J7ournal ofMedical Ethics 1999;25: 16-2 1

Voluntary euthanasia under control?Further empirical evidence fromthe NetherlandsHenk Jochemsen and John Keown Lindeboom Institute for Medical Ethics, the Netherlands and University ofCambridge, respectively

AbstractNineteen ninety-six saw the publication of a majorDutch survey into euthanasia in the Netherlands.This paper outlines the main statisticalfindings ofthis survey and considers whether it shows thatvoluntary euthanasia is under effective control in theNetherlands. The paper concludes that although therehas been some improvement in compliance withprocedural requirements, the practice of voluntaryeuthanasia remains beyond effective control.

(7ournal ofMedical Ethics 1999;25:16-21)Keywords: Euthanasia; the Netherlands; regulation; slip-pery slope

IntroductionWorldwide, the euthanasia debate continues tointensify. In 1997, the Australian parliament votedto repeal euthanasia legislation in the NorthernTerritory and the US Supreme Court upheld theconstitutionality of legislation prohibiting"physician-assisted suicide".' In deciding whethereuthanasia or assisted suicide should be permittedin principle, and whether they can be controlled inpractice, the experience of the Netherlands, wherethey have been officially tolerated and widelypractised for well over a decade, is clearly of pro-

found importance.Nineteen ninety-one saw the publication of the

results of an important survey, by Professor PJ vander Maas, into end-of-life decision making byDutch doctors in the year 1990.2 Despite claims tothe contrary by supporters of Dutch euthanasia,this survey helped to cast serious doubt on Dutchclaims that their guidelines were sufficiently stricteffectively to control the practice of voluntaryeuthanasia (the intentional termination of pa-tients' lives at their request) and to preventnon-voluntary euthanasia (the intentional termi-nation of the lives of patients incapable of makinga request).The survey disclosed the widespread practice of

non-voluntary euthanasia; the use of euthanasiaeven when doctors thought that palliative care was

a viable alternative, and the common practice bydoctors of illegally certifying euthanasia deaths asdeaths by "natural causes" instead of reportingthem, as required by the guidelines, to theauthorities.3

In 1996, Van der Maas and Van der Walpublished the results of an extensive survey intoend-of-life decisions by Dutch doctors in the year1995.4 Do the results of this survey show anyimprovement in the degree of control over eutha-nasia?

I The surveyThe survey sought particularly to ascertain theincidence of intentional life-shortening by doc-tors; the extent to which they complied with theirduty to report such cases (in accordance with aprocedure dating from late 1990 which was givenstatutory force in June 1994), and the quality oftheir reporting. The main purpose of the report-ing procedure is to provide for possible scrutiny ofthe intentional termination of life by doctors andto promote careful decision making in such cases.5The most important quantitative data generatedby the survey are reproduced in table 1.

Before the figures are analysed, it is importantto note that the only objectively verifiable figuresare those concerning the total number of deathsand the total number of cases reported. All theother figures are based on the responses of thephysicians concerning cases in which they saidthey had recently been involved.

It is no less important to stress that this paperdoes not question the methodology used by theresearchers to obtain their data, namely, inter-views with 405 physicians and postal question-naires mailed to physicians who had attended6,060 deaths identified from death certificates. Weuse the researchers' own data and standardly citetheir "best estimate" (though in some cases num-bers have been arrived at on the basis of percent-ages and numbers used in the survey and, in suchcases, we have rounded off the number arrived at).

