Netherlands (2002- )

Overall the evidence shows that euthanasia in the Netherlands is increasingly seen as normative as in 2021 it accounted for 10.63% of all deaths of persons aged between 17 and 79 years of age. Additionally euthanasia for dementia, for psychiatric conditions and for “an accumulation of old age problems” is becoming more frequent.

In 2021 there were 517 cases of euthanasia without explicit request, representing 5.28% of all euthanasia deaths. Nearly 1 in 150 (0.65%) of all deaths (other than sudden and expected deaths) of 17-64 year olds in the Netherlands were caused intentionally by euthanasia without an explicit request from the person being killed.

Euthanasia was formally legalised in the Netherlands on 1 April 2002 following 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 2023 report.

Increasing number of deaths

The number of reported deaths from euthanasia rose fivefold (500%) from 1,815 in 2003, the first year under the new law, to 9,068 deaths reported in 2023.

In 2003 some 1.28% of all deaths were brought about by reported acts of euthanasia.  In 2023 this had risen more than fourfold (418%) to 5.35% of all deaths.

The data above relates only to officially reported cases of euthanasia and assisted suicide. A more comprehensive picture is provided by the five or six 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 2021.

For 2021 there is a significant discrepancy (1,617) between the number of cases of euthanasia (9,038) or assisted suicide (245) with request reported by Statistics Netherlands and the number of such cases reported (as required by law) to the Euthanasia Review Committees – 7,477 cases of euthanasia and 189 of assisted suicide. 

Additionally, the 2021 Statistics Netherlands report records 517 cases of “ending life without an explicit request”.

So in total for 2021, there were 9,799 people whose deaths were caused intentionally by lethal medication representing nearly 1 in 20 (5.73%) of all deaths in the Netherlands – with 2,133 of those deaths (more than one in five or 21.77%) without an explicit request under the law, including 517 (5.28%) with no explicit request at all from the person.

In 2021 more than 1 in 10 (10.63%) of all deaths (other than sudden and expected deaths) of 17–79 year-olds in the Netherlands were caused intentionally by euthanasia or assisted suicide. Nearly 1 out of 3 of these deaths, or nearly 1 in 30 (3.24%) of all deaths (other than sudden and expected deaths) of 17–79 year-olds in the Netherlands were caused intentionally by euthanasia or assisted suicide outside the provisions of the law.

Nearly 1 out of 150 (0.65%) deaths of people aged between 17 and 64 years was caused by the administration  of lethal drugs with no explicit request at all from the person.

Complications

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 2021.

Grounds for euthanasia: psychiatric disorder and dementia

In 2023 there were 138 notifications of euthanasia or assisted suicide involving patients with psychiatric disorders (up 20% from 2022 and nearly ten times the 14 cases in 2012), including 22 people aged between 18 and 40 years.

Case 2022-085 involved the euthanasia of a young woman aged between 20 and 30 years of age who had obsessive-compulsive disorder, autism spectrum disorder (ASD), post-traumatic stress disorder related to being bullied when younger, and recurrent depressive episodes. The patient was also known to have anorexia nervosa and a mild intellectual disability.

In five of the 115 cases (4.35%) of euthanasia for psychiatric conditions in 2022,  the medical practitioner performing the euthanasia did so without complying with the requirement to consider fully the view of an independent psychiatrist who has examined the person in relation to the request for euthanasia.

In Case 2023-002, the medical practitioner who performed euthanasia on woman for her somatic symptom disorder (tinnitus) arrogantly defended his failure to consult an independent psychiatrist. The Review Committee ruled that breach of the due care criteria had occurred. It is not clear what further action, if any, the Review Committee is now taking in such cases

There were 288 notifications involving dementia (up 16.67% from 2022 and eight times the 42 notifications involving dementia in 2012). All these cases were in the absence of any other condition justifying euthanasia.

In 8 dementia cases, and in one case of cerebral haemorrhage, in 2023 euthanasia was performed on the basis of an advanced directive rather than a contemporary request by the person who was euthanased.

Multiple aging disorders

In 2022 there were 379 cases of euthanasia involving “multiple aging disorders” – up 23.45% from 2021.

More than four out of ten (157 cases – 41.4%) of these 379 cases were carried out by doctors from the Expertisecentrum Euthanasie (Euthanasia Expertise Centre).

The Euthanasia Code 2022 published by the Regional Euthanasia Review Committees provides for euthanasia on the basis of “multiple geriatric disorders”:

Multiple geriatric syndromes – such as sight impairment, hearing impairment, osteoporosis, osteoarthritis, balance problems or cognitive deterioration – may cause unbearable suffering without prospect of improvement. These syndromes, which are often degenerative in nature, generally occur in elderly patients, and a combination of these syndromes and the related symptoms can cause suffering. For these patients, too, the suffering and its unbearable nature are connected to matters such as life history, personality and stamina.

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."

In Case 2023-065 a man who had made an advanced directive requesting euthanasia for Alzheimer’s Disease was administered drugs to ”soothe the man before the execution” of euthanasia, the man was given 30 mg of midazolam by a regular trusted nurse. This was justified, according to the Review Committees, “due to the man's troubled behaviour and the possible manifestations of anger, frustration and physical aggression”. “This caused the man to fall asleep. The doctor then performed the euthanasia in the presence of the wife and children in accordance with the Guideline.”

Child euthanasia

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 20 children have been given euthanasia, including a 12 year old child in 2005, a 16 year old child in 2015, five 17 year old children between 2002 and 2015, 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), three children (aged 16 or 17 years) in 2018, one boy (aged between 12 and 16 years) in 2020, one boy, aged 16-17 years in 2021, one child aged 12-15 years in 2022 and two children aged 16-17 years in 2023.

All cases with detailed case reports (14 out of 20) involved end stage cancer. It is not known what the underlying condition was for the other six cases.

Children under 1 year of age may be euthanased after approval by an "expert" committee. Two children have been euthanased under this scheme, including, in 2017, an infant with a serious neurological disorder but a life expectancy of up to 10 years.

Statistics Netherlands reports that in 2021, six children aged less than 1 year with congenital anomalies were killed by intentional by the administration of lethal drugs. It is not clear if these cases involved the "expert" committee.

On 14 April 2023 the Minister for Health, Welfare and Sport announced that the existing regulation would be broadened before the end of 2023 to apply to children aged up to 12 years and streamlined to allow for more ready approvals to euthanase children.

Conclusion

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.

Download a summary on the Netherlands