Dutch Court decision on 'coffee euthanasia' opens the door to dubious practices

Alex Schadenberg
Executive Director, Euthanasia Prevention Coalition

The Netherlands Supreme Court recently approved euthanasia for incompetent people with dementia who had made a previous request for euthanasia.

The case concerned the euthanasia death of a woman with dementia, who had stated in her power of attorney document that she wanted euthanasia but when the doctor came to inject her she resisted. The doctor attempted to sedate the woman by putting the drugs in her coffee but she continued to resist so the doctor had the family hold her down while the doctor lethally injected her.

In January 2017, a Netherlands Regional Euthanasia Review Committee decided that the doctor had contravened the rule of law but that she had done it in "good faith."

According to Reuters, the Supreme Court found that:

The Dutch Supreme Court on Tuesday ruled that doctors could legally carry out euthanasia on people with advanced dementia who had earlier put their wishes in writing even if they could no longer confirm them because of their illness. 

The ruling is a landmark in Dutch euthanasia legislation which up to now had required patients to confirm euthanasia requests. This had not been considered possible for mentally incapacitated patients like advanced dementia sufferers. 

“A doctor can carry out an (earlier) written request for euthanasia from people with advanced dementia,”

Theo Boer

Professor Theo Boer, a former member of a Netherlands Regional Euthanasia Review Committee (2005 - 14), wrote about his concerns about the Supreme Court decision that were published by Trouw in the Netherlands (google translated).

Boer describes the case in Trouw:

The Supreme Court recently ruled on coffee euthanasia. A 74-year-old patient with dementia had stated in a living will that she wanted euthanasia if she ended up in a nursing home. When that indeed happened and she became incapacitated, she gave varying signals: most of the time she didn't want to live, but sometimes she was having a good time. Although the doctor had put something calming in her coffee, the woman resisted during the euthanasia. The Supreme Court ruled that the doctor had acted correctly by taking the patient's advance directive as a compass.

Boer expresses his concern that the number of euthanasia deaths for people with advanced dementia will increase and he questions how these decisions will be made based on the fact that these people are incompetent. He then expresses his concern for what he calls, "dubious euthanasia." He writes:

This also increases the risk of dubious euthanasia. Because people with advanced dementia are by definition not competent (many are even aphrodisiac), the practical request for euthanasia comes from the family. The doctor (nursing home doctor or doctor of the Expertise Center for Euthanasia) may be independent, but he will rely heavily on their judgment when weighing the agony of suffering. After all, the doctor usually did not know the patient before. That opens the door to framing. Despite good intentions, family value judgments ("I would never want to be demented," "What kind of life is that?") Take on a strong role. It cannot be excluded that financial and emotional considerations are a motivating force.

Boer than expresses that the Dutch Supreme Court decision proves that there is not a "border" to euthanasia even as other countries, when debating euthanasia, social distance themselves from the Dutch euthanasia program.

Boer concludes by pointing out that this decision will likely lead to a new opportunities to expand euthanasia. Based on "legal equality and compassion" why would euthanasia be limited to people with dementia who previously requested euthanasia when people who did not request euthanasia also suffer?

The only bright line is rejecting euthanasia. Once it is legal it is unfair or it lacks "compassion" to deny it to others, who are also "suffering."

Covid-19 crisis demonstrates the need for euthanasia and assisted suicide is abstract rather than practical.

Euthanasia is not an essential service.

Alex Schadenberg
Executive Director, Euthanasia Prevention Coalition

Kevin Yuill

Kevin Yuill, the author of the book Assisted Suicide: The Liberal, Humanist Case Against Legalisation, and Theo Boer, a former member of a Netherlands Regional Euthanasia Review Committee (2005 - 14) collaborated to write the article: What Covid-19 has revealed about euthanasia, that was published by Spiked on April 14, 2020.

The authors begin the article by commenting on Covid-19 and healthcare:

There has not been, in living memory, more focus on healthcare, the vital role of doctors, the sacrifices made by nurses, and the wonderful efforts of everyone involved in the sector. Amid the coronavirus crisis, daily heroism, the scale of human loss, and the awful scenes in hospitals underline what is important – and what is not.

Theo Boer

They authors comment on euthanasia and Covid-19 in the Netherlands:

It will surprise some that in the Netherlands, the only dedicated clinic providing euthanasia and assisted suicide has closed. Euthanasia Expertise Centre (formerly known as End of Life Clinic) has suspended all euthanasia procedures. The clinic’s website says that existing procedures have been put on hold and new patients are no longer admitted. The centre – which in 2019 alone ended the lives of 898 patients suffering from cancers, psychiatric problems, early on-set dementia, and accumulated age-related complaints – is willing to make an exception only for those expected to die soon and those who may soon lose their capacity for decision-making.

