1. The ethics of euthanasia: general introduction
1. 1. Since the discussions concerning euthanasia engage some of the most fundamental values and norms of our individual and social life, it seems necessary to say a few words about the questions what these values and norms are and how we can find a foundation for our ethical views.
Morally relevant conduct, as distinguished from behaviour in general, consists of activities that cause approval or disapproval. Such conduct can sometimes be governed by explicit maxims learned from others or formulated for ourselves; but mostly the rules are interiorized as ‘values’ or ‘norms’. They may then elicit either a positive emotion or a moral pain when we are confronted with the results of our own actions, or they may provoke feelings of admiration or indignation when we observe the doings of others. Values and norms, which control the activities of individuals and groups, are of a factual nature: their presence or absence can be ascertained by empirical procedures.
Ethical research may consist of looking for information about the existence (or absence) of particular norms (or values) within a group, but it is concerned primarily with the question of how a foundation can be laid for them. Such foundational problems arise when generally accepted norms are suddenly challenged or when the need to introduce new ones imposes itself.
1.2. In the course of the centuries, philosophers have realized that there is a difference between facts and values, between ‘is’ and ‘ought’, ‘Sein’ and ‘Sollen’. Many of them were also convinced that both domains have an objective character: there is objective truth about facts and there are objective values which should be accepted by everybody. In one opinion, the objectivity of the values and norms was based on the thesis that ethical propositions could be deduced from factual ones (Sollen from Sein); in the other one, both had their own independent foundation.
The thesis proposed here is different from the aforementioned. It starts from the observation that values and norms develop in human societies as a means to organize them and to regulate the partially compatible and partially conflicting drives of the individuals in such a way that the stability and survival of the whole is guaranteed. It follows that morals necessarily change with the development of the economic, social, cultural, etc. components of the society. There is no absolute foundation for ethics, but it is still sensible to ask which type of ethics is most compatible with a peaceful and prosperous state of a society in a given period, including ours.
1.3. More specifically, when studying the history of the ethical attitudes and principles since the oldest civilisations which influenced Western thought (Egypt, Mesopotamia, Israel and the Greco-Roman world), one cannot but be struck by the impression of an ever growing importance and extension of the concept of the fellow human being.
Anthropological studies suggest that people of Palaeolithic and early Neolithic tribes only identified with the members of the own tribe or clan: in many cultures the term ‘human being’ was only applied to kinsmen or members of one’s own tribe.
But with the development of larger kingdoms (e.g. in Egypt and Mesopotamia), in which many tribes were united, the need for broader types of identification with the others gradually arose. As a consequence, there developed an awareness that ethical obligations extend to all the inhabitants of the same kingdom. In the Bible, we notice that the concepts of ‘neighbour’ (the ‘nearest’, ‘Nächtste’) and ‘love for one’s neighbour’, which initially only referred to the closest relatives or friends, are extended to include all Israelites.
Near the end of the first millennium BCE, there is a growing tendency in a number of civilisations to widen even more these feelings of solidarity and identification, to human beings in general (e.g. in Buddhism, Mazdeism, Christianity, Greco-Roman Stoicism and, somewhat later, in Islam). This attitude was crystallised in a moral norm: the so called Golden Rule, the first formulation of which one finds with Confucius (about 500 BCE) but which we know better in the form it took in the Gospel of Matthew (7, 12) : “All things whatsoever ye would that men should do to you, do ye even so to them.”
It seems to me that the growing complexity of human societies and the need for pacified relationships over ever larger domains, contributed to the spread of this moral attitude and to its gaining solidity and persuasiveness.
In the eighteenth and nineteenth centuries, this development has led to a clarification and systematisation of this initially rather vague cluster of attitudes and feelings.
1.4. Without going too much into detail, one can safely say that at least three important principles, which I call ‘values in progress’ were clarified in the course of this development.
