Why the Dutch Keep Pediatric Euthanasia Illegal

In the Netherlands, pediatric euthanasia is illegal. It is also, since February 2024, available to children between the ages of one and twelve. Both statements are true. Understanding how they can both be true is the first thing to know about the Dutch model — and the reason we think it has lessons for the rest of the world.

The Netherlands was the first country to permit euthanasia. Adults came first. Then, in 2007, after years of debate and litigation, came neonates — children under the age of one whose suffering could not be relieved. February's regulation extends the same regime to children between those two endpoints. The age groups now form a continuous ladder; the criteria differ, but the underlying logic is the same.

That logic was articulated long ago by the Royal Dutch Medical Association: a doctor's duty to preserve life sometimes conflicts with the duty to relieve suffering, and the doctor must be free to choose which duty to honor. Euthanasia, on this view, is the last resort — to be used only after every other route to relief has failed.

How a country regulates something it has not legalized

Here is what makes the Dutch approach unusual. The criminal statutes against euthanasia have never been repealed. A physician who ends a patient's life on request is still, technically, breaking the law. What changed is the way the law is interpreted. Every case must be reported to a regional review committee composed of a legal expert, an ethicist, and three physicians. That committee evaluates whether the physician acted with due care. It then forwards its judgment to a public prosecutor, who decides whether to bring charges.

In practice, this means that doctors who follow the criteria face no prosecution. Those who don't, can. The system never had to amend criminal law — it only had to agree on how that law would be enforced.

This is not just bureaucratic cleverness. It is a stance toward the underlying moral question. Euthanasia is ethically controversial; the Dutch model treats it that way. Keeping the practice formally illegal acknowledges that it is not an ordinary medical service. Requiring post-hoc review keeps the practice visible. Leaving discretion with the prosecutor preserves the possibility of accountability without making every act a courtroom drama.

The surprise of the Groningen Protocol

When the Dutch published the Groningen Protocol in 2005, codifying criteria for neonatal euthanasia, the worldwide response was largely alarmed. Critics warned of vagueness, permissiveness, ableism, and slippery slopes. Disabled babies, the prediction went, would be euthanized in large and growing numbers.

What happened was almost exactly the opposite.

Several factors likely contributed. Antenatal folic acid reduced the incidence of severe neural tube defects, the condition behind a substantial share of earlier cases. Prenatal screening caught more cases earlier, shifting some decisions to pregnancy termination. And — perhaps most importantly — the Netherlands built a national pediatric palliative care system more or less from scratch. In 2013 the Dutch Pediatric Association issued professional guidelines; the government later funded eight pediatric palliative care centers and a national center of expertise. Where good palliative care reaches the child, the situations that once led to euthanasia simply stop arising.

The protocol did not produce more deaths. It produced better care.

Why extend the policy to children 1–12

If palliative care can resolve most cases, why open this door at all for older children? Because — as a recent nationwide qualitative study of 64 parents of 44 children with life-limiting conditions made plain — most cases are not all cases. Most suffering can be relieved. Some cannot. Parents and physicians caring for those remaining children began to ask, publicly, why the option available to a newborn and to a thirteen-year-old should be denied to the children in between.

The 2024 regulation answers that question. It is deliberately written as a work in progress. The criteria that will determine eligibility are still being developed by the medical profession itself. Consent or assent will be sought from the child whenever possible. Parental consent is required. Every case will be reviewed.

What can go wrong

We do not want to be glib about this. The risks are real, and Dutch society will have to remain alert to them.

The most basic worry is that legitimizing pediatric euthanasia implies, even faintly, that the lives of disabled and severely ill children are worth less than other lives. We do not believe that has happened in the Netherlands. We do not assume it never could.

There is the slippery-slope concern — that criteria that look strict on paper get loosened in practice, that "due care" erodes into "quick and easy," that euthanasia displaces the harder, slower work of palliation. There is the financial worry — that policymakers who see euthanasia as an option will quietly cut palliative care funding, or that families will feel pressure they should not have to feel. And there is the chilling effect cutting the other way: post-hoc review, however fair, can deter physicians from offering euthanasia even when it is warranted, out of fear of publicity or legal sanction.

These are not hypothetical concerns. They are the things that have to be watched.

What travels

Every country's medical culture is its own. We are not arguing that other countries should copy Dutch law. We are arguing that the Dutch approach to regulating a contested medical practice is worth studying.

Three features in particular seem generalizable. First, the practice remains illegal, which keeps the question morally serious and the doctors morally attentive. Second, every case is reported, which makes the practice legible — the country can see what is actually happening and adjust. Third, no criminal statute had to be changed, which allowed the system to evolve through professional norms, judicial interpretation, and public deliberation rather than through a single up-or-down vote.

The Dutch did not arrive at this by accident. They arrived through public discussion, litigation, professional guideline-setting, and decades of revaluation. As the philosopher John Arras once wrote, ethical ambiguity pervades this terrain, and attempts to flatten that ambiguity into a simple formula will only produce "an illusory and counterproductive quest for moral certainty." The Dutch model does not try to flatten it. It builds a system around it.

That, more than any particular law, is what we think other countries can learn from.

Eduard Verhagen and I develop these arguments at greater length in our Viewpoint, "The Dutch model for regulating paediatric euthanasia," in Archives of Disease in Childhood (2024).