Rites of passage: An inside look at euthanasia in Holland

Candle (© Flickr/webhamster)

Mercy killing or euthanasia continues to provoke heated debates in most parts of the world. In the Netherlands, according to some estimates, up to 10,000 ask for euthanasia, literally the good death, every year. And while everyone admits that euthanasia does take place, it remains a crime under Dutch law.

Producer: Eric Beauchemin

Broadcast: May 22, 1991


Radio Netherlands, the Dutch International Service, presents “Rites of Passage – an inside look at euthanasia in Holland”.  The programme is produced and presented by Eric Beauchemin.

The whole idea of euthanasia is to make it possible to shape your own life and your own death. If people have the right to take their own life, then in circumstances when they are too weak or too ill to take their own life, somebody should help them.

Death isn’t a subject we deal with easily, especially when it’s our own death. But even as modern science makes new advances, enabling us to live longer and better lives, growing numbers of people paradoxically are demanding the final right: the right to decide about their own death. Mercy killing or euthanasia continues to provoke heated debates in most parts of the world. In Holland it’s practiced every day. No one knows the exact figure, but according to some estimates, every year, up to 10,000 Dutchmen opt for euthanasia, literally the good death. And while everyone admits that euthanasia does take place in this country, it remains illegal, as Pit Bakker, the president of the Dutch Right to Die Association told me.

Yes, that’s another question, quite un-understandable for most people abroad because the judges have stretched the laws, the possibilities, they don’t convict doctors at the moment if they give euthanasia along certain rules they have given in general. If the doctor keeps to the rule, the prosecutor won’t prosecute. EB: Rules or conditions. What are these conditions that have to be fulfilled? First of all, the patient should have a written statement that he wants euthanasia. Secondly, that a colleague doctor is introduced as a second opinion. And third of all, that they make a report for the prosecutor so that the prosecutor can control what happened and who was involved in the euthanasia question.

And as long as doctors perform euthanasia under these conditions, they do not face prosecution. Euthanasia though remains a crime under Dutch law. The penalty: 12 years in jail. In Holland, unlike other countries, no distinction is made between active euthanasia – that is, helping someone to die – and passive euthanasia, which involves the withdrawal or withholding of treatment. Dr. Herbert Cohen who has a practice in the western city of Capelle has helped many of his patients terminate their lives.

In Holland these days, we simply use the word euthanasia. And we imply that it is voluntary euthanasia. If it was not voluntary and there was no request, we would consider it to be murder. We do not use the distinction active and passive euthanasia anymore. Euthanasia implies it being active euthanasia, that is giving drugs to a patient with the intent of that patient dying. What used to be called passive euthanasia is withholding treatment because that treatment is futile or because the patient does not want to receive that treatment. And that is now considered to be good medical practice and not a criminal act at all.

In fact, active euthanasia has become such an accepted fact of life here in Holland that the Royal Dutch Medical Association has published guidelines for its 25,000 members. Dr. Theo van Berkenstein is the association’s secretary general.

When a patient asks for euthanasia, the doctor must be able to help him and give a positive answer on that question. Every doctor is free to handle as he thinks he has to do, but if he gives a positive answer, then we think he has to follow our guidelines.

…which are the conditions mentioned earlier: the rites of passage, namely a repeated and well-considered request, unbearable suffering, a second opinion and the absence of reasonable alternative treatments for the patient. So how do people actually request euthanasia? Mrs. Bakker of the Right to Die Association.

If you have severe illness and it was impossible for you to be cured, and you had a long suffering before you, the doctor would recognise that. Then he might discuss that with you. He probably will discuss that with you during a long time. That may take weeks or even months, and if you exactly know both what you want and that there is no other possibility for you to live a reasonable life, that you wouldn’t be able to marry, to have children, to have a job, then the doctor might – with you – decide that euthanasia is the only way out.

The start of the procedure is indeed a request by the patient. The request may be put for the doctor or quite often for a nurse. Well, it’s a round of talks which starts for a few weeks, a few months. I’ve even known to last for a few years. Involved, of course, are the patient, of course the doctor, usually relatives, if possible a priest or a minister if the patient allows them to take part in the decision-making. So everything is discussed again and again, and slowly one grows to a certain decision. In the meantime, of course, there’s the development of the disease. The disease may progress, the condition of the patient may improve. Everything is possible, and quite often it happens that the patient will die a natural death when you are still talking about euthanasia.

But, of course, that’s not always the case. Dr. Cohen again.