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Table 1 End-of-life decisions by doctors in the Netherlands 1990-1995

Deaths in the NetherlandsRequests for euthanasiaEuthanasiaAssisted suicideLife-terminating acts without explicit requestIntensification of pain and symptom treatmenta. Explicitly intended to shorten lifeb. Partly intended to shorten lifec. Taking into account the probability that life will be shortenedWithdrawal/withholding treatment (incl tube-feeding)a. At the explicit request of the patientb. Without the explicit request of the patientb 1. Explicitly intended to shorten lifeb2. Partly intended to shorten lifeb3. Taking into account the probability that life will be shortenedIntentional termination of neonatesa. Without withholding/withdrawing treatmentb. Withholding/withdrawing treatment plus administration of medication explicitly to

shorten lifeAssisted suicide of psychiatric patients

In other words, our paper does not take issue withthe researchers' methodology but with theirinterpretation of the statistics it generated.A final preliminary point is that the Dutch

adopt a particularly narrow definition of "eutha-nasia" as the intentional shortening of a patient'slife at the patient's explicit request. In otherwords, "euthanasia" in the Netherlands means

"active, voluntary euthanasia" and does notinclude intentional life-shortening by omission("passive euthanasia") or euthanasia without thepatient's request (whether non-voluntary if thepatient is incompetent or involuntary if the patientis competent.) For ease of exposition, the Dutchdefinition is followed here unless the contrary isapparent.

1. EUTHANASIA AND ASSISTED SUICIDEBetween 1990 and 1995 the number of requestsfor euthanasia increased, as did the number ofrequests granted.6 Cases of euthanasia andassisted suicide rose from 2,700 cases in 1990 to3,600 in 1995, or from 2.1% to 2.7% of all deaths.According to the attending physicians, there

were treatment alternatives in 17% of these casesbut in almost all the patients did not want them.'However, in 1994, the Dutch Supreme Court heldthat doctors should not hasten death whenever thealternative of palliative treatment was available, atleast in cases of mental suffering8 and theministers of justice and health,9 and the RoyalDutch Medical Association (KNMG),"' havedecided that the same restriction should apply incases of somatic suffering. The above cases

appear, therefore, to have breached this guideline.Life was shortened by one to four weeks in 31%

of euthanasia cases and 45% of assisted suicides

and by more than a month in 7% of cases ofeuthanasia and in 30% of assisted suicides."

Physicians stated that the main reason whypatients requested euthanasia was "intolerablesuffering without prospect of improvement"(74%),12 which has become the standard termi-nology to describe the seriousness of the conditionrequired by the law. But the next most common

reasons were "to prevent loss of dignity" (56%)and "to prevent further suffering" ( 47%). It mustsurely be doubted whether either of these reasons,by itself, satisfies the requirement of unbearablesuffering.

Interestingly, one of the most important reasonsfor rejecting a request for euthanasia (cited by35% of physicians) was the physician's opinionthat the patient's suffering was not intolerable.'3This suggests that, despite the emphasis placed bythe advocates of euthanasia on patient autonomy,the application of euthanasia is more a function ofthe physican's judgment about the quality of thepatient's life than of respect for the patient'sautonomy. This suggestion is fortified by the evi-dence about the extent to which Dutch doctorscontinue to terminate the lives of patients withoutan explicit request.

2. LIFE-TERMINATING ACTIONS WITHOUT EXPLICITREQUESTThe survey confirms that the intentional shorten-ing of patients' lives without explicit requestremains far from uncommon. Nine hundredpatients had their lives ended without explicitrequest in 1995, representing 0.7% of all deaths,only a slight decrease on the 0.8% so terminatedin 1990.'4 In other words, of the 4,500 (3,200 +400 + 900) cases in which doctors admitted they

1990

129000 (100%)8900 (7%)2300 (1.8%)400 (0.3%)1000 (0.8%)

22500 (17.5%)1350 (1%)6750 (5.2%)14400 (11.3%)22500 (17.5%)5800 (4.5%)

2670 (2.1%)3170 (2.5%)10850 (8.4%)

1995

135500 (100%)9700 (7.1%)3200 (2.4%)400 (0.3%)900 (0.7%)

20000 (14.8%)2000 (1.5%)2850 (2.1%)15150 (11.1%)27300 (20.1%)5200 (3.8%)

14200 (10.5%)

7900 (5.8%)

10.0080.00

2-5

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18 Voluntary euthanasia uniider conitrol? Fuirther enmpirical evidence froni the Netherlands

actively and intentionally terminated life, one infive involved no explicit request.The main reason for not discussing the issue

with the patient was stated to be the patient'sincompetence (due, for example, to dementia).But not all patients whose lives were terminatedwithout an explicit request were incompetent. In15% of cases where no discussion took place butcould have, the doctor did not discuss thetermination of life because the doctor thought thatthe termination of the patient's life was clearly inthe patient's best interests.'

