Euthanasia in the Euthanasia in the NetherlandsNetherlands

The Policy and Practice of The Policy and Practice of Mercy KillingMercy Killing

Raphael Cohen-AlmagorRaphael Cohen-Almagor

Preliminaries: Comparative Preliminaries: Comparative LawLaw

Part A: BackgroundPart A: Background

1. The Two Research Reports of 1990 1. The Two Research Reports of 1990 and 1995 and Their Interpretationsand 1995 and Their Interpretations

2. The Practice of Euthanasia and the 2. The Practice of Euthanasia and the Legal FrameworkLegal Framework

Part B: FieldworkPart B: Fieldwork

3. The Methodology3. The Methodology

Phase I: The InterviewsPhase I: The Interviews

4. Why the Netherlands?4. Why the Netherlands?5. Views on the Practice of 5. Views on the Practice of

Euthanasia Euthanasia

66 . .Worrisome DataWorrisome Data

““Some of the most worrisome data in Some of the most worrisome data in the two Dutch studies are concerned the two Dutch studies are concerned with the hastening of death without with the hastening of death without the explicit request of patients. There the explicit request of patients. There were 1000 cases (0.8%) without were 1000 cases (0.8%) without explicit and persistent request in explicit and persistent request in 1990, and 900 cases (0.7%) in 1995. 1990, and 900 cases (0.7%) in 1995. What is your opinion?”What is your opinion?”

77 . .The Remmelink Contention The Remmelink Contention and the British Criticismand the British Criticism

The Remmelink Commission held that actively ending The Remmelink Commission held that actively ending life when the vital functions have started failing is life when the vital functions have started failing is indisputably normal medical practice. Is this correct? indisputably normal medical practice. Is this correct? What is your opinion?What is your opinion?

In its memorandum before the House of Lords, the In its memorandum before the House of Lords, the BMA held that in regard to Holland, “all seem to agree BMA held that in regard to Holland, “all seem to agree that the so-called rules of careful conduct (official that the so-called rules of careful conduct (official guidelines for euthanasia) are disregarded in some guidelines for euthanasia) are disregarded in some cases. Breaches of rules range from the practice of cases. Breaches of rules range from the practice of involuntary euthanasia to failure to consult another involuntary euthanasia to failure to consult another practitioner before carrying out euthanasia and to practitioner before carrying out euthanasia and to certifying the cause of death as natural.” I asked my certifying the cause of death as natural.” I asked my interviewees: Do you agree?interviewees: Do you agree?

8. Should Physicians Suggest 8. Should Physicians Suggest Euthanasia to Their Patients?Euthanasia to Their Patients?

99 . .Breaches of the GuidelinesBreaches of the Guidelines

The physician practicing euthanasia The physician practicing euthanasia is required to consult a colleague in is required to consult a colleague in regard to the hopeless condition of regard to the hopeless condition of the patient. Who decides who the the patient. Who decides who the second doctor will be? second doctor will be?

What happens in small rural villages What happens in small rural villages where it might be difficult to find an where it might be difficult to find an independent colleague to consultindependent colleague to consult. .

Lack of ReportingLack of Reporting Record-keeping and written requests of Record-keeping and written requests of

euthanasia cases have improved euthanasia cases have improved considerably since 1990; there are now considerably since 1990; there are now written requests in about 60% and written written requests in about 60% and written record-keeping in some 85% of all cases of record-keeping in some 85% of all cases of euthanasia. The reporting rate for euthanasia. The reporting rate for euthanasia was 18% in 1990, and by 1995 it euthanasia was 18% in 1990, and by 1995 it had risen to 41%. The trend is reassuring, had risen to 41%. The trend is reassuring, but a situation in which less than half of all but a situation in which less than half of all cases are reported is unacceptable from the cases are reported is unacceptable from the point of view of effective control.point of view of effective control.

What do you think? What do you think? How can the reporting rate be improved?How can the reporting rate be improved?

1010 . .On Palliative Care and the On Palliative Care and the Dutch CultureDutch Culture

It has been argued that the policy It has been argued that the policy and practice of euthanasia is the and practice of euthanasia is the result of undeveloped palliative result of undeveloped palliative care. What do you think? care. What do you think?

I also mentioned the fact that there I also mentioned the fact that there are only a few hospices in the are only a few hospices in the Netherlands.Netherlands.

