2.1.1 History and current situation
Among people who feel their end of life approaching and also among their bystanders, the thought not infrequently arises that perhaps it would be better if suffering would not last too long. In contemporary terms, one then says that the quality of life has become very poor after all. Since around 1970, a movement has emerged in the Netherlands – and later elsewhere – seeking to legalise deliberate life-ending acts to end the suffering of incurably ill people. In the Netherlands, this movement resulted in legislation (the first in the world) that excludes the criminality of life-ending acts on request in the form of euthanasia and assisted suicide under certain conditions. This marks a break in an ancient tradition: since ancient times until well into the 20th century and following in the footsteps of Hippocrates, practically every doctor refrained from acts aimed at deliberately ending life. Particular caution was also taught regarding actions such as risky medical procedures and the administration of heavy analgesics to debilitated patients that might involve life shortening as an unintended side effect. In secular society, especially in England from the last quarter and in Germany from the end of the 19th century and, moreover, in Ohio and Iowa at the beginning of the 20th, there have been opinions that considered an intentionally induced ‘good death’ as a possibility to end life with dignity [: W.J. Eijk. De zelfgekozen dood naar aanleiding van een dodelijke en ongeneeslijke ziekte. Een medisch-historisch en medisch-ethisch onderzoek ten behoeve van een Rooms-Katholiek standpunt inzake euthanasie. Academisch proefschrift. . Brugge: Tabor / Rijksuniversiteit Leiden; 1987, 1-374, p 231-241.]. In the last 30 years of the 20th, century – as mentioned above – euthanasia and assisted suicide have been widely accepted in our country and, with some delay, in neighbouring countries as well, which has been translated into legislation.
In euthanasia, it is the doctor who administers the lethal agent. Assisted suicide is when the sick person himself takes the lethal agent that the doctor has deliberately made available to him for this purpose at. In some countries, euthanasia is understood to include termination of life on request as well as without the patient’s request. In the Dutch discussion, since the early 1980s, euthanasia has been defined as termination of life at the request of the person concerned without further qualification. This usage is spreading in other countries [: E.J. Emanuel. Euthanasia. Historical, ethical and empiric perspectives. Archives of Internal Medicine 1994, 154, 1891.] [: W.J. Eijk. Eutanasia: terminologia e prassi clinica. Rivista Teologica di Lugano 1997, 2, 221-243.]. If there is no request from the patient, for example in the case of a severely disabled newborn, then one speaks of termination of life without a request from the person concerned. This removes the distinctions previously made between voluntary, non-voluntary and involuntary euthanasia. Voluntary euthanasia takes place at the request of the person concerned; involuntary euthanasia is performed against his will. In non-voluntary euthanasia, the will of the person involved is not known; this occurs in comatose and severely mentally disabled patients and also in newborn babies.
Netherlands
Since 1 April 2002, the Wet Toetsing levenbeëindiging op verzoek en hulp bij zelfdoding (Act on the Assessment of Termination of Life on Request and Assisted Suicide), abbreviated as Wtl, has been in force in the Netherlands. This had been preceded by years of political debate, media presentations and research by government-appointed committees [: A. van der Heide and J.M. Bosma. Euthanasia, physician-assisted suicide, and other medical practices involving the end of life in the Netherlands, 1990-1995. N Engl J Med 1996, 335, 1699-1705.]. It is noteworthy that the term euthanasia as such does not appear in the text of the law. The law does not legalise euthanasia or assisted suicide. These acts fall under criminal law, but are not criminalised if they have been performed by a doctor who has observed the requirements of care mentioned in Article 2 of the Wtl (Penal Code, Article 293). One of these care requirements, to which we will return later, is that the doctor is convinced that the patient’s suffering is hopeless and unbearable. Another important requirement is that the doctor who performs euthanasia or provides assisted suicide must report it to one of the five Regional Review Commissions (Burial Act, sections 7,2 and 10). If the Commission finds, that the doctor has implemented the due diligence requirements, he will not be prosecuted. The law applies to persons aged 12 and above. For minors aged 12-16, parental or guardian consent is required; for 16- and 17-year-olds, this is not the case, but the parents or guardian must be involved in the decision-making process.
