Euthanasia and physician-assisted suicide in the United States, Canada, and Europe are increasingly being legalized, but they remain relatively rare, and primarily involve patients with cancer, according to a study appearing in the July 5 issue of JAMA.
The ethics and legality of euthanasia and physician-assisted suicide (PAS) continue to be controversial. In the early 20th century, multiple attempts at legalization were defeated. Recently, several countries have legalized the practices, and a number of countries are considering legalization. Ezekiel J. Emanuel, M.D., Ph.D., of the Perelman School of Medicine, University of Pennsylvania, Philadelphia, and colleagues examined the legal status of euthanasia and PAS and comprehensively reviewed all the available data on attitudes and practices.
The authors found that currently, euthanasia or PAS can be legally practiced in the Netherlands, Belgium, Luxembourg, Colombia, and Canada (nationally as of June 2016). Physician-assisted suicide, excluding euthanasia, is legal in 5 U.S. states (Oregon, Washington, Montana, Vermont, and California) and Switzerland. Public support for euthanasia and PAS in the United States has plateaued since the 1990s (range, 47 percent - 69 percent). In Western Europe, an increasing and strong public support for euthanasia and PAS has been reported; in Central and Eastern Europe, support is decreasing.
Between 0.3 percent to 4.6 percent of all deaths are reported as euthanasia or PAS in jurisdictions where they are legal. The frequency of these deaths increases after legalization. More than 70 percent of cases involved patients with cancer. Typical patients are older, white, and well-educated. Pain is mostly not reported as the primary motivation for seeking euthanasia or PAS. The main motivations appear to be psychological, fear of losing autonomy and no longer enjoying life's activities and other forms of mental distress. A large portion of patients receiving PAS in Oregon and Washington reported being enrolled in hospice or palliative care, as did patients in Belgium. In no jurisdiction was there evidence that vulnerable patients have been receiving euthanasia or PAS at rates higher than those in the general population.
Problems and complications with the performance of euthanasia or PAS--such as not dying, waking up from coma and seizures--occur, but the available data make it difficult to determine the precise rates, although they are more common in PAS than euthanasia. In jurisdictions that have legalized euthanasia or PAS, use of these procedures has increased but alleged slippery-slope cases, such as ending the life of patients who are minors or have dementia, appear to be a very small minority of cases.
In the United States, less than 20 percent of physicians report having received requests for euthanasia or PAS, and 5 percent or less have complied. In Oregon and Washington state, less than 1 percent of licensed physicians write prescriptions for PAS per year. In the Netherlands and Belgium, about half or more of physicians reported ever having received a request; 60 percent of Dutch physicians have ever granted such requests.
The authors note that data about the practices of assisted dying are limited. "Therefore, collecting reliable data to evaluate end-of-life practices should be prioritized in all countries, and not only in countries legalizing euthanasia or PAS. Only such studies can help determine whether and how symptom management differs between patients requesting euthanasia or PAS and those who do not request these interventions."
(doi:10.1001/jama.2016.8499; the study is available pre-embargo to the media at the For the Media website)
Editor's Note: All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported.
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