Furthermore, in a third of the 900 cases, therehad been a discussion with the patient about thepossible termination of life, and some 50% ofthese patients were fully competent, yet their liveswere terminated without an explicit request.

Moreover, in I7'S of the 900 cases, treatmentalternatives were thought to be available by theattending physician.'The physicians thought that life was shortened

by one to four weeks in 3/0 of cases but by morethan a month in 6'Y,., Finally, physicians had notdiscussed their action with a colleague in 40% ofcases, with a close relative in 30'% of cases, andwith anyone at all in 5%.1C

3. INTENSIFICATION OF PAIN ANI) SYMN%PTONITREAT.MENTIn 20,000 cases (according to the physician inter-views) or 25,800 cases (according to the deathcertificate survey), palliative drugs were adminis-tered in doses which almost certainly shortenedlife. In some 2,000 of these cases the doctorexplicitly intended, and in a further 2,850 cases,partly intended, to shorten life.)" The researchersestimate that the grey area between intending toalleviate pain and symptoms and intending toshorten life is about 2% of all deaths, the same asin 1990.2'Where doctors administered palliative drugs

partly in order to shorten life, they had discussedit with the patient in just over half of the cases(52%) and in only 36% of the cases was there anexplicit request for life-shortening doses by thepatient. The physicians stated that 86 patients(3%) with whom they had not discussed thistreatment were fully competent. Moreover, inonly 36%o of the cases had the doctors consulted acolleague. Life was shortened by an estimated oneto four weeks in 70/o of cases but by more than amonth in 1%.23

4. WITHHOLDING/WXITHDRAWING TREATMENTIn some 27,300 cases a treatment was withheld orwithdrawn (in 5,200 cases at the patient's explicitrequest) taking into account a probable shorten-ing of life.

However, in 18,000 of these cases (14,200 ofwhich involved no explicit request by the patient)it was the physician's explicit intention to shortenlife (though the survey does not state in how manycases the treatment was disproportionate, inwhich case doctors could, had they wished, haveproperly withdrawn it for that reason and withoutintending to shorten life.-")

In the majority of cases in which no discussionwith the patient had taken place, the physiciansstated that the patient was either incompetent oronly partly competent. However, in 1% of thesecases (140 patients) the physician considered thepatient fully competent.

In cases where treatment was withheld or with-drawn with the explicit intent to shorten life, thephysician estimated that life was shortened by oneto seven days in 34%S of cases, by one to four weeksin 18%'S and by more than a month in 9%.2"

5. NEONATESThe survey reports that over 1,000 newborns diein the Netherlands before their first birthday andestimates that the lives of about 15 are actively andintentionally terminated by doctors. The figureof 15 seems, however, a significant underestimate.The survey shows that in ten cases (1 %) doctors

administered a drug with the explicit intention ofshortening life. But it also reveals a further 80cases in which, also with the explicit intention ofshortening life, doctors administered a drug andwithdrew or withheld a life-prolongingtreatment.'S In total, therefore, it appears to havebeen the explicit intention of doctors to shortenthe lives of 90 neonates, not 15.)

