In places where it’s legal, how many people are ending their lives using euthanasia?

 

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One paper reported that between 0.3% to 4.6% of all deaths are reported as euthanasia or physician-assisted suicide in jurisdictions where they are legal.
Flickr/Alberto Biscalchin, CC BY-NC-ND

Andrew McGee, Queensland University of Technology

The Victorian Parliament will consider a bill to legalise euthanasia in the second half of 2017. That follows the South Australian Parliament’s decision to knock back a voluntary euthanasia bill late last year, and the issue has also cropped up in the run-up to the March 11 Western Australian election.

With the issue back in the headlines, federal Labor’s justice spokesperson, Clare O’Neil, told Q&A that in countries where the practice is legal, “very, very small” numbers of people use the laws.

Whether or not you agree with O’Neil’s statement depends largely on your interpretation of the subjective term “very, very small”, but there is a growing body of data available on how many people are using euthanasia or assisted dying laws in places such as the Netherlands, Belgium, Luxembourg, Colombia, Canada and some US states.

Assisted dying, assisted suicide and euthanasia

Many people use the terms “assisted dying”, “assisted suicide” and “euthanasia” interchangeably. But, technically, these phrases can have different meanings.

Assisted dying (sometimes also assisted death) is where the patient himself or herself ultimately takes the medication. Euthanasia, by contrast, is usually where the doctor administers the medication to the patient.

Assisted suicide includes people who are not terminally ill, but who are being helped to commit suicide, whereas assisted dying refers to people who are already dying. Some reports do not, however, distinguish between assisted dying and assisted suicide, and I will not distinguish them here.

In some jurisdictions, the word “euthanasia” is used to refer to both assisted dying/suicide (where the patient himself or herself takes the medication) and to euthanasia (where the doctor administers the medication to the patient). So “euthanasia” can sometimes be used as a broad term to cover a range of actions.

Euthanasia and assisted suicide rates around the world

According to a peer-reviewed paper published last year in the respected journal JAMA:

Between 0.3% to 4.6% of all deaths are reported as euthanasia or physician-assisted suicide in jurisdictions where they are legal. The frequency of these deaths increased after legalization … 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.

The authors of that paper said that 35,598 people died in Oregon in 2015. Of these deaths, 132, or 0.39%, were reported as physician-assisted suicides. The same paper said that in Washington in 2015 there were 166 reported cases of physician-assisted suicide (equating to 0.32% of all deaths in Washington in that year).

Interestingly, the same paper noted that US data show that:

pain is not the main motivation for PAS (physician-assisted suicide)… The dominant motives are loss of autonomy and dignity and being less able to enjoy life’s activities.

The authors said that in officially reported Belgian cases, pain was the reason for euthanasia in about half of cases. Loss of dignity is mentioned as a reason for 61% of cases in the Netherlands and 52% in Belgium.

A 2016 Victorian parliamentary report has quoted from the UK Commission on Assisted Dying, which in turn referenced the work of John Griffiths, Heleen Weyers and Maurice Adams in their book Euthanasia and Law in Europe. The commission said:

There are no official data in Switzerland on the numbers of assisted suicides that take place each year, as the rate of assisted suicide is not collected centrally. Griffiths et al observe that there are approximately 62,000 deaths in Switzerland each year and academic studies suggest that between 0.3% and 0.4% of these are assisted suicides. This figure increases to 0.5% of all deaths if suicide tourism is included (assisted suicides that involve non‑Swiss nationals).

Around 3.7% of deaths in the Netherlands in 2015 were due to euthanasia. The Netherlands’ regional euthanasia review committees reported that there were 5,516 deaths due to euthanasia in 2015. That is out of a total of around 147,000 – 148,000 deaths in the Netherlands that year.

This figure represents an increase of 4% of deaths due to euthanasia compared to 2014.

A 2012 paper published in The Lancet reported on the results of nationwide surveys on euthanasia in the Netherlands in 1995, 2001, 2005 and 2010. The researchers said:

In 2002, the euthanasia act came into effect in the Netherlands, which was followed by a slight decrease in the euthanasia frequency … In 2010, of all deaths in the Netherlands, 2.8% were the result of euthanasia. This rate is higher than the 1.7% in 2005, but comparable with those in 2001 and 1995.

