Frequently asked questions

Why legislate on euthanasia ?
In the Netherlands, euthanasia is understood to mean termination of life by a doctor at the request of a patient. The Dutch government does not turn a blind eye to the fact that euthanasia happens. The question of whether – and how – criminal liability for euthanasia should be restricted has been the subject of broad political and public debate for the past thirty years. The inclusion in the Criminal Code of a special ground for exemption from criminal liability means that doctors who terminate life on request or assist in a patient’s suicide can no longer be prosecuted, provided they satisfy the statutory due care criteria and notify death by non-natural causes to the appropriate regional euthanasia review committee.
The main aim of the policy is to bring matters into the open, to apply uniform criteria in assessing every case in which a doctor terminates life, and hence to ensure that maximum care is exercised in such cases.
Pain, degradation and the longing to die with dignity are the main reasons why patients request euthanasia. Doctors in the Netherlands and in many other countries are increasingly faced with decisions about end-of-life issues. The population is ageing, considerable advances have been made with life-prolonging treatments, and cancer is claiming a rising proportion of victims. Euthanasia does not mean simply desisting from treatment when further intervention is pointless and allowing nature to take its course. This is accepted medical practice, as is the administration of drugs necessary to relieve pain even in the knowledge that they will have the side effect of hastening death. People in the Netherlands do not request euthanasia out of concern at the cost of treatment, since everyone is fully insured under the social security system.
What are the criteria for assessing whether a doctor has acted with due care?
When dealing with a patient’s request for euthanasia, doctors must observe the following due care criteria.
They must:
· be satisfied that the patient’s request is voluntary and well-considered;
· be satisfied that the patient’s suffering is unbearable and that there is no prospect of improvement;
· inform the patient of his or her situation and further prognosis;
· discuss the situation with the patient and come to the joint conclusion that there is no other reasonable solution;
· 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;
· exercise due medical care and attention in terminating the patient’s life or assisting in his/her suicide.

Since 1 November 1998, regional review committees have been assessing whether doctors’ actions satisfy the criteria which are now stated in section 2 of the Termination of Life on Request and Assisted Suicide (Review Procedures) Act (see appendix I).
Another important, basic principle established in case law is the existence of a close doctor-patient relationship. A doctor may only perform euthanasia on a patient in his care. He must know the patient well enough to be able to assess whether the request for euthanasia is both voluntary and well-considered, and whether his suffering is unbearable and without prospect of improvement.

Do doctors in the Netherlands always comply with requests for euthanasia?
No. Two thirds of the requests for euthanasia that are put to doctors are refused. Treatment frequently provides relief, while some patients enter the terminal stage of their illness before a decision has been reached.
Doctors are not obliged to comply with requests for euthanasia. Experience shows that many patients find sufficient peace of mind in the knowledge that the doctor is prepared to perform euthanasia and that they ultimately die a natural death.

Why do patients request euthanasia if good palliative and terminal care is available?
The Dutch health care system is accessible to all and guarantees full insurance cover for terminal and palliative care. Unfortunately, even where patients are receiving care of the highest quality, they may still regard their suffering as unbearable and plead with their doctors to terminate their lives. In such cases, euthanasia could represent a dignified conclusion to good palliative care.
Palliative care is provided in a variety of settings. First of all, the incurably ill can be cared for in their own homes by general practitioners, district nurses, home health aides and other care providers. If this is not appropriate, they must be admitted to some form of residential accommodation. Traditionally, such residential terminal care has been provided in hospitals and nursing or old people’s homes. Palliative units have existed for many years in Dutch hospitals and there are several dozen nursing homes and terminal wards within old people’s homes. A more recent development is hospices and “home-from-home” units specially designed to cater for incurably ill patients who are unable to spend the remainder of their lives at home.

Are doctors now no longer punished for performing euthanasia?
Euthanasia (termination of life on request and assisted suicide) is still a criminal offence, but the Criminal Code has been amended to exempt doctors from criminal liability if they report their actions and show that they have satisfied the due care criteria formulated in the Act. The actions of doctors in such cases are assessed by review committees (appointed by the Minister of Justice and the Minister of Health, Welfare and Sport), which focus in particular on the medical and decision-making procedures followed by the doctor. Where a doctor has reported a case and a review committee has decided on the basis of his report that he has acted with due care, the Public Prosecution Service will not be informed and no further action will be taken. But where a review committee finds that a doctor has failed to satisfy the statutory due care criteria, the case will be notified to the Public Prosecution Service and the Health Inspectorate. These two bodies will then consider whether the doctor should be prosecuted.