I received the first request about 10 years ago from a very dear patient. I have many very dear patients, but this one was suffering. And one day she said to me: I have tallied all your visits, and this is the 100th time and I think it’s been enough. And then we started the discussion. EB: Was it a difficult discussion for you? It was very difficult because at that time, I had no experience and hardly anybody else had any experience. So I had to find out for my own conscience: did I want to do it? I had no guidelines. I had no proper instruction as to what drugs to use, etc., etc. It is much more of a well-known procedure now.

As a result, more and more terminally ill patients are considering euthanasia. They see it as a safety valve, the ultimate cure, if the going gets too tough, if the pain becomes unbearable.

Saying goodbye to life is a very difficult thing. But when the patient comes forward with the request, they have gone a very long way, and every objection I make as a kind of devil’s advocate will be met with the answer: I’ve thought of that. If I say: what about your relatives, what about your religion, what about children, the answer is always: I’ve thought of that.

Wim Sonneveld, a person with AIDS, has also thought of all that.

In ’86, I heard for the first time that I was seropositive. So I had the time to think about how and when and what way I want to have my funeral and I want to have my help. So I arranged already all the things in ’86, and then I was not ill. But I had decided then already because four of my friends were already died, and I saw the way they died. I said: one thing is for sure. I don’t want the way they died. It was terrible. I couldn’t stand it. They were my best friends, and I couldn’t stand it. I couldn’t see that anymore. I asked also when is this circus going to end? But they didn’t think of euthanasia. When they thought about it, it was too late because then, there was nothing on paper. They were so sick. It was too late.

People with AIDS are a new factor in the euthanasia equation. In other countries, they might resort to suicide to spare themselves the advanced stages of the disease. In Holland, though, people with AIDS – just like every other terminally-ill patient – can request euthanasia. And many Dutchmen with AIDS attach great importance to this last rite – the rite of passage. Wim Sonneveld again.

Yes, because it’s a sort of heavy thing that was on my shoulders and it’s gone. I know I don’t have to worry. Everything is arranged. I accepted it, so I’m not afraid for death. So my life is more, and that gives you a good feeling because I accepted it.

For Wim, accepting death also involved deciding how he was going to die, and according to Pit Bakker of the Dutch Right to Die Association, this decision is actually nothing more than just another element in the long discussion between patients and their doctors.

I think it is very good to discuss with your doctor, depending on your illness of course, but it’s very good to discuss with your doctor in which way you want to die. Some people just want to have pills or anything and take it themselves. Others are no more able to do so, can’t swallow. They have to have an injection. Some people want to be in the circle of the family. Other people want to be absolutely alone, and I think you should discuss all these things beforehand.

So, how does this gentle death, as the Dutch call it, actually take place? Is there a procedure? Dr. Cohen.

Technically speaking, there is euthanasia in the strict sense of the word where a doctor administers drugs to the patient, usually by intravenous injection, or there is the form of assisted suicide where the doctor prescribes drugs, usually in the form of a liquid medicine to the patient who will take them. The pharmaceutical association has published a booklet which gives drugs that have a certain effect and cause a mild and not gruesome way of being put to sleep. I think it is very important that nothing is left undecided but that everything is prepared very well: the time, who will be present. The occasion is a very sad one but also one which causes a lot of relief to the patient as well, who will be quite changed when the decision is made. He or she feels that there’s a kind of safety valve and the patient is quite often is in a very good humour and very relaxed up to the moment of euthanasia.

On average, a general practitioner in Holland with 2500 patients will receive one of these euthanasia requests every two or three years.

It’s not a very high figure, but it makes an impression on the rest of the two or three years. It’s something to remember, especially if it’s about a young person, somebody with a long life expectancy. It makes a hell of a difference whether it’s a cancer patient who you spare three days of suffering or a young woman in her thirties with multiple sclerosis. The number of nights you don’t sleep about it is different.

Euthanasia has the backing of a large segment of the Dutch population: 85% of Dutchmen support it. Most of those who oppose mercy killing do so because they say it violates the sacred or religious principles of respect for life. Dr. Verhoeven is the former president of the Dutch Doctors Association, a group of some 1000 doctors, which takes a radically different view from that of the Royal Dutch Medical Association.

The reason for that is that I think that one man doesn’t have the right to kill another man. Being a doctor, that doesn’t change anything in that situation. When you are a doctor, you are supposed to treat, to help, to comfort your patients and not to kill them. Killing is something far away from the medical profession. The ethics which I think that must be maintained in my profession is the utmost respect for every human being, from the beginning until the end. In the Hippocratic Oath, euthanasia is forbidden.

But is mercy killing really a violation of the Hippocratic Oath? Dr. Cohen.

Maybe yes, maybe no. I think the Hippocratic Oath is 2500 years old, and what is written there should be seen in the light of that time. Certainly there is no doctor in Holland who really took the Hippocratic Oath. If it is against this very, very old document, well, I think, bad luck for the document.

