For centuries, the Hippocratic Oath, including the admonition against abortion, assisted suicide, and euthanasia, formed the core of Western medical ethics. While the Hippocratic ideal has been eroding for decades, the most direct challenge has emerged in the Netherlands, with the cultural and legal acceptance of the right to die. The medical community and broader citizenry have so embraced the right to choose death for oneself that the Dutch parliament is currently considering legislation that would allow assisted suicide for anyone who has reached the age of seventy and has merely grown tired of living.

In any other country, such a proposal might be considered radical and shocking. But in the Netherlands”the country that first legalized euthanasia”the change in the law will merely decriminalize a practice that has been occurring for decades. An examination of how this formerly conservative, tradition-bound culture could adopt what the modern Hippocratic Oath refers to as “therapeutic nihilism” is useful for understanding how the other nations will begin to accept euthanasia in the near future.

As occurred in many Western countries during the 1960s, the people of the Netherlands began to reject traditional authority structures in favor of increased individual freedom. While the change led most visibly to a liberalization of attitudes toward sex and drugs, it also carried over into the role of doctors and patients, particularly in the expansion of patient’s rights and patient autonomy.

In 1969 the influential physician J. H. Van den Berg published Medische macht en medische ethiek (“Medical power and medical ethics”), which argued that medical technology was making doctors more powerful. According to Van den Berg, doctors, when bound by Hippocratic ethics, are morally required to keep patients alive as long as possible (a dubious interpretation of the oath and its meaning). But in the age of advanced medical technology, he argued, the ancient creed posed new ethical problems. On the basis of this revised ethical code, Berg argued not only for voluntary euthanasia but also for the involuntary killing of individuals who suffer from reduced quality of life, such as elderly patients suffering from dementia. ??

After the release of Van den Berg’s book, end-of-life issues began to be included in the debates on patient’s rights. But while public sentiment was evolving rapidly”becoming much more tolerant of assisted suicide and euthanasia”the law was slower to conform. Despite legal prohibitions against euthanasia and assisted suicide, which had been part of Dutch law since the Dutch Penal Code replaced the French Code Penal in 1886, euthanasia become increasingly common.

A turning point occurred in 1973 when Dr. Geertruida Postma was convicted of killing her elderly mother, but on such grounds and with such limited punishment that the conviction had the practical effect of giving public protection to physicians engaging in certain forms of euthanasia. ??In this landmark case, the criminal court ruled that it was possible to administer pain-relieving drugs leading to the death of the patient provided the purpose of treatment was the relief of physical or psychological pain arising from an incurable terminal illness. Because Postma’s primary goal was to cause the death of her patient, she was found guilty and received a one week suspended sentence and one year’s probation.

The ruling marked a notable shift in the law, allowing the formulation of conditions under which life could be deliberately shortened by physicians. The light sentence also sent a clear signal that cases of euthanasia would be treated mildly by the judicial system. The result was that the publicly popular practice, while not yet decriminalized, began to be carried out more regularly and routinely, but without a studied understanding of its prevalence or the circumstances under which it was administered. ??

In 1990, the Dutch government set up a Commission, chaired by Attorney General Jan Remmelink, to investigate and quantify what was happening in the shadows of the law. Using the narrow definition of euthanasia as “active termination of life upon the patient’s request,” the Remmelink report concluded that 2,300 instances of euthanasia were carried out during 1990. And while the Royal Dutch Medical Association (KNMG) had established in its Guidelines for Euthanasia that terminating a life without a patient’s request is “juridically a matter of murder or killing and not of euthanasia,” the Remmelink Commission found, through interviews with randomly selected physicians and mailed questionnaires, that over 20,000 life-ending actions had been taken in 1990 without the patient’s express consent. These “matters of murder” do not include, as the report notes, the unknown numbers of disabled newborns, children with life-threatening conditions, or psychiatric patients who may have been killed involuntarily but were not included in the survey.

Rather than being disturbed by the findings, the Commission glossed over these instances of involuntary killing by claiming that “active intervention” was usually “inevitable” because of the patients’ “death agony.” In 1993, the Dutch Parliament responded not by tightening controls on doctors but by implementing the Commission’s recommendation to establish in statutory form the report physicians who practice euthanasia should file with the local medical examiner. Euthanasia shifted from being a punishable criminal offense to being a matter of bureaucratic form-filing.

According to the Dutch Ministry of Justice, of the 135,675 deaths recorded in 1995, 3,600 (2.4%) were the result of a doctor-assisted termination of life while another 238 (0.3%) were cases of assisted suicide. The most disturbing statistic, however, is that 913 (0.7%) were terminations of life without the express request of the patient. For every three lives ended at the request of the patient, one person was killed without consent. While it is assumed that these cases consisted of terminally ill patients with no chance of survival, no one in the Netherlands knows for certain. Because the numbers are based on self-reporting by physicians, no accurate data exists to determine exactly how many Dutch citizens have been killed against their will. ??

