Voluntary euthanasia under control?
The latest empirical evidence on euthanasia in the Netherlands
Jochemsen and John Keown
Institute for Medical Ethics, the Netherlands and University of
ninety-six saw the publication of a major Dutch survey into euthanasia in the
Netherlands. This paper outlines the main statistical findings of this survey
and considers whether it shows that voluntary euthanasia is under effective
control in the Netherlands. The
paper concludes that although there has been some improvement in compliance with
procedural requirements, the practice of voluntary euthanasia remains beyond
(Journal of Medical Ethics 1999;25(1):16-21. Reproduced with permission)
(Journal of Medical Ethics 1999;25(1):16-21. Reproduced with permission)
Euthanasia; the Netherlands; regulation; slippery slope
Worldwide, the euthanasia debate
continues to intensify. In 1997,
the Australian parliament voted to repeal euthanasia legislation in the Northern
Territory and the US Supreme Court upheld the constitutionality of legislation
prohibiting "physician-assisted suicide"(1). In deciding whether euthanasia or
assisted suicide should be permitted in principle, and whether they can be
controlled in practice, the experience of the Netherlands, where they have been
officially tolerated and widely practised for well over a decade, is clearly of
Nineteen ninety-one saw the
publication of the results of an important survey, by Professor PJ van der Maas,
into end-of-life decision making by Dutch doctors in the year 1990 (2). Despite
claims to the contrary by supporters of Dutch euthanasia, this survey helped to
cast serious doubt on Dutch claims that their guidelines were sufficiently
strict effectively to control the practice of voluntary euthanasia (the
intentional termination of patients' lives at their request) and to prevent
non-voluntary euthanasia (the intentional termination of the lives of
patients incapable of making a request).
The survey disclosed the widespread
practice of non-voluntary euthanasia; the use of euthanasia even when doctors
thought that palliative care was a viable alternative, and the common practice
by doctors of illegally certifying euthanasia deaths as deaths by "natural
causes" instead of reporting them, as required by the guidelines, to the
In 1996, Van der Maas and Van der
Wal published the results of an extensive survey into end-of-life decisions by
Dutch doctors in the year 1995 (4). Do the results of this survey show any
improvement in the degree of control over euthanasia?
The survey sought particularly to
ascertain the incidence of intentional life-shortening by doctors; the
extent to which they complied with their duty to report such cases (in
accordance with a procedure dating from late 1990 which was given statutory
force in june 1994), and the quality of their reporting. The main purpose of the reporting
procedure is to provide for possible scrutiny of the intentional termination of
life by doctors and to promote careful decision making in such cases (5). The
most important quantitative data generated by the survey are reproduces in table
Before the figures are analysed, it
is important to note that the only objectively verifiable figures are those
concerning the total number of deaths and the total number of cases
reported. All the other figures are
based en the responsos of the physicians concerning cases in which they said
they had recently been involved.
It is no less important to stress
that this paper does not question the methodology used by the rescarchers to
obtain their data, namely, interviews with 405 physicians and postal
questionnaires mailed to physicians who had attended 6.060 deaths identified
from death certificases. We use the
researchers' own data and standardly cite their "best estimate" (though in some
cases numbers have been arrived at en the basis of percentages and
numbers used in the survey and, in such cases, we have rounded off the number
In other words, our paper does not take
issue with the researchers' methodology
but with their interpretation
of the statistics it generated.
final preliminary point is that the Dutch adopt a particularly narrow definition
of "euthanasia" as the intentional shortening of a patient's life at the
patient's explicit request. In
other words, "euthanasia" in the Netherlands means "active, voluntary
euthanasia" and does not include intentional life-shortening by omission
("passive euthanasia") or euthanasia without the patient's request (whether
non-voluntary if the patient is incompetent or involuntary if the patient is
competent.) For ease of exposition, the Dutch definition is followed here unless
the contrary is apparent.
1. EUTHANASIA AND ASSISTED SUICIDE
Between 1990 and 1995 the number of requests for euthanasia
increased, as did the number of requests granted.' Cases of euthanasia and
assisted suicide rose from 2,700 cases in 1990 to 3,600 in 1995, or from 2. 1 %
to 2.7% of all deaths.
