Q&A Briefing Paper

EUTHANASIA DEFINED

EUTHANASIAassisted suicideIn the euthanasia debate there are a number of terms used more or less interchangeably – euthanasia, mercy killing, physician-assisted suicide, assisted dying, withdrawal of life-prolonging treatment – but the concepts are not identical and are often not well-understood.

Voluntary Euthanasia is the act of intentionally, knowingly and directly causing the death of a patient, at the request of the patient. If someone other than the person who dies performs the last act, euthanasia has occurred. Euthanasia is involuntary where the person is able to give consent but has not done so, or where a person was euthanised against their will, and non-voluntary where the person lacks capacity to give consent or request to end his or her life.

Assisted Suicide is the act of intentionally and knowingly providing the means of death to another person at that person’s request, in order to facilitate their suicide. If the person who dies performs the last act, assisted suicide has occurred. Physician assisted suicide is where the person providing the means (e.g. lethal drugs) is a medical practitioner.


WHAT IS NOT  EUTHANASIA

The administration of pain relief
euthanasia-heart-checkEveryone has a right to effective pain relief. The administration of drugs in doses sufficient to alleviate pain and suffering rarely causes death and it is permitted and it is ethical. From time to time, a patient may die whilst receiving such drugs. That is not euthanasia, since the death of the patient was not the intended outcome of the medication. The Australian and New Zealand Society of Palliative Medicine (ANZSPM 2013) states: “Treatment that is appropriately titrated to relieve symptoms and has a secondary and unintended consequence of hastening death, is not euthanasia.”[1]

The withdrawal of burdensome and futile life-prolonging treatment
The common practice of withdrawing futile medical assistance from a patient for whom it is not accomplishing anything useful, despite this action being associated potentially with the person’s death, is lawful. There is no legal or ethical requirement that a diseased or injured person must be kept alive ‘at all costs’. The law has drawn a clear and consistent line between withdrawing medical support thereby allowing the patient to die of his or her own medical condition, and intentionally bringing about the patient’s death by a positive act.[2]


WHAT DOES THE LAW CURRENTLY SAY ABOUT SUICIDE?

s 179 of the Crimes Act 1961 (NZ) states that “Everyone is liable to imprisonment for a term not exceeding 14 years who—(a) incites, counsels, or procures any person to commit suicide, if that person commits or attempts to commit suicide in consequence thereof; or (b) aids or abets any person in the commission of suicide.” Furthermore, under s 151 there is a duty to provide “necessaries” of life to those who have the care or charge of a “vulnerable adult” who is unable to provide himself or herself with these essentials.


WHAT ABOUT MY ‘CHOICE’?

It is important to note that a person may refuse medical treatment and may do so even if it results in his or her death.[3] Section 11 of the New Zealand Bill of Rights Act 1990 reinforces this common law right by providing that “everyone has the right to refuse to undergo any medical treatment.” The Australian and New Zealand Society of Palliative Medicine (ANZSPM 2013) states: “Patients have the right to refuse life sustaining treatments including the provision of medically assisted nutrition and/or hydration. Refusing such treatment does not constitute euthanasia.” Complying with such a refusal does not constitute euthanasia.


ABUSE – EVEN WITH ‘SAFEGUARDS’

Aeuthanasia-a-recipe-for-abuses a NZ Herald editorial put it – “devising a robust euthanasia regime, complete with adequate safeguards, seems hardly feasible.[4] The potential for abuse and flouting of procedural safeguards is a strong argument against legalisation. An overseas study found that 32 percent of all assisted deaths in the Flemish region of Belgium are done without explicit request.[5] The legal requirement to report euthanasia has not been fully complied with in countries that allow euthanasia either. The terminally ill and those suffering great pain from incurable illnesses are often vulnerable. And not all families, whose interests are at stake, are wholly unselfish and loving. There is a risk that assisted suicide may be abused in the sense that vulnerable people may be persuaded that they want to die or that they ought to want to die.[6]

Anyone advocating for euthanasia or assisted suicide should have to answer this question: How many wrongful deaths are they prepared to risk if these practices are introduced in New Zealand? What is the number? What is the acceptable error rate, where error means wrongful death?


