Euthanasia and Assisted Suicide – When Choice is an Illusion and Informed Consent Fails

Dr Gregory Pike

I recently received an excellent research article by Dr Gregory Pike that was published in November, 2020 by the Anscombe Centre titled: Euthanasia and Assisted Suicide - When Choice is an Illusion and Informed Consent Fails. This article is worth studying. (Link to the article).

This is the Executive Summary of the article.

• Arguments for legalising euthanasia and assisted suicide always rely upon the assertion that a patient must always make a persistent, well -considered, and free choice to end his or her life. In other words, that currently accepted standards of fully informed consent in medical practice must apply.
• However, in those jurisdictions where euthanasia and/or assisted suicide are legal, the evidence shows that a large minority, or in some categories a majority of cases, occur where choice is absent, seriously compromised, or subject to unacceptable coercion and pressure. 
• An obvious example concerns infant euthanasia. In Dutch and Belgian reports up till 2010, between 7% and 9% of all infant deaths involved active euthanasia, that is, a lethal injection. More recent reports almost certainly underestimate the rate because practitioners fail to report cases, some of which they considered not to be euthanasia even though a lethal injection was used.
• Cases of non-voluntary euthanasia of adults in Holland and Belgium occur in large numbers. Dutch reports for 1990 and 1995 showed that approximately 1000 deaths per year involved ‘ending of life without patient’s explicit request’. However, the same reports show that many more patients were overdosed with opioids explicitly to end life, approximately 40% of whom made no request. There has been a steady and large increase in deaths within this category from 2001 to 2015 (20% to 36% respectively), more than enough to account for a decline in deaths within the category ‘ending of life without patient’s explicit request’ (0.7% in 2001 to 0.3% in 2015). Overall, cases involving intentionally ending life without request have likely increased with time. In Belgium, the reported rates of non-voluntary euthanasia are even higher than in Holland, but in more recent years poor reporting makes a definitive assessment of numbers impossible.
• Euthanasia can occur via omission when there is an intention to end life. Deeply sedating while removing food and fluids (continuous deep sedation; CDS) can end life when that is the intended goal. Early Dutch reports did not expressly record cases of CDS; however, in 1990 there were 8750 cases of treatment withholding or withdrawal with an intention to hasten death and without request; that is; non-voluntary euthanasia by omission. From 2005 onwards, cases of CDS were recorded and increased from 8.2% of all deaths in 2005 to 18.3% in 2015. 
• In Switzerland the incidence of CDS nearly quadrupled from 6.7% in 2001 to 24.5% in 2013. The proportion in which there was an intention to hasten death more than doubled over that time frame, but patient consent was not recorded.
• Euthanasia by omission also occurs when food and fluids are withdrawn from patients with a prolonged disorder of consciousness when the intention is to end life. There are estimated to be 24,000 such patients in the UK who may be at risk of euthanasia by omission.
• Euthanasia where choice is compromised via a deficiency in capacity include cases of patients who are minors, suffer from dementia, or have psychiatric disorders.
• There is limited information from either Holland or Belgium about euthanasia of minors, either by active means or by omission. Some Dutch reports suggest 1 minor per year receives euthanasia; other research suggests the figure is more likely around 5 cases per year, with a further 15 without request from the minor. In Flanders alone for 2007/2008, 7.9% (10 per year) of all euthanasia deaths of minors occurred without explicit request. Euthanasia of minors by omission, whether by CDS or other means, is so poorly reported that not even an estimate can be made.
• Euthanasia of dementia patients has been increasing in Holland – from 12 in 2009 to 169 in 2017. Controversy exists about how many of these patients were deemed competent at the time of euthanasia. In Belgium, while officially there were only 14 cases of euthanasia of dementia patients (2013), all of whom were deemed competent, separate research from 2010 showed that somewhere in the vicinity of 200 dementia patients were euthanased without consent or an advance directive within the category ‘ending of life without patient’s explicit request’. While no equivalent research exists for Holland it is likely that something similar pertains. There is almost no research on euthanasia of dementia patients by omission. One Belgian study found 9% of patients with dementia received CDS, nearly all of whose dementia was advanced.
• The euthanasia of psychiatric patients is deeply controversial. In Holland the numbers have increased from 0 in 2008 to 83 in 2017. Cases include for depressive disorders, personality disorders, psychosis, posttraumatic stress or anxiety, eating disorders, substance abuse, prolonged grief, and autism. 70% are women. The numbers and increasing incidence is similar in Belgium.
• Euthanasia in the context of pressure, coercion, undue influence and cultural expectation is difficult to identify, but involves patients with particular vulnerabilities. These include where euthanasia is used for organ donation, for prisoners, for those who perceive themselves as burdensome to others, and for persons with a disability. Pressure can be subtler in the context of suicide contagion and when euthanasia and/or assisted suicide become entrenched asculturally accepted practices. 
• Since 2005, in Holland and Belgium at least 70 people have donated organs via euthanasia. In Canada the rate has been much higher, where 30 people donated organs via euthanasia over a three-year period from 2016 to 2018. This number increased for the first 11 months of 2019, where there were 18 donors in Ontario alone.
• Euthanasia for prisoners is rare but under serious consideration in Belgium and Canada. At least one prisoner has been euthanased in Canada, and many more have made requests. 
• Perceiving oneself as a burden near the end of life is common and sometimes encouraged by authority figures and others. Self- perceived burdensomeness has been consistently cited as a reason for seeking euthanasia and assisted suicide. Increasing levels of elder abuse puts vulnerable people at greater risk when euthanasia is accepted. Moreover, the financial burden associated with end of life care is the elephant in the room for the euthanasia debate.
• People with a disability are at particular risk in cultures that accept euthanasia and/or assisted suicide. Assisted suicide proponents have been characterized as ‘‘white, well-off, worried, and well’’, who fail to understand the disproportionate impact of an option of assisted suicide upon people who are socially marginalized and whose limited options for genuine care and support seriously limit their autonomous choices. 
• Suicide contagion is an established phenomenon that operates for assisted suicide as well as unassisted suicide. Media reporting of assisted suicide cases has been linked to a contagion effect for both. Assisted suicide rates in Switzerland doubled for men and tripled for women from 1991 to 2008. Assisted suicides in Oregon have increased year on year from 16 in 1998 to 188 in 2019.
• Establishing a cultural expectation to accept euthanasia is exemplified in a potential new category for euthanasia in Holland, namely for those tired of life, where otherwise healthy individuals over the age of 70 would ‘choose’ euthanasia. The proposal has significant support in that country. Such a change, if adopted, will establish a norm that operates as a cultural pressure upon elderly isolated, lonely, and unwanted souls who perceive that the rest of the community has no interest in their continued existence. They may feel they should just take the pill or accept the injection. Such a choice might in reality be no choice at all.