The Journal of Law, Medicine & Ethics
swers to my questions. This I have done in my forthcoming
book, Euthanasia in the Netherlands.
Journal of Law, Medicine & Ethics, 30 (2002): 95–104.
© 2002 by the American Society of Law, Medicine & Ethics.
Why the Netherlands?
suicide and euthanasia should be legitimized or legalized.
Review of the literature reveals complex and often contra-
dictory views about the Dutch experience. Some claim that
the Netherlands offers a model for the world to follow; oth-
ers believe that the Netherlands represents danger, rather
than promise, and that the Dutch experience is the definitive
answer regarding why we should not make active euthanasia
and physician-assisted suicide part of our lives.
Having investigated the Dutch experience for a number
of years, in the summer of 1999 I went to the Netherlands to
visit the major centers of medical ethics as well as some
research hospitals, and to speak with leading figures in eu-
thanasia policy and practice. This essay commences by
providing some background information on the practice of
euthanasia and on the legal framework, and then reports the
main answers to my first question: Why the Netherlands?
What are the reasons that prompted the Dutch to adopt their
policy? For limitations of space, I do not report all the an-
he Dutch experience has influenced the debate on
euthanasia and death with dignity around the globe,
especially with regard to whether physician-assisted
The Dutch understanding of euthanasia is said to be marked
by its precision. Unlike other countries that distinguish be-
tween active and passive euthanasia, between direct and
indirect euthanasia, and between voluntary and involuntary
euthanasia, the Dutch definition of the term is exact: the
intentional taking of someone’s life at his or her explicit
request. According to the law, only a competent patient’s
request can be accepted. This has several consequences.
First, what is termed “euthanasia” in the Netherlands is
called “active euthanasia” in other parts of the world. In the
Dutch conception, euthanasia is by definition active and there
is no need to specify the act by the term “active,” as other
Second, all other kinds of end-of-life (“terminal”) care
bear other names. Thus, for instance, withdrawal of treat-
ment is not considered euthanasia. Elsewhere it is termed
“passive euthanasia.” In the Netherlands, this term is deemed
illogical and useless insofar as passive euthanasia is self-con-
tradictory because it concerns the omission of treatment to
which the patient has not consented.1 Within the law, the
difference between acting and refraining from acting has no
particular relevance, and such a legal consideration takes
precedence over the psychological experience of the differ-
ence. The prevailing Dutch perspective regards as futile any
treatment that has no clear medical benefit for the patient.
The argument is that no patient should be subjected to use-
less medical interventions and that these treatments should
not be offered as an option to patients. In a leading test case,
a Dutch court ruled that contrary to the wishes of the next of
kin, a hospital was not obliged to return an 80-year-old can-
cer patient to intensive care when his condition was
Third, unintended shortening of life in the course of
treatment to abate suffering is viewed in the Dutch discus-
sion as a physician’s duty to alleviate pain. Some term this as
“indirect euthanasia,” and others see it as coming within the
“double effect doctrine.”3 The possibility that a seriously ill
patient might die as a result of such treatment does not con-
Fourth, the decision to end a life without an explicit
request is legally not termed euthanasia. This is considered
Volume 30:1, Spring 2002
several conversations. However, van der Wal and colleagues
conducted a survey among a random sample of family doc-
tors, showing that in 22 percent of cases the request was
made only once.7
The rate of recordkeeping8 and written requests9 in eu-
thanasia cases improved during the 1990s, but the situation
is still unsatisfactory. There are now written requests in about
60 percent of all euthanasia cases and written recordkeeping
in some 85 percent.10 A most troubling phenomenon is the
significant number of unreported euthanasia cases. Since
November 1990, new state regulations require physicians to
report cases of euthanasia to the local coroner and the public
prosecutor. The number of reports rose from 454 cases in
1990 to 591 in 1991, then to 1,323 in 1992, to 1,318 in
to be killing a person, even though some physicians would
disagree. Involuntary euthanasia is regarded as a contradic-
tion in terms.
Fifth, the distinction between euthanasia and physician-
assisted suicide hardly figures in the Dutch discussion.
Although assisted suicide is considered to be a crime by
law and the distinction may be seen as morally relevant,
no relevance has been attributed to this distinction in the
actual medical context in the cases of euthanasia that have
been brought to trial. In both practices, the physician has to
meet the same substantive and procedural requirements.4
Many of my interviewees said that euthanasia and physi-
cian-assisted suicide are considered in the Netherlands as
one and the same, implying the same responsibility for
THE PRACTICE OF EUTHANASIA
The three relevant categories of Dutch doctors who are in-
volved in the practice of euthanasia are general practitioners,
nursing-home doctors, and specialists. Every person in the
Netherlands has a more or less permanent relationship with
a general practitioner, who provides primary health care and
is the point of entry for specialist care. General practitioners
have the most extensive experience with euthanasia insofar
as they discuss it most frequently with their patients, they
receive two-thirds of all requests, and they are generally the
most willing to perform it (about 90 percent of Dutch doc-
tors have either practiced euthanasia or would be willing to
do so).5 The level of experience with euthanasia among spe-
cialists is about half that of general practitioners (with 3
percent of all deaths in their practice attributable to euthana-
sia). By contrast, euthanasia plays a small role in the practice
of nursing home doctors, who receive relatively few requests
(only a fifth of them have ever honored one).6
The euthanasia guidelines of the Royal Dutch Medical
Association speak of persistent request. A request made on
impulse or as a result of a temporary period of depression
should not be honored. The request must have been dis-
cussed repeatedly and thoroughly a number of times during
1993, and to 1,424 in 1994. In 1999, the total number of
reports was 2,216.11 This considerable increase suggests that
more physicians are willing to acknowledge and report their
actions, having seen that their colleagues are not being pros-
ecuted for performing euthanasia. At the same time, the
Remmelink Commission, appointed in 1990 to investigate
the practice of euthanasia, detected 2,300 cases of euthana-
sia, which means that about half are still unreported.12 John
Griffiths argues that the reporting rate for euthanasia13 was 18
percent in 1990, and that by 1995 it had risen to 41 percent. A
situation in which less than half of all cases are reported is
unacceptable from the standpoint of effective control.14
The Dutch approach to euthanasia is said to reflect an
open attitude toward tackling a difficult moral issue. For the
past twenty years, the debate has been discussed openly by
all circles of society. It has been considered in the Parlia-
ment, addressed by the courts, debated in religious institutions,
and has required the constant attention of the Royal Dutch
Medical Association. It continues to be a focus of the media,
and polls have been conducted from time to time to examine
public attitudes on this issue.
