166. The history of assisted suicide and voluntary
euthanasia in The Netherlands is very different from that in Oregon.
Though a law legalising these practices has only recently been
passed by the Dutch parliament,
the criminal and supreme courts of the country had since 1973
adjudicated on a number of cases where defendants had invokedusually
successfullythe defence of necessity against a charge of
murder. This defence was explained to us by Mr Jakob Kohnstamm,
of the NVVE, as being
"the situation where you have an ethical or moral dilemma
between, on the one hand, someone's request which you feel is
an honest and honourable request and, on the other, something
which is prohibited by law, [so that] in certain circumstances
you are acquitted. It is not that it is not criminal: it remains
a criminal act, but you will not go to prison for it" (Q 1547).
167. As a result, the 2002 Act was effectively
a codification of existing practices which had been built up on
a basis of case law. According to Dr Rob Jonquiere, also of the
NVVE, this had been "a great advantage of the Dutch situation.
After the legalisation was completed, the practice did not change
greatly". What did change, said Dr Jonquiere, was that assisted
suicide and voluntary euthanasia now became "a legalised
option for doctors and patients, but in terms of the process it
did not change greatly" (Q 1541). The purpose of moving
from case law to statute law, we were told, was to remove the
uncertainties, for doctors and patients, which had surrounded
earlier adjudication of cases brought before the courts.
168. There is a key difference between the 2002
Dutch law and the 1997 law in Oregon: Dutch law permits voluntary
euthanasia as well as assisted suicide. We were told that the
medical profession in Holland makes no moral or ethical distinction
between the two. Dr Johann Legemaate, of the KNMG (Royal Dutch
Medical Association), said that "many doctors prefer euthanasia
for practical and clinical reasons, because when it is assisted
suicide you hand over the medication to the patient and he has
to take it himself. It may have side effects which will lead to
the doctor acting anyway. For that reason most doctors prefer
euthanasia" (Q 1233). This was, he said, notwithstanding
guidelines from the KNMG to the effect that assisted suicide was
preferable to voluntary euthanasia "in the psychological
sense for the doctor and in the sense that it emphasizes a little
more the responsibility of the patient" (Q 1234).
169. Euthanasia is defined in The Netherlands
in a highly specific way. In Dutch law, the term "euthanasia"
includes also what we term in this report "assisted suicide".
On the other hand, it specifically excludes the ending of a person's
life without his or her request. In other words, the Dutch do
not recognize the existence of involuntary as well as voluntary
euthanasia: while the latter is now permissible in law, the former
is regarded as murder
(Q 1247). The Dutch definition of euthanasia also excludes
specifically the withholding or withdrawal of treatment, whether
or not at the patient's request, and the administration of pain
relief by a physician with the possible side-effectbut
not the intentionof hastening death. In this respect the
Dutch definition mirrors that which obtains in the United Kingdom.
170. The 2002 law is not limited to adults. Nor
does an applicant for euthanasia have to be terminally ill. As
Dr Legemaate put it, "the main basis is hopeless and unbearable
suffering; it has nothing to do with your life expectancy".
He added however that "in actual practice I think that our
law is very close to your Assisted Dying Bill, in the sense that
95% or 98% of the cases
are patients within the last days
or weeks of their life
But we do not exclude the rather
exceptional situations in which, for instance, somebody who is
55 and has a very severe but incurable mental illnesswhich
relates to a situation of hopeless and unbearable sufferingasks
for assisted suicide. We have had these cases every now and then.
Not many, but they are not excluded" (Q 1285).
171. Approximately 16 million people live in
The Netherlands, of who around 140,000 die every year. We were
told that some 9,700 requests for euthanasia are made annually.
About 3,800 of these actually receive euthanasia, of which some
300 are assisted suicides. Euthanasia therefore accounts for
around 2.5% and assisted suicide 0.2% of all deaths in
The Netherlands. In addition to these, there are about 1,000 deaths
a year (0.7% of all deaths) where physicians end a patient's life
without an explicit request.
172. Under subsection 2 of the 2002 Act a Dutch
physician who carries out euthanasia is exempt from prosecution
if he fulfils a number of specified criteria of "due care"
and notifies the coroner. There are six such criteria. The patient
must have made a voluntary and well-considered request to die;
his suffering must be lasting and unbearable; he must have been
informed about his medical condition and prognosis; both the doctor
and the patient must be satisfied that there is no other reasonable
solution to the situation; the doctor must consult at least one
other (and independent) physician, who must visit the patient
and give his written opinion of whether the requirements of due
care have been met; and, finally, the doctor must terminate the
patient's life with due medical care. The "second opinion"
is now increasingly provided by a team of SCEN (Support Consultation
Euthanasia Network) doctors. We examine this system in more detail
173. Once the patient has died, it is the doctor's
responsibility to report the death to the coroner and to complete
a report. The coroner visits the place of death, performs an external
medical examination of the patient and notifies the public prosecutor
and the civil registrar.