In the years after 2002, except for a single year, both the absolute number of euthanasia cases and the share of euthanasia of total deaths increased:
| Year | 1990 | 2001 | 2005 | 2019 | 2020 | 2021 | 2022 | 2023 | 2024 |
| Reports euthanasia | 2700 | 3800 | 2425 | 6361 | 6938 | 7666 | 8720 | 9068 | 9958 |
| Proportion of euthanasia total deaths (%) | 4.2 | 4.1 | 4.5 | 5.1 | 5.4 | 5.8 |
In the years after 2002, except for a single year, both the absolute number of euthanasia cases and the share of euthanasia of total deaths increased:
Discussions also arose about the “right to euthanasia”, situations of hopelessness and intolerability, including psychological suffering, the assessment and assessability of these criteria by the review committees and life termination in completed life (citizens’ initiative “Uit Vrije Wil”).
In 2012, the Dutch Association for Voluntary Euthanasia (NVVE) set up the Levenseindekliniek, now acting under the name Expertise Centrum Euthanasie (Expertise Centre Euthanasia). Underlying the establishment of this organisation was the idea that not everyone who wanted euthanasia succeeded in obtaining it through the attending physician. [: P. de Jong. Haalbaarheidsonderzoek levenseindekliniek (fase 2). Nederlandse Vereniging voor Vrijwillige Euthanasie; 2010.] The Levenseindekliniek could fill this gap and assess and carry out euthanasia requests outside the treating doctors’ homes. In practice, there appeared to be a lot of interest in this organisation. In 2024, the organisation, received 4782 requests for euthanasia, of which 1412 were granted. The review board rated these euthanasia procedures as careful. [: Expertisecentrum Euthanasie. 2024 in beeld. 2025.]
Another development was the nature of the suffering in which assisted suicide or euthanasia was applied and thus the situations in which there was hopeless and unbearable suffering. The initial idea was that euthanasia would be an option for somatic conditions that would lead to death in the foreseeable future. Gradually, cases emerged in which psychological suffering was also classified as such. In 2002, lawyer Edward Brongersma died of suicide at the age of 86, assisted by his GP, because he was “tired of life”: his situation would have been unbearable and hopeless. The GP involved was convicted for this assisted suicide, but received no punishment. [: Hoge Raad. De zaak Brongersma – 00797/02. 2002.] In 2011, the KNMG published a position paper on the doctor’s role in the self-chosen end of life. In it, the intolerability and hopelessness of suffering are seen as an experience of the patient. [: Koninklijke Nederlandse Maatschappij tot bevordering der Geneeskunst. De rol van de arts bij het zelfgekozen levenseinde. KNMG-standpunt 2011.] This KNMG position clearly marked how thinking about intolerability and hopelessness had changed: from criteria that had been included in the Wtl because of objective assessability, they had become subjective experiences of patients. This way of thinking also meant that the number of euthanasia cases in situations where unbearable and hopeless mental suffering was experienced was increasing. In practice, review committees assessed whether doctors, including SCEN doctors, had established that the patient’s suffering was unbearable and hopeless. There was no longer an objective assessment of suffering. Over time, two prominent members, prof.dr T. Boer and dr. B. van Baarsen, left the Review Committee because of their difficulty with this assessment of suffering. [: B. van Baarsen. De toetsing van euthanasie: zorgen om kwaliteit, argumentatie en normontwikkeling. Tijdschrift Gezondheidszorg en Ethiek 2018, 28, 79-85 ; A.S. Groenewoud and T.A. Boer. How legal euthanasia continues to be transgressive. Some Observations from the Netherlands. In: Schaafsma P, editor. The transcendent character of the good: philosophical and theological perspectives, Routledge: Taylor & Francis Group; 2022, 175-192 doi:10.4324/9781003305323-14.] As a result, euthanasia for mental suffering would be carried out regularly: a guideline for it was also published. [: Nederlandse Vereniging voor Psychiatrie. Levensbeëindiging op verzoek bij patiënten met een psychische stoornis. Richtlijnendatabase: Federatie Medisch Specialisten; 2018, 2025.]