Despite this apparent openness, the 1990 Remmelink
study shows that 22 percent of physicians feel that they should
not be required to always report euthanasia as unnatural death.
The legal ambiguity that existed for twenty years made Dutch
doctors feel uncomfortable with reporting euthanasia, citing
prosecution as an objection. They emphasized that they would
be prepared to report euthanasia as such, but they did not
wish to be considered as a suspect in a criminal act. Thus,
the uncertainty of what might happen to the physician was
considered an obstacle to reporting an unnatural death.15 In
order to address this issue, a careful, clearly stated proce-
dure was needed, one which would be explicitly recognized
under the law.
THE LEGAL FRAMEWORK
The legal ambiguity was the result of prohibiting euthanasia
under the law while allowing the practice under certain cir-
cumstances. T wo articles of the Criminal Code explicitly
prohibit euthanasia: Article 293 prohibits killing a person at
his or her request (“Any person who takes another person’s
life at that person’s express and earnest request shall be li-
able to a term of imprisonment not exceeding twelve years
or a fine of NLG 100,000”); Article 294 prohibits assisted
suicide (“Any person who intentionally incites another per-
son to commit suicide, assists him in the act or provides him
with the means to commit suicide shall, if suicide follows,
be liable to a term of imprisonment not exceeding three
years or a fine of NLG 25,000”).16
Despite these legal provisions, the courts have held that
Article 40 of the Criminal Code (“Any person who was com-
pelled by force majeure to commit a criminal act shall not
be criminally liable”)17 provides a defense to doctors charged
The Journal of Law, Medicine & Ethics
member not present) in favor of the Termination of Life on
Request and Assistance with Suicide Act.
The new legislation made it legal to end a patient’s life,
subject to the following criteria: the patient must be suf-
fering unbearable and unremitting pain, with no prospect
of improvement. The patient must make a sustained, in-
formed, and voluntary request for help to die. All other
medical options must have been previously exhausted. A
second medical opinion must be sought to confirm diagno-
sis and prognosis. The termination of life must then be carried
out with medically appropriate care and attention. The phy-
sician is obliged to report the death to the municipal
pathologist, specifying whether the cause of death was eutha-
nasia or assisted suicide.21
Before arriving in the Netherlands, I wrote to some distin-
guished experts in the fields of medicine, psychiatry,
under Articles 293 and 294. The overmacht defense, which,
like force majeure, translates as overpowering force, envi-
sions a case of urgency whereby the accused is driven by his
or her conscience to commit an offense that amounts to a
lesser evil than would have ensued had events been permit-
ted to run their course. As such, the accused decided to make
the deliberate moral choice to break the law because the
force of circumstances precluded delaying action. However,
the defense does not stand if there was a reasonably available
option whereby the accused could have avoided the commis-
sion of the offense.18
A major step was taken in 1990 on behalf of physicians
practicing euthanasia. Soliciting for the approval and coop-
eration of the Royal Dutch Medical Association with the
Remmelink study, the Ministry of Justice not only promised
legal immunity to physicians participating in the national
investigation, but it also agreed to proclaim a notification
procedure that included the following elements:
• the physician performing euthanasia would not
need to issue a declaration of a natural death,
but would inform the local medical examiner
by means of an extensive questionnaire;
• the medical examiner would report to the dis-
• the public prosecutor would decide whether a
prosecution must be started. As a general rule, if
a doctor had complied with the requirements for
euthanasia, he or she would not be prosecuted.19
The notification procedure was granted a formal legal
status by a procedural law that came into force on June 1,
1994. According to this law, a physician performing eutha-
nasia in compliance with the criteria that had been developed
in case law and medical ethics would not, as a general rule,
On November 28, 2000, the Dutch Lower House of
Parliament, by a vote of 104 to 40, approved the legalization
of euthanasia. On April 10, 2001, the Dutch Upper House
of Parliament voted to legalize euthanasia, making the Neth-
erlands the first and at this time only country in the world to
legalize euthanasia. The Senate had voted 46 to 28 (with one
Doctors are immune from prosecution for helping a
patient die as long as they follow these guidelines. If they do
not, the coroner and a regional panel can recommend pros-
ecution leading to a prison sentence of up to 12 years.
This new act, while not amending the safeguards under
which doctors previously practiced voluntary euthanasia in
the Netherlands, did change who has the burden of proof
regarding whether the code of practice has been breached.
Previously, the onus was squarely on the doctors to prove
that they had followed the guidelines and were therefore
innocent of any offence. However, the new law shifted re-
sponsibility for proving guilt to the five regional committees
that examine the euthanasia reports.22
The law contains special provisions for dealing with
requests from minors for termination of life and assisted
suicide. The most controversial aspect of the original act
was that incurably ill minors between the ages of 12 and 16
could request and receive help to die if they had their par-
ents’ agreement. In exceptional circumstances, doctors could
even help the child to die without parental consent, although
such cases would likely have been rare. Persons aged 16 to
18 would be able to request euthanasia without recourse to
their parents’ approval.23
In July 2000, in response to critical questions by mem-
bers of Parliament, the Cabinet dropped the provision that
euthanasia requests from minors between 12 and 16 could
be granted without their parents’ consent. Some analysts
viewed this retreat as a maneuver to win approval for other
controversial provisions of the new legislation, such as legal-
izing euthanasia for victims of Alzheimer’s.24 Still, allowing
the euthanasia of minors 12 years and older seriously overes-
timates the capacity of minors to evaluate the meaning and
consequences of a request to die. It places an unacceptable
burden on these young people and may well disturb society’s
confidence in the relationship between physicians, parents,
and children. Henk Jochemsen rightly says that unless we
are prepared to give minors the right to do everything else in
life that an adult can do, giving them the right to end their
life seems out of place.25
The new law also establishes a legal basis for advance
euthanasia declarations via a type of living will in which
competent patients can request euthanasia in the event they
become mentally incompetent. Though such a statement does
not imply that a physician has a duty to perform euthanasia,
it provides the legal basis to end the life of an incompetent
patient who has signed such a document.
