“You’re not going to dehydrate mom, are you?”: Euthanasia, versterving, and good death in the...

Social Science & Medicine 58 (2004) 955–966

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‘‘You’re not going to dehydrate mom, are you?’’: Euthanasia,versterving, and good death in the Netherlands

Robert Pool*

London School of Hygiene and Tropical Medicine, 50 Bedford Square, London WC1B 3DP, UK

Abstract

In 1996, a debate erupted in the Netherlands about versterven: dying as a result of abstaining from eating and

drinking. This discussion initially appeared to be one of the many side-shows to the wider Dutch euthanasia debate, but

it continued to dominate the debate for the next few years, with newspaper headlines reporting ‘‘involuntary

dehydration’’ in nursing homes. Part of the reason for this was the term itself. Introduced to refer to terminal

dehydration, the word versterven had peculiar connotations and this, together with the way in which it was used, caused

much confusion and controversy. Was versterven related to euthanasia? Did it denote dying naturally and peacefully or

a horrible death imposed on helpless phychogeriatric patients? Was it (could it be) voluntary? Was the patient in

control? Was it good death? This paper examines the discussion about, and the media representations of, versterven,

focusing on its ambiguity and its relationship to good death.

r 2003 Elsevier Ltd. All rights reserved.

Keywords: Good death; Versterven; Euthanasia; Terminal dehydration; The Netherlands; Media representations

Introduction

Although the first case was tried in 1952, the broad

public ‘‘debate’’ on euthanasia in the Netherlands is

generally said to have started with the trial, in 1973, of a

doctor who killed her terminally ill mother with an

injection of morphine. The doctor was convicted of

contravening Article 293 of the Penal Code1 and given a

1 week suspended sentence. By imposing a largely

symbolic sentence, the court accepted that if a doctor’s

actions conformed to certain criteria then in practice he

or she was justified in responding to a patient’s explicit

request for euthanasia.

I have put ‘‘debate’’ in quotations because it has

involved, and still involves, far more than just debate:

talk, discussion. The Dutch euthanasia debate, rather, is

an ongoing and complex socio-cultural, medical, legal,

0-7299-4718; fax: +44-20-7299-4720.

ess: [email protected] (R. Pool).

es the life of another at the latter’s explicit and

, will be punished with a prison term not

ars or a fine in the fifth category.’

e front matter r 2003 Elsevier Ltd. All rights reserve

cscimed.2003.10.039

and ethical process which has been characterised by

increasing tolerance of physician assisted death, creeping

jurisprudence culminating in the legalisation of eutha-

nasia in November 2000, and a gradually shifting limit

to what is considered ethically acceptable.2

But there is also a lot of real debate as well. Lawyers

wrangle over legal issues in the courts as jurisprudence

gradually develops, parliament considers and decides on

new legislation, professors discuss ethical limits to

interventions in the dying process, and doctors argue

about the nature of suffering and what constitutes

humane death. In this debate, the media play a central

role. In fact, the public debate on euthanasia has been

conducted largely through the media, particularly the

newspapers. Because the Netherlands is a small country,

there are relatively few newspapers, and they tend to be

serious—there are no UK style tabloids—and this has

kept the discussion serious, even scholarly. The news-

papers have been able to respond directly to develop-

ments on the ground, with the professional journals

2 The law was approved by parliament in November 2000 but

took effect on 1 April 2001.

d.

ARTICLE IN PRESSR. Pool / Social Science & Medicine 58 (2004) 955–966956

often trailing behind due to the time lag imposed by

refereeing procedures. Journal articles often simply

repeated or summarised the journalistic debate; some-

times they reflected more deeply on specific legal,

medical, or ethical issues. Part of the reason for the

quality of newspaper coverage and discussion is that

leading professionals from health care, legal, ethical, and

social science disciplines have often used newspapers

rather than (or in addition to) professional journals in

order to respond to developments as they occur and

discuss issues at the point of maximum public interest.

Since 1973, the debate has moved along in bursts

(clearly visible in the newspaper archives), and each

burst has been characterised by the exploration of some

new facet—legal, ethical, practical—of the problem of

how we should die, and often accompanied by an

expansion of what was considered acceptable (oppo-

nents of euthanasia would say a step further down the

slippery slope). And as each new hurdle is crossed

(patients do not need to be in the terminal stage of an

illness, or the suffering need not be physical to justify

euthanasia), new challenges and issues arise.

One of these new issues concerned what is referred to in

Dutch as versterven, and it dominated media attention for

2 years from the latter half of 1996. Basically, versterven

refers to abstaining from giving food and liquid to patients

who refuse or who do not experience sensations of hunger

and thirst due to old age or illness, but it does not translate

unproblematically as ‘‘terminal dehydration’’.

In what follows, I discuss versterven in the Nether-

lands and how it relates to conceptions of good death.

After examining the discussion about versterven, I

summarise the literature on good death in different

cultural settings. I identify the central characteristics of

good death and then focus on control over death as one

of the central defining characteristics of good death.

This paper is more about representations (and media

representations in particular) of versterven, about the

introduction, use, and reception of the term versterven—

and about a particular discourse within the Dutch

‘‘euthanasia debate’’—than about the actual practice

of terminal dehydration, in the Netherlands or anywhere

else. The paper concludes with a discussion of the

relationship between versterven and good death, and the

circumstances under which dying as a result of

dehydration could be considered a good death.

Versterven

In 1996, the psychiatrist B. Chabot introduced the

term versterven3 into the Dutch euthanasia debate. He

3 Versterven is a verb; the noun is versterving. Because there is

no exact English equivalent, and because the meaning of the

term is one of the issues to be discussed, I will use the Dutch

terms throughout this paper.

defined it as dying as a result of refusing food or drink—

fasting. He described it as an ancient way of good death

(going back at least to ancient Greece), recently

rediscovered. Chabot had terminally ill and psychoger-

iatric patients in mind who may abstain from food and

drink spontaneously or reuse to eat and drink as the

result of a deliberate decision. Patients die from a

combination of malnutrition and, particularly, dehydra-

tion. According to Chabot, the (medical) literature

shows that with intensive palliative care, 80% of

terminal patients could use this method of hastening

death without suffering discomfort. He claimed that

versterven might bridge the divide between pro-eutha-

nasia groups and their pro-life opponents because

it would satisfy the former’s ‘‘right-to-die’’ demands

while still being considered a natural death by the

latter. He thought it might also be more acceptable to

doctors who feel uneasy about assisting in euthanasia

(Chabot, 1996).