First, we observe the spread of the concept of ‘love of one’s neighbour’ or ‘identifying with our fellow human being’, which leads to acts of solidarity and it means that we consider him as our equal.
Second, this notion of equality implies that we grant him the same rights we claim for ourselves, especially the rights to life, freedom and self-determination or autonomy. In Kant’s formulation, every person has the right to be treated as his own end and not merely as a means to another’s ends. For him, the quintessence of the Enlightenment was the emergence of the right to self-determination. “Aufklärung… ist der Ausgang des Menschen aus seiner Selbstverschuldeten Unmündigkeit…: das Unvermögen sich seines Verstandes ohne Leitung eines anderen zu bedienen” (1)
In a third, no less important, component the Golden Rule refers to the idea of caring for other people, especially for those who suffer. Already in the Egyptian ‘Book of the Dead’, we find the touching phrases: "I have not made anyone weep, I have not caused anyone suffering”. (2) This growing sensitivity to pain and suffering - even of animals - was beautifully expressed by Bentham: “The question is not, Can they reason? or Can they talk? but, Can they suffer?”. (3)
My first point is that the ‘values in progress’ we observe in the course of the development of our civilisation are: (1) the right to autonomy or self-determination of every individual and (2) the love of one’s neighbour, or solidarity and (3) the obligation to protect from harm all beings liable to suffering.
1.5. In the 20th century we witness a number of mentality changes which lead to some adaptations and reformulations of these values.
Because of the desacralisation of the worldviews, the secularisation of the society and the tendency towards a consumer mentality, the ethical attitudes of the large public evolved from what one would call in German, a Jenseitsmoral to a Diesseitsmoral. There is a growing belief that every human being has the right ‘to pursue happiness’ here and now and to avoid meaningless pain and suffering.
In the same movement of thought, a marked tendency could be observed, especially during the second half of the 20th century, which led to a change of age-old ethical standards and contributed to the break-down of traditional taboos. This manifested itself clearly in the acceptance of new standards concerning contraception, sterilisation, abortion, homosexuality, etc.
A third mentality change was the emergence of the idea of the rights of the patient and the rejection of paternalism. The acceptance of the right to ‘informed consent’ before the medical doctor intervenes for diagnosis and treatment is a major example of this development.
As far as the impact on the discussions about euthanasia is concerned, a very important step was the realisation of the link between paternalism and suffering.
Paternalism consists in the restricting of the self-determination of an individual, without his consent or without adequate information, but with the intention to preserve the individual’s own well-being. Contrary to a time-honoured tradition in medical circles, there is a growing awareness now that paternalist acts and attitudes are no longer justified towards persons capable of taking autonomous decisions. This is especially the case when pain and suffering is involved.
The most radical arguments for this thesis have been put forward by J.S. Mill (4) .
- Since pain and suffering can only be experienced by the suffering subject himself, nobody knows better than he does, when and to what extent he suffers.
- Nobody has more interest concerning his own well-being and suffering than the subject himself.
It follows that - paternalist - decisions by others may be wrong because they lack adequate information and/or real commitment.
1.6. On the basis of the foregoing considerations, the ethical problem concerning euthanasia can be approached as follows. Consider the case of a person, in full possession of his mental capabilities, who endures unbearable suffering due to an incurable illness, and who asks his doctor consistently to terminate his life.
According to the above mentioned “values in progress”: ‘human solidarity’, ‘self-determination’, ‘sensitivity to suffering’; and the “mentality changes”: ‘Diesseitsmoral’, ‘break-down of dated ethical standards’, and ‘rejection of paternalism’; it would be an act of high ethical value when the doctor, provided he respects some due care criteria, complies with this request.
1.6. The possible objections to this approach are the following.
“The ‘right to life’ is a fundamental ethical value which an individual cannot give up.” But ‘right to life’ has been introduced by societies as a protection of the individual against those who would want to take his life against his will. What could be the rationale of introducing a ‘duty to live’ for persons suffering hopelessly?
