SAVES is not affiliated with Exit International / Dr Philip Nitschke and opposes the public availability of a 'peaceful pill'.

No doubt stung by the continuous barrage of criticism and misrepresentation world-wide by opponents of legalising voluntary euthanasia, the Dutch Government have published a comprehensive booklet which explains their policy. The title of the booklet, available in several languages on application to the Dutch Embassy, is "Q & A Euthanasia". It is produced by the Netherlands Ministry of Foreign Affairs, Foreign Information Division, in cooperation with the Ministry of Health, Welfare & Sport and the Ministry of Justice. It is also available on the internet at:

A concise official account of the circumstances under which voluntary euthanasia is available in the Netherlands is particularly timely in South Australia because the Social Development Committee is considering Anne Levy's Voluntary Euthanasia Bill as a prelude to its eventual debate in Parliament. The Dutch Embassy in Canberra have very kindly made copies available for SAVES to provide to members of the Committee and others likely to need this basic information.

Extracts from the booklet comprising most of its text are provided below with permission. The term "euthanasia" is used by the Dutch rather than "voluntary euthanasia" because the patient's wishes are inherent in their concept of its practice. The legal defence of "force majeure" which provides the basis of their acceptance of euthanasia is explained.

Why devise policy on euthanasia?
In the Netherlands, euthanasia is understood to mean termination of life by a doctor at the request of a patient.

The Dutch government does not turn a blind eye to the fact that euthanasia is practiced. The question of whether - and how - criminal law should continue to apply to euthanasia has been the subject of broad political and public debate for the past twenty years. The main aim of policy is to bring matters into the open, to apply uniform criteria in assessing every case in which a doctor terminates life, and hence to ensure that due care is exercised.

Pain, humiliation and the longing to die with dignity are the main reasons why patients request euthanasia. The population is ageing, considerable advances have been made with life-prolonging treatments, and cancer is claiming a rising proportion of victims. As a result, doctors in the Netherlands and in many other countries are increasingly faced with decisions relating to the termination of life.

People in the Netherlands do not request euthanasia out of concern at the cost of treatment, since under the social security system everyone is fully insured.

Are doctors punished for committing euthanasia?
Under the provisions of Dutch criminal law, it is an offence to take another person's life, even at that person's express request (Article 239 of the Criminal Code).

However, Dutch criminal law recognises grounds for exemption from criminal liability. If a person is compelled by force majeure to commit a criminal act (i.e the person acts in an emergency or under duress), the act in question is not regarded as unlawful and the person in question may be exempt from prosecution (Article 40 of the Criminal Code.) This applies to all offences. The Dutch courts acknowledge that a doctor who terminates the life of a patient may, under certain conditions, invoke force majeure, and thus be exempt from sanctions. Each case is examined individually.

It is up to the court to decide whether the doctor was confronted with conflicting duties. Case law has established that a doctor can invoke force majeure if in order to fulfil his duty to do all in his power to relieve unbearable suffering he has complied with the patient's request for euthanasia, provided he has acted with due care, in accordance with certain specific criteria. The doctor may not, however, claim exemption from prosecution solely on the grounds that he has complied with these criteria.

What are the criteria for assessing whether a doctor has acted with due care?
The main criteria developed by the courts are as follows:

• The patient made voluntary, well-considered and persistent requests for euthanasia.
• According to prevailing medical opinion, the patient's suffering was unbearable and without prospect of improvement.
• The doctor consulted at least one other physician with an independent viewpoint.
• Euthanasia was performed in accordance with good medical practice.

Another important, basic principle established in case law is the existence of a close doctor-patient relationship. A doctor may only perform euthanasia on a patient in his care. He must know the patient well enough to be able to assess whether the request for euthanasia is both voluntary and well-considered, and whether his suffering is unbearable and without prospect of improvement.

Are doctors who perform euthanasia always prosecuted?
The Public Prosecution Service is authorised not to prosecute doctors who have complied with the criteria. In accordance with the expediency principle, which is a feature of Dutch policy on investigation and prosecution, the Public Prosecution Service may decide not to prosecute if the general interest would not be served by criminal proceedings. In other countries, the public prosecutor has no such discretion, which means that all cases must be brought before the court.

If, on the basis of statute law and precedent, the court is expected to accept force majeure and decide not to impose a penalty, the public interest is not served by criminal proceedings. However, if the Public Prosecution Service decides to prosecute, and the court rejects the plea of force majeure, the doctor will be convicted in accordance with article 293 of the Criminal Code.

What is the notification procedure?