MISSION CREEP

Many critics emphasise the inevitable extension of euthanasia over time – the so-called ‘mission creep’ or ‘slippery slope’ phenomenon. There is empirical evidence from those countries that have authorised euthanasia that the availability and application of euthanasia expands to situations never initially envisaged as indications for it. So, for example, euthanasia has been extended to enable minors to avail themselves of it (albeit with parental consent) in the Netherlands and Belgium.

down syndrome childBased on overseas experience, it is extremely likely that if legalised in New Zealand, euthanasia will become a mechanism to terminate the lives of those who do not consent to it as well as those who do consent. It will be available to, and thus come to be utilised by, minors. It will be applied to new-born infants with disabilities. Once society accepts one form of euthanasia restricted to a precise set of conditions, it will be difficult or impossible to confine euthanasia to those conditions. For instance, if one allows euthanasia for adults suffering from incurable terminal diseases, then what prevents those with curable diseases from demanding this “treatment”? (Maryan Street’s proposed euthanasia Bill – subsequently withdrawn – already had this extended availability).

When a newly-permitted activity is characterised as a ‘human right’ there is often a constituency who will lobby to extend such a right to a greater number of persons. If some citizens are currently deprived of enjoying this newly-minted right, then ‘equality’ and non-discrimination demands that they be granted it too.

Professor Theo Boer was a member of the Dutch Regional Euthanasia Commission for nine years, during which he was involved in reviewing 4,000 cases. He admitted to being a strong supporter of euthanasia and argued originally that there was no ‘slippery slope’. However, by 2014 he had had a complete change of mind. He testified to UK politicians considering the issue:

“Whereas in the first years after 2002 hardly any patients with psychiatric illnesses or dementia appear in reports, these numbers are now sharply on the rise. Cases have been reported in which a large part of the suffering of those given euthanasia or assisted suicide consisted in being aged, lonely or bereaved. Some of these patients could have lived for years or decades.”[7]


‘RIGHT TO DIE’ OR ‘DUTY TO DIE’

euthanasia-young-and-elderlyProcedural safeguards that require the patient’s consent look convincing in theory. In practice, such safeguards can only go so far. Coercion is subtle. The everyday reality is that terminally ill persons and those afflicted with non-terminal, but irreversible and unbearable physical or mental conditions, are vulnerable to self-imposed pressure. They will come to feel euthanasia would be ‘the right thing to do’, they have ‘had a good innings’, they do not want to be a ‘burden’ to their nearest and dearest.

Annual reports by Oregon Public Health contain data on the numbers of patients who reported that part of their motivation to request euthanasia was because they felt themselves to be a “burden on family and friends”. Forty percent of patients who requested assisted suicide in 2014 did so out of concern for being a burden on their family[8]; only 13% did so in 1998[9].

Elderly and ailing patients are all too aware that their increasingly expensive rest home and geriatric care is steadily dissipating the inheritance that awaits their children. Sadly, the more unscrupulous and callous offspring would not be slow in pointing this out either.

It’s not pain but ‘existential distress’ that leads people to assisted suicide, study suggests Washington Post, May 2017


BURDEN PLACED ON PATIENTS

Simply offering the possibility of euthanasia or assisted suicide shifts the burden of proof, so that patients must ask themselves why they are not availing themselves of it. Society’s offer of an easy death communicates the message to certain patients who are struggling, that they may continue to live if they wish, but the rest of us have no strong interest in their survival. Indeed, once the choice of a quick and painless death is officially accepted, resistance to this choice may be seen as being stubborn, eccentric or even selfish.[10]


ELDER ABUSE

EUTHANASIA elderly handEmeritus Professor David Richmond contends:
It is older people (and those with disabilities, of whom older people form a large percentage) who actually have the most to fear from legalising these practices…. Older people are, by and large, very sensitive to being thought to be a burden, and more likely than a young person to accede to more or less subtle suggestions that they have “had a good innings.”… That is why most District Health Boards in the country have an Elder Abuse team. Hence subtle and not so subtle pressure on older people to request euthanasia where it is available as an option for medical “care” is not always because the family has the best interests of their ageing relative at heart.”[11]


RATIONAL SUICIDE?

The design of a euthanasia or assisted suicide regime is heavily premised on the assumption that persons are clear-minded, rational and free of coercion. But how ‘rational’ a decision can one make when one is suffering from a devastating life event? Research on human decision-making suggests that when a person is suffering, decision-making becomes less rational.[12] Most of the demands for legalising euthanasia and assisted suicide come from exceptional individuals who are intelligent, articulate and who clearly comprehend their predicament. Yet a euthanasia law will have to protect everyone – the inarticulate as well as the articulate, the impaired, gullible or naïve, as well as the intelligent and alert.