He then compiles his own report, noting the cause of death, and
forwards this, together with the doctor's report and, if necessary,
the patient's medical notes, to one of five regional assessment
174. The committees were set up under the 2002
law. We were able to discuss their operation with the committee
covering The Hague. Its chairman, Mr Jan Suyver, told us
that "the committees investigate each reported case and assess
whether or not the criteria are met with. It is black or white,
not grey. However, in its written explanation on its judgement
the committee is entitled to mention all the relevant circumstances
If the committee finds all the criteria fulfilled,
then the case is overend of the story. There are no further
investigations, no prosecution. If not, the committee must also
notify the public prosecution service and the health inspectorate.
The committees do not give advice on whether or not to prosecute
or to bring the case before a disciplinary tribunal. Those are
the exclusive decision powers of the prosecution service and the
health inspectorate" (Q 1439). The committees do not
have a role in monitoring euthanasia practices. Dr Gerrit Kimsma,
the physician member of the committee, told us that they "have
data on the variety in numbers [of euthanasias performed] between
physicians, but we do not keep track" (Q 1455). There
is thus no routine procedure which would show whether some physicians
are performing significantly more euthanasias than others, though
it would be possible, we were told, to "put it a query"
and extract this information (Q 1457).
175. The role of the regional committees is therefore
to assess whether the "due care" requirements have been
met. In doing so, we were told by Dr Kimsma, "we must be
sure there has been no manipulation, no pressure or undue influence,
and that the request is well considered. It must have been expressed
and dealt with several times, sometimes years before the actual
date of the euthanasia or assisted suicide. The wishes preferably
must be supported in writing. This is not exactly a legal condition,
but it certainly helps and makes the assessment simpler. The assessment
of unbearable suffering without the prospect of improvement is
one of the difficult issues of the committee's assessment. What
does "unbearable" mean? It has a very subjective patient-related
side, but it must always be a joint conclusion. In order for a
physician to come to the conclusion that euthanasia is an option,
there should be a joint, shared process of decision-making, where
the physician also has to be very much in conformity with the
wishes of the patient" (Q 1441). Commenting on the SCEN
system for obtaining second opinions, Dr Kimsma said: "It
is now legally possible that a physician without any training
can do a consultation, but what we see in the committee is that
those consultations on paper are inferior. The consultations of
the SCEN, the specifically trained physicians, are much more adequate
and much superior" (Q 1441). Dr Kimsma added that "there
is an absolute condition that [euthanasia] can only be done by
the treating physician. It cannot be any other physician. We do
not want to advertise 'euthanasia tourism'. What we insist on
is that it only takes place within a meaningful medical relationship.
That is an absolute condition" (Q 1441).
176. We have referred above to the SCEN project,
under which doctors can receive training in the operation of the
law and in the problems with which general practitioners can be
faced when a patient requests euthanasia and can volunteer to
be available to provide second-opinion consultations in specific
cases as they arise. According to Dr Legemaate, SCEN "aimed
at professionalising the independent consulting physician".
Dr Tjomme de Graas, a nursing home physician who is also a palliative
care specialist and a SCEN doctor, told us that "SCEN physicians
are a special breed, with special training for a very delicate
task". There were, he said, three reasons for the launching
of the project. The first was to give doctors confronted with
a euthanasia request the opportunity to make contact with an independent
and experienced colleague who could provide medical and emotional
support to the doctor's thought processes. "Because of our
training we can, with the physician, draw the complete context
of the request for euthanasia, hopefully also to clarify some
aspects that may be overlooked in such stressful and extraordinary
situations" (Q 1712). The second was to carry out a
second-opinion consultation, as required by the law; and the third
was to provide encouragement to doctors who carry out euthanasia
to report their actions. "Because of our training,"
said Dr de Graas, "and also because of our experience and
the countrywide availability of SCEN physicians, this guarantees
a uniform and independent view and
control of the procedure"
177. This view of the SCEN project was echoed
by others. Dr van Coevorden, a GP and SCEN physician, believed
that SCEN had the advantage of "not only checking if things
are going exactly according to the law but also being of personal
assistance to a doctor who may have problems during this process"
(Q 1349). Dr Maria van den Muijsenburgh, a GP and palliative
care specialist, felt that SCEN provided helpful "backing
against pressure" on doctors from relatives (QQ 1482-3).
The project, said Dr Legemaate, had so far been focused on GPs,
because that is where most requests for euthanasia are both made
and carried out; but it is now being extended to physicians in
hospitals and nursing homes. In a year or two there would be "100
per cent coverage of all euthanasia situations in this country"
178. Having set the Dutch scene, we turn now
to consider some of the specific issues which we found. The first
is the disclosure that there are around 1,000 instances
every year in The Netherlands of a patient's life being ended
by a doctor without an explicit request. (See Paragraph
171). Dr Legemaate's written evidence on behalf of KNMG stated
that "this happens mostly with patients suffering from cancer
in the last days or hours of their life".
