March 2002

In the fall of 2000 the Dutch Parliament passed a statute that formally legalized euthanasia and physician-assisted suicide in the Netherlands. Although the world media treated the passage as a major event, both practices had long been legally sanctioned as the result of a series of case decisions going back to the early 1970s that had made the Netherlands the only country where euthanasia and physician-assisted suicide were widely practiced.
Those in the Netherlands who seek an explanation for the Dutch embrace of assisted suicide and euthanasia usually emphasize the country's historical tradition of tolerance. The Dutch had fought to secure their religious freedom in the sixteenth and seventeenth centuries, and the Netherlands became a refuge for Jews, Catholics, and free thinkers like Spinoza and Descartes who fled there from religious oppression. Dutch secular society in the same period was marked by the Netherlands becoming a major maritime power whose merchants had to learn to accept different cultures, traditions, and practices.1 In modern times the Dutch point to the presence of fifty different religions--most due to schisms in the Protestant church--and approximately twenty-five political parties. So much diversity in such a small country is seen as a sign of Dutch tolerance.2
Tolerance does not imply integration. Splitting up into so many autonomous groups has been seen as reflecting an inability to tolerate the conflict that differences bring. Derek Phillips, professor of sociology at the University of Amsterdam, sees the division into so many parties and religious denominations as coming from a difficulty in accepting the ambiguity and tension that result when people of different viewpoints are interacting in the same group. Dutch academic journals, for example, do not tend to reflect a diversity of viewpoints; more characteristically, different opinions find expression in separate journals.3 Comparably, when the Royal Dutch Medical Society (KNMG) supported physician-assisted suicide and euthanasia, religious physicians formed a separate medical group opposed to euthanasia. The Dutch medical establishment believes that all opposition to euthanasia is fundamentally religious in nature but is far less tolerant of nonreligious physicians who oppose euthanasia on medical grounds and try to do so within the framework of organized medicine.4 Compartmentalizing differences is seen as avoiding direct engagement and maintaining consensus within respective autonomous groups.
Most scholars point to Dutch Calvinism as an essential starting point in understanding the origins of contemporary Dutch attitudes toward euthanasia. Calvinism in the Netherlands had a puritanical self-righteous intensity in its faith in the virtue and guidance of the elect, its discouragement of pleasure, its belief that the endurance of suffering was admirable as well as redemptive, and its dedication to work, attitudes that once diffused throughout the society. These attitudes found expression in both the Roman Catholic Church and the Dutch Reformed Church. Protestantism and Catholicism were considered to be two of the three pillars on which Dutch society rested; the third was secularism. All three columns had a remarkable degree of autonomy, and each had its own schools, hospitals, and social organizations.5
As social revolution swept through the Western world in the 1960s, the influence of the Dutch Reformed Church and the Roman Catholic Church was eroded in the Netherlands, but the power of secularism remained. A new consensus emerged that held that individual autonomy should prevail whenever possible in seeking pleasure and avoiding pain. Such liberalization is viewed as a welcome shift away from an austere Puritanism toward a broad tolerance of diverse behavior. However, the emphasis on autonomy reflected the tendency to split along lines of difference that was now being defined in terms of autonomous individual behavior. The consensus that developed around euthanasia and other social changes was seen by Dutch observers as Calvinist in its intensity and self-righteousness but organized around the values of a secular culture. Dutch acceptance of drug use, dramatized by the crowds of young people who fill major public squares using drugs openly; acceptance of public displays of prostitution; and embrace of euthanasia have been seen as related evidence of antipuritanical changes that flowed from the social revolution. The view of Dutch tolerance of drug use, pornography, prostitution, and euthanasia as simply a reaction against an earlier set of religious values is not the whole story and will be explored from a contemporary perspective later in this chapter. Before the 1960s, however, there was not the interest in euthanasia in the Netherlands that had been present for some time in England and the United States and led to the formation of voluntary euthanasia societies in both countries in the 1930s--thirty-five years before such a society was organized in the Netherlands.
In 1973, against a background of social ferment, a euthanasia case first received widespread public attention in the Netherlands: a physician ended the life of her ailing seventy-eight-year-old mother at her mother's request. Popular support grew for the physician and for the Dutch court in Leeuwarden that found her guilty but refused to punish her. The court relied on an expert witness, a medical inspector for the national health service, who stated that it was no longer considered right for physicians to keep patients alive to the bitter end under certain conditions. These conditions were spelled out in detail in a subsequent case when, in 1981, a Rotterdam court, in finding a layperson guilty of assisting in a suicide, volunteered the opinion that a physician doing so might be exempt from punishment under the Dutch penal code if there had been a voluntary request from a person suffering unbearably with no reasonable alternatives for relief and if the physician had consulted with another physician in making the decision.
In 1984, a case reached the Dutch Supreme Court. A physician who had assisted in the suicide of a ninety-five-year-old woman had been acquitted, but the decision for acquittal was reversed by an appellate court. The Supreme Court overturned the conviction, arguing that the appellate court had failed to consider whether the physician was placed in an intolerable position because of what it called a "conflict of duties." Was the patient's suffering such that the physician was forced to act in a situation "beyond [his or her] control?" The court referred the case back to an appellate court in The Hague with the instruction to consider the case with one dominant consideration from an objective medical perspective: could the euthanasia practiced by the physician be regarded as an action justified in a situation of medical necessity?7
This ruling invited and obliged the prosecutor in The Hague to rely heavily on the opinion of the Royal Dutch Medical Association (KNMG)as to the acceptability of euthanasia from the professions' standpoint. Critics of the Supreme Court's ruling were unhappy at what they perceived as the court's abdication of moral and legal authority to the medical profession. The statement given by the KNMG to the appellate court paraphrased the Supreme Court's language to declare that in a situation of necessity (force majeure) a physician could be justified in honoring a request for euthanasia.8
Even before the decision was issued in The Hague dismissing the charges against the physician, the KNMG had sent a letter to the Minister of Justice asking for a change in the law to permit euthanasia. Although there was public sympathy for the physicians involved in the euthanasia cases and support for the practice of euthanasia, there was not then support for changing the statute. Physicians were able to practice euthanasia with only the protection of case law. Prosecutions, however, were rare, and punishment, even in cases of conviction, was virtually nonexistent.
Eventually, a consensus on guidelines for practicing euthanasia was reached by the courts, the KNMG, the Ministry of Justice, and the Dutch Health Council. When patients experiencing intolerable suffering that could not be relieved in any other way made a voluntary, well-considered, and persistent request to a physician for euthanasia, the physician, if supported in the decision by another physician, would be justified in performing euthanasia. The doctor should not certify the death as due to natural causes and should notify the medical examiner, who would file a report with the local prosecutor, who could investigate further or allow the deceased to be buried. If these guidelines were followed the physician would not be prosecuted under Dutch law that, at the time, treated euthanasia as a criminal offense. In 1993, a statute was enacted that gave further protection to physicians by explicitly stipulating that a physician following the guidelines would not be prosecuted.
In response to domestic and international concern about reports of abuse, the Dutch government sponsored a study of physician-assisted suicide and euthanasia in 1990.9 That study, which was largely replicated in a 1995 study, was supported by the KNMG with the promise that physicians who participated would receive immunity from prosecution for anything they revealed.

