An outsider's view of Dutch euthanasia policy and practice

Issues in Law and Medicine

Volumn 17, Issue 1, 2001, Pages 35-68

  Cohen Almagor, Raphael ^a,b,c,d,e  

^a UNIVERSITY OF HAIFA   (Israel)

^b UNIVERSITY OF CALIFORNIA   (United States)

^c The Van Leer Jerusalem Institute   (Israel)

^d TEL AVIV UNIVERSITY   (Israel)

^e UNIVERSITY OF OXFORD   (United Kingdom)

Author keywords

[No Author keywords available]

Indexed keywords

ARTICLE; ATTITUDE TO HEALTH; DEATH AND EUTHANASIA; EMPIRICAL APPROACH; EUTHANASIA; HUMAN; INTERVIEW; LEGAL APPROACH; LEGAL ASPECT; MEDICAL RECORD; NETHERLANDS; PATIENT REFERRAL; PRACTICE GUIDELINE;

DEATH AND EUTHANASIA; EMPIRICAL APPROACH; LEGAL APPROACH;

ATTITUDE TO HEALTH; EUTHANASIA; FORMS AND RECORDS CONTROL; HUMANS; INTERVIEWS; NETHERLANDS; PRACTICE GUIDELINES; REFERRAL AND CONSULTATION;

EID: 0035379080     PISSN: 87568160     EISSN: None     Source Type: Journal    
DOI: None     Document Type: Article

References (100)

