Note: This fact sheet is based upon developments in the Netherlands through 1994. It includes data from the "Remmelink Report." For information on developments in Dutch euthanasia and assisted suicide, see the IAETF Update general index or the Update Search.
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Right-to-die advocates often point to Holland as the model for how well physician-assisted, voluntary euthanasia for terminally-ill, competent patients can work without abuse. But the facts indicate otherwise.
BACKGROUND INFORMATION
Dutch Penal Code Articles 293 and 294 make both euthanasia and assisted suicide illegal, even today. However, as the result of various court cases, doctors who directly kill patients or help patients kill themselves will not be prosecuted as long as they follow certain guidelines. In addition to the current requirements that physicians report every euthanasia/assisted-suicide death to the local prosecutor and that the patient's death request must be enduring (carefully considered and requested on more than one occasion), the Rotterdam court in 1981 established the following guidelines:
The patient must be experiencing unbearable pain.
The patient must be conscious.
The death request must be voluntary.
The patient must have been given alternatives to euthanasia and time to consider these alternatives.
There must be no other reasonable solutions to the problem.
The patient's death cannot inflict unnecessary suffering on others.
There must be more than one person involved in the euthanasia decision.
Only a doctor can euthanize a patient.
Great care must be taken in actually making the death decision. (1)
Since 1981, these guidelines have been interpreted by the Dutch courts and Royal Dutch Medical Association (KNMG) in ever-broadening terms. One example is the interpretation of the "unbearable pain" requirement reflected in the Hague Court of Appeal's 1986 decision. The court ruled that the pain guideline was not limited to physical pain, and that "psychic suffering" or "the potential disfigurement of personality" could also be grounds for euthanasia. (2)
The main argument in favor of euthanasia in Holland has always been the need for more patient autonomy -- that patients have the right to make their own end-of-life decisions. Yet, over the past 20 years, Dutch euthanasia practice has ultimately given doctors, not patients, more and more power. The question of whether a patient should live or die is often decided exclusively by a doctor or a team of physicians.(3)
The Dutch define "euthanasia" in a very limited way: "Euthanasia is understood [as] an action which aims at taking the life of another at the latter's expressed request. It concerns an action of which death is the purpose and the result." (4) (Emphasis added.) This definition applies only to voluntary euthanasia and excludes what the rest of the world refers to as non-voluntary or involuntary euthanasia, the killing of a patient without the patient's knowledge or consent. The Dutch call this "life-terminating treatment."
Some physicians use this distinction between "euthanasia" and "life-terminating treatment" to avoid having a patient's death classified as "euthanasia," thus freeing doctors from following the established euthanasia guidelines and reporting the death to local authorities. One such example was discussed during the December 1990 Institute for Bioethics conference in Maastricht, Holland. A physician from The Netherlands Cancer Institute told of approximately 30 cases a year where doctors ended patients' lives after the patients intentionally had been put into a coma by means of a morphine injection. The Cancer Institute physician then stated that these deaths were not considered "euthanasia" because they were not voluntary, and that to have discussed the plan to end these patients' lives with the patients would have been "rude" since they all knew they had incurable conditions. (5)
For the sake of clarity in this fact sheet, the direct and intentional termination of a patient's life, performed without the patient's consent, will be termed "involuntary euthanasia."
THE FACTS
The Remmelink Report-- On September 10, 1991, the results of the first, official government study of the practice of Dutch euthanasia were released. The two volume report (6)--popularly referred to as the Remmelink Report (after Professor J. Remmelink, M.J., attorney general of the High Council of the Netherlands, who headed the study committee)--documents the prevalence of involuntary euthanasia in Holland, as well as the fact that, to a large degree, doctors have taken over end-of-life decision making regarding euthanasia. The data indicate that, despite long-standing, court-approved euthanasia guidelines developed to protect patients, abuse has become an accepted norm. According to the Remmelink Report, in 1990:
2,300 people died as the result of doctors killing them upon request (active, voluntary euthanasia).(7)
400 people died as a result of doctors providing them with the means to kill themselves (physician-assisted suicide).(8)
1,040 people (an average of 3 per day) died from involuntary euthanasia, meaning that doctors actively killed these patients without the patients' knowledge or consent.(9)
14% of these patients were fully competent. (10)
72% had never given any indication that they would want their lives terminated. (11)
In 8% of the cases, doctors performed involuntary euthanasia despite the fact that they believed alternative options were still possible. (12)
In addition, 8,100 patients died as a result of doctors deliberately giving them overdoses of pain medication, not for the primary purpose of controlling pain, but to hasten the patient's death. (13) In 61% of these cases (4,941 patients), the intentional overdose was given without the patient's consent.(14)
According to the Remmelink Report, Dutch physicians deliberately and intentionally ended the lives of 11,840 people by lethal overdoses or injections--a figure which accounts for 9.1% of the annual overall death rate of 130,000 per year. The majority of all euthanasia deaths in Holland are involuntary deaths.
The Remmelink Report figures cited here do not include thousands of other cases, also reported in the study, in which life-sustaining treatment was withheld or withdrawn without the patient's consent and with the intention of causing the patient's death. (15) Nor do the figures include cases of involuntary euthanasia performed on disabled newborns, children with life-threatening conditions, or psychiatric patients. (16)
The most frequently cited reasons given for ending the lives of patients without their knowledge or consent were: "low quality of life," "no prospect for improvement," and "the family couldn't take it anymore."(17)