- Email: [email protected]
Euthanasia in the Netherlands
591
interstitium. The increased interstitial pressure causes increased renal lymph flow (over 10 times normal flow rates have been observed in chronic streptozotocin diabetic rats5), which removes excess proteins. Although the raised renal interstitial pressure may partly or fully compensate for the diminished osmotic gradient, enhance fluid entry into the peritubular capillaries, and increase renal lymph flow, it also has several detrimental effects. Tubules are compressed and intrarenal diameters diminished; a similar effect on capillaries may interfere with nutritive blood supply. The reduced hydrostatic pressure difference across the afferent arteriolar walls leads to vasodilatation (by a mechanism described by the Law of Laplace which states, in a highly simplified form, that the product of the radius of a blood vessel and of the transmural pressure difference tends to be approximately constant), diminished renal vascular resistances, and glomerular hypertension. The combination of glomerular hypertension and increased intratubular pressure caused by tubular compression may mean that although the pressure difference across the glomerular capillary wall may be little altered, the absolute pressures in both compartments may be substantially increased. Moreover, increased pressure and protein concentration in the interstitium may enhance interstitial fibrosis-a common feature in diabetic nephropathy. In theory, the altered balance between the increased forces for filtration and reabsorption could exist for some time, but would be precarious. For example, any relaxation of efferent arterioles would transmit increased glomerular capillary pressure to the peritubular capillaries; uptake of tubular fluid into these capillaries would then further diminish and convective entry of proteins from capillaries into the interstitium would increase, so that filtration and reabsorption forces became balanced again, but at even higher pressures. In the presence of glomerular disease and proteinuria, the positive feedback loop thus formed could rapidly lead to collapse of both filtration and resorption mechanisms. We suggest that microangiopathy within peritubular capillaries may be a causal factor in diabetic nephropathy, and that this mechanism may help to explain the dissociation between glomerular histology and renal failure in diabetes mellitus. In diabetic--or any other-nephropathy it seems reasonable to take account of changes in peritubular capillaries, renal interstitium, and lymphatic vessels, as well as in the glomeruli.
Euthanasia in the Netherlands
Although voluntary euthanasia remains a criminal offence in the Netherlands, doctors who practise it subject to certain narrow guidelines are unlikely to be prosecuted or disciplined. Recently, however, a doctor was disciplined by a Dutch Medical Disciplinary Board for "breach of trust" in misleading a patient into supposing that he was being given a lethal dose of drugs when the doctor knew this was Is it fair to conclude, as Bernard Levin did,l that the was in effect found guilty for "not ... unlawfully killing his patient"? If the decision is interpreted in this way--especially if euthanasia were to be legalised rather than tolerated officially-the next logical step would be proceedings in the civil court for damages based on the doctor’s breach of his duty of care/contract. Would the award of damages then take into account the nervous shock suffered by the patient on still finding himself alive plus the continued cost of existence and any medical
not so.
doctor
expenses? Analogies can readily be drawn with successful negligence claims made by British parents for unwanted babies arising from failed abortions, failure to offer termination when it would have been appropriate, or failed vasectomy. Payments have been made to cover the cost of bringing up not only unwanted handicapped babies but also for healthy and loved children.2 In Canada, a Jehovah’s Witness was awarded$Can20 000 against a casualty surgeon who saved her life by giving her an unwanted blood transfusion.3 Although in certain circumstances a Dutch doctor will not be punished if he practises euthanasia, he is free to refuse to perform euthanasia and to withdraw at any time. In the recent case the Medical Disciplinary Board of Amsterdam expressly restated those freedoms. The doctor was reprimanded not because he did not kill but because he had misled the patient and others into believing that the drugs provided (and the withholding of other drugs and food) would cause the patient’s death in a short while. The reprimand was based on other grounds too but details of the case have not been published. The board took the view that whatever a doctor’s personal feelings might be about euthanasia, he should not mislead his patient on so serious a question.