They comment on euthanasia and Covid-19 in Belgium:

Similarly, in Belgium, Jacqueline Herremans, a member of the federal commission reviewing euthanasia, has noted that there are few resources and even fewer doctors available for euthanasia at the moment: ‘The most important thing right now is that we fight the coronavirus.’

They then comment on euthanasia and Covid-19 in Canada:

In Canada, authorities are also shutting down services. For a process that requires two different medical assessments and witnesses, the lives involved are not worth the risk. According to the Globe and Mail, two places in Ontario, where euthanasia and assisted suicide have been legal since 2016, have stopped providing medical assistance in dying (MAID) because of the coronavirus pandemic (one has since resumed for existing patients and those whose deaths are imminent).

In Ontario, only Hamilton and Ottawa are known to have decided that euthanasia is not an essential service. 

The authors point out that the Netherlands euthanasia clinic state that euthanasia is not a priority during the Covid-19 crisis. The statement from the euthanasia clinic follows an opposite statement last year where Steven Pleiter, the director of the clinic said:

‘If the situation is unbearable and there is no prospect of improvement, and euthanasia is an option, it would be almost unethical [of a doctor] not to help that person’

The authors say that palliative care institutions have not shut-down during the Covid-19 pandemic.

So what has the Covid-19 pandemic taught us about euthanasia? The authors state:

What the Covid-19 crisis has demonstrated is that the need for euthanasia and assisted suicide is abstract rather than practical. In the Netherlands in the 1980s, assisted dying started out as the ultimate solution to impending horrible deaths. In present times, with a high level of care for the dying available in most countries with good healthcare, assisted dying is not about actual deaths, but about deaths that people fear. The reality is that most people die peaceful deaths. But many fear loss of control and find the prospect of others caring for them terrifying. 

Covid-19 brings the reality of death, the necessity of caring for others and being cared for by others, into our living rooms, making the preciousness of all lives and the tragedy of all deaths real. We see the humanity of the elderly and frail; no longer are they burdens to be dispatched from this world, but victims of horrifying disease that all are invested in fighting.

The authors conclude by stating:

"Perhaps, though, we can remember this time when we made huge sacrifices to preserve every life, no matter how frail and vulnerable. We can remember this time when euthanasia no longer seemed necessary."

Thank you Kevin and Theo. Euthanasia is not an essential service and it is not healthcare.

Victoria Australia’s ‘voluntary assisted dying’ law has come into effect; but were legislators right to think they could avoid the ‘slippery slope’?

This article was originally published in ABC Religion & Ethics and Bioethics Outlook (Plunkett Centre for Ethics).

Professor John Keown

By John Keown

The author of Euthanasia, Ethics and Public Policy: An Argument against Legalisation. 

Victoria’s law permitting physician-assisted suicide (PAS) and voluntary euthanasia (VE) came into force in June last year. Other states, particularly Western Australia, may soon follow suit.

All Australians, whether legislators or voters, would do well to reflect on the warning of former Prime Minister Paul Keating, when the bill was being debated in 2017, that VE is a threshold moment for Australia, and a threshold the country should not cross. He cautioned that, once termination of life is allowed, pressure will mount for further liberalisation on the ground that the law discriminates against those denied PAS and VE. “The experience of overseas jurisdictions,” he added, “suggests the pressures for further liberalisation are irresistible.”

His article provoked a critical response from ABC/RMIT “fact checkers,” who concluded that in most jurisdictions where the law had been relaxed “little has changed regarding what practices are allowed or who can access assisted dying.”

They were mistaken. My book Euthanasia, Ethics and Public Policy, provides extensive evidence from abroad confirming slippery slope concerns.

The slippery slope argument holds that PAS and VE should not be legalised because neither prescriptions for lethal drugs, nor lethal injections, can be effectively controlled by the law. This is for two distinct reasons: practical and logical.

Practically, it is not feasible either to craft legal criteria (such as “unbearable suffering” or “terminal illness”) with sufficient precision or, even if it were, to police them. Logically, the moral arguments for lethal prescriptions for the “terminally ill” are also arguments for lethal injections, and lethal injections for patients who are chronically ill and have longer to suffer.

Moreover, the moral case for lethal injections for competent patients is also a case for lethal injections for incompetent patients such as infants: the patient’s lack of autonomy does not cancel the doctor’s duty of beneficence. If some competent patients would be “better off dead” because of their suffering, so would some incompetent patients. There is, then, a logical link between voluntary and non-voluntary euthanasia.