“Only God or Society has authority over life.” But reference to God is not persuasive for those who do not believe in God. Hence, in an enlightened democratic era, society should put forward generally persuasive reasons to forbid euthanasia, which brings us back to the first point.
“It is the duty of the physician to preserve human life, not to terminate it.” But the duties of physicians, as of all professions, are determined by those who ask for their services. The ethical aspects of these duties should be determined by society. Except for reference to professional standards and a ‘clause of conscience’, doctors have to comply with what society asks from them.
“Introducing euthanasia could provoke abuses.” This objection should be taken seriously and in every specific legislation the advantages and disadvantages should be carefully weighed up against each other.
2. The Belgian and Dutch laws on euthanasia: a brief history
2.1. In Belgium, the ethical and legal problems concerning euthanasia have occasionally been treated in the media since de seventies, there was, for instance, a one hour debate on the Flemish television in 1971. Organized action in favour of legislation started in the eighties with the foundation of the “Association belge pour le droit de mourir dans la dignité” (1981) and its Flemish counterpart “Vereniging voor het recht op waardig sterven” (Association for the right to die with dignity) (1983).
By then, the debate had already been launched in the Netherlands by doctor Geertruda Postma in 1971. She had given a lethal dose of morphine to her 78-year-old mother who was deaf and partly paralysed and who had asked her daughter repeatedly to end her life. Afterwards, doctor Postma reported her act to the authorities. The groundbreaking verdict of the Court of Leeuwarden stated that a medical doctor cannot be blamed for shortening a patient’s life if she/he has observed certain due care criteria and if the following conditions are met: incurable illness, unbearable suffering, request by the patient. This ‘shortening of a life’ was not yet equated with euthanasia – the court gave doctor Postma a light sentence – but the debate on the topic was definitely opened.
After some other trials, a State Commission was set up (1982) to give advice on future government policy concerning euthanasia and assisted suicide. The advice (1985) defined the concept of euthanasia as “the intentional taking of someone’s life by someone else, at his explicit request”. A majority of 13 to 2 advised that some articles of the penal code should be changed to make euthanasia permissible, if it is performed by a medical doctor who is following a specific procedure.
In October 1990, the attorney-generals agreed on a ‘notification procedure’: the doctors who performed euthanasia, had to report it to the municipal coroner with a detailed account of the circumstances of the act. The doctor would not be prosecuted if the prescribed conditions were met. The real euthanasia law was only adopted on April 10th 2001 and became effective on April 1st 2002. (5)
2.2. The impact of these ten years of factual impunity of a specific euthanasia practice on the ongoing discussion in Belgium was undeniable. There the political discussion started in the mid 1990’s. During the parliamentary session 1995-1996, euthanasia bills were submitted to the senate by four members of parliament. In 1996, the Belgian Comité consultatif de Bioéthique (Consultative Committee on Bioethics) was founded to advice the federal and ‘community’ governments and parliaments on bioethical problems. This Committee is composed of 35 members and 35 substitute members: medical doctors (two times 11), nurses, magistrates, lawyers, and specialists in the social sciences and moral philosophy and theology. The very first assignment, proposed by the presidents of the Chamber and the Senate, was to give an ‘advice’ concerning the submitted euthanasia bills.
Two such advices were issued: the first one on May 12th 1997, which dealt with ‘euthanasia’ proper (on competent people), the second one on February 22nd 1999 on ‘termination of life of incompetent people’ and on ‘advance instructions’ (‘living wills’).
It is very important to notice that, although the members disagreed on the fundamental questions, there was complete unanimity on the following topics.
(a) The Dutch definition was adopted: “euthanasia is the intentional taking of a person’s life by another, on this person’s own request”. (b) It follows that this definition does not apply in the case of incompetent people: there the proposed terminology is: “termination of life of incompetent people”. (c) More importantly, the act of stopping a pointless (futile) treatment is not euthanasia and it is recommended to give up the expression ‘passive euthanasia’ in these cases. (d) What was sometimes called ‘indirect euthanasia’, viz. to increase the use of analgesics with its possible effect on shortening life, is also clearly distinguished from euthanasia proper.
