During the past twenty-five years in the Netherlands, a practice of helping patients to die has been developed that is unique in the world. Euthanasia has not been formally legalized, but it has been legally tolerated if certain requirements are met: a free and durable request from the patient, a situation of unbearable suffering, consultation by an independent doctor, and a written report. Between 1990 and 1995 the percentage of cases of euthanasia among all deaths rose from 1.8 percent to 2.4 percent. The percentage of cases reported to the authorities has also increased, from 18 percent to 41 percent (Van der Maas et al., "Euthanasia and Other Medical Decisions Concerning the End of Life," Lancet 1991; Van der Maas, Van der Wal et al., "Evaluation of the Notification Procedure for Physician Assisted Death in The Netherlands," New England Journal of Medicine 1996).
Despite this improvement, concerns remain about underreporting. One of the major reasons physicians do not report all cases of euthanasia appears to be that they feel threatened by the legal requirement that reported cases be evaluated by the public prosecutor. Very few cases are ultimately brought to court, but the procedure is unclear and time-consuming. It can also be doubted whether court decisions are the best way to develop a good practice of euthanasia. Therefore, a new policy concerning reporting has been developed: five regional multidisciplinary committees were installed in November 1998 that are to evaluate the cases reported to the authorities and to make recommendations to the public prosecutor. It is expected that the new committees will stimulate doctors to report cases and will give new input to the public debate on euthanasia. For the time being, the committees have only advisory power, but a law now under consideration would give them a more decisive formal role.
Each committee consists of a lawyer (who acts as chairperson), a medical doctor, and an ethicist. All cases that have been reported in the committee's region are discussed, and advice must be formulated within six weeks. The committee receives a written report from the physician (noting among other things what options for palliative care were offered), together with (excerpts from) the patient's medical record, a written declaration of will by the patient, and a report from the consulting doctor. The central issues to be discussed are the patient's condition (especially her suffering), the status of the patient's request (which must be free and durable), the consultation, and the way in which euthanasia was performed. The committee judges whether the procedure was careful.
Over the first six months, the number of cases reported to the committees has been stable. Thus the installation of the committees seems not yet to have encouraged physicians to be more open about their practice. The cases usually show that the doctor was well aware of the requirements, but nonetheless they may raise discussion within the committee. A crucial topic is whether the options of palliative care were thoroughly examined. In answering this question, the physician in the committee plays an important role. Another central topic concerns the patient's wish to die. The committee may discuss not only whether the patient was free in her request, and whether it was durable, but also what kind of communication took place between doctor and patient, and how other parties (such as relatives) were involved in the decisionmaking process. Finally, the committee may explore the role played by the consulting doctor. Mostly, the materials presented enable the committee to get a rich picture of the case. Sometimes questions remain, and the committee will ask the physician or the consultant to provide more information.
The cases reported thus far show that physicians confront difficult issues in dealing with patients who ask for euthanasia: how to assess whether pain is unbearable; how to respond adequately to the patient's fears; how to establish the wishes of the patient; how to improve communication with patient and family; and how to decide whether the right moment for the performance of euthanasia has arrived. …