André den Exter

The Regional Euthanasia Review Committees (RERCs) in the Netherlands are required by statute to report annually on euthanasia and physician-assisted suicide (PAS) procedures carried out in the Netherlands. The general conclusion of the latest periodic evaluation was that euthanasia and PAS procedures are generally carried out with great care. It also concluded that the degree of willingness among physicians to report euthanasia remains high. Apart from these general observations, the report provides valuable information about euthanasia and PAS practice in the Netherlands, as well as how RTEs fulfill their statutory task of reviewing notified cases.

Understanding the Dutch practice requires some further explanation of the legal setting, i.e. Termination of Life on Request and Assisted Suicide Act (‘the Act’). Though euthanasia and PAS remain criminal offenses, physicians are released from liability if the statutory due care criteria are met and the act is reported to an RERC. Requests for euthanasia or PAS typically come from patients experiencing unbearable suffering with no prospect of improvement, who see these options as the only escape. All requests for euthanasia or PAS must be made earnestly and with full conviction. However, patients do not have an absolute right to euthanasia, and doctors have no duty to accept the patient’s request to perform it.

Doctors must report all unnatural deaths to the municipal pathologist. In cases of euthanasia or PAS, the pathologist notifies an RERC, which is comprised, at a minimum, of medical doctors, ethicists, and legal experts. The committee assesses whether the physician has fulfilled the statutory due care criteria. These criteria require the physician to: (i) be satisfied that the patient’s request is voluntary and well-considered; (ii) determine that the patient’s suffering is unbearable, with no prospect of improvement; (iii) inform the patient about situation and prognosis; (iv) confirm that there is no reasonable alternative for the patient’s situation; (v) ensure that an independent physician has examined the patient, and (vi) exercise due medical care and attention in the process of terminating life. Physicians who fail to meet any of these criteria are subject to prosecution. The review committee procedure ensures transparency and consistency in reporting and evaluating cases.

The 2023 report shows an increase in notifications of cases of euthanasia and PAS (9,068 compared to 8,200 in 2022; 7,666 in 2021). Cases involved patients with cancer (5,105); neurological disorders such as Parkinson’s disease, multiple sclerosis and motor neuron disease (605); cardiovascular disease (393); pulmonary disorders (340); or a combination of conditions, usually somatic (1,599) (P. 13). Though cancer was the most common cause, there were also instances of euthanasia or PAS based on mental suffering and dementia causing unbearable suffering with no prospect of improvement. There were 328 cases involving patients in early stages of dementia who still had insight into their condition and its symptoms, such as spatial and temporal disorientation and personality changes. An additional eight notifications involved patients in an advanced stage of dementia who no longer had decision-making capacity and were no longer able to communicate meaningfully regarding their request. In these cases, the patient’s consent was based on an advance directive (P. 13). In addition, 138 euthanasia notifications concerned patients whose suffering was (largely) caused by one or more psychiatric disorders. The report stressed that physicians must exercise particular in these situations (P. 15).

Multiple geriatric syndromes – such as sight impairment, hearing impairment, osteoporosis and its effects, osteoarthritis, balance problems, or cognitive decline – may cause unbearable suffering without prospect of improvement. These syndromes generally develop in older age and can lead to an accumulation of symptoms. In conjunction with the patient’s medical history, life history, personality, values, and stamina, they may give rise to suffering that the patient may experience as unbearable and without prospect of improvement (P. 15).

If both members of a couple make simultaneous requests for euthanasia and both requests are granted, the RERCs register this as ‘double euthanasia’. This occurred 33 times in 2023 (66 notifications). In each case, the due care criteria set out in the Act must be satisfied separately. Each partner must be examined by a different independent physician to safeguard the independence of assessing their requests (P. 20).

In five of the notified cases in 2023, the RERCs found that the physician who performed the act did not comply with all the due care criteria. In one of these cases, the committee found that the independent physician was not truly independent because he was registered as a patient in the practice of the general practitioner who performed the euthanasia. In three cases, the committee found that the physician had not exercised the necessary particular caution concerning a patient whose suffering was caused by a psychiatric disorder or a combination of a somatic condition and a psychiatric disorder. In another case, the committee found that the physician had not exercised due care because he left the medication with the patient before performing euthanasia (P. 20).

What makes the report interesting to read is the practice of euthanasia and physician-assisted suicide in the Netherlands, the number of reported cases, and examples of which physicians are struggling with. That counts particularly for instances of euthanasia or PAS based on mental suffering and dementia causing unbearable suffering. Although the Act was initially aimed at somatic suffering, gradually, its scope has extended towards other instances, causing unbearable suffering with no prospect of improvement.

© Nature of Conditions, Annual report 2023 Regional Euthanasia Review Committees