Dr van Coevorden, on the other hand, told us (Q 1310)
that "it involves ending life without request, but it is
outside the scope of this discussion because it involves newborn
children, with defects and so on"; and this view was echoed
by Mr Jacob Kohnstamm, Chairman of NVVE, who said "they are,
for example, in neonatology, severely handicapped new-born babiesproblems
that are mainly in the medical sphere" (Q 1607). However,
we received yet another account from Ms Irene Keizer, a Senior
Policy Officer of the Dutch Ministry of Health, Welfare and Sport.
"There are some cases," she told us, "in which
it is not careful euthanasia, but in most cases are people who
are not able to make a request because they are not seen as able
to make a requestfor instance, people who are suffering
from a psychiatric disease or people who are in a coma. Also newborn
babies are not capable of making a request" (Q 1420).
When asked what proportions of the total might consist of people
in these various categories, Ms Keizer thought that about half
of them were people not capable of making a request (e.g. they
were in a coma), "25% are people who could have made a request
but did not (so we are wondering about those), 15% are newborn
babies, and 10% are other categories" (Q 1422).
179. Yet another perspective was given to us
by Professor Gerrit van der Wal, Head of the Department of Public
Health at the EMGO Institute in Amsterdam. "Roughly speaking,"
said Professor van der Wal, "in about half of all those cases
there has been some kind of discussion before the patient became
but not an explicit request for euthanasia.
Almost all patientsin our last study 100% of all patientswere
incompetent at the moment of decision
It is about patients
who are mostly very ill, dying and seen to be suffering very much,
by vomiting their stools, having very bad bedsores, severe dyspnoea
and suchlike. As we also know from qualitative studies, doctors
feel that they have their back against the wall; that the family
and nurses are asking him or her to end this suffering and this
unbearable state of life; and then they decide to hasten the end
of life. Whether or not this is very explicit is not that clear.
For example, we found that the drugs used in these kinds of cases
are mostly opioids, as used for intense pain and symptom treatment,
and not neuromuscular relaxants as used in euthanasia. We are
neutral researchers, but we do not like these cases
that they would decrease in number, but it has not happened"
(Q 1699). Professor van der Wal said that, "so far as
we can see, there is no association between the development in
jurisprudence and law and life-ending cases without a request"
180. The second issue which we addressed with
several of our witnesses is the rate of reporting by doctors to
the authorities of euthanasias which they have carried out. We
will not examine here in detail the somewhat complex methodology
by which the latest figure (54% of all euthanasias being reported
to the authorities) is arrived at. The questions on which we have
focused are: how reliable is the quoted 54% reporting rate? And
why do doctors not report?
181. Dr Agnes van der Heide, a senior researcher
at the Erasmus Institute, Rotterdam, believed that the wording
of the research questionnaire which was sent to doctors was insufficiently
precise and that this had resulted in an inadvertent over-stating
of the number of euthanasia cases. "We asked physicians,"
she said, "the following question: Did you provide in this
case a drug with the explicit aim of hastening the patient's death?
And, if you did so, did you do this at the explicit request of
the patient? If both questions were answered positively with 'Yes',
then we classify this case as a case of euthanasia. This is meant
to be an objective classification scheme for euthanasia, but at
the same time it means that our definition is not always similar
to the physician's definition. When the physician answers both
questions 'Yes', it is not that in all cases the physician himself
defines the case as one of euthanasia" (Q 1630). Dr
Jon Bos, a surgical oncologist, believed that, if such misunderstandings
were removed, the reporting rate might rise to around 85%. On
this basis, though Dr Bos did not adduce any hard evidence to
support his 85% figure, some 600 instances of actual euthanasia
might go unreported in The Netherlands annually.
182. We were unclear why, given that one of the
conditions of immunity from prosecution under the 2002 law is
that cases of euthanasia are reported, some doctors did not do
so. Dr Bregje Onwuteaka-Philipsen, an Associate Professor at the
Free University of Amsterdam, believed there were three reasons.
"There are people who still do not want the administrative
bother of it, or the idea that you report it. There are people
who think that you should not report it, either because they feel
that it is not really euthanasia or because it is something between
the doctor and the patient. It is also possible that there are
people who perhaps doubt whether the case would go through easilywhether
they have exactly fulfilled all the requirements" (Q 1626).
Others gave a similar picturesee for example QQ 1337, 1409,
1434 and 1462. Dr Bos felt that, if his 15% figure of unreported
cases were valid, "those 15% may be the doctors who are afraid
to report because they fear prosecution or whatever
the rules may prevent you from helping your patient; going by
the rules might sometimes mean letting the patient down. That
could also be the case in some of those 15%" (Q 1337).
183. The third issue which we examined during
our visit to The Netherlands was the state of palliative care
in that country and its relationship, if any, with euthanasia.
We were told that there had been a substantial investment in palliative
care, as a result of which palliative care departments and regional
specialist teams had been created throughout the country; and
that more resources were being devoted to raising palliative care
standards in nursing homes and care homes (Q 1362). "The
underlying principles of the policy," said Dr Cilie Alberda
of the Ministry of Health, Welfare and Sport, "are integration
in a regular health care system, improving access to and availability
of palliative care. The approach is generalist
that all GPs and nurses must have been trained to give palliative
care" (Q 1362). What this means is that palliative care
is not recognized in The Netherlands as a clinical speciality.