Another Netherlands-based study published in the journal JAMA Internal Medicine reported in 2015 that:

Certainly, not all requests are granted; studies conducted between 1990 and 2011 report rates of granting requests between 32% and 45%.

A 2015 paper in the New England Journal of Medicine about euthanasia rates in the Flanders region of Belgium (the northern half of the country) noted:

The rate of euthanasia increased significantly between 2007 and 2013, from 1.9% to 4.6% of deaths.

Filling in the bigger picture

It can be hard to put these rates in context, but what is clear is that euthanasia is by no means a leading cause of death in countries where it is legal. For example, Statistics Belgium said that for the year 2012, cardiovascular disease was the most common cause of death (28.8%), and cancer was the second most common cause of death (26%).

And in the Netherlands – where 5,516 of deaths were due to euthanasia in 2015 – more than 12,000 Dutch people died from the effects of dementia in 2014, approximately 10,000 Dutch people died from lung cancer and nearly 9,000 died from a heart attack. In 2013, 30% (about 42,000) of Dutch deaths were from cancer and 27% (about 38,000) of Dutch deaths were from cardiovascular disease.


The ConversationIf this article has raised issues for you or if you’re concerned about someone you know, call Lifeline on 13 11 44.

Andrew McGee, Senior Lecturer, Faculty of Law, Queensland University of Technology

This article was originally published on The Conversation. Read the original article.

Sex versus death: why marriage equality provokes more heated debate than assisted dying

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While fear suppresses talk about dying, marriage equality involves sex.
AAP/Danny Casey

Julian Savulescu, University of Oxford

The Greek philosopher Epicurus wrote:

Death does not concern us, because as long as we exist, death is not here. And when it does come, we no longer exist.

We are in the midst of two great ethical debates: marriage equality and assisted dying. The results of the marriage equality postal survey will be announced on November 15; meanwhile, the Victorian parliament is this week debating a new law to allow doctor-assisted dying in the last year of life.

What is striking is the volume of the respective public debates. Everyone is talking about marriage equality; very few are discussing assisted dying.

Given that the ethics of assisted dying are more complex than marriage equality, and what happens in Victoria is likely to provide a template for other states, why is it receiving so much less attention?

How fear of death affects public debate

Public ethical debates are fuelled by emotion and psychological biases on both sides. In the case of assisted dying, most of us are not like Epicurus: we fear death. We hate talking about it.

Despite the fact that polls show that 73% of Australians favour assisted dying, it is not clear whether the legislation will pass, although the mood seems to be leaning slightly in favour: 40 out of 87 MPs in the Legislative Assembly told the Herald Sun they would vote yes.


Further reading: As Victorian MPs debate assisted dying, it is vital they examine the evidence, not just the rhetoric


So, there should be an enormous impetus to show MPs the level of public support. But it has been rather muted. Perhaps for similar reasons we post photos of weddings on Facebook, but not funerals: both are important, but only one makes good dinner party conversation.

Terror management theory, evolution and social signalling

Our fear of death might even be linked to our love of marriage, according to terror management theory (TMT). Neuroscientist Claudia Aguirre writes:

When we’re faced with the idea of death, people defensively turn to things they believe will shield them from death, literal or otherwise. Thinking about death also motivates people to indiscriminately uphold and defend their cultural world views, whatever those may be.

TMT has been linked to our development of regulation and rituals around sex.

In evolutionary terms, sex is more important than death, which is one of the reasons marriage equality provokes such heated debate.
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So, a fundamental commitment to marriage being between a man and a woman may be more of an immovable foundation on which group membership is based to guard against our shared fear of death than an ethical position that can be defended or rebutted on rational grounds.

While fear suppresses talk about dying, marriage equality involves sex. People are intensely interested in love and sex. And sex has been more important than death in evolutionary terms.

As evolved animals, we were only here to survive long enough to reproduce. Reproduction is evolution’s goal, and so practices around its rituals and norms are hugely important in evolutionary and religious terms.

Religions and societies seek to control reproduction. In the Judeo-Christian tradition, sex was to occur within marriage between one man and one woman. Death at an old age is of much less evolutionary significance.


