Vulnerable groups are not at higher risk of physician assisted death

Claims that vulnerable groups, such as the elderly and people with physical or mental disabilities, are at an increased risk of physician assisted death are not supported by evidence, says an expert in this week's BMJ.

Physician assisted death (both voluntary active euthanasia and physician assisted suicide) has been openly practiced in the Netherlands for more than 25 years and was formally legalised in 2002. Physician assisted suicide was also legalised in Oregon in 1997, writes Professor Timothy Quill of the University of Rochester, USA.

Many concerns still surround the practice, but evidence now exists to answer questions about the risks and benefits of legalisation.

For example, a study published in this week's Journal of Medical Ethics analysed data from Oregon and the Netherlands and found no increased incidence of physician assisted death in elderly people, women, people with low socioeconomic status, minors, people with physical disabilities or mental illness.

These findings call into question the claim that the risks associated with legalisation will fall most heavily on potentially vulnerable populations, says Quill.

Further evidence dispels the concern that these practices become more common over time. In Oregon, physician assisted death accounts for around one in 1000 deaths each year, with no significant change in frequency over nine years. The Dutch practices of physician assisted death have also remained stable over the duration of four studies, and hospice and palliative care have become more prevalent in recent years.

Evidence from the US also shows higher rates of assisted death in areas where these practices are prohibited than in Oregon after legalisation. Although the data are not directly comparable, none the less, it raises the possibility that legalisation and regulation with safeguards may protect rather than facilitate the practice, says Quill.

The argument that legalisation is a slippery slope is also not supported by the evidence, he adds. A recent study found that four out of six Western European countries where assisted death is illegal had a much higher incidence of unreported cases than is seen in the Netherlands.

Finally, limited data suggests that the practice of terminal sedation, which has been legal in the US since 1997, accounts for up to 44% of deaths, while in the Netherlands, it accounted for 5.6% of deaths in 2001 and 7.1% in 2005.

These days, patients who are dying are faced with a wide array of uncertainties and choices, and the physical and psychological challenges they experience are more complex, says Quill.

Studies help clarify the risks and benefits of controversial practices like physician assisted death or terminal sedation and suggest that outcomes are more favourable when practitioners work together with patients and families in an open and accountable environment.

Patients who are dying and their families need us to be as objective and honest as possible in these deliberations, he concludes. -BMJ. com

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