The following attempt at a clarification on the much addressed topic of “euthanasia and assisted suicide” – in which the specter of an ongoing “mass crime” in the Netherlands is evoked – consists in presenting an elementary mortality statistic by medical end-of-life decisions in that country over the period 1995 – 2015, according to published data of its national statistics bureau CBS. (1) Four line-graphs have been constructed to illustrate the quantitative levels of deceases according to type and modality of medical proceedings and their development in time. In order to gain an understanding of their relative proportions, the data have subsequently been related to the mortality figure in each of five reporting years. The results are presented in two diagrams, depicting their 1995 and 2015 ratio’s, which highlights the most important changes in the medical accompanying of deceases over the encompassed twenty years. Finally, the overall development is summarized in a fifth line-graph that permits to draw conclusions on a statistical basis.
1 Centraal Bureau voor de Statistiek. English language publications are available: https://www.cbs.nl/en-gb/society/health-and-welfare
An official statistic of deaths by medical end-of-life decisions
The statistic starts with breaking down the annual mortality numbers of five reporting years into two main categories: I.) the number of deceases without any medical end-of-life decision having been implied, and II.) the number of deceases having implied such decisions. We concentrate on this latter super-category, containing three types of medical proceedings: i) withholding or withdrawing medical treatment, ii) intensifying measures to alleviate pain or other symptoms, and iii) the application of drugs with the explicit intention of hastening death.
The first two of the latter types have the following modalities: 1. “taking into account a possible hastening of death” – applying to both i) and ii) – and 2. “partly intending the possible hastening of death” (ii), respectively: “with the explicit intention of hastening death” (i). The third category (iii), implying such an “explicit intention” by definition, is broken down into three subcategories: a) Euthanasia; b) Assisted suicide; and c) Ending of life without an explicit request by the patient.
Table 1 lists the absolute numbers of deceases per (sub-)category in each of the five reporting years of which we have retrieved these data: 1995, 2001, 2005, 2010 and 2015. For reference the respective average population sizes have been included.
Considering a period of twenty years, we have added a column listing the differences between the last and the first reporting year for each (sub-)category in terms of a percentage, which constitutes their rates of change over the period as a whole.
Table 1. Source: CBS, StatLine – Overledenen naar medische beslissing rond levenseinde; Data-sets: a) behandelaar,leeftijd ; b) leeftijd, geslacht (Definitive figures of May 24, 2017).
The four line-graphs that follow visualize the evolution of each listed (sub-)category, including a sum total for each graph.
Graph 1 shows the annual mortality and its break-down into the two main categories of deceases “without” and “with” medical end-of-life decisions. Graph 2 shows the evolution of the five main categories of deceases by medical end-of-life decision types in their absolute values. (2)
Graph 3 shows the evolution of the three categories that describe medical proceedings with an intention of hastening or bringing about death (Table 1: II.3, II.4 and II.5). Graph 4 shows the break-down of category II.5, finally quantifying what is labeled as “euthanasia” and “assisted suicide” by the CBS, along with the sub-category “ending of life without an explicit request by the patient”. (3)
We note that all four line-graphs unfortunately have the itch of situating the values for the year 2001 at the place of the year 2000 on the x-axis. These data points should be moved to the right over 1/5 of a grid interval, entailing changes of the slope of the connected line segments.
2 For readability of the graph we have left out the values of the data points on the red and green lines (cat. II.1 and II.3). These can be found in Table 1.
3 Likewise, the values of the data points on the yellow line (II.2) are left out of the graph. They also can be found in Table 1.
First observations and conclusions
We can make some first, general observations.
Graph 1: Following relatively small fluctuations between 135,675 and 140,377 since 1995, annual mortality (the total number of deceases in a year) has increased markedly since 2010 to reach 147,134 in 2015, which represents an overall growth of 8.4% over the whole period. (4)
Since 2005 the annual mortality without medical end-of-life decisions has diminished from 78,391 to ultimately 61,607 in 2015. Simultaneously the complementary category has risen from 58,011 to 85,527. Having reached a break-even point somewhere between 2005 and 2010, deceases with medical end-of-life decisions have become prevalent since. Over the period as a whole, an inversion appears to have taken place by which the two categories have changed places.
