Silent pressure
Once you have a law … it is absolutely impossible to put a police officer in every hospital room or in every bedroom … and look [for] some silent pressure,” he said.
“That is impossible, because that will infringe very much on the privacy of their patient-doctor relationship, so there is no solution,” Prof Boer said.
‘Assisted dying’ is an umbrella term for two different things that reside under one law in the Netherlands – euthanasia by which the physician uses an infusion or injection to end a patient's life at their request and, secondly, a physician-assisted suicide where a medic hands a patient a deadly poison to end their own life, he explained.
In 97 out of 100 assisted deaths in the Netherlands – up from 90 out of 100 in 2002 – euthanasia is preferred over assisted suicide with the number strongly rising, he said.
Euthanasia has “sky-rocketed” in the Netherlands, he said.
“The legalisation of euthanasia has done much more than just providing some citizens the liberty to take a way out,” he said.
It has created death as a remedy against "unbearable suffering", he said, and moved society from the presumption of "not killing".
Most patients shy away from performing the acts themselves, he added.
'Desperate system'
He described assisted deaths as part of an increasingly “permissive, cynical and sometimes desperate system of end-of-life decisions” for which individuals bear very little personal responsibility.
Prof Boer said that his scepticism did not stem from his Protestant background in the liberal Dutch Reformed Church, which was the first church worldwide to support assisted dying back in the 1970s.
“My critique arises from what I have seen happen in practice,” he said, pointing out that numbers in Holland are now rising significantly and have quadrupled in 20 years.
The increases are accelerating, with assisted deaths now accounting for 15% to 20% of all deaths in some regions, he said.
'Expansion of the pathologies'
There has also been an “expansion of the pathologies” of reasons underlying a request to die, he stated.
“We see a shift to patients who fear years or decades of loneliness, alienation and care dependency,” he said.
In the Netherlands, as in other countries that have legalised assisted dying, this expansion is motivated by a “logic of justice.”
The option of euthanasia has expanded from terminal cancer patients to: those with chronic illnesses, anyone suffering from an illness, non-medical suffering, and legalisation for anyone over the age of 74.
Parents can now request euthanasia for their young children, Prof Boer said. And teens over 16 may opt for euthanasia, simply by informing their parents, but without asking their consent.
The legalisation of euthanasia has altered the whole landscape of dying, including the societal view of illness, suffering, ageing, and care dependency, he added.
Dying as a task
“Dying increasingly has become a life project, a task to be managed,” he said.
“Present considerations and upcoming decisions are among the most consequential that any parliament can ever take,” he told the Irish politicians.
He suggested that euthanasia should not be legalised in Ireland, but that assisted dying should not be criminalised.
Silvan Luley of Dignitas told the committee that: “Voluntary assisted dying should be legalised as a choice for the Irish, alongside other options to soothe suffering and improving quality of life, may it be palliative care, hospice work, suicide-attempt prevention, good care in old age, and more.”
In Switzerland, a patient who wishes to die must take an active role in administering the lethal drugs.
Euthanasia is not legal where another person administers the lethal dose.
Non-residents may travel to Switzerland to avail of assisted dying.
‘Emergency exit door’
Assisted dying gives patients “what everyone deserves: a legal way to exercise the human right of freedom of choice on all options of professional care to soothe suffering and end life, at their home," he said.
“It’s not about making use of this option right away, but having an emergency exit door which provides emotional relief and can prevent people from having to use rough methods,” he said.
He stated that without such means, some may choose to die using more violent methods.
“In my 20 years of working with Dignitas – this might sound strange to you – I’ve never seen somebody who wants to die,” he said.
“The people who come to Dignitas, they don’t want to die; [but] they don’t want to continue living in a situation that they feel does not match their quality of life from their personal perspective.”
Impact of good palliative care
Prof Boer said that it is Western countries alone that debate assisted dying, with cases very uncommon in minority communities.
The availability of good palliative care, and of volunteers to assist the dying with their care needs, lowers the rate of those choosing death, he said.
“In Amsterdam, there are exactly twice as many euthanasia cases as there are in Rotterdam,” he added.
“There's an almost 30 times difference between the lowest and the highest regions,” he said.
Health is defined under physical, mental, spiritual, and social metrics, he said.
Life without hope
“People can live through 30 days without eating, three days without drinking, three minutes without oxygen, but not three seconds without hope,” he said.
“It's the total absence of hope, either in the persons themselves or in their surroundings, that contributes to their suffering,” he commented.
The Netherlands now has up to 10,000 cases per year, and trending upwards, he said.
“Perhaps I would be in favour of the Swiss system,” he added, “in that legalised euthanasia means that the doctor is the primary actor, which has a major impact on the numbers.
“People think that that ‘dying through the needle’, as we say here in the Netherlands, is part of a medical procedure, part of good medical care.
“I think the advantage of the Swiss system is that this [medical-procedure] impression is not given by physicians.”
Psychiatric cases
A Dutch voluntary society runs an end-of-life clinic that will perform euthanasia without any prior patient-doctor relationship, he stated, particularly in psychiatric cases.
There is also a ‘grey zone’ sub section where physicians would describe their own actions as termination of life, but do not report it, which accounts for 1,500 cases yearly.
Societal pressure, because of positive media reporting about euthanasia, also drives the figures up, he said.
“It is what I call internalised pressure,” the academic added, because the existence of legalised euthanasia impacts those who don't want to feel they are a burden on family or society.
Legalised euthanasia has not had the impact of lowering violent suicide rates, which have, in fact, soared by 35%, he said – far higher than in neighbouring Germany, which does not permit euthanasia.
Robert Troy TD said that legalising euthanasia sends an "awful signal" to an ageing population that their life has lost its intrinsic value.