Overall the evidence shows that patient killing in the Netherlands is increasingly seen as normative as it now accounts for 6.54% of all deaths in the Netherlands of persons aged between 60 and 80 years of age. Additionally euthanasia for dementia, for psychiatric conditions and for “a stack of old age problems” is becoming more frequent.
In 2015 there were 431 cases of euthanasia without explicit request, representing 6.06% of all euthanasia deaths. More than 1 in 200 (0.52%) of all deaths (other than sudden and expected deaths) of 17-65 year olds in the Netherlands are caused intentionally by euthanasia without an explicit request from the person being killed.
Euthanasia was formally legalised in the Netherlands in 2002 after several years in which it was practised openly after court decisions allowing it in certain circumstances.
Each year the Regional Euthanasia Review Committees publish data and selected case reports on the practice of euthanasia and assisted suicide.
The most recent data is from the 2018 report .
Increasing number of deaths
The number of reported deaths from euthanasia and physician assisted suicide rose sharply from 1815 in 2003, the first year under the new law, to 6585 deaths reported in 2017. This represents an increase of 262.8% in raw number of reported deaths from euthanasia between 2003 and 2017. In 2003 some 1.28% of all deaths were brought about by reported acts of euthanasia or physician assisted suicide. In 2017 this had risen to 4.38% of all deaths. The percentage of deaths caused by reported acts of euthanasia or assisted suicide thus more than tripled (342.2%) in 14 years. The increase in 2017 from 2016 (6091 deaths) alone was 8.11%.
In 2017, one in sixteen (6.54%) deaths in the Netherlands of persons aged between 60 and 80 years of age resulted from reported acts of euthanasia or assisted suicide.
There was a decrease - for the first time since legalisaion - of 7% in the total number of reported cases from 2017 to 2018 (6126 cases). This represents 45 of all deaths in the Netherlands in 2018.
The data above relates only to officially reported cases of euthanasia and assisted suicide. A more comprehensive picture is provided by the five yearly surveys by Statistics Netherlands on all deaths by “medical end-of-life decision”. The latest data reports on all deaths in the Netherlands in 2015.
In that year there were 7254 deaths caused intentionally by lethal medication – 6672 deaths by euthanasia with a request; 431 deaths by euthanasia with no explicit request; and 150 deaths by assisted suicide.
This represents nearly 1 in 20 (4.93%) of all deaths in the Netherlands.
More than 1 in 10 (10.5%) of all deaths (other than sudden and expected deaths) of 17-65 year olds in the Netherlands in 2015 were caused intentionally by euthanasia or assisted suicide.
Euthanasia without explicit requests
In 2015 there were 431 cases of euthanasia without explicit request, representing 6.06% of all euthanasia deaths.
More than 1 in 200 (0.52%) of all deaths (other than sudden and expected deaths) of 17-65 year olds in the Netherlands are caused intentionally by euthanasia without an explicit request from the person being killed.
For 2015 there is a significant discrepancy (1364) between the number of cases of euthanasia with request reported by Statistics Netherlands – 6672 – and the number of such cases reported (as required by law) to the Euthanasia Review Committees – 5308.
This suggests that in more than 1 in 5 (20.44%) cases where a doctor administers euthanasia with a request there is a failure to comply with the law requiring such acts to be reported.
If the additional 431 cases of euthanasia with no explicit request are included then more than 1 in 4 (25.27%) of cases of explicit killing by euthanasia are not reported.
From 2016 to July 2018 the Board of Procurators General reported on 11 cases of euthanasia with serious breach of protocols by the doctor, including a failed assisted suicide because the doctor ordered the wrong drug; seven cases of the muscle relaxant being administered when the person was not in a full coma and therefore potentially causing pain; and three cases where a first attempt at euthanasia failed and the doctor had to leave the person to get a second batch of lethal drugs.
For assisted suicide in the Netherlands the doctor is required to be present until death occurs. Attempts at assisted suicide regularly fail to bring about death in the desired time frame. In these cases, under the Netherlands protocols, the doctor then administers euthanasia drugs. This occurred in between 7% and 13% of cases of assisted suicide in the years 2014 to 2018.
Grounds for euthanasia: psychiatric disorder and dementia
In 2017 there were 83 notifications of euthanasia or assisted suicide involving patients with psychiatric disorders (nearly six times the 14 cases in 2012 and a 38.33% increase from 60 cases in 2016). There were 166 notifications involving dementia (nearly four times the 42 notifications involving dementia in 2012 and a 17.73% increase from 141 cases in 2016). All these cases were in the absence of any other condition justifying euthanasia. In three of the dementia cases in 2017 euthanasia was performed on the basis of an advanced directive rather than a contemporary request by the person who was euthanased.
Stack of old age disorders
The 2018 Euthanasia Code published by the Regional Euthanasia Review Committees provides for euthanasia on the basis of a “stack of old age disorders”:
If a patient wants to be eligible for euthanasia then the suffering must have a medical basis. But it is not required that a life-threatening condition exists. A stacking of old age disorders - such as visual disturbances, hearing disorders, osteoporosis, osteoarthritis, balance problems, cognitive decline - can cause unbearable and hopeless suffering.
