Euthanasia in the Netherlands is nothing much to worry about, according to The Lancet. The latest survey shows that the overall levels of euthanasia and assisted suicide are about the same now as they were in 2002, when euthanasia was legalised. A small increase since 2005 is just due to the fact that more people are requesting euthanasia. 

At least that was the spin in The Lancet's press release. A closer examination of the article, "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", shows that there are many things to worry about. 

It is true that there is a "V" shaped curve in the number of cases of voluntary euthanasia. In 2001, before legalisation, about 2.6% of all deaths were due to voluntary euthanasia. In 2005, this dropped to 1.7%, and rose in 2010 back up to 2.8%. 

But what accounts for the drop? It was not lack of interest. The proportion of patients requesting euthanasia rose from 4.8% of all patient deaths in 2005 to 6.7% in 2010. And doctors were also more willing to grant it. In 2005, 37% of these requests were granted and in 2010 45%. 

The answer seems to be that doctors who ended the lives of their patients had switched from injecting barbiturates and muscle relaxants to "continuous deep sedation". Although physicians were asked in the questionnaire (included as an appendix) whether this meant withdrawal of nutrition and hydration, it is not clear from the article whether it did. Presumably this continuous deep sedation means drugging the patient into unconsciousness, withdrawing food and water, and waiting for them to die. 

A UK critic of legalised assisted dying, Dr Peter Saunders, quoted a 2010 paper by physicians from Mayo Clinic Arizona. In their opinion, "Continuous deep sedation should be distinguished from common sedation practices for palliation and characterized instead as physician-assisted death." So if this way of dying is counted as euthanasia, the real proportion of euthanised patients in the Netherlands in 2010 was about 15%. 

This is the point taken up in an accompanying commentary in The Lancet. An American physician, Bernard Lo, zeroes in on the issue of palliative sedation. 

"But physicians who say they are undertaking palliative sedation sometimes cross the line to euthanasia. One reason for this happening might be confusion regarding intention. The physician's intention to hasten the patient's death is crucial in the Dutch definition of euthanasia and assisted suicide. Intention should be judged not only by physicians' statements but also by actions. If a physician increases the dose of opioids or sedatives in an unresponsive patient in the absence of clinical signs or symptoms that could reasonably be interpreted as distress… these actions could be inferred as intention to hasten death."

Dr Lo also points out that about 20% of the doctors who administered euthanasia did not report it. The authors seem to regard this figure as good news: a tremendous improvement over the years before legalisation when about half of doctors did not report. But Lo suggests that this 20% might not have been voluntary and therefore not such good news after all. 

As Dr Saunders says, "the Dutch figures seem to reveal incremental extension after legalisation which is being carefully and skilfully disguised by the way the figures are being presented. The Lancet report, far from providing reassurance, actually raises more questions than it gives answers."