Legislation protects the vulnerable?

Chambaere and colleagues describe a decrease in the rate of life-ending acts without explicit request (LAWER) and an increase in the rate of euthanasia since legalization of euthanasia in Belgium. 1 Given this coincidental rise and fall, I propose that legalization has converted instances that would previously have been life-ending acts without explicit request into euthanasia. Instead of performing life-ending acts without explicit request while believing their patients wanted euthanasia, physicians now feel able to explicitly discuss the issue without fear of prosecution.

The data presented by Chambaere and colleagues support this hypothesis. As the authors mention, in 2007, the characteristics of patients receiving life-ending acts without explicit request were dissimilar to those of euthanasia patients: the former were older (53% over the age of 80), nearer the end of their lives and less likely to have cancer (34%). However, data collected in 2001, before legalization of euthanasia, did not show this clear separation of characteristics between the two groups of patients (e.g., only 24% of patients receiving life-ending acts without explicit request were over age 80, and 52% had cancer). This supports the idea that before legalization, some patients who may have wanted euthanasia were receiving life-ending acts without explicit request because communication between physician and patient was not explicit. If this is true, it’s an example of a protective function of regulation.