• The doctor is obliged to notify the municipal pathologist of every instance of death from non-natural causes. In the case of euthanasia or assisted suicide, the doctor compiles a report based on a special model.
• The pathologist also compiles a report establishing that the patient's death was due to non-natural causes. He then sends both reports to the public prosecutor. He also sends the doctor's report to the regional euthanasia review committee.
• The committee assesses whether the doctor has acted in accordance with the due care criteria, and reports its findings to the Public Prosecution Service, the regional health inspector, and the doctor, who is entitled to request a personal interview with the committee. The regional health inspector may put the case before the medical disciplinary tribunal, independently of the Public Prosecution Service.
• If the committee concludes that the doctor has acted with due care, the Public Prosecution Service will generally decide not to prosecute, unless there are grounds for doing so. If the committee concludes that the doctor has not acted with due care, the Public Prosecution Service will consult the Minister of Justice before instituting prosecution proceedings.

What were the conclusions of the 1996 study?
In 1996, the Dutch government commissioned an independent study of current practice with regard to the termination of life by doctors. The study, which was the first of its kind ever to be carried out in the world, compared the situation in 1995 with that in 1990. It showed that matters were by no means getting out of hand. On the contrary, more openness led to the exercise of more care.

The results were obtained from doctors, on the basis of confidential interviews and questionnaires. There were no indications of an increase in action to terminate the lives of vulnerable or less seriously ill patients. There was no disproportionate increase in cases of euthanasia in the 1990-1995 period, and cases in which life was terminated without the request of the patient had in fact decreased. But notifications tripled, and doctors increasingly consulted their colleagues and recorded their decisions in writing.

How do doctors decide that their patient is undergoing unbearable suffering, with no prospect of improvement?

• Suffering is without prospect of improvement if this is the prevailing medical opinion. In other words, doctors agree that the patient's condition will not improve.
• It is difficult to establish objectively whether suffering is unbearable. Each individual case is examined to establish whether the doctor, in all reasonableness, could conclude that the patient was suffering unbearably.

In assessing whether or not a person's suffering was unbearable, the Public Prosecution Service looks at the progression of the illness and the time taken to reach the decision.

Does "unbearable suffering" also include psychological suffering?
It is difficult to assess objectively whether a request for euthanasia is voluntary and well-considered if a patient has a psychological illness, and his suffering is not primarily caused by a physical complaint. In such cases, the attending physician must consult not one but two independent specialists, at least one of whom must be a psychiatrist, and they are required to examine and interview the patient. Invocation of force majeure is not wholly ruled out, but extreme caution will be exercised in assessing the case. Generally speaking, the Public Prosecution Service will institute proceedings, and it will be left to the court to decide whether force majeure can be invoked.

In 1994, a psychiatrist was convicted of assisting a suicide at the request of a patient whose suffering was psychological (the Chabot judgment), though no penalty was imposed. In upholding the conviction, the Supreme Court was of the opinion that if the cause of suffering was psychological, the court must exercise the utmost caution in establishing whether the circumstances constituted force majeure. In April 1995, the Medical Disciplinary Tribunal came to the same conclusion as the Supreme Court and the psychiatrist was reprimanded.

Do doctors in the Netherlands always comply with requests for euthanasia?
No. Two thirds of the requests for euthanasia that are put to doctors are refused. Treatment frequently provides relief, while some patients enter the terminal stage of their illness before a decision has been reached.

Doctors are not obliged to comply with requests for euthanasia. Experience shows that many patients find sufficient peace of mind in the knowledge that the doctor is prepared to perform euthanasia and that they ultimately die a natural death.

But is it not a doctor's main duty to preserve life?
Yes. A doctor's main duty is indeed to preserve life. Euthanasia is not an obligatory medical duty. However, doctors are obliged to do everything they can to enable their patients to die with dignity. They may not administer pointless medical treatments. When all treatment options have been exhausted, the doctor is responsible for relieving suffering.

The 1996 study showed that doctors in the Netherlands exercise the utmost caution in dealing with decisions on the termination of life.

Why do patients request euthanasia if good palliative and terminal care is available?
The Dutch health care system is accessible to all and unlimited terminal and palliative care is guaranteed. Unfortunately, even care of the highest quality does not always relieve suffering, and does not prevent patients requesting euthanasia.

The terminally ill receive care and support in hospitals, nursing homes and at home. Four teaching hospitals have been designated as pain control centres. The development of palliative and terminal care is an essential element of policy on euthanasia and other medical decisions in the terminal stages of life.

What is the procedure for consulting an independent physician?
Before the attending physician complies with a request for euthanasia, he must first consult a colleague, who is neither dependent on him nor involved in treating the patient. He reviews the progression of the illness, establishes whether the request for euthanasia was both voluntary and well-considered, and submits his findings in writing.