These, often degenerative, disorders usually occur as people reach old age. It is the sum of one or more of these disorders and related complaints that cause suffering in connection with the history of the disease, the biography, the personality and the patient's values and capacities.
There were 205 such cases reported in 2018. Of these cases 66 involved persons under 90 years of age. The remaining 139 cases accounted for 27.15% of all cases of euthanasia of persons aged 90 years or more.
Euthanasia despite resistance
The district court in the Hague has ruled that a person with dementia may be euthanased even if the person is actively resisting the process provided that an advanced directive requesting euthanasia was completed when the person was considered competent.
The case involved a 74 year old woman whose coffee was drugged and who was forcibly restrained by family members while a doctor administered a lethal injection. She had said just a few days before that she didn't want to die.
However, the Court ruled that as she was now demented neither her contemporary expressions of a desire to live nor her active resistance were of any legal value. They were trumped by her previous written declaration.
The legal question posed by the case was stated by the Court:
Does the physician have a duty to verify the current desire for life or death of an incapacitated, deeply demented patient in order to speak of a voluntary, well-considered request for euthanasia?
The Court's answer was a clear no.
The court is of the opinion that the doctor did not have to verify the current wish to die. The patient was deeply demented and completely incapacitated. The use of pre-medication [that is drugging her coffee] was discussed with the family and doctors and was not negligent in this case.
The written advanced declaration signed by the woman included the following paragraph:
This euthanasia request remains in full force regardless of the time that may have elapsed since it was signed. It is completely clear to me that I can withdraw this euthanasia request. By signing this euthanasia request I therefore consciously accept the possibility that a doctor will respond to the request, about which I might have started to think differently in the case of current awareness.
There is an apparent contradiction in this paragraph. On the one hand the request can be withdrawn; on the other hand the doctor can act on the request even if the person has "started to think differently".
The Court essentially decided that as soon as a person with dementia becomes incapable of the level of decision making required to make a valid request for euthanasia, the person then can no longer validly revoke a previously made advanced directive for euthanasia.
In the opinion of the court, it would be contrary to the purport of the [euthanasia law] that a person who once became incapable of doing something would be able to revoke a legally valid euthanasia request previously made by him or her.
The Court considered evidence from the woman's GP who had met with her on 28 January 2016, three months before she was euthanased on 22 April 2016. The GP testified:
I wanted to know what she was like and what she thought about this [euthanasia]. I asked how it went and she said "it goes well". I then asked about admission and euthanasia. She didn't know what that was, the euthanasia. I explained it to her and at that moment she said, "no, I don't want that." I explained to her that she would be admitted and that she had to stay there and that she had previously indicated that she did not want that and then I started talking about euthanasia. She said: "yes, maybe I want it, but not now." You ask what my impression of her was, if she still understood. No. (…) For me it was the moment that she did not know exactly what euthanasia meant. You ask if I had the impression that she understood me after I explained what euthanasia meant. Yes, because I explained it to her. Because of her reaction to this, I felt that she understood what I meant. (..)
Counsel asks me whether (patient) was competent on euthanasia on this day, 28 January 2016. Not as far as I can judge. You, Commissioner-in-Law, ask me to explain why not. Before my explanation of euthanasia, she did not know what it meant. I had to go so far that I told her she would get an injection and not wake up. Only then did she say "no, no".
The geriatrician who euthanased the woman testified about an exchange with her on 10 March 2016, just seven weeks before she was euthanased:
(…) March 10, 2016 (...) Then I ask if she hates dementia. She does not recognize that word. I ask further whether she is troubled by the fact that she has less good memory and whether she finds it bad. She replies that she had that, but that this is already better, luckily. Then I ask her if she would rather be dead: yes, if I get sick, I will, but not yet
The Court dismissed medical guidelines requiring a doctor to check whether a person has a current desire before euthanasing him or her.
The court is aware that in the medical world guidelines have been drawn up about medical treatment in euthanasia in which the position is taken that the treating physician must also try to verify the patient's position on his current euthanasia desire even in the case of incapacitated persons. However, as is clear from the legal history cited above, that position is stricter than the law. From the point of view of medical care it may be advisable to speak with the person. However, the court was unable to see the need for this, let alone that there is a legal obligation to do so.
Any resistance can just be dismissed as "reflexive reactions that did not penetrate the consciousness of the patient."
Children as young as 12 years of age may be given euthanasia under the Netherlands euthanasia law.
For 12 to 15 year old children the parents must agree with the child’s request for euthanasia before it can put into effect. For 16 and 17 year olds the parents must be involved but the decision is for the child alone.
A total of fifteen children have been given euthanasia, including one 12 year old child in 2005, a 16 year old in 2015, five 17 year old children between 2002 and 2015 and two children (aged 16 or 17 years) in 2016, three children in 2017 (one aged 16 or 17 years, other two cases no case report), and three children (aged 16 or 17 years) in 2018.
All cases with detailed case reports (11 out of 15) involved end stage cancer. It is not known what the underlying condition was for the other four cases.
The failed euthanasia experiment in the Netherlands has demonstrated that legalised euthanasia rapidly expands from a few hard cases to become the normal way to die - including for people struggling with mental illness or trying to adjust to the usual frailties of old age. It also emboldens some doctors to readily kill their patients without any request from the patient and - in at least one case - in the face of active resistance from the person.