1. Kamisar, Y.Some non-religious views against proposed ‘mercy-killing’ legislation. Minnesota Law Review 1958;42:969–1042Google Scholar; Keown, J.Euthanasia, ethics and public policy: An argument against legalization. New York, NY: Cambridge University Press; 2002:118–27CrossRefGoogle Scholar; Gorsuch, N.The Future of Assisted Suicide and Euthanasia. Princeton, NJ: Princeton University Press; 2006:103–15Google Scholar. Cohn & Lynn found that people’s opinions about the legalization of euthanasia change when they are ‘informed about the Dutch data,’ in Cohn F, Lynn J. Vulnerable people: Practical rejoinders to claims in favor of assisted suicide. In: Foley K, Hendin H, eds. The Case against Assisted Suicide. Baltimore, MD/London: Johns Hopkins University Press; 2002:240.

2. Van der Maas, PJ, van Delden, JJM, Pijnenborg, L.Euthanasia and other medical decisions concerning end of life. Health Policy 1992;22(special issue:1–2):3–262Google Scholar.

3. For example, Griffiths, J, Bood, A, Weyers, H. Euthanasia and Law in the Netherlands. Amsterdam: Amsterdam University Press; 1998:300–3CrossRefGoogle Scholar.

4. For a comprehensive and evenhanded discussion of the available evidence up to 2007, see Lewis, P.The empirical slippery slope from voluntary to non-voluntary euthanasia. Journal of Law and Medical Ethics 2007;35:197–210CrossRefGoogle ScholarPubMed.

5. Van der Heide, A, Deliens, L, Faisst, K, Nilstun, T, Paci, E, Van der Wal, G, et al. (EURELD consortium) End-of-life decision-making in six European countries: Descriptive study. Lancet 2003;362:345–50CrossRefGoogle ScholarPubMed; Pennec, S, Monnier, A, Pontone, S, et al. End-of-life medical decisions in France: A death certificate follow-up survey 5 years after the 2005 Act of parliament on patients’ rights and end of life. BMC Palliative Care 2012;11:25CrossRefGoogle ScholarPubMed.

6. Onwuteaka-Philipsen, B, Legemaate, J, van der Heide, A, van Delden, H, Evenblij, K, El Hammoud, I, et al. Derde evaluatie Wet toetsing levensbeëindiging op verzoek en hulp bij zelfdoding. Den Haag: ZonMw:2017:119Google Scholar.

7. Deliëns, L, Mortier, F, Bilsen, J, Cosyns, M, Vander Stichele, R, Vanoverloop, J, et al. End-of-life decisions in medical practice in Flanders, Belgium: A nationwide survey, Lancet 2000;356:1806–11CrossRefGoogle ScholarPubMed; Chambaere, K, vander Stichele, R, Mortier, F, et al. Recent trends in euthanasia and other end-of-life practices in Belgium. New England Journal of Medicine 2015;372(12):1179–81CrossRefGoogle ScholarPubMed.

8. Jones, DA. Euthanasia and Assisted Suicide in Belgium: Bringing an end to interminable discussion. In: Jones, DA, Gastmans, C, MacKellar, C. Euthanasia and Assisted Suicide: Lessons from Belgium. [Place of publication]: Cambridge University Press; 2017:235–57CrossRefGoogle Scholar.

9. Elsewhere, Jones has defended a version of Keown’s logical slippery slope argument. Jones, DA. Is there a logical slippery slope from voluntary to non-voluntary euthanasia? Kennedy Institute of Ethics Journal 2011;21:379–404CrossRefGoogle Scholar. He is hence presumably committed to the general claim.

10. I use the data from Chambaere, K, Bilsen, J. Incidentie en kenmerken van continue diepe sedatie tot aan het overlijden, chapter 13. In: Deliëns, L, Cohen, J, François, I, Bilsen, J, eds. Palliatieve zorg en euthanasie in België; Evaluatie van de praktijk en de wetten. Brussel: Uitgeverij ASP; 2011:215–26Google Scholar. On the basis of the same research, slightly different figures have been presented in two papers from 2012 and 2014, quoted by Jones.