Dr Alberda said that this generalist-only approach was adopted
because most people in Holland die at home: there were specialists
in the regional consultation teams, from whom GPs and nurses could,
if necessary, obtain advice (QQ 1367-69). According to Dr Ben
Zylicz, a hospice medical director, the result was that hospitals
in general were "totally devoid of input from palliative
care specialists" (Q 1515).
184. Dr van Coevorden felt that there had been
"an enormous boom" in the past few years in palliative
care training and in hospice care, which he felt had been stimulated
by the law on euthanasia (Q 1304). Accepting that palliative
care had been at a low level, he believed that in the last five
years it had come up to a very high level (Q 1305). Dr Zylicz
told us that "many GPs now, knowing the basics of palliative
care, can better resist the pressure from the family if they can
offer something instead of euthanasia. We have also seen the number
of euthanasia requests in hospices really decrease in the last
years" (Q 1484). Patients entering hospices who request
euthanasia were increasingly withdrawing those requests when palliative
care was provided (Q 1510). On the other hand, said Professor
Henk Jochemsen, a medical ethicist, the number of euthanasia requests
in the population at large was not decreasing (Q 1510).
185. Having said that palliative care in Holland
had come up to a high level, Dr van Corvoerden also
told us, when explaining later in his evidence why people in The
Netherlands asked for euthanasia, that "84% of them have
pain; 70% have extreme fatigue; 50% have gastrointestinal complaints
and loss of weight; 70% have coughing, dyspnoea or suffocation;
almost 70% feel extremely weak. Each of these symptoms or combination
of symptoms may lead to a situation that, for these patients,
is unbearable suffering and unacceptable, and that is basically
the reason why they ask their GP to have their life ended"
(Q 1325). Dr van den Muijsenburgh and Dr Zylicz also told
us that, whereas there had been an increase in funding in the
late 1990s to accompany discussion in parliament of euthanasia
legislation, that funding had now ceased (Q 1491). And Professor
Jochemsen suggested that the funding which had taken place had
not produced a growth in the quality (as distinct from the quantity)
of palliative care. "Since there was a lot of money at the
end of the 1990s and the beginning of the century," he said,
"many institutions which were providing nursing care in general
were opening palliative care units, because they got more money
for the patients. The number of palliative care units has therefore
increased considerably, but these people are mostly just continuing
what they were doingin the sense that there is no real
specialist understanding, knowledge and practice of palliative
So the number of places where palliative care is offered
does not say very much about the quality of palliative care in
general in The Netherlands" (Q 1536).
186. During our visit to The Netherlands we visited
Sint Jacob's Hospice in Amsterdam. This is a nursing home and
a home for the elderly, in which 450 people are currently living.
It has wards for medical and psycho-geriatric care and for rehabilitation,
plus a stroke unit; and five years ago it opened a palliative
care unit (Q 1711). Effectively, therefore, St Jacob's provides
a hospice facility within a broader establishment for care of
187. Though St Jacob's has grown out of a religious
foundation, it has not set its face against euthanasia. We were
told however that, though the question of euthanasia has been
raised on a number of occasions within the hospice, it has only
taken place on one occasion in the last five years (Q 1711).
The reason given for this was that the quality of palliative care
in nursing homes was now "at a very reasonable level"
(Q 1728) and, perhaps more important, that there was a difference
in character between those who died in nursing homes and those
who died at home. According to Dr Roeli Dijkman, President of
the Dutch Society of Nursing Home Physicians, "patients who
suffer from terminal illnesses make the request for euthanasia
before they go to the nursing home. In principle, the patients
who ask for euthanasia have a vision of dying and losing their
dignity" (Q 1742). He told us also that "when you
have a terminal illness at home and you do not want to die by
fading away, with palliative care, you decide to have euthanasia
at home. Most euthanasias are by general practitioners" (Q 1728).
Dr Dijkman's view is consistent with what we were told by Dr Onwuteaka-Philipsen
(Q 1668)that, while euthanasia accounts for some 2.7%
of deaths overall in The Netherlands, it accounts for 5% of deaths
under the age of 65, 3.3% of deaths between the ages of 65 and
79 and 1.4% of deaths over the age of 80.
188. We were shown an example of a "euthanasia
statement" which the NVVE offered to its members.
The object of such statements is to help people who so wish to
state in advance that they would not wish to continue to live
if at a future date they should find themselves in specified conditions.
As such, these statements could be said to have similar objectives
to what we would term "advance directives" in regard
to such matters as resuscitation. The example of the statement
which we were shown requests a physician, if the signatory should
be in a state of "unbearable suffering" and/or "a
condition which provides little or no prospect of a return to
what is for me a reasonable and dignified existence," "to
fulfil my death wish by allowing me to take substances under his
or her supervisionor, if I am no longer able to do so,
to administer to me substancesthat will bring about a mild
death". The statement lists a number of conditions, which
signatories are invited to tick as they regard appropriate and
which might be included under the headings of "unbearable
suffering" or "reasonable and dignified existence".
