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Euthanasia and old age.

SIR--The publication of the article by Onwuteaka-Philipsen et al. on euthanasia and old age [1] throws into question the numerical and statistical review process of the journal. The conclusion of the authors that there is no `slippery slope' involving euthanasia in older people is of immense national and international significance. As such, extreme caution should have been taken to ensure that the correct numerical analysis was used.

The concept of a slippery slope depends upon the belief that behaviour of physicians will change with time. A time analysis is therefore an essential prerequisite of any study that purports to demonstrate that a tendency to change behaviour with time does not exist. The paper concerns 1707 reported cases of euthanasia between 1984 and 1993 in the province of North Holland in the Netherlands. Fifty percent of the reported cases (860 deaths) occurred in the last 2 years of the study period. Using cohort data analysis, as if all of the deaths occurred at the same time, the authors showed that (statistically) reported death by euthanasia was less likely to occur in older people; indeed younger ones were at greater risk. From this the authors mistakenly concluded that there is no slippery slope as far as older people are concerned.

However, a time series analysis of their data would seem to indicate that an exponential function is operating, as 50% of cases occurred in the last 2 years. This observation would suggest that the number of cases of euthanasia will increase in the next decade because the doctors will have changed their learnt behaviour. The study therefore shows that the slippery slope involves people of all ages: no group is immune.

Age and Ageing is the official journal of the British Geriatrics Society and of the British Society for Research on Ageing. The British Geriatrics Society has an established position that euthanasia is not in the interests of an ageing population. In the forthcoming debate there is no doubt that the publication in Age and Ageing will be used by the lobby group working for the introduction of euthanasia in the UK. I believe that this would be detrimental to the further development of quality medical and social care for dying people. I am concerned that the article will be quoted to undermine the position of the Society with regard to euthanasia.

Incidentally, I note that the journal contains no statement that the publications within the journal do not reflect the views of the Editor, or the views of the British Geriatrics Society. I think this is an important point and suggest that this statement should be included in future issues of the journal.
Division of Geriatric Medicine;
Research and Training,

St George's Hospital Medical School,
Level 01, Jenner Wing, Cranmer Terrace,
London WI ORE, UK
Fax: (+44) 181 682 0926

[1.] Onwuteaka-Philipsen BD, Muller MT, van der Wal G. Euthanasia in old age. Age Ageing 1997; 26: 487-92.

Author's reply

SIR--In his letter Professor Millard concludes that, in contrast to our conclusion that there is no `slippery slope' involving euthanasia in older people, there is a serious slippery slope that involves people of all ages. We wish to show that his conclusions are based on misconceptions.

The first misconception is that we conclude that there is no slippery slope in general. We only conclude that we found no evidence for the existence of one type of slippery slope--which would result, over the years, in euthanasia being performed with increasing frequency in older people. Of course, a slippery slope could affect other age groups. In our discussion, we explicitly state that this study cannot give insight into the possible existence of such a trend in other groups. However, there is no evidence for a slippery slope in the Netherlands: euthanasia and assisted suicide in 1995 did not involve patients whose diseases were less severe than those involved in 1990, and there were no signs that the decision-making process had become less careful [1].

Another misconception is interpreting the increase in the number of cases of euthanasia over the years in our study as an increase in all cases of euthanasia in North Holland. As we stated clearly in the methods and discussion sections of our paper, our study was limited to reported cases of euthanasia and assisted suicide. Due to changes in notification procedure, the percentage of cases reported increased dramatically after 1990. While in 1990 only 18% of all cases of euthanasia and assisted suicide were reported to the public prosecutor, 41% were reported in 1995 [2]. Therefore, the large increase in cases in our study period cannot be interpreted as an increase in all cases of euthanasia, and thus cannot be used as evidence for the existence of a slippery slope. Other research has shown that in 1995, the number of explicit requests for euthanasia or assisted suicide and the number of cases of euthanasia clearly increased somewhat, but not alarmingly, over the numbers in 1990, while the number of cases of assisted suicide remained the same [1].
Institute for Research in Extramural Medicine,
Vrije Universiteit,
Van der Boechorststraat 7, 1081 BT Amsterdam,
The Netherlands
Fax: (+31) 20 44 48387

[1.] Maas PJ van der, Wal G van der, Haverkate I et al. Euthanasia and other end-of-life decisions in the Netherlands 1990-1995. N Engl J Med 1996; 335: 1699-705.

[2.] Wal G van der, Maas PJ van der, Bosma JM et al. Evaluation of the notification procedure for physician-assisted death in the Netherlands. N Engl J Med 1996; 335: 1706-11.

Editor's reply

SIR--Professor Millard questions the journal's statistical review process. Each paper is sent to three reviewers. When any reviewer requests a statistician's assessment, this is arranged (unless the paper is unacceptable for other reasons). We try to ensure that the standards of numeracy and statistics in Age and Ageing are of the highest order.

I believe that the journal should publish articles which reflect different viewpoints, even when these are contrary to those of the British Geriatrics Society or the British Society for Research on Ageing. Professor Millard's comment about a disclaimer is a good one and this will be introduced in future issues of the journal.

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Author:Millard, Peter H.
Publication:Age and Ageing
Date:Nov 1, 1998
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