Legal voluntary euthanasia compromises palliative and hospice care

The European Association for Palliative Care has recently condemned the model of palliative care used in Belgium and the Netherlands that turns to euthanasia as a last resort [1]. The most experienced palliative care doctors insist that they can control the suffering of their patients without euthanasia [2].

In response to our assertion that legalising voluntary euthanasia and / or assisted suicide will compromise the Hospice movement (and by implication, Palliative Care services,) the Voluntary Euthanasia Society had this to say: “This has been shown to be untrue and opponents of voluntary euthanasia now agree that palliative care and hospice care has (sic) increased and improved in jurisdictions where assistance to die is legal….”
It is fair to point out that promoters of legalising voluntary euthanasia are not opposed to palliative care or hospice services.  But their assertion that palliative care and hospice services are strengthened by the decriminalising of voluntary euthanasia does not stand up to examination.
The concept is presumably based on statements such as that made by Tallis in commenting on one of Lord Joffe’s attempts to legalise euthanasia in the UK. [3] Tallis states: “where assisted dying is available, […] the safeguards around such bills have mandated the improvement and rapid development of palliative care services.” His reference for that statement is the submission by the Voluntary Euthanasia Society to the House of Lords Select Committee considering Lord Joffe’s Bill in 2004. [4] 
The Voluntary Euthanasia Society in turn references a paper by De Korte-Verhoef. [5]  The paper shows an increase in beds in a variety of different units (independent hospices, children’s hospices, units in nursing homes and units in general hospitals) between 1997 and December 2003.  The analysis finishes just under two years after the passage of the Dutch Euthanasia Act.  In the 16 months between August 2002 and December 2003, the data show no change in palliative care units in hospitals and a reduction of beds from 17 to 14, an increase of 9 beds in units in homes for the elderly and 44 beds in units in nursing homes. Whether this represents an “enormous” investment in palliative care services since assisted dying was available as claimed by Tallis is a moot point.  The paper by de Korte-Verhoef makes no such claim: in fact it does not allude to euthanasia at all.  In any case, Tallis’ attempt to link improved palliative care services with the decriminalisation of voluntary euthanasia and / or assisted suicide has to fail on the grounds that in the absence of any data showing that the Health Authorities have planned and financed the parallel development of these services, any supposed linkage is purely speculative.  Could Belgium be the exception?  See below.
A paper published in the Lancet Neurology [6] in which various aspects of euthanasia are discussed, is sometimes cited as giving weight to the argument that legalising voluntary euthanasia and improved palliative care services are linked.  One of the participants, Dr. Zbigniew Zylicz, a consultant in palliative care in the Netherlands, refers in passing to a recent (i.e. 2002-2003) interest by doctors in palliative care education and an increase in the number of hospices and palliative care units in the Netherlands.  He speaks of euthanasia being legalised in the “last 5 years” but as the law was passed in 2001 and became active in 2002, he must be referring to a period before the law came into being. There are no data to support his impressions.
However, a study by Chambaere and Bernheim [7] entitled: Does physician assisted dying impede development of palliative care? somewhat contradicts Zylicz’s opinion. These authors used data from the European Association for Palliative Care to compare ‘structural’ resources for palliative care,  e.g. number of home care teams, hospices, hospital-based palliative care units, total palliative care beds, etc. in each of Iceland, Belgium, the UK, Sweden, Ireland, Luxembourg and the Netherlands.
The UK is taken to be the standard against which to measure palliative care resources.  According to Chambaere and Bernheim, (table 1 above) between 2005 and 2012, Belgium had no increase in home care teams, set up 2 palliative care hospices and disestablished several palliative care beds.  In the same period the Netherlands established 44 home care teams but disestablished 29 palliative care hospices and added 306 palliative care beds.  The authors report this latter figure as showing that there was a large increase in per capita beds in the Netherlands and evidence that palliative care was not impeded there.  However, the data as presented do not necessarily uphold that interpretation. If, for example, the 29 palliative care hospices that were disestablished during that period each supported only 12 beds* (this is an hypothetical number – actual numbers not given) some 348 palliative care hospice beds would have been lost, with a total net loss of 42 beds. Such a scenario would make the case for support of palliative care much less convincing.  On his recent visit to New Zealand, Dr. Rob Jonquiere stated that the model of palliative care developing in the Netherlands was an integrative one rather than running palliative care beds separately.  This makes it difficult to identify beds by service type.
The first hospice in New Zealand, the Mary Potter Hospice, was opened in Wellington in 1979. This was six years before palliative care services were started in Belgium and 12 years before they began in the Netherlands.  Euthanasia has never been legal in New Zealand.  Palliative Medicine was recognised as a specialty in New Zealand in 2001.  A report from the European Association for Palliative Care [8] lists the year in which palliative care was recognised as a speciality in Medicine in 18, mainly European, countries.  First off the mark in 1987 was the UK.  Ireland was next, in 1995.  The most recent countries listed are Denmark and Canada in 2014.  Belgium, Luxemburg and the Netherlands, the only three countries in Europe to legalise euthanasia in some form, do not appear on the list.
The Belgians and the Dutch were late to develop palliative care services, according to an analysis by Clark, Ten Have and Janssens published in 2000. [9]  Yet euthanasia in various forms had been practiced in the Netherlands from the 1970s onwards.  St. Christopher’s Hospice had been founded in London in 1967, but the first services in Belgium did not begin until 1985 and in the Netherlands until 1991.  Clark et al hold up the Belgian palliative care service as a model for others to follow, but provide no data at all on which to judge the merits of this observation. Indeed, 15 years later, an observer of Belgian practice. [10] castigated the medical profession in Belgium for the lack of transparency, lack of record keeping and use of drugs to end a person’s life without an explicit request that results in high levels of abuse of the euthanasia provisions. Palliative care as such does not receive a mention. This suggests that no matter how extensive a palliative service is, if it’s not used and the doctors prefer euthanasia, it might as well not exist.  Clark et al’s comment on the Netherlands was that in 2000, “mainstream provision of hospital and community palliative care services is not well developed, and it is only very recently that significant interest in palliative care has appeared in academic centres.”[11]