In 1996 the investigators published a report of their new findings in Dutch10 and summarized their work in two articles in the New England Journal of Medicine,11 which were supported by an editorial in that journal.12 These reports concluded that, since matters had not grown worse during the five years between the two studies, there was no evidence that "physicians in the Netherlands are moving down a slippery slope."13 That conclusion was misleading.
In this context, the "slippery slope" is the gradual extension of assisted suicide to widening groups of patients after it is legally permitted for patients designated as terminally ill. In the past three decades, the Netherlands has moved from considering assisted suicide (preferred over euthanasia by the Dutch Voluntary Euthanasia Society) to giving legal sanction to both physician-assisted suicide and euthanasia, from euthanasia for terminally ill patients to euthanasia for those who are chronically ill, from euthanasia for physical illness to euthanasia for psychological distress, and from voluntary euthanasia to nonvoluntary and involuntary euthanasia. ("Nonvoluntary" is used to describe euthanasia with patients not capable of requesting it; "involuntary" is used to describe euthanasia with patients who did not request it but were capable of doing so.)
According to the KNMG, it did not seem reasonable medically, legally, or morally to sanction only assisted suicide, thereby denying more active medical help in the form of euthanasia to those who could not effect their own death.14 Most patients and physicians prefer euthanasia because they see it is less subject to complications and failure. Nor could the Dutch deny assisted suicide or euthanasia to chronically ill patients who have longer to suffer than those who are terminally ill, or to those who have psychological pain not associated with physical disease. To do so would be a form of discrimination. Nonvoluntary and involuntary euthanasia are not legally sanctioned by the Dutch, but they are increasingly excused as necessary to end the suffering of patients who, for a variety of reasons, are not able or willing to choose to hasten death.15 Except for the legal sanction of euthanasia for mental suffering without physical illness, all of these other expansions of the practice of euthanasia had taken place by 1990 and were documented by the 1990 study.
Comparing the data for the 1990 and 1995 studies is revealing. From 1990 to 1995, the death rate from euthanasia increased from 1.9 percent to 2.2 percent of all deaths, when based on interviews with 405 Dutch physicians selected from a stratified random sample. The rate increased from 1.7 percent to 2.4 percent when based on responses to a questionnaire completed by more than 4,600 physicians in both years (table 5.1). The increase in euthanasia deaths, ranging from 16 percent to 41 percent (from 573 to 1,064 deaths), would seem significant, but the Dutch investigators do not regard it as such even though they give "generational and cultural changes in patients' attitudes" as a possible explanation for the increase.16 The investigators describe the rates of physician-assisted suicide as remaining constant and low although, based on the interview study, the actual number increased from 380 to 542.

CLICK HERE For Table 5.1 Estimated Incidence of Specific Medical Decisions at the End of Life

Guidelines Have Failed
The extension of euthanasia to more patients has been associated with the inability to regulate the process within established rules. Virtually every guideline set up by the Dutch--a voluntary, well-considered, persistent request; intolerable suffering that cannot be relieved; formal consultation with a colleague; and reporting of cases--has failed to protect patients or has been modified or violated.17
Many of the violations are evident from the officially sanctioned studies. For example, the studies reveal that more than 50 percent of physicians considered it appropriate to suggest euthanasia to patients.18 Neither the physicians nor the study's investigators seem to acknowledge how much the voluntariness of the process may be compromised by such a suggestion.
Intolerable suffering that cannot be relieved has always been regarded as a necessary criterion for euthanasia in the Netherlands. In 74 percent of cases, physicians reported that such suffering was the major reason for patients requesting euthanasia. In a quarter of cases, however, fear of future suffering or loss of dignity was more important; neither of these reasons by itself would seem to satisfy the criterion of unrelievable suffering.
What if patients do not want treatments that will relieve their suffering? That is their right in the Netherlands as elsewhere, but then they do not meet the criterion for euthanasia. The Dutch Supreme Court affirmed that with regard to mental suffering, euthanasia is not permissible if palliative treatment is possible, even if it is refused by the patient. The KNMG stated that this should be true for somatically based suffering as well. In 17 percent of cases in 1995, however, physicians admitted that even though treatment alternatives had been available, euthanasia was performed.
Consultation takes place in about 80 percent of the reported cases, but interviews with physicians revealed that in only 11 percent of the unreported cases was there consultation with another physician.19 Taken together, these figures indicate that there is consultation in about half of Dutch euthanasia cases. When life was terminated without request, there was no consultation in 97 percent of cases.
Of the physicians who had been a consultant more than once, 50 percent had previously been consulted by the same physician; 24 percent had themselves previously consulted the attending physician in euthanasia cases of their own.20 Recognizing that such "pairs" may compromise the independence of consultants, the Dutch investigators subsequently recommended that independent consultants be chosen. In the overwhelming majority of cases, the physician's mind had been made up before consulting; not surprisingly, the consulting doctor disagreed in only 7 percent of cases. In 12 percent of cases the consulting physician did not actually see the patient. Convenience of location and agreement on life-ending decisions were the major reasons given for consulting a particular physician; knowledge of palliative care was hardly mentioned.
Under-reporting has been a serious problem. In only 18 percent of cases in 1990 had physicians reported their euthanasia cases to the authorities as required by Dutch guidelines. To encourage more reporting of cases, a simplified notification procedure was enacted. It ensured that physicians would not be prosecuted if guidelines were followed. The investigators credit this procedural change with contributing to an increase in the cases reported to 41 percent by 1995, while acknowledging that a 59 percent rate of unreported cases is still disturbingly high.
The Dutch studies reveal that half of the physicians who had not reported their most recent case of euthanasia gave as a reason their wish or that of their family to avoid a judicial inquiry, 20 percent the fear of prosecution, 16 percent the failure to fulfill the requirements for accepted procedures, and 14 percent the belief that euthanasia should be a private matter. Between 15 percent and 20 percent of doctors say they will not report their cases under any circumstances. Twenty percent of the physicians' most recent unreported cases involved ending a life without the patient's consent.21 Such cases, both the 1990 and 1995 studies revealed, were virtually never reported.