Let me now proceed by outlining the methodology of
my independent research in the Netherlands and the find-
ings to my question: Why the Netherlands?
Volume 30:1, Spring 2002
cisms. In my cover letter, I explained that I wished to give
each interviewee an opportunity to verify that the references
to our discussion adequately represented his or her views. I
added that the issue at hand was not my analysis and inter-
pretation. Rather, the aim was to ascertain whether the
interviewee’s views were characterized in a fair and honest
manner and whether the opinions attributed to him or her
were correct. The majority of interviewees commented on
the first draft.28
The Netherlands was the first democracy to tolerate eutha-
nasia. My questions on this point were “Why the
philosophy, law, social sciences, and ethics, asking to meet
with them in order to discuss the Dutch policy and practice
of euthanasia. Only one — Dr. Boudewijn Chabot — explic-
itly declined my request for an interview.26
The interviews took place during July–August 1999 in
the Netherlands. They lasted between one and three hours
each. Most interviews went on for more than two hours,
during which I asked more or less the same series of ques-
tions.27 During the interviews, I took extensive notes that
together comprise some 200 dense pages. Later the inter-
views were typed and analyzed.
The interviews were conducted in English, usually in
the interviewees’ offices. Four interviews were conducted at
the interviewees’ private homes, and four in “neutral” loca-
tions (coffee shops and restaurants). T wo interviews were
conducted at the office kindly made available to me at the
Department of Medical Ethics at the Free University of
Amsterdam. To have a sample of different locations, I trav-
eled from Groningen in the north to Maastricht in the south,
making extensive use of the efficient Dutch train system.
The interviews were semi-structured. I began with a list
of fifteen questions, but did not insist on all of them when I
saw that an interviewee preferred to speak about subjects
that were not included in the original questionnaire. With a
few interviewees, I spoke only about their direct involve-
ment in the practice of euthanasia. Because I was interested
in the problematic aspects of the euthanasia practice, after
some general questions I addressed these aspects by refer-
ence to the Remmelink report. This line of questioning
disturbed some of the interviewees, who wanted to know
my own opinion on the subject before continuing to answer
my questions. Others seemed eager to bring the interview to
This article reports the answers to the first question in
my questionnaire. At the start of every interview, I pledged
to my interviewees that I would send them the rough draft of
the book I planned to write prior to submitting it for publi-
cation. After completing the first draft of the manuscript
Euthanasia in the Netherlands in July 2000, I sent it to all
twenty-eight interviewees, inviting their comments and criti-
Netherlands?”; “Why does the Netherlands accept euthana-
sia de facto if not de jure?”; and “What are the significant
factors that made the Dutch tradition and culture hospitable
to the euthanasia movement?”
Some literature addresses these questions. Bert Gordijn
argues that the Dutch policy is a typical example of a policy
of pragmatic tolerance. To better understand this societal
phenomenon, one should look at Dutch history. The histori-
cal roots can be traced to the Dutch republic of the seventeenth
century, where two dominant and sometimes contradictory
societal forces influenced Dutch mentality and policy. The
merchants advocated peace and freedom through a policy of
tolerance, exemptions, and compromises. The Calvinists,
on the other hand, strove for normative regulation of all
human behavior in accordance with their rigid moral stan-
dards. These two forces led to the Dutch policy of pragmatic
tolerance; namely, certain criminal acts remained unpunished,
and certain conditions for immunity from criminal prosecu-
tion were formulated in advance and in public by the
authorities. Gordijn contends that the practice of tolerance
of illegal deeds was normatively regulated and that its influ-
ence is significant in the present euthanasia policy.29
Griffiths and his colleagues provide another layer of ex-
planation. They emphasize the developments that took place
since the 1960s, arguing that the 1960s and 1970s were a
crucial watershed for Dutch society. From a conservative,
tradition-bound country, the Netherlands was transformed
into a society of social and cultural experimentation. The
Netherlands took a prominent place in the sexual revolu-
tion, the legalization of abortion, the acceptance of drugs,
the democratization of educational institutions, and the ques-
tioning of religious authority. The process of secularization
that started in the 1960s gradually undermined the status of
traditional institutions. In 1958, 24 percent of the popula-
tion had no affiliation, 42 percent belonged to the Roman
Catholic Church, and about 33 percent were affiliated with
the Protestant churches. In the 1990s, the respective figures
were 57 percent (no affiliation), 22 percent (Catholic), and a
bit more than 20 percent (Protestant).30
Societal relationships also changed, with the effect that
the social distance between ordinary people and people in
positions of power declined. As such, ordinary citizens de-
veloped expectations about their role and influence in society
and their ability to affect matters concerning their lives. The
political elite accommodated themselves to the new reality.
In many cases, the elite supported the new ideas, and its
members were even spokesmen for them. The political cul-
ture of conflict-avoidance and the traditional conviction that
it is better to guide social developments than to try to stop
them were instrumental in coping with the waves of change.31
Paul van der Maas brought to my attention a study con-
ducted by Loes Pijnenborg, in which thirty-four experts
(twenty-three from the Netherlands and the rest from the
United States, Australia, Canada, the United Kingdom, and
The Journal of Law, Medicine & Ethics
Henk Jochemsen, director of the Professor Lindeboom
Institute, a center for medical ethics, who also holds a pri-
vately funded chair for medical ethics at the Free University,
further explained that Calvinism stressed personal responsi-
bility and that there should be no contradiction between
teaching and practice. When physicians realized that there
were occasions when euthanasia should be performed, they
started pressing for some accommodation to use this practice.35
In 1969, Jan Hendrik van den Berg, a renowned psy-
chiatrist, published his book Medical Power and Medical
Ethics.36 The book discusses the tragic conditions of various
patients who are described as victims of medical power. Had
they lived 100 or even 50 years ago, they would have been
allowed to die in peace. These days, however, they are being
Germany) were asked two questions: What is the explana-
tion of the fact that the current discussion on euthanasia in
the Netherlands differs from the discussion in other coun-
tries? Do you think that the current euthanasia practice in the
Netherlands differs from that of other countries? According to
the respondents, the most important factors influencing the Dutch
policy and practice of euthanasia were the relationship be-
tween the physician, the patient, and health care (mentioned
by 24 respondents); culture and society (22 respondents);
legal aspects (15); history (11); church and religion (10); defi-
nition of euthanasia (6), and moral principles (5).32
These issues were reiterated by my interviewees. Some
preferred to answer “Why the Netherlands?” by delineating
the historical process that brought about the practice of eu-
thanasia.33 They explained that up until the late 1960s, the
Netherlands was a divided society, with Catholic pillars, Prot-
estant pillars, liberal pillars, and socialist pillars. Each
organized its own political party, schools, medical organiza-
tion, newspaper, media, club, union, and so on. These pillars,
especially the religious ones, eventually broke down and
collapsed. The student revolution of 1969 had a profound
effect on the country as the social movement rebelled against
the traditional values, autocracy, and established hierarchies.
