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Assisted dying rates in Dutch-speaking cultures (orange bars) are much higher than elsewhere.

In this whitepaper, Benelux (Belgium, Netherlands and Luxembourg) primary empirical data on assisted dying is analysed — including with new and advanced approaches — to provide fresh insights into contemporary practices. Investigation reveals that the assisted dying rate in Dutch-speaking cultures appears to be uniquely higher than in other cultures irrespective of the permissiveness of the legislative framework, yet is still practiced conservatively.

Download a full copy of the Whitepaper here: PDF (648Kb).

Summary

This new compilation and unique analysis of primary research data from statutory authorities and the peer-reviewed literature provides fresh insights into assisted dying practice in Benelux, including:

  1. Rates of assisted dying in the Netherlands and Belgium have followed an expected sigmoid curve, now beginning to level out.
  2. Several factors have contributed to the higher increase in the Netherlands rate, including recovery from a suppression of cases immediately following statutory reform, a rise in cancer diagnoses, and an increase in granting of assisted dying through new visiting teams launched in 2012.
  3. Both Netherlands and Belgium doctors demonstrate caution if not conservatism when assessing assisted dying requests.
  4. Despite most assisted dying occurring in cases of cancer, fewer than one in ten cancer deaths in the Netherlands and one in twenty in Belgium is an assisted death.
  5. Other conditions such as degenerative neurological, pulmonary and circulatory illnesses each account for a very small proportion of the increase in cases since legalisation in Benelux.
  6. The assisted dying rate in dementia and other mental illness is very low despite controversy around—and a tiny rise in granting of—such cases.
  7. The hypothesis that females or the elderly would be ‘vulnerable’ to assisted dying law is contradicted by the data.
  8. The rate of non-voluntary euthanasia has decreased significantly in both the Netherlands and Belgium since assisted dying was permitted by statute.
  9. Assisted dying rates in Dutch-speaking cultures are significantly higher than in non-Dutch cultures, seemingly unrelated to the permissiveness of the jurisdiction’s legal framework.

 

beneluxratessmall.gif
Benelux country reported assisted dying rates (as a percentage of all deaths)
as at 2014. The three countries have similar assisted dying laws.
 

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Lead author Professor Ezekiel Emanuel discusses the findings of the JAMA study.

Several of the world's foremost researchers in medical end-of-life matters have released a detailed and comprehensive review of the practice of assisted dying in lawful jurisdictions around the world. Published in the Journal of the American Medical Association, it does not support slippery slope hypotheses.

Professors from universities in the USA, the Netherlands and Belgium studied data from government and statutory authority reports, primary scientific studies and other sources to examine how assisted dying has been practiced in different jurisdictions around the world where it is lawful in one form or another: self-administered medication (physician-assisted dying) or physician-administered medication (active voluntary euthanasia).1

Their primary conclusion is that:

"Euthanasia and physician-assisted suicide are increasingly being legalized, remain relatively rare, and primarily involve patients with cancer. Existing data do not indicate widespread abuse of these practices."

Key findings

Key findings include:

  • Public opinion favouring assisted dying in developed countries has been increasing, or remained stable at high levels of approval.
  • The trends seem to correlate with decreasing religiosity in Western countries.
  • The only place where assisted dying approval appears to be decreasing is in eastern Europe, where religiosity has been increasing.
  • Approval amongst physicians seems to be consistently lower than amongst the public.
  • Assisted dying occurs everywhere, including juridictions where it is unlawful (as I have previously reported).
  • Most individuals who choose assisted dying have advanced cancer (as I have previously reported).
  • Supposedly 'vulnerable' groups are not represented in assisted dying figures at rates any higher than their presence in the overall population.
  • Numbers of assisted deaths in lawful jurisdictions continue to increase, but represent a tiny minority of deaths.
    • In jurisdictions where only self-administration is permitted, assisted deaths represent around 0.3% of all deaths.
    • In jurisdictions where physicians may administer, assisted deaths represent around 3–5% of all deaths.
  • Assisted deaths for minors and those with dementia are a very small minority of cases (as I have previously reported).
  • The dominant reasons for requesting assisted death include loss of autonomy and dignity and the inability to enjoy life and regular activities; not physical pain.
  • Doctors still report that honouring a request for assisted death is emotionally burdensome; not a routine or welcomed option.
     

"In no jurisdiction was there evidence that vulnerable patients have been receiving euthanasia or physician-assisted suicide at rates higher than those in the general population."

Complication rates

One aspect of the study is worthy of special mention: the small rate of assisted dying procedure complications. The available data suggests that complications may occur more often for self-administered medication than for physician administration:

  • For self-administration—
    • Difficulty in swallowing in 9.6% of cases
    • Vomiting or seizures in 8.8% of cases
    • Awakening from coma in 12.3% of cases
  • For physician administration—
    • Technical problems such as difficulty in finding a suitable vein in 4.5% of cases
    • Vomiting or seizures in 3.7% of cases
    • Awakening from coma in 0.9% of cases
       

This data is however of Dutch practice in the 1990s, before assisted dying was codified in statute—at a time when practice was poorly defined and a range of drugs, including opioids, were widely used. Now, practice is well-defined with almost universal use of barbiturates. The researchers expressly note that these complication rates may well have reduced.

Further, the authors refer to more recent data from Oregon and Washington which indicate very much lower complication rates (in those jurisdictions for self-administration only):

  • In Oregon, the complication rates are around 2.4% for regurgitation and 0.7% for awakening from coma.
  • In Washington, the complication rates are around 1.4% for regurgitation, plus a single case of seizure.
     

The importance of context

It is worth comparing the complication rates of assisted dying procedures with rates for other medical interventions to provide an appropriate context so that they may be realistically interpreted.

For example, a study of common over-the-counter analgesics for short-term pain management2 found that significant adverse effects occurred amongst 13.7% of ibuprofen users, 14.5% of paracetamol useres and 18.7% of aspirin users.

In another example, an anlaysis of primary research about surgical outcomes found that 14.4% had adverse events, almost half of which (47.5%) were moderate to fatal in severity.3

Conclusion

The study is a solid synthesis of research data and indicates that assisted dying is accessed sparingly and in accordance with the intentions of each legislature.

The adverse event rate for assisted dying appears to be substantially lower than the rate of adverse events in the use of common over-the-counter analgesics and in surgery.

 

References

  1. Emanuel, EJ, Onwuteaka-Philipsen, BD, Urwin, JW & Cohen, J 2016, 'Attitudes and practices of euthanasia and physician-assisted suicide in the united states, canada, and europe', JAMA, 316(1), pp. 79-90.
  2. Moore, N, Ganse, EV, Parc, J-ML, Wall, R, Schneid, H, Farhan, M, Verrière, F & Pelen, F 1999, 'The PAIN Study: Paracetamol, Aspirin and Ibuprofen new tolerability study', Clinical Drug Investigation, 18(2), pp. 89-98.
  3. Anderson, O, Davis, R, Hanna, GB & Vincent, CA 2013, 'Surgical adverse events: a systematic review', Am J Surg, 206(2), pp. 253-62.
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