Euthanasia Practices in the Netherlands
DR. BRIAN POLLARD
Euthanasia in the Netherlands has gone from requiring terminal
illness to no physical illness at all, from physical suffering
to depression only, from conscious patients to unconscious, from
those who can consent to those who cannot, and from being a
measure of last resort to one of early intervention.
The public era of euthanasia in the Netherlands began in 1973,
 when two significant events occurred. A
government commission reported that the ban on active euthanasia should
remain, and a doctor, after admitting killing her sick mother who wanted
to die, was found guilty, and given a suspended sentence. Evidence was
tendered that she had only done what was already commonly, though
unofficially, done by many doctors. The court announced several
conditions which, in its view, would justify the active killing of a
In 1981 and 1983, two courts reached similar conclusions.
A State Commission on Euthanasia decided in 1982,
 that ‘a doctor who terminates the life of a
patient at the latter’s expressed and serious desire no longer should be
punishable, providing that a number of conditions have been met’, even
though Article 293 of the Penal Code provided, as it still does, that
taking the life of another person, even at that person’s express and
serious request, is a serious offence against human life, punishable by
up to 12 years imprisonment.
The guidelines when carrying out euthanasia were formally published
by both the government and the Royal Dutch Medical Association (KNMG) in
1984 and in 1987.  They required that the
request be voluntary, well-considered and durable, that there be
unacceptable suffering and that a second doctor be consulted. For many
years, all these provisions have been known to be often abused. For
example, regarding a well-considered request, a study by van der Wal in
1990  showed that the interval between the
first request and euthanasia was no more than a day in 13% of cases, no
more than a week in another 35% and had been as short as a few hours.
Since 1984, the courts have created increasingly liberal grounds for
exempting doctors from prosecution after euthanasia, accepting
psychological distress as a reason and no longer requiring terminal
illness. To justify what was admittedly an offence, the courts decided
that it was lawful for a doctor, faced with the alternative of leaving
the patient in pain or giving relief by killing, to take the
‘compassionate’ option, by taking life. The doctor is said to be acting
under a higher duty or ‘force majeure’.
Many unsatisfactory court determinations followed. In 1985, a doctor
was charged with being implicated in about 20 deaths in a nursing home,
without the knowledge or consent of the victims. He was found guilty and
sentenced to a year in prison but, following an outcry against the
severity of the sentence, the verdict was overturned on a technicality.
He was then awarded US$150,000 damages by a civil court.
 In 1987, nurses killed three unconscious
patients in an intensive care unit by injecting them with drugs. They
admitted their guilt and were charged with murder, but discharged
because of poor communication between the nurses and doctors over
‘euthanasia policy’. 
Courts accepted that some common practices outside the law could now
be used to justify their legal recognition. The objective criteria
normally required by criminal law were replaced by conformity with
changing medical standards, and by subjective criteria which could not
be tested at law. Prominent among those is ‘unbearable and hopeless
suffering’, a criterion that has been shown by Dutch lawyers to be
incapable of any consistent interpretation. 
The same reasons are invoked in the Netherlands as elsewhere to
justify euthanasia, chiefly respect for self-determination, but only
voluntary euthanasia is openly discussed. While some regard Dutch
euthanasia as the flowering of patient autonomy, others regard it as the
domination of patients by doctors who have gained unprecedented power
over patients’ lives.
Public opinion polls are also used to justify policy, though the same
polls that gain 70% support for voluntary euthanasia in the community
encounter 90% opposition, when conducted in nursing homes.
Official support for non-voluntary euthanasia is readily found. The
State Commission on Euthanasia in 1987 recommended that non-voluntary
euthanasia should not be an offence, if carried out in the context of
‘careful medical practice’, though that was not defined. In 1988, a KNMG
working party condoned euthanasia for deformed infants, in some
instances thinking it ought to be compulsory. In 1991, a KNMG committee
condoned the killing of patients in persistent coma.
THE REMMELINK REPORT AND THE VAN DER MAAS
After years of uncertainty and argument, from within and without,
about its euthanasia practices, the Dutch resolved in 1990 to set up a
Commission, chaired by Attorney General Remmelink. It conducted an
inquiry over a twelve month period and, in 1991, issued the Remmelink
Report.9 The statistical Survey on which the Report was based was
carried out by the Central Bureau of Statistics and published in English
in 1992, under the name of Dr van der Maas. 
Though the Commissioners were surprised at some of the findings,
especially non-voluntary killing, they at once excused such practices in
their Report, but the statistics cannot be denied.
By adopting the narrow definition of euthanasia as ‘active
termination of life upon the patient’s request’, the Dutch reported
there were 2,300 instances of euthanasia in the year of the survey, or
1.8% of all deaths. When, however, to these are added instances of
killing patients without request and intentionally shortening the lives
of both conscious and unconscious patients, the figures are dramatically
altered. They now become: 2,300 instances of euthanasia on request; 400
of assisted suicide; 1,000 of life-ending actions without specific
request; 8,750 patients in whom life-sustaining treatment was withdrawn
or withheld without request, ‘partly with the purpose’ (4,750) or ‘with
the explicit purpose’ (4,000) of shortening life; 8,100 cases of
morphine overdose ‘partly with the purpose’ (6,750) or ‘with the
explicit purpose’ (1,350) of shortening life; 5,800 cases of withdrawing
or withholding treatment on explicit request, ‘partly with the purpose’
(4,292) or with the ‘explicit purpose’ (1,508) of shortening life.