After more than two decades of digesting the horrors of World
War II, the time was ripe for change. The old morality based
on religious perceptions had collapsed. Church values were
no longer appealing to large sectors of the population, who
were looking for a different set of morals upon which to base
Consequently, the Netherlands had to find a secular ba-
sis for morality. Some of the essential moral foundations
established were that of individual choice, liberation from
collective morality, autonomy, and individuality. The reli-
gious view of the sacredness of life was abolished and replaced
by secular moral views. Since then, the discussion on moral-
ity has revolved around the rights of the individual, including
issues like contraceptives, abortion (the law became liberal
in 1969), suffering, and ending of life. The increased democ-
ratization of society and the emphasis on individual control
made the practice of euthanasia more open and available.34
kept alive simply because the capacity to do so is available,
regardless of the patients’ best interests. Van den Berg sug-
gests granting these victims of medical power a dignified
death.37 James Kennedy, Egbert Schroten, and H.J.J. Leenen
maintain that this book started the euthanasia discussion in
earnest, focusing on life that had lost its purpose. Specifi-
cally, the thesis advocated putting an end to pointless suffering
with the help of a doctor.38 At the time, the medical estab-
lishment was very much against physician-assisted suicide
and euthanasia. Some journals, including Tijdschrift Voor
Geneeskunde (Journal of Medicine), refused to discuss eu-
thanasia for a long time. Another leading medical journal,
Medisch Contact, was unique in allowing letters and articles
to be published on this issue.
In 1972, the Council of Health commissioned its own
study on euthanasia, concluding that euthanasia ought to re-
main illegal, but that public opinion was changing and that
there was a need for reprisal.39 In 1973, the first euthanasia
court case occurred in Leeuwarden: the Postma case, which
received a great deal of publicity, prompting certain groups
to argue that euthanasia should be allowed.40 Leenen and
van der Maas see this court case as the most instrumental in
paving the way toward tolerating euthanasia.
In the mid-1970s, the Dutch Euthanasia Society was
formed and the discussion spread into different circles: me-
dia, literature, politics, and academia. The Conservatives,
Socialists and Social-Liberals all included the issue of eutha-
nasia in their political platforms. Long deliberations in the
Parliament failed to result in concrete steps, as all initiatives
were blocked by the ruling party, the Christian-Democrats.
Many physicians felt that the issue needed to be ad-
dressed carefully and sincerely. The Dutch Medical Society
set up a committee in 1983 to examine the practice of eutha-
nasia. The Society did not adopt a specific viewpoint, but
nevertheless said that if physicians practiced euthanasia, they
needed to follow the jurisprudential guidelines that Henk
Leenen helped to formulate. This was a very important step
in the process, and Leenen perceives those years as the for-
mative years in the euthanasia debate. A social movement
was created, involving a variety of different interests: physi-
cians, patients’ groups, politicians, lawyers, courts, and
In 1987, a state committee, under a Catholic president,
recommended legalizing euthanasia and thereby according it
a legitimate status for the first time. However, the Christian-
Democrats continued to block all legislative attempts. Leenen
and Kennedy emphasize that during this period, physicians
continued to practice euthanasia and more cases were brought
before the courts. Arie van der Arend and Govert den Hartogh
noted that patients’ groups and voluntary euthanasia advo-
cates then gained strong influence.
John Griffiths, a professor at the University of Groningen
Faculty of Law, explains that the Dutch have a history of
tolerance and moral ambiguity — they tolerate things that
Volume 30:1, Spring 2002
fering. Similarly, Henk Jochemsen says that the social climate
in the Netherlands is one in which euthanasia seems a good
solution for suffering, and that it is up to the doctor to pro-
vide this solution.
Interviewees emphasized “openness” as the trait that
made euthanasia possible. Dutch people prefer to put things
on the table and to discuss everything openly — from drugs,
prostitution, and pornography to homosexuality, abortion,
and euthanasia. Sex education is explicit and universal in
Dutch schools. There are open debates on moral issues, a
plurality of views, and an overall atmosphere of permissive-
ness.41 Indeed, in a comparative survey of fifteen countries,
including the United States and Canada, the Dutch had by far
the most permissive orientation.42
are illegal but that are not undesirable enough to stop. As
Paul van der Maas puts it, the Dutch raise moral ques-
tions and try to settle them through pragmatic means. For
instance, one of the problems faced by the Netherlands
earlier in the twentieth century was that of squatters,
people who illegally resided in empty buildings. Accord-
ing to Griffiths, the government understood that the
problem might become worse if they evacuated the squat-
ters by force. Hence, it tried to find them housing, and
the squatters even formed their own organization to nego-
tiate with the local municipalities.
A. van Dantzig, one of the nation’s most well-known
psychiatrists, pointed out another phenomenon that illus-
trates how the Dutch have their own way of dealing with
moral questions. Their attitude of “live and let live” is exem-
plified by their policy on soft drugs. It is forbidden for coffee
shops to buy drugs, but they are allowed to sell them and the
authorities don’t ask how the shops obtained the drugs. In
essence, this is a politics of accommodation and compro-
mise among the interests of each fragment of society as long
as they recognize the authority of the State.