There was a whole range of responses to Chabot.

Some were horrified, quoting the remarks of a professor

of anaesthesiology who, some years previously, had

referred to a court decision enabling the termination of

tube feeding to a woman in an irreversible coma as a

cowardly and hypocritical act. ‘‘This death is horrible to

witness’’, he reported in a newspaper article:

The skin and mucous membranes dehydrate, the

blood thickens, the kidneys no longer produce urine

and gradually wither. The eyes are often damaged

because tears are no longer produced. Inflammations

and fungal infections develop in the mouth because

the natural cleansing effect of the saliva is lost. The

body is gradually poisoned by waste products which

can no longer be expelled. In the respiratory system

scabs of dehydrated mucus form which impede

breathing. This is how the patient wastes away under

the eyes of doctors, nurses and loved onesyYou

wouldn’t want to do that to a dog (Smalhout, 1990).

At the opposite end of the spectrum, others argued

that versterven was in fact euthanasia—good death—par

excellence. Yet others, probably with the official Dutch

definition in mind rather than the literal meaning of the

term euthanasia, argued that versterven, although a mild

way of dying, most definitely was not euthanasia.

Doctors working in nursing homes claimed that the

medically supervised process of gradual starvation and

dehydration was part of normal practice in nursing

homes, and that cachexia and dehydration were

frequently reported as the cause of death on death

certificates issued by nursing home doctors (Cools,

1992). One doctor reported that a third of the deaths

in nursing homes were a result of versterving. ‘‘After

weeks or months of gradually eating and drinking less,

these old, sick, sometimes demented people slowly sink

ARTICLE IN PRESS

4 Trouw 26-7-97.

R. Pool / Social Science & Medicine 58 (2004) 955–966 957

into death’’. Speaking about one patient he said, ‘‘He

died naturally, his body gave up’’ (Van der Zalm, 1997).

Chabot was criticised for making a normal way of

dying into a ‘‘sort of pseudo-euthanasia’’. ‘‘What Chabot

calls versterven, I call dying’’, said N. Goudswaard, a

GP. Cancer patients who die at home almost always die

as a result of not eating and drinking, according to

Goudswaard. He emphasised that it was necessary to

distinguish between patients who have been seriously ill

for months or even years and who gradually reduce food

and liquid intake, and relatively more healthy patients

who abruptly decide to stop eating and drinking. ‘‘In the

former case this is part of the natural trajectory of the

illness that we must respect and support (begeleiden); in

the latter case I would advise them to eat and drink. The

healthier the person, the more unpleasant this type of

self-chosen death’’ (quoted in Ten Haaft, 1996).

Part of the reason for all the fuss, as the nursing home

doctor Bert Keizer pointed out, was that the average

person’s experience of the dying process was limited to

films and television. On screen, death is generally clear-

cut: ‘‘the dying person fidgets with the sheets, speaks a

final utterance, then turns his head, resolutely closes his

eyes, and puts a full-stop behind his existence’’. This

deviates so far from reality that most people are not

aware of what is happening when someone really dies:

relatives immersed in deep discussions at the bedside

sometimes have to be interrupted to inform them that

the loved one in the bed is actually in the process of

dying (Keizer, 1996; see also Lawton, 2000, pp. vi–vii).

After March 1996, the discussion of versterven died

down and in the year following Chabot’s publication the

topic only appeared in the media sporadically. There

was a brief spurt of attention in late 1996, when Janine

Pikaar defended a Ph.D. dissertation entitled Endura—

je #une ou suicide? (Endura—fasting or suicide) at the

University of Utrecht. Her dissertation was about the

Cathars, practitioners of a Dualist religion that flour-

ished in Europe between the 12th and 13th centuries.

The Cathars believed that fasting would reduce suffering

and speed up death and a return to the spiritual world.

Pikaar related the practices of this medieval religion to

current discussions about versterven, and argued that

when old people refuse food, their choice should be

respected. She concluded that endura—fasting to death,

i.e. versterven—is not a form of suicide but an instinctive

attempt to die humanely. The dissertation received

attention not only because discussion of versterven was

in vogue and the author had spent 20 years taking care

of her own mother who had eventually died after

refusing food, but also because, at 80 years old, Janine

Pikaar was the oldest person to get a Ph.D. at the

University of Utrecht. After attention for Pikaar’s

dissertation had died down, versterven appeared to have

been all but forgotten. This was the calm before the

storm, however.

The involuntarily dehydration of Mr. Mulder

In late July 1997, the whole discussion about

versterven exploded into national prominence once more

with newspaper reports that a phychogeriatric nursing

home called ‘t Blauwborgje had purposely allowed a

62-year-old Alzheimer’s patient to ‘‘dehydrate’’ in order

to ‘‘let him die a soft death’’. Mr. Mulder’s ex-wife and

daughter, who had apparently not been informed of the

nursing home’s decision, found him unconscious when

they arrived during visiting hours one day. They later

told a newspaper reporter that they had asked staff why

he had not been given a fluid infusion, only to be told

that this was against the nursing home’s ‘‘dehydration

policy’’. Although the man had a mental age of three, his

daughter ‘‘still had a lot of pleasure with him’’ and did

not want him to die until ‘‘our dear Lord decides that his

time has come’’. She had him transferred to a hospital,

where he was revived with an infusion. That evening, he

opened his eyes and soon television pictures of him

eating a plate of spinach were being broadcast into every

home in the country. The daughter reported the nursing

home to the police, accusing staff of attempted murder.

The Justice Ministry initiated an investigation. The

spectre of involuntary versterving, invoked by the anti-

euthanasia criminologist Chris Rutenfrans following

Chabot’s initial launching of the term (Rutenfrans,

1996), had been awakened.

During August, hardly a day went by without some

aspect of versterving being discussed in the newspapers.