These include, in addition to such states as "a life with
serious, permanent paralysis", other conditions such as "being
blind or virtually blind and/or deaf and/or virtually deaf which
make it impossible or virtually impossible for me to perform what
are for me worthwhile activities such as reading, writing, watching
television, listening to music and doing manual work or handicrafts"
and "having a severe impairment or continuing degeneration
of my mental faculties, as a result of which I
must be confined
because I would otherwise go wandering".
189. Commenting on the statements, Dr Jonquiere
of NVVE said that "we try to help our members to formulate
what in their view is unbearable. The identification of what is
unbearable is for the patient. They are the person who says 'This
suffering, for me, is unbearable'. This helps them to formulate
what is unbearable. But 'unbearable' alone is not sufficient to
come to the conclusion that euthanasia is the solution. There
you need medical expertise in terms of the hopelessness of the
suffering. It is those two peoplethe doctor and the patientwho
come together, to compare and discuss, deal and wheelwhatever
you may call itabout the unbearability and hopelessness"
(Q 1557). Dr Jonquiere made clear to us that the presence
of such a statement does not mean that euthanasia will follow
automatically if any of the specified conditions should develop;
it is simply a request, and the physician must satisfy himself
that there is "unbearable suffering" also (Q 1566).
Asked about what might happen in the event of a signatory becoming
unconscious as well as having reached one of the specified conditions,
he replied that, "when a patient is unconscious, it is something
which in practice is presently considered not to be compatible
with suffering, and so not a reason for euthanasia" (Q 1558).
190. Finally, we sought to form a view of how
legalised euthanasia is regarded by Dutch doctors and Dutch society
as a whole. Ms Keizer of the Ministry of Health, Welfare and Sport
said that "we have asked doctors what they think about the
law and whether they think that it is an improvement. They think
that the procedure improved after the law came into force. The
review committees are working fast and are giving clear judgements.
Doctors also expect that there will be more transparency and that
the willingness to report will improve" (Q 1396). Dr
Legemaate, for the KNMG, told us that, "a large part of the
medical profession finds it acceptable that there is, in our society,
the possibility of euthanasia. 20% to 25%... are opposed, mostly
for religious reasons and also on some non-religious reasonsfor
instance that it is not compatible with their medical oath or
the medical profession" (Q 1237). For society as a whole,
according to Dr Legemaate, "there has been a kind of increasing
acceptance of doing euthanasia, which I think incorporates a certain
change of opinion about the moral aspects and how you balance
that" (Q 1250). And Dr Onwuteaka-Philipsen told us that
opinion polls suggested that "92% think that it is good that
a doctor will no longer be prosecuted for euthanasia, if all the
requirements are met. 91% think there should be control on euthanasia"
191. On the other hand, Dr van den Muijsenburgh
reported that in research which she herself had carried out, while
doctors were willing and capable of administering intense and
very personal palliative care that met the needs of their patients,
there was a considerable variation among physicians in regard
to the incidence of euthanasia. While most doctors, she said,
were supportive of their patients, "there were
who were very willing to commit euthanasiadoctors who themselves
thought 'Suffering is useless'and more than half of their
patients die by euthanasia" (Q 1537). And Dr Zylicz
cautioned against acceptance at face value of opinion polls which
suggested that there was a high level of public support for euthanasia.
The result, he felt, depended on the question which was asked
(Q 1502). Dr Zylicz agreed, however, with the statement that
there had been no slippery slope and that some patients, whose
physical symptoms appeared in the eyes of their doctors to be
properly controlled, persisted with requests for euthanasia (Q 1508).
192. The legal position of assisted suicide and
voluntary euthanasia is different in Switzerland from that which
obtains in both Oregon and The Netherlands, though it is closer
to the former than to the latter. Article 114 of the Swiss Penal
Code makes the killing of a human being "upon the latter's
earnest and urgent request" a criminal offence punishable
by imprisonment. Voluntary euthanasia is therefore illegal. Article
115, however, prohibits incitement to and assistance with suicide
if the guilty party acts from self-serving ends but exempts those
who act from entirely honourable motives, such as assisting suicide
in order to help bring an end to suffering. The situation in Switzerland
differs also from the position in Oregon and The Netherlands in
that assistance with suicide is not regarded as the exclusive
province of doctors. Anyone may legally give such assistance from
non-selfish motives. Where lethal medication is required, a doctor's
prescription is needed for this to be obtained, though this requirement
exists in order to ensure control of dangerous drugs and not because
of a view that assistance with suicide is a function of medicine.
