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Reporting of euthanasia in medical practice in Flanders, Belgium: cross sectional analysis of reported and unreported cases

BMJ 2010; 341 doi: (Published 05 October 2010) Cite this as: BMJ 2010;341:c5174
  1. Tinne Smets, junior researcher1,
  2. Johan Bilsen, professor of public health1,
  3. Joachim Cohen, senior researcher1,
  4. Mette L Rurup, senior researcher2,
  5. Freddy Mortier, professor of bioethics3,
  6. Luc Deliens, professor of public health and palliative care12
  1. 1End of Life Care Research Group, Vrije Universiteit Brussel, Brussels, Belgium
  2. 2Department of Public and Occupational Health, EMGO Institute for Health and Care Research, Expertise Center for Palliative Care, VU University Medical Centre, Amsterdam, Netherlands
  3. 3Bioethics Institute Ghent, Ghent University, Ghent, Belgium
  1. Correspondence to: T Smets, End of Life Care Research Group, Faculty of Medicine and Pharmacy, Laarbeeklaan 103, 1090 Brussels, Belgium tinne.smets{at}
  • Accepted 26 July 2010


Objectives To estimate the rate of reporting of euthanasia cases to the Federal Control and Evaluation Committee and to compare the characteristics of reported and unreported cases of euthanasia.

Design Cross sectional analysis.

Setting Flanders, Belgium.

Participants A stratified at random sample was drawn of people who died between 1 June 2007 and 30 November 2007. The certifying physician of each death was sent a questionnaire on end of life decision making in the death concerned.

Main outcome measures The rate of euthanasia cases reported to the Federal Control and Evaluation Committee; physicians’ reasons for not reporting cases of euthanasia; the relation between reporting and non-reporting and the characteristics of the physician and patient; the time by which life was shortened according to the physician; the labelling of the end of life decision by the physician involved; and differences in characteristics of due care between reported and unreported euthanasia cases.

Results The survey response rate was 58.4% (3623/6202 eligible cases). The estimated total number of cases of euthanasia in Flanders in 2007 was 1040 (95% CI 970 to 1109), thus the incidence of euthanasia was estimated as 1.9% of all deaths (95% CI 1.6% to 2.3%). Approximately half (549/1040 (52.8%, 95% CI 43.9% to 60.5%)) of all estimated cases of euthanasia were reported to the Federal Control and Evaluation Committee. Physicians who perceived their case as euthanasia reported it in 93.1% (67/72) of cases. Cases of euthanasia were reported less often when the time by which life was shortened was less than one week compared with when the perceived life shortening was greater (37.3% v 74.1%; P<0.001). Unreported cases were generally dealt with less carefully than reported cases: a written request for euthanasia was more often absent (87.7% v 17.6% verbal request only; P<0.001), other physicians and caregivers specialised in palliative care were consulted less often (54.6% v 97.5%; 33.0% v 63.9%; P<0.001 for both), the life ending act was more often performed with opioids or sedatives (92.1% v 4.4%; P<0.001), and the drugs were more often administered by a nurse (41.3% v 0.0%; P<0.001).

Conclusions One out of two euthanasia cases is reported to the Federal Control and Evaluation Committee. Most non-reporting physicians do not perceive their act as euthanasia. Countries debating legalisation of euthanasia should simultaneously consider developing a policy facilitating the due care and reporting obligations of physicians.


  • We thank Herwin De Kind, Anne Kongs, the team of the Flemish Agency for Care and Health, lawyer Wim De Brock, and Kenneth Chambaere and Geert Pousset for their cooperation in the data collection. We thank Johan Vanoverloop and Steven Gorlé for their statistical advice and Jane Ruthven for her linguistic help. We thank the Belgian National Disciplinary Board of Physicians for their approval of the study and Koen Matthijs for supporting the study. Especially we thank the thousands of physicians who provided the study data.

  • Contributors: LD and FM were project supervisors. TS analysed the data and wrote the manuscript. All authors contributed to data analysis and commented critically on several drafts of the manuscript, including the final version. All authors had full access to all of the data (including statistical reports and tables) in the study and can take responsibility for the integrity of the data and the accuracy of the data analysis. LD is guarantor of the study.

  • Funding: This study is part of the Monitoring Quality of End of Life Care (MELC) study, a collaboration between the Vrije Universiteit Brussel, Ghent University, Antwerp University, the Scientific Institute of Public Health, all in Belgium, and VU University Medical Center Amsterdam, The Netherlands. This study is supported by a grant from the Institute for the Promotion of Innovation by Science and Technology in Flanders (Instituut voor de aanmoediging van Innovatie door Wetenschap en Technologie in Vlaanderen; SBO IWT nr. 050158). The funders had no role in study design; in the collection, analysis and interpretation of the data; in the writing of the manuscript; or in the decision to submit for publication.

  • Competing interests: All authors have completed the Unified Competing Interest form at (available on request from the corresponding author) and declare: no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous 3 years; no other relationships or activities that could appear to have influenced the submitted work.

  • Ethical approval: The ethical review board of the University Hospital of the Vrije Universiteit Brussel, the ethics committee of the University Hospital of Ghent University, the Belgian National Disciplinary Board of Physicians, and the Belgian Federal Privacy Commission approved the study protocol.

  • Data sharing: No additional data available.

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