Another comprehensive survey by Dr. Paul J. van der Maas in 1996 showed that the situation had indeed worsened since 1990. The total number of cases of euthanasia and assisted suicide had risen by a third from 2,700 to 3,600, with an estimated 60 percent not being officially reported. The number of cases of euthanasia without request by the patient also remained high, with 900 cases being reported. Although the government passively accepted the practice, doctors were still legally susceptible to prosecution if a disgruntled family member disagreed with the killing of their relative. Legislation to decriminalize euthanasia, which had been repeatedly proposed since 1984, was finally passed on April 10, 2001. A criminal liability exclusion was added for doctors who willingly reported their actions and demonstrated that they have satisfied the criteria of “due care.”

A survey of 405 Dutch doctors published in the Journal of Medical Ethics in 1999 revealed that safeguards established by the Royal Dutch Medical Association to control how and when euthanasia is performed were often ignored. Dr. Henk Jochemsen of the Lindeboom Institute for Medical Ethics and Dr. John Keown of the University of Cambridge found that almost two-thirds of cases of euthanasia and assisted suicide in 1995 were not reported. According to the findings, in 20 percent of cases the patients did not explicitly request to die and in 17 percent of cases other treatments were available. The doctors surveyed claimed that 56 percent of patients wanted to “prevent loss of dignity” while 47 percent wanted to “prevent further suffering.” “The reality is that a clear majority of cases of euthanasia, both with and without request, go unreported and unchecked,” said Drs. Jochemsen and Keown. “Dutch claims of effective regulation ring hollow.” ??

In 2003, the regional testing committee reported that the total number of euthanasia cases had slowly fallen from 2,123 in 2000 to 1,882 in 2002. What was not clear was whether the change was due to a reduction in euthanasia requests or because fewer doctors were reporting when they terminated a patient’s life. While only 18 percent of euthanasia cases were being reported in 1990, the decriminalization in 2001 only increased the reporting frequency to 54 percent. Since prosecutions only occur if the regional review committee is aware of the case and finds that the due care procedures were not adequately followed, doctors have little incentive to report when they assist in killing a patient. Unless the family of the deceased has an objection, the incident will never receive public scrutiny. While prosecutions may be rare, doctors are leery of taking the unnecessary risk of reporting their actions. ??

The Royal Dutch Medical Association has since called for increased reporting to bolster public trust in euthanasia laws. But enthusiasm for following these procedures and standards remains muted, since doctors know that no penalties will be incurred by simply ignoring the law. Prosecutions for guideline violations are exceedingly rare and no doctor has ever been imprisoned or substantially penalized for noncompliance. Even when the government is made aware of cases of non-voluntary euthanasia, no legal action is likely to be taken. ??

The Dutch have even expanded the scope of protected physician killing to include children. With their parent’s permission, a child between the ages of 12 to 16 years old may request and receive assisted suicide. Initially, minors could obtain an assisted death even if their parents objected, but after domestic and international criticism, the law was changed to require parental consent. Currently, there is no legal provision allowing for the termination of younger children. But the fact that the law does not allow it does not stop it from occurring. Doctors in the Netherlands have taken it upon themselves to end the life of infants and others who do not have the free will to agree to end their own lives, but whose existence doctors or parents deem “unfit.” ??

In October 2004, the Groningen Academic Hospital officially proposed a government policy”dubbed the Groningen Protocol”which would allow doctors to legally euthanize children under the age of twelve for conditions in which suffering was “so severe that the newborn has no hope of a future.” The hospital even admitted to administering a lethal dose of sedatives to four newborns in 2003. In the previous three-year period, fourteen other cases had also been reported by various hospitals to the Justice Ministry. No legal proceedings were ever taken against either the hospitals that condoned the practice or the doctors who carried out the killings. ??

The lack of prosecutions is hardly surprising considering the Dutch people’s attitude toward killing those deemed unworthy of life. A survey by the NIPO Institute in 1998 found that 77 percent of the populace favored non-voluntary euthanasia while only 76 percent favored voluntary euthanasia. Although the one percent difference falls within the margin of error, it may also be attributable to the false belief that non-voluntary killing is considered only as a last resort while voluntary euthanasia can be administered for almost any reason. As reported in one Dutch documentary, a young woman in remission from anorexia was concerned that her eating disorder would return. To prevent a relapse, she asked her doctor to kill her. He willingly complied with her request. ??

The anorexia example is horrifying, but at least in that instance an actual physical illness was involved. As the most recent legislative proposal shows, some advocates of the practice consider the presence of a debilitating illness or physical suffering as too stringent a prerequisite for permitting euthanasia. The Dutch Voluntary Euthanasia Society (DVES), for example, was generally pleased with the relaxation of euthanasia laws, but it was disappointed that the law continued to forbid the killing of people who are simply tired of living. “We think that if you are old, you have no family near, and you are really suffering from life,” said DVES spokesperson Walburg de Jong, “then [euthanasia] should be possible.” Days after the change in the law, Dutch health minister Els Borst admitted in an interview that she had no problems with providing “suicide pills” for elderly citizens who were simply “bored sick” with living. ??