193. Another difference in the Swiss situation
is the involvement of voluntary organisations. There are three
main organisations in Switzerland involved in assisting people
with suicideEXIT, which has a membership of some 50,000
and which caters for the German- and Italian-speaking regions
of the country; AMD, a parallel (and smaller) body dealing with
the French-speaking areas; and DIGNITAS, a recently-founded break-away
group from EXIT with a membership of some 4,500, which provides
assistance with suicide to foreign nationals travelling to Switzerland
for the purpose as well as to Swiss citizens. The active help
which these organisations provide to applicants, including medical
examinations and facilities for suicide to take place, is a distinguishing
feature of assisted suicide in Switzerland.
194. Switzerland is a highly federal country,
with day-to-day government and administration devolved to the
cantons. The laws governing assisted suicide and voluntary euthanasia,
however, are federal in nature and apply to Switzerland as a whole,
though their application is a cantonal responsibility. These laws,
which were written in 1937 and introduced in 1942, were not enacted
specifically with terminally ill people in mind but were rather
a codification of the legal systems which had existed previously
in the cantons. The application of assisted suicide as means of
dealing with the suffering of terminally ill people was a dimension
which, we were told, emerged in the 1980s.
195. The Swiss Penal Code does not regulate assistance
with suicide otherwise than to prescribe that such action should
not be self-serving. We were told by the Federal Ministry of Justice
that the definition of "self-serving ends" in assisting
suicide had been clarified by successive tribunals and included
such situations as that of a person who gave such assistance "to
satisfy his own material or emotional needs
of eliminating some major problem for the family, or other motives
such as gaining an inheritance, relieving himself of the burden
of supporting the individual
or eliminating a person he
hated" (Q 2135).
196. The Swiss authorities appear to have concerns
about some aspects of the present law, in particular regarding
assistance with suicide being given to foreigners coming to Switzerland
for the purposefor the Swiss Penal Code, unlike its counterparts
in Oregon and The Netherlands, does not restrict legal assistance
with suicide to persons living in Switzerland. Dr Andreas Brunner,
Attorney-General of the Canton of Zurich, was concerned about
situations where "a person comes today and dies the same
day" (Q 2269), since this inevitably precluded the building-up
of a proper relationship between a terminally ill person who is
assisted to take his or her own life and the doctor who assesses
the case. There have been a number of proposals put forward in
the Swiss Parliament to combat such "death tourism"
(Q 2127); and, though each of these has so far been either
rejected or abandoned, we were told by Mr Bernardo Stadelmann
of the Federal Ministry of Justice that the Swiss authorities
were aware of the problem and that the Government was trying "to
ascertain whether there is a danger of the situation in Switzerland
being exploited and, if so, [it would] take appropriate steps
to remedy the situation" (Q 2127).
197. Because the Swiss Penal Code does not link
assisted suicide specifically with terminal illness or suffering
as the result of ill health, it does not specify any medical conditions
under which assistance with suicide may be given: it requires
simply that the motivation of the person giving assistance shall
not stem from self-serving motives. However, the Swiss Academy
of Medical Sciences (SAMS) has drawn up a set of medical ethical
principles governing end-of-life care, as part of which guidelines
have been established for use in situations in which doctors may
be asked to assist a patient to end his or her life. The SAMS
guidelines prescribe that "physician-assisted suicide is
not part of medical practice" (Q 2178). They go on to
state that, while a doctor's primary role is to alleviate symptoms
and to support the patient, there may be situations in which the
patient asks for help in committing suicide and persists with
this wish. In this dilemma, between established medical practice
and support for his patient's wishes, the doctor may either refuse
to comply with the patient's request or accede to the request
provided that he is satisfied that three conditions have been
metthat the patient's state of health makes it clear that
he or she is nearing the end of life; that alternative possibilities
have been discussed and, if desired by the patient, implemented;
and that the patient who requests help to end his or her life
is capable, free from external pressure and has thought through
his or her decision. The Academy recommends also that, in such
situations, a third person should verify that the third condition
has been met.
198. In fact, the majority of assisted suicides
which take place in Switzerland are not directly supervised by
doctors. Most people who are assisted to commit suicide are members
of one or another of the country's "suicide organisations".
The development of these organisations was explained to us by
Dr Brunner. He told us that, "when the law was made, we did
not have any suicide organisations
In the late 1980s the
first suicide organisation was established. That was EXIT
Now we have five or six organisations and some splinter organisations
too. Then, in about 2000, suicides of people from England started"
199. The increase in the number of suicide organisations
seems to be matched by an increase in the number of assisted suicides
in Switzerland. According to Mr Stadelmann, up to 1993 EXIT assisted
about 30 cases a year. "Since 1993 we know that there have
been about 100 cases a year" (Q 2128). The figures for
DIGNITAS, he said, followed a similar trend. "They declared
three cases in 2000, 37 or 38 cases in 2001, about 55 cases in
and 91 cases in 2003" (Q 2128).
200. Because the role of suicide organisations
is such a unique feature of assisted suicide in Switzerland, we
took evidence from two of themEXIT and DIGNITASduring
our visit to the country. These two organisations have quite different
internal structures. EXIT is managed by an annually-elected board
of five people, who are supported by an ethics commission (which
considers the handling of difficult cases) and a compliance commission
(which ensures that the association's rules are followed). DIGNITAS
on the other hand is a much smaller body, controlled by a two-man
board and with a doctor and lawyer to give supporting advice.