The disturbing experience overseas illustrates the force of both the practical argument and of the logical argument. Permissive laws have failed to ensure effective control, whether in the Netherlands or Belgium (and now Canada) that permit VE and PAS, or in those US jurisdictions like Oregon that permit only PAS. Five points will show that the “fact checkers”' conclusion that “little has changed” is wide of the mark.

First, VE and PAS became legal in the Netherlands in 1984 (not 2002 as the “fact checkers” state) through a ruling of the Dutch Supreme Court. In 1996, illustrating the logical slope, the Dutch courts declared infanticide lawful. (The “fact checkers” rightly regard this as a liberalisation of the law, though they wrongly assert that infanticide “remains illegal.”)

Second, the “fact checkers” interpret “further liberalisation” to mean that a government has taken steps to expand access or legally protected activities. But this ignores the reality that the interpretation of the law may become more permissive, whether by courts, review committees or doctors, even absent statutory amendment. And this is what has happened in the Netherlands and Belgium.

Professor Theo Boer, for example, a former member of a Dutch euthanasia review committee, has changed his mind about the law. He points to the dramatic increase in numbers and to significant bracket creep, extending to patients with mental illness, disorders of old age, and dementia. Supply has stimulated demand, euthanasia has become normalised and there has been a paradigm shift. Some slopes, he now cautions, truly are slippery.

One may add that, since 1984, official Dutch surveys have shown that thousands of patients have been killed without an explicit request, and thousands of cases have not been reported by doctors to the review committees required to check each case. Why should we expect Victoria’s “review board” to be any more effective in ensuring that the legal criteria are met and that all cases are reported?

Boer’s writing, and that of other leading scholars critical of the Dutch experience such as Dr (now Justice) Neil Gorsuch, are not mentioned by the “fact checkers.” Also noteworthy is their failure to mention the Dutch government's proposal in 2016 to extend the law to allow elderly people who are simply “tired of life” to be given suicide pills by “death counsellors.”

Third, they note that Belgium relaxed its law to allow children to access euthanasia and state that this was the only liberalisation. Not so. Although the Belgian legislation was deliberately limited to VE, the review commission has decided to approve cases of PAS. And, like the Dutch committees, the commission has permitted an increasingly elastic interpretation of the criteria.

Fourth, they write that the Canadian government, having legalised VE and PAS, commissioned studies in relation to access for mature minors, the mentally ill and by advance directive, but that these are only “potential legislative changes.” True, but why commission such studies unless you are considering extending the law? And the existing criteria are already being challenged in court as too restrictive.

Fifth, they attach importance to the fact that the Oregon-style laws in the United States have not been extended to the chronically ill or to permit VE. However, they do not consider whether this may simply be political expediency until a critical mass of states has legalised PAS.

It makes tactical sense for anyone seeking to make a radical change in the law, and whose opponents will raise slippery slope concerns, to get their foot in the door through relatively conservative proposals before prizing the door open wider. The former governor of Washington state, Booth Gardner, said he supported an Oregon-style law in his state as a first step that would weaken the nation’s resistance and produce a cultural shift resulting in laxer laws.

Professor Yale Kamisar wrote in his classic utilitarian essay against legalisation 60 years ago that the arguments against further liberalisation are weaker than the arguments against legalisation, which is itself an argument against legalisation.

Keating’s concerns are, then, amply supported by the experience overseas. Sadly, the “fact checkers” are not alone in misunderstanding that experience, as should be evident to anyone who reads the majority (though not the minority) reports of the parliamentary committees in Victoria or Western Australia. Quite frankly, any legislators who think they can avoid the slippery slope have learned little from other jurisdictions.

John Keown is the Rose F. Kennedy Professor of Christian Ethics in the Kennedy Institute of Ethics at Georgetown University.

Has euthanasia gone too far?

Alex Schadenberg
Executive Director, Euthanasia Prevention Coalition

Christopher de Bellaigue in his comprehensive article published on January 18 in the Guardian asks the question: Has euthanasia gone too far?

de Bellaigue, (the author) examines the experience with euthanasia in the Netherlands, by interviewing supporters and critics of euthanasia. The author outlines how euthanasia was originally promoted as a response to exceptional circumstances and is now being considered for people who think their life is "complete." He writes:

As the world’s pioneer, the Netherlands has also discovered that although legalising euthanasia might resolve one ethical conundrum, it opens a can of others – most importantly, where the limits of the practice should be drawn.

The author interviews Theo Boer, who he calls the most prominent skeptic. Boer who was a member of a regional euthanasia review committee from 2005 - 14, says to interested inquiries:

“when I’m showing the statistics to people in Portugal or Iceland or wherever, I say: ‘Look closely at the Netherlands because this is where your country may be 20 years from now.’”

