Despite increasing global legalization of physician-assisted suicide, use remains rare

A new comprehensive assessment of data from around the world shows that in areas where they are legal, only 0.3 to 4.6 percent of deaths result from euthanasia or PAS, with more than 70 percent of cases involving patients with cancer. The study also shows that the majority of patients requesting euthanasia or PAS 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, is published today 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 about15 years old," Emanuel said. "In the United States, there's been an increase in legalization since Oregon legalized PAS, 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 -- where a physician actively and intentionally ends a patient's life by medical means such as an injection of a neuro-muscular relaxant -- and PAS -- 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. PAS, excluding euthanasia, is legal in Switzerland and five US states: Oregon, Washington, Montana, Vermont and California. Using data from 1947-2016 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 PAS, as well as prevalence and outcomes of the procedures.

Results of the analysis showed that in the U.S., support for euthanasia and PAS increased from 37 percent in 1947 to 53 percent in the early 1970s. Support continued to increase in the following decades, eventually reaching a plateau in 1990, with roughly 66 percent 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 percent in 2005 to 64 percent in 2012.

Comparatively, in Europe there has been no plateau of public support for euthanasia and PAS. 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," 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.

Investigators also examined the implications of legalizing euthanasia and PAS. Specifically, the team sought to determine the circumstances under which patients most frequently request euthanasia or PAS, 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 percent of physicians report receiving requests for euthanasia or PSA, and less than five percent have complied. In Oregon and Washington state, less than one percent of licensed physicians write prescriptions for PAS, 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 percent of PAS cases in Oregon were missing complication data. Of the data that was available from Oregon and Washington state, complications reported included prolonged death (those taking longer than one day), regurgitation of medication, and seizures.

"What data we have strongly suggests that the dominant motivations for requesting euthanasia or PAS are loss of autonomy and dignity, the inability to enjoy life and regular activities, or other mental illnesses, rather than physical pain," 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 PAS."

The authors suggest future studies should examine three areas: the true frequency of PAS cases and how the outcomes of reported versus unreported cases differ, rates of requests and practices of euthanasia and PAS, 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.