REFERENCES 1. Editorial. Glomerular disease in diabetes. Lancet 1972; ii: 1403-04. 2. Editorial. What causes diabetic renal failure? Lancet 1988; i: 1433-34. 3. Thomsen OF, Andersen AR, Christiansen JS, Deckert T. Renal changes in long-term type I (insulin-dependent) diabetic patients with and without clinical nephropathy: a light microscopic, morphometric study of autopsy material. Diabetologia 1984; 26: 361-65. 4. Bader R, Bader H, Grund KE, Mackensen-Hansen S, Christ H, Bohle A. Structure and function of the kidney in diabetic glomerulosclerosis. Correlation between morphological and functional parameters. Pathol Res Pract 1980; 167: 204-16. 5. Pinter GG, Stork JE, Wilson PD, Fajer AB. Peritubular capillaries of the renal cortex in experimental diabetes mellitus in the rat. Clin Sci 1983; 65: 393-97. 6. Pinter GG, Wilson PD, Yuen LSL. Microvascular permeability in experimental diabetes mellitus in the anaesthetized rat: kidney, heart and skeletal muscle. J Physiol (Lond) 1989; 417: 47P. 7. Renkin EM, Gilmore JP. Glomerular filtration. In: Orloff J, Berliner RW, eds. Handbook of physiology: renal physiology. Washington DC: American Physiological Society, 1973: 185-248. 8. Bell DR, Pinter GG, Wilson PD. Albumin permeability of the peritubular capillaries in rat renal cortex. J Physiol (Lond) 1978; 279: 621-40.
Different attitudes In 1984, the Dutch Medical Association (KNMG) accepted the principle of voluntary euthanasia, subject to certain conditions. By contrast, in 1988, a British Medical Association working party recommended against any change in the law.4 In Britain, any euthanasia by doctors will have to be covert. However, English law accepts that a very painful illness can justifiably be alleviated with drugs that also shorten the patient’s life provided the drugs are given with the prime purpose of relieving pain. There may be an uncomfortable grey area in which the doctor risks prosecution5 especially if his motives are suspect.6 In Britain "Any doctor, compelled by conscience to intervene to end a person’s life, will do so prepared to face the closest scrutiny of this action that the law might wish to make."4
ADDRESS: 5 New Square, Lincoln’s Inn, London WC2A 3RJ, UK
(D Brahams, barrister-at-law).
592
As a Dutch academic lawyer notesthere are substantial differences in the attitudes of the British and Dutch medical professions and in the legal framework within which they operate. Not the least seems to be the greater willingness of Dutch doctors to risk prosecution for their principles, though this may in part be due to the more lenient attitude taken by the criminal law in their country. Although in both countries homicide, including "the intentional killing of another person at the express and serious request of that person", is a crime the classifications of homicide and the attendant punishments the crime may attract are different. Dutch law, for example, takes a more lenient view of those who attempt to aid suicides: section 294 of the Dutch penal code states that a person who induces another to commit suicide or helps him to commit suicide is liable to three years imprisonment but an attempt which fails is not criminally liable, as it would be in Britain under the Suicide Act 1961.
Defences submitted in Dutch courts Since the mid-1970s four different legal defences have been submitted by Dutch doctors in defence of euthanasia.7 In the medical exception defence it is argued that a doctor who acts with due care and within generally accepted medical standards should not be convicted under section 293 of the penal code. In 1984, this defence was accepted by a district court in Groningen. It is reminiscent of the judge’s direction to the jury in R v Arthur:5 "I imagine you will think long and hard before concluding that doctors of the eminence
we
have heard here have evolved standards that
committing a crime". However, the medical execption defence was subsequently rejected by the Court of Appeal and the Dutch Supreme Court which stated unequivocally that doctors may not rely on it as a defence to a charge of active euthanasia. A defence which sought to distinguish motive from result so as to avoid the provisions of the legislation was initially accepted by a district court in 1983 but was rejected by the Supreme Court. Again an analogy with the Arthur case is apposite; there the judge told the jury to distinguish the doctor’s intent from his motive in deciding amount to
whether he had intended
to
terminate
or
try
to
terminate
a
handicapped baby’s life. Necessity or force majeure has never been a defence to murder in Britain but article 40 of the Dutch penal code provides that a person who commits an offence under force majeure will not be held liable. This plea has never been accepted by a Dutch court. It was submitted on behalf of a doctor who claimed that he could not withstand the urge to alleviate the distress of the patient by terminating his life; doctors are trained professionals and are expected to be able to withstand such pressure. The emergency defence, also based on article 40, was accepted in 1984 by the Supreme Court. The court ruled that a physician’s duty to abide by the law and to respect the life of his patient "may be outweighed by his other duty to help a patient who is suffering unbearably, who depends upon him and for whom, to end his suffering, there is no alternative but death",7 The court further ruled that "scientific medical views and medical ethical norms" should be taken into consideration. The decision was referred back to the Hague Appeal Court, which acquitted the doctor. The patient, a 93-year-old woman had fallen and broken her hip 2 years earlier. She had refused surgery and lay in bed waiting to die. Eventually her capacity to hear, see, and speak deteriorated sharply and she became spasmodically comatose. Aware of her plight and distressed by her loss of capacity and dignity, she repeatedly asked her doctor to end her life. After consultaton with another physician and with the family, he injected a lethal dose of curarine. This defence has also been accepted in another terminal case, where the patient had severe multiple sclerosis. Sluyters’ concludes that, notwithstanding the prohibition on euthanasia in the Dutch criminal code, the courts have accepted that it may be permissible for a doctor to act so as to alleviate unbearable suffering in certain cases; similarly, a doctor may aid a patient in committing suicide. In January, 1990, following an unsuccessful bid by her husband to get a court order to cease artificial feeding Dutch doctors have stopped artificially feeding a woman who had been in a coma for 15 years. The Court of Appeal decided that the decision was a medical one and must be taken by the doctors.
