DR. BRIAN POLLARD
Advocates of legalised euthanasia almost always insist that they
only want voluntary euthanasia (VE) — and they say they are as
opposed to the taking of life without the subject’s knowledge or
consent, that is, non-voluntary euthanasia (NVE), as anyone
Some do extend their advocacy to some examples of NVE, such as
seriously deformed newborns,  where consent
would not be possible, but this is not usual. It is widely accepted that
sufficient protection against the unwanted extension of VE to NVE would
be ensured by the inclusion of appropriate legal safeguards.
As safeguards, clauses are proposed that would require the doctor to
be satisfied that the patient’s request was freely made and sufficiently
informed, that there was no psychological abnormality such as
depression, and possibly by requiring psychiatric consultation, that
more than one doctor be involved in the decision that it was medically
appropriate to take life in the circumstances, and that there be
adequate documentation. It is also common to find lawyers who declare
that such laws would be feasible to devise, though it is less common to
find actual draft laws published for discussion. In one sense, those
lawyers are correct when they say such law would be possible — but they
stop short of addressing the question of whether they would be safe, in
practice. It is uncommon to find any analysis that assesses the
effectiveness of the so-called safeguards.
By contrast, overwhelming evidence is now available in the published
reports of a number of independent committees of inquiry into the
consequences of legalising VE, which all concluded that NO such law
could be guaranteed to be safe against the likelihood of abuse. In fact,
no committee set up for this purpose has ever reached any conclusion
other than prohibition of legalisation.
Though the first of these reports appeared in 1994 and the last in
1998, their arguments are so compelling that no criticism of them has
ever been published. Until and unless it can be shown that their common
conclusion is unwarranted, they must be regarded as having established
This seems to some to be such an unexpected development, and so
contrary to what is confidently often asserted, that it barely seems
credible. The commonest and most serious form of abuse of any euthanasia
law would be the endangering or the actual taking of the lives of some
of the other terminally ill or disadvantaged groups of the sick or
disabled who did not want their lives taken. That is, the apparently
strict control over the practice of VE would be illusory, and in the
worst case, acceptance of VE would lead to the practise of NVE.
Additionally, since concealment would be easy to carry out, and hence
correspondingly difficult to discover, a truly compassionate society
must rate the risk as too high to be acceptable.
This common finding by each committee is consistent with what had
already been predicted many times, namely that NVE is such a logical
extension of VE that its occurrence should be regarded more as a
fulfilled expectation than a matter for surprise. The arguments for VE
already encompass the rationale for NVE.
That progression would be logical because, once it had been decided
that taking life provided a benefit to one whose quality of life had led
him/her to ask for death, it could then be thought discriminatory and
unfair to withhold that supposed benefit from others in a similar
plight, just because they did not, or could not, ask. NVE, like VE, is
also thought by its practitioners to be compassionate and benevolent,
not malicious or malevolent.
Since nobody would take a life they valued, in each instance of VE or
NVE the ultimate justification is that the particular life no longer has
sufficient value to mandate its continuance. Such reasoning would be
incompatible with recognising the equal, inherent dignity of every
person, as that dignity is declared in statements of human rights to
attach to every life, without exception. That view of human dignity is
also the one that provides the basis in criminal law for the provision
of universal protection for every innocent human life, without
exception. Hence, both practices are radically incompatible both with
what needs to be acknowledged if we are to live well and peaceably with
each other and with the very notion of justice in society, since justice
is founded on and exists to respect equal dignity.
It may be objected that these arguments are theoretical and do not
necessarily apply to the actual decision-making required in medical
practice at or near the end of life. Thus, it is said doctors are not
monsters who would suddenly begin to take life indiscriminately, and the
risk of extension of one euthanasia practice to the other is overstated
and no more than scare mongering, for which, in any case, there is no
evidence. The difficulty with that position is that the evidence for NVE
at present is readily found, even though it is carried out in secret and
to an unknown extent.
Dutch euthanasia has been known to be commonly practised since 1973,
when a court determined that a doctor, who had killed her mother who was
dying and had requested euthanasia, was guilty but that her action was
justified. At her trial, evidence was given on her behalf that she was
doing no more than what was already common but unpublicised. The court
also described circumstances in which it thought that doctors may be
excused after euthanasia.