Perhaps the most significant shift in the public acceptability of voluntary euthanasia occurred in the summer of 1991, crystallizing around another important legal case. Psychiatrist Boudewijn Chabot treated a woman whom he gave the fictional name of “Netty Boomsma.” The woman was suffering from grief over the loss of her youngest son to cancer at the age of twenty. Her eldest son was also dead, having killed himself two years earlier after being rejected by his girlfriend. Boomsma, who had a long history of depression, approached Chabot with the understanding that he would assist her suicide if she did not change her mind about wanting to die. ??

Although the crushing grief over losing a child can last for years, Chabot treated Boomsma for only two months before fulfilling his promise. Four months after the loss of her youngest son to cancer, Chabot gave Boomsma the lethal agent she needed to kill herself. While listening to the sounds of the same Bach flute sonata that had played at her son’s funeral, the grieving mother took the medication and asked the psychiatrist: “Why do young kids want suicide?” Thirty minutes later she was dead. With the aid of the psychiatrist, the mother was able to end her life and fulfill her desire to be buried between the graves of her two sons. In his defense, Chabot insisted that Boomsma was not depressed, nor even a real patient. She was, he claimed, simply a grieving woman who wanted to die. Many Dutch therapists insist that there is an obligation to assist in the suicide of a patient with suicidal ideation if treatment has not succeeded.

But Chabot provided only minimal treatment: The despairing patient became her own diagnostician, and the doctor simply acted as the deadly pharmacist. After reporting the case to the coroner, Chabot was prosecuted for violating Dutch law, but the case was appealed to the country’s supreme court, which upheld the precedent set by the Leeuwarden criminal court in 1973”that pain relief that runs the risk of shortening life is acceptable when helping a patient suffering from a terminal condition. The court found that Chabot was guilty of not having provided an adequate psychiatric review of the patient’s case before assisting with the suicide. However, the court imposed no penalty on Chabot, and the legal ruling established the precedent that physical illness was not a requirement for providing “pain relief” that ends a life when the request is voluntary, well-considered, and reviewed by a second physician. Suicidal depression became a terminal disease; psychic distress became a legitimate ground for doctor-assisted death. ??

While the Supreme Court’s decision was hailed as a victory by euthanasia supporters, it took more than ten years before the medical community openly agreed that neither a terminal illness nor physical suffering should be necessary for ending a patient’s life. After a three-year investigation, the KNMG concluded in January 2005 that doctors should be able to kill patients who are not ill but who are judged to be “suffering through living.”

Jos Dijkhuis, the emeritus professor of clinical psychology who led the inquiry, said that it was “evident to us that Dutch doctors would not consider euthanasia from a patient who is simply ‘tired of, or through with, life.’” Instead, the committee agreed on the term “suffering through living,” because a patient may present a variety of physical and mental complaints that can lead them to conclude that life is unbearable. “In more than half of cases we considered, doctors were not confronted with a classifiable disease,” said Dijkhuis. “In practice the medical domain of doctors is far broader . . . . We believe a doctor’s task is to reduce suffering, therefore we can’t exclude these cases in advance. We must now look further to see if we can draw a line and if so where.”

Over a period of forty years, the Dutch have continued the search for where to draw the line with euthanasia, shifting from acceptance of voluntary euthanasia for the terminally ill, to voluntary euthanasia for the chronically ill, to non-voluntary euthanasia for the sick and disabled, to euthanasia for those who are not sick at all but are merely “suffering through living.” While the initial impetus may have been spurred by a desire to give expanded rights to the person who faces extreme suffering or imminent death, the effect has been to concentrate power into the hands of state-sponsored medical professionals. And while the justification for assisted death is usually the supposed well being of the suffering patient, the Dutch have redefined natural dependency into an unacceptable or unwanted social burden.

By conflating the duty to reduce suffering with the perceived necessity to eliminate all suffering, Dutch physicians have increasingly resorted to euthanasia as a novel form of sympathectomy. A sympathectomy is a medical procedure that is sometimes required after a localized trauma or peripheral nerve injury, when a person may feel a syndrome of pain and tenderness that can only be relieved by the excision of a sympathetic nerve. In a similar manner, when faced with the many pains, heartaches, and disabilities that eventually afflict most of us in one form or another, the Dutch are resorting to the excision provided by euthanasia.

In doing so, they are severing more than the cords of life, they are cutting the sympathetic nerves that tie us to our fellow human beings. By perverting the traditional role of the physician, the Dutch are making a mockery of true human compassion, and providing a stark warning to those aging societies, like our own, which might one day be tempted to allow this sympathectomy of the soul.

Joe Carter is web editor of First Things .

Articles by Joe Carter

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