11. See note 6, Onwuteaka-Philipsen et al. 2017, chapter 5.5.

12. See note 7, Deliëns et al. 2000, at 22–4 (chapter on methodology); 207–8 (chapter on sedation). The report doesn’t contain the full questionnaire that has been used, as the Dutch reports do. See also, Mortier, F, Deliëns, L, Bilsen, J, et al. End-of-life decisions of physicians in the city of Hasselt (Flanders, Belgium). Bioethics 2000;14:254–67CrossRefGoogle Scholar.

13. For the full Dutch questionnaire used in 2015, see note 6, Onwuteaka-Philipsen et al. 2017:293–300. It contains three sets of questions, all concerning the same case: (First set) Did you administer one or more drugs in order to alleviate the patient’s symptoms? If so, was the hastening of the patient’s death part of the purpose of the action? (Second set) Was the death of the patient the effect of the use of a drug or drugs administered with the explicit intention to hasten the patient’s death? If so, did you decide to that action on the explicit request of the patient? (Third set) Was the patient deeply sedated until his death? If so, did you decide to sedate him with the explicit purpose to hasten his death, or with that purpose in addition to the purpose to alleviate her suffering?

14. Duff RA. Intention, mens rea and the Law Commission Report. Criminal Law Review 1980;27:147; Jansen LA. Disambiguating clinical intentions: The ethics of palliative sedation. Journal of Medicine and Philosophy 2010;35:19–31.

15. Even in cases in which the patient had requested the doctor to end his life, by using benzodiazepines and/or morphine, a Dutch doctor would violate one of the requirements of due care of the euthanasia law. A Belgian doctor would only act contrary to a professional rule.

16. Donald van Tol has observed that it is precisely the lack of certainty about the consequences of their actions that makes doctors sometimes prefer the use of morphine to regular euthanatics. It enables them to harbor the somewhat contradictory thoughts: Yes, I am helping this suffering patient, I am not leaving him to his fate, but, no, I am not killing him ‘at the needle,’ I do what doctors always do in such cases. van Tol D. Grensgeschillen: Een rechtssociologisch onderzoek naar het classificeren van euthanasie en ander medisch handelen rond het levenseinde. PhD dissertation, University of Groningen 2005:208.

17. It should be noted that there is a large body of philosophical literature suggesting that the distinction between effects intended as an end or as a means, and merely foreseen side-effects, is fundamentally indeterminate.

18. In 1995, interviews were held with a number of physicians who had first completed a questionnaire. 6 of the 46 physicians on that occasion who had reported an “explicit intention to hasten death” rejected the correctness of that description during those interviews. Van der Wal G, van der Maas PJ. Euthanasie en andere medische beslissingen rond het levenseinde. Den Haag: SDU; 1996:303.

19. The hypothesis that doctors classify their end-of-life decisions mainly for strategic reasons has been discredited. Their classification is determined by the drugs they use, not by their intention. Griffiths J, Weyers H, Adams M. Euthanasia and Law in Europe. Oxford: Hart Publishing; 2008:200–4, referring to research by Van Tol (see Van Tol 2005), and Onwuteaka-Philipsen B, Gevers JKM, van der Heide A. Evaluatie Wet toetsing levensbeëindiging op verzoek en hulp bij zelfdoding. Den Haag: ZonMw; 2007:122–4.

20. Maltoni, M, Scarpi, E, Rosati, M, Derni, S, Fabbri, L, Martini, F, et al. Palliative sedation in end-of-life care and survival: A systematic review. Journal of Clinical Oncology 2012;30(12):1378–83CrossRefGoogle ScholarPubMed; Barathi, B, Chandra, PS. Palliative sedation in advanced cancer patients: Does it shorten life? A systematic review. Indian Journal of Palliative Care 2013;19(1):40–7CrossRefGoogle ScholarPubMed. Many doctors don’t share that belief, as is shown by the surprisingly large numbers of doctors (by now 36 percent of Dutch doctors, See Onwuteaka-Philipsen 2017:122) who at least ex ante think that by administering morphine or midazolam they will probably hasten the death of the patient as an unintended side-effect. In most cases, the doctor herself believes afterwards that no life-shortening effect had actually occurred (63 percent in 2005, according to Rurup, M, Borgsteede, S, van der Heide, A, et al. Trends in the use of opioids at the end of life and the expected effects on hastening death. Journal of Pain and Symptom Management 2009;37(2):144–55CrossRefGoogle ScholarPubMed.

