Getting the facts right on Dutch euthanasia

In opposing the legalization of physician-assisted suicide and voluntary euthanasia, Peter Harrell '02 in his April 3 column claims that the example of the Netherlands — so far the only country in the world where both of these practices take place openly and without fear of prosecution — shows that this would be a dangerous course to follow. But none of the evidence that he offers allows him to draw this conclusion.

It is true that a Dutch government-initiated study, the Remmelink Report, has indicated that Dutch physicians have sometimes terminated the lives of their patients without their consent. This was, almost invariably, when the patients were very close to death, and no longer capable of giving consent. In other cases, there had been discussions with the patient in which the patient had expressed a wish to die, but there had not been a formal request. This fact can legitimately give some ground for concern.

What the Dutch report cannot possibly show, however, is that the introduction of voluntary euthanasia has led to abuse. To show this, one would need either two studies of the Netherlands — made some years apart and showing an increase in unjustified killings — or a comparison between the Netherlands and a similar country in which doctors practicing voluntary euthanasia are liable to be prosecuted.

In fact, such studies do exist, but they do not support Peter Harrell's conclusions. First, there has been a more recent update of the original Dutch survey. This second study, carried out five years after the original one, did not show any increase in the amount of non-voluntary euthanasia happening in that country.

In addition, to discover whether there has been more abuse in the Netherlands than in another comparable country, my colleagues and I at the Monash University Centre for Human Bioethics — where I worked before coming to Princeton — conducted a study to discover how many Australian deaths are preceded by medical decisions that are intended to hasten death, or foreseen to be likely to hasten death. Using the same survey questions as the Dutch report, translated into English of course, we asked doctors about decisions involving foregoing medical treatment (for example, withholding antibiotics or withdrawing artificial ventilation) or supplying, prescribing and administering drugs.

Our findings suggest that while the rate of active voluntary euthanasia in Australia was slightly lower than that shown in the most recent Dutch study (1.8 percent as against 2.3 percent), the rates of non-voluntary euthanasia in Australia are significantly higher. Our study thus refutes earlier speculation that the open practice of active voluntary euthanasia in the Netherlands had led to the practice of non-voluntary euthanasia. Our findings also suggest that making euthanasia illegal does not prevent doctors from practicing it.

Thus, there is no evidence to support the claim that laws against physician-assisted suicide or voluntary euthanasia prevent harm to vulnerable people. It is equally possible that legalizing physician-assisted suicide or voluntary euthanasia will bring the issue out into the open, and thus make it easier to scrutinize what is actually happening, and to prevent harm to the vulnerable.

One final comment: Harrell quotes, from the writings of a well-known Dutch opponent of euthanasia, an anecdote about a woman who may have been influenced to end her life prematurely because her doctor suggested to her that her quality of life was not good enough to be worth living. I agree that, if the facts are as described, this is troubling. But what is remarkable about the example is that the woman ended her life simply by deciding not to continue medical treatment. That is, of course, entirely legal in the United States. No doubt there are American patients who have been influenced by their American doctors to cease treatment and die prematurely. But we do not hear about the instances in which this happens in America, because the opponents of euthanasia are concerned to denigrate what is happening in the Netherlands.

Uncertain whom to believe? Then ask yourself this question: How is it that every opinion poll taken in the Netherlands shows overwhelming public support — in most polls, around 80 percent — for voluntary euthanasia? The Dutch are, on the whole, well-educated, caring people with a free press, and they take issues of social reform seriously. (The amount of aid they give to the world's poorest nations, for example, should put Americans to shame.) Is it possible that there could be such strong public support for a system that is widely abused? I do not think so. Peter Singer is the Ira W. Decamp Professor of Bioethics at the University Center for Human Values. He can be reached at psinger@princeton.edu.