Adapted from The New Eugenics in Medicine: Two Novellas About Power, Science, and the Future of Human Worth.

The Netherlands’ first reported termination of life in a child between ages 1 and 12 under its 2024 framework for regulating pediatric euthanasia has become a global lightning rod for debate over the merits and sins of euthanasia.

A Dutch child was almost 2 years old and had been born at 26 weeks and 3 days. Severe complications of prematurity left the child with extensive brain damage, spastic cerebral palsy, cerebral visual impairment, and profound developmental delay. The child also developed infantile epileptic spasms syndrome, with frequent seizures, severe sleep disturbance, swallowing dysfunction, and worsening respiratory problems. The physicians considered the likelihood of death at a very young age from complications to be very high.

The treating physician and the parents concluded that the child’s suffering was unbearable and without prospect of improvement. However, the medical opinion was not unanimous. Independent physicians agreed that there was no realistic prospect of meaningful improvement and that the situation was irreversible. Yet they initially concluded that the child was not continuously suffering unbearably and that reasonable alternatives remained, including palliative measures and additional medication to improve seizure control.

According to the official review, the treating physician followed the recommended medication regimen, but the child developed additional problems due to side effects, leading to discontinuation of the medication. Palliative options were repeatedly discussed. The parents rejected prolonged sedation, and the physician also concluded that palliative sedation was not a reasonable option. Another independent physician was subsequently consulted and concluded that, except for sporadic better moments, the child experienced continuous discomfort and very frequent seizures, with no reasonable means of relieving the suffering other than ending life. The review committee ultimately concluded that the physician who performed euthanasia had acted with due care.

A colleague sent me a terse reaction to the news: “Now it starts! Aktion T4 reborn in Holland!!” I understand the alarm. I have written before about what I call the “new eugenics“: the danger that modern medicine, armed with increasingly sophisticated methods to predict disability and quantify quality of life, can begin making judgments not merely about how much a person is suffering but about the value of the life being lived.

Aktion T4 was the Nazi regime’s systematic murder program targeting people with mental and physical disabilities. Beginning in 1939, physicians, nurses, and bureaucrats identified and killed people deemed genetically defective, burdensome, or “unworthy of life” under Nazi racial ideology. Disabled children were killed by medication overdoses and starvation; institutionalized adults were transported to killing centers and murdered with carbon monoxide. Roughly 70,000 people were killed during the centralized T4 phase before Hitler formally halted it in 1941. Killings continued by other means, and historians estimate that the broader Nazi “euthanasia” program ultimately killed about 250,000 people.

The similarities to the Dutch case are only at a high level: Physicians intentionally end the life of a profoundly disabled person who is incapable of consent, and judgments about suffering and quality of life play a decisive role. Those facts make historical comparisons and vigilance reasonable.

But the differences are fundamental. Aktion T4 was secret, coercive, ideological, and systematic. Its victims were selected under a state program of racial hygiene and social utility. The Dutch framework is public, case-specific, and subject to medical consultation, parental consent, mandatory reporting, multidisciplinary review, and eventual scrutiny by prosecutors. Its stated purpose is to relieve otherwise unrelievable suffering, not racial purification or the elimination of people deemed economically unproductive.

History also makes me doubt my colleague’s assertion that “now it starts,” which I take to mean a steadily accelerating slide. A review of the Dutch system by a pediatrician and a bioethicist reported that newborn euthanasia became much rarer after the Groningen Protocol formalized it in the early 2000s: from approximately three to five reported cases annually beforehand to only three cases over the following eighteen years. The authors identified expanded pediatric palliative care as a possible contributor.

Yet the review’s authors articulate precisely the concerns critics have raised. They warn that accepting pediatric euthanasia might encourage the belief that the lives of disabled or severely ill children are worth less, that seemingly strict criteria might shift as norms evolve, and that the availability of euthanasia could eventually weaken commitment to palliative care. They conclude that Dutch society must remain vigilant to those potential harms. That, to me, is the most useful lesson.

My colleague is incorrect if “Aktion T4 reborn” is meant to draw a historical equivalence to Dutch law and experience. The evidence does not support equating a transparent, individually reviewed Dutch end-of-life framework with a Nazi program of state-directed mass murder.

But dismissing every comparison with the history of eugenics would miss something important. The question to consider is not whether the Netherlands has recreated Nazi Germany, but whether medicine will gradually grow comfortable translating profound disability, dependency, and limited developmental potential into judgments about an unbearable life, especially when the patient cannot speak for themselves and physicians disagree about how much suffering remains treatable. When does medicine move from judging suffering to judging the quality or worth of a disabled life?

The safeguard against that slippery slope is not historical hyperbole. It is historical memory paired with clinical humility: robust palliative expertise, genuinely independent second opinions, clearly defined standards, transparent reporting, scrutiny of the language we use about disability, and an unwavering distinction between relieving suffering and deciding that a life itself has too little value.

The Dutch case does not prove that a new eugenics has arrived. It gives us reason to keep asking how we would recognize it if it were to begin.

Arthur Lazarus is a physician-author whose work spans narrative medicine, physician leadership, artificial intelligence, health care ethics, medical culture, and fiction. He has published more than 500 articles and essays across scientific journals, professional publications, and online platforms.

He is the author of numerous books on narrative medicine, AI in medicine, career development, and the changing moral landscape of health care, as well as fictional series including Rounds Never End, Sick and Systemic, and Real Medicine, Unreal Stories. His writing explores the forces reshaping modern medicine while preserving a central commitment to story, meaning, judgment, and the human relationship at the heart of care.

He shares updates on LinkedIn.