Doctors killing people becomes normalised
The Netherlands is approaching the position where doctor-initiated dying accounts for one out of every two deaths.  The reasons for this are increasing numbers of applications, increasing rates of approval and an increasing array of conditions deemed suitable for euthanasia. The latter now include psychiatric disorders, terminal disease, personality disorders, birth defects and social problems.
The legalisation of euthanasia leads to an increase in the number of cases
The Voluntary Euthanasia Society agrees with our statement that where (euthanasia) is legal, the killing escalates over time. Their justification for this phenomenon is that one could expect this to some extent as euthanasia becomes more accepted as a way of managing dying but that over time the rates have remained very low (below 3%) as a proportion of all deaths. We think that there is more to it than that.
There are three issues here that need to be addressed. The first is: what are the year on year trends in the rates of killing of people succumbing to ‘legal’ euthanasia and assisted dying in those jurisdictions where this is allowed? The second is: what are the rates of killing of people who are being euthanased outside the boundaries of what is defined as ‘legal’ in those countries? The third is: how reliable are the official data given that many cases of euthanasia and assisted suicide are not reported?
- ‘Legal’ euthanasia and assisted suicide; The case of Belgium. From time to time research groups in Belgium and the Netherlands issue reports in peer-reviewed journals of the progress of euthanasia and assisted suicide in those countries where such management options are legal. In Belgium, euthanasia was legalised in 2002, approximately one year after The Netherlands had taken this step. In 2009, Bilsen, Cohen, Chambaere et al  reported a follow-up study to two nation-wide surveys on medical end-of-life practices in Belgium which had been conducted in 1998 and 2001. They reported that whereas in 1998 1.1% of all deaths in the Flanders region of Belgium were the result of euthanasia and in 2001 0.3%, by 2007 such deaths had risen to 1.9% of all deaths. Chambaere, Bilsen and Cohen et al reported a further study in 2010  in which they calculated that euthanasia deaths had risen to 2% of all deaths. Then, in 2015, Chambaere, Stichele and Mortier et al reported their findings for 2013 using the same study methods as Bilsen et al.  The rate had risen to 4.6% of all deaths. (Table 1.)
Rates of legal euthanasia in Flanders, Belgium for years in which data are available.
|Rate as % of all deaths||1.1||0.3||1.9||2.0||4.6||?|
* The year prior to legalisation.
Some supporters of legalising euthanasia maintain that one of the benefits of doing so is that it causes the rate of euthanasia to fall. This is clearly not the case in Belgium where, from 2001 onwards there is a clear trend to increasing numbers of deaths by euthanasia. In the six years 2007 – 2013, the rate has risen 242%.
The 2013 figure of 4.6% of all deaths equates to 2834 by euthanasia in Flanders Belgium.
But this is not the whole picture. Smets, Bilsen Cohen et al 2010  discovered that only 47.2% of euthanasia cases were reported to the review committee. So the number of cases in 2013 may actually be some 50% higher than these figures show, i.e. in the vicinity of 4250.
Other trends reported by Chambaere, Stichele and Mortier et al were that requests for assisted suicide or euthanasia increased from 3.5% of all deaths in 2007 to 6.0% in 2013 and the percentage of requests for euthanasia or assisted suicide that were granted increased from 56.3% in 2007 to 76.8% in 2013.
Similar trends are evident in Holland.
Official Dutch figures for the number of deaths by euthanasia in the Netherlands obtainable from the Regional Euthanasia Review Committees’ annual reports  together with demographic data from STATLINE (Statistics Netherlands) allow the following conclusions to be drawn. (Table 2)
Increasing numbers of deaths by euthanasia in the Netherlands year by year.
These figures do not include assisted suicide.
Euthanasia deaths as a percentage of all deaths are, contrary to the VES’ analysis, actually increasing: (Table 3)
Rates of legal euthanasia in the Netherlands in years for which the data are available.
|Rate as % of all deaths||1.46||2.3||2.9||3.4|
2013 seems to be the most recently reported year.
However, these figures may not be the whole picture. A study reported in the Lancet online in 2012 revealed that in 2005, 20% of cases of euthanasia in the Netherlands were not reported, and 23% in 2010.  Assuming that this level of non-reporting remains characteristic of the euthanasia programme in Holland one could well argue that the actual figure for deaths due to euthanasia in 2010 for example was closer to 5151 than the reported 4188, approximately 3.8% of all deaths. Dutch euthanasia regulator Dr Theo Boer, told the Daily Mail that he expected to see euthanasia cases smash the 6000 barrier in 2014. 