Nonetheless, many opponents of euthanasia find it deeply troubling that doctors whose main task, they argue, is to preserve life, are helping their patients to die. After all, medicine is supposed to be the enemy of death. But inevitably doctors are confronted with people who have incurable diseases, cancer, multiple sclerosis, AIDS, people who will have a long and excruciatingly painful death. Why refuse euthanasia to these people? Dr. Verhoeven.

Only a very few people have asked me to give them euthanasia. And when you look after the reason why these people are asking that, that are nearly almost situations which you can change. You can treat their pain. You can treat their discomfort. You can help to alleviate their sorrow, their loneliness, etc. When you do that, the question of euthanasia disappears with that patient. That’s my experience.

But what if a patient continues to express the wish to die?

He can make a choice in saying: I do not want to be treated any more, curatively treated. But from that moment on, as a doctor, you have still the plight to care for him, giving care, more and more intensive, and not killing him. EB: But if these people are in severe pain, surely you can’t ask of them that they remain alive longer simply so you can fulfill your task as a doctor to care for them. Yes, and that is what I will do. When they have severe pain, that pain must be treated, and nearly every pain can be treated very well nowadays.

Even advocates of euthanasia admit that almost all forms of pain can be alleviated. But what about quality of life and human dignity, they ask? Shouldn’t the patient have the final say in these matters? Dr. Cohen.

If the patient is of sound mind and constantly thinks his condition of life is unbearable – let me tell you, nobody makes a joke of dying – then it is up to the patient to say that is unbearable. EB: But there are some doctors who would say that all forms of pain can be alleviated. Oh, that’s true. You can alleviate every pain by euthanasia, for instance, but there’s a price attached to that. And the price is feeling miserable, sometimes loss of consciousness if very heavy painkillers are used, and not everybody wants that kind of life. Nobody will ask for euthanasia for fun, and no doctor will consider or suggest euthanasia if there is any other way to alleviate the suffering still open. I’m quite often asked: are you in favour of euthanasia? And my answer is no, I’m not in favour of euthanasia. I think it’s a very difficult decision, and it will always be a very difficult decision, and it’s always a second choice. You would rather make a person healthy and happy again. But very often, the complications, the side effects of killing pain are difficult to bear for that patient, that the patient would rather not receive that treatment and not live anymore.

Wim Sonneveld agrees. We must be the ultimate judges of the quality of our life, he says, and we must have the right to decide when we have paid enough for those rites of passage. So what’s his limit?

When I’m dependent on other people, totally dependent, not realising what is happening, that’s my line. But when I’m on that line, I’m not sure if I keep that line. Maybe I will try to stretch that line. But anyway, I have the possibility to say, well it’s enough.

For Dr. Verhoeven though, it’s not that easy. In fact, he sees doctors who practice euthanasia as nothing more than accomplices to murder. And he feels that mercy killing raises some very fundamental issues about medical treatment in this country. Even doctors who practice euthanasia recognise the moral dilemma. Dr. Cohen.

I think one should be in doubt and remain in doubt always. Sometimes a doctor will ask me: I think it’s very difficult. Should I worry about that? And I tell them you’d better worry when you don’t feel it is very, very difficult.

For people with deep moral convictions, it’s not difficult. It’s wrong. Dr. Dijk is a moral theologian at the conservative Catholic seminary of Rolduc in the south of the Netherlands. `

Life of the human person has an intrinsic value. The life of the human person is a gift from God, which men cannot just return to God at the moment that pleases him. It is our duty to fulfil this life till the very end. Life maintains its value, although our body may perhaps be affected by disease or by other handicaps. Of course, we have all our freedom to decide about our destiny, to fill in our lives as we like, but there are certain frontiers which we are not allowed to pass.

Views like these are what has prevented the passage of a law legalising euthanasia in Holland. Despite its illegal status, though, euthanasia has been practice in Holland for nearly two decades. It first surfaced in 1973 when a general practitioner killed her mother, an aging cancer patient. The GP was found guilty and given a week’s suspended sentence and a year’s probation. Since then, Dutch courts and prosecutors have established that if euthanasia is performed under the right conditions, doctors will not be prosecuted. There have been attempts to come up with a euthanasia law. In the early 80’s, the government established a commission. It presented a report, recommending the adoption of a euthanasia law, as Jacob Kohnstamm, a member of parliament of the left-wing liberal party, D66, told me.