According to the attending physicians, there were treatment
alternativas in 17% of these cases but in almost all the patients did not want
them (7). However, in 1994, the
Dutch Supreme Court held that doctors should not hasten death whenever the
alternativa of palliative treatment was available, at least in cases of mental
suffering (8) and the ministers of justice
and health (9) and the Royal Dutch Medical Association (KNMG)(10) have decided
that the same restriction should apply in cases of somatic suffering. The above cases appear, therefore, to
have breached this guideline.
Life was shortened by one to four weeks in 31% of euthanasia
cases and 45% of assisted suicides and by more than a month in 7% of cases of
euthanasia and in 30% of assisted suicides (11).
Physicians stated that the main reason why
patients requested euthanasia was "intolerable suffering without prospect of
improvement" (74%)(12), which has become the standard terminology to
describe the seriousness of the condition required by the law. But the next most common reasons were
"to prevent loss of dignity" (56%) and "to prevent further suffering"
(47%). It must surely be doubted
whether either of these reasons, by itself, satisfies the requirement of
Interestingly, one of the most important reasons
for rejecting a request for euthanasia (cited by 35% of physicians) was the
physician's opinion that the patient's suffering was not intolerable (13). This
suggests that, despite the emphasis placed by the advocates of euthanasia on
patient autonomy, the application of euthanasia is more a function of the
physicans judgment about the quality of the patient's life than of respect for
the patient's autonomy. This
suggestion is fortified by the evidence about the extent to which Dutch doctors
continue to terminate the lives of patients without an explicit request.
2. LIFE-TERMINATING ACTIONS WITHOUT EXPLICIT
The survey confirms that the intentional
shortening of patients' lives without explicit request remains far from
uncommon. Nine hundred patients had
their lives ended without explicit request in 1995, representing 0.7% of all
deaths, only a slight decrease en the 0.8% so terminated in 1990 (14). In other
words, of the 4,500 (3,200 + 400 + 900) cases in which doctors admitted they
actively and intentionally terminated life, one in five involved no explicit
The main reason for not discussing the issue with
the patient was stated to be the patient's incompetence (due, for example, to
dementia). But not all patients
whose lives were terminated without an explicit request were incompetente. In
15% of cases where no discussion took place but could have, the doctor did not
discuss the termination of life because the doctor thought that the termination
of the patient's life was clearly in the patient's best interests (15).
Furthermore, in a third of the 900 cases, there
had been a discussion with the patient about the possible termination of life,
and some 50% of these patients were fully competent, yet their lives were
terminated without an explicit request (16).
Moreover, in 17% of the 900 cases, treatment
alternativas were thought to be available by the attending physician (17).
The physicians thought that life was shortened by
one to four weeks in 3% of cases but by more than a month in 6%.(18) Finally,
physicians had not discussed their action with a colleague in 40% of cases, with
a close relative in 30% of cases, and with anyone at all in 5%.(19)
INTENSIFICATION OF PAIN AND SYMPTOM TREATMENT
In 20,000 cases (according to the
physician interviews) or 25,800 cases (according to the death certificase
survey), palliative drugs were administered in doses which almost certainly
shortened life. In some 2,000 of
these cases the doctor explicitly intended, and in a further 2,850 cases, partly
intended, to shorten life.(20) The researchers estimate that the grey area
between intending to alleviate pain and symptoms and intending to shorten life
is about 2% of all deaths, the same as in 1990.(21)
Where doctors administered
palliative drugs partly in order to shorten life, they had discussed Ħt with the
patient in just over half of the cases (52%) and in only 36% of the cases was
there an explicit request for life-shortening doses by the patient. The physicians stated that 86 patients
(3%) with whom they had not discussed this treatment were fully competent (22).
Moreover, in only 36% of the cases had the doctors consulted a colleague. Life was shortened by an estimated one
to four weeks in 7% of cases but by more than a month in 1 %.(23)
In some 27,300 cases a
treatment was withheld or withdrawn (in 5,200 cases at the patient's explicit
request) taking into account a probable shortening of life.
However, in 18,000 of these cases (14,200 of which involved no explicit
request by the patient) it was the physician's explicit intention to shorten
life (though the survey does not state in how many cases the treatment was
disproportionate, in which case doctors could, had they wished, have properly
withdrawn it for that reason and without intending to shorten life).(24)
In the majority of cases in which
no discussion with the patient had taken place, the physicians stated that the
patient was either incompetent or only partly competent. However, in 1 % of
these cases (140 patients) the physician considered the patient fully
In cases where treatment was
withheld or withdrawn with the explicit intent to shorten life, the
physician estimated that life was shortened by one to seven days in 34% of
cases, by one to four weeks in 18% and by more than a month in 9%.(26)
The survey reports that over 1,000
newborns die in the Netherlands before their first birthday and estimates that
the lives of about 15 are actively and intentionally terminated by doctors.(27)
The figure of 15 seems however, a significant underestimate.
