Commonalities and differences in legal euthanasia and physician-assisted suicide in three countries: a population-level comparison

  • Sigrid DierickxEmail author
  • Bregje Onwuteaka-Philipsen
  • Yolanda Penders
  • Joachim Cohen
  • Agnes van der Heide
  • Milo A. Puhan
  • Sarah Ziegler
  • Georg Bosshard
  • Luc Deliens
  • Kenneth Chambaere
Original article



To describe and compare euthanasia and physician-assisted suicide (EAS) practice in Flanders, Belgium (BE), the Netherlands (NL) and Switzerland (CH).


Mortality follow-back surveys among attending physicians of a random sample of death certificates.


We studied 349 EAS deaths in BE (4.6% of all deaths), 851 in NL (4.6% of all deaths) and 65 in CH (1.4% of all deaths). People who died by EAS were mostly aged 65 or older (BE: 81%, NL: 77% and CH: 71%) and were mostly diagnosed with cancer (BE: 57% and NL: 66%). Home was the most common place of death in NL (79%), while in BE and CH, more variation was found regarding to place of death. The decision to perform EAS was more frequently discussed with a colleague physician in BE (93%) and NL (90%) than in CH (60%).


EAS practice characteristics vary considerably in the studied countries with legal EAS. In addition to the legal context, cultural factors as well as the manner in which legislation is implemented play a role in how EAS legislation translates into practice.


Euthanasia Physician-assisted suicide End-of-life decision-making Belgium The Netherlands Switzerland 



Data collection in Belgium was part of the ‘Flanders Study to Improve End-of-Life Care and Evaluation Tools (FLIECE) project,’ a collaboration between the Vrije Universiteit Brussel, Ghent University, the Katholieke Universiteit Leuven, Belgium, and VU University Medical Centre Amsterdam, the Netherlands. The study is supported by a Grant from the Flemish Government Agency for Innovation by Science and Technology (Agentschap voor Innovatie door Wetenschap en Technologie) (SBO IWT nr. 100036). Analysis and writing were supported by the Research Council of the Vrije Universiteit Brussel (SRP4). For the Netherlands, the study is supported by a Grant (34008003) from the Netherlands Organization for Health Research and Development. For Switzerland, this study was supported by research Grant 406740-139309 from the Swiss National Science Foundation (National Research Program 67 ‘End-of-life’). We thank all assistants to the projects in the participating countries; those national and regional medical associations and other authoritative bodies that supported the study; and the physicians who participated in the study and provided the study data.

Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflict of interest.

Ethical approval

For Belgium, ethical approval was obtained from the Ethical Review Board of the Brussels University Hospital of the Vrije Universiteit Brussel. In the Netherlands, ethical approval was not required for the posthumous data collection of anonymous patient data under the Dutch Medical Research Involving Human Subject Act. For Switzerland, the study was issued a waiver by the Zurich Cantonal Ethics Board (KEK-StV-Nr. 23/13) since the study did not fall under the regulations for human research acts.

Informed consent

Participants were informed about the study in a cover letter. Questionnaire return was considered to imply consent to participate.


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Copyright information

© Swiss School of Public Health (SSPH+) 2019

Authors and Affiliations

  • Sigrid Dierickx
    • 1
    • 6
    Email author
  • Bregje Onwuteaka-Philipsen
    • 2
  • Yolanda Penders
    • 3
  • Joachim Cohen
    • 1
  • Agnes van der Heide
    • 4
  • Milo A. Puhan
    • 3
  • Sarah Ziegler
    • 3
  • Georg Bosshard
    • 5
  • Luc Deliens
    • 1
  • Kenneth Chambaere
    • 1
  1. 1.End-of-Life Care Research GroupVrije Universiteit Brussel (VUB)BrusselsBelgium
  2. 2.Department of Public and Occupational Health, Amsterdam Public Health Research Institute, VUmc Expertise Center for Palliative CareAmsterdam University Medical CentersAmsterdamThe Netherlands
  3. 3.Epidemiology, Biostatistics and Prevention InstituteUniversity of ZurichZurichSwitzerland
  4. 4.Department of Public HealthErasmus MCRotterdamThe Netherlands
  5. 5.Clinic for Geriatric Medicine, Zurich University Hospital, and Center on Aging and MobilityUniversity of Zurich and City Hospital WaidZurichSwitzerland
  6. 6.End-of-Life Care Research GroupGhent UniversityGhentBelgium

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