Theo Boer

Boer tells states:

“The process of bringing in euthanasia legislation began with a desire to deal with the most heartbreaking cases – really terrible forms of death,” 

“But there have been important changes in the way the law is applied. We have put in motion something that we have now discovered has more consequences than we ever imagined.” 

The author also interviews Bert Keizer, one of 60 doctors who work with the Levenseindekliniek (End of Life Clinic), which was responsible for 750 euthanasia deaths in 2017. Keizer, did his first euthanasia in 1984, when euthanasia was still illegal in the Netherlands. Keizer was not prosecuted.

Keizer states that the patient that he euthanized in 1984 was not in pain but he was experiencing symptoms indicating that he was nearing death. Keizer consider euthanasia as a new era and he believes that euthanasia prevents suicide.

The author explains how euthanasia was normalized:

As people got used to the new law, the number of Dutch people being euthanised began to rise sharply, from under 2,000 in 2007 to almost 6,600 in 2017. (Around the same number are estimated to have had their euthanasia request turned down as not conforming with the legal requirements.) Also in 2017, some 1,900 Dutch people killed themselves, while the number of people who died under palliative sedation – in theory, succumbing to their illness while cocooned from physical discomfort, but in practice often dying of dehydration while unconscious – hit an astonishing 32,000. Altogether, well over a quarter of all deaths in 2017 in the Netherlands were induced.

The author then explains why the number of euthanasia deaths increased quickly.

One of the reasons why euthanasia became more common after 2007 is that the range of conditions considered eligible expanded, while the definition of “unbearable suffering” that is central to the law was also loosened. At the same time, murmurs of apprehension began to be heard, which, even in the marvelously decorous chamber of Dutch public debate, have Concerns center on two issues with strong relevance to euthanasia: dementia and autonomy.

Euthanasia for the incompetent.

Berna Van Baarsen

The author continues by discussing euthanasia for people with dementia. The article explains that last January Berna Van Baarsen resigned from a euthanasia review board based on the growing number of people with dementia who are being euthanised on the basis of a written directive that they are unable to confirm Van Baarsen told the Trouw paper that

“It is fundamentally impossible to establish that the patient is suffering unbearably, because he can no longer explain it.”.

Since then a Dutch doctor has been prosecuted in a case of a woman with dementia who had previously requested euthanasia but at the time of the euthanasia she refused. The doctor put sedation in her coffee and then when she continued to resist the family held her down as the doctor injected her.

Patients demand euthanasia.

Patients have gone from requesting euthanasia to demanding euthanasia leading to some doctors refusing to do euthanasia. Theo Boer shared a story of a physician friend who has stopped doing euthanasia. Boer explains

“In the coldest weeks of last winter, a doctor friend of mine was told by an elderly patient: ‘I demand to have euthanasia this week – you promised.’ The doctor replied: ‘It’s -15C outside. Take a bottle of whisky and sit in your garden and we will find you tomorrow, because I cannot accept that you make me responsible for your own suicide.’ The doctor in question, Boer said, used to perform euthanasia on around three people a year. He has now stopped altogether.

Boer is also concerned about the effects that euthanasia has on the physicians. Boer stated:

“When you euthanise a final-stage cancer patient, you know that even if your decision is problematic, that person would have died anyway. But when that person might have lived decades, what is always in your mind is that they might have found a new balance in their life.”

Steven Pleiter

The author attended a conference organized by the NVVE on psychiatric euthanasia where he had the opportunity to speak with Steven Pleiter, the director of the Levenseindekliniek. Pleiter explains that his goal is to create a "shift in the mindset" about euthanasia. The author explains:

Pleiter said he hoped that in the future doctors will feel more confident accommodating demands for “the most complex varieties of euthanasia, like psychiatric illnesses and dementia” – not through a change in the law, he added, but through a kind of “acceptance … that grows and grows over the years”.

Pleiter clearly adds grease to the slippery slope. Pleiter believes that it is unethical for a doctor not to participate in euthanasia.

Pleiter then says that after opening the euthanasia clinic (Levenseindekliniek) that he negotiated with the insurance companies who agreed to pay the clinic 3000 euro per death, including the same payment if the patient changes his mind. When the author asks Pleiter if it is cheaper to do euthanasia rather than care for the person until they die Pleiter responds:

“This isn’t about money … it’s about empathy, ethics, compassion.” And he restated the credo that animates right-to-die movements everywhere: ‘I strongly believe there is no need for suffering.’