The survey shows that in ten cases
(1 %) doctors administered a drug with the explicit intention of shortening
life. But it also reveals a further
80 cases in which, also with the explicit intention of shortening life, doctors
administered a drug and withdrew or withheld a life-prolonging treatment.(28) In
total, therefore, it appears to have been the explicit intention of doctors to
shorten the lives of 90 neonates, not 15.(29)
Moreover, in no fewer than 41% of
the 1,000 cases, treatment was withdrawn or withheld with the explicit intention
of shortening life. In a
significant proportion of these cases, life was terminated because the babies'
lives were not thought bearable.
Forty-flve per cent of these babies were expected to live more than four
weeks, and some of them more than half a year.(30)
In around a fifth of cases in which
doctors intentionally withheld or withdrew treatment with the explicit purpose
of shortening life because the baby's life was thought unbearable, there had
been no discussion with the parents.(31) Doctors said that in most cases this
was because the situation was so clear that discussion was unnecessary or
because there was no time, though these reasons are not elaborated.
Finally, doctors reported hardly
any cases ofthe intentional shortening of neonatal life to the authorities.
SUICIDE OF PSYCHIATRIC PATIENTS
Based on the replies of
psychiatrists in respect of the year 1995, the survey estimates that although
some 320 psychiatric patients explicitly request assistance in suicide annually,
only two to five are assisted to commit suicide by psychiatrists. Among psychiatrists who would never
grant a request for assisted suicide on the basis of mental suffering (almost
1/3 of the respondents) "professional opinion" was cited by 88% as the most
important reason. Only 2% of
psychiatrists had ever assisted suicide.(32)
This relatively restrictive approach of psychiatrists may owe not a
little to the controversy generated by the case of Dr Chabot, a
psychiatrist criticised by a medical disciplinary court for assisting in the
suicide of a 50-year-old woman who suffered grief after the loss of her two
Disclosing statistics which support a restrictive approach, the survey
also indicates that of those patients not assisted in suicide, 16% committed
suicide without assistance by a physician and that, of those patients still
living, 35% no longer wished for death and that the death wish in a further 10 %
The guidelines for permissible
euthanasia and assisted suicide require the doctor, before agreeing to
either, to engage in a formal consultation (consultatie), and not merely an informal
discussion (overleg), with a
In cases of euthanasia and assisted
suicide 92% of doctors had, according to the survey, discussed the case with a
colleague.(34) In 13% of these cases, however, the discussion did not amount to
a formal consultation. Consultation
took place, therefore, in 79% of cases.
However, other figures in the survey suggest that consultation occurred
in a significantly smaller percentage of cases. For the survey indicates that
consultation occurred in 99% of reported cases but in only 18% of unreported
cases (35) and that almost 60% of all cases of euthanasia and assisted suicide
were not reported,(36) from which it seems that consultation occurred in only
around half of all cases.(37)
In the cases of life-termination
without explicit request, a discussion occurred in 43% of cases but in 40% this
did not amount to consultation.
Consequently, there was no consultation in 97% of such cases.
Moreover, even when consultation
did take place, it was usually with a physician living locally and the most
important reasons given for consulting such a physician were his views on
life-ending decisions and his living nearby: expertise in palliative care
was hardly mentioned. Further, in
the overwhelming majority of cases, the first doctor had made his mind up before
consulting and the doctor consulted disagreed in only 7% of cases.(38) In short,
the requirement of consultation, even when it is satisfied, hardly operates as a
rigorous check on decision making.
In 1995 41%
of cases of euthanasia and assisted suicide were reported to the local medical
examiner, as required by the reporting procedure. While this is an improvement
on the figure of 18% reported in 1990, it means that a clear majority of cases,
almost 60%, still go unreported.