Thus, there were up to 23,350 instances of doctors intending, by act
or omission, to shorten life, lifting the incidence of euthanasia to
over 20% of all deaths in the year. Because of lack of precision in some
of the above categories, it is not possible to be certain about the
exact incidence of the intentional taking of life without consent, that
is, of non-voluntary euthanasia, but there can be no doubt that it was
Although the Report stated that the 1,000 instances of ‘life-ending
actions without request’ were carried out on incompetent patients ‘in
their death agony’, on the doctors’ testimony at interview detailed in
the Survey, 14% of those patients were competent and 11% were partly
competent. According to the death certificate study, 36% of them were
In the preamble to its Guidelines for Euthanasia in 1987, the KNMG
had stated: ‘if there is no request from the patient, then proceeding
with the termination of his life is juridically a matter of murder or
killing, and not of euthanasia’. By their own Society’s definition then,
Dutch doctors were then carrying out medical murder, and have continued
to do so.
As the Report also noted, to these totals should be added unspecified
numbers of handicapped babies, sick children, psychiatric patients and
AIDS patients, whose lives were also terminated by doctors, but for whom
there are no data. It is estimated that some 25% of deaths in AIDS
patients in the Netherlands are now due to euthanasia.
The guidelines for careful practice were found to be frequently
disregarded. 27% of respondents admitted they had killed patients
without any request, and 72% reported that after euthanasia, they
falsified the death certificate to make it appear that death was due to
natural causes. On none of those occasions, therefore, was there any
information about what, if any, guidelines had been observed. It is
reasonable to conclude that this was because guidelines had been
ignored, in whole or in part.
What has happened since 1991?
It may have been expected that uncovering these facts would bring
calls for radical reform of some of these practices, chiefly failure to
report euthanasia, falsification of death certificates and widespread
neglect of the guidelines, and for the total prohibition of life-taking
There ensued a period of official inactivity because some of the
findings were so unexpected, and because euthanasia was well established
and supported by the community. Euthanasia activists lobbied to have
euthanasia formally legalised, without success. In particular, taking
life without consent presented a semantic problem because it was not
euthanasia according to the official definition. To meet this
difficulty, the authorities abandoned their previous frankness of 1987
in favour of an innocuous-sounding acronym, LAWER, ‘life-terminating
acts without explicit request’.  The topic
could now be openly discussed as though it were morally, emotionally and
socially neutral, and was soon to become a medical alternative
acceptable to doctors and the community.
In 1993, authors from the Department of Public Health at the Erasmus
University could write: ‘But is it not true that once one accepts
euthanasia and assisted suicide, the principle of universalizability
forces one to accept termination of life without explicit request, at
least in some circumstances, as well? In our view, the answer to this
question must be affirmative’. 
In February 1993, new regulations about medical reporting of
euthanasia were issued,  but they have had
little impact, either on reporting or on the practices themselves. The
new rules ‘required’ the reporting of both voluntary and non-voluntary
euthanasia (NVE) on the same form. This had the effect of confirming in
many doctors the view that both were equally acceptable to the
authorities. Indeed, in 1993 the Secretary of Health, referring to these
practices, said ‘For a physician, the considerations in these two cases
are not essentially different; from the moral point of view the two
actions are not of entirely different kind’. 
In 1995, the health authorities reviewed the effects of these 1993
changes in the reporting rules.  They said
the changes were to ‘encourage’ physicians to report and to ‘promote’
adherence to them, but they did not say they would be enforced, so that
reform would be achieved. The reporting rate, which had been a mere 18%
in 1990, was found in 1995 to be only 41%, still less than half,
indicating a continuing large pool of euthanasia practice about which
nothing whatever is officially known, and about which little is intended
to be done.
For that review, a number of doctors who had not reported cases of
euthanasia were interviewed with a guarantee of indemnity, to try to
open a window on these hidden practices. 70 doctors had not reported
their last case of NVE and 36% said they would never report such a case,
whatever the law might require. Only 44% had required a written patient
request, only 11% had consulted with a colleague and only 57% had
provided a written report after voluntary euthanasia. The incidence of
NVE among those who had reported their practices was .09%, while among
those who had not reported it was 19%, a staggering difference of 200
times. Despite this, the authors concluded that ‘substantial progress in
the oversight of physician-assisted death has been achieved’, and that
‘there were no major differences between reported and unreported cases,
in terms of...whether there was an explicit request...’.
Visiting Australia in 1996, the then Dutch Minister of Health said
that some doctors did not report their cases because they were afraid of
prosecution.  One may gauge their real
level of concern when one reads, in the 1995 paper, of the fate of 20
doctors who were investigated for non-reporting — 9 were acquitted, 2
were discharged, 3 were found guilty but not punished and 6 were given
suspended sentences of one week to six months. None were prosecuted.