Moreover, in no fewer than 41%' of the 1,000cases, treatment was withdrawn or withheld withthe explicit intention of shortening life. In asignificant proportion of these cases, life wasterminated because the babies' lives were notthought bearable. Forty-five per cent of thesebabies were expected to live more than four weeks,and some of them more than half a year.`

In around a fifth of cases in which doctorsintentionally withheld or withdrew treatment withthe explicit purpose of shortening life because thebaby's life was thought unbearable, there had beenno discussion with the parents. "' Doctors said thatin most cases this was because the situation was soclear that discussion was unnecessary or becausethere was no time, though these reasons are notelaborated.

Finally, doctors reported hardly any cases of theintentional shortening of neonatal life to theauthorities.

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Jochemsen, Keown 19

6. ASSISTED SUICIDE OF PSYCHIATRIC PATIENTSBased on the replies of psychiatrists in respect ofthe year 1995, the survey estimates that althoughsome 320 psychiatric patients explicitly requestassistance in suicide annually, only two to five areassisted to commit suicide by psychiatrists.Among psychiatrists who would never grant a

request for assisted suicide on the basis of mentalsuffering (almost 1/3 of the respondents) "profes-sional opinion" was cited by 88% as the mostimportant reason. Only 2% of psychiatrists hadever assisted suicide.32This relatively restrictive approach of psychia-

trists may owe not a little to the controversy gen-erated by the case of Dr Chabot, a psychiatristcriticised by a medical disciplinary court forassisting in the suicide of a 50-year-old woman

who suffered grief after the loss of her two sons.3Disclosing statistics which support a restrictive

approach, the survey also indicates that of thosepatients not assisted in suicide, 16% committedsuicide without assistance by a physician and that,of those patients still living, 35% no longer wishedfor death and that the death wish in a further 10%had diminished.

7. CONSULTATIONThe guidelines for permissible euthanasia andassisted suicide require the doctor, before agree-ing to either, to engage in a formal consultation(consultatie), and not merely an informal discus-sion (overleg), with a colleague.

In cases of euthanasia and assisted suicide 92%of doctors had, according to the survey, discussedthe case with a colleague.34 In 13% of these cases,however, the discussion did not amount to a

formal consultation. Consultation took place,therefore, in 79% of cases. However, other figuresin the survey suggest that consultation occurred ina significantly smaller percentage of cases. For thesurvey indicates that consultation occurred in99% of reported cases but in only 18% ofunreported cases35 and that almost 60% of allcases of euthanasia and assisted suicide were notreported,36 from which it seems that consultationoccurred in only around half of all cases.37

In the cases of life-termination without explicitrequest, a discussion occurred in 43% of cases butin 40% this did not amount to consultation. Con-sequently, there was no consultation in 97% ofsuch cases.

Moreover, even when consultation did takeplace, it was usually with a physician living locallyand the most important reasons given for consult-ing such a physician were his views on life-endingdecisions and his living nearby: expertise in pallia-tive care was hardly mentioned. Further, in theoverwhelming majority of cases, the first doctor

had made his mind up before consulting and thedoctor consulted disagreed in only 7% of cases.38In short, the requirement of consultation, evenwhen it is satisfied, hardly operates as a rigorouscheck on decision making.

8. REPORTINGIn 1995 41% of cases of euthanasia and assistedsuicide were reported to the local medicalexaminer, as required by the reporting procedure.While this is an improvement on the figure of 18%reported in 1990, it means that a clear majority ofcases, almost 60%, still go unreported. Moreover,the survey confirms that the legal requirementsare breached more frequently in unreported cases,in which there is less often a written request by thepatient, a written record by the doctor, or consul-tation by the doctor.39The most important reasons given by doctors

for failing to report in 1995 were (as in 1990), thewish to avoid the inconvenience (for the doctorand/or the relatives) of an investigation by theauthorities, and to avoid the risk of prosecution(though, as the consistently tiny number ofprosecutions indicates, this risk is negligible).Thirty per cent of doctors stated that they did notreport because they had failed to observe therequirements for permissible euthanasia and 12%because they considered euthanasia was a privatematter between doctor and patient.40

II DiscussionThe second survey confirms at least threedisturbing findings of the first survey.

