Guidelines in the Netherlands
Holland has allowed doctors to end the lives of
under various guidelines and regulations since the 1980s.
The most recent codification of the law was in 2002:
Termination of Life on Request and Assisted Suicide (Review Procedures).
These regulations and procedures are summarized here.
Links are provided to complete explanations of each safeguard.
for Death from the Patient
must be voluntary and carefully considered.
A written request from the patient is much preferred,
which leaves a good record of when the requests were made.
The request should be made some
time before the euthanasia is carried
altho no specific waiting period
Care should be taken to make sure that there is no
from anyone to choose euthanasia prematurely.
The requests for death must not be given with
In case of doubt, a psychiatric
consultation is generally required.
If the patient is demented or has some other mental disorder,
no informed consent can be given.
But this does not rule out euthanasia entirely,
if there was some record of a voluntary and careful request
at some earlier time when the
patient's thinking was not impaired.
This might have taken the form of a general request for death
included in an Advance
Directive for Medical Care.
However, if the patient is severely demented or unconscious,
these might not considered to be conditions of suffering
sufficient to justify euthanasia.
Pain relief and sedation should be sufficient.
other life-ending behavior by doctors at the end of this file.)
However, in practice, the patient is not required to
be completely competent
up until the very last moment of life.
The disease or any medication used might result in impaired capacity at
the very end,
but this will not invalidate earlier decisions to
carry out euthanasia.
The purpose of obtaining careful and consistent
requests for death from the patient
is to clarify and evaluate the basic reasons for choosing death.
2. The patient must have unbearable
with no prospect of improvement.
The suffering is the subjective experience of the
but it must seem intelligible to the physician,
who will report that the suffering was unbearable to the Regional
In practice, the suffering must be conscious.
This means that patients
already in a terminal coma would not qualify
But any signs of suffering can be taken into account,
even if the patient can no longer articulate the suffering.
The suffering must be hopeless or with no prospect of improvement.
This generally means that palliative treatments have already been tried.
And the palliative care has not sufficiently relieved the symptoms.
care is not required as a condition for being
In other words, the patient can refuse comfort care,
thereby creating unbearable suffering, which then qualifies for
3. The doctor must inform the patient about the medical situation and
The decision to end the patient's life must be well-based in medical facts.
And the patient must give fully-informed
consent to the plan for death.
4. The doctor and the patient must be convinced that there is no
euthanasia or physician assisted suicide.
This includes discussion of medical treatments that might still
Palliative care should also be explored.
Such discussions might result in a well-informed consent for
5. The doctor must consult with at
least one other independent
who has examined the patient and given his or her opinion
about the four criteria above.
The purposes of this consultation are several:
The consultant will see if the diagnosis and prognosis were correct.
Have alternative treatments been adequately considered?
Were the prior efforts at cure reasonable?
Has palliative care been provided?
Do both doctors understand the procedural requirement for euthanasia?
In the second doctor's opinion, is euthanasia a valid choice?
Will they cooperate in fulfilling the reporting requirements?
Ideally, this consulting physician should visit with
the patient at least twice:
The first visit should take place while the patient can still
The second visit can take place after the suffering has become
This might be the occasion for choosing the date of death.
It is even better if the consultant is a doctor
who has been especially
trained to deal with cases of euthanasia.
These doctors produce better reports of their cases.
If one doctor called in for consultation
does not agree that euthanasia would be the best choice,
the first doctor can seek
But if the second consultant also does not agree,
the euthanasia should not go forward.
This is the position of the Dutch Medical Association.
6. The doctor will terminate the patient's life with due care
or provide the means by which the patient can terminate his or her
It is generally expected but not required that the doctor be the
But the doctor must have some
meaningful medical relationship with the
besides being the provider of euthanasia.
And the doctor is generally expected to remain at the bedside
until the patient is dead.
7. The doctor reports the case to the municipal pathologist,
who must respond in order for burial or cremation to go forward.
8. The doctor reports the euthanasia to the Regional Review
of a doctor, a lawyer, and an ethicist—
find a violation of procedure,
which could result in professional disciplinary action
or even prosecution for a crime.
In the first decade since the new law was enacted,
no doctors have been recommended for prosecution for not being careful
in their practice of providiving either euthanasia or
About 2% of all deaths in Holland result from such help from a doctor.
A form has been developed,
which covers all the essential points required for reporting
Occasionally the Regional Review Committee
will ask for more information about a specific case.
For example, the report-form asks about discussions
family, friends, nurses, etc.
Such discussions are not required, but when they did take place,
responses from others should be included in the final report.
The patient must be 18 years of age
Younger patients must get cooperation from parents or guardians.
Defective newborns obviously cannot give consent to anything.
Life-ending decisions for them fall under other regulations.
Foreigners are not permitted to go to Holland for euthanasia.
Not included: terminal illness.
Dutch law does not require the patient to be terminally ill
in order to qualify for help in dying.
It is only required that the patient be suffering unbearably.
Patients who are merely tired of living
do not qualify.
Not included: the suffering must have a physical basis.
In other words, psychological
suffering could qualify.
This summary is based on Euthanasia and
Law in Europe.
down to the second book.)
IN SUMMARY—DUTCH SAFEGUARDS IN ORDER
DEATH FROM THE
OF CONDITION AND PROGNOSIS
PHYSICIAN REVIEWS THE CONDITION AND PROGNOSIS
CONSENT FROM THE PATIENT
ABILITY TO MAKE MEDICAL DECISIONS
FOR MEDICAL CARE
PERIODS FOR REFLECTION
ALTERNATIVES TO DEATH
AFFIRMING OR QUESTIONING CHOOSING DEATH
MUST BE AN ADULT RESIDENT OF THE STATE
By this count, there are 13 safeguards in Dutch law
concerning euthanasia and physician-assisted suicide.
The above prioritized list has letters drawn from the list of 26
They retain their original letters from
And two of the safeguards have no letters,
because there are additional, possible safeguards.
Here is the complete list of proposed safeguards:
OTHER LIFE-ENDING DECISIONS BY DOCTORS
THAT ARE PART OF NORMAL
In Holland only about 2-3% of all deaths come under
the safeguards described above
for euthanasia and physican-assisted suicide.
Many other life-ending decisions are considered normal medical practice,
which are governed by medical ethics but do not fall under the
(1) increasing pain-medication,
(2) terminal sedation,
(3) withholding or withdrawing all curative treatments,
(4) withholding or withdrawing life-supports,
(5) medical dehydration.
All of these actions (or withholdings) must be
ordered by a physician.
Such life-ending behavior might be crimes if done by laypersons.
And all of them take place under medical care,
usually in a health-care institution such as a hospital or nursing
In most cases, the doctor who orders these changes
will consult with the family to obtain their consent.
Sometimes the patient is mentally able to agree with these life-ending
And in cases of medical
the doctor can order withdrawal of useless medical treatment
even without agreement from the patient and/or the family.
Some combination of these life-ending decisions
in about half of all deaths
in the Netherlands.
But doctors need not consult with anyone about such choices.
And no special reporting is required.
The resulting deaths will be recorded as natural deaths
due to the underlying illness or condition of the patient.
And they do not fall under the Dutch law
concerning euthanasia and physician-assisted suicide.
In many cases, the withdrawal of such medical
treatments and supports
takes place only in the last few days of life.
When the patient's death is clearly inevitable,
then further medical measures will only prolong the process of dying.
Everything in this file is subject to revision
if someone has studied the guidelines in the original Dutch
and/or who knows the actual practices in the Netherlands.
March 25, 2012; Revised 3-29-2012; 3-30-2012; 5-6-2012; 4-24-2013