More cases of versterving came to light. One newspaper

reported:

Police have received four more reports from relatives

who think that a partner or family member died

under suspicious circumstances in the nursing home

‘t Blauwborgje.4

A few days later another three cases were reported

from ‘t Blauwborgje, bringing the total to 10. A police

spokesman said that although they were taking all

reports seriously, he did not exclude the possibility that

after consultations the relatives would withdraw their

accusations. Then on the 9th of August, under the

headline ‘‘Second case of involuntary versterving’’, it was

reported that following a request from the Ministry of

Justice, the Health Care Inspectorate was to investigate

a case of involuntary versterving in another nursing

home.

According to relatives, versterving was applied to an

81-year-old woman against her express will. She died

on the 28th of March after being admitted to hospital

with symptoms of extreme dehydration. On the 25th

ARTICLE IN PRESS

6 Chabot (1998) has pointed out that this figure does not

necessarily refer to versterving, as in many of these cases

R. Pool / Social Science & Medicine 58 (2004) 955–966958

of May her son reported ‘‘death by dehydration and

culpable homicide’’ to the Ministry of Justice.5

Numerous other articles appeared during the rest of

month, and three main themes emerged from these

articles. First, the question whether or not versterving is

a mild death. The majority view, often based on

personal clinical experience or reviews of the medical

literature, was that it is. Most commentators accepted

versterven as a natural dying process. They saw it as a

mild death and thought it quite normal that many

patients with dementia died in this way. It was

acknowledged that the lives of these patients could be

extended by giving them food and liquid through a tube,

but there appeared to be no good reason for extending

life just for the sake of it, irrespective of the quality.

Indeed, some concluded that there had to be very good

reasons for keeping dying psychogeriatric patient alive

artificially.

Second, there was the inevitable Dutch obsession with

regulation and consultation, and there were calls for

more external control: guidelines for nursing homes,

consultation with relatives. But there were also those

who felt that letting relatives know too much about the

possibility of extending life might not be in the patients’

best interests either. This could lead to relatives

demanding that dying patients be kept alive artificially,

thus extending the dying process in ways that were not

in the patient’s best interest.

Third, the assumption that the patient is sovereign.

Self-determination is central to the whole Dutch debate

on death (and much else), but to what extent are dying

phychogeriatric patients capable of deciding for them-

selves? The classical scholar Anton Van Hooff is typical

of one side of this argument. He claimed that

psychogeriatric patients cannot be said to have a will

of their own. He referred to the old Dutch word for

dementia, kinds—as a child—arguing that when a baby

systematically refuses food its parents do not say, ‘‘Let

him be, he probably wants to die’’ (this example was

used by many of those who claimed to be opposed to

versterven). The same applies, according to Van Hooff,

to anorexia patients. He concluded that the refusal of

food by a patient with Alzheimer’s disease could not be

interpreted as a desire to die (Van Hooff, 1997). Against

this, it was argued that dying psychogeriatric patients

are not the same as small children and that their refusal

to eat is not so much the result of a consciously made

decision, a sign that they want to die, but an integral

part of the dying process itself: reduction of appetite and

thirst are symptoms of terminal Alzheimer’s disease.

Others argued that such patients can make their will

known and do sometimes consciously refuse food and

liquid because they want to die.

5 NRC Handelsblad 9-8-97.

As in all questions relating to decisions at the end of

life in the Netherlands, many felt a need for numbers

and frequencies, and the call was soon made for research

on versterving. Fortunately, research had already been

carried out, as part of a larger study of euthanasia and

medical decisions at the end of life. That study focused

on euthanasia and was intended to evaluate the new

reporting procedure for euthanasia, but the researchers

had also asked doctors about their decisions not to

implement treatment that could extend the lives of

terminally ill patients. A few months after the call for

numbers, the researchers obliged with a paper in the

Dutch Medical Journal (Nederlands Tijdschrift voor

Geneeskunde) (Van der Heide et al., 1997). They

concluded that decisions not to give food and fluid with

the hastening of death as a possible consequence are

made regularly (in 23% of deaths) in nursing homes,

mainly with regard to incompetent (wilsonbekwame)

patients (thus confirming the rough estimates already

suggested by nursing home doctors in the newspapers).6

While the main discussion generally focused on

important and relevant issues, along the fringes it

started to become somewhat frayed. Two political

parties representing the elderly in parliament produced

a pamphlet claiming that because of poverty, many old

people did not have a healthy diet and so found

themselves in a condition of ‘‘pre-versterving’’ (voorver-

sterving). The pamphlet expressed the need to defend the

elderly in nursing homes who ‘‘are silently abandoned

and/or verstorven’’.

The discussion continued during the latter months of

1997, though with much less coverage than in August:

one article a week in September and October, nothing

in November and December (there had been at least 25

articles in the major newspapers in August). There

was a report that ‘t Blauwborgje was to be prosecuted,

but the Ministry of Justice ended up concluding that

the nursing home had done nothing wrong and no

one ended up in court. In fact, in the long, run no one

ended up being prosecuted in relation to versterving.

There was also some discussion about care for the dying

and a lot of letters expressing the whole range of

opinion.

By 2000, the discussion on versterving seemed to have

itself succumbed to versterving, with only two brief

reports on the result of a study by the Inspectorate of

Health on nursing homes’ feeding and hydration policy,

which concluded that there were still no clear guidelines

on paper.

doctors also stop medication and increase the amount of

morphine.

ARTICLE IN PRESSR. Pool / Social Science & Medicine 58 (2004) 955–966 959

Versterven and terminal dehydration

Chabot introduced the term versterven into the

euthanasia debate to focus attention on terminal

dehydration. Both the phenomenon of terminal dehy-

dration and an adequate Dutch terminology to represent

it (terminale dehydratie, terminale uitdroging) were

already present when Chabot introduced the term

versterven. The issue of terminal dehydration had been

neither controversial nor widely debated in the media

until Chabot attracted attention with the word verster-

ven. Speculation as to why Chabot chose to introduce a

new term—one with very peculiar connotations (see

below)—into the discussion is beyond the scope of this

paper. What concerns me here is the way in which

versterven has been represented (the particular discourse

on versterven which developed within the Dutch

euthanasia debate) and the reception of those represen-

tations. It is my contention that the concept of versterven

became so controversial in the popular imagination

partly because it brought to the fore ambiguities about

good death and raised issues of control. However,

before discussing this in more detail, it is necessary to

examine the nature of good death and the role of control

in good death.