Official moves are now being made to set up local committees of
inquiry to receive reports of euthanasia, in order to exclude the law,
and for automatic exemption from further oversight when the doctor
reports having followed the guidelines. Of course, those who do not
report their actions will also not be prosecuted, no matter what they
In an official review in 1996 of developments since the Remmelink
Report,  it was concluded that ‘euthanasia
seems to have increased in incidence since 1990, and the ending of life
without the patient’s explicit request seems to have decreased
slightly’. The latter is discussed with the cool statistical detachment
that befits a practice about which the authors have no concerns,
confirming that it has become just another option for doctors.
In 1993, a Dutch court established a new milestone by extending
toleration for euthanasia to suicidal patients who are not physically
ill. A psychiatrist had assisted a woman to die, because she was
depressed following the breakdown of her marriage and the loss of a son.
He did not treat her depression because she refused treatment, and he
did not consult other doctors. He was originally found guilty of murder,
but this finding was overturned on appeal. 
Because a sustained wish for death is almost always associated with
profound psychological disturbance, it is now accepted that every person
who requests euthanasia should be referred to a psychiatrist.
Surprisingly, a survey of 552 psychiatrists in the Netherlands,
published in 1997, revealed that only one third of them had ever been
asked by another doctor to see a patient for that reason.
In 1995, two separate Dutch courts upheld the actions of doctors who
had deliberately ended the lives of handicapped neonates with lethal
injections, so providing the first legal endorsement of NVE. In one
case, the judge said “In the decision of active ending of life, Dr
Kadjik had acted with scientific responsible insight and in accordance
with the medical ethic and accepted norms and in consideration of due
care resulting therefrom; he is entitled to an appeal of force majeure.”
Euthanasia in the Netherlands has gone from requiring terminal
illness to no physical illness at all, from physical suffering to
depression only, from conscious patients to unconscious, from those who
can consent to those who cannot, and from being a measure of last resort
to one of early intervention.
Although respect for patient autonomy is the main ethical argument in
favour of euthanasia, power has passed almost exclusively into doctors’
hands. Patient autonomy has been subverted by the unprecedented rights
given by the courts to doctors to decide the fate of patients.
Euthanasia was widely developed in defiance of the statute law,
though with apparent community approval, to be later rationalised by
court determinations. This was followed by even more objectionable
medical practices, again outside the official guidelines, with ethics
and common law trying to catch up. Instead of principle being enunciated
to inform both the law and ethical medical practice, principle has been
taken captive by widespread abuse of them both.
Two important messages emerge. First, in legalising euthanasia, one
has to contend with what has been described as ‘the tendency of a
principle to expand itself to the limit of its logic’, and second,
attempting to make law in the absence of a full understanding of its
consequences is highly dangerous.
It has recently been announced (August 1999) that voluntary
euthanasia will soon be legalised in the Netherlands. It is too soon to
know what the structure of that law may be, but events there since 1973
give little hope to suppose that the law would pass scrutiny for safety,
by the standards of British or Australian criminal law.
The Dutch government issued its draft for such a law in 1998, and
while the final bill as presented in parliament may differ from that
early draft, it provides the best clue to the government’s thinking.
Here are the first four sections of the 1998 draft:
A. The Penal Code Article 293 will read as follows:
- He who intentionally takes another’s life at his explicit and
serious request, is to be punished with a prison term of, at the
most, twelve years or a fine of the fifth category.
- He who intentionally incites another to suicide, is to be
punished if the suicide follows, with a prison term of, at most,
three years or a fine of the fourth category.
- He who intentionally assists another with suicide or offers
him/her the means thereto if the suicide follows, is to be punished
with a prison term of, at most, three years or a fine of the fourth
- The first and the third section do not apply if the termination
of life, or the assisted suicide, or the offering of the means
thereto is done at the patient’s explicit and repeated request on
account of the hopeless emergency situation in which he finds
himself, by a medical doctor who meets the requirements of
carefulness and who informs the coroner accordingly as to what is
proscribed in Article 7, Section.
The wording of the fourth section is so loose that it changes nothing
about the circumstances of Dutch euthanasia over the past twenty years,
namely that Dutch doctors have gained virtually total control over the
practice of euthanasia, when it will happen and to whom it will happen.
The government will have caved in to the powerful medical lobby to
confirm them in their position of dominance. The only change that MAY
eventuate could be the incidence of honest reporting, but even the
making of specific regulations about that in 1993 in the past brought
little change for the better.
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Pollard, Dr. Brian. “Euthanasia Practices in the Netherlands.” NSW
Website (June 2000).
Published by permission of Dr. Brian Pollard.
Dr. Brian Pollard is a former anaesthetist (anesthesiologist) who
founded and directed, from 1982, one of Australia’s first palliative
care services. Dr. Pollard is the author of The Challenge of
Euthanasia and is involved in active opposition to legalised
euthanasia in Australia.
Copyright © 2000
NSW Right to Life Association