EUTHANASIA IN THE NETHERLANDS

In the Netherlands, euthanasia is understood to mean termination of life by a physician at the request of a patient. It is to be clearly distinguished from withdrawing from treatment when further medical intervention is pointless, allowing nature to take its course. The latter is normal and accepted medical practice, as is the administration of drugs necessary to relieve pain even in the knowledge that they may have the side effect of hastening death. It should be emphasized that both termination of life upon request and assisting at a suicide are prohibited in the Netherlands. But in the Dutch penal code a special ground for exemption from criminal liability has been developed for physicians who terminate a patient's life on request or assist in a patient's suicide, provided they satisfy the due-care criteria formulated in an act that went into effect in April 2002. This regulation on euthanasia—called the Termination of Life on Request and Assisted Suicide (Review Procedures) Act—is clearly a political compromise between Dutch liberals and Social Democrats, on the one hand, and the Christian Democrats, on the other. If this act had wholly decriminalized euthanasia it would not have received Christian Democrat support. In Belgium, the second country with legislation on euthanasia, the practice is not very different from that in the Netherlands with one exception: Premature termination of life is not considered a criminal act.

Theory and Practice

Pain, degradation of life, and the longing to die with dignity are the main reasons why patients request euthanasia. The initiative is on the part of the patient. To put it bluntly, without such a request it is a matter of murder. People in the Netherlands, as in other advanced countries, are living longer lives, so that, for example, cancer and its pains claim a rising proportion of victims. It should be emphasized that people in the Netherlands do not request euthanasia out of concern at the cost of treatment, because everyone is fully insured under the social security system.

When dealing with a patient's request for euthanasia, physicians must observe the following due-care criteria. They must (1) be satisfied that the patient's request is voluntary and well-considered; (2) be satisfied that the patient's suffering is unbearable and that there is no prospect for improvement; (3) inform the patient of his or her situation and further prognosis; (4) discuss the situation with the patient and come to the joint conclusion that there is no other reasonable solution; (5) consult at least one other physician with no connection to the case, who must then see the patient and state in writing that the attending physician has satisfied the due-care criteria listed in the four points above; and (6) exercise due medical care and attention in terminating the patient's life or assisting in his or her suicide.

Regional review committees (appointed by the Minister of Justice and the Minister of Health, Welfare and Sport) assess whether physicians' actions satisfy these criteria. If the assessment is positive, the Public Prosecution Service will not be informed and no further action will be taken. But if a review committee finds that a physician has failed to satisfy the statutory due-care criteria, the case will be referred to the Public Prosecution Service and the Health Inspectorate. These two bodies will then consider whether the physician should be prosecuted. The existence of a close physician–patient relationship is taken as premise. Physicians may perform euthanasia only on patients in their care. They must know their patients well enough to be able to determine whether the request for euthanasia is both voluntary and well-considered, and whether the suffering is unbearable and without prospect for improvement.

Even in cases in which patients are receiving care of the highest quality, they may still regard their suffering as unbearable and plead with their physicians to terminate their lives. In such cases, euthanasia could represent a dignified conclusion to good palliative care. There is, however, no requirement that physicians comply with the requests for euthanasia. Physicians can refuse to terminate life; after all it is not a normal medical procedure. The ability to refuse a request for euthanasia or assisted suicide guarantees physician's freedom of conscience. If a physician does not want to be involved, he or she is obligated to refer the patient to a colleague.

It is the task of the physician to try to imagine what the patient is feeling and based on his or her medical experience attempt to assess the patient's suffering objectively. Unbearable suffering also includes psychological suffering. If a patient has a psychological illness and his or her suffering is not primarily caused by a physical complaint, it is difficult to assess objectively whether a request for euthanasia is voluntary and well-considered. In such cases, the attending physician should consult two independent specialists, at least one of whom must be a psychiatrist, and they must personally examine and interview the patient. 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 needs 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 for improvement. In response to questions on this subject in the Dutch Parliament, the Minister of Health, Welfare and Sport stated that dementia can make the patient's quality of life unacceptable if the patient him- or herself regards his or her condition in this way, but that even then the physician must decide whether the patient's suffering is unbearable and without prospect for improvement in the light of prevailing medical opinion.

The aim of the Dutch policy is to bring matters into the open, to apply uniform criteria in assessing cases of euthanasia, and hence to ensure that maximum care is exercised in such cases. The price for this openness is a lot of formalistic procedures with no respect to content or guarantee of care. In this area the regional review committees function quite adequately. But not all end-of-life issues are covered by the issue of euthanasia. In the concentration on euthanasia and assisted suicide all forms of sedation with and without consent of the patient fall outside the scope and competence of the assessing committees. Palliative care is not concentrated on recovery but on alleviation of pain and other symptoms. Palliative and in particular terminal sedation may come close to euthanasia. For physicians who do not want to get involved with euthanasia for religious, bureaucratic, or whatever reasons these forms of sedation are a refuge.