Apparently, though most doctors, health lawyers, and courts in the Netherlands would accept that it was pointless to continue nasogastric feeding in this case, the doctors and nurses at the nursing home were at first unwilling to supervise what they perceived as process of dehydration and starvation that would lead to death. The Court of Appeal did not feel that it could ask this of the home, which has now reportedly agreed to have the feeding tube removed." The patient has since died.
The future The issue has been publicly ventilated in the Netherlands, and the State Prosecutor has now said that he will bring a test case, in which a comatose patient died in September, 1987, after being given a fatal injection by a neurologist in Delft. The appeals procedures could take two years. In Britain, reportedly, discussions were secretly conducted last year between doctors having the care of a comatose accident victim and the district coroner with a view to discontinuing artificial feeding. This initiative seems to have been dropped when the coroner indicated that he would have no alternative but to refer the case for criminal investigation. The anxiety of what to do and how long to maintain irreversibly comatose patients against the wishes of the family remains unsolved and publicly unvoiced in Britain. If a decision is taken to remove an artificial feeding tube with the intent to allow life to end it is debatable whether this would count as an act of omission or commission intended to end life and qualifying for a charge of murder or manslaughter. In 1981, the Director of Public Prosecutions informally commended a bill to limit the legal requirements for the treatment of severely handicapped newborn babies but this bill did not permit the withholding of food unless in the view of medical opinion it would increase the pain and suffering of the patient. It is uncertain whether artificial feeding would in law qualify as medical "treatment" in Britain. In the Netherlands guidelines on prosecution for euthanasia were issued in 1982 and though several doctors and nurses have been convicted, decisions to prosecute have to be approved by a committee of not less than five senior prosecuting officers. Most doctors and the families do not wish to be subject to scrutiny and when possible death will be certified as due to natural causes. Attempts to alter the substantive law in the Netherlands to legalise euthanasia have failed. The new coalition government of Christian Democrats and Socialists has suspended discussion on the two draft acts on euthanasia that were before the Dutch parliament and proposes to set up a commission to further investigate the matter. I thank Prof B. Sluyters for his comments and for help with Dutch cases. Further background to the Dutch experience can be had from reviews by Sluyters7 and Righter et al.9
REFERENCES 1. Levin B. Under patient’s orders to kill. Times Dec 11, 1989. 2. Emeh v Kensington and Chelsea and Westminster Area Health Authority [1985] QB 1013; Thake v Maurice [1986] QB 644; Benarr v Kettering Health Authority. Med-Leg J 1988; 56: 179-80. 3. Brahams D. Jehovah’s Witness transfused without consent: a Canadian case. Lancet 1989; ii: 1407. 4. The euthanasia report: report of the Working Party to review the British Medical Association’s guidance on euthanasia. London: BMA, 1988. 5. Brahams D. Acquittal of paediatrician at Leicester. Lancet 1981; ii: 1101. 6. Devlin P. Easing the passing. London: Bodley Head, 1985. 7. Sluyters B. Euthanasia in the Netherlands. Med-Leg J 1989; 57: 34-43. 8. Leenen HJ. Coma patients in Holland. Br Med J 1990; 300: 69. 9. Righter H, et al. Euthanasia across the North Sea. Br Med J 1988; 297: 1593-95.