A special form of mental suffering is dementia. An essential difference from many other forms of mental suffering is that in advanced dementia, the patient no longer has the capacity to make a euthanasia request himself. People who have considered at an earlier stage that they might find themselves in such a dementia situation usually record their request for euthanasia in a living will years earlier. A special case in this regard was the one that has become known as the “coffee euthanasia”. It involved a specialist in geriatrics who performed euthanasia on a 74-year-old incapacitated patient with severe dementia in 2016. When the woman found out earlier that she suffered from dementia, she recorded her death wish in a written statement in case she became severely demented and ended up in a nursing home. At one point, the disease had progressed to the point where she was incapacitated and no longer gave unambiguous signals about her death wish. Her family raised her will with the relevant doctor. Prior to performing the euthanasia, this doctor had put a sedative in the patient’s coffee. When the euthanasia was performed, the patient was under the influence of the sleeping drug but not yet completely unconscious. During the insertion of the infusion, the woman made a retreating movement and when the euthanasia drug was administered, she stood up. While the family held the woman, the doctor proceeded with the termination of life. The outcry over this case was multiple. First, the woman was no longer able to express her will and requested euthanasia. In addition, the retreating movement did get interpreted as refusal of euthanasia and the woman’s retention was seen by the family as coercion. The RTE ruled that the geriatrics specialist had not met all due care requirements, the disciplinary board imposed a reprimand on the doctor. The court did not go along with these sentences and found that the doctor had acted with care. To obtain case law up to the highest level, the Supreme Court’s attorney general instituted “leapfrogging” proceedings, allowing the Supreme Court to consider the case directly. It ruled that a doctor may act on a written request to grant euthanasia to patients with advanced dementia, provided the legal requirements relating to euthanasia are met (hopeless and unbearable suffering, prior assessment by two independent doctors). Moreover, the patient’s written will must specifically request euthanasia in the situation where the patient can no longer express his or her will due to advanced dementia. [: Hoge Raad. Koffie-euthanasie – ECLI:NL:HR:2020:712. Den Haag 2020, 1-28.]
In the meantime, i.e. even before the Supreme Court ruling, Verenso, the association of specialists in geriatrics, had issued an exploration. This was still quite cautious, but steered towards a vision document. [: Verenso. Euthanasie bij gevorderde dementie. Een verkenning. 2018.] The Koninklijke Nederlandsche Maatschappij tot bevordering van de geneeskunst (KNMG; Dutch Medical Society) wrote three years later, after the Supreme Court verdict, in a handbook that given a Supreme Court verdict, euthanasia in cases of advanced dementia fits within the legal framework under circumstances. Nevertheless, the KNMG found “that the life of a person with advanced dementia is worthy of protection, regardless of what the patient has previously written about it. The actual wishes, interests and preferences of a person with advanced dementia deserve to be respected. That said, the previous written euthanasia request can be respected in exceptional situations. This is then only justified if the execution of the euthanasia corresponds to the earlier written euthanasia request and if there are no contraindications for this (such as clear signs that the patient no longer wants euthanasia). In addition, there must be actual unbearable suffering of the patient.” [: Koninklijke Nederlandse Maatschappij tot bevordering van de Geneeskunst. Beslissingen rond het levenseinde. KNMG-standpunt 2021.]
