Assisted dying: we are not aloneBMJ 2011; 342 doi: https://doi.org/10.1136/bmj.d3772 (Published 15 June 2011) Cite this as: BMJ 2011;342:d3772
All rapid responses
To discuss Desmond O'Neill's objections to assisted dying , Sir Terry
Pratchett's documentary film on assisted dying on June 13th on BBC2 and
the ensuing Jeremy Paxton-led debate, I will as much as possible try to
stick to robust epidemiological data published in peer-reviewed journals.
Dr O'Neill's comment on the film focused on a peculiar coercion: not
the nudging of people to opt for premature death, but the risk that a
patient expressing a request for assisted dying would coerce family and
caregivers, overriding their feelings. Indeed, from experience, I concur
that loved ones often try to dissuade patients from euthanasia. However, I
submit this is a legitimate but secondary concern because the patient's
feelings should count for more than the caregivers'. In fact, as for
family, evidence from the Netherlands is reassuring: on aggregate,
bereavements are more serene after euthanasia than after other deaths (1)
. As for professional caregivers, I know of no hard data, but let me offer
my own experience: euthanasia feels much more like delivering a baby than
like carrying out an abortion.
Just one comment on the Pratchett film. The gentle Mr Smedley's
dignified but sad death after drinking a lethal cocktail on the cold sofa
of Dignitas in Zurich (2), in a house overshadowed by a Maschinenbau
factory, appealed more to reason than to emotion. Had this occurred in
Belgium, The Netherlands or Luxembourg, he would likely have died in his
home, much more solemnly and warmly. Recently I assisted in the
euthanasia of an advanced cancer patient in Belgium. She hugged
and kissed an intense farewell to all her loved ones and died smiling, her
son holding her arm and resting his head on her shoulder and her mother in
a similar embrace on her other side. Her relatives and friends stood
around in a semi-circle holding hands.
The crux of the ensuing television debate was not the right of
patients to self-determination and its precedence over caregivers'
preferences, which are no longer seriously disputed, but whether legal
physician-assisted dying 1) would endanger the vulnerable and 2) detract
from good palliative care. These are legitimate questions, and they were
hotly debated with oratory, but left unanswered in ignorance or disregard
of abundant factual evidence. In fact, many robust studies published in
top journals have investigated the characteristics and evolution of end-of
-life practices in the permissive Benelux countries and the American
First re slippery-slope concerns. In these countries, the more
vulnerable such as the elderly, mentally ill, nursing-home residents, poor
and low-educated are underrepresented among recipients of assisted dying
(3,4). The most notable epidemiological evolutions following legal and
regulated physician-assisted dying in 2002 in Belgium were: 1) an
unchanged total number of physician-assisted deaths, but a shift away from
hastening death without the patient's request to voluntary euthanasia
(about 2% of all deaths now) and 2) a major increase in palliative care
practices. The carefulness of end-of-life decisions increased: doctors now
more frequently discuss them with the patients, their relatives,
colleagues and nurses (4). The adoption of a model of Integral End-of-Life
Care, including euthanasia, has not eroded the confidence of Belgians in
their health-care system, on the contrary: confidence was 87% in 1999 and
rose to 92% in 2008, the highest of all countries studied in the European
Values Study (5). Before the law, pathetically, an irreversibly suffering
patient who did not request assisted dying may have been more likely to
receive it clandestinely and out of mercy than one who did request it: the
risk of other caregivers or family who object to euthanasia filing charges
against the doctor was just too high. Whether this also applies to the UK
(6) , we don't know.
Next re palliative care. In the Netherlands palliative care
provisions have multiplied since euthanasia was legalised there (7). In
2002, the Belgian euthanasia Bill was passed by Parliament together with a
Palliative Care Bill extending palliative care to all hospitals and
districts and doubling its public funding. Luxembourg acted similarly in
2009. In Belgium about 30% of deaths are preceded by multidisciplinary
palliative care services (8). Physicians trained in palliative care tend
to practice more assisted deaths than their untrained colleagues (9) and
about half of the cases of euthanasia occur at the end of a palliative-
care pathway (8). Receiving intensive spiritual care was associated with
higher frequencies of euthanasia than receiving little spiritual care (8).
The highest per capita participation in conferences of the European
Association of Palliative Care (EAPC) is from Belgium, followed by the
Netherlands (10). Most Belgian physicians support regulated euthanasia and
in a survey of Belgian PC nurses 78% were mildly to firmly in favour of
legal euthanasia and 22% were opposed, and then only mildly (11).
Several of these and other data demonstrating mutual reinforcement of
palliative care and legal euthanasia have been documented in extenso (12).
