Euthanasia in the Netherlands.

• Author: Fenigsen, Richard

In 1973 a lady doctor who had killed her sick mother was sentenced by the court in Leeuwaarden to a one-week suspended prison sentence. The judge declared that the court never doubted the defendant's integrity. The trial initiated the present open practice of euthanasia in the Netherlands. Many people expressed support for the accused doctor, and in the wake of this campaign two associations were founded: the Dutch Society (Vereniging) for Voluntary Euthanasia, and the Foundation (Stichting) for Voluntary Euthanasia.

The public had been prepared for these events, first and foremost by the publication of Dr. Jan Hendrik van den Berg's book Medical Power and Medical Ethics in 1969.(1) In this work Van den Berg, a professor of neurology, declared that the ethics of unconditional respect for human life belonged to the past, to the time when medicine had been powerless. The new era of medical power required a new ethic allowing doctors to terminate human life.(2) Why it should be so was not clear, since Van den Berg failed to validate this assertion. However, his vivid pictures of human suffering (supposedly created by doctors exercising their power), the serene descriptions of euthanasia, and the daring reversal of many habits of thinking immediately captured the public imagination. The book went through ten printings in the first year and twenty-five in all.

Since this work has strongly influenced Dutch public opinion on the issue of euthanasia, it is important to know the ideas it promoted. Van den Berg insisted that "defective" children must not be allowed to live.(3) In his view doctors are not only authorized(4) but have the duty to terminate meaningless lives.(5) In his book Van den Berg did not mention voluntary active euthanasia, but advocated involuntary active euthanasia. In all model case histories he cited, the decisions to actively terminate the patients' lives were taken by the doctors and the patients' families without the patients' knowledge. Van den Berg condemned the families who failed to request euthanasia and showed an attachment to hopelessly ill patients, this being a dishonor and an adherence to the old dismissed ethics.(6) Neither the patient's nor the family's consent was necessary to carry out euthanasia: in case of the family's refusal a committee of doctors and laymen should impose the decision.(7) Thus, Van den Berg went further than the demand to release the destruction of lives unworthy of being lived: he planned the enforcement of such policy and made provisions for the suppression of possible resistance.

The book was an enormous publishing success and evoked virtually no protests. On the contrary, many concurring declarations followed, issued by Protestant ministers,(8) Protestant church authorities,(9) Catholic intellectuals,(10) ethical bodies,(11) and even by leaders of the movement in favor of voluntary euthanasia.(12) Apparently, Van den Berg expressed the views held by a large part of the public. This was later confirmed by opinion polls,(13) which showed that 77% of the public supported involuntary euthanasia.

The Present Open Practice of Euthanasia

During the Leeuwaarden trial it was revealed that some practice of euthanasia had already existed: in support of the defendant, eighteen doctors declared that they, too, had actively terminated the lives of their patients. It is certain, however, that after the Leeuwaarden trial the practice of euthanasia increased. How many people at present die by active euthanasia is not known because so long as Article 293 of the Dutch Penal Code, which makes euthanasia a punishable crime, remains formally valid, many doctors who perform euthanasia do not state it in the death certificates. All published figures are estimates, often based on questionnaires. The most often cited figure is ten thousand cases of active euthanasia a year.(14) However, a recent study done by VARA TV Corporation and interview polling firm has indicated that the number of cases of active euthanasia may be as high as 18,400 a year, and that in another 21,600 cases medical treatment is withdrawn with intention to cause death.(15) The total number of deaths in the Netherlands being 120,000 a year, the VARA figures, if correct, would mean that every sixth death is due to active euthanasia, and every third death is intentionally hastened either by action or by omission. According to all estimates up to now, in about half the cases active euthanasia is performed by general practitioners at patients' homes, and the other half takes place in the hospitals and nursing homes. The unexpected finding of the VARA study was that in 18% of the cases euthanasia was carried out by nurses without the involvement of a physician.(16)

The Legal Situation

Euthanasia is still lacking legal grounds in Holland. Of the three bills legalizing euthanasia that were proposed, one was passed by the Second Chamber of the Parliament but rejected by the First Chamber, and the other two, including one in 1988,(17) could not be put to a vote due to difficulties in merging the points of view of different political parties. The present coalition government of Christian Democrats (CDA) and Labor (PvdA) is the first in five years that has not promised to introduce a bill legalizing euthanasia. Instead, it appointed a new state committee presided over by an Attorney of the Supreme Court, Professor Remmelink, to study and assess the present practice of euthanasia. Meanwhile, the practice is to some extent regulated by the guidelines issued by the Minister of Justice and accepted by the Secretary of Health, the Health Council, the Board of the Royal Dutch Society of Medicine, and the judiciary. According to these guidelines, doctors performing euthanasia are not prosecuted if they conform to the so-called rules of careful conduct. The doctor should inform the patient about his condition and, in particular, about the measures that could be taken to alleviate his sufferings. Unless the patient objects, his nearest relations should be consulted. The doctor must be convinced that the patient's decision to request euthanasia was taken voluntarily and after careful consideration. The doctor should consult at least one other physician and keep a written record of all proceedings. Contrary to the well-known advice of the Health Council,(18) the final provision states that consent of legal guardians is required to perform euthanasia when the request is submitted by a child or a minor.

In 1987, 125 cases of active euthanasia (about 1% of all cases) were reported to the public prosecutors; in 123 cases the charges were dismissed, and in two a preliminary judicial inquiry was started.(19)

In the very few cases that make it to the court, the doctors are found not guilty, having acted out of higher necessity. The proviso of higher necessity was included in the euthanasia bill prepared by the government in 1988.(20)

The Shaping and the Present State of Public Opinion

The opinion polls conducted in the last two decades have shown a steadily increasing acceptance of euthanasia by the Dutch public. In the 1986 polls 76% of the respondents supported voluntary euthanasia and 77% supported involuntary euthanasia.(21) Now in 1990 these figures might be even higher, reaching perhaps 85%. The readiness to accept euthanasia had apparently been quite widespread even before the Leeuwaarden trial and the publication of Van den Berg's book; nevertheless, the consolidation of the present overwhelming majority must be seen as a remarkable phenomenon in the very pluralistic Dutch society, where so many religious denominations coexist and no less than eleven political parties compete in the elections.

One of the influences that have contributed to creating those exceptionally high percentages in favor of euthanasia was the way the polls were conducted. With social acceptance of euthanasia known to be on the rise, asking solely the positively construed questions of the type "Do you agree with . . . ," as all the questionnaires did, was bound to elicit many quick and less than thoroughly considered affirmative answers. The results could be different had the questionnaires been drawn up in a way that would induce the respondents to consider both the pros and the cons of euthanasia.

The selective information supplied to the Dutch public has been of utmost importance in shaping opinion on the issue of euthanasia. In the last twenty years a great number of books, monographs, official documents, press reports, and scientific papers on this subject have been published in Holland, symposia have been held and attended by large crowds, and television programs on euthanasia have been exceedingly frequent. Among these thousands of publications and telecasts, some were open-minded on the issue of euthanasia, and most favored it or discussed euthanasia as an established practice beyond any dispute. All this time it was difficult to find publications objecting to euthanasia. From 1982 to 1985, 166 items pertaining to the euthanasia issue were printed in a big-circulation independent moderate Dutch daily, Brabants Dagblad; only two of these opposed euthanasia. The same situation prevails in other newspapers and on television. Of the eleven existing television corporations, only one telecasts programs allowing the opponents of euthanasia...