Further reading: To Christians arguing ‘no’ on marriage equality: the Bible is not decisive


We are social animals, motivated to support our in-group and reject out-group members. Tribalism can help explain our devotion to football teams, for example. We have developed social signalling to show our group which side we are on and maintain trust.

Add to that a status quo bias, and public debates where the topic in question is seen to express something foundational about ourselves can become little more than cheering for our own team.

Anchoring

Anchoring is a psychological bias that means we evaluate how good or bad something is relative to the anchor of existing examples.

In the UK, the 2013 same-sex marriage legislation was fairly uncontroversial. One reason could be that civil partnerships – same-sex marriage in all but name – were created back in 2004. Each step in the UK’s progress towards marriage equality was a short step from the previous state of being.

In contrast, the Australian campaign against same-sex marriage portrays the choice as a paradigm shift in our culture, extending far beyond marriage. Former prime minister Tony Abbott linked the debate to political correctness, gender fluidity and even the date of Australia Day, saying:

This isn’t just about marriage … there are lots and lots of implications here and we’ve got to think them through before we take this big leap into … the dark.

A better approach

For assisted dying to be an appropriate activity for medicine, we should show that death can be an appropriate therapeutic end and in a patient’s best interests. That is, that their life is no longer worth living.

That is an extremely difficult case to prove, and I haven’t seen any good arguments for how to evaluate that. Why wouldn’t we just go on what a competent person says? If a suffering person believes they’re better off dead, they’re probably right.

But here is another way to think about it. The Victorian legislation will provide assistance only to those in the last year of life from a physical illness. They are effectively in the process of dying.

While palliative care may be able to control pain and suffering, it cannot do everything.
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One major objection to the assisted dying bill is that we don’t need it because good palliative care is sufficient. Relief of suffering is very important, and more should be spent on end-of-life planning and palliative care.

But this objection is complicated for several reasons. If palliative care is outstanding, people won’t request assistance in dying. So there is no need to ban it.

More importantly, while palliative care may be able to control pain and suffering, it cannot do everything.

Together with colleagues at Barwon Health and Oxford University, we surveyed 382 people from the general population and 100 attendees at an advance care planning clinic, where people think about and express their values relating to end-of-life care. We didn’t ask them about assisted dying, but we did ask them to rank four factors at the end of life: pain relief, dignity, independence and living as long as possible.

The highest proportion of both groups ranked the relief of pain and suffering as the most important value, followed by maintaining dignity and remaining independent.

Living as long as possible was ranked as most important by the lowest proportion of participants – only 4% of palliative care patients and 2.6% of the general population (30–35% regarded this as either not important or not very important).

People care not only about pain relief, but also about dignity and independence at the end of life. These are much more subjective and less amenable to control by palliative care. So while palliative care can address part of what people care about, it may not be able to address all their values.

Moreover, people can already shorten their lives by more than a year for any medical condition, or no medical condition at all, by refusing to eat and drink by mouth. It takes around ten days to die of thirst. Such people could be given palliative care to relieve their suffering during this period of suicide.

But surely the Victorian law offers a better way to die? As with the palliative care, this kind of death does not provide the dignified death, or the independence, that people value.

As distressing as public debate on heartfelt, emotive issues like assisted dying and marriage equality can be, it is an important collective exercise. Like many other people, I thought the marriage equality survey was a waste of money. But on reflection, this idea maybe misplaced. When the views of one part of the community are deemed politically incorrect and suppressed, they foment, then erupt in a Brexit or a Trump.

Debate is vitally important to democracy. What we should hope is that people engage in these debates with their heads, not their hearts. It will take considerable effort on both sides to overcome the psychological obstacles to finding the most fair and reasonable policy.

As Epicurus also said:

The ConversationThe art of living well and the art of dying well are one.

Julian Savulescu, Uehiro Chair in Practical Ethics, Visiting Professor in Biomedical Ethics, Murdoch Childrens Research Institute and Distinguished Visiting Professor in Law, Melbourne University, University of Oxford

This article was originally published on The Conversation. Read the original article.

