(CNSNews.com) -- A study published this month in the Journal of Medical Ethics examined the “deliberate” euthanasia of patients in Belgium without their explicit, voluntary consent as required by law.

The study’s author, Raphael Cohen-Almagor, a professor of philosophy and ethics at the United Kingdom's Hull University, found that life-ending drugs were used “with the intention to shorten life and without explicit request” in 1.7 percent of all deaths in Belgium in 2013.

In 52.7 percent of these cases, the patients were 80 years of age or older. The decision to euthanize was not discussed with the patient in 77.9 percent of the cases because he/she was comatose, had dementia, or “because discussion would have been harmful to the patient’s best interest,” according to the study.

Belgium passed the Euthanasia Act in 2002, which states that only voluntary euthanasia is legally permissible.

“At the heart of this legislation is the free will of the patient who asks for euthanasia,” Cohen-Almagor noted. “It is worrying that some physicians take upon themselves the responsibility to deliberately shorten patients’ lives without a clear indication from the patients that this is what they would want.”

According to the law, the patient must request euthanasia, and such a request must be “voluntary, well-considered, and repeated and...not the result of any external pressure.” The patient must also be “an adult or an emancipated minor, capable and conscious at the time of his/her request.”

Although annual euthanasia cases are steadily multiplying in Belgium, growing from 235 in 2003 to 1,807 in 2013, Cohen-Almagor noted that instances of euthanasia without explicit consent from the patient have actually decreased since 1996, when they accounted for 3.3 percent of all deaths.

He gives three possible explanations:

1) Gained experience in practicing euthanasia might allow more physicians to involve the patient in the decision-making process;

2) Physicians often use methods such as terminal sedation, which is not reported as euthanasia; and

3) Physicians might not be “well acquainted with the labelling of all the medical practices at the end of life.”

In 2014, Belgium became the first nation in the world to eliminate age limits for euthanasia, allowing terminally-ill children to end their lives.

The Belgian Society of Intensive Care Medicine Council released a paper in 2014 discussing the use of sedatives “with the direct intention of shortening the dying process of terminal palliative care in patients with no prospect of a meaningful recovery.”

This document, which applies to both children and adults, holds that “suffering should be avoided at all times,” adding that the process of withdrawing treatment and increasing the doses of “sedative/opioids” to fatal levels in patients in intensive care “must not be interpreted as killing.”

“Shortening the dying process by administering sedatives beyond what is needed for patient comfort can be not only acceptable but in many cases desirable,” the council document stated.

Although end-of-life decisions should be discussed with the patient’s relatives, the statement noted that the final decision is “made by the care team and not by the relatives.”

A 2010 research study conducted in Flanders revealed that only one out of every two euthanasia cases was reported to Belgium’s Federal Control and Evaluation Committee because most non-reporting physicians did not view the active hastening of their patients’ deaths as euthanasia.

Unreported cases were also generally handled less carefully than reported cases and “the lethal drugs were often administered by a nurse alone, not by a physician,” the study noted.

“Whether deliberately or not, the physicians were disguising the end-of-life decision as a normal medical practice,” Cohen-Almagor pointed out.