Moreover, the survey confirms that the legal requirements are breached
more frequently in unreported cases, in which there is less often a written
request by the patient, a written record by the doctor, or consultation by
important reasons given by doctors for failing to report in 1995 were (as in
1990), the wish to avoid the inconvenience (for the doctor and/or the relatives)
of an investigation by the authorities, and to avoid the risk of prosecution
(though, as the consistently tiny number of prosecutions indicates, this risk is
negligible). Thirty per cent of
doctors stated that they did not report because they had failed to observe the
requirements for permissible euthanasia and 12% because they considered
euthanasia was a private matter between doctor and patient.(40)
survey confirms at least three disturbing findings of the first survey
1. INCIDENCE OF INTENTIONAL
LIFE-SHORTENING WITH AND WITHOUT EXPLICIT REQUEST
first survey, the second indicates a sizeable incidence of intentional
life-shortening by Dutch doctors.
Even adopting the unusually narrow Dutch definition of euthanasia as
active, voluntary euthanasia there were no fewer than 3,200 cases in 1995
(2.4% of all deaths), an increase of almost a thousand on the 1990 total of
2,300 (1.8% of all deaths).
But if all
cases in which doctors explicitly intended to shorten life (whether by act or
omission, and whether with or without the patient's request) are included, the
total rises steeply. Adding the
cases of assisted suicide (400); life-termination without explicit request (900)
and the intensification of pain and symptom treatment with the explicit intent
to shorten life (2,000), the total more than doubles from 3,200 to 6,500.
And if to
this number are added the cases of withholding or withdrawing treatment with the
explicit intent to shorten life (18,000)(41); cases in which neonates were
intentionally terminated (90 cases) and psychiatric patients assisted in suicide
(two to five cases), the total rises to over 24,500 cases.
2. EUTHANASIA AS AN
ALTERNATIVE TO PALLIATIVE CARE
comment that "the quality of medical treatment near the end of life has
improved"(42) might not unreasonably be thought to display a certain
complacency, particularly in a country which has some way to go in the provision
of adequate palliative care. The
high incidence of intentional life-shortening disclosed by the survey and the
relative weakness of the reasons for euthanasia given in many cases by the
doctors tend to suggest that euthanasia is not confined to cases of "last
resort" and is at least sometimes used as an alternativa to palliative
care. The case of Dr Chabot, in
which the defendant doctor assisted a grieving woman, whom he did not consider
to be physically or mentally ill, to kill herself, and in which the Supreme
Court held that such suffering could indeed justify assisted suicide,
ĦIlustrases the elasticity of the requirement of "unbearable suffering".
confirms that, even when doctors believe that treatment alternativas are
available, they not infrequently resort to euthanasia. The opinion of the Supreme Court, the
ministers of justice and health, and the KNMG, that euthanasia is
impermissible when treatment alternativas are available, even if the patient
refuses them, has clearly not prevented its administration in such
circumstances. In a move that would
make the prospect of prosecution even more remote, the then minister of justice
appeared to reverse her earlier position and instructed the attorneys general
that the refusal by the patient of available treatment alternativas does not
tender euthanasia unlawful.(43)
3. WIDESPREAD BREACH OF THE
REQUIREMENT TO REPORT
of cases (1,466) were reported in 1995 as opposed to 18% (486) in 1990, it
remains true that in both years, as in every year in between, a clear majority
of cases has gone unreported. There
was, in short, no official control whatever over the majority of cases of
euthanasia, assisted suicide or the termination of life without explicit
the alleged increase in reporting be accepted uncritically. First, the second survey records an
increase in cases of euthanasia between 1990 and 1995 (900 cases) almost as
large as the increase in cases reported (980 cases). Secondly, if the total of 6,500 cases of
active, intentional life-shortening is used, then the proportion of unreported
cases rises from 59% to 77%. On the
total of 24,500 cases, the proportion unreported reaches 94%.
It will be recalled that the
purpose of the reporting procedure is to allow for scrutiny of the intentional
termination of life by doctors and to promote observance of the legal and
professional requirements for euthanasia.
