Is euthanasia legal in the Netherlands?

In the Netherlands euthanasia (termination of life on request) and assisted suicide are criminal offences under articles 293 and 294 of the Dutch Criminal Code. The only exception is when the procedure is performed by a physician who has satisfied six statutory due care criteria. These criteria are laid down in the Termination of Life on Request and Assisted Suicide (Review Procedures) Act. The physician is also required to notify the municipal pathologist.

Difference between termination of life on request and assisted suicide

Termination of life on request is when a physician administers the substances to the patient.
Assisted suicide is when the physician hands a lethal substance to the patient who then ingests it.

Below, the word ‘euthanasia’ is used to refer to both forms of helping a person to die.

Only the patient can request euthanasia

The patient must make the request personally. A request for euthanasia made by another person on behalf of the patient cannot be granted. It must always be clear that the request has been made by the patient personally.

The request must have been made without any undue influence from others. The physician must be satisfied that the patient’s request is voluntary and well considered.

Euthanasia and minors

A child may request euthanasia from the age of 12. However, the following additional requirements apply:

the child must be capable of assessing and understanding what is best for them in their situation;
if a child is aged 12-15, euthanasia can only be carried out with the consent of the child’s parent or parents, or the child’s guardian;
if a child is aged 16 or 17, the parent(s) or guardian must be consulted in the decision-making process, but their consent is not required.

Oral request for euthanasia

It is not necessary for a patient to make a euthanasia request in writing. An oral request is sufficient.

Advance directive

A patient who is decisionally competent can draw up a written request for euthanasia, an ‘advance directive’. An advance directive can replace an oral request for euthanasia if at a later point the patient is no longer able to express their will with regard to euthanasia (due to, for instance, advanced dementia or reduced consciousness).

It is important that the patient describe as specifically as possible the circumstances in which they would wish their life to be terminated. It is the responsibility of the patient to discuss their advance directive with the physician when drafting or updating the document. The physician should include this information in the patient’s medical records.

There is no prescribed format for an advance directive, and the patient can write in their own words.

Due care criteria

According to the Termination of Life on Request and Assisted Suicide (Review Procedures) Act the physician must:

be satisfied that the patient’s request is voluntary and well considered;
be satisfied that the patient’s suffering is unbearable, with no prospect of improvement;
have informed the patient about their situation and their prognosis;
have come to the conclusion, together with the patient, that there is no reasonable alternative in the patient’s situation;
have consulted at least one other, independent physician, who must see the patient and give a written opinion on whether the due care criteria set out in (1) to (4) have been fulfilled; and
have exercised due medical care and attention in terminating the patient’s life or assisting in the patient’s suicide.

Under what conditions is euthanasia allowed?

Euthanasia is only allowed for patients whose unbearable suffering with no prospect of improvement has a medical dimension. This can be the case with somatic diseases such as cancer or cardiovascular disease, but also with psychiatric disorders, dementia or multiple geriatric syndromes. The Act does not allow euthanasia in cases where a person is ‘finished with life’ or deems their life to be ‘completed’.

Patient has no right to euthanasia and physician is not obliged to perform euthanasia

Physicians are not obliged to grant a request for euthanasia, even if the due care criteria set out in the Act have been fulfilled. Patients do not have a right to euthanasia, and physicians are entitled to refuse to carry out euthanasia, for instance because of their religious beliefs.

If a physician is unwilling to perform euthanasia, it is prudent from a medical professional point of view to inform the patient accordingly as early as possible. The patient can then, if they so wish, contact another physician. Physicians may also refer the patient to a colleague.

Notification and review

A physician who has performed euthanasia must always notify this to the municipal pathologist, providing a detailed report. The municipal pathologist investigates the death and must then send the notification, including all the associated documents, to one of the five regional euthanasia review committees in the Netherlands. This committee reviews the reports and the euthanasia procedure and establishes whether the physician satisfied all the due care criteria in performing euthanasia.

If the committee finds that the physician failed to fulfil one or more due care criteria, it is legally required to report its findings to the Public Prosecution Service (OM) and the Health and Youth Care Inspectorate (IGJ). These bodies then consider what further steps need to be taken. For instance, they can file a disciplinary complaint against the physician or decide to prosecute the physician. A physician who is found guilty of unlawfully performing euthanasia is liable to:

in the case of termination of life on request: up to 12 years in prison, or a fine.
in the case of assisted suicide: up to 3 years in prison, or a fine.

Euthanasia and non-residents

The Termination of Life on Request and Assisted Suicide (Review Procedures) Act does not explicitly prohibit a physician from granting a request for euthanasia from a patient who does not reside in the Netherlands. But in practice this almost never happens due to the following issues and objections.

A physician who terminates a patient’s life on request or assists with their suicide must satisfy the six due care criteria set out in the Act. Among other things, the physician must be satisfied that the patient’s request is voluntary and well considered, that their suffering is unbearable with no prospect of improvement, and that there are no reasonable alternatives in the patient’s situation. In order to ascertain this, the physician must be fully informed about the patient’s situation and prognosis; the physician needs a reliable and clear medical history. The physician must personally determine that all the due care criteria have been met.

In addition, the physician must consult an independent physician who must see the patient for themselves and give their written opinion on whether the due care criteria have been fulfilled.

This assessment procedure is complex and multi-faceted and – depending on the patient’s medical situation – can span several weeks to months, or even years. It is up to the physician to decide whether such an assessment is possible in the case of a request from a person who does not reside in the Netherlands and has only recently arrived here.

Euthanasia can be the last stage of a care process. It is not a service that can be simply requested by a patient who wants to come to the Netherlands for the sole purpose of euthanasia.

The focus of the Act is on the physician who performs euthanasia. This is generally the attending physician who has known the patient for some time and who will be able to base their conclusion that all the due care criteria have been met on their knowledge of the patient and the patient’s situation.

Even if it is possible to find a physician who is willing to perform euthanasia to someone coming from abroad, the costs of the procedure are only reimbursed for people with Dutch health insurance whose health insurance policy does not exclude euthanasia. If the procedure is not covered by the patient’s health insurance policy, the costs will be charged to the deceased’s estate.

People who live in another European Union member state who wish to request euthanasia in the Netherlands but do not have Dutch health insurance should ask their own health insurer in advance whether they will reimburse the costs of euthanasia in the Netherlands. Without such prior authorisation, there is no right to reimbursement and the costs of the euthanasia procedure will be charged to the deceased’s estate.

The Dutch Euthanasia Expertise Centre (Expertisecentrum Euthanasie) provides counselling and support to physicians with patients who have requested euthanasia. The Centre also helps patients whose physician, for reasons of their own, cannot perform euthanasia. However, the Centre explicitly states that they only accept applications from people who:

have a residential address in the Netherlands
are registered with a general practitioner in the Netherlands
have Dutch health insurance, and
have a good command of Dutch and/or English.

Situations that do not fall within the scope of Dutch euthanasia legislation

The Termination of Life on Request and Assisted Suicide (Review Procedures) Act does not apply in the following cases of death:

medical treatment is discontinued or is not started at the patient’s request;
the physician refrains from performing a procedure that is medically pointless;
the physician administers increasingly strong medication with the aim of alleviating the patient’s suffering, which may have the secondary effect of shortening the patient’s life;
the physician administers drugs to render the patient unconscious at the end of their life, with the aim of alleviating suffering that can no longer be relieved in any other way (palliative sedation).