201. The team of witnesses whom we met from EXIT
emphasised that they took their work conscientiously. According
to Dr Klaus Hotz, EXIT operates "conditions for assisted
suicide [which] are much higher than the penal law
firstly have a poor medical prognosis, unbearable pain or substantial
impairment. The full discretion of the person committing suicide
is the second part" (Q 2401). There is, however, no
requirement on the part of EXIT that the patient will otherwise
die a natural death within a specific time frame. "For us,"
said Dr Hotz, "the autonomy of the person is in a way our
first point of view. We are rather liberal on this medical prognosis"
(Q 2404). And, according to Dr Giancarlo Zucco, there has
been "a change of philosophy because in the beginning EXIT
was only prepared to assist people who were terminally ill or
had very strong pains or were disabled, for instance
it has been decided that we would also assist elderly people who
simply decide that they do not see any meaning in their life any
more". (Q 2428)
202. If the existence of organisations which
give assistance with suicide is an unusual feature of the Swiss
scene, DIGNITAS represents an unusual feature within these organisations
by offering assistance with suicide for foreign nationals travelling
to Switzerland for the purpose. DIGNITAS has members in 52 countries,
of which United Kingdom membership (approximately 560 people)
is second only to German. To join, members must pay a registration
fee of 100 Swiss francs and a minimum annual subscription of 50
Swiss francs. Members may, in addition to supporting the aims
of the organisation, apply for assistance with suicide for themselves.
Since December 2004 DIGNITAS has levied a fee in such cases of
1000 Swiss francs to cover the preparations necessary for an assisted
suicide and a further fee of 1000 francs for arranging burial,
if the organisation is asked to do that.
203. A member who wishes for help with ending
his or her life must request this in writing from DIGNITAS and
send the organisation a copy of his or her medical records. These
latter are considered by one of the doctors associated with DIGNITAS
who, if he believes that the applicant's circumstances would enable
him to write a prescription for lethal medication and on the understanding
that he will be able at some point to assess him or her in person,
agrees to the applicant being given a "provisional green
light" (Q 2326). We were told by Mr Ludwig Minelli,
Director General of DIGNITAS, that "about 80% of the members
who have got the provisional green light never call again"
but that, for those who persist with their requests, the organisation
prefers that they come twice to Switzerland, once to see the physician
and again to receive assistance with ending their lives. (Q 2326).
He added, however, that in many casesfor example, where
applicants were seriously ill or severely disabledit was
not possible to insist on two visits and one visit, for confirmation
of the Swiss doctor's assessment, was considered sufficient (Q 2326).
204. On arrival for the final or only visit,
an applicant is met at the airport or railway station by a representative
of DIGNITAS and taken to an apartment in Zurich which the organisation
rents for the purpose. The DIGNITAS representative remains with
the applicant throughout the visit, to ensure that his or her
needs are met (including, if there has been no prior visit, a
consultation with a doctor to confirm that the application meets
the required criteria for assisted suicide), to oversee the necessary
preparations (including the mixing of the lethal medication in
a glass of water) and to make clear to the applicant that he or
she is free at any time to discontinue the process. If the applicant
wishes to go ahead, the medication is placed within his or her
reach. When it has been ingested and death has occurred, the death
is reported to the authorities. The DIGNITAS representative receives
a fee for his or her services of 500 Swiss francs.
205. The Swiss Penal Code very clearly states
that direct, active euthanasia is illegal. In practice this means
that the final act has to be taken by the patient. According to
Dr Zucco of EXIT, "we prepare the solution that the patient
has to drink and we put it on the table and he or she is supposed
to take it into his or her hands. This is the normal way"
(Q 2413). However, there are cases where, because of a disability,
the patient is unable to perform this action. In these situations
the medication is intravenously infused. This means that the patient's
final act is an extremely small part of the processfor
example, in some cases "there is a small wheel that they
have to push" (Q 2417). In the past some concern has
been raised about these situations by the authorities. They felt
that, as an infusion required more preparation, the patient might
be less likely to decide not to proceed. However, according to
Dr Zucco, "now it has been accepted because what we do is
keep asking until the last second, 'Do you really want it?'. We
try to make it easy for the patient to say no" (Q 2421).
In these cases, Dr Hotz told us, the organisations are careful
to make sure that they could not be accused of breaking the law:
"we try in these cases to have two people, that the assistant
from EXIT has a witness, and there have also been cases where
a video has been made to prove afterwards that the person opened
the valve, which is of course a delicate action" (Q 2419).
206. We found at DIGNITAS a similar trend to
that at EXIT for making assistance with suicide more widely available.
Mr Minelli told us that he would like to be able to help mentally
ill people to commit suicide. "Until now," he said,
"we have been very reluctant to have mentally ill people
because there is one procedure in the Canton of Aargau where this
question has been raised. We had last week a hearing at the court
If the decision is favourable, then I think we will have more
possibilities to help mentally ill people" (Q 2371).