The undisputed fact that a clear majority of cases (59% according to the
survey, at least 77% on our calculations) still goes unreported, serves only to
reinforce doubts about the ability of the procedure to fulfil its purpose
and to undermine Dutch claims of effective regulation, scrutiny and
control. Further, even those cases
which are reported are reported by the doctor, and one may wonder whether the
doctor's report is any more likely to disclose evidence of wrongdoing than is a
tax return to disclose evidence of undeclared earnings.
publication of the first Van der Maas survey in 1991 it became clear that the
so-called "strict safeguards" laid down in 1984 by the courts and the Royal
Dutch Medical Association had largely failed. The survey cast doubt on central
assurances which had been given by the advocates of voluntary euthanasia:
that euthanasia would be performed only at the patient's explicit request and
that doctors terminating life without request would be prosecuted for murder;
that euthanasia would be used only in cases of "last resort" and not as an
alternativa to palliative care; and that cases would be openly reported and duly
scrutinised. The Dutch reaction to
the survey's findings was also revealing: the cases of nonvoluntary
euthananasia Ħt disclosed, far from being criticised, were largely
condoned. In short, the survey
indicated that, in less than a decade, the Dutch had slid down the slippery
It is therefore surprising that an
American commentator should observe that the similarity between the findings in
respect of 1990 and 1995 shows that the Dutch are apparently not descending
a slippery slope.(44) This observation quite overlooks the fact that the
first survey showed that the descent had already occurred by 1990: the second
survey, far from showing that there has been no descent from 1984 to 1995 shows
merely that there has been no significant ascent from 1990 to 1995.
The second survey is little more
reassuring than the first. Dutch
proponents of voluntary euthanasia claimed that tolerating voluntary
euthanasia, subject to "safeguards", would allow it to be "brought into the
open" and effectively controlled.
As the valuable surveys by Van der Maas and Van der Wal disclose, and as
severas expert commentators have now concluded,(45) the reality is that a clear
majority of cases of eutanasia both with and without request, go unreported and
unchecked.(46) In the face of the undisputed fact that in a clear majority of
cases there is not even an opportunity for official scrutiny, Dutch claims of
effective regulation ring hollow.
Jochemsen, PhD, is Director of the Lindeboom Institute for Medical Ethics. John Keown, DPhil, is
University Lecturer in the Law and Ethics of
Medicine in the Faculty of Law,
University of Cambridge.
Washington v Glucksberg
(1997) 117 S Ct
2258; Vacco v Quill (1997) 117 S
2 Maas Pj
van der et al. Medische beslissingen rond
's-Gravenhage: SDU Uitgeverij Plantijnstraat,
1991 (published in translation as Euthanasia
and other medical decisions concerning the end oflife. Amsterdam: Elsevier,
3 See for
example Jochemsen H. Euthanasia in Holland: an ethical critique of the new
law. _yournal of Medical Ethics
1994;20:212; Keown J. Euthanasia in the Netherlands: sliding down the slippery
slope? In: Keown J, cd.
Cambridge University Press, 1995: ch 16.
4 Wal G van der, Maas
Pj van der. Euthanasie en andere niedische beslissingen rond het levenseinde. De praktijk en de
(Euthanasia and other medical decisions concerning the end of
life. Practice and reporting procedure.)
Den Haag: SDU uitgevers, 1996.
For summaries of the research in English see Maas Pj van der. Euthanasia, physician-assisted suicide,
and other medical practices involving the end of life in the Netherlands,
1990-1995. New England _7ournal of Medicine
1996;335:1699; van der Wal G. Evaluation of the notification
procedure for physician-assisted death in the Netherlands. New
England Journal of Medicine
5 See reference 4:
6 See reference 4:
tables 5.3; 6.2; 9. 1.
7 See reference 4:
Juristenblad 1994; 69 nr26:
895ff. See also Jochemsen H. The
Netherlands experiment. In: Kilner
JF et al, eds. Dignity and dying .
Grand Rapids: Eerdmans, 1996: ch 12; Hendin H. Seduced by death: doctors, patients and the Dutch
cure. New York: WW
Norton, 1997: ch 2.
9 Sorgdrager W,
Borst-Eilers E. Euthanasie - De stand van zaken. Medisch Contact 1995;12: 381-4.
10 Kastelijn WR. Standpunt hoofdbestuur KWMG inzake
euthanasie. Utrecht: KNMG, August
11 See reference 4:
12 See reference 4:
13 See reference 4:
14 See reference 4:
table 6.2; 92.
15 See reference 4:
16 This suggests a
disturbing incidence not only of non-voluntary euthanasia but also of
17 See reference 4:
18 See reference 4:
19 See reference 4:
20 See reference 4:
This figure is
calculated from the researchers'percentages and estimates at pages 92-93. In fact the figure of 2,000 is
conservative as Ħt is derived from the total number of 20,000 cases yielded by
the physician-interviews rather than from the larger total of 25,800 in the
death certificase study."Explicit" is the rescarchers' translation of the word
"uitdrukkelijk". We think a more
accurate translation would be "primary" as a purpose can be explicit yet
secondary or primary yet implicit.
