Euthanasia was formally legalised in the Netherlands in 2003
after several years in which it was practised openly after court decisions
allowing it in certain circumstances.
Assisted suicide for “completed life”
On 12 October 2016 the Netherlands Government formally
reported to the Parliament its response to the February 2016 report of a
commission on assisted suicide for “completed life”.[1]
The report considered the possibility of expanding the law to specifically
provide for legalised assisted suicide for people who felt their life was
complete but who did not qualify under the existing law because there was no
medical basis for the feeling that life was an unbearable burden. The report
suggested that in most cases such people could be accommodated under the
existing law by the increasingly broad interpretation being given to its
requirements.
However, the government’s response, cosigned by Edith
Schippers, Minister of Health, Welfare and Sport and Ard van der Steur,
Minister of Security and Justice, proposes a new law – to be drafted in 2017 –
to specifically legalise assisted suicide for those who feel that their life is
complete and who wish to die in cases where there is no underlying medical
basis for this feeling.
The government proposes the creation of a new category of
community worker – stervenshulpverlener
– a death worker
The role of a death worker would be to assess whether the person’s request
for assisted suicide was voluntary and persistent and that there were no
reasonably available medical or social measures to relieve the feeling that
life was a burden.
The government response points out that the existing law on
euthanasia is premised on a doctor being confronted with a patient who has
unbearable suffering that cannot be relived other than by deliberately ending
the patient’s life. Euthanasia is portrayed as an act of mercy.
The government response suggests that for persons who feel
that they have completed their life and that to continue living it is a burden
the State also can facilitate an act of mercy – namely after approval by a
death worker and confirmation by a second death expert, facilitating assisted
suicide.
There is a suggestion that as this feeling of completed life
is most common in elderly people it would be in order to impose a minimum age
limit but no indication is given as to what this might be.
Complications
Technical problems, complications and problems with
completion in the administration of lethal drugs for euthanasia have been
reported from the Netherlands.
Technical problems occurred in 5% of cases. The most common technical problems were
difficulty finding a vein in which to inject the drug and difficulty
administering an oral medication.
Complications occurred in 3% of cases of euthanasia,
including spasm or myoclonus (muscular twitching), cyanosis (blue colouring of
the skin), nausea or vomiting, tachycardia (rapid heart beat), excessive
production of mucus, hiccups, perspiration, and extreme gasping. In one case the patient’s eyes remained open,
and in another case, the patient sat up.
In 10% of cases the person took longer than expected to die
(median 3 hours) with one person taking up to 7 days.[2]
Increasing number of deaths
The number of reported deaths from euthanasia and physician
assisted suicide has risen sharply from 1815 in 2003, the first year under the
new law, to 5516 deaths reported in 2015.[3]
This represents an increase of 204% in raw number of
reported deaths from euthanasia between 2003 and 2015.
In other words the number of euthanasia
deaths has more than trebled in the first 13 years of legalisation.
In 2003 some 1.28% of all deaths were brought
about by reported acts of euthanasia or physician assisted suicide. In 2015 this had risen to 3.75% of all
deaths.[4]
Failure to report cases of euthanasia
According to a 2012 paper only 77% of deaths by euthanasia
or physician assisted suicide were reported in 2010, that is there were 914
unreported acts of euthanasia as well as the 3136 reported acts of euthanasia
making a total of 4050 or 2.8% of all deaths resulting from euthanasia or
physician assisted suicide in 2010.[5]
The authors of this study speculate that the temporary
decrease of euthanasia deaths following the enactment of the law may have been
a result of doctors being uncertain about how the law would be applied. It is clear now that the codification of the
law has not led to any lasting decrease in the rate of euthanasia and the trend
has increased steadily for the past 13 years.
Grounds for euthanasia
As is usually the case when legalised euthanasia is first
proposed supporters in the Netherlands initially focussed solely on unbearable
and unrelievable physical suffering associated with a terminal illness.
