1. Euthanasia in the Netherlands The Policy and Practice of Mercy Killing Raphael Cohen-Almagor

2. Preliminaries: Comparative Law

3. Part A: Background 1. The Two Research Reports of 1990 and 1995 and Their Interpretations 1. The Two Research Reports of 1990 and 1995 and Their Interpretations 2. The Practice of Euthanasia and the Legal Framework 2. The Practice of Euthanasia and the Legal Framework

4. Part B: Fieldwork 3. The Methodology 3. The Methodology

5. Phase I: The Interviews 4. Why the Netherlands? 4. Why the Netherlands? 5. Views on the Practice of Euthanasia 5. Views on the Practice of Euthanasia

6. 6. Worrisome Data Some of the most worrisome data in the two Dutch studies are concerned with the hastening of death without the explicit request of patients. There were 1000 cases (0.8%) without explicit and persistent request in 1990, and 900 cases (0.7%) in 1995. What is your opinion? Some of the most worrisome data in the two Dutch studies are concerned with the hastening of death without the explicit request of patients. There were 1000 cases (0.8%) without explicit and persistent request in 1990, and 900 cases (0.7%) in 1995. What is your opinion?

7. 7. The Remmelink Contention and the British Criticism The Remmelink Commission held that actively ending life when the vital functions have started failing is indisputably normal medical practice. Is this correct? What is your opinion? The Remmelink Commission held that actively ending life when the vital functions have started failing is indisputably normal medical practice. Is this correct? What is your opinion? In its memorandum before the House of Lords, the BMA held that in regard to Holland, all seem to agree that the so-called rules of careful conduct (official guidelines for euthanasia) are disregarded in some cases. Breaches of rules range from the practice of involuntary euthanasia to failure to consult another practitioner before carrying out euthanasia and to certifying the cause of death as natural. I asked my interviewees: Do you agree? In its memorandum before the House of Lords, the BMA held that in regard to Holland, all seem to agree that the so-called rules of careful conduct (official guidelines for euthanasia) are disregarded in some cases. Breaches of rules range from the practice of involuntary euthanasia to failure to consult another practitioner before carrying out euthanasia and to certifying the cause of death as natural. I asked my interviewees: Do you agree?

8. 8. Should Physicians Suggest Euthanasia to Their Patients? 8. Should Physicians Suggest Euthanasia to Their Patients?

9. 9. Breaches of the Guidelines The physician practicing euthanasia is required to consult a colleague in regard to the hopeless condition of the patient. Who decides who the second doctor will be? The physician practicing euthanasia is required to consult a colleague in regard to the hopeless condition of the patient. Who decides who the second doctor will be? What happens in small rural villages where it might be difficult to find an independent colleague to consult. What happens in small rural villages where it might be difficult to find an independent colleague to consult.

10. Lack of Reporting Record-keeping and written requests of euthanasia cases have improved considerably since 1990; there are now written requests in about 60% and written record-keeping in some 85% of all cases of euthanasia. The reporting rate for euthanasia was 18% in 1990, and by 1995 it had risen to 41%. The trend is reassuring, but a situation in which less than half of all cases are reported is unacceptable from the point of view of effective control. Record-keeping and written requests of euthanasia cases have improved considerably since 1990; there are now written requests in about 60% and written record-keeping in some 85% of all cases of euthanasia. The reporting rate for euthanasia was 18% in 1990, and by 1995 it had risen to 41%. The trend is reassuring, but a situation in which less than half of all cases are reported is unacceptable from the point of view of effective control. What do you think? What do you think? How can the reporting rate be improved? How can the reporting rate be improved?

11. 10. On Palliative Care and the Dutch Culture It has been argued that the policy and practice of euthanasia is the result of undeveloped palliative care. What do you think? It has been argued that the policy and practice of euthanasia is the result of undeveloped palliative care. What do you think? I also mentioned the fact that there are only a few hospices in the Netherlands. I also mentioned the fact that there are only a few hospices in the Netherlands.

