FAQ – Euthanasia in the Netherlands

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In 2002, the Netherlands decriminalised euthanasia in cases where very strict criteria are met. This change in the law has been widely misreported abroad. Here are the essential facts about the Dutch policy on euthanasia.

-  What is the difference between euthanasia and assisted suicide?

Assisted suicide is the process by which an individual, who may otherwise be incapable, is provided with the means (drugs or equipment) to commit suicide. In some cases, the terms ‘aid in dying’ or ‘death with dignity’ are preferred.

The term ‘euthanasia’ refers to an act that ends a life in a painless manner, performed by someone other than the patient. This may include withholding common treatments resulting in death, removal of the patient from life support, or the use of lethal substances or forces to end the life of the patient.

- Is euthanasia legal in the Netherlands?

Yes and no. In April 2002, the Netherlands introduced a new law on euthanasia, becoming the first country in the world to legalise the practice within strict boundaries. Euthanasia remains a criminal offence, but is decriminalised if all of the very strict criteria are met.

- What are the criteria for decriminalisation?

The due care criteria which must be met in order to obtain exemption from criminal liability require that the attending physician:

  • be satisfied that the patient has made a voluntary and well considered request
  • be satisfied that the patient's suffering is unbearable, and that there is no prospect of improvement has informed the patient about his or her situation and prospects
  • has come to the conclusion, together with the patient, that there is no reasonable alternative in the light of the patient's situation
  • has consulted at least one other physician, who must have seen the patient and given a written opinion on the due care criteria referred to above, and
  • has terminated the patient's life or provided assistance with suicide with due medical care and attention.

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.

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- How does the system work in practice?

The current system depends on the voluntary reporting of euthanasia by doctors to the Euthanasia Commission via five regional euthanasia monitoring committees. Euthanasia can only be carried out if the patient requests it and is judged by two doctors to be in unbearable suffering without prospect of improvement. The Euthanasia Commission looks carefully at each case and subsequently decides whether the doctor(s) will be pursued for causing a death or murder. The commission members are always a lawyer, a doctor and an ethicist.

- Is there pressure to broaden the criteria under which euthanasia is permitted?

There is an ongoing debate about whether the boundaries of legalised euthanasia should be extended. Right to Die-NL set up a commission to examine the 'tired of life' euthanasia issue after a Dutch doctor was prosecuted for answering a request for euthanasia from an ageing politician, Edward Brongersma, who, although ill, was not facing imminent death. The senator was tired of living and didn't want to go on.

The commission, under the chairmanship of emeritus professor of clinical psychology and psychotherapy Jos Dijkhuis, decided that the rules do indeed, under strict conditions, allow for a doctor to help in such cases. Research has shown that 30 percent of Dutch doctors have received a request for euthanasia from people who were tired of living.

- What do the public think about ‘tired of life’ euthanasia?

A poll by Dutch research bureau Intomart GfK showed that 63 percent of the 1,000 people surveyed supported granting the right to die to the elderly, even if they were not ill, while 74 percent supported the controlled distribution of "suicide" pills to those who felt their lives were done.

However, changes to the law look unlikely under the present government as the Christian Union is a junior partner in the ruling coalition, and is opposed to euthanasia in all circumstances.

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- Have any doctors or other individuals been prosecuted under this legislation?

According to the annual report published by the five regional euthanasia monitoring committees, ten cases of assisted suicide in 2008 were found not to have followed official guidelines and have been referred to the Public Prosecution Office and Health Inspectorate for their comments. No decisions have been announced so far.

However, in May 2009 a leading advocate of euthanasia was charged with illegally aiding in assisted suicide, drawing attention to the complexities of the law. A court in the eastern town of Almelo convicted the chairman of the Stichting Vrijwillig Leven (Voluntary Life Foundation or SVL) for assisting in the suicide of an 80-year-old Parkinson’s patient.

In the 29 May verdict, the court found Gerard Schellekens guilty of knowingly violating the laws regarding assisted suicide. “The criminal law should protect people against possible bad intentions or carelessness of others,” said the court. Schellekens was sentenced to imprisonment of ten months, with eight months imposed probation and two months jail time. SVL also faced condemnation by the court, receiving a penalty fine of 25,000 euros. Both parties are currently appealing.

- What is the legal definition of “unbearable suffering with no prospect of improvement”?

According to the Dutch Public Prosecution Office, suffering is without prospect of improvement if this is the prevailing medical opinion. In other words, if doctors agree that the patient's condition will not improve. It is difficult to establish objectively whether suffering is unbearable. The review committee examines each individual case to establish whether the doctor could reasonably conclude that the patient was suffering unbearably.

- Who makes the final decision on whether the criteria have been met?

The doctor and patient must discuss every possible alternative treatment. As long as a feasible alternative is available, there is, in a medical sense, a prospect of improvement. This can be assessed objectively. By contrast, the extent to which suffering is unbearable is a highly subjective matter. Nevertheless, where suffering is not obvious either to himself or to the patient's relatives or carers, the doctor will have to try to imagine what the patient is feeling and - based on his medical experience - attempt to assess his suffering objectively. So, in practice, the doctor makes the final decision.