After psychological suffering was recognised as a ground for euthanasia, the next group of people presented itself: young people with long-term or therapy-resistant psychological suffering. A case in point is Zoraya ter Beek. This young woman had herself interviewed by a number of North American media in 2024 to make it clear, based on her own medical history, that it is possible in the Netherlands, through the Expertise Centrum Euthanasie, to undergo euthanasia at a young age because of psychological suffering. [: H. Sherwood. Dutch woman, 29, granted euthanasia approval on grounds of mental suffering. The Guardian 2024, 15 May.] She also mentioned that his had set a euthanasia date for himself later in the year. Another case involved euthanasia of a 17-year-old young woman, Milou, where there was also said to be hopeless psychological suffering. Partly as a result of these two cases, a group of 13 psychiatrists and general practitioners sent a fire letter to the College of Prosecutors General in the same year, expressing concern about the practice of euthanasia in psychiatric patients, including very young psychiatric patients. [: J. van Os and D. Denys. Ontsporend discours over euthanasie bij psychisch lijden schaadt kwetsbare patiënten. Brandbrief aan het college van procureurs-generaal. 2024.] The concerns were about stretching the limits of the euthanasia law and possibly inciting patients to euthanasia. Questions were also posed from the Tweede Kamer (House of Commons) to the state secretary of Health Care. [: V. Karremans. Antwoorden op Kamervragen van het lid Paulusma (D66) over het artikel “Psychiaters eisen strafrechtelijk onderzoek naar euthanasie van Milou (17)” (2024Z12208, ingezonden 26 juli 2024). Den Haag: Ministerie van Volksgezondheid, Welzijn en Sport; 2024.] It led to a very heated debate among psychiatrists, including in the media. The state secretary announced round-table discussions with all field parties. These should lead to a new guideline.
The 2002 Brongersma case had drawn attention to assisted suicide in addition to psychological suffering. In 2010, an initiative group called Uit Vrije Wil presented a citizens’ initiative to create options for assisted suicide. [: J. Peters, E. Sutorius, Y. van Baarle, W. Beekman, S. Daniels, L. de Fauwe and G. den Hartogh. Uit Vrije Wil. Waardig sterven op hoge leeftijd. Amsterdam: Boom; 2011.] Within 10 days of its launch, the initiative group had collected the required 40000 signatures needed for consideration by the Tweede Kamer. The Tweede Kamer did not agree to the bill that Uit Vrije Wil had prepared, arguing that it did not fit within the existing system regarding end-of-life decisions. The initiative group’s last request to set up a state committee was granted. In the run-up to the Parliamentary debates with Uit Vrije Wil, the KNMG broadened its position on euthanasia: a sum of medical and non-medical problems, which in themselves are not life-threatening, could however, all together, be a justifiable reason for euthanasia, the KNMG said. [: Koninklijke Nederlandse Maatschappij tot bevordering der Geneeskunst. De rol van de arts bij het zelfgekozen levenseinde. KNMG-standpunt 2011.] The state commission set up was tasked with advising on assisted suicide for people who consider their lives complete. In their report in 2016, the committee chaired by P. Schnabel first concluded that completed life is an umbrella term that can cover situations with suffering without a medical basis or with an unclear medical basis, or situations where there is no suffering. To the surprise of many – the committee did not recommend amending the Wtl. In the committee’s view, the size of the group with a completed life, absence of medical problems and an active death wish was probably very small, and the Wtl offered all kinds of possibilities that were either not used or used to a limited extent. [: Adviescommissie voltooid leven, P. Schnabel, B. Meyboom-de Jong, W.J. Schudel, C.P.M. Cleiren, P.A.M. Mevis, M.J. Verkerk, A. van der Heide, G. Hesselmann and L.F. Stultiëns. Voltooid leven. Over hulp bij zelfdoding aan mensen die hun leven voltooid achten. Den Haag 