The murky issue of whether the public supports assisted dying

Katherine Sleeman, King’s College London

The High Court has rejected a judicial review challenging the current law which prohibits assisted dying in the UK. Noel Conway, a 67-year-old retired lecturer who was diagnosed with Motor Neurone Disease in 2014, was fighting for the right to have medical assistance to bring about his death. Commenting after the judgement on October 5, his solicitor indicated that permission will now be sought to take the case to the appeal courts.

Campaigners are often quick to highlight the strength of public support in favour of assisted dying, arguing that the current law is undemocratic. But there are reasons to question the results of polls on this sensitive and emotional issue.

There have been numerous surveys and opinion polls on public attitudes towards assisted dying in recent years. The British Social Attitudes (BSA) Survey, which has asked this question sequentially since the 1980s, has shown slowly increasing public support. Asked: “Suppose a person has a painful incurable disease. Do you think that doctors should be allowed by law to end the patient’s life, if the patient requests it?” in 1984, 75% of people surveyed agreed. By 1989, 79% of people agreed with the statement, and in 1994 it had gone up to 82%.

Detail of the question matters

But not surprisingly, the acceptability of assisted dying varies according to the precise context. The 2005 BSA survey asked in more depth about attitudes towards assisted dying and end of life care. While 80% of respondents agreed with the original question, support fell to 45% for assisted dying for illnesses that were incurable and painful but not terminal.

A 2010 ComRes-BBC survey also found that the incurable nature of illness was critical. In this survey, while 74% of respondents supported assisted suicide if an illness was terminal, this fell to 45% if it was not.

Wording counts.
from http://www.shutterstock.com

It may not be surprising that support varies considerably according to the nature of the condition described, but it is important. First, because the neat tick boxes on polls belie the messy reality of determining prognosis for an individual patient. Second, because of the potential for drift in who might be eligible once assisted dying is legalised. This has happened in countries such as Belgium which became the first country to authorise euthanasia for children in 2014, and more recently in Canada where within months of the 2016 legalisation of medical assistance in dying, the possibility of extending the law to those with purely psychological suffering was announced.

It’s not just diagnosis or even prognosis that influences opinion. In the US, Gallup surveys carried out since the 1990s have shown that support for assisted dying hinges on the precise terminology used to describe it. In its 2013 poll, 70% of respondents supported “end the patient’s life by some painless means” whereas only 51% supported “assisting the patient to commit suicide”. This gap shrank considerably in 2015 – possibly as a result of the Brittany Maynard case. Maynard, a high-profile advocate of assisted dying who had terminal cancer, moved from California to Oregon to take advantage of the Oregon Death with Dignity law in 2014.

Even so, campaigning organisations for assisted dying tend to avoid the word “suicide”. Language is emotive, but if we want to truly gauge public opinion, we need to understand this issue, not gloss over it.

Information changes minds

Support for assisted dying is crucially known to drop-off simply when key information is provided. Back in the UK, a ComRes/CARE poll in 2014 showed 73% of people surveyed agreed with legalisation of a bill which enables: “Mentally competent adults in the UK who are terminally ill, and who have declared a clear and settled intention to end their own life, to be provided with assistance to commit suicide by self-administering lethal drugs.” But 42% of these same people subsequently changed their mind when some of the empirical arguments against assisted dying were highlighted to them – such as the risk of people feeling pressured to end their lives so as not to be a burden on loved ones.

This is not just a theoretical phenomenon. In 2012, a question over legalising assisted dying was put on the ballot paper in Massachusetts, one of the most liberal US states. Support for legalisation fell in the weeks prior to vote, as arguments against legalisation were aired, and complexities became apparent. In the end, the Massachusetts proposition was defeated by 51% to 49%. Public opinion polls, in the absence of public debate, may gather responses that are reflexive rather than informed.

The ConversationPolls are powerful tools for democratic change. While opinion polls do show the majority of people support legalisation of assisted dying, the same polls also show that the issue is far from clear. It is murky, and depends on the responder’s awareness of the complexities of assisted dying, the context of the question asked, and its precise language. If we can conclude anything from these polls, it is not the proportion of people who do or don’t support legislation, but how easily people can change their views.

Katherine Sleeman, NIHR Clinician Scientist and Honorary Consultant in Palliative Medicine, King’s College London

This article was originally published on The Conversation. Read the original article.