Re-examined: Did Rick Santorum exaggerate the euthanasia experience in the Netherlands?

By Alex Schadenberg

Last February, Rick Santorum, who was running to become the Presidential candidate for the Republican party was lambasted for comments that he made related to the Netherlands euthanasia statistics.

Now that the 2010 meta-analysis of the Netherlands euthanasia statistics have been published in the Lancet, it is important to do a re-appraisal of what Rick Santorum said and consider where he was right and where he was wrong.

It is important to read the 2010 cross-sectional analysis and my commentary about the Lancet article before assessing the previous Santorum comments. Link to my commentary: Lancet Study proves significant increase in euthanasia deaths in the Netherlands.

What did Rick Santorum say?
1. Dutch people wear a bracelet that says - "Do not euthanize me."
2. 10% of elderly people die by euthanasia.
3. Half of the euthanasia deaths are involuntary.
4. Many Dutch people go to another country for medical care, rather than a Dutch hospital.

The facts.
1. There is a group in the Netherlands that distribute cards to people who are opposed to euthanasia that states something like: do not euthanize me. No it is not a bracelet. It is possible that a similar group is distributing bracelets, but I only have knowledge of the card. Same comment as before.

 2. The Dutch are very specific concerning what euthanasia is, and what it is not. The Dutch define euthanasia as a voluntary act that is done on request. More recently the NVVE (Netherlands euthanasia lobby) has established "Mobile Euthanasia Units" that will be oriented to euthanizing people who have dementia, who have disabilities, or who have been turned down by other doctors. It is also considered acceptable for Dutch Psychiatrists to euthanize their patients for "loneliness". The Netherlands euthanasia lobby anticipate that the mobile euthanasia units will do 1000 euthanasia deaths per year.

The number of official euthanasia deaths has increased significantly over the past few years. In 2010 it is reported that their were 3136 official euthanasia deaths which was up by 19% over 2009 and 2009 increased by 13% from 2008.

Now that the 2010 report has been published in the Lancet we know that there were actually 4050 euthanasia deaths (23% rate of under-reporting, was up from a 20% rate of under-reporting in 2005), there were 192 assisted suicide deaths, there were 310 deaths without explicit request or consent and then there are the deaths of people, who were not otherwise dying, but died by intentional dehydration.

It is interesting to note that the 2010 study that was published in the Lancet indicated that approximately 4050 euthanasia deaths occurred in 2010 (23% under-reporting) and stated that this represented 2.8% of all deaths in the Netherlands. The fact is that there were 136058 deaths in the Netherlands in 2010, meaning that 4050 euthanasia deaths represents 2.98% (almost 3%) of all deaths in the Netherlands.

A 2005 study of End-of-Life Practices in the Netherlands that was published in the New England Journal of Medicine found that death by dehydration had increased significantly from 2001. In 2005, 8.2% of all deaths in the Netherlands were done by deep-continuous sedation followed by dehydration. The 2010 report that was published in the Lancet states that 12.3% of all deaths in the Netherlands were by deep-continuous sedation. Some of the 12.3% of deaths by deep-continuous sedation followed by dehydration are cases of euthanasia by dehydration. A recent article by bioethicist Wesley Smith estimates that approximately (10% of the 12.3%) of the deaths by deep-continuous sedation/dehydration are either euthanasia deaths or they represent an abuse of the use of deep-continuous sedation.

When a person, who is not otherwise dying, is intentionally sedated and dehydrated to death, that death is clearly an act of euthanasia (euthanasia by dehydration or slow euthanasia), even though the definition used in the Netherlands, and most of the world, does not recognize euthanasia by dehydration as euthanasia.

My conclusion in February was: Santorum numbers may be high, but they also may be close to the reality. Now that I have examined the 2010 report from the Lancet it is not clear that the numbers used by Santorum were not high, but either accurate or low.

3. Santorum stated that half of all euthanasia deaths in the Netherlands are involuntary.

The 2010 study that was recently published in the Lancet indicates that there were approximately 300 deaths without explicit request or consent in the Netherlands. There would also be deaths without request or consent related to the deaths by deep-continuous sedation. This does not represent half of all euthanasia deaths.

Before we ignore the problem of deaths without explicit request or consent one needs to examine the three studies published in 2010 concerning euthanasia in Belgium:
1. 32% of euthanasia deaths that were done by physicians in the Flanders region of Belgium were done without explicit request or consent.
2. A similar study that analysed euthanasia deaths that were done by nurses in Belgium found that 45% were done without explicit request or consent.
3. The third study concerning the reporting of euthanasia in Belgium found that only 52.8% of all euthanasia deaths were reported.

4. Santorum stated that people in the Netherlands go outside of the country for medical treatment. I have read an article that stated that some people who oppose euthanasia have gone to nursing homes in Germany.

An article that was written by Raphael Cohen-Almagor entitled: "Non-voluntary and Involuntary Euthanasia in the Netherlands: Dutch Perspectives" was published in - Issues in Law and Medicine - March 2003, provides some insight into the concerns related to people avoiding medical treatment out of fear of euthanasia. This article is based on interviews with dutch doctors and others who support and oppose euthanasia in the Netherlands. Cohen-Almagor interviewed Evert van Leeuwen who argued that: "there are elderly people in nursing homes who fear that their lives will be ended without consent." Cohen- Almagor then points out that there were very few euthanasia deaths in nursing homes in the Netherlands at that time.

There is no research, that I know of, proving that people are leaving the Netherlands, out of fear of euthanasia, to receive medical treatment or to live in a nursing home. It does not mean that this doesn't happen. Maybe someone will send me an article on this issue.

In conclusion:
1. There are people in the Netherlands who carry cards in their wallets that state that they do not want to die by euthanasia.
2. The comments by Rick Santorum that 10% of all people in the Netherlands die by euthanasia is factual. The numbers may be higher than 10%.
3. Half of all euthanasia deaths are not involuntary. Even though the number of deaths without request or consent has dropped in the Netherlands, the fact is that no doctors are being prosecuted or even losing their medical license for euthanizing their patients without request or consent, even though the studies continue to show that it occurs.
4. There is no known research that proves that Dutch patients are going to other countries to avoid death by euthanasia.