The context of euthanasia in the Netherlands

Background information on euthanasia

Even today, sections 293 and 294 of the Dutch Penal Code outlaw euthanasia and assisted suicide. However, doctors who directly kill patients or help patients commit suicide cannot be prosecuted as long as they follow certain guidelines, according to the outcome of various court cases. In addition to the current requirement that doctors report every euthanasia/assisted suicide death to the district attorney and that the patient's request for death be persistent (carefully considered and requested multiple times), the Rotterdam Court established the following guidelines in 1981:

1. The patient must be experiencing unbearable pain.
2. The patient must be alert and alert.
3. Requests for death must be voluntary.
4. The patient must have been offered alternatives to euthanasia and had time to consider these alternatives.
5. There must be no other reasonable solution to the problem.
6. The death of a patient must not cause unnecessary suffering to others.
7. More than one person must be involved in the euthanasia decision.
8. Only doctors can euthanize patients.
9. Great caution must be taken when actually making the decision to die.

Since 1981, the interpretation of these guidelines has been continuously expanded by Dutch courts and the Royal Netherlands Medical Association (KNMG). An example is the interpretation of the "intolerable pain" requirement in a 1986 judgment of the Court of Appeal in The Hague. The court ruled that the pain guidelines were not limited to physical pain, and that "mental distress" or "underlying character defects" could also be grounds for euthanasia.

The main argument in support of euthanasia in the Netherlands has been the need for more patient autonomy - the right of patients to make their own end-of-life decisions. Over the past 20 years, however, the practice of euthanasia in the Netherlands has ended up giving more and more power to doctors rather than patients. The question of whether a patient should live or die is often decided solely by the doctor or team of doctors.

The Dutch definition of "euthanasia" is very limited: "Euthanasia is understood as an act aimed at ending the life of another person at his explicit request. It involves an action with death as its aim and result." This definition only applies to voluntary euthanasia , does not include what the rest of the world calls involuntary or involuntary euthanasia, which is killing a patient without their knowledge or consent. The Dutch call it "life-ending treatment".

Some doctors use the distinction between "euthanasia" and "life-ending treatment" to avoid classifying a patient's death as "euthanasia," thereby freeing doctors from having to follow established euthanasia guidelines and report the death to local authorities. One such example was discussed at a Bioethics Institute meeting in Maastricht, the Netherlands, in December 1990. A doctor at the Netherlands Cancer Institute described about 30 cases a year in which doctors deliberately end a patient's life by injecting morphine into a coma. Doctors at the cancer institute later said the deaths were not considered "euthanasia" because they were not voluntary and that it would be "rude" to discuss plans to end the lives of these patients, who all knew they had an incurable disease. Disease conditions.

For the purposes of clarity in this fact sheet, the direct and intentional act of ending a patient's life without the patient's consent will be referred to as "involuntary euthanasia."

The facts about euthanasia

Remmelink Report —On September 10, 1991, the government published the results of the first official study of euthanasia practices in the Netherlands. The two-volume report – commonly known as the Remmelink Report (after Professor J. Remmelink, chairman of the research committee and Attorney General of the Dutch High Council) – documents the prevalence of involuntary euthanasia in the Netherlands and, indeed, to a large extent , doctors have taken over end-of-life decisions about euthanasia. Data show that despite long-standing court-approved euthanasia guidelines designed to protect patients, abuse has become an accepted norm. According to the Remmelink report, 1990:

• 2,300 people died as a result of executions performed by doctors on request (active, voluntary euthanasia).
• 400 people died as a result of doctors providing the means to commit suicide (physician-assisted suicide).
• 1,040 people (an average of 3 per day) died from involuntary euthanasia, meaning doctors actively killed these patients without their knowledge or consent.
  • 14% of these patients were fully competent.
  • 72% of people have never stated that they wish to end their lives.
  • In 8% of cases, doctors performed involuntary euthanasia despite believing other options were still possible.
• Additionally, 8,100 patients died as a result of physicians deliberately overdosing on painkillers, whose primary purpose was not to control pain but to hasten the patient's death. 61% of these cases (4,941 patients) were intentional overdoses without the patient's consent .
• According to the Remmelink report, Dutch doctors intentionally and deliberately ended the lives of 11,840 people through fatal overdoses or injections - a figure that represented 9.1% of the overall mortality rate of 130,000 people per year. The majority of all euthanasia deaths in the Netherlands are involuntary.
• The Remmelink reporting data cited here does not include the 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 intent to cause the patient's death. These figures also do not include cases of involuntary euthanasia of disabled newborns, children with life-threatening conditions or the mentally ill.
• The most frequently cited reasons for ending a patient's life without the patient's knowledge or consent were: "low quality of life," "no prospect of improvement," and "the family can't take it anymore."
• In 45% of inpatient involuntary euthanasia cases, the patient's family did not know that their loved one's life was intentionally terminated by the doctor.
• According to the 1990 census, the population of the Netherlands was approximately 15 million. That's just half of California's population. In order to understand how the statistics reported by Remmelink apply to the United States, these numbers must be multiplied by a factor of 16.6 (based on a 1990 US Census population of approximately 250 million).

Falsified death certificates – In the vast majority of Dutch euthanasia cases, doctors deliberately falsify patients’ death certificates, claiming that death was caused by natural causes in order to avoid additional paperwork and scrutiny by local authorities. Regarding Dutch euthanasia guidelines and the requirement for doctors to report all euthanasia and assisted suicide deaths to local prosecutors, a government health inspector recently told the New York Times: "Ultimately, the system depends on the integrity of the doctor. What and how he reports "If family doctors don't report cases of voluntary euthanasia or assisted suicide, there's nothing that can be controlled."