Considerations of the funding and historical development of palliative care and hospice services aside, there are three ways in which the legalisation of euthanasia can compromise these services.  The first is exemplified by the path followed by the Belgians to subvert the principles of palliative care.  Belgium, which allocated considerable resources to palliative care at about the time euthanasia was legalised, is lauded by those advocating legal voluntary euthanasia as demonstrating that the latter does not compromise palliative care.  However, it turns out that there was a conflicting motive behind pouring resources into starting a national palliative care programme in Belgium.  In a discussion in Belgium at the launching of the Euthanasia Prevention Coalition Europe  Dr. Bernheim, an oncologist, medical researcher, biomedical consultant and pioneer in palliative care, revealed that he regarded euthanasia as a logical therapeutic endpoint in the spectrum of palliative care.  Unlike Dame Cicily Saunders who developed palliative care services in the UK as a means of preventing euthanasia, he stated that had developed palliative care in Belgium in order to legalise euthanasia.[12] In other words, his purpose was to subvert one of the chief aims of palliative care which is to neither lengthen nor shorten life.  Later in the interview when confronted with data revealing the large numbers of people who are euthanized in Belgium without explicit consent, Bernheim admitted that there were ”problems with the Belgian euthanasia law”.  He is not the only one with underlying concerns about the direction of euthanasia in Belgium.
The second consideration is an economic one.  Palliative and hospice care are not inexpensive services for a health administration to fund.  Euthanasia is cheap.  There are influential voices in the community expressing concern about the ability of our society to afford the rising numbers of old people predicted over the next decades. [13] Some suggest voluntary euthanasia and assisted suicide as a strategy to cure the problem: “’If you are demented, you are wasting people’s lives, your family’s lives, and you are wasting the resources of the National Health Service.” [14] Chambaere and Bernheim report that even in relatively affluent Belgium, the principal palliative care organisation in that country complains about a lack of funding that is making it difficult to maintain the quality of its services. [15]  The Dutch Voluntary Euthanasia Society, the NVVE, announced in November 2015 that they are campaigning to have an “end-of-life pill” made available to everyone older than 70 years who wants to die, irrespective of their health status. [16] (How long will it take to become compulsory?)
The third consideration, long predicted, has finally surfaced.  A Dutch general practitioner is being sued by the family of Milou de Moor, a 19-year-old woman with systemic lupus erythematosus (SLE) for withdrawing approval for her assisted suicide.  The young woman then committed suicide. [17]  If the case is successful, Dutch doctors will be wary of offering palliative care as an alternative to euthanasia because of the threat of legal action.  Under such circumstances, euthanasia will both compromise palliative care and subvert both the art and science of Medicine.