1. INCIDENCE OF INTENTIONAL LIFE-SHORTENINGWITH AND WITHOUT EXPLICIT REQUESTLike the first survey, the second indicates asizeable incidence of intentional life-shortening byDutch doctors. Even adopting the unusually nar-row Dutch definition of euthanasia as active, vol-untary euthanasia there were no fewer than 3,200cases in 1995 (2.4% of all deaths), an increase ofalmost a thousand on the 1990 total of 2,300(1.8% of all deaths).But if all cases in which doctors explicitly

intended to shorten life (whether by act oromission, and whether with or without thepatient's request) are included, the total risessteeply. Adding the cases of assisted suicide (400);life-termination without explicit request (900)and the intensification of pain and symptomtreatment with the explicit intent to shorten life(2,000), the total more than doubles from 3,200to 6,500.And if to this number are added the cases of

withholding or withdrawing treatment with theexplicit intent to shorten life (18,0004'); cases in

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20 Voluntary euthanasia under control? Further empirical evidence from the Netherlands

which neonates were intentionally terminated (90cases) and psychiatric patients assisted in suicide(two to five cases), the total rises to over 24,500cases.

2. EUTHANASIA AS AN ALTERNATIVE TO PALLIATIVECAREThe survey's comment that "the quality of medi-cal treatment near the end of life has improved"42might not unreasonably be thought to display acertain complacency, particularly in a countrywhich has some way to go in the provision ofadequate palliative care. The high incidence ofintentional life-shortening disclosed by the surveyand the relative weakness of the reasons for eutha-nasia given in many cases by the doctors tend tosuggest that euthanasia is not confined to cases of"last resort" and is at least sometimes used as analternative to palliative care. The case of DrChabot, in which the defendant doctor assisted agrieving woman, whom he did not consider to bephysically or mentally ill, to kill herself, and inwhich the Supreme Court held that such sufferingcould indeed justify assisted suicide, illustrates theelasticity of the requirement of "unbearablesuffering".The survey confirms that, even when doctors

believe that treatment alternatives are available,they not infrequently resort to euthanasia. Theopinion of the Supreme Court, the ministers ofjustice and health, and the KNMG, that euthana-sia is impermissible when treatment alternativesare available, even if the patient refuses them, hasclearly not prevented its administration in suchcircumstances. In a move that would make theprospect of prosecution even more remote, thethen minister of justice appeared to reverse herearlier position and instructed the attorneysgeneral that the refusal by the patient of availabletreatment alternatives does not render euthanasiaunlawful.43

3. WIDESPREAD BREACH OF THE REQUIREMENT TOREPORTAlthough 41% of cases (1,466) were reported in1995 as opposed to 18% (486) in 1990, it remainstrue that in both years, as in every year in between,a clear majority of cases has gone unreported.There was, in short, no official control whateverover the majority of cases of euthanasia, assistedsuicide or the termination of life without explicitrequest.Nor should the alleged increase in reporting be

accepted uncritically. First, the second surveyrecords an increase in cases of euthanasia between1990 and 1995 (900 cases) almost as large as theincrease in cases reported (980 cases). Secondly, ifthe total of 6,500 cases of active, intentional

life-shortening is used, then the proportion ofunreported cases rises from 59% to 77%. On thetotal of 24,500 cases, the proportion unreportedreaches 94%.

It will be recalled that the purpose of thereporting procedure is to allow for scrutiny of theintentional termination of life by doctors and topromote observance of the legal and professionalrequirements for euthanasia. The undisputed factthat a clear majority of cases (59% according tothe survey, at least 77% on our calculations) stillgoes unreported, serves only to reinforce doubtsabout the ability of the procedure to fulfil its pur-pose and to undermine Dutch claims of effectiveregulation, scrutiny and control. Further, eventhose cases which are reported are reported by thedoctor, and one may wonder whether the doctor'sreport is any more likely to disclose evidence ofwrongdoing than is a tax return to discloseevidence of undeclared earnings.

