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Special Communication |

Attitudes and Practices of Euthanasia and Physician-Assisted Suicide in the United States, Canada, and Europe

Ezekiel J. Emanuel, MD, PhD1; Bregje D. Onwuteaka-Philipsen, PhD2; John W. Urwin, BS1; Joachim Cohen, PhD3
[+] Author Affiliations
1Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia
2Department of Public and Occupational Health, EMGO Institute for Health and Care Research and Cancer Center Amsterdam, VU University Medical Center, Amsterdam, the Netherlands
3End-of-Life Care Research Group, Vrije Universiteit Brussels (VUB) and Ghent University, Brussels, Belgium
JAMA. 2016;316(1):79-90. doi:10.1001/jama.2016.8499.
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Importance  The increasing legalization of euthanasia and physician-assisted suicide worldwide makes it important to understand related attitudes and practices.

Objective  To review the legal status of euthanasia and physician-assisted suicide and the available data on attitudes and practices.

Evidence Review  Polling data and published surveys of the public and physicians, official state and country databases, interview studies with physicians, and death certificate studies (the Netherlands and Belgium) were reviewed for the period 1947 to 2016.

Findings  Currently, euthanasia or physician-assisted suicide can be legally practiced in the Netherlands, Belgium, Luxembourg, Colombia, and Canada (Quebec since 2014, nationally as of June 2016). Physician-assisted suicide, excluding euthanasia, is legal in 5 US states (Oregon, Washington, Montana, Vermont, and California) and Switzerland. Public support for euthanasia and physician-assisted suicide in the United States has plateaued since the 1990s (range, 47%-69%). In Western Europe, an increasing and strong public support for euthanasia and physician-assisted suicide has been reported; in Central and Eastern Europe, support is decreasing. In the United States, less than 20% of physicians report having received requests for euthanasia or physician-assisted suicide, and 5% or less have complied. In Oregon and Washington state, less than 1% of licensed physicians write prescriptions for physician-assisted suicide per year. In the Netherlands and Belgium, about half or more of physicians reported ever having received a request; 60% of Dutch physicians have ever granted such requests. Between 0.3% to 4.6% of all deaths are reported as euthanasia or physician-assisted suicide in jurisdictions where they are legal. The frequency of these deaths increased after legalization. More than 70% of cases involved patients with cancer. Typical patients are older, white, and well-educated. Pain is mostly not reported as the primary motivation. A large portion of patients receiving physician-assisted suicide 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 physician-assisted suicide at rates higher than those in the general population.

Conclusions and Relevance  Euthanasia and physician-assisted suicide are increasingly being legalized, remain relatively rare, and primarily involve patients with cancer. Existing data do not indicate widespread abuse of these practices.

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Figure 1.
National Projections for Public Support of Euthanasia and Physician-Assisted Suicide in the United States, 1947-2014

All surveys were conducted among adults in the United States. Sample sizes varied by year but were most recently 1028 for Gallup (2014) and 1664 for the General Social Survey (2014). Projected public support for euthanasia (Gallup)37 was assessed using the question “When a person has a disease that cannot be cured, do you think doctors should be allowed by law to end the patient’s life by some painless means if the patient and his family request it?” (“Yes” answers indicate support.) Projected public support for euthanasia (General Social Survey)38 was assessed using the question “When a person has a disease that cannot be cured, do you think doctors should be allowed to end the patient’s life by some painless means if the patient and his or her family request it?” (“Yes” answers indicate support.) Projected public support for physician-assisted suicide (PAS) (Gallup)37 was assessed using the question “When a person has a disease that cannot be cured and is living in severe pain, do you think doctors should or should not be allowed by law to assist the patient to commit suicide if the patient requests it?” (“Yes” answers indicate support.) DWDA indicates Death With Dignity Act.

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Figure 2.
Public Support of Euthanasia in Europe, 1981-200848

Public support assessed using the question “Please tell me whether you think euthanasia (terminating the life of the incurably sick) can always be justified, never be justified, or something in between. Rated on a scale from 1 (never justified) to 10 (always justified).” All surveys were conducted among adults in specified countries. Sample size was 102 701 across all 23 countries and 4 surveys (1981, 1990, 1999, 2008). Brown curves indicate countries with legalized euthanasia (the Netherlands, Belgium); blue indicates countries without legalized euthanasia (France, Spain, Great Britain, Germany); dashed orange lines indicate regional averages (Western Europe, Central/Eastern Europe). Only countries with populations greater than 10 000 000 were included in the graph. Data for Germany concern West Germany and the same geographic area in the survey years after the reunification of Germany.

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Euthanasia and the Hippocratic Oath
Posted on July 15, 2016
William W. Resinger, MD
Retired radiologist in Palmer and Nome, Alaska since 1984
Conflict of Interest: None Declared
When I took the Hippocratic oath in 1969, it was the \"classical version,\" as described in the PBS Special of 2001. I forswore euthanasia (and abortion) along with generations of physicians 2500 years before me. In only a few decades the general population and medical leaders have rushed down a \"slippery slope\" away from the sanctity of human life, espoused by even pagan physicians at the dawn of Western Civilization. I pray that my colleagues of all ages will soberly consider where the path down this dark tunnel will lead.

At one time proponents of abortion said that they desired the procedure to be \"rare\" and \"safe.\" At one time only Christians saved unwanted babies thrown into the streets by the Romans. At one time hospitals were established and were named for the Christian Denominations that founded them. At one time the oldest hospital in America had a Scripture, Matthew 25:40, chiseled into a marble panel on the wall. That Scripture, placed on the wall 200 years before I saw it, inspired me in my third year to complete my medical training.

As physicians we must seek out the highest moral ground in these matters of life and death. Maybe the \"classical version\" of the Hippocratic Oath is not outmoded. Dare I say, maybe even a little Scripture may apply?
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