Death without Consent
The most alarming concern to arise from the Dutch studies has been the documentation of cases in which patients who have not given their consent have had their lives ended by physicians. The 1990 study revealed that in 0.8 percent of the deaths (more than 1,000 cases) in the Netherlands each year, physicians admitted they actively caused death without the explicit consent of the patient. The 1995 figure is 0.7 percent (fewer than 1,000 cases), but the researchers, while pointing to the decline, concede that differences in the way this particular information was obtained make its significance uncertain. In both studies, however, about a quarter of physicians stated that they had "terminated the lives of patients without explicit request" from the patient to do so, and a third more of the physicians could conceive of doing so. The use of the word explicit is somewhat inaccurate, since in 48 percent of these cases there was no request of any kind22 and in the others there were mainly references to patients' earlier statements of not wanting to suffer.23
The 1990 study documented, and the 1995 study confirmed, that cases classified as "termination of the patient without explicit request" were a fraction of the nonvoluntary and involuntary euthanasia cases. International attention had centered on the 1,350 cases (1% of all Dutch deaths) in 1990 in which physicians gave pain medication with the explicit intention of ending the patient's life.24 The investigators minimized the number of patients put to death who had not requested it by not including these 1,350 patients in that category.
By 1995 there had been an increase in the number of deaths in which physicians gave pain medication with the explicit intention of ending the patient's life from 1,350 cases to 1,896 (1.4% of all Dutch deaths).25 These are comparisons that the Dutch investigators do not make. As reported by the physicians in the 1995 study, in more than 80 percent of these cases (1,537 deaths), no request for death was made by the patient.26 Since these are cases of nonvoluntary, and involuntary (if the patient was competent), euthanasia, this is a striking increase in the number of lives terminated without request and a refutation of the investigators' claim that there has been perhaps a slight decrease in the number of such cases.
If one totals all the deaths that resulted from euthanasia, assisted suicide, ending the life of a patient without consent, and giving opioids with the explicit intention of ending life, the estimated number of deaths caused by active intervention by physicians increased from 4,813 (3.7% of all deaths) in 1990 to 6,368 (4.7% of all deaths) in 1995 (table 5.1). Based on data from the questionnaire study, this is an increase of 27 percent in cases in which physicians actively intervened to cause death. Of the more than 6,000 deaths in which physicians admit to having actively and intentionally intervened to cause death, 40 percent involved no explicit request from the patient for them to do so.
The Dutch investigators minimize the significance of the number of deaths without consent by explaining that the patients were incompetent.27 But in the 1995 study, 21 percent of the individuals classified as "patients whose lives were ended without explicit request" were competent; in the 1990 study, 37 percent were competent.28 We are not told what percentage of those patients who were given pain medication intended to end their lives without discussing it with them were competent, but analysis of the data for opioid administration indicated that it is likely to be at least 20 percent.
More than 4,000 additional competent patients were given pain medication in amounts likely to end their lives by physicians who did not discuss the decision with them, but whose primary intention was not to end their lives.29 Whether the intention was to end life or whether death was simply likely, physicians usually gave as the reason for not discussing the decisions with the patients that they had previously had some discussion of the subject with the patients.30 Apparently they thought that was sufficient justification for ending a life or putting it at risk without determining the patient's current wishes.
The practice of involuntary euthanasia is often defended on the grounds of compassion. An illustration given me by the attorney for the Dutch Voluntary Euthanasia Society of why it was sometimes necessary for physicians to end the lives of competent patients without their consent was the case of a nun whose physician ended her life a few days before she would have died because she was in excruciating pain but her religious convictions did not permit her to ask for death.31 Compassion is not the only motive in such cases. A Dutch woman with disseminated breast cancer who had said she did not want euthanasia had her life ended because, in the physician's words, "It could have taken another week before she died. I just needed this bed."32

The Limitations of the Dutch Studies
Political considerations have admittedly influenced the Dutch studies and their conclusions. I asked the Dutch investigators why physicians were not challenged when they offered implausible explanations for ending fully competent patients' lives without consulting them. The investigators explained that securing and retaining the cooperation of the KNMG and the participating physicians demanded that the physicians and policies not be challenged.33
The reasons given by physicians for failure to report their cases, such as the families' fear of judicial inquiry or the physician's fear of prosecution, also seem to require further questioning. The investigators state that the doctors' violations were not substantive but procedural, by which they mean failure to obtain written request from the patient, to write a written report, or to obtain a consultation. Failure to obtain a consultation is procedural only if the investigators have accepted the attitude of so many Dutch physicians that consultation is not for the benefit and protection of the patient but only to meet a legal requirement. In addition, the "procedural" explanation ignores the large number of unreported cases that involve the death of a patient who has not requested it, a matter that under any definition is not merely "procedural."
In addition, the researchers draw conclusions that exceed their evidence.34 The 1990 and 1995 studies accepted physicians' assertions that their patients had received the best possible care and that there was no alternative to euthanasia. These statements are not supported by any objective data. Indeed, studies have demonstrated the inadequacy of physicians' training in palliative care in the Netherlands.35 Since the statements of the responding physicians were accepted by the investigators without challenge, there was no exploration of possible alternatives to euthanasia.36 Since neither the attending doctors, nor the consultants, nor the physician- interviewers in the government-sponsored studies were trained in palliative care, they were not in a position to ask the right questions.
The Dutch investigators, the KNMG, and the Dutch government are most sensitive to the charge of "involuntary euthanasia," a term they avoid by referring to such cases as "termination of the patient without explicit request." After the first report on the Dutch findings was published, the project investigators wrote an article and one of them published a thesis, trying in both publications to justify the involuntary cases (the patients did not have long to live; the same thing was happening in other countries but secretly), while admitting it would be preferable if such cases were kept to a minimum.37 At some point the investigators seem to have realized that "termination of the patient without explicit request" had an Orwellian sound to the English-speaking world that was even worse than "involuntary euthanasia," and they now use the acronym LAWER, "life-ending acts without the explicit request of the patient," an acronym that vaguely suggests legality.
I asked Paul van der Maas, the principal Dutch investigator, why patients who had consented to be given pain medication by physicians with the explicit intention of ending their lives were not counted as euthanasia cases. He agreed that such cases could have been counted as euthanasia cases, thereby increasing that total. The only difference was that in ordinary euthanasia cases, since a drug to stop respiration was also administered, death took place almost immediately, while in patients given only overdoses of pain medication, death could take a number of hours. I then asked why patients who had not consented and were given pain medication by physicians with the explicit intention of ending their lives were not counted as cases whose lives had been terminated without explicit request. He not only was reluctant to do so, but also could not give me a reason. Of course, counting these cases would have made evident that their number had more than doubled since 1990, which would have aroused worldwide concern and criticism. The true number of cases in which patients' lives are terminated without their explicit request is being concealed by the way such deaths are labeled.
Both the 1990 and 1995 studies are flawed for all of the above-mentioned reasons. When cases are classified and counted so as to minimize disturbing findings, when implausible explanations are accepted without challenge, and when conclusions that might offend are not stated, there is a need for more objective and inclusive exploration and analysis. That exploration and analysis will have to include a realization that notification by physicians of all euthanasia cases would not by itself diminish abuse of euthanasia in the Netherlands. Nor could better case counting and classification do the job without exploring the interactive decision-making process that is at the heart of euthanasia and is not addressed in the Dutch research.
Despite the limitations of the government-sanctioned studies, on the basis of those studies alone it has been possible for investigators to conclude "that the so-called strict safeguards laid down by the courts and the Royal Dutch Medical Association . . . had largely failed."38 When, as the 1990 and 1995 studies document, 59 percent of Dutch physicians do not report their cases of assisted suicide and euthanasia, when more than 50 percent feel free to suggest euthanasia to their patients, and when 25 percent admit to ending patients' lives without the patient's consent, it is clear that terminally ill patients are not adequately protected.
All of these problems were evident in the 1990 study, but it took a long time for them to be realized and understood. A brief article in the British journal the Lancet39 followed by several equally brief articles hardly did justice to the findings. The study was published in a 1991 book that was translated and published in English a year later. The book is difficult to read in either Dutch or English, and much of the key information must be found in tables. The few observations made in the book tend to minimize problems in ways that are misleading. For example, the book points out that a large majority of the patients whose lives were ended without request were incompetent; the table reveals that 37 percent were competent, which means that hundreds of competent patients had their lives ended without their consent.
The Dutch findings were accepted uncritically both in the Netherlands and abroad by observers who, I have been surprised to find, had invariably not read the full report. The 1995 study was also published in full in Dutch and in two articles in the New England Journal of Medicine, but there are currently no plans to translate the full report into English. It has taken years and a thorough comparison of the two studies by scholars in the Netherlands, England, and the United States to begin finally to make the educated public fully aware of the extent of the problems in the Dutch system.

