[Dutch Euthanasia #2] Details of the process from application to completion based on the contents of the Dutch Euthanasia Bill, and safeguards to avoid the risk of coercion
- リップディー（RiP:D)
- Nov 21
- 10 min read
[Details of the process from application to completion based on the contents of the Dutch Euthanasia Bill, and safeguards to avoid the risk of coercion]
This paper focuses on the euthanasia law in the Netherlands.
・"The specific process from requesting euthanasia to its completion"
- "Safety measures in place to prevent harm to patients"
--I will explain this while focusing on the above two points.
The following website is official information provided by the Dutch government for the general public, and provides a very clear explanation of the euthanasia system.
Please refer to it as it will help you understand the system.
The actual "Euthanasia Law" and related guidelines can be found here.
It is extremely useful for verifying legal operations and clinical procedures .
⇩
The Dutch euthanasia system was established early on by global standards, and has had a major influence on the legislative processes of other countries since then . It can be said that the systems of many countries that legalize euthanasia have learned the basic framework from the Dutch system, while making adjustments to suit their own country's soil (cultural and social background) (however, the systems of Switzerland and some US states have their own historical backgrounds and are slightly different in structure).
We believe that by understanding the process that the euthanasia system goes through and the safety devices that are in place to operate it, the true nature of the system will become clearer .
The following is the "general outline" of the Dutch euthanasia system, and systems around the world generally adopt a similar structure .
① Application stage:
The stage where the patient's doctor first clarifies the patient's wishes (first check)
⇩
② Evaluation stage:
The second check is when another doctor determines compliance with legal standards.
⇩
③ Consultation stage:
Re-evaluation by an external third-party doctor (or institution) (third check)
⇩
④ Implementation and reporting stage:
Carrying out euthanasia and submitting a detailed report to the local review board
A more simplified explanation of this process is as follows:
1. Consultation and diagnosis by your doctor
2. (In the Netherlands) Additional review by specialized staff, including psychiatrists, and a second independent doctor
3. Final comprehensive check by a third-party organization
4. Implementation and Reporting
In the Netherlands, the reliability of the system is strengthened by the "independence of a third-party organization" and "post-mortem review by the Regional Review Board (RTE)." The review board is made up of doctors, lawyers, ethics experts, etc., and submits a detailed public report every year, so the system is also highly regarded for its transparency.
To put it more simply,
Primary doctor → Secondary doctor → Comprehensive check by specialized institution → Implementation
--Let 's imagine that this four-stage system is the basic method. After that, each country will add its own unique methodology.
Many books on the market simply state that "two doctors must diagnose and examine the patient separately," but please be aware that there is also a " third examination " (note that in some countries there is no third examination).
For example, a bill being discussed in the UK is considering introducing a " panel system (committee system) involving High Court judges " at the final review stage (③) above, which would more clearly incorporate judicial involvement.
In this way, other countries are attempting to design systems with their own unique structures based on the Dutch model.
[Legal name]
"Euthanasia and Assisted Suicide Review Act"
(Wet toetsing levensbeëindiging op verzoek en hulp bij zelfdoding) Abbreviated as "Wtl"
*In the Netherlands, the term "euthanasia" is commonly used in English (Euthanasi e in Dutch ).
[Eligibility conditions]
The patient's request is spontaneous and carefully thought out
The patient's suffering is desperate and unbearable
The doctor has provided the patient with a sufficient explanation of the condition and prognosis.
Both the doctor and the patient concluded that no other reasonable solution existed.
At least one independent physician must provide an examination and written opinion
Euthanasia is performed through medical procedures
The six conditions may seem obvious now, but they were groundbreaking in 2001 .
For more detailed information on conditions, eligibility, and the situation in 2024, please see Dutch Euthanasia #1 .
[Review process]
Details of the process from application to completion based on the contents of the Dutch Euthanasia Bill
[Application stage]
(The stage where the patient's wishes are first clarified)
Starting conditions:
It begins when the patient clearly tells the doctor that they wish to be euthanized .
Doctor's response:
The physician carefully listens and assesses whether this wish is a passing emotion or a well-thought-out, enduring intention .
The need for distinction:
At this stage, a clear distinction must be made between impulsive suicidal thoughts and a persistent desire for euthanasia.
Family Involvement:
It is recommended that family members and close friends and family be involved at this stage, but this is not a legal requirement ( it is entirely up to the individual's wishes ).