Reflective Implications

Traditionally, as specified in the Hippocratic oath, physicians ended their care at the deathbed. Once death was inevitable, the office of the physician—which was to help people avoid the evils of sickness, physical deficiencies, the ailments of old age, and a premature death—had come to an end. In modern society the physician's task has been enormously extended so that the entire life of a human has been brought under a medical regime. Medical examinations are the order of the day. It is impossible to avoid the physician when going to school, participating in sports, holding down a job, taking out life insurance, and so on. Whomever is unwell hurries to make at least a short visit to the doctor or hospital in order to make use of the paraphernalia of modern medicine. Human health is controlled as a matter of routine. Not only has life undergone medicalization, but dying has also been brought under the medical regime. The result is that human death has become artificial. Many bitter deaths might be a product of modern medical science because postponement of death as a result of medical monitoring in a sense requires its toll. In the early twenty-first century, a natural death is likely an exception to the norm. Thus in normal cases the physician swings the scepter at a person's last bed by prompting the possibilities and impossibilities left to him or her. In some municipalities in the Netherlands in the early twentieth century, more than half of all deceased had no medical intervention while dying. That is now inconceivable.

Physicians play the role of experts in the end-of-life decisions. In some sense they act as examiners, while their patients attempt to pass an exam. A physician scrutinizes whether the wish to die is voluntary, whether it is well considered, whether the wish has been long-standing, whether it is not liable to emotions, whether the suffering is unacceptable to the patient, and so on. What at first sight seems to be a matter of self-determination turns out to be a matter of complete dependency. It is not surprising that well-educated people stand a better chance of having their request granted than those who are less educated. Physicians—in former times absent at the deathbed but now prominently present—find themselves in the position of the expert only because they have access to lethal drugs. This technologically privileged position maneuvers them at the same time into the role of moral examiner. For patients, the inaccessibility of lethal drugs makes the whole procedure into a technological adventure in which they are incompetent. Being alienated from nature, patients have no knowledge about the herbs and fruits in their own garden. Confronted with these final questions they have to throw themselves into the arms of the experts. Tried and tested methods out of ancient times have been blotted out.

The issue of unbearable pain on the deathbed is often technologically transformed into a mild death. Physician and patient talk about pain and how to get rid of it along technological lines. In contemporary technological society humans cannot deal with pain in another way. The opinion that pain should be tolerated, alleviated, and interpreted is no longer widely held. The medicalization of pain robs a culture of an integrative program of pain treatment. In traditional societies opium, acupuncture, or hypnosis were means of alleviating pain, but they were always put into practice in combination with language, rites, and myth. Most people who are morally against euthanasia support sedative treatment. Their position shows how difficult it is to leave the technological society behind, because from a technological point of view euthanasia is not very different from sedative treatment. In practice the outcome is often the same, but only in the mind of the physician does one find the difference between euthanasia and sedative treatment.

A society that denies a patient's request for euthanasia would best abstain from modern technological medical care. Living in a technological society may be compared with climbing mountains. People who have ascended too high must descend very carefully. Under some circumstances a descent may be more difficult than the ascent. When patients cannot tolerate pain any longer, who dares to ask them to interpret the meaning of their pain? Has the modern technological society not abandoned such questions or left them to personal decisions?

PIETER TIJMES

SEE ALSO Bioethics;Death and Dying;Euthanasia;Medical Ethics;Right to Die.

BIBLIOGRAPHY

Griffiths, John; Alex Bood; and Heleen Weyers. (1998). Euthanasia and Law in the Netherlands. Amsterdam: Amsterdam University Press.

van der Heide, Agnes; Luc Deliens; Karin Faisst; et al. (2003). "End-of-Life Decision-Making in Six European Countries: Descriptive Study." Lancet 362(9381): 345–350. Includes discussion of euthanasia in the Netherlands.

van Hees, Martin, and Bernard Steunenberg. (2000). "The Choices Judges Make: Court Rulings, Personal Values, and Legal Constraints." Journal of Theoretical Politics 12(3): 305–324.

Weyers, Heleen. (2003). Euthanasie: Het proces van rechtsverandering [Euthanasia: The process of legal change]. Amsterdam: Amsterdam University Press. The best survey of the Dutch discussion on euthanasia.