Dutch euthanasia revisited.

• Author: Fenigsen, Richard

Five years after the first survey of euthanasia ordered by the Dutch government (the publication widely known as the Report of the Remmelink Committee(1)), a follow-up study was undertaken, again on the government's initiative. The political constellation has changed in the meantime: the party which used to be most cautious in endorsing euthanasia, the Christian Democratic Alliance, lost their share in the government. The new governing coalition was formed by political parties that have repeatedly declared their support for immediate and full legalization of euthanasia: the Labor, the VVD liberals, and the progressive liberals "D66." However, upon assuming governing responsibilities the three parties renounced legalization plans.(2) Instead, a new nation-wide survey of the practice was commissioned. Professor Paul J. van der Maas and prof. Gerrit van der Wal were charged with conducting the study.

The results were published on November 26, 1996,(3) and two days later comprehensive English summaries appeared in the New England Journal of Medicine.(4)

Care was taken to obtain results comparable with those of the 1990 study. This goal has largely been achieved, although only two of the Remmelink study's three parts have now been repeated: the interviews with 405 physicians and the study of a sample of death certificates taken from the national registry (the size of this sample was now somewhat reduced). Of the three special groups of cases that had been mentioned in 1990 but not investigated, two were now included in the study: euthanasia on newborns and infants, and assisted suicide of psychiatric patients.

Comparison of 1990 and 1995 Studies

A large part of the study has now been focused on the "notification procedure." According to this procedure which has been followed by some physicians since 1991, and was sanctioned by the Parliament in 1994, the physician who performs euthanasia upon request of the patient, or without such request, should report the case to the coroner who notifies the public prosecutor. If it is evident from the doctor's report that he had not followed the "rules of careful conduct," an inquiry might be launched. The numbers of reported and not-reported cases, the doctor's reasons for not reporting, their opinions concerning the procedure, and the proceedings, experiences, and attitudes of the coroners and the public prosecutors have been studied.

As in 1990, national estimates were obtained by weighted extrapolation of numbers found in the studied samples. As stated in the report, the error inherent in the method is rather large.(5) For example, the number of cases of active voluntary euthanasia in 1995, estimated at 2.4% of all deaths, that is, 3,256 cases, may in fact lie anywhere between 2.1% (2,849 cases) and 2.6% (3,866 cases). Thus, it should be borne in mind that the reported national estimates are not precise figures but may deviate from reality. Nevertheless, they do provide useful information on the approximate extent of the practice of euthanasia and the trends.

As can be seen in Table 1, in 1995 less people died by active involuntary euthanasia ("active termination of life without the patient's request") than in 1990. The difference remains within the range of the method's error; however, the findings do show that the practice of involuntary euthanasia has not expanded.

Table 1.(6) Active Euthanasia in the Netherlands, 1990 - 1995

1990 1995 Total number of deaths in the country 128,786 135,675 Requests for euthanasia / Assistance In suicide 9,000 9,700 Active euthanasia upon request of the patient 2,300 2,400 Assisted suicides 400 400 Active euthanasia without explicit request of the patient 1,000 900 Intentional lethal overdose of morphine-like drugs: with consent of the patient 3,159 2,046 without the patient' knowledge 4,941 1,889 The number of patients who died in 1995 as a result of overdoses of morphine-like drugs, administered with intention to terminate life, was strikingly lower than in 1990. The total number of patients who died of morphine overdose actually increased (from 22,500 in 1990(7) to 25,900 in 1995(8)). But in 1995 fewer cases were labeled as intentional. The report states that in 1995 the questioning on this issue was done in a different way and more thoroughly than in 1990.(9) A doctor's statement that it was his intention to cause death was not as readily accepted as in 1990; other possibilities were suggested with some insistence: that the overdose of morphine could have been given "without the intention but reckoning with the probability, or certainty, of causing death," or "without the intention but in the hope to cause death," or "without the intention but with the feeling that it would not be inopportune to cause death."(10)

Apparently, the reduced number of cases in which the lethal overdose of morphine was declared intentional, does not reflect a change in the practice itself but results from more restrictive questioning and labeling.

Active voluntary euthanasia, and requests for euthanasia, increased by 39%, and 8%, respectively (see Table 1). There was a sharp increase in the number of requests made in advance, for euthanasia "in due time," "later in the disease": from 25,000 in 1990(11) to 34,500 in 1995.(12)

Physician-assisted suicide (400 cases a year, both in 1990 and in 1995) remains the least frequently used form of active euthanasia.

The withdrawing or withholding of (medically nonfutile) life-prolonging treatment significantly increased: from 22,500 cases in 1990(13) to 27,400 cases in 1995.(14) In 13.3% of these cases (3,644 patients) this was done with the definite aim to hasten death.(15) In 62%...