A network is to be set up in the Netherlands comprising general practitioners and other physicians trained to assist doctors confronted with decisions relating to the terminal stages of life. Once the network is in place, these doctors will be able to act as independent consultants.

Can people come from other countries to undergo euthanasia in the Netherlands?
This is impossible, given the need for a close doctor-patient relationship. The legal procedure for the notification and assessment of each individual case of euthanasia requires the patient to have made a voluntary, well-considered request and to be suffering unbearably without any prospect of improvement. In order to be able to assess whether this is indeed the case, the doctor must know the patient well. This implies that the doctor has treated the patient for some time.

Granting a request for euthanasia places a considerable emotional burden on the doctor. Doctors do not approach the matter lightly. From this point of view too, longstanding personal contact between the doctor and the patient plays an important role.

Does the medical profession have its own disciplinary body?
The Medical Disciplinary Tribunal is designated by law to deal with complaints relating to negligence or improper conduct. The Tribunal may also be requested to assess cases relating to the termination of life. It may impose a number of measures, ranging from a warning to striking a member off the roll.

The regional public health inspector or a member of the public may lodge a complaint in cases involving the public interest. They may relate to the treatment provided by a doctor, a dentist, a midwife, a nurse, a physiotherapist, a psychotherapist, a psychologist or a dispensing chemist.

Is the Netherlands planning to legalise euthanasia?
A clear majority of both doctors and the general public are in favour of legalisation. The present government is planning to submit a bill, which, under strict conditions, will remove euthanasia from the realm of criminal law. The notification procedure and the review by the special regional committees will, in that case, remain in force.

Lifting the criminal law ban on euthanasia would not lead to the abandonment of government monitoring. On the contrary, policies pursued to date on euthanasia have been accompanied by more effective statutory monitoring of doctors.

• Assisted suicide
• Termination of life without the request of the patient
• Cessation of medical treatment
• Withholding essential nutrients and fluids at the patient's request

In these situations, the doctor supplies a drug with which the patient can terminate his own life. The only difference between assisted suicide and euthanasia is that the patient, not the doctor, administers the drug. Article 294 of the Criminal Code is applicable. It is not an offence in the Netherlands to commit suicide, or attempt to do so.

Can a doctor who terminates the life of a patient without his/her request invoke force majeure?
Force majeure might arise when the patient is already terminally ill and cannot make his wishes known because his vital body functions are failing. In these cases, patients have often made it abundantly clear at an earlier stage that they would prefer to die in such circumstances. Sometimes, the people in question are incapable of making decisions (e.g. patients in coma or suffering from senile dementia, or new-born babies). They have fallen victim to a terminal illness, which clearly gives rise to dreadful suffering, with no prospect of improvement. In the case of new-born babies, the child is suffering such serious congenital disorders that it is not or hardly viable. It occurs an estimated fifteen times a year in the Netherlands that the parents and the doctor decide in such circumstances to take active steps to hasten death.

It is possible that a doctor who terminates life without the request of the patient can invoke force majeure, but these cases will be assessed with extreme caution. Doctors who take such action have not complied with the criterion, established in case law, that the patient must make explicit, persistent, well-considered requests for euthanasia. The Public Prosecution Service will usually institute criminal proceedings on the basis of Articles 287 or 289 of the Criminal Code. It is then up to the court to decide whether force majeure may be invoked. Senile dementia, old age or disability alone can never constitute grounds for a doctor to invoke force majeure.

May a doctor cease treatment if this will lead to the patient's death?
If further treatment is pointless, it is accepted medical practice for the doctor to withhold or cease treatment and allow nature to take its course. Patients sometimes refuse treatment, and the doctor is obliged to act accordingly.

The decision to withhold or cease pointless treatment is accepted medical practice in other countries too. The same applies to palliative treatment which has the side effect of hastening death. The doctor's duty to respect a patient's refusal of treatment does not mean that he is obliged to comply with a request for euthanasia.

Is a doctor obliged to respect a patient's refusal of essential nutrients and fluids?
Yes. Patients sometimes consciously refuse to take essential nutrients and fluids. The doctor must then decide to withhold or cease administering them. He may also decide to take this course of action if he is of the opinion that, from the medical viewpoint, administering nutrients and fluids is pointless. This too is accepted medical practice. The Ministers of Justice and of Health, Welfare & Sport have taken measures to make the processes leading to these decisions more transparent.

Here, nature is allowed to take its course in the terminal stages. The patients in question may be suffering from either somatic or psychological disorders. Where patients are incapable of making an informed decision, it is up to the doctor to decide to administer essential nutrients and fluids if, in his judgment, this is what the patient would want, or if there are other good reasons. In some cases, for example, the patient may be suffering from an illness that responds well to treatment.