More Than Figures
Since the government-sanctioned Dutch studies in 1990 and 1995 are primarily numerical and categorical, they do not give a picture of what these violations of guidelines mean in actual practice with patients. Nor do the studies examine the interactions among physicians, patients, and families that determine the decision for euthanasia. We need to look elsewhere for a fuller picture. Other studies conducted in the Netherlands have indicated how voluntariness is compromised, alternatives are not presented, and the criterion of unrelievable suffering is bypassed.40 Some examples may be helpful.41
A wife who no longer wished to care for her sick, elderly husband gave him a choice between euthanasia and admission to a home for the chronically ill. The man, afraid of being left to the mercy of strangers in an unfamiliar place, chose to have his life ended; the doctor, although aware of the coercion, ended the man's life. In a study done in Dutch hospitals, doctors and nurses reported that more requests for euthanasia came from families than from patients themselves. The investigator concluded that the families, the doctors, and the nurses were involved in pressuring patients to request euthanasia.42

A physically healthy fifty-year-old woman who had recently lost her son to cancer refused all psychiatric treatment and said she would accept only help in dying. Her case contributed to extending the criteria for euthanasia to include mental suffering without physical illness. It also provides some insight into the Dutch legal system.
The woman was assisted in suicide by a psychiatrist, Boudewijn Chabot, within four months of her son's death. Chabot had told her that he could not make such a decision until he knew her better, implying that if after time he considered her decision appropriate he would assist her. The woman saw him for a number of sessions over a two-month period, eventually telling him she would leave if he did not help her, at which point he did.
During the course of our interviews Chabot told me that his patient suffered from incurable grief. Her refusal of treatment was considered by him to make her suffering unrelievable. The woman had told Chabot that if he did not help her she would kill herself without him. He seemed on the one hand to be succumbing to emotional blackmail and on the other to be ignoring the fact that even without treatment, experience has shown that time alone was likely to have affected her wish to die. Before assisting in the suicide, Chabot had sent a written account of the case to a number of consultants, requesting their opinion and asking one of them to see the patient. The majority felt he should go forward, but none, including the one asked, felt it was necessary to see the patient. Since Chabot, as required, filed a report with the local coroner, and since the case was breaking new ground in being the first involving purely mental suffering to come to public attention, it was taken to court by a reluctant public prosecutor, who asked for a verdict of a year's suspended sentence. The prosecutor's own witness agreed that the assisted suicide was justified. Chabot was acquitted and that acquittal sustained on appeal.43
To American eyes accustomed to a legal system in which each side tries to win, the trial seems strange. In the Netherlands, however, the legal system is consensual, that is, it aims at a decision that tries to meet the needs of all concerned, including the community at large, rather than adversarial, where one side wins and the other loses. And the consensus shared by doctors, patients, lawyers, and judges in the Netherlands is strongly supportive of physicians in assisted suicide or euthanasia cases.
In reviewing this case, however, the Dutch Supreme Court, while affirming that mental suffering alone could be reason for performing euthanasia, found Chabot guilty of not having had a consultant see the patient, which it said was necessary in a case in which no physical illness was involved. No punishment was imposed because the court felt that in all other respects Chabot had behaved correctly. The KNMG felt even this mild reprimand was unfair, since in previous cases involving physical illness, courts had not been willing to convict simply because a consultant was not called, and Chabot had no reason to assume the situation in this case would be different. I felt that all of the consultants shared responsibility for not having asked to see the patient, whether required to or not, but this was not a view shared by those in the association with whom I spoke.
Wilfrid van Oijen, a Dutch physician who was filmed ending the life of a patient recently diagnosed with amyotrophic lateral sclerosis, said of the patient, "I can give him the finest wheelchair there is, but in the end it is only a stopgap. He is going to die and he knows it." That death may be years away, but a physician with this attitude may not be able to present alternatives to this patient. The patient in this case was clearly ambivalent about proceeding and wanted to put off the date for his death. This ambivalence was ignored by the doctor, who was supporting the desire of the patient's wife to move forward quickly. Van Oijen never saw the patient alone, permitted the wife to answer all questions for the patient about whether he wanted to die, and presented an exaggerated picture of the death that awaited him without euthanasia.44
In Appointment with Death, a documentary film by the Dutch Voluntary Euthanasia Society that was intended to promote euthanasia, a forty-one-year-old artist was diagnosed as HIV positive. He had no physical symptoms but had seen others suffer with them and wanted his physician's assistance in dying. The doctor compassionately explained to him that he might live for some years symptom free. Despite this, over time the patient repeated his request for euthanasia. Although the doctor thought his patient was acting unwisely and prematurely, he did not know how to deal with his patient's terror. He rationalized that respect for the patient's autonomy required that he grant the patient's request.
Consultation in the case was pro forma; a colleague of the doctor saw the patient briefly to confirm his wishes. And while the primary doctor kept establishing that the patient was persistent in his request and competent to make the decision, thus formally meeting those criteria, the doctor did not address the terror that underlay the patient's request.
This patient had clearly been depressed and overwhelmed by the news of his situation. Had his physician been able to deal with more than formal criteria regarding a request to die--more likely in a culture not so accepting of assisted suicide and euthanasia--this man would probably not have been assisted in suicide.45