12. Culture of Death Daniel Callahan argues that there is aculture of death in the Netherlands. Daniel Callahan argues that there is aculture of death in the Netherlands. What do you think? What do you think? I intentionally refrained from explaining the term culture of death. I wanted to see whether the interviewees have different ideas on what would constitute such a culture. I intentionally refrained from explaining the term culture of death. I wanted to see whether the interviewees have different ideas on what would constitute such a culture.

13. 11. On Legislation and the Chabot Case 11. On Legislation and the Chabot Case

14. Phase II: Interviewees General Comments Preliminaries Preliminaries General Comments General Comments

15. Phase III: Updates Preliminaries On the New Act On the Work of the Regional Committees Further Concerns

16. Part C: Conclusions Preliminaries Preliminaries Suggestions for Improvement Suggestions for Improvement

17. Since November 1990, prosecution is unlikely if a doctor complies with the Guidelines set out in the non-prosecution agreement between the Dutch Ministry of Justice and the Royal Dutch Medical Association. Since November 1990, prosecution is unlikely if a doctor complies with the Guidelines set out in the non-prosecution agreement between the Dutch Ministry of Justice and the Royal Dutch Medical Association. These Guidelines are based on the criteria established in court decisions relating to the conditions under which a doctor can successfully invoke the defense of necessity. These Guidelines are based on the criteria established in court decisions relating to the conditions under which a doctor can successfully invoke the defense of necessity.

18. The substantive requirements are as follows: The request for euthanasia or physician- assisted suicide must be made by the patient and must be free and voluntary. The request for euthanasia or physician- assisted suicide must be made by the patient and must be free and voluntary. The patient s request must be well considered, durable and consistent. The patient s request must be well considered, durable and consistent.

19. The patient s situation must entail unbearable suffering with no prospect of improvement and no alternative to end the suffering. The patient s situation must entail unbearable suffering with no prospect of improvement and no alternative to end the suffering. The patient need not be terminally ill to satisfy this requirement and the suffering need not necessarily be physical. The patient need not be terminally ill to satisfy this requirement and the suffering need not necessarily be physical. Euthanasia must be a last resort. Euthanasia must be a last resort.

20. The procedural requirements are as follows: No doctor is required to perform euthanasia, but those opposed on principle must make this position known to the patient early on and help the patient to get in touch with a colleague who has no such moral objections. No doctor is required to perform euthanasia, but those opposed on principle must make this position known to the patient early on and help the patient to get in touch with a colleague who has no such moral objections. Doctors taking part in euthanasia should preferably and whenever possible have patients administer the fatal drug themselves, rather than have a doctor apply an injection or intravenous drip. Doctors taking part in euthanasia should preferably and whenever possible have patients administer the fatal drug themselves, rather than have a doctor apply an injection or intravenous drip.

21. A doctor must perform the euthanasia. A doctor must perform the euthanasia. Before the doctor assists the patient, the doctor must consult a second independent doctor who has no professional or family relationship with either the patient or doctor. Before the doctor assists the patient, the doctor must consult a second independent doctor who has no professional or family relationship with either the patient or doctor. Since the 1991 Chabot case, patients with a psychiatric disorder must be examined by at least two other doctors, one of whom must be a psychiatrist. Since the 1991 Chabot case, patients with a psychiatric disorder must be examined by at least two other doctors, one of whom must be a psychiatrist.

22. The doctor must keep a full written record of the case. The doctor must keep a full written record of the case. The death must be reported to the prosecutorial authorities as a case of euthanasia or physician- assisted suicide and not as a case of death by natural causes. The death must be reported to the prosecutorial authorities as a case of euthanasia or physician- assisted suicide and not as a case of death by natural causes. Since the legalization of the new law, cases of euthanasia and PAS are reported to the regional committees instead of the prosecutorial authorities. Since the legalization of the new law, cases of euthanasia and PAS are reported to the regional committees instead of the prosecutorial authorities.