It is a pity that some medical doctors, even among those confronted on a daily basis with the situations falling under (c) and (d), still take the view that the Belgian euthanasia law is relevant for such decisions. There was agreement among the members of the Committee that the ‘end of life decisions’ of this type are not to be considered as ‘taking the life of someone’. Although some of them pleaded for enacting a law prescribing the procedures of decision making in these ‘end of life’ cases, others were confident that the specialists could be trusted when drawing up a system of rules in collaboration with their local ethical committees (e.g. Not To Resuscitate directions).
On the core question, three basic views came to the fore. Some members advanced that euthanasia could be allowed under no circumstances because it would compromise the inviolable value of the life of a fellow human being. Others were of the opinion that, out of compassion and respect for self-determination, euthanasia should be allowed. A middle group - some of them doubtless of Christian conviction - proposed that euthanasia should be allowed in cases of ‘force majeure’ where two conflicting duties of the doctor are involved (preserving life and relieving unbearable suffering).
These views were expressed in four proposals: (a) a revision of the law so that euthanasia is no longer punishable; (b) an agreement between the attorney generals not to prosecute in some cases: i.e. a proposal similar to the regulation prevailing at that moment in the Netherlands. In both cases the doctor should take advice from a colleague and afterwards fill in a certain form describing the circumstances and hand it over to the legal authorities; this is the a posteriori procedure. (c) In what is called the a priori procedure, before any decision is made concerning euthanasia, an ethical debate should take place between the doctor, a second doctor, the family, the nursing team and an ethicist. If euthanasia follows, the doctor gives notice to the legal authorities with a plea of ‘force majeure’. Of course, in all of these three proposals the euthanasia could only be executed by a medical doctor who made certain that the patient was in a state of unbearable suffering and that his request was completely free and well informed. (d) The fourth proposal rejected every form of euthanasia and hence any change of the law.
This Advice stimulated a debate in the Senate on December 9th and 10th 1997, but the discussion did not lead to any result until the elections of 1999. The major problem was that the Christian Democrats could not accept a regulation that would change the penal law; they were only prepared to leave room to an appeal to ‘force majeure’ in extreme situations, whereas most of the other parties wanted to go much further. Only the ultra-right ‘Vlaams Blok’ did not accept any change.
After the elections, a coalition of Liberals, Socialists and Greens formed the government banishing the Christian Democrats to the opposition bench. Very soon, a number of senators, each representing one of the coalition partners, introduced a bill that was partly inspired by proposal nr 1 of the two Advices of the Consultative Committee on Bioethics. The Christian Democrats also introduced a bill inspired by proposal 3 of the first Advice.
Some party leaders feared that this euthanasia law would be the first in the world and therefore they hoped that a compromise was possible in order to arrive at a larger majority. But even a reflection period introduced during the months of April and May 2000, and about forty hearings of experts, only resulted in a number of amendments to the majority bill. The ‘great compromise’ did not succeed.