A Cure for Suicide
This last case appeared to cry out for psychiatric consultation, but one was never considered. Even though a desire for suicide is considered a primary indication for psychiatric evaluation, such consultation is not likely in the Netherlands. This is true despite the fact that terminally ill patients with a desire to hasten death are, like other suicidal patients, likely to have a depression that will respond to treatment. A survey of Dutch psychiatrists indicated that only 3 percent of Dutch patients requesting assisted suicide or euthanasia are referred for psychiatric consultation. In cases where there is physical illness, only 19 percent of Dutch psychiatrists thought a psychiatric consultation should always be requested.46 They were perhaps unfamiliar with the substantial evidence that general physicians are not able to evaluate when patients have psychiatric disorders that may be interfering with their judgment. The Dutch psychiatrists and the government-sponsored investigators make a fairly rigid distinction between physical and mental suffering. Yet in most cases, as in the case of the young man discussed above, both physical and psychological suffering are apt to be present, and the psychological is often the more important. That physical/psychological dichotomy, pervasive in the Netherlands, has had an important impact on the treatment of medical patients who become suicidally depressed.
Since the early 1980s, as assisted suicide and euthanasia have become increasingly available in the Netherlands, the suicide rate among those over fifty has fallen by a third.47 This is the age group containing the greatest number of euthanasia cases (86% of the men and 78% of the women) and the greatest number of suicides. The remarkable decline in suicide in this older age group appears to be due to the fact that older suicidal patients are now asking to receive euthanasia instead. The likelihood that patients would end their own lives if euthanasia was not available to them was one of the justifications given by Dutch doctors for providing such help. If any significant percentage of these cases had been counted as suicides, the suicide rate would actually have risen.
Of course, proponents of euthanasia can maintain that making suicide "unnecessary" for those over fifty who are physically ill is a benefit of legalization rather than a sign of abuse. Such an attitude depends, of course, on whether one believes that there are alternatives to assisted suicide or euthanasia for dealing with the problems of older people who become ill.
Among an older population, physical illness of all types is common, and many who have trouble coping with physical illness become suicidal. In a culture accepting of euthanasia, their distress is accepted as a legitimate reason for dying.

Procedure, Not Substance
Consistent with its view that any Dutch problems with euthanasia are basically procedural, the KNMG has made various recommendations to improve the procedures for dealing with euthanasia cases without addressing the basic substantive problems. In 1995 the organization refined its guidelines: assisted suicide rather than euthanasia should be performed whenever possible; a second physician who has no professional or personal ties to the first should actually see the patient; physicians need not participate in euthanasia but must refer the patient to doctors who will; and physicians must report all cases of euthanasia to the authorities.
The protection of the patient is usually cited as the reason for preferring assisted suicide to euthanasia, but the strain on the doctor was given by the KNMG as the reason for this suggested change. A KNMG spokesperson explained that "many doctors find euthanasia a difficult and burdensome action and the patient's participation diminishes the burden slightly."48 Physicians who perform euthanasia infrequently may follow the KNMG suggestion, and the guideline seems intended to encourage reluctant doctors to participate. Physicians who perform euthanasia more often are not likely to be deterred, since they see assisted suicide as more open to complications and failure.
The KNMG does not see a contradiction between saying that doctors need not participate in euthanasia and demanding that they make a referral that is against their conscience. The KNMG spokesperson explained that a doctor cannot "leave a patient in the cold at the last moment. He should help find alternatives." But no alternatives other than suffering or euthanasia are envisioned.
The reasonable recommendation by the KNMG that independent consultants should actually see the patients is, unfortunately, not likely to make much of a difference. Practitioners of euthanasia are known by reputation to every doctor, but they are not expert in palliative care; their seeing the patient or their not being a friend of the referring physician is not apt to change the result.
The Dutch investigators have recommended that some physicians specialize as euthanasia consultants, building up experience in the "medico-technical aspects of assisted suicide and euthanasia and the possibilities of palliative care."49 Acting as a consultant in euthanasia cases, however, does not somehow make a physician knowledgeable about palliative care. My own experience with a few physicians in the Netherlands who had performed or been consultants in dozens of euthanasia cases was that they were surprisingly uninvolved in palliative care. Nor did they show sensitivity to the ambivalence that accompanies most requests to die, which was clearly evident in some of the cases we discussed.50 They seemed to be facilitators of the process rather than independent evaluators of the patient's situation who might be able to relieve suffering so that euthanasia seemed less necessary to the patient. One prominent consultant described his role as easing the doubts of physicians who were uncertain as to whether to go forward with euthanasia. He and the other consultants were certainly knowledgeable in the "medico-technical" aspects of euthanasia (i.e., they could end life quickly and efficiently).

