Euthanasia in the Netherlands

Euthanasia in the Netherlands is regulated by the "Termination of Life on Request and Assisted Suicide (Review Procedures) Act" from 2002. It states that euthanasia and physician-assisted suicide are not punishable if the attending physician acts in accordance with criteria of due care. These criteria concern the patient's request, the patient's suffering (unbearable and hopeless), the information provided to the patient, the absence of reasonable alternatives, consultation of another physician and the applied method of ending life. To demonstrate their compliance, the Act requires physicians to report euthanasia to a review committee.

Legal framework

The legal debate concerning euthanasia in the Netherlands took off with the "Postma case" in 1973, concerning a physician who had facilitated the death of her mother following repeated explicit requests for euthanasia. While the physician was convicted, the court's judgment set out criteria when a doctor would not be required to keep a patient alive contrary to their will. This set of criteria was formalized in the course of a number of court cases during the 1980s.

Termination of Life on Request and Assisted Suicide (Review Procedures) Act took effect on April 1, 2002. It legalizes euthanasia and physician assisted suicide in very specific cases, under very specific circumstances. The law was proposed by Els Borst, the D66 minister of Health. The procedures codified in the law had been a convention of the Dutch medical community for over twenty years.

The law allows medical review board to suspend prosecution of doctors who performed euthanasia when each of the following conditions is fulfilled:

• the patient's suffering is unbearable with no prospect of improvement
• the patient's request for euthanasia must be voluntary and persist over time (the request cannot be granted when under the influence of others, psychological illness or drugs)
• the patient must be fully aware of his/her condition, prospects, and options
• there must be consultation with at least one other independent doctor who needs to confirm the conditions mentioned above
• the death must be carried out in a medically appropriate fashion by the doctor or patient, and the doctor must be present
• the patient is at least 12 years old (patients between 12 and 16 years of age require the consent of their parents)

The doctor must also report the cause of death to the municipal coroner in accordance with the relevant provisions of the Burial and Cremation Act. A regional review committee assesses whether a case of termination of life on request or assisted suicide complies with the due care criteria. Depending on its findings, the case will either be closed or, if the conditions are not met, brought to the attention of the Public Prosecutor. Finally, the legislation offers an explicit recognition of the validity of a written declaration of will of the patient regarding euthanasia (a "euthanasia directive"). Such declarations can be used when a patient is in a coma or otherwise unable to state if they wish to be euthanized.

Euthanasia remains a criminal offense in cases not meeting the law's specific conditions, with the exception of several situations that are not subject to the restrictions of the law at all, because they are considered normal medical practice:

• stopping or not starting a medically useless (futile) treatment
• stopping or not starting a treatment at the patient's request
• speeding up death as a side-effect of treatment necessary for alleviating serious suffering

Euthanasia of children under the age of 12 remains technically illegal; however, Dr. Eduard Verhagen has documented several cases and, together with colleagues and prosecutors, has developed a protocol to be followed in those cases. Prosecutors will refrain from pressing charges if this Groningen Protocol is followed.

Practice

In 2003, in the Netherlands, 1626 cases were officially reported of euthanasia in the sense of a physician assisting the death (1.2% of all deaths). Usually the sedative sodium thiopental is intravenously administered to induce a coma. Once it is certain that the patient is in a deep coma, typically after less than a minute, Pancuronium is administered to stop the breathing and cause death.

Officially reported were also 148 cases of physician assisted dying (0.14% of all deaths), usually by drinking a strong (10g) barbiturate potion. The doctor is required to be present for two reasons:

• to make sure the potion is not taken by a different person, by accident (or, theoretically, for "unauthorized" suicide or perhaps even murder)
• to monitor the process and be available to apply the combined procedure mentioned below, if necessary

In two cases the doctor was reprimanded for not being present while the patient drank the potion. They said they had not realized that this was required.

Forty-one cases were reported to combine the two procedures: usually in these cases the patient drinks the potion, but this does not cause death. After a few hours, or earlier in the case of vomiting, the muscle relaxant is administered to cause death.

By far, most reported cases concerned cancer patients. Also, in most cases the procedure was applied at home.

A study in 2000 found that Dutch physicians who intend to provide assistance with suicide sometimes end up administering a lethal medication themselves because of the patient's inability to take the medication or because of problems with the completion of physician-assisted suicide.

In 2010 there were 3136 cases reported of a physician assisting the death of a patient. Split out it were 2910 cases of "end of life on request", 182 cases of assisted suicide and in 44 cases it was a combination. The evaluation commissions decided that in 9 cases the procedures were not according to protocol and referred the cases to the Public Prosecution Service and the Health Care Inspectorate. It was the fifth year in a row that the number of reported cases was rising. The reason for this rise is not clear.

In 2010, 4050 persons died from euthanasia or from assisted suicide on request. According to research done by the Vrije Universiteit (Amsterdam), University Medical Center Utrecht and Statistics Netherlands, and published in The Lancet, this is not more than before the introduction of the "Termination of Life on Request and Assisted Suicide (Review Procedures) Act" in 2002. Both in the Netherlands and in Belgium, the number of termination of life without explicit request for terminally ill patients, decreased after the introduction of the legislation about the termination of life. In effect, the legislation did not lead to more cases of euthanasia and assisted suicide on request.

Further developments

In February 2010 a citizens' initiative called Out of Free Will further demanded that all Dutch people over 70 who feel tired of life should have the right to professional help in ending it. The organization started collecting signatures in support of this proposed change in Dutch legislation. A number of prominent Dutch citizens supported the initiative, including former ministers and artists, legal scholars and physicians. Under current Dutch law, euthanasia by doctors is only legal in cases of "hopeless and unbearable" suffering. In practice this means that it is limited to those suffering from serious medical conditions like severe pain, exhaustion or asphyxia. Helping somebody to commit suicide without meeting the qualifications of the current Dutch euthanasia law is illegal.

Foreign views

Dutch euthanasia laws are commonly put in a bad light in the United States and even proponents would rather not be associated with them. The Netherlands is commonly under fire by conservative American politicians for its euthanasia policies, being accused of "killing senior citizens." In 2000, Republican Steve Forbes stated that Dutch doctors "routinely kill patients without the patients' permission because they want a hospital bed," suggesting that there are well-documented abuses of official policies.

In 2012, Republican presidential candidate Rick Santorum falsely claimed that forced euthanasia accounted for 5% of all deaths in the Netherlands and that elderly Dutch people wear a bracelet reading “Do not euthanize me.” This claim was mocked by various Dutch sources and prompted the Dutch embassy to respond with relevant statistics disproving Santorum's claim, but the lack of a formal statement by Dutch officials angered Dutch politician Frans Timmermans, who demanded minister of foreign affairs Uri Rosenthal to take a public stance against such assertions.

External links

• Dutch Assisted Suicide & Euthanasia Annual Reports in English, German, French and Dutch.

• (Dutch) Regionale toetsingscommissies euthanasie Jaarverslag 2003 (PDF)
• "'Right to die' for elderly back at centre of Dutch debate"
• " Citizens group argues 'right to die' - A citizens action group wants to legalise assisted suicide for all people over 70"