Even before formal legalisation the grounds for euthanasia
were expanded by the courts well beyond physical suffering allowing psychiatric
conditions such as depression, anorexia, and anxiety associated with
asymptomatic HIV to be are sufficient grounds to justify a physician granting a
request by a person for the administration of lethal drugs.[6]
One of the requirements of careful practice, under which physicians
performing euthanasia and assisting with suicide were assured freedom from
prosecution, required that the patient be suffering. Doctors with patients who were suffering
physically were not subject to prosecution, but it was not yet clear whether
they would be treated the same in cases involving patients with non-somatic
suffering. The psychiatrist and general
practitioner of a woman suffering from depression decided to assist the woman
with suicide. Although they were
acquitted, the Rotterdam District Court noted that in cases of non-somatic
suffering the consultation of another independent physician is preferable.
In another case, the Almelo District Court held that although the
suffering of a 25 year-old anorexia nervosa patient was not primarily physical,
it was unbearable and therefore sufficient to dismiss the indictment against
the pediatrician who had assisted in the patient’s suicide.
The Supreme Court addressed the issue of non-somatic suffering in the
landmark 1994 case of Chabot.
Dr. Boudewijn Chabot was a psychiatrist who supplied lethal drugs to a
patient who had recently experienced a series of traumatic events that had left
her with no desire to live. Although offered treatment for her condition, the
patient refused. The Court began by
affirming its earlier holdings that euthanasia and assisted suicide can be
justified if:
the defendant acted in a situation of necessity, that is to say … that
confronted with a choice between mutually conflicting duties, he chose to
perform the one of greater weight. In particular, a doctor may be in a
situation of necessity if he has to choose between the duty to preserve life
and the duty as a doctor to do everything possible to relieve the unbearable
and hopeless suffering of a patient committed to his care.
The prosecution argued that the defense of justification should not be
available to doctors who assist with suicides in cases where the suffering is
non-somatic and the patient is not in the “terminal phase.”
The Supreme Court rejected this contention, and held that in such cases
the justification can be rooted in the autonomy of the patient herself. The Court noted that,“the wish to die of a
person whose suffering is psychic can be based on an autonomous judgment.”[7]
Euthanasia is now legally permitted in the Netherlands for
dementia patients and for persons with depression or other mental health issues
in the complete absence of any physical illness or suffering.[8]
In 2015 there were 56 notifications of euthanasia or
assisted suicide involving patients with psychiatric disorders (four times the
14 cases in 2012) and 109 notifications involving dementia (more than two and a
half times the 42 notifications
involving dementia in 2012). These cases were in the absence of any other
condition justifying euthanasia.[9]
More than half (33) of the 56 cases of euthanasia for
psychiatric disorders in 2015 were carried out by doctors from the Levenseindekliniek (End
of Life Clinic).[10]
Psychiatric conditions for which euthanasia was performed in
2015 included personality disorder with post traumatic stress disorder and
self-mutilation; and obsessive compulsive disorder.[11]
In its June 2011 publication The role of the physician in the voluntary termination of life the
Royal Dutch Medical Association (KNMG) states that as the elderly experience “various other ailments and complications
such as disorders affecting vision, hearing and mobility, falls, confinement to
bed, fatigue, exhaustion and loss of fitness take hold … The patient perceives
the suffering as interminable, his existence as meaningless and – though not
directly in danger of dying from these complaints neither wishes to experience
them nor, insofar as his history and own values permit, to derive meaning from
them.” The KNMG considers that “such
cases are sufficiently linked to the medical domain to permit a physician to
act within the confines of the Euthanasia Law.”[12]
The 2015 report cites 183 cases of euthanasia involving
“multiple aging disorders”. These cases probably represent the kind of “tired
of life” cases discussed by the KNMG.[13]
In its first year of operation (1 March 2012 to 1 March
2013) the Levenseindekliniek
(End of Life Clinic) granted euthanasia to 11 out of 34 cases of persons who
requested on the sole grounds of being “tired of living” without any other
medical (physical or psychological) condition.[14]
Euthanasia on wheels
In March 2012 the Dutch Right to Die organisation launched
the Levenseindekliniek
(End of Life Clinic) with six mobile teams of doctors to “end their lives free of charge in their own
homes”.[15] By the end of 2014 there were 29 mobile teams
and the clinic dealt with 1035 requests for euthanasia in 2014.[16] This approach bypasses
any need for the person’s regular physician to be involved in the decision
making about euthanasia.