2016.] It was clear from the report that little information was available on completed life. Aspects such as the size of the number of people with such feelings, the proportion who have a death wish as a result and extent to which a possible death wish remains present over time had never been systematically investigated. To shed more light on this, the ministry commissioned ZonMW to investigate this. The resulting PERSPECTIVE study was published in 2020. [: E. van Wijngaarden, G. van Thiel, I. Hartog, V. van den Berg, M. Zomers, A. Sachs, C. Uiterwaal, C. Leget, M. Buijsen, R. Damoiseaux, M. Mostert and M. Merzel. Het PERSPECTIEF-onderzoek. Perspectieven op de doodswens van ouderen die niet ernstig ziek zijn: de mensen en de cijfers. Den Haag: ZonMw; 2020.] The study found that 0.18% of elderly people have a death wish without being ill, but that this death wish appears to be changeable over time and, therefore, not continuous. They are more often people without children, with deterioration and loneliness playing a role. The results of the study gave reason to think that people with a death wish could also be helped other than with assisted suicide. As recently as 2023, D66 tabled a bill in which elderly people over 75 could be given help to end their lives if they considered it complete. The Tweede Kamer has not yet debated this bill anno 2025. However, the KNMG has raised objections to the age limit of 75 and the mandatory role to be played by the attending physician. In objecting to the age limit of 75, the KNMG argues that it raises the idea that a life in an elderly person over 75 is worth less than in a younger person; the assessment of whether someone has a treatable condition should, according to the KNMG, be judged by an independent doctor and not by the attending physician. [: Koninklijke Nederlandse Maatschappij tot bevordering van de Geneeskunst. Reactie KNMG op het initiatiefwetsvoorstel ‘Wet toetsing levenseindebegeleiding van ouderen op verzoek’ (maart 2024). 2024.] Although the discussion on assisted suicide in the case of the feeling of a completed life has not ended yet, in practice the discussion has led to suffering due to a completed life or multiple old-age ailments being recognised as unbearable and hopeless suffering covered by the Wtl and euthanasia is applied to these people if required.
Belgium
The Belgian Euthanasia Act came into force only six months after the Dutch Wtl, on 30 September 2002. This law implies a legalisation of euthanasia, but not of medical assistance in suicide [: F. Judo. Het wetgevend kader inzake euthanasie in België en Nederland: een korte verkenning. In: Eijk WJ, Stockman R, Raymakers JA, editors. Kwaliteit van leven in christelijk perspectief, Gent: International Institute Canon Triest; 2007, 33-49.]. This means that euthanasia performed by a doctor is no longer considered a crime under certain conditions. From a medical perspective, the condition is that the doctor has satisfied himself that the patient is in a medically hopeless condition of persistent physical or psychological suffering, which cannot be alleviated and is a consequence of a serious and incurable condition, caused by accident or disease (Art. 3, par. 1, 3eindent). It was notable that the Belgian Act on euthanasia explicitly allowed euthanasia for psychological suffering from the very beginning. There are also regulations for patients who are terminally and non-terminally ill and for patients who are no longer conscious. These patients do need to have a previously drafted written will. This must be co-signed by 2 witnesses who have no interest in the patient’s death. In 2020, the law was changed giving unlimited validity to these living wills. The University Hospital of Brussels introduced an “End-of-Life Clinic” in 2011. This clinic does not perform euthanasia, but mediates in end-of-life questions and in situations where other healthcare institutions did not consider euthanasia permissible.
As in the Netherlands, the number of euthanasia cases increased over time. [: Federale Controle- en Evaluatiecommissie Euthanasie. 11de verslag aan de wetgevende kamers (jaren 2022-2023). Brussel 2024.]