Wilfrid van Oijen, the Dutch physician mentioned earlier who was filmed performing euthanasia on a patient with amyotrophic lateral sclerosis, is a case in point. Although the film seems to minimize van Oijen's role as a euthanasia consultant, showing him in his family practice attending to regnant women and small children, he tells us, "I perform euthanasia three or four times a year. It's not like I plan to go out with my Uzi and mow down crowds of people." In the Dutch version of the film he indicates that he is the consulting physician in three or four euthanasia cases a year in addition to the three or four he "believes" he performs himself. The average Dutch doctor in a general practice, however, is not involved in six to eight cases a year and is likely to have performed euthanasia only a relatively few times in a career. The Dutch Voluntary Euthanasia Society was sufficiently familiar with van Oijen's work as a specialist in euthanasia that when approached by a filmmaker who wished to film an actual case the society referred him to van Oijen. And while the physician is certainly not a terrorist or mass murderer mowing down people with an Uzi, he is more of a professional hired for a special skill than he is willing to admit. His dismissive attitude toward a wheelchair for his patient makes clear that while he is a euthanasia consultant it is not because of any interest in or knowledge he has of palliative care.51
It is worth noting that in 2001, van Oijen was found guilty by a Dutch court of ending the life of an eighty-four-year-old woman at her daughters' request--not the woman's own. The woman had heart problems and was increasingly bedridden. She was not in pain and said she did not want to die but could not care for herself. She had indicated a desire to be with her daughters, who cared for her at home, but her care had evidently become burdensome to them. Van Oijen gave her a medication that paralyzed her breathing but claimed he was not intending to end her life, only to speed up the process of dying. The case turned on the opinion of expert witnesses that the medication as given could not be considered part of palliative care. Although declaring van Oijen legally guilty of murder, the court imposed no punishment since it felt that while he made an "error of judgment" he had acted "honorably and according to his conscience" in what he considered the interests of his patient. Van Oijen had not asked for a second opinion in the case; he had also falsely reported the death as due to natural causes, and for this he was found guilty and fined 5,000 guilders ($2,140). The KNMG defended van Oijen's actions, claiming that he acted with "complete integrity.52
Neither the opinion of the KNMG nor that of the Dutch Supreme Court is likely to prevent euthanasia in cases in which a patient has refused a viable treatment alternative. Patients in the Netherlands, like patients elsewhere, have a right to refuse unwanted treatment. The physician may in good faith wrongly believe there are no treatment options available, and there is no requirement that anyone with expertise be consulted. Moreover, the Dutch Minister of Justice explicitly stated and instructed the attorneys general that refusal by the patient of treatment alternatives does not render euthanasia illegal.53 Some in the Netherlands see a shift away from justifying euthanasia on the basis of unrelievable suffering and the possibility of relieving it toward justifying euthanasia based on patient choice as the natural progression of a liberal society's increasing emphasis on autonomy.54 Such a shift would remove one of the bedrock safeguards on which the Dutch system was built. It also ignores the reality of what actually happens when a suffering patient is confronted with a physician who does not know how to relieve that suffering except by euthanasia. If the only alternatives are continued suffering or an early death, patients are not likely to feel they have a choice.
To encourage more reporting of cases, in 1998 the Dutch government adopted a procedure whereby cases are reported to nongovernmental regional groups of three people who evaluate the case--a lawyer, a physician, and an ethicist--as well as to the coroner and the local prosecutor. The prosecutor was to be guided by the group's opinion in deciding whether the case required investigation. This procedure was incorporated into subsequent legislation with a significant modification stipulating that only if the three-person group considered that the physician violated the Dutch guidelines for assisted suicide or euthanasia would the case be reported to the coroner and the prosecutorial authorities. Since the physician in the group is not required or likely to have training in palliative care, and since the group members will know only what the physician reporting the case chooses to tell them, it is hard to see how the group will be able to evaluate such cases. Of course, if patient interests and protection were part of the Dutch agenda, the case reviews would be done while the patients were still alive.
The KNMG has also supported having cases in which physicians end the lives of patients who have not requested death treated in the same way by these regional groups. There has not so far been public or governmental support for this proposal. The new legislation did not include original language that would have permitted children over twelve to request and receive euthanasia even if their parents were opposed, while they could previously do so only if they were sixteen. Opposition to this provision caused the government to modify this proposal to permit child euthanasia in the twelve to sixteen age group, but not over parental objection. Dutch physicians have pointed out that young children and parents will seldom be in conflict in such a situation. That misses the essential point. There is more danger that the parents will become discouraged or exhausted by a child's illness and that the child will respond to a sense that the family would feel relieved if he or she were not there. What is needed are physicians who recognize this and can intercede to help the child by easing the burden on the family.
The original bill considered permitting physicians to perform euthanasia on persons with dementia if they made a request for euthanasia while they were still competent. The request would have been dispositive even if the individual later seemed content with a reduced mental status and did not want to die. And for individuals who develop dementia without having made such a request, their families would be empowered to request it for them. The bill as passed did not clearly address this question. The Health Ministry stated that it believes that only early-stage dementia patients in intolerable pain are eligible for euthanasia.
It is worth noting that the Dutch authors of the 1995 study concluded their report by saying that it would be desirable to reduce the number of cases in which life is terminated without the patient's request, but this must be the common responsibility of the doctor and the patient. The person who does not wish to have his or her life terminated should declare this clearly, in advance, orally and in writing, preferably in the form of a living will. In a press conference, one of the investigators went even further in stating that the person responsible for avoiding involuntary termination of life is the patient. That remark is both a harbinger of the direction in which Dutch euthanasia policies are heading and a summation of much that is wrong with them.
As we will see, Dutch efforts at regulating assisted suicide and euthanasia have served as a model for proposed statutes in the United States and other countries.55 Yet the Dutch experience has indicated that these practices defy adequate regulation. Given legal sanction, euthanasia, intended originally for the exceptional case, has become an accepted way of dealing with serious or terminal illness in the Netherlands. In the process, palliative care is one of the casualties, while hospice care lags behind that of other countries.56
In recent testimony before the British House of Lords, Zbigniew Zylicz, one of the few palliative care experts practicing in the Netherlands, emphasized Dutch deficiencies in palliative care and the lack of hospice care in the Netherlands, attributing them to the availability of the easier alternative of euthanasia.57 (His personal experience is described in the next chapter.) In its 1997 ruling denying a constitutional right to assisted suicide, the U.S. Supreme Court cited these deficiencies in particular and the Dutch experience in general as evidence that it is dangerous to give legal sanction to assisted suicide.