1. HERBERT HENDIN, SEDUCED BY DEATH 23 (1997).
2. The Medical Association Executive Board emphasized that there are only limited possibilities for verifying whether suffering is unbearable and without prospect of improvement. The Board considered it in any case the doctor's task to investigate whether there are medical or social alternatives that can make the patient's suffering bearable. JOHN GRIFFITHS ET AL., EUTHANASIA AND LAW IN THE NETHERLANDS 66 (Amsterdam: Amsterdam University Press, 1998).
3. John Keown, The Law and Practice of Euthanasia in the Netherlands, 108 L. Q. REV. 51, 56 (1992).
4. THE ROYAL DUTCH MEDICAL ASSOCIATION'S REFINEMENTS OF THE 1984 GUIDELINES ON EUTHANASIA AND PHYSICIAN-ASSISTED SUICIDE (Dutch Ministry of Justice & Royal Dutch Medical Association, Aug. 25, 1995); cf. Marlise Simons, Dutch Doctors to Tighten Rules on Mercy Killings, N.Y. TIMES, Sept. 11, 1995, at A3.
5. THE ROYAL DUTCH MEDICAL ASSOCIATION'S REFINEMENTS OF THE 1984 GUIDELINES ON EUTHANASIA AND PHYSICIAN-ASSISTED SUICIDE (Dutch Ministry of Justice & Royal Dutch Medical Association, Aug. 25, 1995); cf. Marlise Simons, Dutch Doctors to Tighten Rules on Mercy Killings, N.Y. TIMES, Sept. 11, 1995, at A3.
6. Supreme Court of the Netherlands, Criminal Chamber, June 21, 1994, no. 96.972 [Nederlandse Jurisprudence 1994, nr 656; Tijdschrift voor Gezondheidrect 1994/96 nr 47]. For translation, see John Griffiths, et al., Euthanasia and Law in the Netherlands, The Chabot Case, 58 MOD. L. REV. 232, 232-39 (1994); and GRIFFITHS, supra note 2, App. 11 (2).
7. . See also Marcia Angell, Editorial, Euthanasia in the Netherlands - Good News or Bad? 335 NEW ENG. J. MED. 1676, 1676-78 (1996); Adriaan Jacobovits, Euthcmasia in the Netherlands, WASH. POST, Jan. 23, 1997, at A16; GENERAL HEALTH COUNCIL, A PROPOSAL OF ADVICE CONCERNING CAREFUL REQUIREMENTS IN THE PERFORMANCE OF EUTHANASIA (The Hague, 1987).
8. . See also Marcia Angell, Editorial, Euthanasia in the Netherlands - Good News or Bad? 335 NEW ENG. J. MED. 1676, 1676-78 (1996); Adriaan Jacobovits, Euthcmasia in the Netherlands, WASH. POST, Jan. 23, 1997, at A16; GENERAL HEALTH COUNCIL, A PROPOSAL OF ADVICE CONCERNING CAREFUL REQUIREMENTS IN THE PERFORMANCE OF EUTHANASIA (The Hague, 1987).
9. . See also Marcia Angell, Editorial, Euthanasia in the Netherlands - Good News or Bad? 335 NEW ENG. J. MED. 1676, 1676-78 (1996); Adriaan Jacobovits, Euthcmasia in the Netherlands, WASH. POST, Jan. 23, 1997, at A16; GENERAL HEALTH COUNCIL, A PROPOSAL OF ADVICE CONCERNING CAREFUL REQUIREMENTS IN THE PERFORMANCE OF EUTHANASIA (The Hague, 1987).
10. Cf. P.J. VAN DER MAAS, et al., EUTHANASIA AND OTHER MEDICAL DECISIONS CONCERNING THE END OF LIFE, HEALTH POLICY MONOGRAPHS (Amsterdam, Elsevier 1992).
11. For further discussion, see Chris Ciesielski-Carlucci & Gerrit Kimsma, The Impact of Reporting Cases of Euthanasia in Holland: A Patient and Family Perspective, 8 BIOETHICS 151, 151-58 (1994); J.K.M. Gevers, Physician Assisted Suicide: New Developments in the Netherlands, 9 BIOETHICS 309, 309-12 (1995); Henk Jochemsen, Euthanasia in Holland: An Ethical Critique of the New Law, 20 J. MED. ETHICS 212, 212-17 (1994); Tony Sheldon, Euthanasia Law Does Not End Debate in the Netherlands, 307 BRIT. MED. J. 1511, 1511-12 (1993); Johannes J.M. van Delden et al., Deciding Not to Resuscitate in Dutch Hospitals, 19 J. MED. ETHICS 200, 200-05 (1993).
12. For further discussion, see Chris Ciesielski-Carlucci & Gerrit Kimsma, The Impact of Reporting Cases of Euthanasia in Holland: A Patient and Family Perspective, 8 BIOETHICS 151, 151-58 (1994); J.K.M. Gevers, Physician Assisted Suicide: New Developments in the Netherlands, 9 BIOETHICS 309, 309-12 (1995); Henk Jochemsen, Euthanasia in Holland: An Ethical Critique of the New Law, 20 J. MED. ETHICS 212, 212-17 (1994); Tony Sheldon, Euthanasia Law Does Not End Debate in the Netherlands, 307 BRIT. MED. J. 1511, 1511-12 (1993); Johannes J.M. van Delden et al., Deciding Not to Resuscitate in Dutch Hospitals, 19 J. MED. ETHICS 200, 200-05 (1993).
13. For further discussion, see Chris Ciesielski-Carlucci & Gerrit Kimsma, The Impact of Reporting Cases of Euthanasia in Holland: A Patient and Family Perspective, 8 BIOETHICS 151, 151-58 (1994); J.K.M. Gevers, Physician Assisted Suicide: New Developments in the Netherlands, 9 BIOETHICS 309, 309-12 (1995); Henk Jochemsen, Euthanasia in Holland: An Ethical Critique of the New Law, 20 J. MED. ETHICS 212, 212-17 (1994); Tony Sheldon, Euthanasia Law Does Not End Debate in the Netherlands, 307 BRIT. MED. J. 1511, 1511-12 (1993); Johannes J.M. van Delden et al., Deciding Not to Resuscitate in Dutch Hospitals, 19 J. MED. ETHICS 200, 200-05 (1993).
