The legalisation of euthanasia and physician-assisted suicide in the Netherland is considered by many to be a social experiment [7], and people in many other countries keep a (sometimes critical) eye on Dutch practices and debates [8]. While several studies have provided reliable estimates about the frequency and characteristics of the practice of euthanasia in the Netherlands [9], this is the first study providing an overview of how euthanasia is described and debated in Dutch newspapers. Our study shows that nearly a quarter of Dutch newspaper articles used the term euthanasia for practices that were outside the scope of Dutch euthanasia law. Further, our analysis showed the wide-ranging nature of the public debate. Euthanasia was discussed in varying contexts and situations: for terminally ill patients but even more so for other groups such as older persons, persons with dementia, or persons with a psychiatric disorder. Also, there was a large variety of organisations and associations used as sources as well as there being variety in the arguments for or against euthanasia.
The term euthanasia, literally meaning a “good death”, has had different meanings depending on the historical and political context. Nowadays, euthanasia is understood by authorities to be the intentional ending of life by the administration of drugs by a physician at the explicit request of a patient[1], This definition is broadly accepted and adopted in legal regulations and in research. Yet nearly a quarter of the newspaper articles used the term euthanasia for practices that are outside the scope of this definition. In several instances, the term euthanasia referred to physician-assisted suicide (where the patient and not the physician administers the lethal drug), a practice that provokes quite similar moral debates as euthanasia, but is a different practice [1]. In other instances, the term euthanasia referred to practices that involve moral considerations that are different from those associated with euthanasia, such as the ending of life without a request of the patient (morally more problematic than euthanasia, many would feel) or the forgoing of potentially life prolonging treatments (usually morally less problematic, most would say). Also, the term was sometimes used for practices that do not involve a physician, including for example assisted suicide by non-physicians, suicide, or metaphorical usages. Taken together with the fact that 40% of the newspaper articles did not give any description of what practices the term euthanasia referred to, this means that one should be very cautious as to what people mean when they think they are discussing ‘euthanasia’. Because newspapers are generally considered to be an important source of health information [6], this kind of definitional variability is likely to feed misunderstanding and confusion in public debates. Moreover, for effective public health policy and compliance with Dutch legal regulations, a shared understanding of key concepts and terminology is essential.
In 2010, of all deaths in the Netherlands, 2.8% were the result of euthanasia [9]. Physician-assisted suicide was practiced less often, in 0.1% of all deaths. The large majority of euthanasia patients were diagnosed with cancer, were younger than 80 years of age, had a very short life expectancy and all were considered to be mentally competent when they made their request [9]. Euthanasia for persons who are old but not terminally ill, or who have (partly) lost mental capacity (e.g. due to a psychiatric disease, a coma or dementia) is practiced rarely. Yet euthanasia for these patients groups is quite commonly discussed in Dutch newspaper articles. Rather than reflecting practice, this reflects current medical and political debates about euthanasia which predominantly focus on the boundaries of current legislation. Examples of such boundary debates include the legitimacy of accepting “unbearable suffering” as a reason for euthanasia in patients with no serious medical condition [10, 11], and the degree to which advance directives might substitute for a verbal request when the patient has become mentally incapacitated [12–14]. Media coverage of the practice of euthanasia, therefore, reflects a focus on more controversial cases rather than reporting on the majority of situations in which euthanasia is actually performed. While the media as such fulfils an important task of contributing to a societal debate and highlighting controversy, such coverage may lead to an inaccurate perception of the practice of euthanasia by the public [15].
Until recently, the Netherlands was known for tolerant policies on controversial issues such as abortion, drug abuse and euthanasia [16]. Factors often mentioned as contributing to these policies are the openness of the Dutch in discussing difficult issues, their tendency to prefer consensus and a strong trust in health-care providers [8, 17]. This is also reflected in the fact that the Euthanasia Law receives ample support among the general public and health care professionals [18]. However, our study shows that Dutch public debate about euthanasia, especially its boundaries, does not necessarily involve an easy consensus. The opinions of both advocates and opponents allowing euthanasia for controversial groups are clearly visible, with a wide array of arguments for and against euthanasia being presented. The most commonly used arguments for euthanasia were that self-determination is a right and that the practice alleviates severe or unbearable suffering. The responsibility of society to regulate the response to the wish for assistance in dying of patients experiencing unbearable suffering was emphasised in these arguments, which are all central in current medical, ethical and political debates about euthanasia. A few newspaper articles argued that euthanasia might be a solution for the aging of the population or be a way of conserving scarce resources, which is obviously a morally more problematic argument, though perhaps attractive to journalists wanting to focus on more extreme positions. Arguments against the use of euthanasia refuted the right to self-determination and presented a different perspective on the core responsibilities of society, by focussing on the need to protect the vulnerable. There were also claims that suffering can be meaningful.
Our study also sheds light on a less debated aspect of the practice of euthanasia, that is, whether euthanasia contributes to a good death. This argument divides opponents and advocates of euthanasia. On the one hand, it is argued that euthanasia might contribute to a good, dignified, “civilized” death, for example by preventing distressing forms of suicide. On the other hand, euthanasia is described by some as too abrupt and unnatural for both patients and relatives and as a disturbing experience for physicians. This illustrates how perceptions about this practice and the dying phase in general may vary, and it underlines the need for medical practitioners to both counsel patients and their families about the course of their illness and dying phase, and to consider their own responses to such momentous end-of-life decisions as euthanasia.