Not everyone is happy with the increased sense of secu-
larization and the prevailing liberalism. G.F. Koerselman,
another well-known psychiatrist, explains that the Nether-
lands shifted too rapidly from one extreme to another.
Whereas before the 1950s, the country was very religious,
since then the secularization process has brought about “to-
talitarian humanism.” It is totalitarian because humanism
cannot be discussed; it is self-evident, unquestioned, taken
This view has significant implications for public life.
First and foremost, there is absolute respect for individual
autonomy. It is almost dogma that people should be, and
are, autonomous. Consequently, the prevailing view is that
decisions, especially about life and death, should be left
in the hands of individuals. Second, argues Koerselman,
there is a societal battle against suffering. It is strongly
believed that people should not suffer and, in the name of
relieving suffering, it is thought that it is better to seek
death. Euthanasia is one form of resolving the issue of suf-
Interviewees noted that the Dutch enjoy having the kind
of theological discussion which includes probing norms and
values. They further mentioned compromise as a basic
mechanism by which resolutions are reached, explaining that
the Netherlands has been in trade for centuries and conse-
quently developed the necessary ability to compromise. The
ambiguity of having euthanasia guidelines, yet prohibiting
euthanasia under the penal code, is the result of compromise
between the religious and secular circles of society, between
the legalistic and the realistic, in trying to resolve the issue of
suffering.43 The Netherlands has a history of consensus gov-
ernments based on compromise and mutual tolerance. The
Dutch resent authority and have never had an authoritarian
regime. As Gerrit van der Wal and Johannes J.M. van Delden
have pointed out, the average Dutch citizen is liberal, prag-
matic, and tolerant, and appreciates plurality. There is a sense
of obligation in Dutch society to try to reach a consensus on
Another important consideration is the Dutch attitude
toward the law. Some interviewees argue that one of the
lessons of World War II relates to the limits of authority and
the need to dissent when strong moral grounds are provided.44
Many Dutch physicians during the war felt that the state should
not intervene in the doctor-patient relationship and thus refused
to participate in the German euthanasia program, openly defy-
ing an order to treat only those patients who had a good
chance of full recovery.45 In this context, Chris Rutenfrans of
the Trouw newspaper spoke of a lack of sufficient safeguards
against abuse as a result of historical shortsightedness. Un-
like the United States, Germany, and other countries where
the eugenics movement was active during the 1930s, the
Netherlands did not have such a movement. While those
countries were alarmed at how the Nazis implemented eu-
thanasia, the Dutch collective memory is unaware of the
Nazi experience in this regard. If one has compelling moral
reasons, it is considered acceptable to break the law in com-
pliance with one’s conscience. The fact that the courts tended
to be very lenient towards doctors who performed euthana-
sia reflects the prevailing positive attitude on this issue.
Many interviewees emphasized the importance of the
Dutch health-care system. As previously mentioned, the
Netherlands has all-inclusive health insurance based on gen-
eral practitioners who have longstanding relationships with
their patients. The result is that most patients trust their doc-
tors.46 Emphasis is put on the autonomy of patients, enabling
them to have self-determination. At the same time, their
strong trust in their general practitioners may lead patients
to yield their autonomy or, ultimately, even their lives. This
possibility exists especially when doctors suggest euthanasia
to their patients.
The literature describes the strongly developed system
of primary care in the Netherlands, with 6,300 general prac-
titioners and additional nursing care at home. Many patients
(40 percent) die at home, especially patients with cancer (48
The Journal of Law, Medicine & Ethics
Switzerland), and whose legislatures advance more bills that
would legitimize euthanasia further, while broadening the
scope of the practice. Many Dutch scholars lump euthanasia
and physician-assisted suicide together and have even invented
an acronym for this purpose: EAS. It should be noted, how-
ever, that in August 1995, in an effort to improve the control
mechanisms guiding these procedures, the Royal Dutch
Medical Association refined its guidelines to recommend
that assisted suicide, rather than euthanasia, be performed
I believe that the medical profession should not turn its
back on patients who clearly request to shorten their lives.
However, this issue should be open to a constant public de-
bate. Wherever euthanasia is practiced, it should be subject
percent of all cancer deaths). Almost all patients (99.4 per-
cent) have health care insurance, and 100 percent of the
population is insured for the cost of protracted illness.47
When faced with the choice of going to the hospital to
obtain the necessary health care or staying at home to receive
care, the Dutch generally prefer the latter. The same is true
for giving birth, and a high percentage of births take place at
home. While women are aware of the possible risks involved
in giving birth at home, many still prefer home delivery.
Home is seen as the place to start life and to finish life. The
general practitioner typically visits the patient at home and
establishes a personal relationship that is discrete and pri-
vate. In this realm of intimacy, outside control often does not
exist and is conceived by both parties as interfering and dam-
aging to the personal trust and special bond that have evolved
over time. Many incidents of euthanasia happen at home
and are not reported, given that this is considered a private
matter, something between the patient, his or her family, and
The aim of this essay was to describe the reasons interviewees
gave to explain what prompted the Netherlands to adopt its
policy and practice of euthanasia. Multiple reasons were
mentioned: historical, social, cultural, religious, and politi-
cal as well as the pivotal importance of the local health-care
system. A complex combination of factors brought the Neth-
erlands to adopt a very tolerant attitude regarding euthanasia
and physician-assisted suicide.
In the United States, Oregon’s Measure 16 that allows
assisted suicide is facing a challenge.48 In Australia, the North-
ern Territory Bill that allowed terminally ill patients to commit
suicide with a doctor’s help was declared void. The legisla-
tures of Canada and England have resisted attempts to legalize
assisted suicide and euthanasia. The Netherlands remains
the only country in the liberal world (with the possible ex-
ception of Belgium) that generally accepts the policy and
practice of both euthanasia and physician-assisted suicide,
without seeing much difference between the two (unlike
to constructive criticism. It is preferable to draft a better
legal framework than the one that governed the practice of
euthanasia in the Netherlands until November 2000, which
was ambiguous and presented an illegal-yet-tolerated model.
