The Dutch experience.

• Author: Hendin, Herbert
• Position: Euthanasia

Abstract: Euthanasia has been legally sanctioned in the Netherlands by a series of court decisions going back to the 1970s. The author discusses the cultural and historical factors that may have contributed to this development. In the past decade, studies sactioned by the Dutch government reveal that guidelines established for the regulation of euthanasia--a voluntary, well-considered, persistent request, intolerable suffering that cannot be relieved, consultation with a colleague, and reporting of cases---are consistently violated. Of greatest concern is the number of patients who are put to death without their consent--there are more involuntary than voluntary cases. Euthanasia intended originally for the exceptional case has become an accepted way of dealing with the physical and mental distress of serious or terminal illness. In the process palliative care has become one of the casualties while hospice care lags behind that of other countries. Case examples are given.

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In the fall of 2000 the Dutch Parliament passed a statute that formally legalized euthanasia and physician-assisted suicide in the Netherlands. Although the world media treated the passage as a major event, both practices had long been legally sanctioned as the result of a series of court decisions going back to the early 1970s that had made the Netherlands the only country where euthanasia and physician-assisted suicide were widely practiced.

Those in the Netherlands who seek an explanation for the Dutch embrace of assisted suicide and euthanasia usually emphasize the country's historical tradition of tolerance. The Dutch had fought to secure their religious freedom in the sixteenth and seventeenth centuries, and the Netherlands became a refuge for Jews, Catholics, and free thinkers like Spinoza and Descartes who fled there from religious oppression. Dutch secular society in the same period was marked by the Netherlands becoming a major maritime power whose merchants had to learn to accept different cultures, traditions, and practices. (1) In modern times the Dutch point to the presence of fifty different religions--most due to schisms in the Protestant church--and approximately twenty-five political parties. So much diversity in such a small country is seen as a sign of Dutch tolerance. (2)

Tolerance does not imply integration. Splitting up into so many autonomous groups has been seen as reflecting an inability to tolerate the conflict that differences bring. Derek Phillips, professor of sociology at the University of Amsterdam, sees the division into so many parties and religious denominations as coming from a difficulty in accepting the ambiguity and tension that result when people of different viewpoints are interacting in the same group. Dutch academic journals, for example, do not tend to reflect a diversity of viewpoints; more characteristically, different opinions find expression in separate journals. (3) Comparably, when the Royal Dutch Medical Society (KNMG) supported physician-assisted suicide and euthanasia, religious physicians formed a separate medical group opposed to euthanasia. The Dutch medical establishment believes that all opposition to euthanasia is fundamentally religious in nature but is far less tolerant of nonreligious physicians who oppose euthanasia on medical grounds and try to do so within the framework of organized medicine. (4) Compartmentalizing differences is seen as avoiding direct engagement and maintaining consensus within respective autonomous groups.

Most scholars point to Dutch Calvinism as an essential starting point in understanding the origins of contemporary Dutch attitudes toward euthanasia. Calvinism in the Netherlands had its own unique character with its self-righteous view of predestination, its extreme emphasis on simplicity, self-denial, and avoidance of worldly pleasures, its belief that the endurance of suffering was redemptive as well as admirable, and its dedication to one's work as a calling, attitudes that once diffused throughout society. These attitudes found expression in both the Roman Catholic Church and the Dutch Reformed Church. Protestantism and Catholicism were considered to be two of the three pillars on which Dutch society rested; the third was secularism. All three columns had a remarkable degree of autonomy, and each had its own schools, hospitals, and social organizations. (5)