Dutch Euthanasia #1 I also emphasized this here:
*The fundamental difference between suicide and euthanasia is whether or not a doctor is involved, and whether or not the patient's wishes are fully considered. Highly impulsive acts are not eligible for euthanasia.
In other words, as long as the patient and doctor are on the same page and reach an agreement after careful deliberation and ongoing dialogue, there are no particular restrictions on the reasons for wishing for euthanasia .
In other words, the reason may be anything, such as pain caused by a non-terminal illness, serious difficulties in daily life due to mental illness, or an intractable disease, but what is important is that the motivation for seeking euthanasia is clear .
Unlike systems in the United States, Australia, and the United Kingdom, the focus here is on "current psychological suffering," and there are no regulations limiting it to specific diseases or clear requirements regarding life expectancy .
However, depending on the patient's situation and the nature of the disease, the next stage cannot be proceeded to unless the doctors reach an agreement, and it is by no means easy to pass the review.
In fact, many people are ineligible at the application stage.
[Evaluation stage]
・Initial check by a doctor
Discuss repeatedly and reach an agreement to ensure that the six requirements mentioned above are met and understood.
*As mentioned earlier , the concept of "unbearable pain" is not limited to objective physical pain.
It also includes "mental and existential suffering."
・Second opinion
A second opinion by an independent specialist psychiatrist is mandatory to determine remaining treatment options, diagnosis, and, where possible, assessment of decision-making capacity.
- Involvement of other medical professionals
Gather information from and consult with other health professionals involved in the patient's care, such as family physicians, nurses, psychologists, and spiritual counselors.
Multidisciplinary collaboration is encouraged, and team discussions are held when difficult decisions or dilemmas arise.
・Involvement of family and close relatives
The active involvement of family and close relatives throughout the process is crucial .
Patients are informed in advance about the involvement of their families, and although families do not have formal decision-making powers, their opinions are taken into account .
If the patient refuses contact with family members, physicians should make every effort to involve them and should not avoid contact with family members except in rare cases with good reason.
- Confirmation of spontaneous and well-considered requests
Ensure that the request is not due to external pressure or simply the influence of a mental illness (in this case, an unstable psychological state) .
The patient must have decision-making capacity (cognitive capacity, appropriate emotions, not based on pathological values, related to important values in life). The request must be consistent and persistent .
-Assessment of hopeless and unbearable pain
The doctor must have sufficient insight into the patient's situation and suffering.
Hopeless suffering refers to a condition where there is no reasonable possibility of treatment remaining and is supported by a second opinion.
Unbearable pain is subjective, but it needs to be understandable to the physician.
・Explanation of the situation and prognosis
The patient is provided with sufficient and understandable information about their diagnosis, treatment options, the effects and side effects of treatment, and prognosis (including palliative care), and their family is involved.
- Absence of reasonable alternatives
Review previous treatments and outcomes, and discuss with the patient available treatments and their chances of success.
Consider the reasonableness of the treatment (balance between expected improvement and burden on the patient) and the time it takes for the treatment to be effective. If the patient refuses reasonable treatment, the request may be denied .
[Discussion stage]
(Reevaluation by an external organization )
・Independent consultant physicians. Consult with a physician who has completed SCEN training . Consultant physicians must be independent.
Consultant role : Assess eligibility criteria, examine patients and speak to family members or other carers as required.
Disagreements - if you have a fundamental disagreement with a consultant, consider consulting another consultant. Doctors are not obliged to follow the consultant's opinion, but they should have strong reasons for making a different decision.
*“ SCEN (Support and Consultation on Euthanasia in the Netherlands)”:
To ensure the proper and careful implementation of euthanasia and physician-assisted suicide in the Netherlands,
This refers to a "professional consultation system . "
Founded by the Royal Dutch College of Physicians (KNMG) to provide professional consultation and support to doctors when dealing with requests for euthanasia.
As an independent third party, the SCEN physician will assess whether the attending physician's judgment is impartial and meets legal requirements (such as voluntary and deliberate request, intolerable suffering, and lack of reasonable alternatives).
"Submit formal written opinions . "
[Implementation stage]
・Preparation
This includes consultation with family and carers (parting, location, attendance), advance notice to the local coroner (usually 24 hours), and consultation with pharmacists regarding medication supplies.