- Are doctors obliged to comply with requests for euthanasia?

No. Because honouring a request for euthanasia conflicts with the doctor’s duty to preserve life, doctors are allowed to refuse. Nurses may also refuse to assist in performing euthanasia or preparing for it. Neither doctors nor nurses can ever be censured for failing to comply with requests for euthanasia. However if a doctor refuses to perform euthanasia he must refer the patient to another doctor who may be
willing to grant the request.

Two thirds of the requests for euthanasia that are put to doctors in the Netherlands are refused. Treatment frequently provides relief, while some patients enter the terminal stage of their illness before a decision has been reached.

- Has the legalisation of euthanasia caused an increase in cases?

In 2008 the number of euthanasia cases registered went up by ten percent compared to 2007. Regional euthanasia vetting committees report that 2,300 cases were reported.

According to the committees the rise is due to the new law on euthanasia which was introduced in 2002, which made a clearer distinction between several kinds of treatment. The difference between palliative sedation - administering pain killers but not actively bringing about the death of the patient - and actual euthanasia has been made clearer.

It is thought that the stricter definitions cause doctors to report euthanasia more often, instead of reporting the use of palliative sedation. In addition, the vetting committees think that the doctors' preparedness to report euthanasia may have increased because the new law clearly describes the medication that is allowed in the process.

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- What about patients who are unable to make their own wishes clear?

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 he/she wishes to be euthanised.

Some patients, for example very young children and those suffering from dementia, may be unable to make their wishes clear in advance. The commonest form of dementia is Alzheimer's disease, a key symptom of which is forgetfulness. The presence of dementia or some other such condition is not in itself a reason to comply with a request for termination of life or assisted suicide.

For some people, however, the very prospect of one day suffering from dementia and the eventual associated loss of personality and dignity is sufficient reason to make an advance directive covering this possibility. Each case will have to be individually assessed to decide whether, in the light of prevailing medical opinion, it can be viewed as entailing unbearable suffering for the patient with no prospect of improvement.

In response to questions on this subject in parliament, the Minister of Health, Welfare and Sport, Ab Klink, stated that dementia can make the patient's quality of life unacceptable if he himself regards his condition in this way but, even then, the doctor must decide whether the patient's suffering is unbearable and without prospect of improvement in the light of prevailing medical opinion.

- How is the law applied to very young children?

Eduard Verhagen, paediatrician at the Groningen University Medical Centre and one of the doctors who set up what is now known as the Groningen Protocol, says: “Discontinuation of care is acceptable for newborns in specific cases all over the world. In most cases children die subsequently. However there is a very small group - and this is the group that we are focusing on - that remains alive if you discontinue the care.” According to a national survey this group consists of 15 to 20 of the 200,000 children born in the Netherlands per year. But even within the Groningen Protocol it remains illegal in the Netherlands to deliberately end the life of a severely ill newborn.

Related article + video:
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- Can people from other countries come to the Netherlands to die?

The Netherlands Ministry of Justice believes that it is not possible for people to come from other countries to seek termination of life or assistance with suicide in the Netherlands because of the legislation's procedural requirements.

The procedure for the notification and assessment of each case requires the patient to have made a voluntary, considered request and to be suffering without any prospect of improvement. In order to be able to assess whether this is the case, it is considered that the doctor must know the patient well and implies that the doctor has treated the patient for some time.

- Can a minor request euthanasia?

The law contains special provisions dealing with requests from minors for termination of life and assisted suicide. The age groups to which it applies mirror the existing statutory provisions regarding consent for medical treatment. The law allows 12 to 15-year-olds to request euthanasia, but requires parental consent for euthanasia to be performed in these cases. By contrast, it permits 16 and 17-year-olds to make such decisions for themselves, although it prescribes that their parents must always be involved in discussions with them. Before complying with requests from minors, doctors must of course always satisfy themselves that the patient's suffering is unbearable and without prospect of improvement, and that the usual due care criteria have been met.

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- Do the majority of the Dutch public support the euthanasia law?

Two years before the law was passed in 2002, the country was divided down the middle. An opinion poll two years ago showed support from 50 per cent of the population, with the remainder either opposed or undecided. By the time the law was passed, a clear majority of the population were in favour of the legislation.

The law was condemned in a joint petition to the Senate by Catholics, Muslims and Jews, as well as by 35 Protestant, Pentecostal and Orthodox churches. Despite this, the Senate voted 46 to 28 to approve the legislation. Pentecostal pastor and Bible teacher T J de Ruiter writes that this shows “the decreasing influence of the Church on society. Its view on the origin and nature of man, its Christian message, the Gospel and its ethical code, all based on the Bible, have lost their authority and importance for most national leaders and the majority of the people.”