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SEVEN CAVEATS CONCERNING THE DISCUSSION OF EUTHANASIA IN HOLLAND MARGARETP. BATTIN* As the discussion ofvoluntary active euthanasia heats up in the United States (indeed, I believe it will be the major social issue of the next decade, replacing abortion in that role), increasing attention is being given to its practice in the Netherlands. Proponents of the view that the United States should legalize euthanasiat (as legislation being proposed by the Hemlock Society in California, Oregon, and Washington would do) often cite the Netherlands as a model of practice; opponents, on the other hand, claim that Dutch practice already involves widespread abuse and will inevitably lead to more. For the most part, these generalizations invite misunderstanding, and they often reflect only the antecedent biases of those who make them. I would like to offer a few caveats for bioethicists about to become embroiled in the discussion of euthanasia— caveats offered in the hope ofcontributing to better mutual understanding during the next decade, rather than to greater polarization. 1.There are no hard data about the practice of euthanasia in Holland.— Despite the policy that cases of active euthanasia are to be reported to the Ministry of Justice, only a very small fraction are: of the estimated annual 6,000 cases (itself a very loose estimate), in 1987 only 197 were actually reported and provide the only reliable set of data. There have been no comprehensive empirical studies of unreported euthanasia— nor, given its tenuous legal status (to be described below), is it clear how unbiased data could be obtained. Most discussions of euthanasia—both pro and con—appeal to anecdotes about specific cases, not to data covering the full range of cases. 2.Exaggerations are frequent.—It is also sometimes supposed that euthanasia is a routine, frequent, everyday practice in the Netherlands, a commonplace that happens all the time. On the contrary, euthanasia is comparatively rare. If the estimate of 6,000 cases a year is accurate *Department of Philosophy, University of Utah, Salt Lake City, Utah 84112.© 1990 by The University of Chicago. All rights reserved. 0031-5982/91/3401-0705$01.00 Perspectives in Biology and Medicine, 34, 1 ¦ Autumn 1990 \ 73 (though most observers now believe this is too high, and informal estimates are being revised downward), this would represent, in a country with (in 1987) a population of 14.5 million and a total annual mortality of about 120,000, at most 5 percent of all deaths. In other words, 95 percent or more of deaths in Holland do not occur in this way. 3.Terminological differences operate to confuse the issue.—By and large, Dutch proponents of euthanasia use the term to refer only to what in the United States would be called voluntary active euthanasia. The term "active euthanasia" is considered essentially redundant and the term "passive euthanasia" meaningless. However, the Dutch also employ the term levensbeeindigend handelen (life-ending treatment) to refer to practices that result in the death of the patient but cannot be considered voluntary active euthanasia; these for the most part are confined to withholding or withdrawing treatment, for instance in severely defective newborns, permanent coma patients, and psychogeriatric patients (situations in which withholding or withdrawing treatment is ubiquitous in the United States), but may sometimes, though rarely, involve direct termination . Thus the claim that there is no nonvoluntary active euthanasia in Holland may seem to be merely analytically true. On the other hand, it is clear that claims by some of the more vocal opponents of euthanasia also rest on terminological confusion. For instance, the Dutch cardiologist Richard Fenigsen's assertion that involuntary euthanasia outside the guidelines is widespread rests on his conflating what in the United States would be called active and passive euthanasia: Fenigsen, like many others ofthe opposition, does not distinguish between causing death and withholding or withdrawing treatment, that is, what we call "allowing to die." In the United States, withholding or withdrawal of treatment, including respiratory support, chemotherapy, and nutrition and hydration , tends to be regarded as morally acceptable in certain circumstances even when these decisions are not made by the patient but by second parties (a view reflected in (¿uinlan, Saikewicz, Conroy, and to...


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