The author continues his investigation by recognizing that not all euthanasia deaths are "ideal" and collateral damage does exist. The author writes:

This legal nicety would become painfully significant to a middle-aged motorcycle salesman from Zwolle called Marc Veld. In the spring of last year, he began to suspect that his mother, Marijke, was planning to be euthanised, but he never got the opportunity to explain to her doctor why, in his view, her suffering was neither unbearable nor impossible to alleviate. On 9 June, the doctor phoned him and said: “I’m sorry, your mother passed away half an hour ago.”

Marc explains that his mother was not terminally ill but depressed. Since his mother wanted euthanasia she made complaints about her health and slumped over when speaking to her physician. Some people suggest that it was none of Marc's concern that his mother died by euthanasia. 

Theo Boer confirms the concern about euthanasia for depression. The author writes:

During his time on the review board, Theo Boer came across several cases in which the “death wish preceded the physical illness … some patients are happy to be able to ask for euthanasia on the basis of a physical reason, while the real reason is deeper”.

The author interviews a physician whose patient die by euthanasia without consent. The patient, who had dementia, had requested euthanasia will still competent. The patient had now changed his mind about euthanasia, but his wife strongly supported euthanasia. The man's wife exclaimed:

“If only he had the courage! Coward!”

When the doctor went on vacation, her colleague, who strongly supports euthanasia, lethally injected this patient. The doctor, who is now planning to move her practice, stated:

“How can I stay here?” 

“I am a doctor and yet I can’t guarantee the safety of my most vulnerable patients.”

The author completes his article by discussing the Netherlands debate concerning the "completed life pill" once known as the last will pill.

The concept of the "completed life" is that medical criteria would not be necessary to receive a lethal prescription only the desire to end one's life.

The author writes that some physicians support this idea because it frees them from euthanizing their patients and enables the patient to do it themselves. The reality is that most people would rather have the physician lethally inject them than the person take the lethal mixture themselves.

de Bellaigue does an excellent job of explaining the support for euthanasia while uncovering the concerns with euthanasia. Since de Bellaigue has received funding to research euthanasia it is likely that he will continue to write articles on this topic. I hope that his future articles will continue in this engaging style.

Netherlands euthanasia clinic data

Dr Mark Komrad shared the following information about the Levenseindekliniek (euthanasia clinic) in the Netherlands. It is important to note that most of the euthanasia deaths for psychiatric reasons are done at the euthanasia clinic. There are also euthanasia clinics in Belgium and Canada.

1. The Levenseindekliniek is located in the Hague. They have 55-60 physician teams who travel the country doing euthanasia—in patients’ homes.

2. The Levenseindekliniek was a private initiative by the euthanasia lobby. Theo Boer, a past member of a regional euthanasia review committee noted that “Establishing of the End of Life Clinics came fully out of the blue [originally predicted to “no longer be needed by 2018"] and has now become a necessity."

• Mobile euthanasia started in the Netherlands today.
  

3. The doctor is ALWAYS new to the patient. These physicians are not part of a patient’s established treatment team for their condition.

4. Circumventing the treating doctors by consulting a Levenseindekliniek doctor for euthanasia evaluation (and possibly completion) is a typical scenario.

5. Approximately 750 people were euthanized at the Levenseindekliniek in 2017.

6. 77% of all psychiatric euthanasias in the Netherlands occurred via the Levenseindekiniek network in 2016. This is the predominant approach to euthanizing psychiatric patients in The Netherlands. There were 6585 reported euthanasia deaths in the Netherlands in 2017 with 11.4% of these deaths done through this peripatetic euthanasia service. Most of the euthanasia deaths are done by family physicians who are treating the patient, according to the Royal Dutch Medical Association.

• Netherlands 2017 euthanasia data.

Euthanasia assessor resigns over euthanasia for dementia in the Netherlands

This article was published by Bioedge on January 20, 2018

By Michael Cook, the editor of Bioedge.

Berna van Baarsen

A medical ethicist has resigned from a Dutch regional assessment committee for euthanasia over a law which allows non-consenting demented patients to be euthanised. For ten years Berna van Baarsen helped to assess whether euthanasia had been performed in accordance with the law in the North Holland region. She resigned on January 1.

“'I do not believe that a written declaration of intent can replace an oral request for incapacitated patients with advanced dementia,” she told the magazine Medisch Contact.

Under Article 2.2 of the Dutch euthanasia law, a doctor may euthanize a patient who can no longer make clear what he wants, but who had previously left a written declaration. The law says:

If a patient aged sixteen or over who is no longer capable of expressing his will, but before reaching this state was deemed capable of making a reasonable appraisal of his own interests, has made a written declaration requesting that his life be terminated, the physician may comply with this request unless he has well-founded reasons for declining to do so. 


