Euthanasia in the Netherlands: Who decides about the end of life?

What do we mean by euthanasia? 

The word euthanasia comes from Ancient Greek and literally means ‘a good death’. Buijsen explains that the Netherlands distinguishes between two forms of euthanasia: “These are termination of life on request and assisted suicide. In the termination of life on request, the doctor administers the substance that causes death, usually using an infusion pump. In assisted suicide, the patient administers the substance themselves in the presence of a doctor.” According to Buijsen, a mentally competent patient may, in principle, indicate which method they prefer: “If a patient is still fully competent, they may prefer to do it themselves. However, if the patient wants the doctor to do it, that is also an option. Only when a patient is incompetent may the doctor administer the substance.” 

A criminal offence? 

Although the Netherlands is known for its relatively liberal euthanasia practice, euthanasia is still embedded in criminal law. Buijsen explains: “Termination of life on request and assisted suicide are criminal offences.” This criminalisation was deliberately retained because lawmakers regard ending life as a severe act, permissible only under strictly defined circumstances. The Termination of Life on Request and Assisted Suicide (Review Procedures) Act (Wtl), introduced in 2002, provides an exemption for doctors, but a very limited one. A doctor can avoid criminal liability only if all due care criteria are met and the case is reported to the municipal pathologist, after which a Regional Euthanasia Review Committee assesses whether the doctor acted with due care and diligence. 

No right to euthanasia 

Euthanasia is often discussed in terms of self-determination. Many people believe they should be able to decide for themselves when their life is complete. Remarkably, Dutch law is not based on that principle. Buijsen explains: “The right to self-determination is mainly a moral right. The Wtl is not based on self-determination, but on compassion.” This means that the core of the law lies in the moral notion that a doctor may, out of mercy, help to end hopeless and unbearable suffering, but only if there are good reasons. A patient may request euthanasia, but the final decision always rests with the doctor. 

The due care criteria 

Central to the Wtl are the so-called “due care requirements”. Buijsen calls these the core of the medical law and lists them: “Firstly, the patient’s request must be voluntary and well-considered. Secondly, the patient’s suffering must be hopeless and unbearable. Thirdly, the doctor must have informed the patient about their situation and prognosis. Fourthly, the doctor and patient must be convinced there is no reasonable alternative. Fifthly, at least one other independent doctor must be consulted, who must examine the patient and give a written opinion on the due care criteria. Finally, the life-ending procedure or assistance in suicide must be performed with medical care.” 

This extensive set of criteria shows that euthanasia is not easily granted. It is a process that takes time, ensuring the patient is well-informed and that careful consideration is given to whether the suffering truly has no prospect. 

Incompetence and advance directives 

One of the most complex issues within the euthanasia law concerns patients who become incompetent, for example, due to advanced dementia. Such patients can no longer make a verbal request. Buijsen explains: “Euthanasia is only possible if the incompetent patient made a written request while still competent.” An advance directive can therefore serve as a valid euthanasia request, but only if it was drafted before incompetence and is sufficiently specific. Still, practical difficulties remain. Doctors may observe that someone with severe dementia, who previously requested euthanasia, appears content or happy in the moment. This creates ethical and legal tensions: should the doctor follow the earlier request, or consider the patient’s present state? Again, doctors are never obliged to carry out the request. The written statement creates a possibility, not an entitlement. 

Psychological suffering: one of the most complex areas 

Euthanasia in cases of psychological suffering has been a subject of legal and medical debate for decades. Since the Chabot ruling, it has been recognised that psychological suffering, like physical suffering, can be hopeless and unbearable, provided it involves a medically classifiable disorder. However, assessing hopelessness in mental illness is far more difficult than in physical conditions. Buijsen notes: “Psychological suffering can also be hopeless and unbearable, but not all psychiatrists are prepared to regard such suffering as hopeless.” While some psychiatrists acknowledge that long-term treatment-resistant depression or other severe disorders may be hopeless, others believe treatment options always remain. This can lead to differences between practitioners. 

The Chabot case 
In the case of psychiatrist Chabot, who assisted a woman with severe depression and complicated grief to end her life, the Supreme Court made important rulings. The woman, who was not physically ill, received from Chabot the means to end her life. Although lower courts exempted him from prosecution due to necessity, the Public Prosecution Service appealed to the Supreme Court. 

The Supreme Court held that necessity may apply in cases involving psychological suffering in non-terminal patients, and that a mental disorder does not automatically exclude a patient’s capacity for autonomous decision-making. It emphasised that great caution is required in such cases and that an independent doctor must examine the patient, which had not happened in this instance. Chabot’s appeal to necessity was rejected, but he received no punishment, indicating that his actions were not considered ethically blameworthy. 

When a treating physician concludes differently from what the patient had hoped for, another option exists within Dutch euthanasia practice. The Euthanasia Expertise Centre plays an important role here. Buijsen explains: “Patients may encounter a doctor who believes the suffering is not hopeless. They can then turn to psychiatrists affiliated with the Expertise Centre. These people may assess the suffering differently and may be willing to proceed with euthanasia. Nevertheless, they too must comply with the due care criteria.” 

The call for more autonomy 

Organisations such as Coöperatie Laatste Wil advocate for greater autonomy for people who consider their lives complete, even in the absence of a medical basis for their suffering. This would mean permitting life-ending on request or assisted suicide without requiring a medically classifiable disorder. Buijsen notes that the European Convention on Human Rights (ECHR) leaves room for such a political choice: “A political decision in favour of self-determination-based end-of-life legislation can be compatible with the ECHR.” Yet he emphasises that such a system cannot coexist with the current Wtl. If self-determination becomes central, the requirement of suffering becomes redundant, and there is no reason to wait until suffering is unbearable. This would fundamentally shift the basis of the euthanasia law, which is grounded in compassion from doctors. It would create an entirely different system, incompatible with the current structure, where the doctor is at the heart of the careful decision-making process. 

The future: stable law, changing practice 

Despite societal developments, Buijsen does not expect the euthanasia law to change in the coming years. He says: “The Wtl has not been amended in all these years, and no legal changes are currently on the horizon.” At the same time, he observes changes in practice. Whereas euthanasia was once mainly associated with terminal cancer patients, the law is now applied across a much broader range of patient groups, such as people with neurodegenerative diseases, complex psychiatric conditions or cumulative age-related complaints. Buijsen expects this trend to continue: “More and more patient groups have been included, and this development will continue. A law that remains unchanged while practice evolves — that is what the future will look like in the Netherlands. Choosing a different, self-determination-based law will be complicated for the Netherlands. The country is no longer a frontrunner in legalising euthanasia. The Netherlands is firmly anchored in the idea of doctor-based compassion. Countries currently considering legalisation and prioritising self-determination are opting for different legislation.” 

Continuing the conversation about dignified dying 

The conversation about euthanasia remains essential. The debate is not only about legal boundaries but also about how society approaches the end of life and what constitutes dignified care. As every situation is unique, euthanasia demands continuous reflection and careful consideration: how much autonomy do we give patients, what responsibility do we place on doctors, and how do we protect vulnerable individuals? It is important to discuss the topic openly, thoughtfully and without taboos, because as Buijsen aptly puts it: “Living with dignity inherently includes dying with dignity.”