Loneliness
In nearly half the cases where the Levenseindekliniek (End of Life Clinic) granted a
request for euthanasia in its first year of operation (1 Mar 2012 to 1 Mar
2013) loneliness was listed as a type of unbearable suffering in nearly half
(49.1%) the cases.[17]
Euthanasia “experts” trump physicians giving care
On 22 April 2015 a woman with dementia,
Cobi Luck, was euthanased by a doctor at the Levenseindekliniek
(End of Life Clinic), after a court ruled that doctors from the clinic had an
expertise in euthanasia leading him to prefer their testimony to that of the
doctors and staff from the nursing home who were providing her with daily care.
They testified that Ms Luck
only spoke about euthanasia after her family had paid a visit. She still appeared
to enjoy life and made comments which were not consistent with a desire for
euthanasia. The nursing home staff knew her well and believed that she was not
competent to make such a momentous decision. They stressed that people like Ms
Luck were very vulnerable.[18]
Review is too late for the dead patient
Of course the woman can get no relief from this finding of error on the part of the doctor who failed her and then euthanased her as she is already dead by euthanasia.[19]
The same lack of remedy applies to the two cases of people
with dementia who were euthanased in 2012 in relation to which the Review
Committees found “not to have been
handled with due care”.[20]
In 2015 there were four cases where the Review Committee
found a lack of due care before euthanasia
was carried out. These included:
·
Case 2015-01 where euthanasia was carried out
on a woman with a history of stomach pains from an undiagnosed cause, who was
reluctant to be examined by a geriatrician; [21]
·
Cases 2015-28 and 2015-29 where the doctor
failed to give an adequate dose of propofol to induce coma before administering
rocuronium, a neuromuscular blocker that causes paralysis of all muscles except
the heart and brings on respiratory arrest. Consequently these people may have
experienced the distress of suffocation;[22]
·
Case
2015-81 where, after the person was still breathing with a full pulse 25
minutes after being given thiopental to
induce coma and rocuronium to cause respiratory failure, the doctor
administered a second dose of rocuronium without adequately ensuring the person
was in a full coma.[23]
Even where the Review Committees identify failures and
report the cases to the Public Prosecution Service action is seldom taken apart
from “counselling” the offending doctor. In Case 2014-02 a doctor performed euthanasia
on a woman with aphasia after a stroke solely based on a twenty year old living
will in which she expressed a desire for euthanasia if she ever had to live in
a nursing home. The doctor subjectively concluded that she would be
experiencing unbearable suffering simply from being in the nursing home despite
the woman being unable to communicate. There were no signs of distress. Both the and the Council of Attorneys-General
recommended no prosecution.[24]
Euthanasia without request
In the Netherlands between 500 and 1000 adults each year are
given lethal injections without making an explicit request.[25]
Pressure from family members
Professor Theo
Boer, who served on a regional euthanasia committee for 9 years says that ‘In some
instances there is pressure from the family.’ From the 4,000 case files that have crossed his desk,
Boer estimates that “ the family is
a factor with one in five patients. The doctor doesn’t want to put it in the
dossier; you need to read between the lines. Sometimes it’s the family who go
to the doctor. Other times it’s the patient saying they don’t want their family
to suffer. And you hear anecdotally of families saying: “Mum, there’s always
euthanasia”.’
Dr Ruben Van Coevorden, an Amsterdam physician who has performed
euthanasia, believes Boer’s
figure of one in five is realistic: ‘There was one case where a woman was dying and
had terrible stomach pains, her doctor was tearing his hair out, and when I
turned up at the house the family practically pinned me to the wall and said:
“You need to give mum the jab now, she’s in agony!” ‘I discovered that her
treatment wasn’t working, she was on the wrong type of laxatives and was
terribly constipated. I organised a palliative regime that made her more
comfortable, and afterwards the family were extremely grateful. She was close
to dying anyway, but it allowed them to say goodbye in a better way.’[26]
Euthanasia by family members
On 13 May 2015 the Arnhem-Leeuwarden Court of Appeals, in
acquitting Albert Heringa of assisting the suicide of his stepmother by feeding
her a cocktail of pills, ruled that for lay people as well as doctors the defence
of force majeure applies.[27]
It was court decisions, beginning in 1973, ruling that this defence was available
for a doctor who euthanased a patient if “no reasonable alternative was
available”, that led to euthanasia becoming widespread in the Netherlands well before
it was formally legalised by Parliament in 2003.
Moek Heringa was aged 99 and not seriously ill. Her doctor
refused to give her euthanasia as she was not eligible under the law.