The State of Oregon USA is the third jurisdiction with lengthy experience of legal assisted suicide. Each year Oregon’s Public Health Department publishes a report on the working of the State’s Death with Dignity Act. The figures for death due to assisted suicide as reported in the latest iteration, that for 2014, show that there has been a steady increase in the number of deaths from 16 in 1998 to 105 in 2014. The latter equates to 310 deaths per 100 000 population and was a 44% increase over 2013. But this may not be the whole picture either because record keeping is neither rigorous nor transparent and about one third more prescriptions are written than deaths by assisted suicide are officially recorded. 
2.Illegal euthanasia and assisted suicide. Wherever euthanasia or assisted suicide are legalised there invariably arise problems of misuse – some would say abuse – of these techniques. Misuse chiefly refers to involuntary and non-voluntary forms of euthanasia in which a person is euthanased without making an explicit request for it, although perfectly capable of doing so, or euthanased without making a request because the individual has been rendered unable to request it. Both forms are illegal.
The survey by Chambaere, Stichele, Mortier et al  with reference to Belgium found that the number of deaths that were hastened without an explicit request from the patient ranged from 1.5% of all deaths in 2001, through 1.8% in 2007 to 1.7% in 2013 (statistically non-significant differences). These might seem like small numbers until one realises that given Belgium’s total deaths in 2013 for example, 1.7% equates to approximately 1050 illegal deaths per annum perpetrated by doctors and nurses. (Other sources have put the number as high as 1432 in 2012 and 1807 in 2013.  None of these illegal deaths – effectively homicides, has attracted the attention of the courts. A likely reason for this is that Dr. Wim Distelmans, Chair of the Federal Euthanasia Commission is a long-time exponent of euthanasia who has himself conducted some of the most bizarre examples of euthanasia including that of a person with a failed sex-change operation. Professor Cohen-Almagor, an expert on euthanasia in Belgium has stated that “the system is very protective of its physicians (including when) they act independently of the patient’s best interests”. 
A Dutch study published in 2010, showed that 0.2% of a random sample of 6861 deaths were by ‘ending of life without explicit request’. This extrapolates to ~300 of all deaths in the Netherlands each year.  Everywhere but in the Netherlands these deaths would be counted as non-voluntary or involuntary euthanasia. Within the Netherlands they are illegal but tolerated. This illegal practice has not attracted the attention of the Courts despite having been well-publicised because the Justice system, in abdication of its responsibility, has essentially devolved the monitoring of the law to the Royal Dutch Medical Association (KNMG) which advocates an increasingly liberal view of euthanasia . The practice of euthanasia in Holland and Belgium began with the voluntary euthanasia of a small number of patients. But over the years the practice has been manipulated by doctors, nurses and enthusiastic volunteers who are now the drivers for its ongoing liberalisation in the process of which tens of thousands of Dutch and Belgian citizens have been killed illegally, a process that appears to have no limits. It is notable that, when reading these reports of Dutch and Belgium origin, one never finds any expression of regret about these illegal killings –essentially homicides. They are just statistics to them.
Since euthanasia was legalised in 2002, another form of ending people’s lives has emerged. The technique is known as continuous deep sedation until death – sometimes called “slow euthanasia”. Patients are heavily sedated until unconscious then denied food or fluid in order to hasten death. Chambaere et al (2015)  reported cases running at 14.5% of all deaths in Belgium in 2007 with a slight reduction to 12.0% in 2013. There are no data for the proportion of these cases that are voluntary and the proportion that are not because of high rates of failure to report instances of it. Knowledgeable commentators, such as Schadenberg  believe that the technique has been introduced in order to camouflage the rate of involuntary and non-voluntary euthanasia occurring in the Low Countries.
A further sub-classification of ‘assisted killing’ has emerged in the Netherlands where it is labelled “Intensified Alleviation of Symptoms”.  It involves the use of high dosage opioids (i.e. morphine like drugs) instead of the recommended barbiturates and muscle relaxants to terminate life. The singular features are that most cases go unreported, the number of cases is huge – some three times greater than claimed for legal euthanasia – and few of the doctors discuss the issue with their patients before the event. Intensified Alleviation of Symptoms is clearly a euphemism for in-voluntary or non-voluntary euthanasia performed with different drugs to those recommended, but nevertheless euthanasia by anyone’s definition bar the Netherlands’. If these cases are added to the total euthanased, the numbers increase by thousands per annum.