Conclusion: Culture, Character, and Change
The Dutch medical authorities view euthanasia as a form of healing that is an integral part of palliative care. In the words of the Dutch Minister of Health, the doctor who grants the patient's request for euthanasia "acts as the healer par excellence."58 Given this attitude, it is understandable that many Dutch physicians feel comfortable suggesting euthanasia to their patients. So regarded, euthanasia can be seen as simply another option for patients, and failure to suggest it could be considered malpractice. Those, including some Dutch physicians, who believed euthanasia was to be a last resort in desperate situations are alarmed because frightened and suffering patients are inclined to listen to suggestions by doctors even when the doctors are telling them their lives are not worth living.
The casualness with which Dutch physicians treat the need for a second opinion in euthanasia cases reflects the view they frequently expressed to me that such consultations were for the purpose of meeting legal requirements. When I asked one of the leading Dutch practitioners of euthanasia whether consultation did not provide some protection for patients, he explained that the concept of patient protection, so accepted in the United States, was foreign to the Dutch. His view was supported by the official spokesperson for the KNMG.
Although these physicians are wrong in assuming that Dutch patients do not need protection, they are correct in assuming that the vast majority of the Dutch do not consider that they do. The Dutch accept the authority of physicians in ways that would seem foreign in the United States. Malpractice suits are rare in the Netherlands. Even when physicians end the lives of patients who have not requested it, the Dutch are inclined to be forgiving on the grounds that the physicians' intentions were benevolent. Seeing their choice when confronted with painful illness as between prolonged suffering and a quick death, a large proportion of people in the country are also unaware that there may be better alternatives.
The embrace by the Dutch medical establishment of euthanasia and the Dutch population's willingness to follow them in doing so can be understood in part by what we know of Dutch culture and character--particularly the uniquely ambivalent Dutch attitude toward authority. Although Calvinism was born in opposition to papal authority, magistrates were seen as "ministers of Divine Justice, vice regents of God."59 In modern times the Dutch impulse seems to be to resist formal authority--the Catholic Church in the Netherlands is uniquely resistant to papal authority60--and to replace it with authority that is less direct and obvious; doctors and judges fall into this category.
Writing decades before euthanasia became a preoccupation in the Netherlands, the eminent Dutch social historian Johan Huizinga was concerned with a weakening of judgment and morality in the country. It was not crime, prostitution, or drunkenness that worried him (although the rise of fascism in Europe did) but a "betrayal of the spirit." He feared that his fellow citizens liked tranquility to the point of passivity and found them lacking in passion, insensitive to myth, self-satisfied, and obstinate.61
Huizinga and other historians have seen the virtues of Dutch character (sobriety, domesticity, commercial spirit, honesty, cleanliness, and respectability) as originating in the bourgeois nature of the society that developed in the seventeenth century.62 Although Calvinist piety and faith played an important role in the culture, it was urban society that was mainly responsible for the miraculous Dutch achievements when, for a period of at least fifty years, this small country--still establishing its freedom from Spain--became the pre-eminent commercial and artistic center of the world.63
Political liberation, mercantile achievement, and the growth of Calvinism were matched by the simultaneous liberation from the sea of an enormous part of the land that forms the Netherlands today.64 Mercantile success, Calvinism, and the triumph in claiming land from the sea shaped the Dutch as powerfully as the conquest of the Western frontier shaped the American experience.
If the seventeenth century shaped Dutch character, so too did dealing with the decline that followed it. In the first half of the eighteenth century, England and France were able to use their military power to end the pre-eminent position of the Dutch as world traders. To this period social historians attribute the origin of what are described as the Dutch middle-class vices--being unromantic, unemotional, unimaginative, and stubborn.65
What is seen as unimaginativeness and insensitivity is perhaps reflected in a concreteness illustrated by the way so many Dutch doctors did not hear the ambivalence expressed in patients' requests for euthanasia. Such deficiencies concerned a Dutch colleague who supported euthanasia. She told me a story about her mother, who had dementia and was in a nursing home. Her mother told her not to throw away some violets in her room because you "don't throw away living things." She feared that the doctors in the home would not understand her mother's expression of a desire to live even with diminished capacities.
From a different perspective, Derek Phillips, who although American born has lived and worked as a sociologist in the Netherlands for thirty years, shares Huizinga's concern about Dutch moral and social attitudes. He sees the Dutch as relatively uninterested in moral philosophy and as lacking in moral passion. The Dutch, he points out, tend to equate morality with religion, and most see themselves as nonreligious. He considers the single most important social fact regarding morality in the Netherlands to be that "indifference masquerades as tolerance."66
His observations resonated with one personal aspect of my own experience in the Netherlands. I was troubled, as were other foreign observers, by what we regarded as Dutch indifference to their system's failure to protect patients and their physicians' failure to follow their own euthanasia guidelines.67 I found that while some physicians supportive of euthanasia were willing to admit abuses in general, and even to concede that in a particular case euthanasia should not have been performed or that a wrongful death had taken place, they did not express anger or indignation that a life had been taken unnecessarily. The common attitude was that the doctor may have been mistaken but was entitled to his or her judgment of the matter. This casualness, often rationalized by the Dutch as tolerance, appears to a foreign observer to border on a callousness that seems consistent with Huizinga's and Phillips's observations about the Dutch lack of moral passion and unwillingness to assign individual responsibility. Huizinga notes that "tolerance is a virtue that can become a vice. Respect for the rights of others too often leads to respect for their wrongs."68 In an even stronger sentence that could become an epigram for euthanasia in the Netherlands, he states, "the belief that what is evil becomes good if only enough people want it is one of the most terrifying aberrations of the age."69

The Dutch government, acknowledging the country's deficiencies in palliative care, has taken steps to improve the care of dying patients. As part of a five-year program begun in 1996, the Dutch Health Research and Development Council designated six medical institutions as centers for palliative care and provided aid that made possible an increase in the number of palliative care units in nursing homes from three to thirty.70 (A palliative care unit in these nursing homes usually consists of three to four beds set aside for this purpose.) The nursing home palliative care units are not staffed by palliative care specialists, but the physicians who do staff them are being trained in palliative care.71
Probably the greatest hope for change lies in the grassroots efforts of a small number of palliative care physicians to educate Dutch physicians in the care of terminally ill patients and in the response of the physicians to these efforts. Ten times a year since 1994 three palliative care physicians, including Zylicz, have conducted a one-day course in palliative care for twenty physicians. The course is booked a year in advance. The palliative care specialists make an additional effort to reach nursing home physicians by holding yearly a three-day basic course for fifty of them and an advanced course that can accommodate thirty-five.72
Similar local initiatives have been responsible for an increase in the number of hospices in the country from six to ten. In the traditional middle-class virtues of industriousness, initiative, and a desire for improvement expressed by these Dutch doctors lies the best opportunity to improve the care given to dying patients. Although the Dutch experience suggests that engaging physicians in palliative care is much harder when the easier option of euthanasia is available, for a significant number such training has become a welcome option. If education of Dutch doctors by their palliative care instructors is successful, a reduction in the number of cases of assisted suicide and euthanasia will be one measure of that success.