Empirical evidence should not have been ignored in the debate.
1) Swarte NB, van der Lee ML, van der Bom JG, van den Bout J, Heintz
AP . Effects of euthanasia on the bereaved family and friends: a cross
sectional study. BMJ 2003;327(7408):189
2) Fischer S, Huber CA, Imhof L, Mahrer Imhof R, Furter M, Ziegler
SJ, Bosshard G. Suicide assisted by two Swiss right-to-die organisations.
J Med Ethics. 2008 Nov;34(11):810-4
3) Battin MP, van der Heide A, Ganzini L, van der Wal G, Onwuteaka-
Philipsen BD. Legal physician-assisted dying in Oregon and the
Netherlands: evidence concerning the impact on patients in "vulnerable"
groups. J Med Ethics 2007;33(10):591-7
4) Chambaere K, Bilsen J, Cohen J, Onwuteaka-Philipsen BD, Mortier F,
Deliens L. Trends in Medical End-of-Life Decision Making in Flanders,
Belgium 1998-2001-2007. Med Decis Making 2011;31(3):500-10.
5) European Values Study 2008, 4th wave, Integrated Dataset. GESIS
Data Archive, Cologne, Germany, ZA4800 Data File Version 1 0 0 (2010-06-
30) DOI:10 4232/1 10059 [ 2010
6) Seale C. National survey of end-of-life decisions made by UK
medical practitioners. Palliat Med 2006; 20: 1_8.
7) Centeno C, Clark D, Lynch T, Racafort J, Praill D, De Lima L et
al. Facts and indicators on palliative care development in 52 countries of
the WHO European region: results of an EAPC Task Force. Palliat Med 2007;
8) Van den Block L, Deschepper R, Bilsen J, Bossuyt N, Van Casteren
V, Deliens L. Euthanasia and other end of life decisions and care provided
in final three months of life: nationwide retrospective study in Belgium.
BMJ 2009; 339:b2772.
9) Deliens L, Mortier F, Bilsen J, Cosyns M, Vander Stichele RH,
Vanoverloop J et al. End-of-life decisions in medical practice in
Flanders, Belgium: a nationwide survey. Lancet 2000; 356(9244):1806-1811.
10) European Association for Palliative care. EAPC taskforce on the
palliative care development in Europe.
www.eapcnet.org/Policy/CurrentAchiev.htm). Assessed in 2008.
11) Gielen J, Van Den Branden S, van Iersel T, Broeckaert B. Flemish
palliative care nurses' attitudes toward euthanasia: a quantitative study.
Int J Palliat Nurs. 2009 Oct;15(10):488-97
12) Bernheim JL, Deschepper R, Distelmans W, Mullie A, Bilsen J,
Deliens L. Development of palliative care and legalisation of euthanasia:
antagonism or synergy? BMJ 2008; 336(7649):864-867
Competing interests: No competing interests
As members of the Healthcare Professionals for Assisted Dying (HPAD)
Steering Committee, founded by the late Dr Ann McPherson CBE, we welcome
both Desmond O'Neill's and Terry Pratchett's contributions to the debate;
we believe an honest and open exploration of the issues surrounding
assisted dying is crucial.
We are therefore dismayed to note a motion for debate at the
forthcoming Annual Representatives Meeting (ARM) of the BMA, detailed on
the BMA's website, which criticises the current editorial position of the
BMJ on assisted dying (no 305 by the Agenda Committee proposed by the
Yorkshire Regional Council). We also note the inherent contradiction in
the same motion, which attacks the Commission on Assisted Dying, chaired
by Lord Falconer. It calls on the BMA ARM to "support the BMA's stance in
not giving evidence" to the Commission whilst at the same time calling on
the "BMA Ethics Committee to make the Association's opposition... clear to
It is entirely appropriate that the media, including the BMJ, should
question the proposals of those who seek change. But surely it is also
entirely reasonable to question the validity of the arguments of those who
seek to defend the status quo. As advocates of change we accept with good
grace the editorial hostility of some sections of the media, but we
welcome the fact that publications like the BMJ and organisations like the
BBC are able to present both sides of the argument.
This is a serious issue, on which people hold strong opinions. But
can we not strive to have a respectful debate in which we accept that
within the healthcare professions views are divided? With this in mind we
repeat our call for the professional bodies to remain neutral on the issue
of assisted dying and for an evidence based debate where both sides are
held to account.
Competing interests: As members of Healthcare Professionals for Assisted Dying we are supportive of a chagne in the law on assisted dying for terminally ill, mentally competent adults, within up-front safeguards.