A group of patients at particular risk from euthanasia and assisted suicide is that with psychiatric diagnoses. Dr. Wim Distelmans, Chair of the Federal Euthanasia Commission reported that 2 -3 % of the 1924 people who died of euthanasia in Belgium in 2014 were psychiatric patients. Bipolar disorder was the majority diagnosis. Others included depression and autism. At that rate, Belgium euthanizes one person with a psychological diagnosis per week. Thienpont, Verhofstadt, van Loon et all( 2015) reported a study they did to identify patterns in euthanasia requests from psychiatric patients in Belgium . They followed 100 patients who had been followed up for between 12 and 60 months as outpatients prior to their deaths. Depression and personality disorders were the most common diagnoses but Autism spectrum disorder was also well represented. 48 of the euthanasia requests were accepted and 35 carried out. Six died by suicide.
The Mail Online for 3 October 2014 published a report by Simon Caldwell that 42 patients with mental illness had been killed by lethal injection in the Netherlands in 2013. This represented three times the number killed in 2012. It was data like this that caused psychiatrist Professor B. Chabot, one of the pioneers of legalised euthanasia in Holland to remark that “Euthanasia law in the Netherlands has derailed”. 
IN SUMMARY, wherever one looks where euthanasia and assisted suicide are legal, the message is the same: deaths by these means, both legal and illegal are rising rapidly.
 Richmond, D.E. (2016, Oct 30). A Submission to the Health Select Committee, New Zealand Parliament in respect of its inquiry into Ending one’s life in New Zealand: International insights (2nd ed.). par 43-65. Retrieved from https://www.parliament.nz/resource/en-NZ/51SCHE_EVI_51DBHOH_PET63268_1_A540354/26316bac92e7459b4ac9b2b266d7a9b4bd4bf7a5
 Bilsen, J., Cohen, J., Chambaere, K., et al. (2009). Medical End of Life Practices under the Euthanasia Law in Belgium. N. Eng. J. Med. 361, 1119 – 1121. Chambaere, K., Bilsen, J., Cohen, J., et al. (2010). Physician-assisted deaths under the euthanasia law in Belgium: a population based survey. C.M.A.J., 182(9), 895 – 901. doi: 10.1503/cmaj.091876  Chambaere, K., Stichele, R. V., Mortier, F. et al. (2015). Recent trends in Euthanasia and other End –of-Life Practices in Belgium. N. Eng. J. Med, 372(12), 1179 – 1181.  Smets, T., Bilsen, J., Cohen, J., et al. (2010). Reporting of euthanasia in medical practice in Flanders Belgium: cross sectional analysis of reported and unreported cases. B.M.J., 341, c5174. Retrieved from doi: http://dx.doi.org/10.1136/bmj.c5174  Regional Euthanasia Review Committees. (2013). 2013 Annual Report. Retrieved from http://manifestarotterdam.nl/misc/EN/  Onwuteaka-Philipsen, B. D., Brinkman-Stoppelenburg, A., Penning, C. et al. (2012, July 11) Trends in end-of-life practices before and after the enactment of the euthanasia law in the Netherlands from 1990 to 2010: a repeated cross-sectional study. The Lancet. Retrieved from http://dx.doi.org/10.1016/S0140-6736(12)61034-4  Caldwell, S. (2014, October 3). Daily Mail, Retrieved Online.  Oregon Public Health Division. (2014). Annual Report on Death with Dying Act. Fig.1. Retrieved from http://public.health.oregon.gov/ProvidentPartnerResources/EvaluationResearch/DeathwithDignityAct/Documents/year17.pdf  Chambaere, K., Stichele, R. V., Mortier, F. et al. (2015). Ibid.  Cohen-Almagor, R. (2015, August 5). Foreigners do not understand us. An interview with BioEdge. Bioethics news from around the world.  Cohen-Almagor, R. (2015, August 5). Ibid.  Onwuteaka-Philipsen, B. D., Brinkman-Stoppelenburg, A. et al. (2012). Op sit.
 Van Loenen, G. (2015). Do you call this life? Blurred boundaries in the Netherlands Right to Die laws. (pp. 114 – 119). London Ont.: Ross Lattner.
 Chambaere, K. et al. (2015). Op cit.
 Schadenberg, A. (2013, September 24). Netherlands 2012 euthanasia report: sharp increase in euthanasia deaths. Euthanasia Prevention Coalition. Retrieved from www.epcc.ca
 Onwuteaka-Philipsen, B. D., et al (2012). Op cit.
 Thienpont, L., Verhofstadt, M., Van Loon, T., et al. (2015). Euthanasia requests, procedures and outcomes for 100 Belgian patients suffering from psychiatric disorders: a retrospective study. BMJ Open (5), e007454. doi:1136/bmjopen-2014-007454
 Chabot, B. (2014, January 15). The euthanasia law is derailed. NRC Handelsblad. Retrieved from http://www.nrc.nl/nieus/2014/01/15/psychiater-chabot-euthansiewet-is-ontspoord/