CONFLICTING MESSAGES ABOUT SUICIDE PREVENTION

EUTHANASIA suicide prevention assisted suicide cartoonThere will always be concerns about conflicting messages being sent regarding suicide if assisted suicide becomes lawful. On the one hand society will offer some individuals assistance to commit suicide, yet on the other hand seek to take a zero-tolerance approach to individual suicides. The arguments put forward for allowing assisted death can also be reasons given for any suicide. Legalising euthanasia could potentially institutionalise suicide as a method of coping with personal problems. The risk of ‘suicide contagion’ associated with a media campaign around promoting euthanasia is also a real concern.

A study published in 2015 found that legalising assisted suicide was associated with a 6.3% increase in total suicides, an effect that was especially pronounced in individuals older than 65.

READ Family First NZ’s Oral Submission to the Inquiry into ending one’s life in NZ “You don’t discourage suicide by assisting suicide”


DEPRESSION

Many people with depression who request euthanasia revoke that request if their depression and pain are satisfactorily treated.[13] EUTHANASIA depressed girlEven very mild depression – of the kind that would not render a person legally incompetent – can have a marked effect on one’s predisposition to live or die. Virtually all patients who are facing death or battling an irreversible debilitating disease are depressed at some point. If euthanasia or assisted suicide is allowed, many patients who would have otherwise traversed this difficult dark phase (and found meaning in continued living) may not get that chance and will die prematurely. The Netherlands has seen a sharp increase in the number of people choosing to end their own lives due to mental health problems such as trauma caused by sexual abuse.

ACT MP David Seymour’s bill allows assisted suicide for those with a grievous and irremediable condition, or in advanced state of irreversible decline, or with unbearable suffering unable to be relieved in a manner the person considers tolerable. The fact that “unbearable suffering” is self-determined means that this bill effectively allows for assisted suicide on demand for any condition – not just the terminally ill. Yet the most common reason for people taking this view of their condition is depression, which is often poorly diagnosed and is potentially treatable.

For example, in the Netherlands:
euthanasia - Netherlands 2016 psychiatric disorder casesNetherlands sees sharp increase in people choosing euthanasia due to ‘mental health problems’ Telegraph, May 2016


THE ‘ELEPHANT IN THE ROOM’

elephant in the roomA large amount of the public purse is spent on healthcare for the dying, those with dementia and the elderly. Euthanasia is cheap; good palliative care and hospice services expensive. Bureaucrats are always looking for the cheapest ways to spend health care budgets. This harsh argument from economics is seldom, if ever, heard issuing from the lips of advocates for euthanasia, but it is arguably the ‘elephant in the room’ in the debate. The cold, fiscal reality is that end of life care is expensive and having citizens opt for an earlier death is associated with substantial government savings.[14] Another smaller-sized ‘elephant’ is the increasing demand for human organs suitable for transplants.[15]

Insurance companies abusing assisted suicide laws (US) Washington Post, June 2017


WHAT DO THE MEDICAL PROFESSIONALS THINK?

The majority of the medical profession and national medical associations around the world remain resolutely opposed to the introduction of euthanasia or assisted suicide.[16] The role of the doctor would be irrevocably changed from healer to sometime killer, from caring professional who saves lives to one who takes them. “Therapeutic killing” would have arrived. Inevitably, patient trust would be eroded.

euthanasia assisted suicide not safe“The NZMA is opposed to both the concept and practice of euthanasia and doctor assisted suicide. Euthanasia, that is the act of deliberately ending the life of a patient, even at the patient’s request or at the request of close relatives, is unethical. Doctor-assisted suicide, like euthanasia, is unethical … This NZMA position is not dependent on euthanasia and doctor-assisted suicide remaining unlawful. Even if they were to become legal, or decriminalised, the NZMA would continue to regard them as unethical.”“The NZMA however encourages the concept of death with dignity and comfort, and strongly supports the right of patients to decline treatment, or to request pain relief, and supports the right of access to appropriate palliative care. In supporting patients’ right to request pain relief, the NZMA accepts that the proper provision of such relief, even when it may hasten the death of the patient, is not unethical.

