Systematic Review of Euthanasia and Physician-Assisted Suicide for Older People

Systematic Review on Euthanasia and Physician-Assisted Suicide in Older People with Non-Terminal Conditions

Authors and Affiliations

  • James Baee

    • Brookvale Community Health Centre, Northern Sydney Local Health District, Brookvale, NSW, Australia

  • Brian Draper

    • Discipline of Psychiatry and Mental Health, University of NSW, Sydney, NSW, Australia

  • Chanaka Wijeratne

    • Euroa Centre, South Eastern Sydney Local Health District, Kogarah, NSW, Australia

Abstract

  • Objective: Investigate the ethical arguments for and against euthanasia and physician-assisted suicide (EUT/PAS) for older individuals with non-terminal conditions, particularly dementia and various geriatric syndromes.

  • Method: Systematic review following PRISMA guidelines; utilized content, thematic, and discourse analysis.

  • Results: Review included 17 studies. Arguments identified: 16 (22.9%) for EUT/PAS, and 54 (77.1%) against. Key themes derived: duty to die, precedent capacity, ageism, coercion, psychological factors, healthcare economics, sociocultural elements, and legislation.

  • Conclusion: There is skepticism regarding EUT/PAS for older non-terminal patients; further engagement with affected communities is recommended.

Keywords

  • Voluntary assisted dying, euthanasia, dementia, old age, bioethics, physician-assisted dying, non-terminal conditions.

Introduction

  • EUT/PAS has been legalized in various countries for individuals with incurable conditions who experience unbearable suffering.

  • Recent legislation in New Zealand and all Australian jurisdictions (except Northern Territory) permits EUT/PAS.

  • Most recipients are aged 65 and older, with a substantial proportion of applicants being in their 70s or older.

    • Median age of applicants in Australia: 70-79 years.

    • In New Zealand, 76.9% of applicants aged 65+.

  • In Belgium, the Netherlands, and Switzerland, 71-81% of recipients are aged 65+.

  • Significant rise in the oldest old (>80 years) accessing EUT/PAS, particularly in Belgium (from 16% to 39.3% from 2003 to 2019).

  • EUT/PAS requests primarily arise from malignancies, neurological diseases, and end-organ failure; some jurisdictions allow broader eligibility like psychiatric disorders.

Context Specific to Older People with Non-Terminal Conditions

  • In the Netherlands, EUT/PAS can be requested for dementia and multiple geriatric syndromes, defined as concurrent non-terminal illnesses affecting quality of life (e.g., falls, frailty).

  • In 2023, Dutch committees reported 328 EUT/PAS cases for dementia, primarily from those retaining decisional capacity.

  • Public discourse has emerged in Australia regarding EUT/PAS access for those with dementia.

  • Dementia Australia has adopted a neutral stance while advocating for engagement with those affected.

Objectives of the Review

  • To summarize and categorize ethical arguments regarding EUT/PAS for older people without terminal illness.

  • No value judgment is made regarding the practice.

Methods

Search Strategy

  • Utilized PRISMA methodology for systematic literature review.

  • Databases searched: Embase, Medline, Psycinfo (inception to February 22, 2024).

  • Search terms focused on:

    • Euthanasia/physician-assisted suicide

    • Non-terminal illnesses

    • Ethics

    • Old age

  • Inclusion criteria:

    1. Primary focus on EUT/PAS in older people without terminal illness, including those with dementia.

    2. Provision of ethical arguments for/against EUT/PAS.

    3. Peer-reviewed, written in English.

  • Exclusions: Studies predominantly focused on mental illness or terminal illness, descriptive studies, and general discussions of ageing or withdrawal of care.

Data Extraction Process

  • Two authors independently screened abstracts to reduce bias.

  • Discrepancies resolved through discussion.

  • Broad themes were extracted from relevant papers through content and thematic analysis.

  • No formal data extraction tool was used; the total number of identified arguments related to the subject matter was calculated.

  • Discourse analysis assessed the sentiment (for/against) of each article concerning ethical questions.

Results

  • Included Studies: 17 papers dated from 1999 to 2024; primarily from Western nations; 8 authored by medical practitioners and the rest by ethicists.

  • Sentiment: Predominantly against EUT/PAS (54 arguments), with only 16 arguments presented in favor.

  • Main Themes Identified: (summarized in Table 1)

    1. Precedent Capacity

    2. Duty to Die in Individuals with Dementia

    3. Psychological Factors

    4. Healthcare Economics

    5. Ageism

    6. Abuse/Coercion

    7. Sociocultural Factors

    8. Legislation

Arguments in Favor of EUT/PAS
1. Precedent Capacity

  • Allows individuals with dementia to sign advanced euthanasia directives (AEDs).

  • Premises include:

    • Relationship establishment with a physician pre-capacity decline.

    • Equality of opportunity for EUT/PAS regardless of dementia status.

2. Duty to Die in a Person with Dementia

  • Preserves moral agency and prevents unnecessary societal resource consumption.

Arguments Against EUT/PAS
1. Psychological Factors

  • Negative implications on families and caregivers.

  • Requests often stem from feelings of being a burden or loss of dignity.

  • Psychological evaluations are essential.

2. Healthcare Economics

  • Economic incentives could lead to coercion and favoritism in resource allocation.

  • Risk of incentivizing EUT/PAS as a cheaper alternative to chronic care.

3. Ageism

  • Potential reflection of societal stigma and perceived redundancy of older persons.

Conclusion

  • Preliminary literature presents skepticism on EUT/PAS for older people without terminal illness.

  • Engagement with diverse older populations and advocacy is crucial.

  • EUT/PAS discussions are likely to grow as societal attitudes evolve towards this aspect of care and autonomy.

Appendix

A: Search Strategy Details

  • Search Terms Used:

    • Euthanasia, Assisted Suicide, Non-terminal, Ethics, Old age

  • Exclusions:

    • Non-peer-reviewed articles, discussions not focused on EUT/PAS.

B: Tables of Arguments

  • See Table 1 for comprehensive detail of arguments for and against EUT/PAS.

Acknowledgments

  • Author contributions in methodology, literature search, writing, and ethics statement provided.

Ethical Considerations

  • No human subjects involved in the study; therefore, ethical approval was unnecessary.