| Year | 2003 | 2019 | 2020 | 2021 | 2022 | 2023 | 2024 |
| Number of euthanasia reports | 235 | 2.655 | 2.444 | 2.699 | 2.966 | 3.423 | 3.991 |
| Proportion of euthanasia total deaths (%) | 0,22 | 2,44 | 1,93 | 2,40 | 2,55 | 3,08 | 3,56 |
Interestingly, although the share of euthanasia in all deaths is increasing, it remains lower than in the Netherlands (2024 3.56% versus 5.8% in the Netherlands). Following this increase in euthanasia cases, the question also arose in Belgium as to whether the increase is caused by euthanasia being used in more situations and, in fact, a slippery slope has emerged. The researchers who examined the euthanasia cases of the first 20 years concluded that this is not the case and that the increase is mainly due to demographic changes, with the population ageing. [: J. Wels and N. Hamarat. Incidence and Prevalence of Reported Euthanasia Cases in Belgium, 2002 to 2023. JAMA Netw Open. 20250401 ed 2025, 8, e256841 doi:10.1001/jamanetworkopen.2025.6841; L. Deliens. Assisted Dying and the Slippery Slope Argument-No Empirical Evidence. JAMA Netw Open. 20250401 ed 2025, 8, e256849 doi:10.1001/jamanetworkopen.2025.6849.] However, a shift was visible from euthanasia for malignant tumours to euthanasia for multimorbidity. There was no increase in euthanasia in psychiatric patients or in nursing homes.
Belgium also has a commission that reviews euthanasia retrospectively, the Federale Controle- en Evaluatiecommissie Euthanasie (Federal Control and Evaluation Commission on Euthanasia). The composition of this commission generated much debate from Belgium itself as well as from other countries, particularly due to the fact that its chairman, prof.dr. Wim Distelmans also performs euthanasia himself and thus cannot be independent in his assessments. [: A.S. Groenewoud and T.A. Boer. How legal euthanasia continues to be transgressive. Some Observations from the Netherlands. In: Schaafsma P, editor. The transcendent character of the good: philosophical and theological perspectives, Routledge: Taylor & Francis Group; 2022, 175-192 doi:10.4324/9781003305323-14.] The European Court of Human Rights also ruled that the Belgian monitoring commission was not sufficiently independent. [: European Court of Human Rights. Affaire Mortier c. Belgique. Strasbourg: Euroepan Court of Human Rights; 2023, 78017/17.] However, the composition of control commission has not been changed thereafter.
Luxembourg
In 2009, euthanasia and assistance in suicide by a doctor were legalised in Luxembourg under similar conditions as in the Netherlands and Belgium (Loi du 16 mars 2009 sur l’euthanasasie et l’assistance au suicide, 2009). In Luxembourg, this required a change in the constitutional power of the head of state, which was implemented almost without opposition. Grand Duke Henri had announced he would not approve the law due to conscientious objection to euthanasia. The constitutional amendment removed the need for approval of laws by the head of state. Grand Duke Henri received the Vatican’s Van Thuan human rights award in 2015 for his stance on the issue. Like the Belgian Law, Luxembourg’s also explicitly mentions mental suffering (if constant, unbearable and with no prospect of improvement) in addition to physical suffering as a reason to apply euthanasia (article 2.1.3). Luxembourg law requires majority (Article 2.1.1) and written confirmation of the person’s request (Article 2.1.4). Furthermore, the Law provides that there is a register with the Commission Nationale de Contrôle et d’Evaluation (Commission Nationale de Contrôle et d’Evaluation), where adults can deposit their wills regarding the conditions and circumstances under which they wish to undergo euthanasia in the event that the doctor establishes with them that they are suffering from an accidental illness or a serious and incurable disease, are unconscious and this situation is irreversible according to the current state of science (Article 4.1.). Any doctor treating a patient in a terminal stage of life or a patient in a hopeless medical condition is obliged to consult this register (Article 4.2.).
Anno 2025, apart from the Benelux countries, euthanasia has become available in Spain (since 2021), Canada (since 2021), Colombia, Peru, Ecuador, New Zealand (law from 2019, in force since 2021) and the six states of Australia (since 2021). In Switzerland, there has long been the possibility of assisted suicide. Generally, this is legislation that applies to people aged 18 and above. In France, a law allowing assisted suicide in cases of unbearable suffering was passed in 2025, In Portugal and Germany, the admission of euthanasia is under discussion. In the UK, the House of Commons passed a bill in June 2025 making euthanasia legal for terminally ill patients. The House of Lords is yet to consider the bill.
