Euthanasia – legal regulations and practices

Here’s the third post in our special series to mark the publication of the EAPC’s latest white paper on euthanasia and physician-assisted suicide.

Lukas Radbruch (Germany), Carlo Leget (The Netherlands), Patrick Bahr (Germany) and Paul Vanden Berghe (Belgium, who are all contributing authors to the paper, discuss the background to the longer paper that is published in Palliative Medicine Online First.

Lukas Radbruch (top) Carlo Leget

Lukas Radbruch (top)
Carlo Leget

The Netherlands, following a long public discussion and a policy of tolerance, introduced the Termination of Life on Request and Assisted Suicide (Review Procedures) Act in 2001, (Staten-Generaal 2001). This act suspended prosecution of euthanasia and physician-assisted suicide if the physician: holds the conviction that the request by the patient was voluntary and well considered; the patient’s suffering was lasting and unbearable; has informed the patient about the situation he was in and about his prospects; and the patient holds the conviction that there was no other reasonable solution for the situation he was in; has consulted at least one other, independent physician who has seen the patient; and has terminated a life or assisted in a suicide with due care. A combination of first barbiturate (to induce coma) and then a muscle relaxant (causing respiratory arrest) is used most often for euthanasia. After the death of the patient, the doctor must report the procedure to the Regional Euthanasia Review Committees (RERCs), which assess whether or not the criteria have been met.

Euthanasia can be performed in adults and in adolescents older than 16 years. Children between 12 and 16 years require parental consent if they want to receive euthanasia. The legislation also recognized the validity of a written advance directive specifying conditions where the patient might want to receive euthanasia.

Patrick Bahr (top) Paul Vanden Berghe

Patrick Bahr (top)
Paul Vanden Berghe

Repeated epidemiological surveys have described euthanasia as the cause of 2.6% of all deaths in the Netherlands in 2001, 1.7% in 2005 and 2.8% in 2010. (Onwuteaka-Philipsen et al. 2012). In addition, the surveys reported the number of physician-assisted suicides as 0.1% of all deaths. Ending of life without the explicit request of the patient was reported in 0.2% of deaths in 2010, a lower percentage than in previous years (0.7% in 2001 and 0.4% in 2005). The 2013 report of the Regional Euthanasia Review Committees has documented 4,501 cases of euthanasia (corresponding to 3.2% of all deaths), 286 cases of physician-assisted suicide (0.2% of all deaths) and 42 cases of a combination of both. (Regionale Toetsingsocmmissies Euthanasie 2014). The latest report has documented 5,033 cases of euthanasia (3.6% of all deaths), 242 cases of physician-assisted suicide (0.2% of all deaths) and 31 cases of a combination of both. (Regionale Toetsingscommissies Euthanasie 2015). The total number of 5,306 cases in 2014 has increased by 27% compared to the 4,188 cases in 2012.

Belgium also introduced legislation of euthanasia with similar regulations to those in the Netherlands in 2002. (Ministerie van Justitie 2002). Physicians will not be prosecuted if they provide euthanasia for competent patients of legal age, who have expressed a repeated and consistent request made under no external pressure who are subject to persistent and intolerable physical and/or mental suffering due to an irreversible medical condition (accident or disease) with no prospect of improvement, and if the physician follows the procedures detailed in the law. Requests expressed in a written advance directive are acceptable in the case of patients in an irreversible state of unconsciousness.

Regular reports have shown an increase in the number of cases from 235 in 2003 to 1,133 cases in 2011 (Federale Controle- en Evaluatiecommissie Euthanasie 2012), 1,432 cases in 2012 and 1,807 cases in 2013 (corresponding to 1.7% of all deaths in Belgium). (Federale Controle- en Evaluatiecommissie Euthanasie 2014). The number of registered euthanasia cases has increased predominantly in the Flemish part of the country, with 1,454 cases (80%) in Flanders and only 353 cases in Wallonia. (Federale Controle- en Evaluatiecommissie Euthanasie 2014). An even steeper increase in numbers was reported in a large-scale survey among physicians certifying death certificates in Flanders, with a significant increase from 1.9% of all reported deaths in 2007 to 4.6% in 2013. (Chambaere et al. 2015). This was related to increases both in the number of requests and the proportion of requests granted.