The aim of exempting doctors from prosecution is to ensure that they no longer feel like criminals and can act openly and honestly in relation to requests for euthanasia, provided that their decision-making and medical procedures satisfy the statutory due care criteria. The requirement of prior consultation with a physician who is not otherwise involved in the case and the review procedures constitute important safeguards for patients voluntarily requesting euthanasia in circumstances where they face unbearable suffering with no prospect of improvement.

Are doctors obliged to comply with requests for euthanasia?
No. Doctors can refuse to perform procedures to terminate life and nurses can refuse to be involved in preparations for euthanasia. Neither doctors nor nurses can ever be censured for failing to comply with requests for euthanasia.
The ability to refuse a request for euthanasia or assisted suicide guarantees doctors’ freedom of conscience. The basic principle underlying the legislation is that patients have no absolute right to euthanasia and doctors no absolute duty to perform it.

But is it not the duty of the doctor to preserve life?
Yes. A doctor's main duty is indeed to preserve life. Euthanasia is not part of the medical duty of care. However, doctors are obliged to do everything they can to enable their patients to die with dignity. They may not administer pointless medical treatments. When all treatment options have been exhausted, the doctor is responsible for relieving suffering. The 1996 study showed that doctors in the Netherlands exercise the utmost caution in dealing with end-of-life decisions.

How willing were doctors to notify cases of euthanasia in 1990-1999?
Statistical material obtained by independent research (commissioned by the Dutch government) in 1991 and 1996 into medical action to terminate life showed that there was no question of a “slippery slope”, but that greater openness had on the contrary led to increasing care in the performing of euthanasia (see appendix II). Statistics included in the annual reports of the regional review committees for 1998/1999 and 2000 support this conclusion by showing an increase in the number of notifications by doctors. The Netherlands is the only country in which such research has so far been conducted. A new study is to be launched in 2001. This will evaluate the operation and procedures of the regional review committees, examine factors influencing the willingness of doctors to report euthanasia and assess the latest state of affairs surrounding medical action to terminate life. The last of these will permit comparison with the data from the 1991 and 1996 studies.
The 1996 study included interviews and an anonymised survey of doctors. The results showed no increase in the number of euthanasia cases among vulnerable categories of patients or the less seriously ill. In fact, it showed that the number of cases in which life was terminated without the patient’s request had actually decreased over the 1990-1995 period. At the same time, the number of cases of termination of life on request over that period had not risen disproportionately, although the number of notifications of termination of life on request and assisted suicide had tripled. The existence of the notification procedure had led doctors to consult more frequently with colleagues and to record in writing how they had reached their decisions.

What is the notification procedure?
· The doctor is obliged to notify the municipal pathologist of every instance of death from non-natural causes. In the case of euthanasia or assisted suicide, he compiles a report based on a special model (see Appendix III).
· The pathologist also compiles a report establishing that the patient's death was due to non-natural causes. He sends this to the Public Prosecutor, who must give consent for burial.
. The regional euthanasia review committee receives these two reports, plus a statement by the independent physician consulted by the doctor and any written directive by the deceased.
· The committee assesses whether the doctor has acted in accordance with the due care criteria. If it concludes that he has, no further action is taken against him.
· If the committee finds that the doctor has not acted in accordance with the due care criteria, it reports its findings to the Public Prosecution Service and the regional health inspector. These two agencies will then consider what action, if any, should be taken against the doctor.
An important feature of the legislation is that the regional review committees (each of which includes a doctor) have discretion to decide whether or not a doctor has satisfied the due care criteria. The reason for this is that research has shown that doctors are more likely to report cases of euthanasia if their own peers have a hand in the initial review of them. Otherwise, they feel that they face the threat of immediate condemnation by the Public Prosecution Service.

What is the procedure for consulting an independent physician?
Before the attending physician complies with a request for euthanasia, he must first consult a colleague who is neither connected with him nor involved in treating the patient. The independent physician must see the patient for himself, review the progression of the illness, establish whether the request for euthanasia is both voluntary and well-considered, and communicate his findings to the attending physician in writing.
A network has been set up in the Netherlands of general practitioners and other physicians trained to assist doctors facing decisions relating to the terminal stages of life (the SCEN project). Attending physicians dealing with requests for euthanasia should preferably consult one of these doctors.