14. For further discussion, see Chris Ciesielski-Carlucci & Gerrit Kimsma, The Impact of Reporting Cases of Euthanasia in Holland: A Patient and Family Perspective, 8 BIOETHICS 151, 151-58 (1994); J.K.M. Gevers, Physician Assisted Suicide: New Developments in the Netherlands, 9 BIOETHICS 309, 309-12 (1995); Henk Jochemsen, Euthanasia in Holland: An Ethical Critique of the New Law, 20 J. MED. ETHICS 212, 212-17 (1994); Tony Sheldon, Euthanasia Law Does Not End Debate in the Netherlands, 307 BRIT. MED. J. 1511, 1511-12 (1993); Johannes J.M. van Delden et al., Deciding Not to Resuscitate in Dutch Hospitals, 19 J. MED. ETHICS 200, 200-05 (1993).
15. For further discussion, see Chris Ciesielski-Carlucci & Gerrit Kimsma, The Impact of Reporting Cases of Euthanasia in Holland: A Patient and Family Perspective, 8 BIOETHICS 151, 151-58 (1994); J.K.M. Gevers, Physician Assisted Suicide: New Developments in the Netherlands, 9 BIOETHICS 309, 309-12 (1995); Henk Jochemsen, Euthanasia in Holland: An Ethical Critique of the New Law, 20 J. MED. ETHICS 212, 212-17 (1994); Tony Sheldon, Euthanasia Law Does Not End Debate in the Netherlands, 307 BRIT. MED. J. 1511, 1511-12 (1993); Johannes J.M. van Delden et al., Deciding Not to Resuscitate in Dutch Hospitals, 19 J. MED. ETHICS 200, 200-05 (1993).
16. P.J. VAN DER MAAS, ET AL., supra note 7, at 41.
17. Gerrit van der Wal & Paul J. van der Maas, Empirical Research on Euthanasia and Other Medical End-of-Life Decisions and the Euthanasia Notification Procedure, in ASKING TO DIE 171 (David C. Thomasma, et al. eds., Dordrecht, Kluwer Academic Publishers 1998). See also Bill Mettyear, South Australian Voluntary Euthanasia Society, Advocating Legalising Voluntary Euthanasia (Feb. 1997), .
18. Gerrit van der Wal & Paul J. van der Maas, Empirical Research on Euthanasia and Other Medical End-of-Life Decisions and the Euthanasia Notification Procedure, in ASKING TO DIE 171 (David C. Thomasma, et al. eds., Dordrecht, Kluwer Academic Publishers 1998). See also Bill Mettyear, South Australian Voluntary Euthanasia Society, Advocating Legalising Voluntary Euthanasia (Feb. 1997), .
19. P.J. VAN DER MAAS, ET AL., supra note 7, at 58.
20. Id. at 61.
21. Id. at 62.
22. The 48% figure has been cited as the total percent of cases on which there had been consultation when the reported and unreported cases are taken together. Virtually none of the cases whose lives are ended without request are reported. See P.J. VAN DER MAAS, ET AL., supra note 7, at 65.
23. In another study among family doctors, one quarter of the physicians said that they did not ask for a second opinion before administering euthanasia or assisted suicide. Twelve percent of the General Practitioners had no kind of consultation with any professional health worker. Cf. generally G. van der Wal, et al., Euthanasia and Assisied Suicide. II. Do Dutch Family Doctors Act Prudently? 9 FAM. PRAC. 140 (1992).
24. P.J. VAN DER MAAS ET AL. supra note 7, at 65.
25. Henk A.M.J. ten Have, Euthanasia: The Dutch Experience, CXII ANNALS DE LA REAL ACADEMIA NACIONAL DE MEDICINA 429 (Madrid, 1995).
26. P. J. VAN DER MAAS, ET AL., supra note 7, at 65.
27. See FOREIGN INFORMATION DEPARTMENT, NETHERLANDS MINISTRY OF FOREIGN AFFAIRS, 1996 STUDY FINDINGS, EUTHANASIA AND OTHER DECISIONS CONCERNING THE END OF LIFE IN THE NETHERLANDS (1996).
28. One of the referees notes that estimations by physicians that patients have only a week or two to live have been demonstrated to be grossly inaccurate.
29. Remmelink Commission, Rapport Medische Beslissingen Rond het Levenseinde 37 (The Hague, SDU, 1991). See also Henk A.M.J. ten Have, supra note 17, at 429. In his comments on the first draft of this study, Leenen wrote that the proposal of the Remmelink Commission was rejected by nearly all the Dutch commentators and also by the government. Letter from H. J. J. Leenen, former Prof, of Social Medicine and Health Law, Medical Faculty and Faculty of Law, University of Amsterdam, to author (July 25, 2000) (on file with author).
30. In his letter dated June 5, 1999, Dr. Chabot wrote: "After four years waiting for the final court judgment (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." Letter, Dr. Chabot to author (June 5, 1999) (on file with author). He, however, agreed to answer via e-mail some specific questions relating to his conduct that brought about the charges against him. I am in the process of writing a detailed analysis of the Chabot case.
31. My questionnaire was comprised of fifteen questions. The Dutch comprehensive study of 1995 consisted of 120 pages and the interviews lasted for an average of two and a half hours. The pace of questioning was, apparently, frantic. Cf. generally Paul J. van der Maas, et al., Euthanasia, Physician-Assisfed Suicide, and Other Medical Practices Involving the End of Life in the Netherlands, 1990-1995, 335 NBV ENG. J. MED. 1700(1996).