As social revolution swept through the Western world in the 1960s, the influence of the Dutch Reformed Church and the Roman Catholic Church was eroded in the Netherlands, but the power of secularism remained. A new consensus emerged that held that individual autonomy should prevail whenever possible in seeking pleasure and avoiding pain. Such liberalization is viewed as a welcome shift away from an austere Puritanism toward a broad tolerance of diverse behavior. However, the emphasis on autonomy reflected the tendency to split along lines of difference that was now being defined in terms of autonomous individual behavior. The consensus that developed around euthanasia and other social changes was seen by Dutch observers as Calvinist in its intensity and self-righteousness but organized around the values of a secular culture. Dutch acceptance of drug use, dramatized by the crowds of young people who fill major public squares using drugs openly; acceptance of public displays of prostitution; and embrace of euthanasia have been seen as related evidence of antipuritanical changes that flowed from the social revolution. The view of Dutch tolerance of drug use, pornography, prostitution, and euthanasia as simply a reaction against an earlier set of religious values is not the whole story and will be explored from a contemporary perspective later in this chapter. Before the 1960s, however, there was not the interest in euthanasia in the Netherlands that had been present for some time in England and the United States and led to the formation of voluntary euthanasia societies in both countries in the 1930s--thirty-five years before such a society was organized in the Netherlands.

In 1973, against a background of social ferment, a euthanasia case first received widespread public attention in the Netherlands: a physician ended the life of her ailing seventy eight year old mother at her mother's request. Popular support grew for the physician and for the Dutch court in Leeuwarden that found her guilty but refused to punish her. The court relied on an expert witness, a medical inspector for the national health service, who stated that it was no longer considered right for physicians to keep patients alive to the bitter end under certain conditions. These conditions were spelled out in detail in a subsequent case when, in 1981, a Rotterdam court, in finding a lay person guilty of assisting in a suicide, volunteered the opinion that a physician doing so might be exempt from punishment under the Dutch penal code if there had been a voluntary request from a person suffering unbearably with no reasonable alternatives for relief and if the physician had consulted with another physician in making the decision. (6)

In 1984, a case reached the Dutch Supreme Court. A physician who had assisted in the suicide of a ninety five year old woman had been acquitted, but the decision for acquittal was reversed by an appellate court. The Supreme Court overturned the conviction, holding that the appellate court had failed to consider whether the physician was placed in an intolerable position because of what it called a "conflict of duties." Was the patient's suffering such that the physician was forced to act in a situation "beyond [his or her] control?" The court referred the case back to an appellate court in The Hague with the instruction to consider the case with one dominant consideration from an objective medical perspective: could the euthanasia practiced by the physician be regarded as an action justified in a situation of medical necessity? (7)

This ruling invited and obliged the prosecutor in The Hague to rely heavily on the opinion of the Royal Dutch Medical Association (KNMG) as to the acceptability of euthanasia from the professions' standpoint. Critics of the Supreme Court's ruling were unhappy at what they perceived as the court's abdication of moral and legal authority to the medical profession. The statement given by the KNMG to the appellate court paraphrased the Supreme Court's language to declare that in a situation of necessity (force majeure) a physician could be justified in honoring a request for euthanasia. (8)

Even before the decision was issued in The Hague dismissing the charges against the physician, the KNMG had sent a letter to the Minister of Justice asking for a change in the law to permit euthanasia. Although there was public sympathy for the physicians involved in the euthanasia cases and support for the practice of euthanasia, there was not then support for changing the statute. Physicians were able to practice euthanasia with only the protection of case law. Prosecutions, however, were rare, and punishment, even in cases of conviction, was virtually nonexistent.

Eventually, a consensus on guidelines for practicing euthanasia was reached by the courts, the KNMG, the Ministry of Justice, and the Dutch Health Council. When patients experiencing intolerable suffering that could not be relieved in any other way made a voluntary, well-considered, and persistent request to a physician for euthanasia, the physician, if supported in the decision by another physician, would be justified in performing euthanasia. The doctor should not certify the death as due to natural causes and should notify the medical examiner, who would file a report with the local prosecutor, who could investigate further or allow the deceased to be buried. If these guidelines were followed the physician would not be prosecuted under Dutch law that, at the time, treated euthanasia as a criminal offense...