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
In Case 2016-85 the Review Committees found that a doctor had not acted with due diligence in administering euthanasia to a woman with Alzheimer’s disease. The woman had made a general reference in a living will to wanting euthanasia at the “right time”. At the time the doctor euthanased her she was not competent to voluntarily request it.
The doctor put medication in her coffee to reduce her consciousness deliberately so as to avoid her resisting being given drugs. Nonetheless she physically struggled against the administration of an intravenous lethal injection. She was physically restrained by family members while the doctor completed the administration of the lethal drugs.
On 13 June 2018 the Regional Disciplinary Court for Healthcare in The Hague considered a complaint against the doctor brought by the Inspectorate for Health Care and Youth. The decision was published on 24 July 2018.
The Court found that the written declaration of intent was not sufficiently clear to justify euthanasia in this case. It also found that the doctor should have tried to discuss the execution of euthanasia with the patient beforehand.
“In view of the irreversibility of termination of life and the ethical aspects connected with the deliberate ending of the life of a fellow human being, a written euthanasia declaration must be unambiguous, not needing any further interpretation.”
The Court did not completely ruled out that ambiguities in a written declaration of intent could be removed (even in the case of a demented patient) if a patient is later unambiguous, consistent and tenacious (verbally or non-verbally) in his statements about wanting death. However, with this patient this was not the case because she sometimes said she wanted to die and sometimes not.
Despite its finding that the doctor had seriously breached the requirements for euthanasia it only imposed a reprimand on the doctor.
On 9 November 2018 it was announced that a criminal investigation into this case by the Board of Public Prosecutors had concluded and that the doctor would be prosecuted.
This is the first time that the Dutch Public Prosecution Service (OM) will prosecute a doctor for euthanasia since the introduction of the Act on Termination of Life on Request and Assisted Suicide in 2002.
“After extensive investigation, the public prosecutor came to the conclusion that the nursing home doctor had not acted in accordance with the legal standards. The public prosecutor considers it important that the court assesses whether the doctor was entitled to rely on the living will completed by the woman. In addition, the OM reproaches the physician that she assumed that the woman still wanted to die without verifying this with the woman. Although the woman had regularly stated that she wanted to die, on other occasions she had said that she did not to want to die. In the opinion of the OM, the doctor should have checked with the woman whether she still had a death wish by discussing this with her. The fact that she had become demented does not alter this, because according to the Public Prosecution, the law also requires the doctor to verify the euthanasia request in such a situation. These two legal questions on the termination of life of people suffering from dementia justify the submission of this case to the criminal court judge.”
It is not yet known when the case will be heard by the District Court of The Hague.
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.