Good and bad death

There is a vast literature on what it means to die a

good death. Good death in western societies is described

and discussed mainly in the medical journals, although

there are various sociological and anthropological

studies as well. Discussion of good death in non-western

societies is limited to the anthropological literature.

Discussions of good death in the west generally occur

in the context of palliative care, and the hospice

movement’s holistic and person-centered conception

the good death is very much in evidence. This includes

high standards of care, including the physical, psycho-

logical, and spiritual needs of the patient, adequate

symptom control, and the provision of comfort to both

patient and family, dying peacefully and with dignity, in

full awareness and acceptance of death. Hospice patients

in England described good death in terms of dying in

one’s sleep, dying quietly, peacefully, and with dignity,

being pain-free, and accepting death, while for hospice

staff, adequate symptom control, family involvement,

peacefulness, lack of distress, acceptance, and not dying

young were important (Payne, Hillier, Langley-Evans, &

Roberts, 1996; Payne, Langley-Evans, & Hillier, 1996).7

7 This is by no means an exhaustive literature review. It is a

summary of the most important characteristics of good death

taken from a small but generally representative sample of

publications.

In a study in a university medical centre and a

veterans’ affairs medical centre in the US, Steinhauser

et al. (2000) found that patients, families, and care

providers saw the good death as having the following

characteristics: pain and symptom management, com-

munication and clear decision making, preparation for

death, resolving conflicts, spending time with loved ones,

saying goodbye, sharing knowledge, helping others,

personal relationships between carers and patients,

seeing the patient as a person rather than a disease

(2000).

In discussing whether dialysis discontinuation leads to

a good death, Cohen, McCue, Germain, and Kjellstrand

operationalise good death in terms of brevity, a

subjective assessment of lack of suffering, and subjective

evaluation of the presence of certain psychological

characteristics (circumstances leading to decision, level

of consciousness, capacity to communicate, whether

patient was alone or with family at the time of death)

(1995).

According to Kaufman (2000), the American cultural

ideal of a good death entails dignity, lack of pain or

suffering, autonomy, and dying not being prolonged

(2000). For Quill and Brody, good death is dying in

relative physical comfort, supported by and connected

to important persons in one’s life, with spiritual conflicts

resolved, and acceptance of death (1995).

In his study of people dying of cancer in Australia,

Kellehear relates good death to the Greek kalos thanatos

rather than eu thanatos. The latter, he argues, refers to

‘‘dying ‘well’, that is, painlessly and easilyyas in the

broad meaning of ‘euthanasia’’’. Kalos thanatos, on the

other hand, translates as ‘‘beautiful death, the ideal of

exemplary death’’ which, according to Kellehear, is ‘‘a

set of culturally sanctioned and prescribed behaviours

set in motion by the dying and designed to make death

meaningful for as many concerned as possible’’ (Kelle-

hear, 1990, p. 29). Although various people are involved

in good death, the dying themselves must be the ‘‘critical

directors’’ of it; it is crucial that the dying themselves

‘‘set the tone’’ for their own death (Kellehear, 1990,

p. 30).

In January 2000, the British Medical Journal carried

an editorial entitled ‘‘A good death. An important aim

for health services and for us all’’ (Smith). In it, the

‘‘principles of a good death’’ were set out as follows:

* To know when death is coming, and to understand

what can be expected.* To be able to retain control of what happens.* To be afforded dignity and privacy.* To have control over pain relief and other symptom

control.* To have choice and control over where death occurs.* To have access to information and expertise of

whatever kind is necessary.

ARTICLE IN PRESS

8 I see awareness and acceptance of death, both character-

istics on which the hospice movement places much emphasis, as

less central to a general conception of good death because

people often express opposite characteristics as being important

for a good death, e.g. dying suddenly in one’s sleep.


* To have access to any spiritual of emotional support

required.* To have access to hospice care in any location, not

only in hospital.* To have control over who is present and who shares

the end.* To be able to issue advance directives which ensure

wishes are respected.* To have time to say goodbye, and control over other

aspects of timing.* To be able to leave when it is time to go, and not to

have life prolonged pointlessly.

Turning to the anthropological literature on good

death in non-western societies, Bloch and Parry, in their

book Death and the regeneration of life, describe good

death as suggesting a ‘‘degree of mastery over the

arbitrariness of the biological occurrence by replicating

a prototype to which all such deaths conform, and which

can therefore be seen as an instance of a general pattern

necessary for the reproduction of life’’. A bad death, in

contrast, is one that is characterised by lack of control

(Bloch & Parry, 1982, p. 15).

In Hinduism, according to Parry, the good death is

one to which the individual voluntarily submits him or

herself. ‘‘In the ideal caseythe dying man forgoes all

food for some days before death, and consumes only

Ganges water and charan-amrit (the mixture in which

the image of a deity has been bathed), in order to

weaken his body so that the ‘vital breath’ may leave it

more easily’’ (Parry, 1982, p. 82). Justice, describing

good death in a religious home for the dying in India,

and Firth, discussing death and bereavement in a British

Hindu community, list similar characteristics of Hindu

good death: death in a religious environment, controlled

and predicted, conscious, while concentrating on God,

and with tulsi leaves and Ganges water offered at the last

moment (Firth, 1998; Justice, 1997).

A good death is one that occurs at the right time and

in the proper setting; after a full life, a person comes to a

peaceful and predictable end surrounded by family and

friends. Among the Ugandan Lugbara, a good death is

when a man dies at the time that he has foreseen so that

his sons and brothers can be present. ‘‘He should die

with his mind still alert and should be able to speak

clearly even if only softly; he should die peacefully and

with dignity, without bodily discomfort or disturbance’’

(Middleton, 1982, p. 142).

