The evidence of studies in several countries suggests that legislation to allow euthanasia does not affect the number of cases significantly – it just makes them more open and transparent. This has never deterred panic-mongers, who spin data to create a climate of fear in attempt to maintain its illegal status. A recent study in Belgium, where assistance in dying is legal, has been distorted by groups opposing legal reform.
On 23 September, 2002, the Belgian law on euthanasia came into force. A contributing factor that helped to get the law though was a comparative survey conducted by the Universities of Brussels, Ghent (Belgium) and Nijmegen (Netherlands), published in The Lancet in 2000. This study revealed that in Belgium, which had no regulations on end-of-life decisions at that time, three-quarters of medical decisions to interrupt life were reached without consulting the patient – the opposite of what happens in The Netherlands.
In the UK (and many countries that outlaw assistance at the end of life), there is a war of words over practices that are fiercely pushed into one classification or the other. Do UK hospices ever perform ‘euthanasia’? Of course not! (hands up in horror!) But they perform exactly the same actions that Belgian nurses are being pilloried for in the popular press.
When a patient is in the last few hours of life, opioids and sedative drugs are frequently and correctly increased (especially in hospices, that have less fear of legal reprisals) to reduce or eliminate suffering in the final moments. Generally these drugs to not necessarily hasten the end. If they do, it is by a few hours perhaps, and it is thought of as double effect – a neat way of asserting that the intention was to relieve pain and suffering, not to hasten death. This insulates the medical establishment, both legally and from the press, should there be any accusation of euthanasia.
In most cases in Belgium ‘without explicit request’ the drugs probably didn’t shorten life at all anyway. The authors of the study clearly state, ” . . . although physicians specified an intention to hasten death, opioids were often given in doses that were not higher than needed to relive the patient’s pain. This suggests that the practice of using life-ending drugs without an explicit patient request resembles more intensified pain alleviation with a ‘double effect,’ and that death was in many cases not hastened.”
The authors also note that, “. . . the life-shortening effect of opioids is subject to speculation. Recent studies have shown that the actual effect on the end of life is prone to overestimation.”
There is a clear wish to involve patients in end of life decisions. That might involve some discussions which would be illegal in the UK, where any explicit request from the patient to shorten life triggers alarm bells and a rush to prove that medical staff would never break the law by considering such an option. At least in Belgium, if the patient is conscious and competent, such discussions can take place. There is much greater opportunity for patient involvement merely because requests to shorten life do not threaten to implicate staff in illegal actions.
Say the authors of the study: “Opponents of euthanasia often argue that legalizing the procedure will lead to a rise in the use of life-ending drugs without a patient’s explicit request, especially in vulnerable patient groups. Thus far, however, no indications of this have been found in studies of physician-assisted deaths before and after legalization in Belgium and the Netherlands. In Belgium, the percentage of deaths in which life-ending drugs were used remained stable, and the proportion without an explicit request from the patient decreased.”
The concern in Belgium is not over whether an unethical practice has occurred, but over whether nurses do not have appropriate guidelines to cover them legally. “. . . the nurses we surveyed who administered the life-ending drugs did not do so on their own initiative. Although the act was often performed without the physician being present, it was predominantly carried out on the physician’s orders and under his or her responsibility.” They argue that professional guidelines are needed to help clarify nurses’ involvement in these practices lest they get caught in a vulnerable position when following a physician’s orders.
Physician-assisted deaths under the euthanasia law in Belgium. CMAJ June 15, 2010, 182(9)
The role of nurses in physician-assisted deaths in Belgium. CMAJ May 17, 2010
Questionnaire used in Belgian nurses study (CMAJ appendix)
Belgian euthanasia law: a critical analysis. J. Med. Ethics 2009;35;436-439
Development of palliative care and legalisation of euthanasia: antagonism or synergy? BMJ 2008;336:864-867 (19 April)
Euthanasia in Europe. Lancet, Volume 357, Issue 9261, Page 1038
End-of-Life Practices in the Netherlands under the Euthanasia Act. NEJM 356:1957-1965, May 10, 2007, No.19
Euthanasia: a continent divided (BBC report)
Pain Control in Terminal Care. Patient UK