The NZMA is opposed to both the concept and practice of euthanasia and doctor assisted suicide. Euthanasia, that is the act of deliberately ending the life of a patient, even at the patient’s request or at the request of close relatives, is unethical. Doctor-assisted suicide, like euthanasia, is unethical … This NZMA position is not dependent on euthanasia and doctor-assisted suicide remaining unlawful. Even if they were to become legal, or decriminalised, the NZMA would continue to regard them as unethical.”
NZ Medical Association: Position Statement on Euthanasia (approved 2005) [17]

Don’t change euthanasia laws – NZ Medical Association Newshub, Sep 2016
Australian Medical Association rejects assisted suicide The Australian, Nov 2016


POLLS HAVE CONFUSED THE ISSUE

Opinion polls in New Zealand suggest the majority supports the legalisation of euthanasia and/or assisted suicide. But as we showed earlier, many people simply want to ensure that the administration of pain relief and the withdrawal of burdensome treatment are not treated as illegal. The questions have sometimes been misleading in that they conflate actions that are perfectly legal and moral with those that are unlawful. They consistently ask about a patient in insufferable pain, thus playing on peoples’ fears, whilst failing to acknowledge that pain is no longer a good reason for requesting euthanasia. In the 10 years that assisted suicide has been legal in Oregon State, it is doubtful if there has been a single request for it from a person suffering from uncontrolled pain. The continued emphasis on pain suggests a degree of cynicism on the part of those who compile such questions. Support typically drops for euthanasia or assisted suicide when state-funded palliative care is on the table.

Strong Opposition to legalising euthanasia – Inquiry
euthanasia 16000 voicesParliament’s health select committee received 21,277 submissions as it considered the investigation into ending one’s life in New Zealand over the past year. The majority (77%) opposed the legalisation of euthanasia, according to an analysis of the submissions by the Care Alliance, an umbrella group opposed to law change, which includes Family First, Euthanasia Free NZ, Hospice NZ and Not Dead Yet Aotearoa. Its research concluded that 16,411 of the submissions opposed legalisation, while 4142 supported it. Care Alliance secretary Matthew Jansen said the submissions reflected the depth and breadth of public attitudes about euthanasia.
READ MORE https://www.16000voices.org.nz/


WHAT HAS THE OVERSEAS EXPERIENCE SHOWN US?

Oregon

  • From 1998 to 2014, the number of deaths from assisted suicide has increased from 16 to 105 per year – a 656% rise over 16 years[18]
  • No healthcare provider was present in over 80% of assisted suicide deaths in 2014—officials do not know under what conditions these people died[19]
  • The state records complications in 2.7% of all assisted suicide deaths between 1998 and 2014, though whether or not complications occurred in nearly 60% of all assisted suicide deaths is unknown[20]
  • Studies have found that 1 in 6 patients who receive a prescription for lethal drugs have clinical depression[21]
  • Forty percent of patients who requested assisted suicide in 2014 did so out of concern for being a burden on their family[22]; only 13% did so in 1998[23]

Netherlands

  • At least 23% of euthanasia deaths are not reported each year as is required by law[24]
  • The Dutch have practiced euthanasia on infants since 2005, under guidelines laid out in the Groningen Protocol. One of the authors of the Groningen Protocol, Professor John Griffiths, believes that the legalisation of euthanasia “assuredly changed” the cultural norms in the Netherlands “in the direction of open acceptance of the legitimacy of termination of life of severely defective newborn babies”[25]
  • The Netherlands has seen a sharp increase in the number of people choosing to end their own lives due to mental health problems such as trauma caused by sexual abuse.

Belgium

  • Roughly 30% of euthanasia deaths in the Flanders region are performed without patient request or consent (1.8% of all deaths in the region) – those most often euthanised without their request or consent are the elderly, the incompetent, and those dying in hospitals[26]
  • Euthanasia deaths increased by over 5000% between legalisation in 2002 and 2011[27]; between 2011 and 2012, the rate of euthanasia deaths increased by a further 25%[28] In 2016, it was reported that euthanasia cases in Belgium had doubled in just five years.
  • Only about 50% of euthanasia deaths in the Flanders region are reported to the Federal Control and Evaluation Committee as is required by law[29]
  • As of 2014, there is no age limit on who may access euthanasia and assisted suicide
  • Among those euthanised in the past few years: deaf 45-year-old twins who were going blind; a 44-year-old woman with chronic anorexia nervosa; a 64-year-old woman with chronic depression without informing her family

(Source: Maxim Institute)

In 2017 alone, assisted suicide bills have been stopped or defeated in Maine, Tasmania, Hawaii, Utah, New Mexico, Nebraska, Minnesota, and Maryland while in several other states, assisted suicide bills were introduced but lacked support to even be debated. Of the roughly 196 countries in the world and 50 US states, only 11 have legalised some form of assisted dying – about 4% of jurisdictions worldwide.