References

Chapter 5: The Dutch Experience1. T.H.C. Bueller, "The Historical and Religious Framework for Euthanasia in the Netherlands," in Euthanasia: The Good of the Patient, The Good of Society, ed. R. I. Misbin (Frederick, Md.: University Publishing Group, 1992), 183-88.2. Ibid.3. D. Phillips, De Naakte Nederlander [The Dutch Exposed] (Amsterdam: Utgeverij, Bert Bakker, 1985).4. H. Hendin, Seduced by Death: Doctors, Patients, and Assisted Suicide (New York: Norton, 1998).5. See n. 1, Bueller 1992.6. C. Gomez, Regulating Death: Euthanasia and the Case of the Netherlands (New York: Free Press, 1991).7. Ibid.8. KNMG, Medisch Contact 42 (1986):770-75.9. P. J. van der Maas, J. J. M. van Delden, and L. Pijnenborg, Euthanasia and Other Medical Decisions Concerning the End of Life (New York: Elsevier, 1992).10. G. van der Wal and P. J. van der Maas, Euthanasia en Andere Medische Beslissingen Rond het Levenseinde [Euthanasia and Other Medical Decisions at the End of Life] (The Hague: Staatsuitgeverj, 1996).11. P. J. van der Maas, G. van der Wal, I. Haverkate, et al., "Euthanasia, Physician-Assisted Suicide, and Other Medical Practices Involving the End of Life in the Netherlands, 1990-1995," New England Journal of Medicine 335 (1996):1699-1705; G. van der Wal, P. J. van der Maas, J. M. Bosma, et al., "Evaluation of the Notification Procedure for Physician-Assisted Death in the Netherlands," New England Journal of Medicine 335 (1996):1706-11.12. M. Angell, "Euthanasia in the Netherlands: Good News or Bad?" [editorial], New England Journal of Medicine 335 (1996):1675-78.13. See n. 11, van der Wal et al. 1996, 1705.14. General Board, Royal Dutch Medical Society, "Vision on Euthanasia," in Euthanasia in the Netherlands (Utrecht: Royal Dutch Medical Association, 1994), 12-26.15. See n. 9, van der Maas et al. 1992.16. See n. 11, van der Maas et al. 1996, 1703.17. See n. 6, Gomez 1991.18. See n. 9, van der Maas et al. 1992, 101-2.19. See n. 11, van der Wal et al. 1996, 1708.20. B. D. Onwuteaka-Philipsen, G. van der Wal, P. J. Kortense, and P. J. van der Maas, "Consultants in Cases of Intended Euthanasia or Assisted Suicide in the Netherlands," Medical Journal of Australia 170 (1999):360-63.21. See n. 11, van der Wal et al. 1996, 1708.22. See n. 11, van der Maas et al. 1996, 1704.23. See n. 9, van der Maas et al. 1992, 58.24. See n. 9, van der Maas et al. 1992, 73.25. See n. 11, van der Maas et al. 1996, 1700.26. See n. 11, van der Maas et al. 1996, 1704.27. See n. 11, van der Maas et al. 1996, 1702.28. See n. 11, van der Maas et al. 1996, 1704.29. See n. 11, van der Maas et al. 1996, 1704.30. See n. 11, van der Maas et al. 1996, 1704.31. H. Hendin, Seduced by Death: Doctors, Patients, and the Dutch Cure (New York: Norton, 1996), 79.32. R. Twycross, "A View from the Hospice," in Euthanasia Examined: Ethical, Clinical, and Legal Perspectives, ed. J. Keown (Cambridge: Cambridge University Press, 1995), 141-68, 161.33. See n. 31, Hendin 1996, 77, 78.34. H. Hendin, C. Rutenfrans, and Z. Zylicz, "Physician-Assisted Suicide and Euthanasia in the Netherlands: Lessons from the Dutch," Journal of the American Medical Association 277 (1997):1720-22.35. K. L. Dorrepaal, N. K. Aaronson, and F.S.A.M. van Dam, "Pain Experience and Pain Management among Hospitalized Cancer Patients," Cancer 63 (1989):593-98; Z. Zylicz, "The Story behind the Blank Spot: Hospice in Holland," American Journal of Hospice and Palliative Care 10 (1993):30-32; Z. Zylicz, "Euthanasia" [letter], Lancet 338 (1991):1150; H. Matthews, "Better Palliative Care Could Cut Euthanasia," British Medical Journal 317 (1998):617; R. de Wit, F. van Dam, A. Vielvoye-Kerkmeer, C. Mattern, and H. H. Abu-Saad, "The Treatment of Chronic Cancer Pain in a Cancer Hospital in the Netherlands," Journal of Pain and Symptom Management 12 (1999):333-50.36. See n. 9, van der Maas et al. 1992.37. L. Pijnenborg, P. J. van der Maas, J. J. M. van Delden, and C. W. N. Loonan, "Life-Terminating Acts without the Explicit Consent of the Patients," Lancet 341 (1993):1196-1199; L. Pijnenborg, End-of-Life Decisions in Dutch Medical Practice (The Hague: CIP-Gegevens Kononklijke Bibliotheek, 1995), 119-35.38. H. Jochemsen and J. Keown, "Voluntary Euthanasia under Control? Further Empirical Evidence from the Netherlands," Journal of Medical Ethics 25 (1999):16-21, 20.39. P. J. van der Maas, J. J. M. van Delden, L. Pijnenborg, and C. W. L. Loonan, "Euthanasia and Other Medical Decisions Concerning the End of Life," Lancet 338 (1991):669- 74.40. See n. 6, Gomez 1991; n. 11, van der Wal et al. 1996; n. 32, Twycross 1995, 141-68.41. H. Hendin, "Assisted Suicide, Euthanasia, and Suicide Prevention," Journal of Suicide and Life-Threatening Behavior 25 (1995):193-203.42. H. W. Hilhoorst, Euthanasie in het Ziekenhuis [Euthanasia in the Hospital] (Lochem: De Tijdstroom, 1983).43. See n. 31, Hendin 1996.44. H. Hendin, "Selling Death and Dignity," Hastings Center Report 25, no. 3 (1995):19- 23.45. See n. 34, Hendin et al. 1997.46. J. Groenwoud, P. van der Maas, G. van der Wal, et al., "A Physician-Assisted Death in Psychiatric Practice in the Netherlands," New England Journal of Medicine 336 (1997):1795- 1807.47. Figures from the Netherlands Central Bureau of Statistics.48. M. Simons, "Dutch Doctors to Tighten Rules on Mercy Killings," New York Times, 11 September 1995, A3.49. See n. 20, Onwuteaka-Philipsen et al. 1999.50. See n. 31, Hendin 1996.51. See n. 44, Hendin 1995.52. T. Shelton, British Medical Journal 322 (2001): 509.53. See n. 38, Jochemsen and Keown 1999.54. J. van Delden, "Slippery Slopes in Flat Countries: A Response," Journal of Medical Ethics 25 (1999):22-24.55. D. Callahan and M. White, "The Legalization of Physician-Assisted Suicide: Creating a Regulatory Potemkin Village," University of Richmond Law Review 30 (1996):1-83.56. See n. 35, Dorrepaal et al. 1989; Zylicz 1991, 1993; Matthews 1998; de Wit et al. 1999.57. See n. 35, Matthews 1998.58. E. Borst-Eilers, "Euthanasia in the Netherlands: Brief Historical Review and Present Situation," in Misbin 1992 (see n. 1), 55-68, 68.59. The Encyclopedia of Philosophy (New York: Macmillan, 1972), 2:9.60. See n. 1, Bueller 1992.61. J. H. Huizinga, Dutch Civilization in the Seventeenth Century and Other Essays (New York: Harper Torchbooks, 1969), 122.62. B. van Heerikhuizen, "What Is Typically Dutch?" Netherlands Journal of Sociology 18 (1982):103-25; A. Hauser, The Social History of Art (New York: Knopf, 1952), 1:461.63. See n. 61, Huizinga 1969.64. S. Schama, The Embarrassment of Riches (New York: Knopf, 1987).65. See n. 62, van Heerikhuizen 1982.66. D. Phillips, letter to H. Hendin, 26 April 1995.67. See n. 6, Gomez 1991, 95; D. Callahan, "When Self-determination Runs Amok," Hastings Center Report 22, no. 2 (1992):52-55.68. See n. 61, Huizinga 1969, 114.69. See n. 61, Huizinga 1969, 121.70. Bert Gordijn, "Euthanasia and Palliative Care: The Dutch Experiment," lecture at Congress of the Research Network in Palliative Care, Berlin, Germany, 9 December 2000.71. Zbigniew Zylicz, personal communication, 18 January 2001. 72. Ibid.

"Practice versus Theory: The Dutch Experience", by H. Hendin.
Reprinted with permission of The Johns Hopkins University Press.