32. CARLOS F. GOMEZ, REGULATING DEATH 59-60 (1991).
33. In her remarks on the first draft of this essay, Heleen Dupuis wrote: "We do not want to defend our views, nor do we want to persuade others to adopt them. We are just very weary when a hundred and umpteenth foreigners come with questions we already have discussed the same number of times. Personally I am very tired by the endless interrogations, whereas I feel that euthanasia is a private matter, such as abortion, and even more so. I also feel that there is a certain exaggeration when it comes to the gravity of the problem." Letter from Prof. Heleen Dupuis, Dep't of Metamedicine, University of Leiden, to author (July 25, 2000) (on file with author).
34. In his comments on the first draft of this study, Leenen wrote that he doesn't agree that there is a lack of criticism in the Netherlands: "We have for more than 25 years discussed euthanasia publicly and between all kinds of opinions in a good atmosphere. Nobody was excluded. I personally lectured in meetings of opponents who invited me. I don't know of a country where this is possible." Leenen maintained that gradually a kind of consensus has grown "within a majority" and the problem is that 'people like Fenigsen' never took part in this debate and only ventilated their opinions elsewhere. Letter from H.J.J. Leenen, former Prof, of Social Medicine and Health Law, University of Amsterdam, to author (July 25, 2000) (on file with author). One referee remarked that this statement is incorrect. Before publishing an article on Dutch euthanasia in The Hastings Center Report (1989), Fenigsen had tried for nine years to alert the Dutch doctors and public opinion of the dangers involved in the practice. Fenigsen submitted a memorandum to the staff of Willem-Alexander Hospital (1980) and to the Board of the Royal Society of Medicine (1984). Fenigsen also published in Dutch a book and two articles opposing euthanasia, delivered public lectures to that effect, and expounded his views in interviews given to Dutch newspapers and periodicals.
35. One referee questioned my statement, arguing that in the Netherlands, as in the United States, there is no particular reverence for "the central government," nor is the Dutch government the source or a creator of the euthanasia policy. If it acts, it's to investigate or to confirm the consensus already reached by the majority of the public, the medical profession, and the judiciary. The referee maintained that the Dutch assume a defensive attitude when this national consensus and the practice in which they have a stake are questioned.
36. GOMEZ, supra note 24.
37. John Keown, The Law and Practice of Euthanasia in the Netherlands, 108 L.Q. REV. 51-78 (1992); Euthanasia in the Netherlands: Sliding Down the Slippery Slope? NOTRE DAME J.L. ETHICS & PUB. POL'Y 407-48 (1995).
38. John Keown, The Law and Practice of Euthanasia in the Netherlands, 108 L.Q. REV. 51-78 (1992); Euthanasia in the Netherlands: Sliding Down the Slippery Slope? NOTRE DAME J.L. ETHICS & PUB. POL'Y 407-48 (1995).
39. HENDIN supra note 1.
40. This statement spurred Van der Maas to react by saying: "I consider myself as an independent researcher, with a primary responsibility in collecting reliable data and basing impartial estimates and interpretations on that empirical information. I see no position for myself in a pro versus contra euthanasia debate and 1 think such kind of debate is entirely unproductive. As a researcher I think my responsibility is to find out what people do and how that might fit in high quality end of life medicine. During the last years part of our study has been replicated in Australia and Belgium and we have obtained funding from the European Union for an international collaborative study in order to estab-lish empirical comparisons between countries." Personal communication of Professor Paul van der Maas, Dep't of Public Health, Erasmus University, Rotterdam (Amsterdam, Sept. 18, 2000) (notes on file with author).
41. John Keown supra note 29, at 68.
42. Death on Request, IKON, Interkerkelijke Omroep Nederland, Postbus 10009, 1201 DA Hilversum. I thank IKON for sending me a copy of this film. For deliberation and critique of the content of this film, see HENDIN, supra note 1, at 114-20.
43. G. van der Wal, et al., supra note 15, at 113, 115.
44. Bregje Dorien Onwuteaka-Philipsen, Consultation of Another Physician in Cases of Euthanasia and Physician-Assisted Suicide 29, 31 (unpublished doctoral thesis, Dep't of Social Medicine, Vrije Universiteit, Amsterdam 1999) (on file in Vrije Universiteit Library).
45. Bregje D. Onwuteaka-Philipsen, et al., Consultants in Cases of Intended Euthanasia or Assisted Suicide in the Netherlands, 170 MED. J. AUSTRALIA 360, 360-63 (1999).