If we see that the new euthanasia policy opens the way to
abuse, then yet again we should pursue a public debate in
which different sectors of society can take part.
While it is necessary to devise a better working frame-
work to help patients in need, respect for human life is and
should remain the prime concern. Ending a human life with-
out acquiring the patient’s consent might be motivated by
mercy — or, alternatively, the motivation may be quite dif-
ferent. The ending of a patient’s life should be conducted in
the light, not in shadowy areas where only selected people
I also think that physicians should not suggest euthana-
sia to their patients as an option. By now, the Dutch people
are fully aware that euthanasia is available. If patients wish, they
can raise the issue themselves. Most of the euthanasia cases in-
volve cancer patients; at some time during the progressive course
of their illness, they can take the initiative and discuss it with
their physicians if they are so inclined. If they do not initiate
such a discussion, then the physician can assume that the
patient does not wish to move in this direction.
The author is most grateful to the referees of the Journal of
Law, Medicine & Ethics for their useful comments, to Evert
van Leeuwen and Martine Bouman for facilitating the re-
search, to Dareen Jacobe for her research assistance, and to
the interviewees for their kind cooperation.
The names and affiliations of those interviewed (with the
location and date of their interview in parenthesis) are as
1. Dr. Arie J.G. van der Arend, Health Ethics and Phi-
losophy, Maastricht University (Maastricht, July 26, 1999).
2. Dr. Ron Berghmans, Institute for Bioethics, Maastricht
University (Maastricht, August 11, 1999).
3. Dr. George Beusmans, Maastricht Hospital
(Maastricht, July 26, 1999).
4. Professor G.F. Koerselman, Sint Lucas Andreas Hos-
pital, Amsterdam (Amsterdam, July 27, 1999).
5. Ms. Barbara de Boer, the widow of a man who was
euthanized, and her three children (Amsterdam, August 2,
6. Professor A. van Dantzig, retired expert in psychiatry
(Amsterdam, July 20, 1999).
7. Dr. Johannes J.M. van Delden, Senior Researcher,
Center for Bioethics and Health Law, Utrecht University
(Utrecht, August 10, 1999).
Volume 30:1, Spring 2002
23. Professor Bert Thijs, Medical Intensive Care Unit,
VU Hospital, Amsterdam (Amsterdam, July 20, 1999).
24. Dr. Margo Trappenburg, Department of Political Sci-
ence, University of Leiden (Leiden, July 22, 1999).
25. Dr. Jaap J.F. Visser, Ministry of Health, Department
of Medical Ethics, The Hague (Amsterdam, July 21, 1999).
26. Professor Gerrit van der Wal, Institute for Research
in Extramural Medicine, Department of Social Medicine,
Free University of Amsterdam (Amsterdam, July 21, 1999).
27. Dr. Henri Wijsbek, Department of Medical Ethics,
Erasmus University of Rotterdam (Rotterdam, July 23, 1999).
28. Dr. Dick Willems, Institute for Research in Extramu-
ral Medicine, Department of Social Medicine, Amsterdam
(Amsterdam, July 20, 1999).
8. Professor Heleen Dupuis, Department of
Metamedicine, University of Leiden (Leiden, July 22, 1999).
9. Professor J.K. Gevers, Professor of Health Law, Uni-
versity of Amsterdam (Amsterdam, July 19, 1999).
10. Professor John Griffiths, Department of Legal Theory,
Faculty of Law, University of Groningen (Groningen, July
11. Professor Govert den Hartogh, Faculty of Philosophy,
University of Amsterdam (Amsterdam, August 10, 1999).
12. Dr. Rob Houtenpen, Health Ethics and Philosophy,
Maastricht University (Maastricht, August 11, 1999).
13. Professor Henk Jochemsen, Director, Professor
Lindeboom Institute (Ede Wageningen, July 27, 1999).
14. Dr. James Kennedy, Department of History, Hope
College, Michigan. Visiting Research Fellow at the Insti-
tute for Social Research, Amsterdam (Amsterdam, July
15. Dr. Gerrit K. Kimsma, Department of Metamedicine,
Free University of Amsterdam (Koog aan de Zaan, July 28,
16. Professor H.J.J. Leenen, formerly professor of social
medicine and health law, Medical Faculty and Faculty of
Law, University of Amsterdam (Amsterdam, July 21, 1999).
17. Professor Evert van Leeuwen, Department of
Metamedicine, Free University of Amsterdam (Amsterdam,
July 19, 1999; Haarlem, July 28, 1999).
18. Professor Paul van der Maas, Department of Public
Health, Faculty of Medicine, Erasmus University, Rotterdam
(Amsterdam, July 29, 1999).
19. Professor Ruud ter Meulen, Director, Institute for
Bioethics and Professor, University of Maastricht (Maastricht,
August 11, 1999).
20. Dr. Arko Oderwald, Department of Metamedicine,
Free University of Amsterdam (Amsterdam, July 30, 1999
and August 8, 1999).
21. Dr. Chris Rutenfrans, T rouw (Amsterdam, July 30,
22. Professor Egbert Schroten, Director, Center for Bio-
ethics and Health Law, Utrecht University (Utrecht, August
1. G.K. Kimsma and E. van Leeuwen, “Dutch Euthanasia:
Background, Practice, and Present Justifications,” Cambridge Quar-
terly of Healthcare Ethics, 2 (1993): 19–35, especially at 24.
2. See T. Sheldon, “Doctors Not Obliged to Carry Out Treat-
ment They Think ‘Futile,’” British Medical Journal, 319 (October
23, 1999): 1088.
3. For a discussion of the double effect doctrine, see R.
Cohen-Almagor, “Language and Reality at the End of Life,” Jour-
nal of Law, Medicine & Ethics, 28, no. 3 (2000): 267–278.
4. See J. Legemaate, “T wenty-Five Years of Dutch Experi-
ence and Policy on Euthanasia and Assisted Suicide: An Overview,”
in David C. Thomasma et al., eds., Asking to Die (Dordrecht:
Kluwer Academic Publishers, 1998): at 20; G.K. Kimsma, “Eu-
thanasia and Physician Assisted Suicide in the Netherlands,”
Medizin, Ethik, Recht (1994): 161–69.