Try to legalise euthanasia within the framework of the penal code. So, keep it as a criminal act, but if a doctor helps someone who asks for it deliberately, who really wants to die and is in a hopeless situation, and then if the doctor does it carefully, which means he consults another doctor, talks with the closest friends and relatives of the patient, keeps book of everything he does and doesn’t, and finally reports to the public prosecutor about what he did, if a doctor does it that way, he won’t be prosecuted.

In essence, these are the conditions which must be fulfilled today to perform euthanasia in the Netherlands. The commission’s findings were incorporated in a bill submitted to parliament by Jacob Kohnstamm’s left-wing liberal party. The bill was defeated because of opposition from Holland’s Christian Democrats. The Christian Democrats are the constant in the Dutch political equation. They’ve been in every single coalition government since the early 1900’s, and they reject mercy killing. Nevertheless, they’ve learned to live with the status quo. Jacob Kohnstamm.

By the way, what now happened is that the minister of justice wrote a letter to the public prosecutor stating that under certain circumstances, they shouldn’t prosecute euthanasia any more. So there’s a very sort of double standard. In the penal code, it says that it is forbidden and you get 12 years of imprisonment if you help someone to die. There is a letter to the public prosecutor saying that under certain circumstances, don’t prosecute euthanasia cases, and there’s a proposal in parliament where politically speaking, at this point, there is a majority, but the majority is blocked by a minority. The main thing why I still want to change the law – and I think it’s a necessity – is that if there’s another minister of justice who writes another letter to the public prosecutor, then suddenly all those who are in favour of euthanasia, and that’s a majority, might be in problems.

The 24,000-strong Right to Die Association takes a similar view.

We want a really good law because as long as euthanasia is illegal, it can be done in darkness and secrecy. And darkness and secrecy can’t be controlled. We want euthanasia controlled like every operation in a hospital. On the other hand, the way the judges and the prosecutor handle the euthanasia questions at the moment is very helpful for getting the idea of euthanasia spread in the country, and we can see that lots of people are talking very freely about it. But the time has come that a real good law is made by the government now.

One key provision of this new law, says Pit Bakker, is that euthanasia would remain in the penal code. But why? Jacob Kohnstamm.

Partly because I think that any decision on euthanasia is a very risky one. It’s a final one. So I’d really rather have the public prosecutor control whether the doctor rightfully did what he did. That’s the first argument. Then there’s the more political argument: it’s difficult to have a big, vast majority on this matter in parliament. A majority really feels more comfortable if we change the law but keep it in the penal code.

Opponents of mercy killing say legalisation would be the first step down a slippery slope. It might lead, they say, to the killing of the elderly, the disabled or severely deformed babies. But Jacob Kohnstamm feels the fear of a slippery slope is totally unjustified.

It couldn’t occur, if you look at the proposal of law, because the main thing of euthanasia is that a woman or man that wants to die decides deliberately that he or she wants to die. So it’s always asked for. Those who argue that in Nazi Germany, euthanasia was used to kill all sorts of people, I wouldn’t call it euthanasia. It’s downright murder. We’re not trying to get murder out of the penal code. Murder will stay murder, and if someone doesn’t ask for euthanasia, then it’s murder. So euthanasia is out of the question. Euthanasia is per se – I mean, in the definition, in the word euthanasia – there is the person asking for it. If the person doesn’t ask for it, it’s murder.

So what are the chances of a euthanasia law ever being passed in the Netherlands?

Of course, it has been in discussion from ’73 on heavily. So nearly everyone has been thinking of it and discussing it. A majority, 85%, favours the changing of the law. Even 65% of the Christian Democrat voters, by the way, favour a changing of the law. But finally it’s a compromising atmosphere which makes it difficult to get the law changed, but in the end I’m sure we will manage.

Holland has become a proving ground for euthanasia, for the rights of the dying. The reason? Some would say it’s because of the openness and tolerance of the Dutch. For Dr. Cohen, it’s actually proof of how advanced Holland’s medical system is, for in this country, medical treatment is virtually free. Abuses are few and far between. Patients and their doctors have learned to accept the limits of medical science, to say enough is enough, to allow people to die with dignity and to respect the ultimate rite of passage.

One of the principles, maybe the main principle of the members of our organisation is the right to self-determination. And if you have the right to self-determination, you also have the right to choose your own way of dying. You are able to choose your life, whether you want to marry, have children, what kind of job, whether you want to play the piano or not, whether you want to be operated or not. Why shouldn’t you have the right to decide how you should die if the natural way to die – what everybody wants, of course, the easy way, not to wake up the next morning. But that’s very seldom that that happens, why shouldn’t you, if you are suffering, have the right to choose how you die?

Rites of Passage was produced and presented by Eric Beauchemin. Technical production: Robert Meider. This has been a Radio Netherlands’ presentation.