·method
The patient and doctor agree on the preferred method of administration: oral (pentobarbital solution) or intravenous (injection) (barbiturate or propofol followed by a muscle relaxant).
・Final confirmation
Just before the actual procedure, the patient should clearly reaffirm their wishes.
・Post-death paperwork and reporting
Submit a report immediately.
After implementation, all progress and decisions will be reviewed by a Regional Review Board (RTE) . If a decision is deemed inappropriate, the doctor may face administrative sanctions or legal liability. This will prevent abuse of the system and careless decision-making.
・Aftercare
Within six weeks of the death, contact should be made with family and friends to identify any complications or emotional issues in the loss process . A follow-up review with the care team is also recommended.
Incidentally, if a request for euthanasia is denied, ongoing care for the patient will be arranged immediately due to the high risk of suicide.
[Other protective measures (safety guards)]
• Patient-initiated request
The process begins when the patient requests euthanasia due to psychological distress. Rather than a question of "disease," the first thing to consider is whether or not the patient is suffering from "excessive psychological distress ."
• Clear distinction from suicidal thoughts
Doctors distinguish between acute suicidal thoughts and requests for euthanasia, assess suicide risk if present, and apply different treatment strategies. Suicidal thoughts are usually impulsive and temporary, whereas a request for euthanasia must be "a spontaneous, deliberate, consistent, and persistent wish."
• Physician right of refusal and obligation to refer
If a doctor is unwilling to proceed with the process for personal or ethical reasons , it is their responsibility to communicate this clearly to the patient, help them find another doctor, and ensure that any relevant information is passed on appropriately.
*Doctors have the right to " conscientious objection to diagnosis ," similar to "conscientious objection to military service" (this is adopted in all countries where it is legal).
-Hopeless suffering is a state in which there is no possibility of reasonable treatment remaining.
-SCEN physicians must be independent and have no family, personal, team, or therapeutic relationships with treating physicians or patients.
• Involvement of other health professionals
It is recommended to gather information from and consult with other health professionals involved in the patient's care, such as family physicians, nurses, psychologists, spiritual counselors, etc. Team discussions and moral debates may be held when difficult decisions or dilemmas arise.
• Reviewed by a judging committee
After euthanasia has been carried out, the local coroner submits these documents to the Local Euthanasia Review Board (RTE) to assess whether the duty of care requirements of the Wtl (Euthanasia Act) have been complied with.
The RTE not only serves as a post-event check mechanism, but is also an important organization involved in future euthanasia updates .
・Minor
Requests from minors aged 12 and over are also subject to the WTL, but the younger the minor, the more careful an assessment of their decision-making capacity is required. Parental consent is required for those aged 12 to 15, and parents must be involved in the decision-making process for those aged 16 to 17 .
• Intellectually disabled people
When mental illness is compounded by intellectual disability, special attention is paid to assessing decision-making capacity.
• Patients under legal protection
For patients who have a guardian or are involuntarily hospitalized, requests are still reviewed, but are subject to a more rigorous assessment of their free will and the availability of alternatives.
[The Dutch Euthanasia Process] (Super simplified image)
( The process from application to completion, as seen from the contents of the Dutch Euthanasia Bill, and protective measures to avoid the risk of coercion)
①Apply to your family doctor (first check)
⇩
② Evaluation by independent physicians, including psychiatrists, and other care staff (second check)
⇩
3) Consultation by SCEN (professional euthanasia doctors) (third check)
⇩
④ After implementation, RTE will review the project ( in a sense, this is the fourth check).
remarks
You must have felt that it was a very strict system.
With such a careful framework in place, it may seem as though patients are under some kind of "strong constraint" under the control of national policy and doctors and care staff.
However, as shown in the diagram above, euthanasia is not just
"The End of a Life with Tests"
There has never been a confirmed case of the system being misused for criminal purposes .
Even if a problem does occur, it is limited to incomplete documentation on the doctor's side.
There has never been any questioning of the dangers of the system itself, nor has there ever been any talk of abolishing it .
(Note: Of course, some fundamentalist Christian groups and media outlets have consistently expressed opposition to the idea. In fact, they have spread rumors and conspiracy theories .)
Even in the Netherlands, a country that pioneered the euthanasia system and is often perceived as having relatively lenient conditions internationally , the system is actually operated carefully based on the strict regulations and procedures we have seen so far.