By Professor Theo Boer, Former reviewer of euthanasia cases in the Netherlands
As early as next week, Irish Members of Parliament could be casting a vote on the complicated and emotive issue of assisted suicide and euthanasia.
After euthanasia was legalised in 2002, I supported the Dutch legislation and worked for the authorities reviewing euthanasia cases between 2005 and 2014. I was convinced that the Dutch had found the proper balance between compassion, respect for human life, and respect for individual liberties.
Over the years, however, I became increasingly concerned about some developments. After an initial stabilization we saw a dramatic increase in the numbers, which went from 2,000 in 2002 to 6,300 in 2019. In some urban districts in the Netherlands, between 12 and 14% of all deaths are the result of assisted dying. The outgoing director of the Euthanasia Expertise Centre – which provides assisted dying to almost 1,000 patients yearly – expects the euthanasia numbers to double again in the near future.
We also saw differences in the way the legal criteria were interpreted. In the pioneering years of Dutch euthanasia, it was found almost exclusively in terminally ill mentally competent adults. After some decades, the practice extended to include those with chronic conditions, disabled people, those with psychiatric problems, and incompetent adults with an advance directive. Expansion is under debate for euthanasia in young children and for elderly persons without a medical diagnosis.
Understandably, Irish advocates of assisted dying argue for a more restricted law than is found in the low countries. Here is my prediction: any law that allows assisted dying will by some be experienced as an injustice and will be challenged in the courts.
A year ago the Superior Court in Quebec ruled that the condition of a terminal illness in Canadian law is discriminatory and thus unconstitutional. Why only euthanasia for terminally ill patients, who already have access to an ever widening array of palliative care, whereas chronic patients may suffer more intensely and much longer?
We can envisage the next steps: why exclude psychiatric patients, many of whom are suffering most heartbreakingly of all? Why only an assisted death for people suffering from a disease, and not for those suffering from meaninglessness, alienation, loneliness, from life itself?
The paradox of legalising assisted dying is that what starts out as a welcome opportunity for those who love their self-determination, becomes an invitation to despair to others. I have seen literally hundreds of euthanasia reports in which the wish to shield one’s relatives from the agony of witnessing their suffering and carrying the burden of long-time care was one of the reasons, if not the essential reason, for asking for an assisted death. In a society where assisted dying is available, people are confronted with one of the most dehumanizing choices possible: do I want to live on, or do I want to effectuate my death?
The logic of many is that assisted dying will bring down the numbers of violent and traumatizing suicides. If true, this would be a powerful argument in favour of changing the law. But the Dutch statistics speak another language.
Whereas the percentage of euthanasia of the total mortality went from 1.6% in 2007 to 4.2% in 2019, the suicide numbers went also up: from 8.3 suicides per 100,000 inhabitants in 2007 to 10.5 in 2019, a 15% rise. If we would include the deaths through assisted suicide in patients considered to be at risk of committing suicide (psychiatric patients, people with chronic illnesses, dementia patients, elderly and lonely people), the total increase in self chosen deaths over the past decade would be closer to 50% than to 15%. Meanwhile in Germany, very similar to the Netherlands in terms of religion, economy and population, the suicide rates went down by 10%.
So as Members of Parliament start to look at this issue, the Netherlands must act as an alarm to what can happen. Look at the Netherlands and you may see Ireland in 2040.
Like those currently arguing for a change in the law in Ireland, I once believed it was possible to regulate and restrict killing to terminally ill mentally competent adults with less than six months. (Paradoxically, I doubt whether my country would have legalised assisted dying if we had had the level of palliative care in 1994 that we have now.) Moreover, by taking this bold step I believed we could regulate suicide and death in this way that would curtail those all too familiar cases where someone ends their own life.
I was wrong.
If not even the most well-regulated and monitored system worldwide cannot guarantee that assisted dying remains a last resort, why would Ireland be more successful?
Theo Boer is Professor of Health Care Ethics at Groningen Theological University in the Netherlands and Visiting Professor of Ethics at the University of Sunderland in England.