Dutch Legalize Euthanasia and Assisted Suicide

By Jenny Nolan, Department of Medical Ethics

Sixty years ago the footsteps of Nazi soldiers drummed through the streets of the Netherlands and swastikas blazed from windows like furious eyes. Hitler's Aktion T4 program, designed to eliminate "life unworthy of life" through euthanasia, was in full swing. Designed to purge the "Aryan race" of congenital defects, it required that hospitals and institutions to report patients with disabling or incurable conditions. Across Nazi Europe, physicians killed nearly 100,000 of them.

Evil reigned, but courage lived. In the face of the enemy, Dutch doctors alone, in contrast to every other occupied country, refused to recommend or participate in a single case of euthanasia during World War II. Even Nazi orders not to treat the old or those with little chance of recovery were disobeyed, according to a famous New England Journal of Medicine article written in 1949 by Dr. Leo Alexander.

How times have changed.

On April 10, as an estimated 10,000 Dutch people stood in protest outside The Hague, the Senate voted 46 to 28 to legalize euthanasia. The bill passed the lower house last November and now awaits only the formality of the signature of Queen Beatrix to become law. (Like the Queen of England, the monarch of the Netherlands in practice has no discretion to veto laws.)

News of the vote immediately shot across the globe, igniting heated debate on the international scene, but nowhere was the expression of horror more intense than in Germany. The New York Times reported, "Front-page newspaper editorials, statements from ministers and criticism from doctors all took the view that, in the words of George Paul Hefty in the Frankfurter Allgemeine Zeitung... the Dutch had 'breached a dike' with dangerous consequences."

Die Welt, a German daily, compared the old Aktion T4 program with the new Dutch law. Under Hitler, "The government thugs that went into institutions for the handicapped to select who was unworthy for life were very careful not to broadcast their intentions. At some level, the old scruples linked to the commandment against killing were present.... The scandal in The Hague is that a parliament has imposed a state norm in place of the freedom to uphold such scruples."

The German outcry included those with the most experience in dealing with pain and suffering. The New York Times wrote, " German doctors seemed unanimous today in seeing sinister trends behind the Dutch law."

Dr. Stephen Sahm, a cancer specialist in Wiesbaden, pointed to research suggesting that many of the Netherlands' euthanasia deaths "involve life-ending practices without explicit request." " The process has gained its own dynamics and logic, which is nothing short of merciless," he wrote. "Everyone has the right to a dignified death," said Jarg-Dietrich Hoppe, the president of a leading association of German doctors, "but nobody has the right to be killed. The dangers of abuse are too great."

Dutch courts have favored euthanasia in ever-expanding circumstances in cases going back to 1973. The new law makes legally binding the guidelines that Parliament adopted in 1993. Ostensibly, patients must be undergoing irremediable and unbearable suffering, be aware of all other medical options, have sought a second professional opinion, and made their request for euthanasia voluntarily, persistently, and independently while being of sound mind.

Legally, children as young as 12 may be euthanized with their parents' consent. Sixteen and 17-year-olds do not need consent, but must have involved their parents or guardians in the decision-making process.

Physicians may not suggest euthanasia, but patients can leave written instructions authorizing it at their physicians' discretion, should the patients become too physically or mentally ill to decide for themselves. All euthanasia cases must be reported to regional review committees.

Proponents lauded the Senate's decision. "We have a good law at last," said Rob Jonquiere, a retired family doctor in the Netherlands who heads the Dutch Association for Voluntary Euthanasia.

He dismissed German criticism, saying, "The Germans have a war trauma and to compare our euthanasia law with what happened in the German past is unacceptable because these methods have nothing to do with each other."

Given that the law is mostly a codification of regulations that have defined the practice of euthanasia in the Netherlands for decades, and that its abuses have been amply demonstrated all along, the assurances from people like Jonquiere that now things are different seem somewhat absurd.

For example, the requirement that the patient be enduring irremediable and unbearable suffering has been interpreted so broadly that last year an elderly former senator with no significant illness was euthanized solely because he felt he was living a "pointless and empty existence." His doctor was acquitted.

Speaking independently of that particular case, four days after Parliament's vote legalizing euthanasia in certain circumstances, Health Minister Els Borst declared her readiness to enlarge them. In an April 14 interview, she told a Dutch newspaper that she would not oppose allowing suicide pills for very old people who are healthy.

"Being tired of life has nothing to do with the euthanasia law, with medicine and doctors," Borst said. "You may be releasing someone from their suffering, but it is a suffering that has no link with illness or handicap."

Proponents of euthanasia argue that because a patient's request must be voluntary, there is no danger of people being killed either without their consent or against their expressed wishes to live. But Peter Huurman, a leading opponent, emphasized the weight that falls upon those people who choose to live, and must justify that choice, when euthanasia is a legal and widely acceptable option.

From a practical standpoint, the Dutch group Cry for Life pointed out that there is no real watchdog standing guard since a doctor has to report euthanasia only after it has been carried out and the main witness can no longer speak. In a press release, Cry for Life claims that recent research shows that 60% of all cases are not reported.

The most vulnerable are the very old, the very young, and those with disabilities. Some 8% of all infants who die in the Netherlands are killed by their doctors, according to a 1997 study published in the British medical journal, The Lancet.

In 1991 a Dutch government study found 1,000 cases of euthanasia without patient consent in a total of 8,200 euthanasia deaths that year. A follow-up investigation in 1995 found that number decreased by only .1%.

Taken together, the statistics show that 11-12% of Dutch euthanasia deaths occur without consent. Of the 1995 patients who were killed absent a request for death, 21% were fully competent at the time but 79% were not.

A small but indomitable, cadre of pro-life forces within Holland is fiercely maintaining the position against euthanasia. Cry for Life, led by Dr. Bert Dorenbos, gathered 40,000 signatures in a last-ditch plea with Parliament not to legalize euthanasia and helped organize the 10,000-person protest in The Hague.

As the bill snaked through the legislative process, members of the Christian party Christenunie and the Christian Democrats, the main opposition party, spoke relentlessly against its passage. Their objections ranged from the practicalities of the bill and its potential to prey on the vulnerable to the overall ethical problem of introducing euthanasia into the normal practice of medicine.

In spite of their efforts, for the moment at least, the Netherlands continues to slide deeper into the mentality that death is a cure-all solution. Other countries are watching. Belgian lawmakers have been drafting an assisted suicide bill for months which they hope to present to both chambers of their parliament later this year.

Following the Dutch vote on April 10, French health minister Bernard Kouchner declared his plans to work toward legalizing euthanasia in France, claiming in a Reuters article that there had been an "unquestionable change in French public opinion."

In the United States, Faye Girsh, president of the Denver-based Hemlock Society, hoped for the same result in this country, though she admitted in an Associated Press article that it was doubtful the vote in Holland would help win approval for the expansion of assisted suicide in the U.S. Still, "We are very excited," she said. "We have admired what the people of Holland have been doing for the last 20 years."

David N. O'Steen, Ph.D., NRLCexecutive director, holds another view. "This decision to further codify the current practice of euthanasia is tragic," he stated.

"The so-called new restrictions are little consolation in a country whose justification for euthanasia has slipped inexorably from the terminally ill, to the chronically ill, to the mentally ill, and most recently to those who have no mental or physical illness at all."