical director of the Academic Hospital at the University of Utrecht, addressed such questions in her conference presentation. Prior to publication of the Remmelink Committee's report in 1991,[3] hard data on the incidence of euthanasia were not readily available. Dr. Borst-Eilers attributed this to the fact that many Dutch doctors do not clearly and carefully maintain the distinction between euthanasia, the deliberate termination of a person's life at his or her request, and other medical decisions concerning the end of life, such as forgoing treatment. Moreover, because it is still a criminal offense under Dutch law, not all cases of euthanasia properly so called are accurately reported. Nonetheless, the number of instances reported by the physicians involved is increasing every year - from 180 cases in 1988 to 340 in 1989, for example. Dr. Borst-Eilers estimated that as of December 1990, the overall incidence of euthanasia was probably between 4,000 and 6,000 cases annually; that is, between 3 and 4.5 percent of all deaths.

Request for euthanasia come mainly from patients with incurable cancer (70%), chronic degenerative neurological disorders (10%), and chronic obstructive pulmonary disease. The primary reason patients give for requesting aid in dying is unbearable suffering, both physical and psychological. A common misunderstanding is that adequate pain treatment would eliminate patients' perceived need for euthanasia. Physical pain alone does not explain all request for euthanasia, however. Patients may experience other physical symptoms, …

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Publication information: Article title: Euthanasia in the Netherlands. Contributors: de Wachter, Maurice A. M. - Author. Journal title: The Hastings Center Report. Volume: 22. Issue: 2 Publication date: March-April 1992. Page number: 23+. © 1999 Hastings Center. COPYRIGHT 1992 Gale Group.

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