5. J. Griffiths, A. Bood, and H. Weyers, Euthanasia and Law
in the Netherlands (Amsterdam: Amsterdam University Press,
1998): at 213.
6. J. Griffiths, “Effective Regulation of Euthanasia and Other
Medical Behavior that Shortens Life,” in E. Mackaay, ed., Uncer-
tainty and the Law (Montreal: Editions Thémis, 1999): 61–94,
especially at 72–73.
7. G. van der Wal, J.Th.M. van Eijk, H.J.J. Leenen, and C.
Spreeuwenberg, “Euthanasia and Assisted Suicide. II. Do Dutch
Family Doctors Act Prudently?,” Family Practice, 9, no. 2 (1992):
8. A doctor has an obligation to maintain a full dossier on
every patient and to accurately record therein what he or she
does and why. Keeping adequate records is a general require-
ment of medical practice, and is specifically one of the
requirements of careful practice in the case of euthanasia.
9. Kimsma notes that written requests of euthanasia are
preferable but not mandatory. Another acceptable solution is a
10. Griffiths, supra note 6, at 74.
11. I thank Henk Leenen for this piece of information.
12. H.A.M.J. ten Have, “Euthanasia: The Dutch Experience,”
Annals de la Real Academia Nacional de Medicina, Tomo CXII
(Madrid, 1995): 425–44, at 436–37.
13. Reporting, as opposed to recordkeeping, refers to the
requirement that a doctor report a case of euthanasia to the
authorities as an unnatural death.
14. Griffiths, supra note 6, at 74–75.
15. P .J. van der Maas, J.J.M. van Delden, and L. Pijnenborg,
Euthanasia and Other Medical Decisions Concerning the End of
Life, Health Policy Monographs (Amsterdam: Elsevier, 1992): at
16. For further reading, see H.J.J. Leenen, “Euthanasia, As-
sistance to Suicide and the Law: Developments in the
Netherlands,” Health Policy, 8 (1987): 197–206; J.K.M. Gevers,
“Legal Developments Concerning Active Euthanasia on Request
in the Netherlands,” Bioethics, 1, no. 2 (1987): 156–162.
17. “Euthanasia and Physician Assisted Suicide in the Neth-
erlands,” at <http://www.nlembassy.or.kr/c_hlteuth.html> (last
visited January 14, 2002). This website is a service of the Royal
Netherlands Embassy in Seoul, Korea.
18. B. Sneiderman and M. Verhoef, “Patient Autonomy and
the Defence of Medical Necessity: Five Dutch Euthanasia Cases,”
Alberta Law Review, XXXIV , no. 2 (1996): 374–415, at 376. In
England and Canada, the defense of medical necessity has been
recognized in abortion cases (see R. v. Bourne  3 All E.R.
615 and R. v. Morgentaler  20 C.C.C. (2d) 449), but it is not
available in euthanasia cases. For England, see R. v. Cox  12
The Journal of Law, Medicine & Ethics
“Euthanasia, Physician-Assisted Suicide, and Other Medical Prac-
tices Involving the End of Life in the Netherlands, 1990–1995,”
N. Engl. J. Med., 335, no. 22 (1996): 1699–1711, at 1700.
28. Those commenting included Arie J.G. van der Arend,
Rob Houtepen, Henk Jochemsen, Margo Trappenburg, James
Kennedy, H.J.J. Leenen, A. van Dantzig, Heleen Dupuis, Johannes
JM van Delden, John Griffiths, Sjef Gevers, Ron Berghmans,
Ruud ter Meulen, Govert den Hartogh, Arko Oderwald, Evert
van Leeuwen, Paul van der Maas, and Gerrit Kimsma. Bert Thijs
and George Beusmans read the draft and had no problem with
my account of their views.
29. B. Gordijn, “Euthanasie: strafbar und doch zugestanden?
Die niederlandische Duldungspolitik in Sachen Euthanasie” (Eu-
thanasia: Criminal offense and still allowed? The Dutch policy of
permissiveness/tolerance in cases of euthanasia), Ethik Med, 10
(1998): at 12.
30. Proceedings of Euthanasia and Assisted Suicide in the Neth-
Frank Koerselman, Egbert Schroten, and Govert den Hartogh.
BMLR 38 (England); R. Porter, “Doctor Convicted of Attempted
Murder,” Sunday Telegraph (London), September 20, 1992. For
Canada, see M. O’Malley and O. Wood, “‘Cruel & Unusual’:
The Law and Latimer,” CBC News, at <http://www.cbc.ca/news/
indepth/background/latimer_robert.html> (last visited January
15, 2002), describing the Robert Latimer case, which involves a
Saskatchewan farmer who killed his 12-year-old daughter, Tracy,
who suffered from severe cerebral palsy and had the capacity of
a three-month-old child. Latimer is currently serving a life sen-
tence, which holds no possibility of parole until 10 years.
19. R.J.M. Dillmann and J. Legemaate, “Euthanasia in the
Netherlands: The State of the Legal Debate,” European Journal
of Health Law, 1 (1994): 81–87, especially at 84.
20. A translation of the law can be found in Griffiths, Bood,
and Weyers, supra note 5, at 308–13.
21. Reuters, “Dutch Parliament Votes to Legalize Euthana-
sia,” November 28, 2000, available at <http://www.worldrtd.org/
22. On the regional committees, see E. van Leeuwen and G.
Kimsma, “Problems Involved in the Moral Justification of Medi-
cal Assistance in Dying: Coming to Terms with Euthanasia and
Physician Assisted Suicide,” in R. Cohen-Almagor, ed., Medical
Ethics at the Dawn of the 21st Century (New York: New York
Academy of Sciences, 2000): 157–173; B. Onwuteaka-Philipsen,
Consultation of Another Physician in Cases of Euthanasia and Phy-
sician-Assisted Suicide, Doctoral Thesis (Amsterdam: Department
of Social Medicine, Vrije Universiteit, 1999).