Among the Dinka in southern Sudan, chiefs and

religious leaders known as ‘‘masters of the spear’’ were

traditionally not supposed to wait until they actually

died before burial, but requested burial alive when they

were about to die (Lienhardt, 1961; Deng, 1972). Part of

the significance of the ‘‘proper’’ death of the spearmaster

was that it robbed death of its contingency, enhancing

the prosperity and fertility of the community (Bloch &

Parry, 1982, p. 16). Burial was voluntarily initiated by

the spearmaster himself when he was old and felt himself

to be dying. (Burial of a spearmaster against his will was

not unknown but considered wrong). ‘‘The act of burial

is a collective act; it is neither suicide nor regicidey It is

performed by the master and people in concert’’

(Metcalf & Huntington, 1991, pp. 185–186).

The various descriptions and definitions of good

death above are all different (and there are more

varieties in the literature). So is there an essential

meaning or characteristic that all these descriptions have

in common, or is it only the use of the term that unites

them? What justifies referring to them all as forms of

good death is the fact that they are related to each other

through a series of ‘‘family resemblances’’ (Wittgenstein,

1953, pp. 65–67). There are a number of overlapping

characteristics, but no single one that they all share.

These characteristics fall into three main groups. The

first is related to the patient’s experience of dying (mild,

painless, peaceful, dignified, brief). The second refers to

the social context (family involvement, good relation-

ships, communication, conflicts resolved). The third

relates to the patient’s autonomy and control over the

dying process.8

It seems to me that control is not only a central

characteristic in itself of good death, but that it is also an

important aspect of many of the other characteristics.

This is clear in the list of ‘‘principles of good death’’ in

the BMJ editorial as listed above. For a death to be

painless, peaceful, dignified, etc., it is necessary that pain

and other unpleasant and demeaning symptoms are

brought under control. This control might be in the

hands of the doctor rather than the patient, but it is

done according to the will of the patient. Similarly, good

relationships, family involvement, communication, and

conflict resolution imply that the patient is still in

control of him or herself in the sense of retaining the

necessary social skills to be able to play an active part in

social interaction.

This implies being in control of the final phase of the

life trajectory preceding actual dying. Ludovic Kennedy,

for example, argues that a good death is one that is

arranged while you are still competent, i.e., in control.

This then avoids later suffering, pain, deterioration, etc.

(Kennedy, 1990). And in a study of euthanasia in a

hospital in the Netherlands (Pool, 2000), I have shown

that long-term euthanasia requests, made at the start of

the illness trajectory, contribute to patient control,

thereby enhancing the chance of the request being

granted later. And Clive Seale has discussed how those


in the social environment of the elderly living alone are

constantly on the lookout for signs of a breakdown in

control, as expressed through failure to maintain

appropriate levels of personal and household cleanli-

ness, and how the elderly try to show that they are in

control by ‘‘keeping active’’ and trying to maintain a

reputation for independence. ‘‘In this way people living

alone demonstrated the successful accomplishment of a

meaningful and orderly life, conducted with an appro-

priate degree of reciprocity with others’’. Declining

ability to initiate social contact—loneliness—was an

indicator of failure to cope (i.e. lack of control) (Seale,

1998, pp. 152–154). Referring to the papers collected in

their volume, Bloch and Parry claim that ‘‘in nearly all

of our examples, those deaths which most clearly

demonstrate the absence of control are those which are

represented as ‘bad’ deaths and which do not result in

regeneration’’ (Bloch & Parry, 1982, p. 15).

There is also another side to control as a characteristic

of hospice good death. Good death in the hospice setting

entails control of pain and symptoms, but it also entails

control of the patient. ‘‘We like to have the symptoms

controlled and hopefully have the patient come to terms

with their death, but inevitably most patients will ask at

some time ‘why me?’’’ Bad deaths occur when, in the

words of a hospice nurse, families and patients do not

‘‘internalise hospice philosophies’’. ‘‘It’s so much bet-

ter’’, another nurse says, ‘‘if they fit into the standard

‘Hospice Story’yyou know when they are realistic

and accepting’’ (McNamara, Waddell, & Colvin, 1994,

p. 1504). Hart, Sainsbury, and Short (1998) speak of an

ideology of good death that ‘‘legitimises a new form of

social control within which socially approved dying and

death are characterised by proscribed and normalised

behaviours and choices’’. This form of institutional

control obviously impedes the patient control discussed

above.

9 Algemeen Dagblad, 6-2-97.10 Algemeen Dagblad, 17-2-97.11 Haagse Courant, 8-2-97.12 Algemeen Dagblad, 6-2-97.13 Haagse Courant, 6-2-97.

Controlled death in the Netherlands

In much of the literature, good death is simply

equated with euthanasia (for example, in the title of

Ludovic Kennedy’s book Euthanasia: The good death).

However, although ‘‘euthanasia’’ means good death, the

words ‘‘good death’’ hardly figure in the euthanasia

discussion in the Netherlands.

The ‘‘official’’ definition: ‘‘Euthanasia is the deliberate

termination of a person’s life by another person at the

former’s request’’ (Staatscommissie Euthanasie 1985)

does not include the words ‘‘mild death’’ or ‘‘soft death’’

or ‘‘good death’’. These terms are sometimes used, but

this is not part of the definition of euthanasia because it

is assumed that euthanasia and physician assisted

suicide are, or should be, a mild death (although a

doctor shooting a patient at his or her request would,

strictly speaking, fall within the official definition of

euthanasia, it is difficult to imagine such a death being

referred to as euthanasia).

While euthanasia is not explicitly referred to as good

death, it is obviously considered good death in a wider

sense than being simply a mild death—i.e. devoid of

suffering. So what is that surplus value that makes

euthanasia a good death in the Netherlands? A few well-

publicised examples will suggest an answer.