Culture of DeathCulture of Death

Daniel Callahan argues that there is aDaniel Callahan argues that there is a ““culture of deathculture of death” ” in thein the Netherlands.Netherlands.

What do you think? What do you think? I intentionally refrained from explaining I intentionally refrained from explaining

the term “culture of death.” I wanted to the term “culture of death.” I wanted to see whether the interviewees have see whether the interviewees have different ideas on what would different ideas on what would constitute such a cultureconstitute such a culture..

11. On Legislation and the 11. On Legislation and the Chabot Chabot CaseCase

Phase II: Interviewees’ General Phase II: Interviewees’ General CommentsComments

PreliminariesPreliminariesGeneral CommentsGeneral Comments

Phase III: UpdatesPhase III: Updates

PreliminariesPreliminariesOn the New ActOn the New ActOn the Work of the Regional On the Work of the Regional

CommitteesCommitteesFurther ConcernsFurther Concerns

Part C: ConclusionsPart C: Conclusions

PreliminariesPreliminariesSuggestions for ImprovementSuggestions for Improvement

Since November 1990, prosecution is Since November 1990, prosecution is unlikely if a doctor complies with the unlikely if a doctor complies with the Guidelines set out in the non-prosecution Guidelines set out in the non-prosecution agreement between the Dutch Ministry of agreement between the Dutch Ministry of Justice and the Royal Dutch Medical Justice and the Royal Dutch Medical AssociationAssociation. .

These Guidelines are based on the criteria These Guidelines are based on the criteria established in court decisions relating to the established in court decisions relating to the conditions under which a doctor can conditions under which a doctor can successfully invoke the defense of successfully invoke the defense of necessitynecessity..

The substantive requirements The substantive requirements are as followsare as follows::

The request for euthanasia or The request for euthanasia or physician-assisted suicide must be physician-assisted suicide must be made by the patient and must be made by the patient and must be free and voluntary.free and voluntary.

The patient’s request must be well The patient’s request must be well considered, durable and consistent.considered, durable and consistent.

The patient’s situation must entail The patient’s situation must entail unbearable suffering with no unbearable suffering with no prospect of improvement and no prospect of improvement and no alternative to end the suffering.alternative to end the suffering.

The patient need not be terminally ill The patient need not be terminally ill to satisfy this requirement and the to satisfy this requirement and the suffering need not necessarily be suffering need not necessarily be physical.physical.

Euthanasia must be a last resort.Euthanasia must be a last resort.

The procedural requirements are The procedural requirements are as followsas follows::

No doctor is required to perform euthanasia, No doctor is required to perform euthanasia, but those opposed on principle must make but those opposed on principle must make this position known to the patient early on this position known to the patient early on and help the patient to get in touch with a and help the patient to get in touch with a colleague who has no such moral colleague who has no such moral objections.objections.

Doctors taking part in euthanasia should Doctors taking part in euthanasia should preferably and whenever possible have preferably and whenever possible have patients administer the fatal drug patients administer the fatal drug themselves, rather than have a doctor apply themselves, rather than have a doctor apply an injection or intravenous drip.an injection or intravenous drip.

A doctor must perform the euthanasia.A doctor must perform the euthanasia. Before the doctor assists the patient, the Before the doctor assists the patient, the

doctor must consult a second independent doctor must consult a second independent doctor who has no professional or family doctor who has no professional or family relationship with either the patient or relationship with either the patient or doctor. doctor.

Since the 1991 Since the 1991 ChabotChabot case, patients with case, patients with a psychiatric disorder must be examined a psychiatric disorder must be examined by at least two other doctors, one of whom by at least two other doctors, one of whom must be a psychiatrist.must be a psychiatrist.

The doctor must keep a full written record The doctor must keep a full written record of the case.of the case.

The death must be reported to the The death must be reported to the prosecutorial authorities as a case of prosecutorial authorities as a case of euthanasia or physician-assisted suicide euthanasia or physician-assisted suicide and not as a case of death by natural and not as a case of death by natural causes.causes.

Since the legalization of the new law, Since the legalization of the new law, cases of euthanasia and PAS are reported cases of euthanasia and PAS are reported to the regional committees instead of the to the regional committees instead of the prosecutorial authorities.prosecutorial authorities.