"In people with a terminal illness like cancer, in whom euthanasia has already been agreed but who suddenly ended up in a coma because of their illness, that's fair," says van Baarsen.

However, dementia is a very different kind of ailment, she told Trouw. "That disease is more erratic and patients often live longer. A lot of things can happen during that period. "For instance, a patient might say that she would want euthanasia if she no longer recognizes his relatives. "This could happen. But at a next visit she can still recognize her partner or her children. What is the right moment to grant euthanasia? "

Furthermore, the suffering of a dementia patient is difficult to assess.

"It is fundamentally impossible at this stage to establish that the patient is suffering unbearably, because he can no longer explain it", says van Baarsen.

Sometimes patients act aggressively after being admitted to a nursing home, even shouting that they want to leave. "It is of course possible that the patient is suffering unbearably,” she admits. “But does the same applies to a nursing home resident who is sitting quietly in a corner? If you are not entirely sure, you cannot presume that they are suffering unbearably.”

Van Baarsen is not the only member of a euthanasia review committee to resign over the interpretation of the law. Three years ago ethicist Theo Boer also stepped down and has become a harsh critic of the Dutch euthanasia system.

• Theo Boer - "Assisted suicide: Don't go there."

Euthanasia deaths in the Netherlands increasing quickly.

Alex Schadenberg
Executive Director - Euthanasia Prevention Coalition

The Guardian News published an article by Daniel Boffey concerning the increasing number of euthanasia deaths at the Levenseindekliniek (euthanasia clinic) in the Hague and in the Netherlands in general. According to the article, the number of euthanasia deaths will exceed 7000 in 2017 representing, at least, a 67% increase in deaths since 2012.

• Netherlands 2016 euthanasia report. Euthanasia deaths increase by another 10%.

Boffey interviewed Steven Pleiter, the director of the euthanasia clinic who is hiring more staff for his death clinic. From the article:

Steven Pleiter, director at the clinic, said that in response to growing demand he was now on a recruitment drive aimed at doubling the number of doctors and nurses on his books willing to go into people’s homes to administer lethal injections to patients with conditions ranging from terminal illnesses to crippling psychiatric disorders.

• Dutch doctors oppose euthanasia for dementia.

Pleiter stated that he has 57 doctors on call and he may soon require 100 doctors.

“It’s the first time,” Pleiter said of the recruitment drive, sitting in his bright and airy office near the centre of The Hague, where the clinic’s neighbours include legal firms and a kindergarten. “Until today we rarely needed to search for doctors. That is changing now. We need a dramatic growth in doctors as the numbers have changed so much... 

“We ask the doctors to work eight to 16 hours a week for this organisation. A full-time job involved in the death of people is probably a bit too much, and ‘probably’ is a euphemism.”

Theo Boer

In response to Pleiter, Boffey interviewed Professor Theo Boer, who is a past member of a regional euthanasia review committee and now believes that the law has gone too far.

“Starting from 2007, the numbers increased suddenly,” Boer said. “It was as if the Dutch people needed to get used to the idea of an organised death. I know lots of people who now say that there is only one way they want to die and that’s through injection. It is getting too normal.” 

“In the beginning, 98% of cases were terminally ill patients with perhaps days to live. That’s now down to 70%.

• Rushing toward death - Euthanasia in the Netherlands.

The Guardian article brought forth interesting information, but the article fails to look deeper into the Netherlands euthanasia law.

The New England Journal of Medicine (NEJM) (August 3, 2017) published the data from a Netherlands euthanasia study entitled: End-of-Life Decisions in the Netherlands over 25 years.

• Netherlands study uncovered abuse of the law.

The data from the study indicates that in 2015 there were 7254 assisted deaths (6672 euthanasia deaths, 150 assisted suicide deaths, 431 terminations of life without request) and 18,213 deaths whereby the medical decisions that were intended to bring about the death in the Netherlands.

The Netherlands 2015 euthanasia report stated that there were 5561 reported assisted deaths in 2015 and yet the data from the study indicates that there were 7254 assisted deaths in 2015.

Therefore, according to the data from the study, in 2105, 1693 (23%) of the assisted deaths were not reported and 431 assisted deaths were without request.

Since the Netherlands euthanasia law uses a voluntary self-reporting system, meaning the doctor who lethally injects the patient also submits the report and since people do not self-report abuse of the law, therefore the law enables doctors to cover-up "abuse" of the law.

Is it actually possible to know how many people are dying by euthanasia in the Netherlands? Is it actually possible to determine how many  involuntary euthanasia deaths occur in the Netherlands?