ConclusionsWith the publication of the first Van der Maassurvey in 1991 it became clear that the so-called"strict safeguards" laid down in 1984 by thecourts and the Royal Dutch Medical Associationhad largely failed. The survey cast doubt on cen-tral assurances which had been given by the advo-cates of voluntary euthanasia: that euthanasiawould be performed only at the patient's explicitrequest and that doctors terminating life withoutrequest would be prosecuted for murder; thateuthanasia would be used only in cases of "lastresort" and not as an alternative to palliative care;and that cases would be openly reported and dulyscrutinised. The Dutch reaction to the survey'sfindings was also revealing: the cases of non-voluntary euthananasia it disclosed, far frombeing criticised, were largely condoned. In short,the survey indicated that, in less than a decade, theDutch had slid down the slippery slope.

It is therefore surprising that an Americancommentator should observe that the similaritybetween the findings in respect of 1990 and 1995shows that the Dutch are apparently not descend-ing a slippery slope.44 This observation quite over-looks the fact that the first survey showed that thedescent had already occurred by 1990: the secondsurvey, far from showing that there has been nodescent from 1984 to 1995 shows merely thatthere has been no significant ascent from 1990 to1995.The second survey is little more reassuring than

the first. Dutch proponents of voluntary euthana-sia claimed that tolerating voluntary euthanasia,subject to "safeguards", would allow it to be"brought into the open" and effectively control-

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Jochemsen, Keown 21

led. As the valuable surveys by Van der Maas andVan der Wal disclose, and as several expertcommentators have now concluded,45 the reality isthat a clear majority of cases of euthanasia, bothwith and without request, go unreported andunchecked.46 In the face of the undisputed factthat in a clear majority of cases there is not even anopportunity for official scrutiny, Dutch claims ofeffective regulation ring hollow.

Henk Jochemsen, PhD, is Director of the LindeboomInstitute for Medical Ethics. John Keown, DPhil, isUniversity Lecturer in the Law and Ethics ofMedicinein the Faculty ofLaw, University of Cambridge.

References and notesI Washington v Glucksberg (1997) 117 S Ct 2258; Vacco v Quill

(1997) 117 S Ct 2293.2 Maas PJ van der et al. Medische beslissingen rond het levenseinde.

's-Gravenhage: SDU Uitgeverij Plantijnstraat, 1991 (publishedin translation as Euthanasia and other medical decisionsconcerning the end of life. Amsterdam: Elsevier, 1992).

3 See for example Jochemsen H. Euthanasia in Holland: an ethi-cal critique of the new law. Journal of Medical Ethics1994;20:212; Keown J. Euthanasia in the Netherlands: slidingdown the slippery slope? In: Keown J, ed. Euthanasia examined.Cambridge: Cambridge University Press, 1995: ch 16.

4 Wal G van der, Maas PJ van der. Euthanasie en andere medischebeslissingen rond het levenseinde. De praktijk en de meldingsproce-dure. (Euthanasia and other medical decisions concerning the end oflife. Practice and reporting procedure.) Den Haag: SDU uitgevers,1996. For summaries of the research in English see Maas PJvan der. Euthanasia, physician-assisted suicide, and othermedical practices involving the end of life in the Netherlands,1990-1995. New England Journal of Medicine 1996;335:1699;van der Wal G. Evaluation of the notification procedure forphysician-assisted death in the Netherlands. New England Jour-nal ofMedicine 1996;335:1706.

5 See reference 4: 25.6 See reference 4: tables 5.3; 6.2; 9.1.7 See reference 4: table 5.5.8 NederlandsJ7uristenblad 1994; 69 nr26: 895ff. See also JochemsenH. The Netherlands experiment. In: Kilner JF et al, eds. Dignityand dying. Grand Rapids: Eerdmans, 1996: ch 12; Hendin H.Seduced by death: doctors, patients and the Dutch cure. New York:WW Norton, 1997: ch 2.