21. Sterckx S, Raus K. The Practice of continuous sedation at the end of life in Belgium: How does it compare to UK practice and is it being used as a form of euthanasia? In: Jones 2017:86-100; Swart, SJ, van der Heide, A, Van Zuylen, L, Perez, RSGM, Zuurmond, WWA, van der Maas, PJ, et al. Considerations of physicians about the depth of palliative sedation at the end of life. Canadian Medical Association Journal 2012;184(7):E360–6CrossRefGoogle ScholarPubMed.

22. Chambaere, K, Bernheim, JL, Downar, J, Deliëns, L. Characteristics of Belgian “life-ending acts without explicit patient request”: A large-scale death certificate survey revisited. Canadian Medical Association Journal Open 2014;2(4):E 262–7Google ScholarPubMed. I suppose that about the remaining cases, no information was available.

23. Van der Heide, A, Brinkman-Stoppelenburg, A, van Delden, H, Onwuteaka-Philipsen, B. Sterfgevallenonderzoek 2010: Euthanasie en andere medische beslissingen rond het levenseinde. Den Haag: ZonMw; 2012:23, 37Google Scholar.

24. See note 6, Onwuteaka-Philipsen et al. 2017, at 119, 132, with a slight correction after recalculation. Figure kindly provided by Dr. A. van der Heide.

25. See note 6, Onwuteaka-Philipsen, et al. 2017, at 119; see note 22, Chambaere et al. 2014.

26. Van Dijk AA. Strafrechtelijke aansprakelijkheid heroverwogen: Over opzet, schuld, schulduitsluitingsgronden en straf. Dissertation, Rijksuniversiteit Groningen, 2008; Dupont, L.Beginselen van Strafrecht deel 1. Leuven: Acco; 2004Google Scholar; or any introduction to Belgian or Dutch penal law.

27. Euthanasie: Rapport van de Staatscommissie Euthanasie. Den Haag: Staatsuitgeverij; 1985. For Belgian law, see VanSweevelt, T.Comparative legal aspects of pain management. Medicine and Law 2008;27:899–912Google ScholarPubMed.

28. Cf. the decision of the medical board Zwolle in the Vencken-case, 10 Mar 2005, Medisch Contact 2005:499-501; and the Belgian decision in KI Gent, 9 Dec 2004, T. Gez. /Revue de Droit de la Santé 2007:39, with comment by E. Delbeke.

29. See note 2, Keown 2002, at 100.

30. Thomson, JJ. Physician-assisted suicide: Two moral arguments. Ethics 1999;109:497–518, at 511CrossRefGoogle ScholarPubMed; Kamm, FM. Intricate Ethics: Rights, Responsibilities, and Permissible Harm. Oxford: Oxford University Press; 2007:132–5CrossRefGoogle Scholar; Sumner, LW. Assisted Death: A study in ethics and law Oxford: Oxford University Press; 2011:70CrossRefGoogle Scholar; Den Hartogh, G.The medical exception to the prohibition of killing: a matter of the right intention? Ratio Juris 32 (2019): 157-76CrossRefGoogle Scholar.

31. The points made in sub-sections three and four also apply to termination of life on the patient’s request. As a result, the figures given about the actual number of euthanasia cases in all Dutch and Flemish surveys since 1992 are incorrect, see Den Hartogh, G.The regulation of euthanasia: How successful is the Dutch system? In: Youngner, SJ, Kimsma, GK, eds. Physician-Assisted Death in Perspective: Assessing the Dutch Experience. Cambridge: Cambridge University Press; 2012:351–91CrossRefGoogle Scholar. The reporting rate of euthanasia cases as calculated by these reports relies on these incorrect figures, as do some of the criticisms standardly made about the Belgian practice, e.g., about the involvement of nurses and the consultation of colleagues who cannot be considered sufficiently independent. These supposed violations of the requirements of due care may largely occur in cases that the doctors involved rightly do not classify as cases of euthanasia at all.