Professor Theo Boer:

I will begin since I was first to be addressed. I thank Senator Ruane for her questions. The first question is about what we call regional variations in euthanasia whereby we have found that in some districts in the Netherlands, the euthanasia rate is 30 times higher than in others. We have, of course, tried to find the reason for these differences.

We have gone into depth and we have included biographical data, ethnological data etc. I sometimes say that one of the criteria for euthanasia in the Netherlands is being white. In 4,000 euthanasia cases I have only seen two non-white, non-western immigrants. Both were Muslims and they were both married to a Dutch spouse who was Catholic. That is why, of course, it is western countries that debate assisted dying so much. Assisted dying is a very western thing, maybe even a very Protestant thing. I told the committee that Protestantism was the primary force in the Netherlands to push for euthanasia. There is no special euthanasia rate in the minorities' suburbs. However, we have also tried to find out what other aspects there could be. We have looked at political parties, church membership, the availability of good palliative care, and the availability of volunteers. Normally, religious people, especially conservative Protestants, tend to be more reticent. Conservative voters and populist voters tend to be more conservative than greens, socialists and social democrats. That is why in Amsterdam there are exactly twice as many euthanasia cases as there are in Rotterdam, so that makes a difference. Income makes a difference in that the more affluent you are the more questions and requests we see. The availability of volunteers makes a difference. In regions where there are many volunteers, the euthanasia rate is lower. However, when we have corrected those numbers, there is almost a 30 times difference between the lowest and the highest regions. We have only explained those differences to a factor of ten. We have reduced it to a factor of ten, which means that there is still an unexplained tenfold difference between some regions and we are now investigating in depth why that is. We do not know. That was the Senator's first question.

The second question was about pain and suffering. I think that is one of the hardest issues. The World Health Organization defines health in terms of four categories, namely, physical, mental, spiritual, and social. I think it is the playing together of those four, and it is hardly ever only one aspect. There is a saying that people can live 30 days without eating, three days without drinking, three minutes without oxygen but not three seconds without hope. Sometimes it is the total absence of hope, either in the persons themselves or in their surroundings, that contributes to their suffering. I remember one case that impressed me very much. There was a lady that was in the funnel, so to speak, in the trajectory towards receiving assisted dying at the expert centre for euthanasia that performs 1,100 euthanasia cases per year in our country. She was in that trajectory for psychiatric reasons. She had all kinds of depressions, such as bipolarity etc. She was almost at the point where she would get euthanasia and then all of a sudden, without any reason, she inherited an enormous sum of money. I think it was €500,000 from some distant family member. That gave her the possibility to buy a horse breeding company and she is still alive and she is doing that with great passion.

I am not saying that she did not suffer or that she was not seriously ill. What I saying is that suffering never comes alone. In particular, social suffering and maybe financial suffering are serious co-contributors to suffering. That is all I can say because I am not an expert on suffering.

As I understand it, the third question was about whether I have any examples. Because I live in a country where, as I indicated, we have 10,000 cases a year and the tendency is up, it is a very hard question to answer but I would congratulate Mr. Luley. Perhaps I would be in favour of the Swiss system. Where countries legalise euthanasia, which means that the doctor really is in charge, offers you the syringe and the infusion and is the primary actor, it seems to have a major impact on the numbers because people think that dying through the needle, as we put it in the Netherlands, is part of medical procedure and good medical care. The advantage of the Swiss system is that this impression is not given by physicians.

I would be for that but, again, you must be aware that any system - even the Swiss system - will be susceptible to the problem that it is injust. For example, what happens if you cannot swallow? Is there a machine with something you can push? I see Mr. Luley is nodding. Perhaps you can do it by nodding your eye. As this is possible, I would be strongly in favour of such a system while still being aware that some categories of patients will still feel that they are being done an injustice. That will always be the case. There is no watertight system where everybody is happy. Does that answer the Senator's questions?