There ensued many years during which the Dutch maintained that
euthanasia was closely supervised and controlled by the authorities,
while some well informed outsiders maintained that this was certainly
not the case, and that abuse was already common and extended as far as
medical life-taking without the patient’s consent.
During this period, even though VE was the only practice publicly
discussed, official support for NVE could be readily found in the
Netherlands. The State Commission on Euthanasia in 1987 had recommended
that NVE should not be an offence, if carried out in the context of
‘careful medical practice’, though that term was not defined.
 In 1988, a Royal Dutch Medical Association
(KNMG) working party condoned euthanasia for deformed infants, in some
instances thinking it might be compulsory. In 1991, a KNMG committee
condoned the killing of patients in persistent coma.
Dutch euthanasia practices were first officially examined in the
Remmelink Report of 1991 which was based on medical practice throughout
1990,  for which the statistical study was
done by van der Maas and others.  This study
was later repeated and its findings were reported in 1996.
In 1991, by adopting the narrow definition of euthanasia only as
‘active termination of life upon the patient’s request’, there were
2,300 instances of euthanasia in the year of the study, or 1.8% of all
deaths. When, however, to these are added instances of life-taking
without request and intentionally shortening the lives of both conscious
and unconscious patients, the figures for which are found in the
statistical study, the conclusions are dramatically altered.
They now become: 2,300 instances of euthanasia on request; 400 of
assisted suicide; 1,000 instances of life-ending actions without patient
request; 8,750 patients in whom life-sustaining treatment was withdrawn
or withheld without request, ‘partly with the purpose’ (4,750) or ‘with
the explicit purpose’ (4,000) of shortening life; 8,100 cases of
morphine overdose ‘partly with the purpose’ (6,750) or ‘with the
explicit purpose’ (1,350) of shortening life; 5,800 cases of withdrawing
or withholding treatment on explicit request ‘partly with the purpose’
(4,292) or ‘with the explicit purpose’ (1,508) of shortening life.
 Thus, there were up to 23,359 instances of
doctors intending, by act or omission, to shorten life. The true
incidence of euthanasia could have been as high as 20% of all deaths in
Although the Report stated that the 1,000 instances of ‘life ending
actions without request’ were carried out on incompetent persons ‘in
their death agony’, on the doctors’ testimony at interview as described
in the Survey, 14% of these patients were competent and 11% were partly
so. According to that part of the Survey known as the death certificate
study, 36% were competent. While NVE is generally thought of, and
defined, as taking the life of an incompetent patient who could not
choose at the time, these figures include another and unexpected
category of NVE as killing practised on persons who were competent —
those who could have been consulted, but were not.
One observer who has closely studied Dutch euthanasia estimated that
the Dutch statistics allow for the possibility that there were ‘about
five thousand cases in which physicians made decisions that might or
were intended to end the lives of competent patients without consulting
them’. When he tried to obtain a possible explanation for this
astonishing practice while he was visiting the Netherlands, he could get
none. He was left to conjecture that when a doctor already thought it
was appropriate to end the patient’s life, he might think it safer not
to seek consent, since if it was refused, to proceed would evidently be
In the preamble to its Guidelines for Euthanasia in 1987, the KNMG
had written: ‘If there is no request from the patient, then proceeding
with the termination of his life is juridically a matter of murder or
killing, and not of euthanasia’.  Using
their own society’s definition, Dutch doctors were carrying out medical
murder in 1991, and have continued to do so ever since.
There followed a period of official inactivity because some of the
findings were so unexpected, and because euthanasia was well supported
by the community. Euthanasia activists lobbied to have it formally
legalised, but without success. In particular, NVE presented a semantic
problem because by the official definition, it was not any form of
euthanasia. To meet this difficulty, the authorities abandoned their
candour of 1987 in favour of an innocuous-sounding acronym, LAWER,
‘life-terminating acts without explicit request’.
 The topic could now be openly discussed as though it were
morally, medically and socially neutral, and it was soon to become just
another medical alternative available to doctors and the community.
In 1993, authors from the department of Public Health at the Erasmus
University could write: ‘But is it not true that once one accepts
euthanasia and assisted suicide, the principle of universalizability
forces one to accept termination of life without explicit request, at
least sometimes, as well? In our view, the answer to this question must
be in the affirmative’. 
In February 1993, new regulations about the medical reporting of
euthanasia were issued,  but they had
little impact, either on reporting or on the practices themselves. The
new rules required the reporting of both VE and NVE on the same form.