On a Monday evening in early 1997, a 64-year-old

man died as a result of euthanasia. He had been

diagnosed with throat cancer a year before, but refused

surgery which would have deprived him of his sense of

smell and taste and the ability to talk. Later, he decided

to abandon chemotherapy. He was one of several

thousand cases of officially reported euthanasia in the

Netherlands each year, but his death did not go

unnoticed. He was not merely another number in the

euthanasia statistics; he was Frans Swarttouw, ‘‘the six

billion Guilder man’’, ‘‘one of the Netherlands’ most

renowned captains of industry’’, and his death was

described by the press as a ‘‘national happening’’,

invoking newspaper headlines like ‘‘One should be able

to die like a gentleman’’ (referring to a well-known

Dutch cartoon),9 ‘‘Dying like a man’’,10 and ‘‘The

directed death’’.11

Swarttouw was described as ‘‘a real decision-maker, a

real negotiator, right until the end’’. His greatest fear

was languishing in a hospital bed, being kept alive

through tubes, unable to decide his own fate. So when it

became clear that nothing more could be done, he

insisted on determining the time and place of his own

departure. Not everyone is strong enough to achieve

this, according to a psychologist at the Dutch Voluntary

Euthanasia Society (NVVE), and this kind of death is

still only reserved for the elite. ‘‘For 80–90% of the

population, the right to euthanasia is undisputed, and

when the time comes, its implementation is not an

issue’’, the psychologist said. ‘‘But only a minority (4%)

has registered this desire in a document. And only a

small group can direct their own death in such a way

that they really undergo euthanasia without too many

problems’’.12 Swarttouw, we were told, belonged to this

elite. A spokesperson for the NVVE said, ‘‘We couldn’t

have wished for a better ambassador. His integrity and

openness could break a lance for euthanasia’’. She

referred to his death as ‘‘an example of how it can be

done’’.13

The emphasis was very much on the self-directed

nature of Frans Swarttouw’s death, with the word

ARTICLE IN PRESS

14 It is, of course, possible that different individuals or groups

involved in a particular death may define it differently.

McNamara et al. (1994) have shown that hospice staff and

patients may have differing conceptions of what good death

entails, and they may have interests in defining good death

differently. Referring to hospice death, they argue that ‘the

Good Death is a conceptualisation used by the interactants

other than the dying person. The act of naming the death

‘‘good’’ is therefore a coping strategy in itself; it allows nurses

the opportunity to place death in a context separate from their

own individual experience’.


‘‘directed’’ being used in the cinematographic sense

(de geregisseerde dood). When you can no longer direct

your own life, then you can still at least direct the way

you die.

Control over the time and manner of death were

central themes in almost all the euthanasia requests I

studied during 2 years of research in a Dutch hospital

(Pool, 2000). Although patients in my study often spoke

of not wanting to suffer pain, in practice, control was

more important and they sometimes chose to suffer pain

and be in control rather than be pain free but drowsy

from the morphine. The ALS (amyotrophic lateral

sclerosis) patient in the controversial Dutch documen-

tary film Death on request did not request euthanasia

because of pain, suffering, or inadequate psychological

support, but because he wanted to determine the time

and manner of his death, he wanted to die when he was

ready, on his birthday, in the evening, after sharing a

glass of genever with his wife and doctor: he wanted to

be in control.

In my study, euthanasia requests and related planning

(establishing control over dying) often long preceded

actual physical decline. Although most patients with

incurable, life-threatening diseases such as cancer never

mentioned euthanasia at all, those who did broach the

subject often did so at the very beginning of their illness

trajectory, as soon as it became clear that they were

incurably ill. These are ‘‘long-term’’ euthanasia requests

and, when the doctor agrees that euthanasia is negoti-

able and would be considered if the patient so desired

when the time came, they are seen as a kind of insurance

against unnecessary suffering and physical decline. The

negotiation of such long-term agreements is motivated

by the desire to ‘‘have things under control’’. The

patients in my study whose euthanasia requests were

taken seriously tended to be in control of themselves and

their lives, though not necessarily powerful and educated

like Frans Swarttouw. This was part of a repertoire of

social assets and communicative skills which patients

utilised to convince doctors that their requests were

justified. Patients lacking these assets were at a

disadvantage in negotiating their request, even though

their claims might be equally justified from an ethical

and medical perspective. In other words, you have to be

in control to have your euthanasia request taken

seriously (Pool, 2000).

That control, self-direction, and self-management are

central characteristics of Dutch good death is empha-

sised by the death of another celebrity. On the 11th of

July, 2001, the popular rock musician and painter

Herman Brood (b. 1946) decided that it was time to die,

and so he jumped from the roof of the Amsterdam

Hilton Hotel. His suicide note apparently showed that it

was a well-considered decision, not taken under the

influence of alcohol or drugs, or in the depths of

depression: he wrote that he was going bungy-jumping

without the elastic, and advised his family to have a big

party and celebrate. Rather than shock at an abomin-

able end, the general reaction was that he had taken a

‘‘brave’’ step in choosing death when he had had enough

of life. Smashing into the ground after a ten-story drop

became a good death because he was in control.

Good death is, to a large extent, an individual issue

(Quill & Brody, 1995). In the final instance, it is only the

individual in question who can determine whether his or

her own death is a good one. As Weisman (1972) states,

‘‘good death is the type of death one would choose if

there were a choice’’ (quoted in Cohen, McCue,

Germain, & Kjellstrand, 1995). It seems unlikely that

many people would freely choose to relinquish control

over their own death.14

Finally, in the Netherlands, the very definition of

euthanasia as ‘‘the deliberate termination of a person’s

life by another person at the former’s request’’, implies

control. If the person has not actively asked to die

(is not in control), then the actions are not euthanasia

(good death) by definition. The whole procedure entails

control: consultations with a second doctor to make sure

the patient is mentally stable and really wants to die, the

doctors continually emphasising that the patient is in

charge and can change his/her mind at any time, etc.

Natural and unnatural death

The distinction between natural and unnatural death

is also relevant here. What is ‘‘natural’’, however,

depends on what is defined and constructed as natural

by different people in different contexts. In traditional

African aetiologies, natural death ‘‘just happens’’ at the

end of life, whereas unnatural death is caused, either by

another person, or by spirits, ancestors, or witches. The

death of a young person is always considered to have

been caused by someone in the final instance, i.e. it is

always unnatural (Pool, 1994).

In a western hospice setting, ‘‘natural’’ death is a

heavily sedated one. During my study of euthanasia,

doctors sometimes told me that they were going to put

the patient to sleep with a large dose of morphine, and

that it was to be a ‘‘completely natural dying process’’.


In the Netherlands, when a patient dies, the doctor can

register on the death certificate that the patient has died

of natural causes or that the death was unnatural. A

young person dying as a consequence of an incurable

illness will have natural death recorded on the death

certificate. In the case of euthanasia—as with homi-

cide—an unnatural death will be recorded.