[1]  Radbruch, L., Leget, C., Bahr, P., Mueller-Busch, C., Ellershaw, J., De Conno, F., and Vanden Berghe, P. (2015). Euthanasia and physician-assisted suicide: A white paper from the European Association for Palliative Care. Paliative Medicine. doi: 10.1177/0269216315616524 Retrieved from

[2]  Bridge, D. (2017. March 20). Palliative care, euthanasia and physician-assisted suicide. MJA InSight. Retrieved from

[3]  Tallis, R. (2004). The Assisted Dying for the Terminally Ill Bill 2004. Clin. Med, 4(6), 534 – 540, p.537. Retrieved from

[4]   Retrieved from

[5]  De Korte-Verhoef, R. (2004). Developments in palliative care services in the Netherlands. Eur J Palliat Care, 2004(11), 34 -37.

[6]  Zylicz, Z. (2003, Oct) Lancet Neurology, 2003(2), 637-643.

[7]  Chambaere, K., & Bernheim, J. (2015, February 3). Does legal physician assisted dying impede the development of palliative care? J Med Ethics doi:10.1136/medethics-2014-102116. Retrieved from

[8]  Bolognesi, D., Centano, C., & Biasco, G., (2014). Specialisation in palliative medicine for physicians in Europe 2014: a supplement of the EAPC Atlas of palliative care in Europe. p.5. Retrieved from

[9]   Clark, D., ten Have, H., Janssens, R., (2000). Common threads? Palliative Care service developments in seven European Countries. Palliat. Med., 14, 479-90 ↩

[10]  Cohen-Almagor, R. (2015, June 3). First do no harm: intentionally shortening lives of patients without their explicit consent in Belgium. J.M.E. doi:10.1136/medethics-2014-102387 ↩

[11]  Clark, D., ten Have, H., Janssens, R., (2000). Common threads? Palliative Care service developments in seven European Countries. Palliat. Med., 14, 479-90 ↩

[12]  Schadenberg, A.(2013, November 15). Belgian euthanasia promoter admits there are problems with euthanasia in Belgium and the author of the Belgium law admits it was designed for people with disabilities.Retrieved from Website and blog archive at: ↩

[13]  Gibbs, J. in Bills, P. (2012, January 17). Dame with a streak of altruism. NZ Herald. Retrieved from ↩

[14]  Warnock, M. in Doughty, S. (2008, September 20). Old people with dementia have a duty to die and should be pushed towards death, says Baroness Warnock. Daily Mail. Retrieved from ↩

[15]  Chambaere, K. & Bernheim, J. (2015). Op cit. ↩

[16]  Voluntary euthanasia society renews calls for end-of-life pill. Dutch News. 13 November 2015. Retrieved from ↩

[17]  Cook, M. (2015, September 28). Is the Netherlands moving towards euthanasia-on-demand? Retrieved from ↩