This had the effect of confirming in many doctors the view that both
were equally acceptable to the authorities. Indeed, in 1993 the
Secretary of Health, referring to these practices, said: ‘For a
physician, the considerations in these two cases are not essentially
different; from the moral point of view, the two actions are not of an
essentially different kind’. 
In the official 1996 review of developments since 1991, it was
concluded that ‘euthanasia seems to have increased in incidence since
1990, and the ending of life without the patient’s explicit request
seems to have decreased slightly’. Later in this paper, the matter of a
possible ‘slippery slope’ associated with euthanasia is discussed, and
it is mentioned that some euthanasia supporters insist there is no
evidence that it has ever happened or would even be likely to happen.
The reader’s attention is therefore drawn again to the last quote above,
where the Dutch can say simply, in essence, that medical murder (their
own term) seems to have decreased slightly in the five years since it
was first officially detected. The Dutch have reached the position where
medical murder is now entrenched, and is not seen by their authorities
as anything that might represent a deterioration in standards or call
for correction. Not only have the Dutch become unwilling or unable to
recognise the corruption of medicine and law attributable to their
acceptance of any form of euthanasia, it seems that neither have some of
the Australian supporters.
In 1995, two separate Dutch courts upheld the actions of doctors who
had deliberately ended the lives of handicapped neonates with lethal
injections, thus providing the first legal endorsement of NVE. In one
case, the judge said ‘In the decision of active ending of life, Dr
Kadjik had acted with scientific responsible insight and in accordance
with the medical ethic and accepted norms and in due consideration of
due care resulting therefrom; he is entitled to an appeal of force
majeure’.  To justify what is admittedly
an offence, courts in the Netherlands are allowed to decide that it is
lawful for a doctor, faced with the alternative of leaving a patient in
pain or of giving relief by taking life, to take the ‘compassionate’
option, by taking life. The doctor is said to be acting under a higher
Most jurisdictions elsewhere regard this so-called dilemma as a
fiction, on account of the proven effectiveness of palliative care to
control such pain. This was specifically referred to by the US Supreme
Court in its historic judgment of November 1996, when Justice O’Connor
noted: ‘A patient who is...experiencing great pain has no legal barriers
to obtaining medication from qualified physicians to alleviate that
suffering, even to the point of causing unconsciousness and hastening
The significance of NVE in the Netherlands has now been reduced
almost to the point where discussion about it relates only to its
detail, while the fact that it is still a major criminal offence by
Dutch statute law, as it is elsewhere throughout the world, is no longer
given special mention. That its incidence hardly fell between 1991 and
1995, or that it occurs at all, elicits no critical comment. An American
psychiatrist estimated that, if NVE had been practised in the US at the
same rate as prevailed in the Netherlands in 1990, the figure would have
exceeded the ‘combined total of all deaths from suicides and homicides’
in that year. 
In all Australian states, euthanasia is the crime of murder. In a
study by sociologists in South Australia reported in 1994, using an
anonymous questionnaire sent to 10% of the medical practitioners in that
state, a significant incidence of NVE was discovered.
 The authors had seeded linked questions
in different parts of their questionnaire, so that their association
would be less evident to the respondents. 19% of doctors surveyed
admitted they had ended life deliberately, and on 49% of those
occasions, the answers revealed they had done so without patient
This study has not been repeated in Australia, but it is known that
there is a high incidence of illegal euthanasia among the gay
communities in the large cities, and it is probable that this includes
In 1998, the results were published of a national survey of the
attitudes and practices, concerning assisted suicide and euthanasia, of
physicians in the 10 specialties in which doctors are most likely to
receive requests for euthanasia.  61% of
the 3,102 physicians surveyed responded. Under the heading
‘Characteristics of Patients Receiving Assistance’ where a request for
death had been met, it is reported that ‘54 per cent of the requests for
a lethal injection were made by a family member or partner’. This
brought no specific comment from the authors, though it reveals that
slightly more than half the medical killing reported by some 1,800
doctors was NVE. Does this mean that, as in the Netherlands, NVE no
longer causes surprise in the US, or did the authors not realise that
they had uncovered a deeply disturbing state of affairs?
This paper went on: “requests for a lethal injection were
characterised as indirect rather than explicit in 79 per cent of cases.