207. As indicated above, there are concerns in
Switzerland about the activities of these organisations. Dr Christoph
Rehmann-Sutter, President of the National Advisory Commission
on Biomedical Ethics, referred to "the impossibility of the
state having legal oversight of the practice of the organisations"
(Q 2183). He felt that perhaps they "do not put enough
weight on the lengthy process of evaluation and assessment of
the person or on giving support to the person to make him or her
change their mind" (Q 2183). Dr Brunner believed that
the suicide organisations should be more tightly regulated by
the authorities. At present, he said, "there is no surveillance;
they are associations without any state control. I think that
should change" (Q 2290).
208. In Dr Brunner's opinion a number of additional
duties should be placed on the organisations to allow the authorities
to regulate them more effectively. For example, while the organisations
already publish annual reports of their activities, Dr Brunner
felt that they should be legally required to disclose all their
accounts as well, thereby making it easier for the authorities
to satisfy themselves that no financial profit was being derived
from assistance with suicide (a key consideration given the insistence
of Swiss law on non-self-serving motives). He felt also that it
was important to ensure that the organisations were staffed by
"a good approved selection of people
is a danger from so-called angels of death" (Q 2263).
209. The Belgian Act on Euthanasia was passed
on 28 May 2002. It defines euthanasia as "intentionally terminating
life by someone other than the person concerned at the latter's
such, it is similar to the Dutch definition and equates to what
we have referred to in our report as voluntary euthanasia, though
to avoid confusion in this section we use the Belgian terminology.
210. The Act differs from similar laws in Oregon,
The Netherlands and Switzerland in that it legalises only euthanasia,
not assistance with suicide. The conditions laid down include
that the patient should have attained the age of majority, that
the request should be "voluntary, well-considered and repeated"
and that the patient should be "in a futile medical condition
of constant and unbearable physical or mental suffering that cannot
The Act requires the assessing doctor to satisfy himself of, inter
alia, "the durable nature" of the patient's request
for euthanasia. "To this end," it prescribes, "the
physician has several conversations with the patient spread out
over a reasonable period of time".
The doctor must obtain a second medical opinion and, if the request
satisfies all the criteria laid down, must "allow at least
a month between the patient's written request and the act of euthanasia".
211. Acts of euthanasia must be reported to the
authorities. The documentation for each case is reviewed by a
Federal Control and Evaluation Commission (FCEC), which either
confirms the physician's immunity from prosecution (on the grounds
that the paperwork submitted indicates compliance with the law)
or refers the case to the public prosecutor.
212. The first report of the FCEC, covering the
15-month period from 23 September 2002 to 31 December 2003 recorded
259 cases of euthanasia, an average of 17 cases per month. More
than 80% of these acts of euthanasia took place in Dutch-speaking
Flanders (where some 60% of the population lives) and less than
20% in French-speaking Wallonia (where about 40% of the population
lives). The 259 cases were reported by 143 different physicians.
In 2004, 347 cases of euthanasia were reported, an average of
29 cases per month. The Commission's first report did not report
any instances of non-compliance with the law and did not see a
need for new legislative initiatives.
213. The Act provides for patients requesting
euthanasia to be made aware of the option of palliative care,
though this is not seen as a filteri.e. a process through
which applicants must go in order to see to what extent their
needs can be met through good quality palliative care before deciding
to have their lives ended. Legislation on palliative care was
introduced at the same time as the euthanasia law, though it is
written in more general terms prescribing that every Belgian should
have access to proper palliative care. According to the FCEC's
first report, in 101 of the 259 reported cases of euthanasia (40%)
in 2002/3 palliative care teams were consulted by attending physicians.
214. We would like to record our sincere thanks
both to the British Embassy staff in Seattle (for the visit to
Oregon), The Hague and Berne who put considerable efforts into
arranging visit programmes for us and briefing us on the demographic
and cultural contexts of the countries we were visiting and to
the organisations and individual witnesses in these places who
took the time and trouble to meet us and to give oral evidence
to support our inquiry.
53 Equivalent to the United Kingdom Department of Health Back
Equivalent to the United Kingdom General Medical Council Back
Equivalent to the British Medical Association Back
The Termination of Life on Request and Assisted Suicide (Review
Procedures) Act 2002 Back
The Dutch equivalent of the United Kingdom Voluntary Euthanasia
For these reasons, when discussing the situation in The Netherlands
we use hereafter the term 'euthanasia' to mean voluntary euthanasia
only and to include assisted suicide as well as action taken by
a doctor directly to end a patients life. Back
See Volume II: Evidence, HL Paper 86-II, Page 393 Back
Equivalent to the United Kingdom Registrar of Births, Marriages
and Deaths Back
Equivalent of the United Kingdom General Medical Council Back
See Volume II: Evidence, HL Paper 86-II, Page 393 Back
See Appendix 6 Back
The Act, Section 2 Back
Section 3 Back
Section 3.2.2 Back
Section 3.3.2 Back