In spite of these differences, I think there is a general

consensus that, at the very least, natural death can be

said to consist of fading away peacefully at the end of a

long and full life, and that dying as a result of accidents,

uncontrolled violence, or disease while relatively young

is generally considered unnatural. Good death can be

either natural (not many people would disagree that

dying peacefully after a long life is a good death,

whether or not the person has any direct control over the

dying process) or unnatural (controlled).

Suicide

Suicide is obviously an unnatural death, but is it good

or bad? Although it can be death with maximum control,

it is often considered the bad death par excellence. In

traditional African settings, suicides are often buried

outside the village or, in the Christian tradition, away

from consecrated ground (Bloch & Parry, 1982, p. 16).

I have argued that the suicide of Herman Brood

entailed maximum control and was therefore considered

by many to be a good death. But what of psychiatric

patients who fling themselves in front of trains, or

depressives who take overdoses of barbiturates? In this

regard, it is useful to distinguish between different kinds

of suicide. Bloch and Parry distinguish between self-

inflicted death and the voluntary renunciation of life

(as in the case of the Dinka spearmaster or the pious

Hindu). In German, there is a distinction between

Selbsmord (self-murder, a tragic act associated with

despair, depression) and Freitod (free death). The latter

term is ‘‘free from connotations of either moral

wrongness or pathologyyit is associated with voluntary

individual choice and the expression of basic, strongly

held personal values or ideals, especially those running

counter to conventional societal norms, and suggests the

triumph of personal integrity in the face of threat or

shame’’ (Battin, 1994, p. 261).15

Discussion: The ambiguity of versterven

Very generally, and at the risk of simplification, we

might conclude that good death is dying naturally in old

15 I would like to thank Elke Hausmann, whose Ph.D.

dissertation, Media Representations of Euthanasia, drew my

attention to Battin’s discussion of the German terms.

age, dying peacefully and painlessly with or without the

assistance of pain medication, or dying unnaturally but

in a way that has been chosen and is controlled

(euthanasia, suicide in the sense of Freitod, or the

voluntary renunciation of life). Bad death is dying

unnaturally as a result of accidents, uncontrolled

violence, disease, or suicide (Selbsmord), while relatively

young, dying in pain, or dying in a way that has not been

chosen or is not controlled by the dying person.

Versterving was controversial because of the ambi-

guities and connotations of the term itself, ambiguity

about the nature of tube feeding, uncertainly about

whether or not it was painless, and the extent to which

the dying person was in control, and uncertainty about

what constitutes natural death.

First, much of the discussion about versterven

stemmed from confusion about the term itself. Many

interpreted versterven as a transitive verb, i.e. a kind of

killing, when it is in fact—and was intended by Chabot

to be interpreted as an intransitive verb, i.e. a kind of

dying. Versterven is not something you can do to people,

it is something that happens to them. In the discussion,

however, versterven was equated with terminating

hydration or feeding, or actively not initiating artificial

feeding and hydration in patients who did not sponta-

neously abstain from eating and drinking. There was

much talk of actively starving or dehydrating people

to death. Doctors were confronted by worried

relatives asking, ‘‘You’re not going to dehydrate

mom, are you?’’ (Keizer, 1997). The pamphlet distrib-

uted by the political parties representing the elderly

expressed the need to defend the elderly in nursing

homes who ‘‘are silently abandoned and/or verstorven’’.

Use of the term in this sense was also clearly visible

in the scientific journals. An article in the Dutch

Medical Journal in 1998 summarising the previous year’s

discussion in the newspapers began, ‘‘Recently the

discussion about versterven, abstaining from giving food

and liquid to patients who refuse or who do not

experience sensations of hunger and thirst due to old

age or illness, has flared in the media’’ (Klaren, 1998).

This confusion was hardly surprising, however, given

the term’s close association with ‘‘starving’’ and

‘‘dehydrating’’.

Second, the term’s religious etymology added to the

ambiguity in a debate in which the secular/religious

divide coincided to a large extent with the pro/anti

euthanasia camps. A brief consultation of a few

dictionaries (the Dutch-English Van Dale and the Dutch

Van Dale) reveal the following meanings:

1. To die (out), to wither, to wilt

2. To descend (in the sense of ‘‘to pass on by

inheritance’’), to devolve

3. To hang (meat)

4. To fast, mortify the flesh, renounce earthly pleasures


The associations with ‘‘hanging meat’’ and with terms

like ‘‘wither’’ and ‘‘wilt’’ obviously spoke to the

imagination of those opposed to versterving. But apart

from this, and in addition to the primary meaning of

‘‘dying’’, the term versterven also has strong currents of

religious meaning. Indeed, when criticised for using this

particular term, Chabot claimed that he had been

motivated in his choice by Job 14:8: ‘‘Though the root

thereof wax old in the earth, and the stock thereof die in

the ground’’ (Indien zijn wortel in de aarde veroudert, en

zijn stam in het stof versterft). (Here I think that ‘‘withers

in the ground’’ more accurately reflects the feel of the

Dutch ‘‘in het stof versterft’’). Fasting, mortification of

the flesh, renunciation, all suggest voluntary choice and

control, as well as some higher end to which these

sacrifices are a means. In her dissertation, Janine Pikaar

had related the fasting of the medieval Cathars—which

was meant to reduce suffering and speed up death and a

return to the spiritual world—to contemporary discus-

sions about versterven. In this discourse, versterven

acquired, or re-acquired, a spiritual meaning. Although

this resonance with Christian tradition and belief was

only a minor thread in a secular discussion, it was

nonetheless present, and it contributed to the ambiguity.

This religious aspect also links versterven to the

remaining characteristic of good death as described by

Bloch and Parry and Metcalf and Huntington which has

not played a role in the secularised Dutch euthanasia

debate: the link between good death and regeneration.

Third, there was ambiguity regarding whether tube

feeding and hydration were to be considered as eating

and drinking, or as a form of medication. Commensality

plays a central role in maintaining the social bond—i.e.

social life. Dying severs the social bond and at the end of

life the disruption of commensality becomes a symbol of

‘‘defeat for the cultural construction of the human social

bond’’ (Seale, 1998, p. 7). Giving food to the sick

symbolises compassionate care; the gift of food is

equated with the gift of life. This symbolic relationship

may, Seale points out, also lie behind the practice of

artificially feeding and hydrating terminally ill patients.