Five per cent of patients who received prescriptions and 7 per cent of
those who received a lethal injection were described as ‘confused 50% or
more of the time”‘. Since all these events were carried out in private
and therefore unsupervised, the figures give grounds for great concern
about the potential for the uncontrolled extension of the euthanasia
practices of some doctors. Because they are done in secret, not even a
law to allow VE could hope to prevent such extension.
The opinion that there is no evidence for a ‘slippery slope’, by
which is meant the progression of VE to NVE, is still commonly heard,
even though evidence for it is available, as just discussed. When this
is pointed out, the response has been that, though this may be so, there
is no evidence that one has actually led to the other. This evasive
answer fails to offer any explanation at all for the occurrence of NVE,
which is, by any legal criterion, medical murder, and shows little
concern that it is happening at all. It would seem that, to some, it is
more important simply to deny the facts or to denigrate those who draw
attention to them, than to lose face by condemning NVE.
Ready proof that the progression of VE to NVE has grounds in logic is
available whenever euthanasia becomes a topic for public discussion
following the media disclosure of some instance of mercy killing. At
such times, radio talk-back programs quickly come round to discussing
the plight of the senile, elderly people in nursing homes, how their
lives are futile, how they, their families and the public purse would
all experience great relief from their demise, and particularly singled
out for comment are those who are irreversibly mentally incompetent.
This is heard from those who, shortly before, professed to want only VE,
and who, I suspect, do not even realise they have made this subtle but
significant mental shift.
Two dangerous ideas lie just below the surface of awareness in an
unknown number of people in the community, though they are not usually
thought proper to be voiced openly: that there are groups of unfortunate
people whom society could well do without, and that they cost a lot of
money that could be better spent. These ideas are rejected by the usual
advocates of VE, as they should be, but those who hold them would
constitute a significant problem were legalisation of VE to be voted on.
They would cast a vote in favour, but they would not forever be
satisfied with VE only, and would be likely to push for its extension to
NVE. And if that vote were made reliant on compassion, even though it
may be misplaced compassion, these disadvantaged people would often seem
to be the most deserving of compassionate release.
It is impossible for those who would have VE legalised to guarantee
that such law could or would remain unaltered in the future. When
legalised VE had in time caused a lowering of the community’s respect
for all human life, as it undoubtedly would, and when health costs had
escalated to what were seen to be unsustainable levels, as they
undoubtedly will, a precedent for the further erosion of protection for
human life would already exist, having been created when VE was
As long as notions of life-taking without consent are simplistically
thought to be only associated with some degree of malicious intent, it
can be considered insulting to suggest that NVE might also be practised,
if VE were legally permitted. Especially is such a suggestion thought to
reflect adversely on doctors, who, while they are often criticised on
other grounds, are not generally thought to be unprincipled or
malicious. But when the actual motivation for NVE, in its practitioners’
estimation, is that it is an act of kindness, the risk to the lives of
some of the more vulnerable in society then becomes more apparent.
The prospect of NVE then changes from being repugnant and rare to an
act that can be thought to be desirable and beneficial, in some
circumstances. So regarded, NVE could be confidently predicted to be, in
time, virtually inevitable. Any instance of NVE is a case in practice of
‘the tendency of a principle to expand itself to the limits of its
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Law Q Rev 1992; 108: 51-78. Back to text.
- Report of the Committee to Investigate Medical Practice
Concerning Euthanasia. Medical Decisions about the End of Life. I.
Remmelink Report. The Hague; Ministry of Justice and Ministry
of Welfare, Public Health and Culture. 1991.
Back to text.
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the Light of The Remmelink Report and the van der Maas Study.
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terminating acts without explicit request of patient. Lancet
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Report; Two Years Later. Hastings Center Report 1993; Nov/Dec
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- Fenigsen R. The Netherlands; New Regulations Concerning
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attitudes and practices of medical practitioners in South Australia.
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Pollard, Dr. Brian. “Non-voluntary Euthanasia.” NSW Website
Published by permission of Dr. Brian Pollard.
Dr. Brian Pollard is a former anaesthetist (anesthesiologist) who
founded and directed, from 1982, one of Australia’s first palliative
care services. Dr. Pollard is the author of The Challenge of
Euthanasia and is involved in active opposition to legalised
euthanasia in Australia.
Copyright © 1999
NSW Right to Life Association