• Mobile euthanasia units started in the Netherlands today (March 1, 2012).

Do suicides increase where euthanasia is legal?

This article was published by Mercatornet on May 22.

The euthanasia debate is on the front-burner in Australia, especially in the states of Victoria and Tasmania. In one of the latest salvos, ethicist Professor Margaret Somerville claimed that suicide rates rise in jurisdictions where euthanasia and assisted suicide are legal. This prompted a blast from Neil Francis, a former President of the World Federation of Right To Die Societies and a leading campaigner for euthanasia in Australia. This is Professor Somerville’s response.

B

Margaret Somerville

y Margaret Somerville

Neil Francis is correct in criticizing me for a loose statement that "the general suicide rate has increased in every jurisdiction that has legalized assisted suicide." 

Although I believe that my statement will prove to be correct, at this point in time I should have left out the word "every." 

One problem in obtaining the required evidence, is that it’s difficult if not impossible to know how often physician-assisted suicide or euthanasia (PAS-E) is being used in countries where those interventions are legal to commit what we should view as “ordinary suicide”–if one can ever regard suicide as “ordinary”, but for want of a better term. 

“Suicide by police”–a suicidal person engages in conduct with the intention that the police will respond by shooting them - is a recognized phenomenon. Now we can consider “suicide by physician”. 

Two features of legalized PAS-E make “suicide by physician” seem likely: The percentage of deaths occurring from PAS-E, for instance, in The Netherlands and Belgium, is rising by approximately 10 per cent each year and is now around 4 percent of all deaths. And the conditions for access to PAS-E are expanding in both jurisdictions. If one is not terminally or physically ill, neither of which is a legal requirement in either country, is euthanasia “ordinary suicide”? And what about if a person wants PAS-E because they are just “tired of life” or feel they have a completed life as the Netherlands is now contemplating allowing or, as an elderly couple proposed on ABC’s Q&A, simply want to avoid going into a nursing home, should these be classified as “ordinary suicide” cases? 

Cases in which using PAS-E as a substitute means of suicide seems very likely have made headlines around the world. They include the deaf Belgian twins who were going blind; the young gender-dysphoric woman with the botched sex-change operation; the anorexic woman in her 20s; the depressed 34 year old Eva, whose death by euthanasia is focused on in real time in the documentary film, “End Credits”, made by Dutch pro-euthanasia advocates; the convicted rapist and murderer in the Belgium prison. 

Dutch Professor Dr. Theo Boer, a former member of one of Holland’s five Euthanasia Regional Review Committees (2005-2014) has undertaken a study which will be published shortly which, in his words, shows 

Theo Boer

the assumption that euthanasia will lead to lower suicide rates finds no support in the numbers. The percentage of euthanasia deaths of the total mortality rate tripled from 1.3% in 2002 to 4.08% in 2016. During that same period, the suicide numbers did not go down: From being 1,567 in 2002, they went up to 1,871 in 2015, a rise of 19.4%. The suicide rates reached a relative low of 1,353 in 2007, compared to which the 2015 numbers constitute a rise of 38.3%. This is even more significant given the fact that from 2007 on euthanasia started becoming available to people with chronic diseases–psychiatric diseases, dementia, and others. In terms of the percentage of the overall mortality of suicide deaths, the numbers went up from 1.01% in 2007 to 1.27% in 2015.  

…For the sake of comparison, I have looked at the suicide rates of some countries which are close to the Netherlands in terms of ethnicity, age, religion, and language but which, with the exception of Belgium, lack the option of euthanasia. If the suicide numbers in the Netherlands have gone up, one would expect, at least a similar increase in the suicide numbers would occur in countries without the option of euthanasia. However,…the Netherlands of all countries show the biggest increase in the suicide numbers.” 

Mr. Francis dismisses researchers David Jones' and David Paton’s report on suicide data in Oregon on which I relied to show a rise in the state’s suicide rates on the basis that it was “published in a minor journal”, the Southern Medical Journal. This claim is specious, even if it were a “minor journal”. For the record, it is a peer-reviewed medical journal indexed and abstracted in Index Medicus, Current Contents, Science Citation Index, and EMBASE which has published over 45,000 articles. I leave it to others to decide its status. 

Moreover, if Mr. Francis’ claim as to its status were correct and if Jones’ and Paton’s article were, as Mr. Francis describes it, “a wobbly econometric modelling study”, it stands to reason that the journal would be more accessible in terms of publishing rebuttals or questions about the article. To date, to my knowledge, no one has done so, not there, not anywhere. 