SOME DISTURBING CASES IN THE MEDIA RECENTLY

It’s not pain but ‘existential distress’ that leads people to assisted suicide, study May 2017
Terminal cancer patient told hospital would rather spend money on others (New Zealand!) Mar 2017
Dutch gov’t panel: Doctor who forcibly euthanized elderly woman ‘acted in good faith’ Feb 2017
Netherlands offers euthanasia for alcoholics Dec 2016
Assisted-suicide law prompts insurance company to deny coverage to terminally ill California woman Oct 2016
Dutch may allow assisted suicide for those who feel they have ‘completed life’ Oct 2016
UK woman given 2 months to live survived for nine years Sep 2016
74% of Belgian mental suffering euthanised were women Aug 2016
Belgium man seeks euthanasia to end his sexuality struggle June 2016
Sex abuse victim in her 20s allowed to choose euthanasia May 2016
UNICEF lobbies Canadian Parliament to allow euthanasia for children May 2016
Belgian woman euthanised after heartbreak Feb 2016
Woman, 50, granted right to die after complaining she’s ‘lost her sparkle’ Dec 2015
Belgium experts ask for end to euthanasia based on mental health problems Dec 2015
German Parliament approves assisted suicide for ‘altruistic’ reasons Nov 2015
Young and fit and killing themselves using euthanasia drug (Australia) Oct 2015
Growing number of mentally ill Dutch choosing to be killed at euthanasia clinic Aug 2015
Belgium study Finds Euthanasia Targets Women and People With Depression or Autism July 2015
Deaths among young an unintended consequence of euthanasia movement: Australian mother July 2015
A healthy, 24-year-old woman to be euthanised in Belgium for psychological reasons June 2015
Euthanasia wanted for man in constant pain after having a tumour despite not being terminally ill May 2015
Doctors Killed His Belgian Mom Because She Was Depressed. Now He Speaks Out Against Euthanasia Jan 2015
Elderly Scottish cousins undergo joint euthanasia for fear of being put in separate care homes Feb 2015
Documentary shows Belgian doctor euthanizing a depressed, suicidal woman Jan 2015
Mentally ill patients killed by euthanasia in Holland trebles in a year Oct 2014
Man with same brain cancer as Brittany Maynard (US) has lived 13 years after being given just 6 months Nov 2014
Euthanasia for ‘depressed’ alleged murderer by campaigner Philip Nitschke (Aust) July 2014
Swiss – assisted dying for elderly who are not terminally ill May 2014


THE WAY FORWARD FROM HERE

Hospice NZNew Zealand has a well-developed network of hospices, and palliative medicine is widely practiced. There is research on the actual experience of those nearing the end of life indicating that fears of dying tend to dissipate when terminally-ill patients receive good hospice or palliative care.[30]

The key priority must be to improve the provision of high quality palliative care and practical support. This should be available in all areas of New Zealand. The highest quality of pain control and palliative medicine should be given priority in medical training so that every New Zealander can benefit. Patients facing death have a fundamental human right – a right to receive the very best palliative care, love and support that we can give to alleviate the ‘intolerable suffering’ that they fear. This is real death with dignity – surrounded and supported by loved ones, rather than a right to try and preempt the ‘uncertainty’ and timing of the end. Assisting suicide is not the answer.


SUMMARY

Voluntary euthanasia and physician-assisted suicide is a complex and challenging subject. Both the advocates and opponents of euthanasia are sincere and committed to what they see as the most humane and prudent policy for society.

killing me softly cover pageVoluntary euthanasia has the allure of being an enlightened and compassionate response to the plight of the suffering, but its practical operation is fraught with risks and there are slippery slopes that are indeed very slippery. Perhaps the most ominous change is one that cannot be proved. There will be an irreversible alteration to the way society and medical professionals view the demise of the elderly, the disabled, the incurably afflicted and the terminally ill. Death will be planned, coordinated and state-sanctioned in a manner hitherto unknown.

We should increase care, support, and funding for the best palliative care regime in the world – but we should not allow euthanasia and assisted suicide.