46. Id.
47. Henri Wijsbek reiterated this point of lenient courts saying he did not know of any prosecutions for lack of consultation, and that the duty to consult should be "observed and complied [with] closely." Leenen, on the other hand, wrote that it is incorrect to say that the courts are very lenient toward lack of consultation. Letter from Prof. H.J.A. Leenan (formerly Medical Faculty and Faculty of Law, University of Amsterdam) to author (July 25, 2000) (on file with author). But it is clear from the Chabot case, see note 5, supra and accompanying text, that the courts do not regard consultation (except in cases of non-somatic suffering) as an absolute requirement.
48. Jacqueline M. Cuperus-Bosma, et al., Physician-Assisted Death: Policy-Making by the Assembly of Prosecutors General in the Netherlands, 4 EUR. J. HEALTH L. 225, 232 (1997).
49. In his book, Griffiths writes that twelve percent of Dutch doctors are unwilling to perform euthanasia on principle and that most of them would refer a patient requesting it to another doctor. See GRIFFITHS, ET AL., supra note 2, at 253. According to Van der Maas et al., 9% of all physicians would never perform euthanasia and assisted suicide but would refer patients seeking it to another physician. Three percent would never perform the practices or refer patients. Cf. Paul J. van der Maas, et al., supra note 23, at 1702.
50. Prof. Bert Thijs, Medical Intensive Care Unit, V.U. Hospital, Amsterdam (July 20, 1999); Dr. Rob Houtepen, Health Ethics and Philosophy, Maastricht University (Aug. 11, 1999); Arie van der Arend, Health Ethics and Philosophy, Maastricht University (July 26, 1999); Dr. Jaap Visser, Ministry of Health, Dep't of Medical Ethics, The Hague (Amsterdam, July 21, 1999); Prof. Ruud ter Meulen, Director, Institute for Bioethics and Professor, University of Maastricht (Aug. 11, 1999); and Prof. Henk Jochemsen, Lindeboom Institute (Ede Wageningen, July 27, 1999) (notes on file with author).
51. Leenen maintained that consultation might be a problem in small villages. But in May 1999, following "Support and Consultation of Euthansaia in Amsterdam" (SCEA), see note 62, infra and accompanying text, the government initiated the organization of consultation teams all over the country. Consultants will travel to small villages to examine medical files and see patients. Hospital specialists are required to examine the files. The scheme is not fully worked out yet, and time will tell to what extent it will succeed, but Leenen thinks the consultation mechanism has gradually improved.
52. Freud recognized that doctors' unconscious emotional responses may have an impact on their relations with patients. Counter-transference has been defined in the psychoanalytic literature as the emotional reactions in the therapist engendered by the patient. Cf. JAY KATZ, THE SILENT WORLD OF DOCTOR AND PATIENT 147 (1984).
53. BERT KEIZER, DANCING WITH MISTER D 117 (London, Black Swan 1997).
54. Interviews with Prof. Evert van Leeuwen, Dep't of Metamedicine, Free University of Amsterdam (July 19, 1999); Prof. John Griffiths, Dep't of Legal Theory, Faculty of Law, University of Groningen (July 16, 1999); Prof. J.K. Gevers, Prof, of Health Law, University of Amsterdam (July 19, 1999); Dr. Dick Willems, Institute for Research in Extramural Medicine, Dep't of Social Medicine, Amsterdam (July 20, 1999); Prof. Gerrit van der Wal, Institute for Research in Extramural Medicine, Dep't of Social Medicine, Free University of Amsterdam (July 21, 1999); Dr, Jaap Visser, Ministry of Health, Dep't of Medical Ethics, The Hague (Amsterdam, July 21, 1999); H.J.J. Leenen, former Prof, of Social Medicine and Health Law, Medical Faculty and Faculty of Law, University of Amsterdam (July 21, 1999); Prof. Henk Jochemsen, Lindeboom Institute (Ede Wageningen, July 27, 1999); Dr. Gerrit Kimsma, Dep't of Metamedicine, Free University of Amsterdam (Koog 'aan de Zaan, July 28, 1999); Prof. Paul van der Maas, Dep't of Public Health, Faculty of Medicine, Erasmus University, Rotterdam (Amsterdam, July 29, 1999); Prof. Govert den Hartogh, Faculty of Philosophy, University of Amsterdam (Aug. 10, 1999); and Dr. Johannes van Delden, Senior Researcher, Center for Bioethics and Health Law, Utrecht University (Aug. 10, 1999).
55. Bregje Onwuteaka-Philipsen, supra note 35, at 91.
56. Written comments from Govert den Hartogh to author (Aug. 27, 2000) (on file with author).
57. Id.
58. As a nurse, Van der Arend is dissatisfied that nurses are not represented on the committees. In his mind, it would be better to have a balance of ideas before making the euthanasia decision by including nurses and independent physicians, and by following the rules of carefulness in detail.