Who sits on the regional review committees and how do they operate?
There are five regional review committees (the five regions are: Groningen, Friesland and Drenthe; Overijssel, Gelderland, Utrecht and Flevoland; North Holland; South Holland and Zeeland; North Brabant and Limburg), dealing with reported cases of euthanasia or assisted suicide. Each has an odd number of members, including in any event one legal expert (who also chairs the committee), one physician and one expert on ethical issues. This ensures that proper consideration is given to the legal, procedural, medical and moral aspects of cases. The committees reach their decisions by majority vote. The chairs and the ordinary members are all appointed by the Minister of Justice and the Minister of Health, Welfare and Sport for a period of six years. The five regional review committees have been in operation since 1 November 1998. Under the new Act, they are no longer obliged to report cases to the Public Prosecution Service if they feel that the statutory due care criteria have been met. The committees are also responsible for the registration of cases of termination of life on request or assisted suicide notified to them. This does not mean, however, that they have taken over the role of the Public Prosecution Service, since their remit goes no further than assessing whether the due care criteria have been met. The Public Prosecution Service is still free to institute an investigation in any case where there is reason to suspect that a crime has been committed.

Does a written directive have the same status as an oral request?
The Act recognises written directives (living wills) as well as oral requests as legitimate forms of request for euthanasia. The recognition of written directives is especially important where a doctor decides to comply with a request for euthanasia in circumstances where the patient is no longer able to express his wishes orally. In such circumstances, a written directive counts as a well-considered request for euthanasia, but its existence can never discharge the doctor from his duty to reach his own decision on the request in the light of the statutory due care criteria. The doctor must normally give serious consideration to any written directive. The only exception is where he has reason to believe that the patient was not competent to make a reasonable appraisal of his own interests at the time when he signed it. In that case, the directive will not constitute a request for euthanasia within the meaning of the Act. It is important that the doctor and patient discuss the terms of the directive, if at all possible.
The statutory provision for written directives makes it possible for patients to indicate in advance that they wish their lives to be terminated if they eventually find themselves experiencing unbearable suffering with no prospect of improvement, in circumstances which render them incapable of expressing their wishes personally. Since the Act applies only to termination of life on request, it follows that it is not applicable to patients who have made no advance directive and are unable to decide or express their wishes. The government will make additional statutory provision for this category of patients.

Can people come from other countries to seek euthanasia in the Netherlands?
This is impossible, given the need for a close doctor-patient relationship. The legal procedure for the notification and assessment of each individual case of euthanasia requires the patient to have made a voluntary, well-considered request and to be suffering unbearably without any prospect of improvement. In order to be able to assess whether this is indeed the case, the doctor must know the patient well. This implies that the doctor has treated the patient for some time. Granting a request for euthanasia places a considerable emotional burden on the doctor. Doctors do not approach the matter lightly. From this point of view too, longstanding personal contact between the doctor and the patient plays an important role.

Is Dutch law on euthanasia compatible with international conventions guaranteeing the right to life?
The Dutch government does not believe that the new Act conflicts with its duty under international law to defend its citizens’ right to life against violation by government or by individuals. That duty is laid down, for example, in article 6 of the UN’s International Covenant on Civil and Political Rights (ICCPR) and article 2 of the European Convention on Human Rights (ECHR). What underlies both provisions is respect for life. The conventions deprive government and others of the right to take an individual’s life against his will (except in specified circumstances).
These provisions are not intended to perpetuate unbearable suffering where there is no prospect of improvement, but rather to offer the individual protection against the violation of his right to life. Neither the wording nor the drafting procedure clarifies what constitutes such unlawful violation. It is generally believed that signatories to the conventions have considerable freedom to interpret their broadly worded provisions within their own national legal systems. However, even if the conventions cannot be interpreted as imposing a general prohibition on the termination of life on request or assisted suicide, the national provisions of signatory states must certainly provide sufficient protection to meet the criterion of “respect for life”. This is the basis of Dutch legislation on euthanasia. Performing euthanasia in response to a voluntary request from a patient does not constitute intentional deprivation of life within the meaning of the articles of the conventions cited above.

Article 2 of the ECHR reads as follows:

· Everyone’s right to life shall be protected by law. No one shall be deprived of his life intentionally save in the execution of a sentence of a court following his conviction of a crime for which this penalty is provided by law.

· Deprivation of life shall not be regarded as inflicted in contravention of this Article when it results from the use of force which is no more than absolutely necessary: (a) in defence of any person from unlawful violence; (b) in order to effect a lawful arrest (…).

The new Act is therefore not incompatible with international conventions and the most fundamental human rights laid down in them. The Dutch government vigorously endorses these rights, but does not go so far as to forbid individuals to decide for themselves whether or not their lives are worth living. For that reason, suicide is not an offence in the Netherlands, as it is in some other countries.