This information was primarily sourced from the research paper “Killing Me Softly: Should Euthanasia Be Legalised?” by Professor Rex Ahdar (2014). The full paper (including the Executive Summary) can be downloaded for free HERE


REFERENCES

[1] Australian and New Zealand Society of Palliative Medicine (ANZSPM 2013). The Double Effect principle was endorsed by the NZ High Court in Seales v Attorney-General [2015] NZHC 1239 at [101]-[106]

[2] Nicklinson v A Primary Care Trust [2013] EWCA Civ 961 at [25] and [26]

[3] Skegg et al 2006: 230, 534

[4] New Zealand Herald (2004) “Legal mercy killing just not feasible”, 2 April 2004

[5] Chambaere, Kenneth, Johan Bilsen, Joachim Cohen, et al (2010) “Physician-assisted deaths under the euthanasia law in Belgium: a population-based survey” Canadian Medical Association Journal 182(9): 895-901

[6] Pretty v DPP [2001] UKHL 61 at [54]

[7] http://www.dailymail.co.uk/news/article-2686711/Dont-make-mistake-As-assisted-suicide-bill-goes-Lords-Dutch-regulator-backed-euthanasia-warns-Britain-leads-mass-killing.html

[8] Oregon Public Health Division, Oregon’s Death with Dignity Act—2014 [Annual Report-Year 17] (Salem: Oregon Public Health, 2015

[9] Department of Human Resources, Oregon Health Division, Center for Disease Prevention and Epidemiology, Oregon’s Death with Dignity Act: The First Year’s Experience (Portland: Oregon Health Division, 1999

[10] Recommended Reading: “Do You Call This A Life?: Blurred Boundaries in The Netherlands’ Right-To-Die Laws” by Gerbert van Loenen (available on Amazon)

[11] Richmond, David (2013) “Why elderly should fear euthanasia and assisted suicide” Euthanasia-Free NZ, 16 June 2013: http://euthanasiadebate.org.nz/84/

[12] Apkarian, A Vania, Yamaya Sosa et al (2004) “Chronic pain patients are impaired on an emotional decision-making task” Pain 108: 129-136

[13] Mishara, Brian L and David N Weistubb (2013) “Premises and evidence in the rhetoric of assisted suicide and euthanasia” International Journal of Law and Psychiatry 26: 427-435

[14] Mishara and Wiesstubb 2013: 434

[15] Graham and Prichard 2013: 20

[16] See Seales v Attorney-General [2015] NZHC 1239 at [56]-[57]

[17] http://www.nzma.org.nz/__data/assets/pdf_file/0004/16996/Euthanasia-2005.pdf

[18] Oregon Public Health Division, Oregon’s Death with Dignity Act—2014 [Annual Report-Year 17] (Salem: Oregon Public Health, 2015).

[19] Oregon Public Health Division, 2015.

[20] Oregon Public Health Division, 2015.

[21] L Ganzini, E Goy, S Doscha, “Prevalence of depression and anxiety in patients requesting physician’s aid in dying: cross sectional survey,” in British Medical Journal (2008), 337: 1682; Ilana Levene and Michael Parker, “Prevalence of depression in granted and refused requests for euthanasia and assisted suicide: a systematic review,” in Journal of Medical Ethics (2011), 37(4): 205-211.

[22] Oregon Public Health Division, Oregon’s Death with Dignity Act—2014 [Annual Report-Year 17] (Salem: Oregon Public Health, 2015.

[23] Department of Human Resources, Oregon Health Division, Center for Disease Prevention and Epidemiology, Oregon’s Death with Dignity Act: The First Year’s Experience (Portland: Oregon Health Division, 1999).

[24] B Onwuteaka-Philipsen, A Brinkman-Stoppelenburg, C Penning, G Jong-Krul, J van Delden, A van der Heide, “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 survey,” in The Lancet (2012), 908-915.

[25] E Jackson & J Keown, Debating Euthanasia (Portland: Hart Publishing, 2012), 100.

[26] K Chambaere, J Bilsen, J Cohen, B Onwuteaka-Phililpsen, F Mortier, L Deliens, “Physician-assisted deaths under the euthanasia law in Belgium: a population-based study,” in Canadian Medical Association Journal (2010), 182 (9): 895-901.

[27] W D Bondt, W Distelmans, M De Maegd, M Englert, J Herremans, Cinquieme rapport aux Chambres Législatives (Années 2010-2011) (Commission Fédérale de Contrôle et d’Évaluation de l’Euthanasie, 2012).

[28] European Institute of Bioethics, “Belgique: toujours plus d’euthanasies: 1432 en 2012,” on www.ieb-eib.org (18 February 2013).

[29] T Smets, J Bilsen, J Cohen, M Rurup, F Mortier, L Deliens, “Reporting of euthanasia in medical practice in Flanders, Belgium: cross sectional analysis of reported and unreported cases,” in British Medical Journal (2010), 341: 5174.

[30] Kastenbaum, Robert (2006) The Psychology of Death, 3rd ed. New York: Springer; Mishara and Weisstub 2013: 433

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