59. Cf. discussion of opinions of Prof. J.K. Gevers, Prof, of Health Law, University of Amsterdam (July 19, 1999); Prof. Govert den Hartogh, Faculty of Philosophy, University of Amsterdam (Aug. 10, 1999); Dr. Johannes J.M. van Delden, Senior Researcher, Center for Biotheics and Health Law, Utrecht University (Aug. 10, 1999); Dr. Jaap J.F. Visser, Ministry of Health, Dep't of Medical Ethics, The Hague (Amsterdam, July 21, 1999) as well as Prof. H.J.J. Leenen, former Prof, of Social Medicine and Health Law, Medical Faculty and Faculty of Law, University of Amsterdam (July 21, 1999) and Prof. Henk Jochemsen, Lindeboom Institute (Ede Wageningen, July 27, 1999).
60. Prof. Evert van Leeuwen, Dep't of Metamedicine, Free University of Amsterdam (July 19, 1999); Prof. John Griffiths, Dep't of Legal Theory, Faculty of Law, University of Groningen (July 16, 1999); J.K. Gevers, Prof, of Health Law, University of Amsterdam (July 19, 1999); Prof. Bert Thijs, Medical Intensive Care Unit, V.U. Hospital, Amsterdam (July 20, 1999); Dr. Rob Houtepen, Health Ethics and Philosophy, Maastricht University (Aug. 11, 1999); Henk Jochemsen, Prof., Lindeboom Institute (Ede Wageningen, July 27, 1999); Dr. Arie J.G. van der Arend, Health Ethics and Philosophy, Maastricht University (July 26, 1999); Prof. Govert den Hartogh, Faculty of Philosophy, University of Amsterdam (Aug. 10, 1999); Dr. Johannes J.M. van Delden, Senior Researcher, Center for Bioethics and Health Law, Utrecht University (Aug. 10, 1999); Dr. Jaap J.E Visser, Ministry of Health, Dep't of Medical Ethics, The Hague (Amsterdam, July 21, 1999); and Prof. Paul van der Maas, Dep't of Public Health, Faculty of Medicine, Erasmus University, Rotterdam (Amsterdam, July 29, 1999).
61. Griffiths et al. argue that the facts found by the District Court, involving multiple and serious failures to conform to the requirements of careful practice, seem to call for a serious medical disciplinary measure, perhaps revocation of the license to practice medicine. See GRIFFITHS, ET AL., supra note 2, at 293.
62. One referee noted that the percentage of cases of voluntary euthanasia and assisted suicide reported in 1990 is uncertain and might be 28%, not 18%.
63. John Griffiths, Effective Regulation of Euthanasia and Other Medical Behavior that Shortens Life 10, 11 (Oct. 14, 1998) (unpublished manuscript on file with author); GRIFFITHS, ET AL., supra note 2 at 236-37.
64. In his comments on the first draft of this article, Griffiths denied saying that the criminal law is "ineffective." He wrote: "I do not regard it as perfect, the imperfections are a matter of concern, and something should be done about them. As a matter of fact, something is being done: unlike other countries, the Dutch are continually working on the adequacy of control of this sort of intrinsically dangerous medical behavior." Personal communication with Prof. John Griffiths, Dep't of Legal Theory, Faculty of Law, University of Groningen (GRONINGEN, July 10, 2000).
65. For elaborated discussion, see GRIFFITHS, ET AL., supra note 5, chap. 6.
66. Cf. Jacqueline M. Cuperus-Bosma, et al., Assessment of Physician-Assisted Death by Members of the Public Prosecution in the Netherlands, 25 J. MED. ETHICS 8, 8-15 (1999).
67. Sjef Gevers, Prof, of Health Law, University of Amsterdam (July 19, 1999); Dr. Rob Houtepen, Health Ethics and Philosophy, Maastricht University (Aug. 11, 1999); Prof. Ruud ter Meulen, Director, Institute for Bioethics and Professor, University of Maastricht (Aug. 11, 1999); Dr. Margo Trappenburg, Dep't of Political Science, University of Leiden (July 22, 1999); Dr. Ron Berghmans, Institute for Bioethics, Maastricht University (Aug. 11, 1999); Prof. H.J.J. Leenen, former Prof, of Social Medicine and Health Law, Medical Faculty and Faculty of Law, University of Amsterdam (July 21, 1999); and Prof. Egbert Schroten, Director, Center for Bioethics and Health Law, Utrecht University (Aug. 5, 1999).
68. should note that Van der Maas and his colleagues stated that after performing euthanasia and assisted suicide, three quarters of the general practitioners and about two thirds of the specialists reported "natural death" in the declaration of death. The most important reasons for falsely declaring natural death were: the "fuss" of a legal investigation (55%), fear of prosecution (25%), the desire to safeguard relatives from judicial inquiry (52%) and bad experiences in the past with stating non-natural death (12%). P.J. VAN DER MAAS, ET AL., supra note 7, at 46-48. See also Gerrit van der Wal, et al., Evaluation of the Notification Procedure for Physician-Assisted Death in the Netherlands, 335 NEW ENG. J. MED. 1706, 1707 (1996); Martien Tom Muller, Death on Request 73 (Amsterdam, Vrije Universiteit, 1996) (unpublished doctoral thesis on file at Vrije Universiteit Library).