9 Sorgdrager W, Borst-Eilers E. Euthanasie - De stand vanzaken. Medisch Contact 1995;12: 381-4.

10 Kastelijn WR. Standpunt hoofdbestuur KNMG inzake euthana-sie. Utrecht: KNMG, August 1995.

11 See reference 4: table 5.4.12 See reference 4: table 5.6.13 See reference 4: table 5.12.14 See reference 4: table 6.2; 92.15 See reference 4: table 6.5.16 This suggests a disturbing incidence not only of non-voluntary

euthanasia but also of involuntary euthanasia.17 See reference 4: table 6.4.18 See reference 4: table 6.3.19 See reference 4: table 6.6.20 See reference 4: table 7.2.

This figure is calculated from the researchers' percentages and

estimates at pages 92-93. In fact the figure of 2,000 isconservative as it is derived from the total number of 20,000cases yielded by the physician-interviews rather than from thelarger total of 25,800 in the death certificate study."Explicit" isthe researchers' translation of the word "uitdrukkelijk". Wethink a more accurate translation would be "primary" as a pur-pose can be explicit yet secondary or primary yet implicit.

21 See reference 4: 93.22 See reference 4: table 7.4.23 See reference 4: tables 7.3; 7.5.24 See reference 4: tables 8.1; 8.3; 84.25 See reference 4: tables 8.1; 8.3.26 See reference 4: table 8.2.27 See reference 4: 189.28 See reference 4: table 17.2.29 The researchers' estimate of 15 cases may be traced to their

observation that in 17% of cases in which drugs were adminis-tered with the explicit intent to shorten life (totalling 15 cases),one of the drugs administered paralysed muscles and thereforecaused death almost immediately whereas in a majority of casesin which drugs were administered in combination with thewithdrawal of treatment, the treatment withdrawn was artificialventilation and the medication may have been administered toprevent suffocation.

30 See reference 4: table 17.3.31 See reference 4: table 17.5.32 See reference 4: table 18.1.33 See reference 8: Hendin: ch 2.34 See reference 4: table 10.1.35 See reference 4: table 10.2.36 See text on page 19 immediately preceding reference 39.37 The reason for the discrepancy between the two totals might be

a certain bias in the physicians' responses. The authors of thesurvey suggest that some of the physicians interviewed, whenasked to discuss their most recent case of euthanasia, in fact dis-cussed a recent case which had a stronger impact, probablybecause it was reported. See reference 4: 113.

38 See reference 4: 102-7.39 See reference 4: table 11.6.40 See reference 4: table 11.8; 225.41 14,200 of these cases involved no explicit request from the

patient. In cases where the patient had refused treatment, thedoctors could properly, had they wished, have omittedtreatment for this reason and without intent to shorten life.Similarly, as was mentioned above, it is unclear in how manycases of non-treatment the treatment was in fact disproportion-ate and could properly have been withdrawn for that reasonwithout the doctors resorting to an intention to shorten life.

42 See reference 4: 240.43 See reference 4: 144-5.44 See for example Angell M. Euthanasia in the Netherlands -

good news or bad? New England Journal ofMedicine 1996;335:1677.

45 See for example Gomez C. Regulating death. New York: FreePress, 1991; see reference 8: Hendin; see reference 3:Jochemsen; see reference 3: Keown.

46 While acknowledging this fact, Dr Angell suggests that doctorsfail to report because they find the reporting procedure"burdensome" and "daunting". See reference 44: 1677. But itis difficult to see how the procedure - the filing of a report withthe local medical examiner (another doctor) in the sure knowl-edge that if the guidelines have been followed there is no pros-pect of prosecution - can realistically be so described. Indeed,many doctors admit that they omit to report simply becausethey do not want the inconvenience of an investigation eitherfor themselves or the family (see text at page 19 immediatelypreceding reference 40).

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