interstitium. The increased interstitial pressure causes increased renal lymph flow (over 10 times normal flow rates have been observed in chronic streptozotocin diabetic rats5), which removes excess proteins. Although the raised renal interstitial pressure may partly or fully compensate for the diminished osmotic gradient, enhance fluid entry into the peritubular capillaries, and increase renal lymph flow, it also has several detrimental effects. Tubules are compressed and intrarenal diameters diminished; a similar effect on capillaries may interfere with nutritive blood supply. The reduced hydrostatic pressure difference across the afferent arteriolar walls leads to vasodilatation (by a mechanism described by the Law of Laplace which states, in a highly simplified form, that the product of the radius of a blood vessel and of the transmural pressure difference tends to be approximately constant), diminished renal vascular resistances, and glomerular hypertension. The combination of glomerular hypertension and increased intratubular pressure caused by tubular compression may mean that although the pressure difference across the glomerular capillary wall may be little altered, the absolute pressures in both compartments may be substantially increased. Moreover, increased pressure and protein concentration in the interstitium may enhance interstitial fibrosis-a common feature in diabetic nephropathy. In theory, the altered balance between the increased forces for filtration and reabsorption could exist for some time, but would be precarious. For example, any relaxation of efferent arterioles would transmit increased glomerular capillary pressure to the peritubular capillaries; uptake of tubular fluid into these capillaries would then further diminish and convective entry of proteins from capillaries into the interstitium would increase, so that filtration and reabsorption forces became balanced again, but at even higher pressures. In the presence of glomerular disease and proteinuria, the positive feedback loop thus formed could rapidly lead to collapse of both filtration and resorption mechanisms. We suggest that microangiopathy within peritubular capillaries may be a causal factor in diabetic nephropathy, and that this mechanism may help to explain the dissociation between glomerular histology and renal failure in diabetes mellitus. In diabetic--or any other-nephropathy it seems reasonable to take account of changes in peritubular capillaries, renal interstitium, and lymphatic vessels, as well as in the glomeruli.
Euthanasia in the Netherlands
Although voluntary euthanasia remains a criminal offence in the Netherlands, doctors who practise it subject to certain narrow guidelines are unlikely to be prosecuted or disciplined. Recently, however, a doctor was disciplined by a Dutch Medical Disciplinary Board for "breach of trust" in misleading a patient into supposing that he was being given a lethal dose of drugs when the doctor knew this was Is it fair to conclude, as Bernard Levin did,l that the was in effect found guilty for "not ... unlawfully killing his patient"? If the decision is interpreted in this way--especially if euthanasia were to be legalised rather than tolerated officially-the next logical step would be proceedings in the civil court for damages based on the doctor’s breach of his duty of care/contract. Would the award of damages then take into account the nervous shock suffered by the patient on still finding himself alive plus the continued cost of existence and any medical
not so.
doctor
expenses? Analogies can readily be drawn with successful negligence claims made by British parents for unwanted babies arising from failed abortions, failure to offer termination when it would have been appropriate, or failed vasectomy. Payments have been made to cover the cost of bringing up not only unwanted handicapped babies but also for healthy and loved children.2 In Canada, a Jehovah’s Witness was awarded$Can20 000 against a casualty surgeon who saved her life by giving her an unwanted blood transfusion.3 Although in certain circumstances a Dutch doctor will not be punished if he practises euthanasia, he is free to refuse to perform euthanasia and to withdraw at any time. In the recent case the Medical Disciplinary Board of Amsterdam expressly restated those freedoms. The doctor was reprimanded not because he did not kill but because he had misled the patient and others into believing that the drugs provided (and the withholding of other drugs and food) would cause the patient’s death in a short while. The reprimand was based on other grounds too but details of the case have not been published. The board took the view that whatever a doctor’s personal feelings might be about euthanasia, he should not mislead his patient on so serious a question.