69. should note that Van der Maas and his colleagues stated that after performing euthanasia and assisted suicide, three quarters of the general practitioners and about two thirds of the specialists reported "natural death" in the declaration of death. The most important reasons for falsely declaring natural death were: the "fuss" of a legal investigation (55%), fear of prosecution (25%), the desire to safeguard relatives from judicial inquiry (52%) and bad experiences in the past with stating non-natural death (12%). P.J. VAN DER MAAS, ET AL., supra note 7, at 46-48. See also Gerrit van der Wal, et al., Evaluation of the Notification Procedure for Physician-Assisted Death in the Netherlands, 335 NEW ENG. J. MED. 1706, 1707 (1996); Martien Tom Muller, Death on Request 73 (Amsterdam, Vrije Universiteit, 1996) (unpublished doctoral thesis on file at Vrije Universiteit Library).
70. Most notably of Schroten and Trappenburg, supra note 58, Thijs and Van Leeuwen, supra note 51, Gevers, supra note 50, Dr. Henri Wijsbek, Dep't of Medical Ethics, Erasmus University of Rotterdam (July 23, 1999); and Dr. Dick Willems, Institute for Research in Extramural Medicine, Dep't of Social Medicine, Amsterdam (July 20, 1999).
71. Martien T. Muller, et al., Euthanasia and Assisted Suicide: Facts, Figures and Fancies with Special Regard to Old Age, 13 DRUGS & AGING 190, 190 (1998).
72. Evert van Leeuwen & Gerrit Kimsma, Problems Involved in the Moral Justification of Medical Assistance in Dying: Coming fo Terms with Euthanasia and Physician Assisted Suicide, in MEDICAL ETHICS AT THE DAWN OF THE 21sT CENTURY 151-73 (R. Cohen-Almagor, ed. 2000).
73. This is an agency, independent of the public prosecution. Its activities may lead to disciplinary law trials.
74. Written correspondence from Prof. Govert den Hartog, Faculty of Philosophy, University of Amsterdam to author (Aug. 27, 2000) (on file with author).
75. In his comments on the first draft of this article Van Delden explained that his hesitation to disclose numbers at that point in time derived from the fact that these numbers were not public yet. He emphasized that he had "no inclination to hide anything." Written comments from Dr. Johannes J.M. van Delden, Senior Researcher, Center for Bioethics and Health Law, Utrecht University, to author (Aug. 4, 2000) (on file with author).
76. In his comments on the first draft of this study, Van Dantzig wrote that this assertion is fundamentally incorrect: "The whole of Dutch society is based on the cohabitation of people who fundamentally disagree on everything. The sometimes very creative solutions (soft drugs may not be bought by coffee shops, but their sale is not punished within certain limits) have given rise to the word 'poldermodel,' which expressly means living by compromise, or as I have once put it, the fair division of discontent. I write to you because such a fundamental misunderstanding may harm the quality of your paper." Written comments from Prof. A. van Dantzig, retired expert in pshychiatry (Amsterdam), to author (July 14, 2000) (on file with author).
77. JOHN STUART MILL, UTILITARIANISM, LIBERTY, AND REPRESENTATIVE GOVERNMENT (London, J. M. Dent 1948) (Everyman's edition).
78. For further deliberation, see HENDIN, supra note 1, at 105-107.
79. A poll in 1996 showed that 84% of the population is in favor of euthanasia if a fellow human being is in an unacceptable and futureless situation. For further discussion, see The Voluntary Euthanasia Society, The Debate, .
80. In his comments on the first draft of this essay, Griffiths reacted to this statement by writing: "Nowhere do you suggest that anywhere else there is a better system. The Dutch know about the system's defects and are working to improve it. Can you tell me about another country where that is true? In short, I think you need to think again, and a lot more carefully, about what you are writing about, before you can expect to be taken seriously." Written comments from Prof. John Griffiths, Dep't of Legal Theory, Faculty of Law, University of Groningen (July 10, 2000) (on file with author). Griffiths, it seems, finds a lot of comfort in comparative studies to the point of blurring his own careful thinking about the current situation in his country.
81. 71In his remarks on the first draft of this study, Griffiths wrote that this assertion is "of course pretty silly." He asked: "Do you know of a single legal policy that 'works' 100%? The fact that the Guidelines are not yet effective enough does not mean they are having no effect at all. I would argue that the situation in the Netherlands is much better than elsewhere, that the difference is that here we know the extent to which control is not yet adequate." Written comments from Griffiths to author (July 10, 2000) (on file with author).