23. “Minderjarige mag euthanasie vragen” (A minor may/is
allowed to ask/request for euthanasia), NRC Handelsblad (New
Rotterdam), July 10, 1999, at 3. See also M. Gardner, “Dutch
Poised to Legalize Euthanasia,” Christian Science Monitor, June
30, 2000, available at <http://www.csmonitor.com/durable/2000/
24. Associated Press, “Dutch Call Off Aided Suicide for Chil-
dren,” International Herald-Tribune, July 15, 2000.
25. H. Jochemsen, “The Legalization of Euthanasia in The
Netherlands,” Ethics & Medicine, 17, no. 1 (January 2001).
26. In his letter dated June 5, 1999, Dr. Chabot wrote: “Af-
ter four years waiting for the final court judgement (1991–1995)
and discussing the case with many people from abroad, I hope
you will understand that I prefer to remain in the background
now and not to make an appointment with you.” He, however,
agreed to answer via e-mail some specific questions relating to his
conduct that brought about the charges against him.
27. My questionnaire comprised fifteen questions. The
Dutch comprehensive study of 1995 consisted of 120 pages and
the interviews lasted for an average of 2.5 hours. The pace of
questioning was, apparently, frantic. See P .J. van der Maas et al.,
erlands and in Europe, Maastricht, June 10–11, 1994 (Luxem-
bourg: Office for Official Publications of the European
Communities, 1996): at 101.
31. Griffiths, Bood and Weyers, supra note 5, at 12–13.
32. L. Pijnenborg, “The Dutch Euthanasia Debate in Inter-
national Perspective,” in End-of-Life Decisions in Dutch Medical
Practice, Doctoral Thesis (Rotterdam: Department of Public
Health, Erasmus University, 1995): 119–132. I am most grateful
to Paul van der Maas for sending me this work as well as some
33. These included James Kennedy, Govert den Hartogh,
Heleen Dupuis, Henk Jochemsen, and A. van Dantzig.
34. Evert Van Leeuwen, Jaap Visser, Margo Trappenburg,
Bert Thijs, and Gerrit van der Wal expressed similar views.
35. Ruud ter Meulen made a similar point. For further delib-
eration on Calvinism, see D.E. Holwerda, ed., Exploring the Heritage
of John Calvin (Grand Rapids, Michigan: Baker Book House,
1976). See especially the chapter by T. Minnema, “Calvin’s Inter-
pretation of Human Suffering,” at 140–162.
36. The book was translated to English and published by
W .W . Norton in 1978.
37. J. van Holsteyn and M. Trappenburg, “Citizens’ Opin-
ions on New Forms of Euthanasia. A Report from the
Netherlands,” Patient Education and Counseling, 35 (1998):
38. Van den Berg’s book responded to widely felt concerns
and was reprinted twenty-one times within seven years and end-
lessly discussed in magazines and other media. See Griffiths, Bood
and Weyers, supra note 5, at 48.
39. On changes in public opinion from 1966 to 1991, see P .J.
van der Maas, L. Pijnenborg, and J.J.M. van Delden, “Changes in
Dutch Opinions on Active Euthanasia, 1966 Through 1991,”
JAMA, 273, no. 18 (May 10, 1995): 1411–14; D.J. Hessing, J.R.
Blad, and R. Pieterman, “Practical Reasons and Reasonable Prac-
tice: The Case of Euthanasia in the Netherlands,” Journal of
Social Issues, 52, no. 2 (1996): 161–66. According to two con-
secutive polls, 70 percent of the Dutch people accepted active
euthanasia in 1985, and 76 percent in 1986. See R. Fenigsen, “A
Case Against Dutch Euthanasia,” Hastings Center Report, 19, no.
1 (Supp. January/February 1989): 22–25. A 1998 survey showed
that more than 90 percent of the population favors euthanasia.
See S. Daley, “The Dutch Seek to Legalize Long-Tolerated Eutha-
nasia,” New York Times, June 20, 2000, available at <http://
40. C.F. McKhann, A Time to Die: The Place for Physician
Assistance (New Haven, Connecticut: Yale University Press, 1999):
at 122. The Postma case was the best known prosecution during
this period of a person who killed another at the latter’s request,
but it wasn’t the only one. There were at least three other pros-
ecutions for violations of Articles 293 or 294. See C.F. Gomez,
Regulating Death (New York: The Free Press, 1991): at 28–32;
Griffiths, Bood, and Weyers, supra note 5, at 53.
41. This is supported by my interviews with John Griffiths,
J.K. Gevers, Bert Thijs, Arie van der Arend, Ron Berghmans, and
Ruud ter Meulen.
42. P . Ester, L. Halman, and R. de Moor, The Individualizing
Society: Value Change in Europe and North America (Tilburg: Tilburg
University Press, 1994): at 56–60.
43. This is supported by my interviews with Jaap Visser, Dick
Willems, and John Griffiths. This point was reiterated also by
44. These include Evert van Leeuwen, John Griffiths, and
Gerrit van der Wal.
45. L. Alexander, “Medical Science Under Dictatorship,” N.
104 Download full-text
Volume 30:1, Spring 2002
Engl. J. Med., 241 (July 14, 1949): 39–47, especially at 45.
46. This is supported by my interviews with J.K. Gevers, Jaap
Visser, Heleen Dupuis, Margo Trappenburg, Gerrit van der Wal,
Henk Jochemsen, Govert den Hartogh, Arko Oderwald, and
47. G. van der Wal and R.J.M. Dillmann, “Euthanasia in the
Netherlands,” British Medical Journal, 308 (1994): 1346–49. For
further deliberation on the Dutch health-care system, see J. van
der Made and H. Maarse, “Access to Health Care in the Nether-
lands,” in J. Lenaghan, ed., Hard Choices in Health Care: Rights
and Rationing in Europe (London: BMJ Publishing Group, 1997):
48. See R. Cohen-Almagor and M.G. Hartman, “The Or-
egon Death with Dignity Act: Review and Proposals for
Improvement,” Journal of Legislation, 27, no. 2 (2001): 269–98.
49. See H. Hendin, Seduced by Death (New York: W .W .
Norton, 1997): at 122.
50. See R. Cohen-Almagor, The Right to Die with Dignity: An
Argument in Ethics, Medicine, and Law (NJ.: Rutgers University