Mr. Francis’, at best, woolly statements about what Jones’ and Paton’s study found need clarifying. They write: 

[W]e found that legalizing PAS was associated with a 6.3% (95% confidence interval 2.70%–9.9%) increase in total suicides (including assisted suicides). This effect was larger in the individuals older than 65 years (14.5%, CI 6.4%–22.7%). Introduction of PAS was neither associated with a reduction in nonassisted suicide rates nor with an increase in the mean age of nonassisted suicide. (Emphasis added)  

Conclusions: Legalizing PAS has been associated with an increased rate of total suicides relative to other states and no decrease in nonassisted suicides. 

As Jones and Patton recall, pundits claimed at the time of the public debate in Oregon about legalizing physician-assisted suicide that having access to assisted suicide would reduce “nonassisted” or “ordinary suicide”, which it clearly did not. This is something Australian legislators should note. 

I will just mention California, which has very recently legalized physician-assisted suicide. There was concern that people who were involuntarily hospitalized because they were mentally ill and “dangerous to themselves (they were suicidal) or others” could not have access to physician-assisted suicide. This has now been “remedied” and a special process established to allow them to apply to have physician assistance in killing themselves. 

The Dutch concern with international scrutiny of euthanasia law.

Paul Russell published this article on the Hope Australia website on April 25 under the title: The Dutch Mouse that Roared.

Paul Russell

Paul Russell, the Director of Hope Australia.

Public challenges to the zeitgeist on euthanasia are rare in the Netherlands. The practice of deliberately killing patients in Holland has a long history reaching back more than thirty years. The Dutch, like their Belgian neighbours, have grown used to the idea. Promotion of the practice through sympathetic propaganda on prime time television and even a euthanasia film festival a few years ago have served the agenda to normalise the practice.

This has lead some commentators to suggest that everything is going just fine and dandy in the Low Countries, supposing that the cultural acceptance of euthanasia is a sign that the practice is entirely under control. The lack of political opposition has been cited by the likes of Peter Singer in an attempt to confirm this. This is thinking in a bubble: it ignores the realities that what is legal becomes broadly accepted as being moral and that repeal or reform is incredibly difficult in such circumstances.

But opposition does exist and has always existed. Principally held by disenfranchised voices, there is nevertheless significant disquiet in many quarters; exemplified by the public declarations of people like Professor Theo Boer who once supported the Dutch law but has changed his mind under close observation of developments in recent years.

One would think that, in such circumstances and in a society noted for its tolerance, that the occasional roar of a mouse against the zeitgeist would be simply noted and then largely ignored. Not so if the recent declarations by the Reformed Political Party (SGP) at their annual convention are anything to go by.

The SGP is Holland's oldest political party. Confessionally Calvinist, they have been a consistent yet very small player in the Dutch Parliament currently holding three seats in the Dutch House of Representatives (out of 150) and being one of thirteen parties in that chamber.

At their national convention this week in Hoevelaken, party leader, Kees van der Staaij, took the SGP's longstanding opposition to Dutch Euthanasia Laws to a new level. Van der Staaij wants to fuel the international concern about Dutch euthanasia through the production of an English language documentary on Dutch euthanasia practice so as to engage the international anglophone media.

"Van der Staaij says people are shocked abroad when he says that it is used in the Netherlands (for) euthanasia on people with mental illness and dementia. He also claims that this happens "without being able to explain at the time that they really want, and without a court is involved." (see, for example, the recent Dutch nursing home dementia case)

The Dutch Euthanasia organisation NVVE are not amused. But instead of ignoring the SGP commentary - as would any rational organisation confident of its position and confident that such a call would simply fade into obscurity - the NVVE and others have fought back in the media. Is there something to hide here? Is the NVVE cultural reign on shaky ground?

The NVVE railed against the SGP in the Dutch media claiming that they are putting Dutch euthanasia policy in a 'deliberately bad light'. Full marks there. Spokesperson, Dick Bosscher cited support from 'sister' organisations around the globe to somehow claim that the international opinion of the Dutch death regime is somehow positive.

Another commentator, Rik de Jong, claimed that van der Staaij had 'crossed a line' by seeking to expose the Dutch regime internationally. Somehow, according to de Jong, it is acceptable for the SGP to hold a Christian perspective on the issue and to make a 'constructive contribution' to debate; but clearly not to rattle the cage internationally: keep 'the opinion of foreign conservatives outside'!

So what's the problem? If everything is above board, if there are no problems, if there are no abuses, surely there is a robust defence of the Dutch euthanasia laws from within the polity and the public that can stand such scrutiny?

Maybe not!

• Netherlands 2016 euthanasia deaths increased by 10% again.
• Netherlands review committee says that forced euthanasia of woman with dementia was done in "good faith".