The prevalence of euthanasia in 2007 was greatest among patients younger than 65 years, cancer patients, and those dying at home, whereas among this same group of patients the administering of life-ending drugs without the patient’s explicit request had decreased the most. (Chambaere et al. 2011). In 2013, this had changed to highest prevalence in the age group of 40 to 79 years. (Federale Controle- en Evaluatiecommissie Euthanasie 2014).

According to the legislation, a patient requesting euthanasia has to be of age (i.e. > 18 years) or an emancipated minor (being married or, in exceptional cases, with a judge’s verdict). Euthanasia was performed only very rarely in young people. In a recent parliamentary debate the relevance of age was regarded as less important than the capacity for discernment of involved issues and implications, and in consequence a new bill was approved in February 2014, which rests on the same fundamental principles as the 2002 legislation, but which incorporates no reference to any age limit, contrasting sharply with the Dutch legislation. However, although the Belgian legislation extends its application to children, it restricts its scope by excluding psychiatric disorders. More importantly, the new bill also specifically addresses the issue of discernment, which has to be assessed by a multidisciplinary team including a clinical psychologist or psychiatrist. Parents or guardians must agree with the request. (Dan et al. 2014).

New ethical questions have emerged, for example when patients in Belgium wish to be organ donors. For several patients, euthanasia has been performed immediately before organs were removed for transplantation though care was taken that the transplantation team acted independently. (Ysebaert et al. 2009). The establishment of a virtual ‘life’s end clinic’ in the Netherlands, for people whose euthanasia request was not met by their own physician, providing euthanasia for 134 cases in 2013 and 232 cases in 2014 (Levenseinde Kliniek 2015), has raised concerns as this mobile team exclusively services euthanasia requests.

In 2009, Luxembourg also introduced euthanasia and physician-assisted suicide.(Ministre de la Santé et de la Sécurité Sociale 2009). Similar to the criteria in the Netherlands and Belgium, patients must be suffering unbearably, with no prospect of improvement, but the illness does not have to be terminal. (Steck et al. 2013). In the years 2011 and 2012 only 14 cases of euthanasia have been reported, corresponding to 0.18% of all deaths in the two years. (Commission Nationale de Contrôle et d’Evaluation de la loi du 16 mars 2009 sur l’euthanasie et l’assistance au suicide 2012).

To find out more…
This post relates to the paper: Radbruch L, Leget C, Bahr P, Müller-Busch C, Ellershaw J, De Conno F, Vanden Berghe P. Euthanasia and physician-assisted suicide: A white paper from the European Association for Palliative Care on behalf of the board members of the EAPC, Palliative Medicine. Prepublished 20 November 2015, DOI: 10.1177/0269216315616524. (Available to download on subscription from Palliative Medicine OnlineFirst.

Or download a free copy from the EAPC website
English version. German version. (You can also download the German version in the ‘EAPC documents in other languages’ section of the website).

Read more posts in this special series on the EAPC Blog. The final post in the series will be published on Monday 30 November when the authors will be discussing Euthanasia and assisted suicide – the struggle continues.

References
Bundesamt für Statistik. Todesursachenstatistik 2009 –  Sterbehilfe (assistierter Suizid) und Suizid in der Schweiz. 2013.  (abgerufen am 2.3.2014).

Chambaere K, Bilsen J, Cohen J, Onwuteaka-Philipsen BD, Mortier F, Deliens L (2011). Trends in Medical End-of-Life Decision Making in Flanders, Belgium 1998-2001-2007. Med Decis Making 31(3): 500-10.

Chambaere K, Vander Stichele R, Mortier F, Cohen J, Deliens L (2015). Recent Trends in Euthanasia and Other End-of-Life Practices in Belgium. N Engl J Med.

Commission Nationale de Contrôle et d’Evaluation de la loi du 16 mars 2009 sur l’euthanasie et l’assistance au suicide. Deuxieme rapport à l’attention de la Chambre des Députés (Années 2011 et 2012). 2012. (abgerufen am 19.2.2014).