He refers to McInery, who writes of a ‘‘nurturing ritual’’

in which feelings of hunger and thirst are projected on

dying patients who are anorexic because of disease

(Seale, 1998, p. 160).

Changes in feeding practices, alterations to the type

and consistency of foodstuffs, a decline in appetite and

eventual cessation run closely in parallel with a decline

and eventual extinction of life itself. A progressive

dissolution of structure and daily routine occurs as the

complex reciprocities required for the performance of

normal, mannered eating cannot be sustained. This

mirrors the decline of the body and of self-control,

leading eventually to the withdrawal of the self in a

final fall from culture (Seale, 1998, p. 165).

When tube feeding and hydration are construed as

eating and drinking, then rules of commensality make it

difficult for care providers and relatives to acquiesce in

the patient’s request to abstain, or to make the decision

not to tube feed and hydrate an incompetent patient.

When food and hydration are defined as medication,

however, the decision becomes one of whether to

terminate medically pointless treatment, and this is

much easier because no fundamental cultural rules are

being transgressed.

Fourth, it was unclear, initially at least, whether

versterven was a mild and painless death or a horribly

unpleasant one. Among those (the majority) who

claimed it was a mild death, there were basically two

main definitions of versterven that were not necessarily

mutually exclusive: firstly, as a mild way of dying

resulting from a conscious decision by psycogeriatric

patients, the very old, or the terminally ill to refuse food

and liquid, and a parallel (though perhaps implicit)

decision by the doctor to abstain from, or terminate,

artificial feeding and hydration (i.e. a form of, or

something similar to, euthanasia). This definition raised

the question of the ability of psychogeriatric patients to

make a well-considered decision regarding the termina-

tion of feeding and hydration: i.e. was versterven

voluntary and did patients know what they were doing?

Secondly, as the natural process of dying in psychoger-

iatric patients, the very old, the terminally ill. As the

discussion progressed, the emphasis tended to shift from

the first to the second definition. And it was because of

this that the discussion finally faded.

Fifth, it was unclear to what extent versterven was, or

could be, voluntary, and there was much worry about

possible involuntary speeding up of death through

dehydration. And related to this was the question of

the extent of patient control. According to Chabot,

versterven gave the patient more control by shifting the

responsibility for the decision to die from doctor to

patient. In this scenario, the patient stops eating and

drinking, the doctor explains the consequences and

offers tube feeding and hydration, but the patient

refuses, thus consciously taking responsibility for his

or her own death. Or, according to the other argument,

it gives the patient less control. The cancer surgeon, A.

Smook, who performs euthanasia five or six times a

year, was radically opposed to dehydration. ‘‘It is an

admission of weakness’’, he said. ‘‘An inhumane way of

dying [because] the patient is no longer captain on his

own ship’’ (quoted in Baart, 1996). As Seale has pointed

out, while ceasing to eat may signify a loss of control for

some, for others this can be transformed into an act of

ultimate control over the manner and timing of death

(Seale, 1998, p. 165).

Finally, in addition to clarifying what we mean by

good death, the discussion about versterven served to

nuance popular attitudes towards euthanasia and dying.


For one thing, it focused people’s attention on what

dying—natural death—really entails: i.e. that it is very

different from Hollywood death, but not necessarily

horrific. This enabled people to see that they were not

confronted by an exclusive choice between two options,

good death (euthanasia) and bad death (all other ways

of dying), which is what many people assumed (hence

the rush to sign living wills and the clamour for

euthanasia among so many of the dying). It bridged

the divide between life and death by making (natural)

death more visible. Related to this, the discussion

focused attention on the nursing home as not necessarily

a house of horrors (where the decrepit and demented

elderly soil themselves and drool, unaware of where they

are, kept alive through tubes, awaiting release when they

are allowed to die) but as an institution where many of

us will end up despite other intentions, and where it is

possible to die a good death.

Conclusion: Versterven; good death, and control

All the central concepts in this discussion are

ambiguous to a greater or lesser extent. Versterven is

situated ambiguously between good and bad death and

natural and unnatural death (Fig. 1).

Unnatural death

verster

GOOD D

BAD DEA

accidents, violent death, starvation, suicide (Selbsmord)

euthanasia

Increasing control

Suicide (Freitod)

disease

Fig. 1. The ambiguit

It has been described as the natural outcome of

diseases such an cancer and Alzheimer’s disease, or

simply the result of very old age, where the patient is

‘‘spent’’ and gradually loses appetite and sensations of

thirst, i.e. the person spontaneously and unintentionally

stops eating and drinking. It can also be the result of a

conscious and deliberate decision by an elderly person or

patient with advanced terminal illness to abstain from

all food and liquid in order to hasten death (suicide/

Freitod). Depending on the role of the doctor in this, it

could also, in some circumstances, be construed as

euthanasia, though this is a matter for discussion

(indeed, it has been presented as an alternative to

euthanasia and physician assisted suicide, (see Chabot,

1996). In all these cases, it would be considered a good

death because it is natural, peaceful, or controlled. The

deaths of psychogeriatric patients, the very sick, or the

very old who died as a result of being deliberately

refused or deprived of food and liquid against their will

would be considered bad due to lack of control

(starvation). Very generally, then, we may conclude that

if versterving is natural, then it is generally good death,

but if it is unnatural, then whether or not it is good

death depends on the degree of control that the dying

person has.

The fuss caused by the term versterven supports the

argument about the centrality of control in the Dutch

Natural death

ving

EATH

TH

disease

old age

y of versterven.


discussion. Terminal dehydration was not controversial

until Chabot’s paper was published. The controversy

started with the introduction of the term versterven

because versterven, due to its various connotations,

implied a death that was not natural and, more

importantly, the transitive use of the term implied that

helpless psychogeriatric patients were being dehydrated,

i.e. killed without their consent (the very epitome of lack

of control and therefore bad death). It was the

suggestion of lack of control that attracted media

attention in the first place and triggered the whole

controversy.

Acknowledgements

The author would like to thank two anonymous

referees for their comments and suggestions.

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