Inadequate pain control and comfort care – In 1988, the British Medical Association published the results of a Dutch euthanasia study conducted at the request of UK rights-to-die advocates. The study found that although health care is available to everyone in the Netherlands, palliative care (comfort care) programs with adequate pain management skills and knowledge are poorly developed. Where euthanasia is the accepted medical solution to treating patients' pain and suffering, there is little incentive to develop programs that provide patients with modern, available, and effective pain control. As of mid-1990, there were only two hospice programs operating in the entire Netherlands, and they provided very limited services.

Expanded explanation of euthanasia guidelines

• In July 1992, the Dutch Pediatric Society announced that it would issue formal guidelines on the killing of severely disabled newborns. Dr. Zier Versluys, chairman of the association's neonatal ethics working group, said, "For parents and children, it is better to die young than to live." Dr. Versluys also pointed out that euthanasia is an integral part of good medical practice for neonates. Doctors will determine whether the baby's "quality of life" is such that it should be killed.
• A statement issued by the Dutch Ministry of Justice on February 15, 1993 proposed extending the court-approved euthanasia guidelines to formally include "aggressive medical intervention that shortens life without an express request ." "(Emphasis added.) Health Ministry spokesperson Liesbeth Rensman said this would be a formal approval of euthanasia for those who cannot request euthanasia, especially the mentally ill and disabled newborns. first step.
• On April 21, 1993, a Dutch court issued a landmark judgment confirming euthanasia for mental reasons. The court found that psychiatrist Dr. Boudewijn Chabot was medically reasonable and followed established euthanasia guidelines in helping a healthy but depressed patient commit suicide. The patient, Hilly Bosscher, 50, said she wanted to die after the deaths of her two children and the subsequent breakdown of her marriage.

The "consequences" of euthanasia - all levels of Dutch society have felt the impact of euthanasia policy and practice:

• Some Dutch doctors offer "self-help programs" for teenagers to end their lives.
• GPs who wish to admit elderly patients to hospital are sometimes advised to give their patients lethal injections instead.
• Cost control is one of the main goals of Dutch healthcare policy.
• Euthanasia training has become part of the medical and nursing school curriculum.
• Euthanasia has been performed on victims of diabetes, rheumatism, multiple sclerosis, AIDS, bronchitis and accidents.
• In 1990, disability rights group Dutch Patients Association developed wallet-sized cards that stipulated that if the signer was admitted to hospital, "treatment aimed at ending life may not be performed." Many Dutch people believe the card is necessary to help prevent involuntary euthanasia for people who do not want to end their lives, especially those with a low quality of life.
• In 1993, the Dutch senior citizens' group the Protestant Christian Seniors Association surveyed 2,066 seniors on general health care issues. The survey did not address the issue of euthanasia in any way, but ten percent of older respondents explicitly stated that due to the Dutch euthanasia policy they feared that their lives might be terminated without their request. According to Hans Homans, director of the Association for the Elderly. "They worry that at some point, based on age, treatment will no longer be deemed financially feasible and life will end prematurely."

An irony of history - during World War II, the Netherlands was the only occupied country whose doctors refused to participate in the German euthanasia program. Dutch doctors openly flouted orders to treat only those patients with a better chance of full recovery. They recognized that complying with the order would be the first step away from their responsibilities of caring for all patients. The German officer who issued the order was later executed for war crimes. Remarkably, throughout the German occupation of the Netherlands, Dutch doctors never recommended or participated in euthanasia deaths. Commenting on this fact in his article "Humanitarian Holocaust," the respected British journalist Malcolm Muggeridge wrote that it took only a few decades "to transform a war crime into an act of compassion."

The impact of the Dutch euthanasia experience

• Right-to-die advocates often argue that euthanasia and assisted suicide are "matters of choice." The Dutch experience clearly shows that where voluntary euthanasia and assisted suicide are accepted, a significant number of patients end up with no other option.
• No matter how many safeguards are put in place, euthanasia is no longer a "right" claimed only by terminally ill, competent adults. As a "right" it inevitably applies to those who are chronically ill, disabled, elderly, mentally ill, mentally retarded and depressed - on the grounds that these people should have the same "right" to end their suffering as everyone else, Even if they did not or could not voluntarily ask for death.
• Euthanasia, by its very nature , is the abuse and eventual abandonment of the patient.
• In practice, euthanasia simply gives doctors greater power and permission to kill.
• Once doctors are given the power to kill, the nature of the doctor-patient relationship will be adversely affected. Patients are no longer sure what role the doctor will play - healer or killer.
• Unlike the Netherlands, where health care is automatically provided to everyone, in the United States, millions of people cannot afford health care. If euthanasia and assisted suicide were accepted in the United States, death would be the only "medical option" many people could afford.
• Even with health care reform in the United States, many people are still unable to form long-term relationships with their doctors. A large number of Americans belong to health maintenance organizations (HMOs) and managed care plans, and they often don't even know the doctors who end up treating them. Given these circumstances, doctors will not be able to identify whether a patient's request for euthanasia is the result of depression or the sometimes subtle pressure exerted on the patient to "get out of the way." Additionally, given the current push for health care cost containment in the United States, many medical groups and institutions tend to view patients based on the cost of their treatment rather than their inherent value as human beings. For some, the “bottom line” is that “dead patients cost less than living patients.”
• Giving doctors the legal authority to kill patients is dangerous public policy.