Dan B, Fonteyne C, de Clety SC (2014). Self-requested euthanasia for children in Belgium. Lancet 383(9918): 671-2.

Director of Public Prosecutions. Policy for Prosecutors in respect of Cases of Encouraging or Assisting Suicide. 2014.  (abgerufen am 16.3.2015).

Federale Controle- en Evaluatiecommissie Euthanasie. Vijvde Verslag aan de Wetgevende Kamers (2010 – 2011). 2012. (abgerufen am 28.2.2014).

Federale Controle- en Evaluatiecommissie Euthanasie. Zesde Verslag aan de Wetgevende Kamers (2012 – 2013). 2014. (abgerufen am 28.2.2014).

Levenseinde Kliniek. Levenseindekliniek helpt opnieuw meer mensen. 2015.  (abgerufen am 15.3.2015).

Ministerie van Justitie. Wet betreffende de euthanasie (1) 2002.  (abgerufen am 18.2.2014).

Ministre de al Santé et de la Sécurité Sociale. Legislation reglementant les soins palliatifs ainsi que l’euthanasie et l’assistance au suicide. 2009. (abgerufen am 18.2.2014.

Northern Territory of Australia. RIGHTS OF THE TERMINALLY ILL ACT 1995. 1995.  (abgerufen am 18.2.2014).

Onwuteaka-Philipsen BD, Brinkman-Stoppelenburg A, Penning C, de Jong-Krul GJ, van Delden JJ, van der Heide A (2012). Trends in end-of-life practices before and after the enactment of the euthanasia law in the Netherlands from 1990 to 2010: a repeated cross-sectional survey. Lancet 380(9845): 908-15.

Oregon Health Authority. The Oregon Death with Dignity Act, Oregon Revised Statutes. (abgerufen am 18.2.2014).

Oregon Health Authority. Oregon’s Death with Dignity Act 2014. 2015. (abgerufen am 18.2.2015).

Parliament of Australia. Bills Digest 45 1996-97 Euthanasia Laws Bill 1996. 1996. (abgerufen am 18.2.2014).

Regionale Toetsingscommissies Euthanasie. Jaarverslag 2014. 2015.  (abgerufen am 11.11.2015).

Regionale Toetsingsocmmissies Euthanasie. Jaarverslag 2013. 2014. (abgerufen am 15.3.2015).

Schmidlin E, Elger BS, McLennan S (2014). Assisted suicide in Switzerland: Where do we come from and where are we going? European Journal of Palliative Care 21: 61-65.

Staten-Generaal EKd. Toetsing van levensbeëindiging op verzoek en hulp bij zelfdoding en wijziging van het Wetboek van Strafrecht en van de Wet op de lijkbezorging (Wet toetsing levensbeëindiging op verzoek en hulp bij zelfdoding). 2001.  (abgerufen am 18.2.2014).

Steck N, Egger M, Maessen M, Reisch T, Zwahlen M (2013). Euthanasia and assisted suicide in selected European countries and US states: systematic literature review. Med Care 51(10): 938-44.

Supreme Court of Canada. Carter v. Canada (Attorney General), 2015 SCC 5. 2015. .

Washington State Department of Health. 2013 Death with Dignity Act Report. 2014. (abgerufen am 27.9.2014).

Ysebaert D, Van Beeumen G, De Greef K, Squifflet JP, Detry O, De Roover A, Delbouille MH, Van Donink W, Roeyen G, Chapelle T, Bosmans JL, Van Raemdonck D, Faymonville ME, Laureys S, Lamy M, Cras P (2009). Organ procurement after euthanasia: Belgian experience. Transplant Proc 41(2): 585-6.

Vanden Berghe P, Mullie A, Desmet M, et al. Assisted dying – the current situation in Flanders: euthanasia embedded in palliative care. Eur J Palliat Care 2013; 20: 266–272.

This entry was posted in EAPC ACTIVITIES, EAPC White Papers, Guidelines & Recommendations, Euthanasia and physician-assisted suicide and tagged . Bookmark the permalink.

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