It is true that proposal 3 of Advice nr 1 of the Consultative Committee, where the ideas of a priori procedure and ‘force majeure’ were proposed, did open up a possibility of an agreement with the Christian Democrats. However, it turned out that part of the rank and file of this party remained opposed to every form of euthanasia and certainly against a change of the law. It is true that some progressive Christian Democrats were aware of the fact that a rather large majority of the population had a positive attitude towards euthanasia: many have been confronted with unbearable suffering of relatives or friends. But the majority of the Christians Democrats wanted to stand by what they considered a basic value of the Christian tradition: the absolute respect for human life. In the Explanation of the proposal of the CVP (Flemish Christian Democrats) we read: “This age-old tradition of respect for life has become a norm for our Western civilisation, also for those denying the belief in God. Each life is unique and deserves esteem, respect, protection. The need to protect life is felt in the keenest way during the process of dying. The value of a life does not depend on its individual assessment.” (emphasis supplied). (6)
2.3. Characteristic of this approach is a fundamental option for heteronomy - in contradistinction to those who see the autonomy of the person as the central value - : the origin of the value of human life and of the human person is not found in this person himself (autos), but in another authority (heteros). Since the thesis that God is the other authority is no longer universally accepted, there is a tendency to replace it by society: “Like birth, dying is a social event. When the human being approaches death when a helping hand is missing, there is a denial of the social character of crossing over from life to death.” (ibidem)
Whoever starts from this point of view cannot agree with the proposal that a text with universal impact such as the articles on killing in the penal law could allow the taking of a life. This would mean that the autonomy, the right to self-determination, would become a value in itself in some circumstances, which would eliminate the prevalence of the heteronomous authority. “The duty of the authorities to protect human life…is founded on the belief that human life is valuable from the perspective of human dignity alone, that means that it is good in itself, regardless of its endorsement or denial of it by the individual.” (ibidem).
Even a life that has become meaningless and unbearable for the person concerned, imposes itself on him as an inescapable matter of fact, adorned by the aureole of ‘human dignity’. As far as the foundations are concerned, this is also the view of those absolutely opposed to euthanasia. However, in the aforementioned third proposal of the Advice and in the bill of the Christian Democrats, it received a more humane expression. There it is accepted that, in some exceptional circumstances, the doctor could be confronted with a situation of emergency, which generates a conflict between the two values that he should, but cannot, realize at the same time. Nevertheless, we have to emphasize that, in this context, the right to self-determination of the patient is not mentioned: the euthanasia issue is considered essentially as a moral dilemma of the medical doctor. In this way, the basic principle of heteronomy is upheld.
The fundamental disagreement concerning the essence of the human condition: the central role of the heteronomous authority on the one hand, and the emphasis on autonomy and on respect and reserve in front of human suffering on the other hand, explains why a compromise was impossible, unless one of the two groups accepted to become unfaithful to its basic principles. For, whatever nuances there may have been among the opinions of the members of the majority, there was a general agreement that the admission of euthanasia was founded: (a) on the fundamental right of everybody to autonomy: every person has the right to self-determination with regard to his own health and life, especially when confronted with unbearable suffering. (b) In so far as the doctor, in performing euthanasia, expresses his compassion and solidarity with the suffering person, this can be considered an act of high ethical standing. (c) Even those who have a different vision of human life, should, in a pluralistic society, respect the values of the others and let them act according to these values as long as they do not harm others.
Once the latter values are admitted as basic principles, the only problem for the lawmaker is to find a set of rules that take into account the rights implied by them, while ruling out all possible forms of abuse.
The bill in which the majority tried to meet these requirements was approved by the joint Senate commissions of Justice and Social affairs on March 20th 2001 (after having discussed 687 amendments); in the Senate on October 25th 2001 and finally in the Chamber on May 16th 2002 (with 86 votes pro, 51 contra and 10 abstentions). The law came into force on September 23rd 2002.
3. The Belgian law on euthanasia
The essential points of this law are that euthanasia can be performed by a physician (and only by a physician) without committing a crime, when the patient who requests it is of age, legally competent and conscious; when the request is voluntary, well-considered and repeated and the patient is enduring unbearable and consistent physical or psychological suffering as a result of an incurable pathological situation, caused by illness or accident. The patient needs to be informed about his health situation and his life expectancy and the doctor must be convinced of the authenticity of the patient’s request. Another physician should be consulted to verify the elements mentioned above. If possible, the request should also be discussed with the nursing staff and the relatives of the patient.
When the patient is not in a so called ‘terminal’ state, i.e. when it is not expected that he/she will die naturally in the near future, a second doctor should be consulted and at least one month should elapse between the written request of the patient and the act of euthanasia.