REFERENCES 1. Editorial. Glomerular disease in diabetes. Lancet 1972; ii: 1403-04. 2. Editorial. What causes diabetic renal failure? Lancet 1988; i: 1433-34. 3. Thomsen OF, Andersen AR, Christiansen JS, Deckert T. Renal changes in long-term type I (insulin-dependent) diabetic patients with and without clinical nephropathy: a light microscopic, morphometric study of autopsy material. Diabetologia 1984; 26: 361-65. 4. Bader R, Bader H, Grund KE, Mackensen-Hansen S, Christ H, Bohle A. Structure and function of the kidney in diabetic glomerulosclerosis. Correlation between morphological and functional parameters. Pathol Res Pract 1980; 167: 204-16. 5. Pinter GG, Stork JE, Wilson PD, Fajer AB. Peritubular capillaries of the renal cortex in experimental diabetes mellitus in the rat. Clin Sci 1983; 65: 393-97. 6. Pinter GG, Wilson PD, Yuen LSL. Microvascular permeability in experimental diabetes mellitus in the anaesthetized rat: kidney, heart and skeletal muscle. J Physiol (Lond) 1989; 417: 47P. 7. Renkin EM, Gilmore JP. Glomerular filtration. In: Orloff J, Berliner RW, eds. Handbook of physiology: renal physiology. Washington DC: American Physiological Society, 1973: 185-248. 8. Bell DR, Pinter GG, Wilson PD. Albumin permeability of the peritubular capillaries in rat renal cortex. J Physiol (Lond) 1978; 279: 621-40.
Different attitudes In 1984, the Dutch Medical Association (KNMG) accepted the principle of voluntary euthanasia, subject to certain conditions. By contrast, in 1988, a British Medical Association working party recommended against any change in the law.4 In Britain, any euthanasia by doctors will have to be covert. However, English law accepts that a very painful illness can justifiably be alleviated with drugs that also shorten the patient’s life provided the drugs are given with the prime purpose of relieving pain. There may be an uncomfortable grey area in which the doctor risks prosecution5 especially if his motives are suspect.6 In Britain "Any doctor, compelled by conscience to intervene to end a person’s life, will do so prepared to face the closest scrutiny of this action that the law might wish to make."4
ADDRESS: 5 New Square, Lincoln’s Inn, London WC2A 3RJ, UK
(D Brahams, barrister-at-law).
592
As a Dutch academic lawyer notesthere are substantial differences in the attitudes of the British and Dutch medical professions and in the legal framework within which they operate. Not the least seems to be the greater willingness of Dutch doctors to risk prosecution for their principles, though this may in part be due to the more lenient attitude taken by the criminal law in their country. Although in both countries homicide, including "the intentional killing of another person at the express and serious request of that person", is a crime the classifications of homicide and the attendant punishments the crime may attract are different. Dutch law, for example, takes a more lenient view of those who attempt to aid suicides: section 294 of the Dutch penal code states that a person who induces another to commit suicide or helps him to commit suicide is liable to three years imprisonment but an attempt which fails is not criminally liable, as it would be in Britain under the Suicide Act 1961.
Defences submitted in Dutch courts Since the mid-1970s four different legal defences have been submitted by Dutch doctors in defence of euthanasia.7 In the medical exception defence it is argued that a doctor who acts with due care and within generally accepted medical standards should not be convicted under section 293 of the penal code. In 1984, this defence was accepted by a district court in Groningen. It is reminiscent of the judge’s direction to the jury in R v Arthur:5 "I imagine you will think long and hard before concluding that doctors of the eminence
we
have heard here have evolved standards that
committing a crime". However, the medical execption defence was subsequently rejected by the Court of Appeal and the Dutch Supreme Court which stated unequivocally that doctors may not rely on it as a defence to a charge of active euthanasia. A defence which sought to distinguish motive from result so as to avoid the provisions of the legislation was initially accepted by a district court in 1983 but was rejected by the Supreme Court. Again an analogy with the Arthur case is apposite; there the judge told the jury to distinguish the doctor’s intent from his motive in deciding amount to
whether he had intended
to
terminate
or
try
to
terminate
a
handicapped baby’s life. Necessity or force majeure has never been a defence to murder in Britain but article 40 of the Dutch penal code provides that a person who commits an offence under force majeure will not be held liable. This plea has never been accepted by a Dutch court. It was submitted on behalf of a doctor who claimed that he could not withstand the urge to alleviate the distress of the patient by terminating his life; doctors are trained professionals and are expected to be able to withstand such pressure. The emergency defence, also based on article 40, was accepted in 1984 by the Supreme Court. The court ruled that a physician’s duty to abide by the law and to respect the life of his patient "may be outweighed by his other duty to help a patient who is suffering unbearably, who depends upon him and for whom, to end his suffering, there is no alternative but death",7 The court further ruled that "scientific medical views and medical ethical norms" should be taken into consideration. The decision was referred back to the Hague Appeal Court, which acquitted the doctor. The patient, a 93-year-old woman had fallen and broken her hip 2 years earlier. She had refused surgery and lay in bed waiting to die. Eventually her capacity to hear, see, and speak deteriorated sharply and she became spasmodically comatose. Aware of her plight and distressed by her loss of capacity and dignity, she repeatedly asked her doctor to end her life. After consultaton with another physician and with the family, he injected a lethal dose of curarine. This defence has also been accepted in another terminal case, where the patient had severe multiple sclerosis. Sluyters’ concludes that, notwithstanding the prohibition on euthanasia in the Dutch criminal code, the courts have accepted that it may be permissible for a doctor to act so as to alleviate unbearable suffering in certain cases; similarly, a doctor may aid a patient in committing suicide. In January, 1990, following an unsuccessful bid by her husband to get a court order to cease artificial feeding Dutch doctors have stopped artificially feeding a woman who had been in a coma for 15 years. The Court of Appeal decided that the decision was a medical one and must be taken by the doctors.
