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Euthanasia in the Netherlands: distinguishing facts from fiction.

Euthanasia in The Netherlands: Distinguishing Facts from Fiction

As far as active, voluntary euthanasia is concerned, the Dutch sometimes feel like members of an extra-terrestrial species, being the subject of others' wild guesses and morbid fantasies. The American lay and medical press abound with inaccurate accounts. For example, one author writes: "In The Netherlands, where euthanasia is tolerated, there's evidence that patients are avoiding health care facilities because of this fear" (of being sneaked upon by a doctor). Another writes that "there is clear evidence that active voluntary euthanasia has been clinically extended (in The Netherlands) to include involuntary active euthanasia at family request, and secret involuntary active euthanasia by both physicians and nurses."

The "evidence" alluded to simply does not exist. In fact, there is a growing demand in The Netherlands for health care facilities such as nursing homes to the extent that parliament recently stressed the need of providing more funds to curtail waiting lists. Apart from that, euthanasia "at home" is much more common than euthanasia in a health care facility. Moreover, the extensive jurisprudence on euthanasia shows that virtually all of the doctors brought to trial for performing euthanasia, or whose case was investigated by a public prosecutor, appeared to have followed the generally accepted rules of practice (see below). There has been one case of nurses ending the life of a comatose patient on the request of the family. They were tried and found guilty.

What, then, are the facts concerning the practice of euthanasia in The Netherlands? Since the early 1970s, euthanasia has been hotly debated in our country. Most of its supporters and opponents have now reached agreement on what "euthanasia" means, based on the definition employed by the State Commission on Euthanasia in 1985: Euthanasia is the deliberate action to terminate life, by someone other than, and on request of, the patient concerned.

Euthanasia is thus distinct from requested nontreatment; giving assistance to east dying that unintentionally shortens life; and discontinuing or omitting medically useless treatment. The confusing term "passive euthanasia" has been dropped in official documents. "Euthanasia" is by definition active and voluntary.

Euthanasia is a criminal offense under article 293 of the Penal Code of the Netherlands: Any person who terminates the life of another person at the latter's express and earnest request is liable to a term of imprisonment not exceeding twelve years. this article construes terminating life on request as manslaughter or murder, subject to the mitigating circumstance of the request. In the absence of a patient request the perpetrator renders him or herself guilty of manslaughter or murder. Moreover, the present government has not adopted a longstanding proposal to legalize euthanasia. Instead, it has decided that physicians who terminate life on request of the patient will not be punished only if they invoke a defense of force majeure and have satisfied the criteria discussed below, and then only on condition that the court accepts this defense. Such possible immunity from prosecution applies only to doctors.(2).

Thus, doctors practicing euthanasia do so in violation of the law. In practice, however, they will not be prosecuted if they appear to have followed strict guidelines. Three tiers of the Dutch judicial system--district courts, appeal courts, and the Supreme Court--have handed down judgments in which these guidelines are precisely defined. They have been affirmed and elaborated upon by the Royal Dutch Medical Association (KNMG), the State Commission on Euthanasia, and the Dutch government.(3)

In brief, these conditions require, among other things, that there be an explicit and repeated request by the patient that leaves no reason for doubt concerning his desire to die; that the mental or physical suffering of the patient must be very severe with no prospect of relief; that the patient's decision be well-informed, free, and enduring; that all options for other care have been exhausted or refused by the patient; and that the doctor consult another physician (in addition, he may decide to consult nurses, pastors, and others). The doctor is advised to note down the course of events.

Unfamiliarity and unease with the legal process is probably a major reason why cases of euthanasia are underreported by physicians. The district public prosecutor of Rotterdam recently instructed a large audience of physicians on these procedures. According to the prosecutor, there is no guarantee that a doctor performing euthanasia is ever exempt from prosecution, but, for those adhering to the guidelines, judicial red tape will be minimal. At the same meeting, the Rotterdam chapter of the KNMG announced that it will appoint consultants to advise doctors prepared to honor a request for euthanasia, helping them to follow the guidelines and through the ensuing legal process. In addition, many nursing homes and hospitals have developed (or are planning) euthanasia protocols incorporating the above guidelines.