Graph 2: Category II.2, the deceases following “intensifying measures to alleviate pain or other symptoms while taking into account the possible hastening of death” (the yellow line), already was the largest category in 1995 with a count of 21,589. It has incessantly grown in absolute numbers throughout the whole period. In 2010 it had already more than doubled. Notwithstanding that the rapidity of this growth subsequently slowed down, in 2015 the size of this category attained 50,911, preserving it as the largest single category of medical end-of-life decisions, at a growth of 136% over the preceding twenty years.
The second largest category, the deceases as a consequence of “withholding or withdrawing medical treatment with the explicit intention of hastening death” (II.4, the purple line), has in 2015 eventually regained its initial level of 1995, after having substantially diminished from 18,038 in that year to 10,261 in 2005. The line-graph suggests a continuing growth in absolute numbers beyond 2015.
The third and last category that shows a tendency towards net growth over the period as a whole describes the deceases induced by “administering, supplying, or prescribing drugs with the explicit intention of hastening death” (II.5, the light blue line). Starting at 4,171 in 1995, and following a substantial decrease to 2,960 in 2005, it has augmented since, reaching 7,254 in 2015. As Graph 4 shows, the fluctuations of this compound category are essentially due to those of its “euthanasia” component, the size of which has increased by about 120% since 1995. (5)
4 The average population size has increased from 15,424,122 in 1995 to 16,900,726 in 2015 (+9,6%). The average annual increase has been 73,830 in this period or +0.48% (of 1995) per year.
5 To all appearances “euthanasia” in this statistic refers to the ‘voluntary’ variant, carried out by a physician on condition of a prior, certified will by the patient, which is legally admitted in the Netherlands under specific conditions; and “assisted suicide” to its “do-it-yourself” variety. See for instance Wikipedia: “Euthanasia in the Netherlands”.
The relative distributions for 1995 and 2015
In order to determine the “relative weight” of each category in the whole of medical end-of-life decisions for a given year, we have calculated their proportions relative to the respective annual mortality figure (=100%).
The two circle diagrams below highlight the quantitatively most important changes that have taken place over the period as a whole, by contrasting the distributions of 2015 and 1995. (6)
The diagrams demonstrate the significant increase of the relative proportion of deceases with medical end-of life decisions at all, as opposed to deceases without such decisions. In this context, they clearly show that category II.2 has occupied by far the largest part of this increase (the yellow surface areas). The latter in fact covers the medical practice of palliative sedation, (7) and it alone accounts for almost 35% of all deceases in 2015. This is statistically consistent with a tendency of the relative size of all other categories to diminish, except for the one comprising “euthanasia”, “assisted suicide” and “ending of life without patient’s request” (II.5). Albeit this compound category has significantly grown in the reported period, it still accounts for only up to 5% of the total mortality in 2015. The sum total of all three categories describing a medical intention to end lives, immediately or by hastening it, (II.3, II.4, II.5; the upper left slices of the diagram, including “euthanasia” and “assisted suicide”) accounts for about 18,5% of total mortality in the last reporting year.
Relative distribution of deaths with medical end-of-life decisions (1995 and 2015)
Finally, Graph 5 (analogous to Graph 2) permits to examine the evolution of the main categories of deceases by medical end-of-life decision types over this period with more depth. To facilitate a global overview, the three categories relating ‘intended deaths’ have been substituted by their sum (the grey line, as in Graph 3).
It appears that the category covering ‘palliative sedation’ (II.2) reached a historic maximum of 35.2% in 2010 and has more or less maintained the attained level since (-0.6% in 2015). The three ‘intentional’ categories, together, declined to a minimum in 2005 (10.8%), but have significantly grown since, tending to regain the 1995 level of 19.2%. As the Graphs 2 and 3, and both diagrams show, among these “Withholding or withdrawing medical treatment with the explicit intention of hastening death” (II.4) clearly takes the second place, followed by its variety of “taking into account the possible hastening of death” (II.1) – albeit it has declined since 2005. For the time being, we find “Euthanasia” only in the fourth place of medical end-of-life decisions.
Our first conclusion from this brief quantitative review is that a unilateral focus on “euthanasia and assisted suicide” overlooks the role and weight of other, more important types and modalities of medical end-of-life decisions that seem part of a general tendency towards a medicalization of decease.
H.C., July 12, 2019
6 The increase of the annual mortality over this period as a whole (+8.4%) is visualized by increasing the circle’s surface area for 2015 at the same proportion.
7 See for instance Wikipedia, https://en.wikipedia.org/wiki/Palliative_sedation