The Court
of Appeals found that there was no reasonable chance of finding another doctor
who would agree to perform euthanasia so that, faced with his stepmother being
“tired of life”, Albert Heringa was morally forced to help her by killing her.
This judgement opens the door to assisted suicide by family members as well as
to assisted suicide or euthanasia on the grounds of being “tired of life” or
having “completed a life”.
Child euthanasia
Children as young as 12 years of age may be given euthanasia
under the euthanasia law.
For 12 to 15 year olds the parents must agree with
the child’s request for euthanasia. For 16 and 17 year olds the parents must be
involved but the decision is for the child alone. A total of seven children
have been given euthanasia, including one 12 year old child in 2005, a 16 year
old in 2015 and five 17 year old children.[28]
[1] Kamerbrief over
Kabinetsreactie en visie Voltooid Leven, 12 Oct 2016, https://www.rijksoverheid.nl/binaries/rijksoverheid/documenten/kamerstukken/2016/10/12/kamerbrief-over-kabinetsreactie-en-visie-voltooid-leven/kamerbrief-over-kabinetsreactie-en-visie-voltooid-leven.pdf ; Rapport Adviescommissie Voltooid leven, 4 February
2016, https://www.rijksoverheid.nl/binaries/rijksoverheid/documenten/rapporten/2016/02/04/rapport-adviescommissie-voltooid-leven/01-adviescommissie-voltooid-leven-voltooid-leven-over-hulp-bij-zelfdoding-aan-mensen-die-hun-leven-voltooid-achten.pdf
[2] Groenewoud
J, et al. (2000) “Clinical Problems with the Performance of
Euthanasia and Physician-Assisted Suicide in the Netherlands”, New England Journal of Medicine, Vol
342, p. 551-556, http://content.nejm.org/cgi/reprint/342/8/551.pdf
[3]Regionale
Toetsingscommissies Euthanasie, Jaarverslag
2015, p. 4 https://www.nvve.nl/files/8414/6166/0719/RTE_jaarverslag2015DEF.pdf
[4] Denominator
for calculations for percentage of all deaths (141,936 in 2003; 147,134 in 2015) from Centraal Bureau voor der
Statistiek; http://statline.cbs.nl/StatWeb/publication/?DM=SLEN&PA=37943eng&D1=1,21-46,438-439,442-443&D2=(l-16)-l&LA=EN&VW=T
[5] Bregje D Onwuteaka-Philipsen et al., “Trends in
end-of-life practices before and after the enactment of the euthanasia law in
the Netherlands from 1990 to 2010: a repeated cross-sectional survey”, The Lancet, Published online July 11,
2012, http://press.thelancet.com/netherlands_euthanasia.pdf
[6] “Choosing
Death,” The Healthcare Quarterly,
WGBH-Boston, aired March 23, 1993.
[7] Smies.
Jonathan T. “The legalization of euthanasia in the Netherlands”, Gonzaga Journal of International Law, (2003-4)
7, p. 19-20, http://www.gonzagajil.org/pdf/volume7/Smies/Smies.pdf
[8] Regional
Euthanasia Review Committees, Annual
report 2010, p. 10, 13, 22-23, http://www.euthanasiecommissie.nl/Images/JV%20RTE%202010%20ENGELS%20(EU12.01)_tcm52-30364.pdf
[9] Regionale
Toetsingscommissies Euthanasie, Jaarverslag
2015, p. 7, 9 https://www.nvve.nl/files/8414/6166/0719/RTE_jaarverslag2015DEF.pdf
[10] Regionale
Toetsingscommissies Euthanasie, Jaarverslag
2015, p. 7 https://www.nvve.nl/files/8414/6166/0719/RTE_jaarverslag2015DEF.pdf
[11] Regionale
Toetsingscommissies Euthanasie, Jaarverslag
2015, p. 50-52 https://www.nvve.nl/files/8414/6166/0719/RTE_jaarverslag2015DEF.pdf
[12] KNMG
[Royal Dutch Medical Association], The
role of the physician in the voluntary termination of life, June 2011, p.