21 See reference 4:
22 See reference 4:
23 See reference 4:
tables 7.3; 7.5.
24 See reference 4:
tables 8. l; 8.3; 84.
25 See reference 4:
tables 8.l; 8.3.
26 See reference 4:
27 See reference 4: 1
28 See reference 4:
29 The researchers'
estimate of 15 cases may be traced to their observation that in 17% of cases in
which drugs were administered with the explicit intent to shorten life
(totalling 15 cases), one of the drugs administered paralysed muscles and
therefore caused death almost immediately whereas in a majority of cases in
which drugs were administered in combination with the withdrawal oftreatment,
the treatment withdrawn was artificial ventilation and the medication may have
been administered to preyent suffocation.
30 See reference 4:
31 See reference 4:
32 See reference 4:
table 1 S. l.
33 See reference S:
Hendin: ch 2.
34 See reference 4:
table 1 0. l.
35 See reference 4:
36 See text en page 19
immediately preceding reference 39.
37 The reason for the
discrepancy between the two totals might be a certain bias in the physicians'
responsos. 'ne authors of the
survey suggest that some of the physicians interviewed, when asked to discuss
their most recent case of
euthanasia, in fact discussed a recent case which had a stronger impact,
probably because Ħt was reported.
See reference 4: 113.
38 See reference 4:
39 See reference 4:
table 1 l. 6.
40 See reference 4:
table 1 I.S; 225.
41 14,200 of these
cases involved no explicit request from the patient. In cases where the patient had refused
treatment, the doctors could properly, had they wished, have omitted treatment
for this reason and without intent to shorten life.
Similarly, as was
mentioned above, it is unclear in how many cases ofnon-treatment the treatment
was in fact disproportionate and could properly have been withdrawn for
that reason without the doctors resorting to an intention to shorten life.
42 See reference 4:
43 See reference 4:
44 See for example
Angell M. Euthanasla in the Netherlands good news or bad? New
England Journal of Medicine 1996;335: 1677.
45 See for example
Gomez C. Regulating death. New York: Free Press, 1991;
see reference 8: Hendin; see reference 3: Jochemsen; see reference 3:
46 While acknowledging
this fact, Dr Angell suggests that doctors fail to report because they find the
reporting procedure "burdensome" and "daunting". See reference 44: 1677. But it is difficult to see how the
procedure - the filing of a report with the local medical examiner (another
doctor) in the sure knowledge that if the guidelines have been followed
there is no prospect of prosecution - can realistically be so describes. Indeed, many doctors admit that they
omit to report simply because they do not want the inconvenience of an
investigation either for themselves or the family (see text at page 19
immediately preceding reference 40).
Table 1 End-of-life decisions by
doctors in the Netherlands 1990-1995
|Deaths in the Netheriands||129000 (100%)||135500 (100%)|
|Requests for euthanasia||8900 (7%)||9700 (7.1%)|
|Euthanasia||2300 (I.S%)||3200 (2.4%)|
|Assisted suicide||400 (0.3%)||400 (0.3%)|
|Life-terminating acts without explicit request||1000 (0.8%)||900 (0.7%)|
|Intensification of pain and symptom treatment||22500 (17.5%)||20000 (14.8%)|
|a. Explicitly intended to shorten life||1350 (I%)||2000 (I.S%)|
|b. Partly intended to shorten life||6750 (5.2%)||2850 (2.1%)|
|c. Taking into account the probability that life will be shortened||14400 (11.3%)||15150 (11.1%)|
|Withdrawal/withholding treatment (incl tube-feeding)||22500 (17.5%)||27300 (20.1%)|
|a. At the explicit request of the patient||5800 (4.5%)||5200 (3.8%)|
|b. Without the explicit request of the patient|
|b1. Explicitly intended to shorten life||2670 (2.1%)||14200 (10.5%)|
|b2. Partly intended to shorten life||3170 (2.5%)||-|
|b3. Taking into account the probability that life will be shortened||10850 (8.4%)||7900 (5.8%)|
|Intentional termination of neonates|
|a. Without withholding/withdrawing treatment||-||10.00|
|b. Withholding/withdrawing treatment plus administration of medication explicitly to shorten life||-||80.00|
|Assisted suicide of psychiatric patients||2-5|