Termination of the life of unconscious persons is also possible when the patient has made a ‘living will’ (advance instructions) concerning euthanasia, which is maximally five years old.
After performing euthanasia, the doctor is obliged to report this act to the Federal Commission of Control and Evaluation.
4. Comparison of the Belgian and Dutch laws
Since the ethical discussions – including the publications concerning the relevant facts and figures – preceding the approval of the laws in Belgium and in the Netherlands were similar in many respects, it seems instructive to compare the two laws. (7) In my opinion, the Dutch law is by far the superior one; not only because it is the most ‘liberal’ - a fact which, although undeniable, has been denied repeatedly in the common place political discussion - but also because it is more consistent from the ethical and the legal point of view.
4.1. The first aspect appears clearly from the divergent treatment of children and minors in general. According to the Dutch law, a request for euthanasia can be complied with on an autonomous basis from the age of 16; for people between the ages 12 and 16, the consent of the parents is required. This takes into account that the senseless suffering of minors might be as horrible as that of adults and that the capacity to self-determination is a variable quality, which gains in relevance the more one progresses in age and the more one is confronted with unbearable suffering. In Belgium nothing is possible for minors, although no one has ever given an ethically sound reason for that.
4.2. The superiority from the legal point of view lies in the fact that in the Netherlands the concept (although not the term) of euthanasia is clearly introduced in the penal law. Of course, this is the most honest thing to do: if a society decides that there is an important exception to the general interdiction of killing (apart from the case of legal self-defence), it should be added explicitly as a restriction of the general rule. At the same time, this makes it possible to mention specific penalties for negligent application of the rules. In Belgium, euthanasia is introduced in a separate law with the (less than honest) aim of seeming to uphold the general interdiction and with the undesirable side-effect that every breach of the rule is to be prosecuted as murder.
4.3. Another remarkable distinction between the two laws, which depends on divergent appreciation within the public opinion of the two countries, concerns the so called ‘non terminal’ patients. In the Netherlands, the central issues in the euthanasia discussion have always been the autonomy of the patient and the compassion with his suffering: whether the natural death is close or not does not really matter; neither does the law introduce this distinction. In Belgium, the most fierce opposition to the coalition bill was aimed at the fact that euthanasia would also be possible for the ‘non terminal’ patients. Again, the reason seems to be related to the (Christian) attitude towards self-determination. In the ‘terminal’ case, the death is caused by a ‘heteronomous’ agent, viz. Nature, and the sole effect of euthanasia is to accelerate the process of dying. In the ‘non terminal’ case, the decision lies completely with the patient himself. The opposition to this was so strong that the lawgiver had to introduce the requirements of the advice of another physician and a waiting period of one month.
4.4. A final matter of intense debate in Belgium was the clause that the physician could take into account “unbearable and consistent physical or psychological pain or suffering” (emphasis supplied). The objection, especially in medical circles, was that this proviso would pave the way to the practice of euthanasia in cases of extreme distress or depression without a somatic cause. This, however, was a misinterpretation, since the law lays down explicitly that an incurable pathological situation, caused by illness or accident should be present. Furthermore, when the patient is not in a terminal phase, a third physician (in cases of depression, a psychiatrist) should give advice and it is clear that in most cases of this type he would have to conclude that there is no incurable illness and hence that euthanasia is not permitted.
Why then does the law take ‘psychological suffering’ into account? Because, as soon as an incurable illness is diagnosed, whether such a situation is experienced by the patient as unbearable and hopeless depends also on psychological aspects. The prospect of dragging on a tarnished and humiliating form of life for example, can be experienced as a sufficient reason to ask for a mercy death for a number of persons.
