These safeguards do exist. In practice, however, they are hard to enforce. A poignant illustration was recently aired on Dutch television. An older woman stricken with semantic dementia had lost her ability to use words to convey meaning. “Upsy-daisy, let’s go,” she said. Both her husband and her physician at the end-of-life clinic interpreted her words to mean, “I want to die.” A review committee judged her euthanasia was in accordance both with the law and her earlier written instructions, an outcome very few would have imagined possible as recently as 10 years ago.

Such episodes have many Dutch people worried about the erosion of protections for the socially vulnerable and medically fragile. A broad and heated public debate recently flared about whether doctors may administer fatal drugs to those with severe dementia based on a previously signed “advance directive.” In several controversial cases, assisted suicide was not directly discussed with patients who were incapable of reaffirming earlier written death wishes. In one case, a doctor slipped a dementia patient a sleeping pill in some apple sauce so that he could be easily taken home and given a deadly injection