The extent of euthanasia in The Netherlands is not known. According to a recent report, there were some 200-300 cases of euthanasia in Amsterdam in 1987, 10 percent of which were reported to the public prosecutor.(4) The frequently cited figure is 5000-8000 cases per year but the Amsterdam data suggests this figure is too high. According to one estimate, the average general physician has recourse to euthanasia once every three years.(5)

Euthanasia is more common in family practice than in nursing homes or hospitals. The annual number of euthanasia cases in the two major cancer hospitals does not exceed twenty.(6) The relatively low incidence of euthanasia in these hospitals is not due to their technological superiority. Rather, terminal patients themselves request to be released from the hospital, or refuse to return, preferring to die at home to make sure that dying is a family affair.(7)

It is sometimes suggested that the need for euthanasia is reinforced by inferior terminal care. However, while there may be waiting lists for some (nonacute) health care facilities, extensive, sophisticated, sensitive terminal care is universally available in The Netherlands. Futhermore, foreign commentators occasionally wonder whether economic motives play a role in the practice of euthanasia. The answer is no. In the relatively well-funded health care system of The Netherlands there is no economic stimulus for doctors or institutions to end the lives of patients. Dutch general physicians even lose money by performing euthanasia because of the per capita reimbursement system.

Is The Netherlands unique with regard to euthanasia? Not really, or at least not any more. The existence of euthanasia in other countries is finally coming out into the open. Substantial public support for euthanasia is not an idiosyncrasy of the Dutch, as shown by findings of opinion polls abroad. However, it may be some time before leaders of other countries follow the example of the Dutch prime minister, who recently professed that he personally would opt for euthanasia given certain circumstances.(8) "Euthanasia enthusiasts" do not exist in The Netherlands any more than in other countries. Dutch physicians find euthanasia distressing, to be avoided if possible, but in some cases acceptable. If the situation in our country is unique at all, it is perhaps in the wish of physicians to subject their actions to public scrutiny. References (1)Mark Siegler, "Should Euthanasia Be Legalized? No.," Washington Post Health, 4 October 1988; M.D.M. Fowler, "Legislation to Legalize Active Euthanasia," Heart and Lung 17 (1988), 458-9. I have found only one referenced source: R. Fenigsen, Wall Street Journal, 29 September 1987. No data have been presented to support the allegations made. (2)J.K.M. Gevers, "Legal Developments Concerning Active Euthanasia on Request in The Netherlands," Bioethics 1 (1987), 156-62; H.J.J. Leenen, "Euthanasia, Assistance to Suicide and the Law: Developments in The Netherlands," Health Policy 8 (1987), 197-206. (3)The Central Committee of the Royal Dutch Medical Association, Vision on Euthanasia (Utrecht: KNMG, 1986); Netherlands State Commission on Euthanasia, "An English Summary," Biothics 1 (1987), 163-74; Committee of the Health Council of The Netherlands, "Conditions of Euthanasia" (in Dutch) (The Hague: Gezondheidsraad, 1987); H. Rigter, E. Borst-eilers, and H.J.J. Leenen, "Euthanasia Across the North Sea," British Medical Journal (in press). (4)"Annual Report 1987" (in Dutch) (Amsterdam: GG & GD, 1988). (5)A.P. Oliemans, H.J.G. Nijhuis, "Euthanasia in Family Practice" (in Dutch), Medisch Contact 41 (1986), 691. (6)J.H. Mulder, "Nontreatment and Euthanasia in a Cancer Hospital" (in Dutch), Medisch Contact 46 (1986), 1417-19. (7)Rigter, Borst-Eilers, and Leenen, "Euthanasia Across the North Sea." Case reports are available from the author. (8)Second Chamber of Parliament, Questions and Answers No. 71, Parliament session 1988-89 (The Hague, 1988).
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Title Annotation:Mercy, Murder, & Morality: Perspectives on Euthanasia
Author:Rigter, Henk
Publication:The Hastings Center Report
Date:Jan 1, 1989
Previous Article:A case against Dutch euthanasia.
Next Article:The heart of the matter.

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