Apparently, though most doctors, health lawyers, and courts in the Netherlands would accept that it was pointless to continue nasogastric feeding in this case, the doctors and nurses at the nursing home were at first unwilling to supervise what they perceived as process of dehydration and starvation that would lead to death. The Court of Appeal did not feel that it could ask this of the home, which has now reportedly agreed to have the feeding tube removed." The patient has since died.
The future The issue has been publicly ventilated in the Netherlands, and the State Prosecutor has now said that he will bring a test case, in which a comatose patient died in September, 1987, after being given a fatal injection by a neurologist in Delft. The appeals procedures could take two years. In Britain, reportedly, discussions were secretly conducted last year between doctors having the care of a comatose accident victim and the district coroner with a view to discontinuing artificial feeding. This initiative seems to have been dropped when the coroner indicated that he would have no alternative but to refer the case for criminal investigation. The anxiety of what to do and how long to maintain irreversibly comatose patients against the wishes of the family remains unsolved and publicly unvoiced in Britain. If a decision is taken to remove an artificial feeding tube with the intent to allow life to end it is debatable whether this would count as an act of omission or commission intended to end life and qualifying for a charge of murder or manslaughter. In 1981, the Director of Public Prosecutions informally commended a bill to limit the legal requirements for the treatment of severely handicapped newborn babies but this bill did not permit the withholding of food unless in the view of medical opinion it would increase the pain and suffering of the patient. It is uncertain whether artificial feeding would in law qualify as medical "treatment" in Britain. In the Netherlands guidelines on prosecution for euthanasia were issued in 1982 and though several doctors and nurses have been convicted, decisions to prosecute have to be approved by a committee of not less than five senior prosecuting officers. Most doctors and the families do not wish to be subject to scrutiny and when possible death will be certified as due to natural causes. Attempts to alter the substantive law in the Netherlands to legalise euthanasia have failed. The new coalition government of Christian Democrats and Socialists has suspended discussion on the two draft acts on euthanasia that were before the Dutch parliament and proposes to set up a commission to further investigate the matter. I thank Prof B. Sluyters for his comments and for help with Dutch cases. Further background to the Dutch experience can be had from reviews by Sluyters7 and Righter et al.9
REFERENCES 1. Levin B. Under patient’s orders to kill. Times Dec 11, 1989. 2. Emeh v Kensington and Chelsea and Westminster Area Health Authority [1985] QB 1013; Thake v Maurice [1986] QB 644; Benarr v Kettering Health Authority. Med-Leg J 1988; 56: 179-80. 3. Brahams D. Jehovah’s Witness transfused without consent: a Canadian case. Lancet 1989; ii: 1407. 4. The euthanasia report: report of the Working Party to review the British Medical Association’s guidance on euthanasia. London: BMA, 1988. 5. Brahams D. Acquittal of paediatrician at Leicester. Lancet 1981; ii: 1101. 6. Devlin P. Easing the passing. London: Bodley Head, 1985. 7. Sluyters B. Euthanasia in the Netherlands. Med-Leg J 1989; 57: 34-43. 8. Leenen HJ. Coma patients in Holland. Br Med J 1990; 300: 69. 9. Righter H, et al. Euthanasia across the North Sea. Br Med J 1988; 297: 1593-95.