The Dutch law does not mention ‘psychological suffering’, but it is evident from the court decisions and from the reports of the evaluation committees that these aspects of the patient’s experience are fully taken into account. (8)
It is understandable that the Netherlands, where a thoroughgoing discussion of the euthanasia problem started ten years earlier, could bring about a more consistent and well-considered law. In Belgium, there is also the opinion that the actual law has serious shortcomings and that a change is advisable, especially as far as children and minors are concerned. Nevertheless, in spite of its inadequacies, we may hope that even as it is now, the law provides the last expedient to most of those who prefer a self-elected death to unbearable suffering.
- Beantwortung der Frage: was ist Auklärung (1784) Akademie-Ausgabe, VIII, 35.
- Pritchard, James, B. (ed.), Ancient Near Eastern Texts relating to the Old Testament, 1955, Princeton U.P. Princeton, p. 34.
- Bentham, Jeremy, Introduction to the Principles of Morals and Legislation, Chapter 17, footnote.
- Mill, John Stuart, On Liberty, (1860), Fontana Library Edition, pp. 206-207.
- For a good detailed exposition of the history of the euthanasia law in the Netherlands, I refer to a study by Alina Fazal: Death on Demand, which I received trough E-mail: email@example.com.
- Sénat de Belgique, Session de 1999-2000 , Proposition de loi relative à l’euthanasie, déposée par Mr. Hugo Vandenberghe.
- The debate concerning the euthanasia laws in Belgium and the Netherlands was influenced in a significant way by a series of studies concerning the end-of-life decision making and the practice of euthanasia and physician-assisted suicide. These studies were based on a methodology developed by van der Maas et al. and were characterized by their comprehensiveness and by their rigorous method, which guaranteed complete anonymity to the physicians and the patients, and hence reliable significance. Before the study of June 17, 2003, such studies were only available for the Netherlands, the Flemish part of Belgium and part of Australia. It has to be stressed that general statements concerning the frequency of euthanasia in other countries have no sound scientific basis and certainly cannot be used in comparison to the former ones. The most impressive difference between the Dutch and the Flemish results was the following. These studies on euthanasia were undertaken during the period when it was completely forbidden in Belgium, whereas it was admissible in practice in the Netherlands. Nevertheless, the percentages of termination of life by the physician were comparable, with the remarkable exception that termination of life without request by the patient was four times higher in Belgium than in the Netherlands.
The studies I am referring to are the following.
- van der Maas , PJ, van Delden JJM, Pijnenborg L, Looman CWN, “Euthanasia and other medical decisions concerning the end of life.” Lancet 1991; 338: 669-74.
- Van der Maas, PJ, van der Wal, G, Haverkate I. et al. “Euthanasia, physician-assisted suicide, and other medical practices involving the end of life in the Netherlands, 1990-1995.” N Engl. J Med. 1996; 335: 1699-705.
- Deliens L, Mortier F, Bilsen J et al. “End-of-life decisions in medical practice in Flanders, Belgium: a nationwide survey.” Lancet 2000; 356: 1806-11.
- Kuhse H, Singer P, Baume P, Clark M, Rickard M. “End-of-life decisions in Australian medical practice.” Med.J Aust 1997; 166: 191-96.
- Van der Heide A, Deliens L, Faisst K, Nilstun T, Norup M, Paci E, van der Wal G, van der Maas PJ. “End-of-life decision making in six European countries: descriptive study.” Lancet, published online, June 17, 2003.
- The misunderstanding concerning this ‘psychological suffering’ has led some journalists to the conclusion that a great number of cases of euthanasia in the Netherlands are only psychologically motivated. This is totally wrong. In the yearly report of the Evaluation Commission Euthanasia (www.Minbuza.nl/default.asp?CMS_ITEM=MBZ414060 ), we read that for the year 2000, 2123 cases of euthanasia or physician-assisted suicide were reported to the Commission. In 1893 cases, the illness was cancer; in 28, cardiovascular disease; 51 were diseases of the nervous system; 45 lung diseases other than cancer; 10 cases of AIDS and 96 other diseases. There is no indication of euthanasia in cases without illness.