23, Available at: http://knmg.artsennet.nl/Publicaties/KNMGpublicatie/Position-paper-The-role-of-the-physician-in-the-voluntary-termination-of-life-2011.htm
[13] Regionale
Toetsingscommissies Euthanasie, Jaarverslag
2015, p. 10 https://www.nvve.nl/files/8414/6166/0719/RTE_jaarverslag2015DEF.pdf
[14] 6 cases where the person died before a decision was
made or withdrew the request are excluded. A Study of the First Year of the End-of-Life Clinic
for Physician-Assisted Dying in the Netherland”, JAMA Internal Medicine, Published online 10 Aug 2015, Table 2: Outcomes of Requests to the
End-of-Life Clinic for Euthanasia or Physician-Assisted Suicide, According to
Medical Conditions, http://archinte.jamanetwork.com/article.aspx?articleID=2426428
[15] Tony
Paterson “Euthanasia squads offer death by delivery”, The Independent, 5 March
2012, http://www.independent.ie/health/health-news/euthanasia-squads-offer-death-by-delivery-3039420.html
[16] A
Study of the First Year of the End-of-Life Clinic for Physician-Assisted Dying
in the Netherland”, JAMA Internal
Medicine, Published online 10 Aug 2015, http://archinte.jamanetwork.com/article.aspx?articleID=2426428
[17] A Study of the First Year of the End-of-Life Clinic for
Physician-Assisted Dying in the Netherland”, JAMA Internal Medicine, Published online 10 Aug 2015, Table 3: Outcome of Requests for
Euthanasia or Physician-Assisted Suicide According to Patient Characteristics
and Other Circumstances http://archinte.jamanetwork.com/article.aspx?articleID=2426428
[18] “Vrouw (80) krijgt euthanasie tegen wil van haar
behandelaars [80 year old woman receives euthanasia against the will of her
carers”, nrc.nl, 3 April 2015, http://www.nrc.nl/nieuws/2015/04/23/vrouw-80-krijgt-euthanasie-tegen-wil-van-haar-behandelaars/
[19] Regional
Euthanasia Review Committees, Annual
report 2011, p. 17 http://www.euthanasiecommissie.nl/Images/RTE.JV2011.ENGELS.DEF_tcm52-33587.PDF
[20] Regional
Euthanasia Review Committees, Annual
report 2012, p. 13 http://www.euthanasiecommissie.nl/Images/JV.RTE2012.engelsDEF2_tcm52-39100.pdf
[21] Regionale
Toetsingscommissies Euthanasie, Jaarverslag
2015, p. 28-31 https://www.nvve.nl/files/8414/6166/0719/RTE_jaarverslag2015DEF.pdf
[22] Regionale
Toetsingscommissies Euthanasie, Jaarverslag
2015, p. 44-46 https://www.nvve.nl/files/8414/6166/0719/RTE_jaarverslag2015DEF.pdf
[23] Regionale
Toetsingscommissies Euthanasie, Jaarverslag
2015, p. 47-48 https://www.nvve.nl/files/8414/6166/0719/RTE_jaarverslag2015DEF.pdf
[24] Regionale
Toetsingscommissies Euthanasie, Jaarverslag
2015, p. 68-69 https://www.nvve.nl/files/8414/6166/0719/RTE_jaarverslag2015DEF.pdf
[25] Allen,
Mason L, (2006) “Crossing The Rubicon: The Netherlands’ Steady March Towards
Involuntary Euthanasia”, Brook Journal of
International Law, 31:2, pp 535-575; www.brooklaw.edu/students/journals/bjil/bjil31ii_allen.pdf
; van der Heide, A et al. (2007) “End-of-Life
Practices in the Netherlands under the Euthanasia Act”, New England Journal of Medicine,
Vol 356:1957-1965, http://content.nejm.org/cgi/content/full/356/19/1957
[26] “Rise in euthanasia requests sparks
concern as criteria for help widen”, DutchNews.nl,
3 July 2015, http://www.dutchnews.nl/features/2015/07/rise-in-euthanasia-requests-sparks-concern-as-criteria-for-help-widen/
[27] J
Smits, “Dutch court acquits man who euthanized his mother after doctor refused”,
LifeSite News, 21 May 2015, https://www.lifesitenews.com/opinion/dutch-court-acquits-man-who-euthanized-his-mother-after-doctor-refused
[28] Regionale
Toetsingscommissies Euthanasie, Jaarverslag
2015, p. 14 https://www.nvve.nl/files/8414/6166/0719/RTE_jaarverslag2015DEF.pdf
