Despite increasing legalization of euthanasia and physician-assisted suicide worldwide, the practices remain relatively rare and, when carried out, are primarily motivated by psychological factors such as loss of autonomy or enjoyment of life, rather than physical pain.
A new comprehensive assessment of data from around the world shows that in areas where they are legal, only 0.3% to 4.6% of deaths result from euthanasia or physician-assisted suicide, with more than 70% of cases involving patients with cancer. The study also shows that the majority of patients requesting euthanasia or physician-assisted suicide are older, white, and well-educated. The study, led by Ezekiel J. Emanuel, MD, PhD, Chair of the Department of Medical Ethics & Health Policy at the Perelman School of Medicine at the University of Pennsylvania, was published in JAMA.
“There are perceptions that euthanasia and physician-assisted suicide are widespread regardless of its legal status, that it's quick and painless, and flawless. But, the best data we have on these issues is about 15 years old,” Dr. Emanuel said. “In the United States, there's been an increase in legalization since Oregon legalized physician-assisted suicide, and several other states are considering passing legislation that would make these practices legal, but we don't currently have a comprehensive understanding of the practices themselves, or how the public and health-care providers view them. We need more data before turning to these practices as a solution for end-of-life care.”
Euthanasia and Physician-Assisted Suicide
Euthanasia—where a physician actively and intentionally ends a patient's life by medical means such as an injection of a neuro-muscular relaxant—and physician-assisted suicide—which occurs when lethal drugs are prescribed or supplied by a physician but are self-administered by the patient—can be legally practiced in the Netherlands, Belgium, Luxembourg, Colombia, and Canada. Physician-assisted suicide, excluding euthanasia, is legal in Switzerland and five U.S. states: Oregon, Washington, Montana, Vermont, and California.
Using data from 1947 to 2016 collected from polls, published surveys of the public and physicians, official state and country databases, interviews with physicians, and death certificates, the team sought to determine how legalization affects attitudes and practices of euthanasia and physician-assisted suicide, as well as prevalence and outcomes of the procedures.
Historic and Present Levels of Support
Results of the analysis showed that in the United States, support for euthanasia and physician-assisted suicide increased from 37% in 1947 to 53% in the early 1970s. Support continued to increase in the following decades, eventually reaching a plateau in 1990, with roughly 66% of the U.S. population supporting one of the practices. Support in the United States saw a resurgence in the early 2000s but has declined in recent years, dropping from a peak of 75% in 2005 to 64% in 2012.
Comparatively, in Europe there has been no plateau of public support for euthanasia and physician-assisted suicide. Between 1999 and 2008, support for euthanasia increased in most Western European countries, while most countries in Central and Eastern Europe saw a decline in support. The authors say the data suggest there may be a correlation between attitudes toward the practices and religious views.
“In the United States, several characteristics were consistently associated with favoring or opposing the practices. In general, people who were supportive were white, male, younger, and religiously unaffiliated,” Dr. Emanuel said. “We also noticed a similar trend in Europe, where support in Western Europe increased as rates of religiosity decreased, while simultaneously, support in the post-communist Eastern European countries decreased as religiosity increased.
Rate at Which Practices Are Requested
Investigators also examined the implications of legalizing euthanasia and physician-assisted suicide. Specifically, the team sought to determine the circumstances under which patients most frequently request euthanasia or physician-assisted suicide; the prevalence of complications; and the likelihood that where legal, the procedures would become standard practice rather than being used only in extreme cases.
Analysis revealed that in U.S. jurisdictions where the practices are legal, less than 20% of physicians report receiving requests for euthanasia or physician-assisted suicide, and less than 5% have complied. In Oregon and Washington state, less than 1% of licensed physicians write prescriptions for physician-assisted suicide, and in the vast majority of cases, patients are already or had previously received hospice care. Belgium and the Netherlands also report a positive association between euthanasia and receiving or consulting with palliative care teams or pain specialists.
Of note, the authors found no data on complication rates from any country other than the United States and the Netherlands, and in those cases, reports were largely incomplete. For example, between 1998 and 2015, more than 40% of physician-assisted suicide cases in Oregon were missing complication data. Of the data available from Oregon and Washington state, reported complications included prolonged death (those taking longer than 1 day), regurgitation of medication, and seizures.
“What data we have strongly suggest that the dominant motivations for requesting euthanasia or physician-assisted suicide are loss of autonomy and dignity, the inability to enjoy life and regular activities, or other mental illnesses, rather than physical pain,” Dr. Emanuel said. “However, given the incomplete and outdated information available about the practices of assisted dying, collecting reliable data to evaluate end-of-life practices should be prioritized around the world, not just in countries legalizing euthanasia or physician-assisted suicide.”
The authors suggest future studies should examine three areas: the true frequency of physician-assisted suicide cases and how the outcomes of reported vs unreported cases differ; rates of requests and practices of euthanasia and physician-assisted suicide; and complications, including how many patients wake up after ingesting the prescribed medications. In countries where the practices are legal, the authors say more rigorous retrospective research is needed to determine reasons for the requests, complications, and familial and social situations of the deceased.
The content in this post has not been reviewed by the American Society of Clinical Oncology, Inc. (ASCO®) and does not necessarily reflect the ideas and opinions of ASCO®.