The Netherlands
Euthanasia became legal in the Netherlands on April 10, 2001. Prior to that date, active euthanasia was a criminal offense under Article 293 of the Dutch Penal Code, which read, "He who takes the life of another person on this person's explicit and serious request will be punished with imprisonment of up to twelve years or a fine of the fifth category." At the same time, however, Section 40 of the same penal code stated that an individual was not punishable if he or she was driven by "an irresistible force" (legally known as force majeure) to put another person's welfare above the law. This might include a circumstance in which a physician is confronted with the conflict between the legal duty of not taking a life and the humane duty to end a patient's intolerable suffering.
ORIGIN OF OPEN PRACTICE
In 1971 Dr. Geertruida Postma granted an elderly nursing home patient's request to die by injecting the patient with morphine and ending her life. The patient was her seventy-eight-year-old mother, who was partially paralyzed and was tied to a chair to keep her from falling. Dr. Postma was found guilty of murder, but her penalty consisted of a one-week suspended jail sentence and one-year probation. This light sentence encouraged other physicians to come forward, admitting they had also assisted in patients' suicides.
Two years later the Royal Dutch Medical Association announced that, should a physician assist in the death of a terminally ill patient, it was up to the court to decide if the physician's action could be justified by "a conflict of duties." In Alkmaar, Netherlands, Dr. Schoonheim helped Marie Barendregt to die in 1982, using a lethal injection. The ninety-five-year-old, severely disabled Barendregt had initially signed an advance directive refusing artificial (life-prolonging) treatment. Schoonheim assisted in Barendregt's death with the knowledge of the patient's son and after consultation with two independent physicians. In 1984 the Dutch Supreme Court, ruling on this well-known Alkmaar case (the court case is referred to by the name of the city where the trial took place), found Schoonheim not guilty of murder.
Since then, until euthanasia was legalized, each euthanasia case brought under prosecution was judged on its individual circumstances. The force majeure defense ensured acquittal, while compliance with certain guidelines for performing euthanasia laid down by the Royal Dutch Medical Association and the Dutch courts in 1984 protected physicians from prosecution.
On April 10, 2001, the Dutch Parliament voted forty-six to twenty-eight to legalize physician-assisted suicide by passing the Termination of Life on Request and Assisted Suicide (Review Procedures) Act. Arguments in favor of the bill included public approval ratings of 90%. In May 2001 the results of a Dutch public opinion poll revealed that nearly half of respondents favored making lethal drugs available to older adults who no longer wanted to live.
MONITORING OF EUTHANASIA AND PHYSICIAN-ASSISTED SUICIDE
Euthanasia and physician-assisted suicide have been monitored in the Netherlands since 1994, with the first review procedure given approval by the Dutch government in 1991. Although euthanasia and PAS were not yet legal in that country, physicians were required to report cases and would not be prosecuted if they met the requirements for prudent practice that had been developed. The substantive requirements asserted that "the patient's request must be voluntary and well considered"; "the patient's condition must be unbearable and hopeless"; "no acceptable alternatives for treatment are available"; and "the method is medically and technically appropriate." The procedural requirements asserted that "another doctor is consulted before proceeding" and "the case is reported as an unnatural death" (Bregje D. Onwuteaka-Philipsen et al, "Dutch Requirements for Prudent Practice in Euthanasia and Physician Assisted Suicide," in "Dutch Experience of Monitoring Euthanasia," British Medical Journal, vol. 331, no. 7518, September 24, 2005). The procedure was evaluated in 1996, and a new system was introduced in 1998, but euthanasia and PAS remained illegal.
The Termination of Life on Request and Assisted Suicide (Review Procedures) Act was passed in 2001 and enacted in 2002. Along with legalizing euthanasia and PAS, this law established a revised review procedure (as suggested in its name). Throughout the review changes, the requirements for prudent practice did not change and were the main focus of review. The purpose of the review process was to have physicians report on euthanasia and PAS, and to follow prudent practice.
Success of the review process depends on whether physicians report euthanasia and PAS. Onwuteaka-Philipsen and colleagues reported that cases increased from 480 in 1990 (before the review procedure) to 1460 in 1995 and to 2216 in 1999. The numbers decreased during 2001 to 2003 but rose in 2004. The researchers also compared the reported cases with the total number of cases, which they determined by large-scale anonymous survey research of Dutch physicians in 1990, 1995, and 2001. The researchers determined that the notification rate increased from 18% in 1990 to 54% in 2001. Thus, the review process appears to have been successful in increasing the reporting of euthanasia and PAS. Research is ongoing to determine whether the decrease in reported cases since 1999 is due to a decrease in reporting or to a decrease in the occurrence of euthanasia and PAS.
Euthanasia in Belgium
The Belgian Act on Euthanasia passed in 2002 after the Netherlands law, making Belgium the second country to legalize euthanasia. The law applies to competent adults who have an incurable illness causing unbearable, constant suffering and patients in a persistent vegetative state who made their wishes known within the prior five years in front of two witnesses. It allows someone to terminate the life of another at their "voluntary, well-considered, and repeated" request, but does not allow PAS. All acts of euthanasia must be reported.
Switzerland Allows Assisted Suicide but Not Euthanasia
Euthanasia is not legal in Switzerland, but the country allows suicide assisted by physicians or people with no medical training. Suicide and assisted suicide has been legal in Switzerland since 1937. The Swiss criminal code states that suicide may be assisted for altruistic reasons, but that assisted suicide is a crime if motivated for financial gain or for what it deems "negative" reasons.
Although legal, assisted suicide is not considered an appropriate part of medical practice by the Swiss Academy of Medical Sciences, so physicians do not assist in suicides of the terminally ill. Members of EXIT (the Swiss Society for Humane Dying) are allowed to help terminally ill Swiss residents commit suicide in their homes. In January 2006 the Vaud University Hospital Center in Lausanne began allowing EXIT to help patients already admitted to the hospital and who could no longer go home to take their own lives.
Great Britain Considers Euthanasia and Physician-Assisted Suicide
In November 2005 a bill was introduced in the House of Lords that would allow both assisted suicide and euthanasia. It sets requirements for either procedure, including assessment by a physician that the adult patient is likely to die within a few months, is competent to make a request to die, and is suffering unbearably. The patient must sign a declaration of intent to choose death. If the declaration is not revoked by the patient within fourteen days, then the patient can receive the means to take his or her own life.
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