82. For deliberation on the range of what "unbearable suffering" means, see CARLOS F. GOMEZ, REGULATING DEATH 99-104 (1991).
83. Griffiths' analysis in Assisted Suicide in the Netherlands: The Chabot Case, supra note 5, at 239-48.
84. Martien Tom Muller, supra note 59, at 52.
85. For deliberation, see Jacqueline M. Cuperus-Bosma, et al., Physician-Assisted Death: Policy-making by the Assembly of Prosecutors General in the Netherlands, 4 EUR. J. HEALTH L 225, 225-38 (1997).
86. In his comments on the first draft, Van Dantzig wrote: "Please remove this, this is far from true." Written comments from Prof. A. van Dantzig, retired expert in psychiatry (Amsterdam) to author (July 8, 2000) (on file with author).
87. 77The number of citizens who approve of euthanasia at the patient's explicit request grew from 40% in 1966 to over 60% (in some polls, almost 80%) in 1993. Likewise the number of opponents decreased steadily (21% in 1986, 17% in 1989, 12% in 1994). Cf. Joop van Holsteyn & Margo Trappenburg, Citizens' Opinions on New Forms of Euthanasia: A Report from the Netherlands, 35 PATIENT EDUC. & COUNSELING 63, 64 (1998). A 1998 poll indicated that 92% of the population supports the practice of euthanasia. Cf. Dutch Might Legalize Euthanasia, Associated Press (July 12, 1999), .
88. 77The number of citizens who approve of euthanasia at the patient's explicit request grew from 40% in 1966 to over 60% (in some polls, almost 80%) in 1993. Likewise the number of opponents decreased steadily (21% in 1986, 17% in 1989, 12% in 1994). Cf. Joop van Holsteyn & Margo Trappenburg, Citizens' Opinions on New Forms of Euthanasia: A Report from the Netherlands, 35 PATIENT EDUC. & COUNSELING 63, 64 (1998). A 1998 poll indicated that 92% of the population supports the practice of euthanasia. Cf. Dutch Might Legalize Euthanasia, Associated Press (July 12, 1999), .
89. In his comments on the first draft, Jochemsen asked me to add that he does realize that in the present situation a simple reiteration of the prohibition would not improve the practice immediately. This would require a whole package of measures. Written comments from Prof. Henk Jochemsen, Lindeboom Institute (Ede Wageningen) to author (July 5, 2000) (on file with author).
90. In his comments, Arie van der Arend contested my argument that there is not enough reflective thinking about euthanasia, arguing that (a) I cannot expect extensive and balanced reflective thinking during interviews that were taken from people who were busy with totally different tasks at that moment; (b) my study does not cover the extensive Dutch literature on the subject; (c) I did not interview one of the best 'reflective thinkers', Theo Beemer, Prof. of Moral Theology and Health Care Ethics, Catholic University of Nijmegen and (d) that such a value judgment could have been justified only after comparing the Dutch practice to the situation in other countries. Written comments from Dr. Arie J.G. van der Arend, Health Ethics and Philosophy, Maastricht University to author (July 3, 2000) (on file with author).
91. Hendin reached a similar conclusion. Cf. HENDIN, supra note 1, at 100.
92. See R. COHEN-ALMAGOR, A Circumscribed Plea for Voluntary Physician-Assisted Suicide, in MEDICAL ETHICS AT THE DAWN OF THE 21ST CENTURY 127-49, especially 140-44 (2000).
93. Tony Sheldon, Holland Decriminalises Voluntary Euthanasia, 322 BRIT. MED. J. 947 (2001).
94. Dutch Parliament Votes to Legalize Euthanasia, REUTERS, Nov. 28, 2000.
95. .
96. Cf. R. Cohen-Almagor, The Patients' Right to Die in Dignity and the Role of Their Beloved People, 4 ANN. REV. L. & ETHICS 213, 213-32 (1996); Reflections on the intriguing Issue of the Right to Die in Dignity, 29 ISRAEL L. REV. 677, 677-701 (1995); Autonomy, Life as an Intrinsic Value, and Death With Dignity, 1 SCI. & ENGINEERING ETHICS 261, 261-72 (1995).
97. Cf. R. Cohen-Almagor, The Patients' Right to Die in Dignity and the Role of Their Beloved People, 4 ANN. REV. L. & ETHICS 213, 213-32 (1996); Reflections on the intriguing Issue of the Right to Die in Dignity, 29 ISRAEL L. REV. 677, 677-701 (1995); Autonomy, Life as an Intrinsic Value, and Death With Dignity, 1 SCI. & ENGINEERING ETHICS 261, 261-72 (1995).
98. Cf. R. Cohen-Almagor, The Patients' Right to Die in Dignity and the Role of Their Beloved People, 4 ANN. REV. L. & ETHICS 213, 213-32 (1996); Reflections on the intriguing Issue of the Right to Die in Dignity, 29 ISRAEL L. REV. 677, 677-701 (1995); Autonomy, Life as an Intrinsic Value, and Death With Dignity, 1 SCI. & ENGINEERING ETHICS 261, 261-72 (1995).
99. Cf. HENDIN, supra note 1, at 122.
100. explain my view point in detail in THE RIGHT TO DIE WITH DIGNITY: AN ARGUMENT IN ETHICS, MEDICINE, AND LAW (Rutgers University Press, 2001).