Life in the Netherlands ain’t what it used to be.

Euthanasia, which accounted for 1.7% of deaths in 1990, before it was legalized in 2002, rose to 4.5% of deaths in 2015, according to a 25-year review published in Thursday’s New England Journal of Medicine.

Lead author Dr. Agnes Van der Heide of Erasmus University Medical Center in Rotterdam stated, “It looks like patients are now more willing to ask for euthanasia and physicians are more willing to grant it.”

The Netherlands was the first country in the world that made it legal for doctors to help people die, whether by euthanasia, where doctors actively kill patients, or assisted suicide, where physicians prescribe patients a lethal dose of drugs.

Those who choose to die do not have to suffer from a fatal condition, as in Oregon, where physician-assisted suicide is permitted for those given six months or less to live. Instead, in the Netherlands, people must be “suffering unbearably.” That can range from serious illness, which represented 92% of those who chose to die in 2015, to health problems from old age, early-stage dementia or psychiatric problems.

Van der Heide said the percentage of those asking to die who aren’t terminally ill has increased; adding, “When assisted dying is becoming the more normal option at the end of life, there is a risk people will feel more inclined to ask for it.”

Penney Lewis, co-director of the Centre of Medical Law and Ethics at King’s College London, echoed, “If you legalize on the broad basis (that) the Dutch have, then this increase is what you would expect. Doctors become more confident in practicing euthanasia and more patients will start asking for it. Without a more restrictive system, like what you have in Oregon, you will naturally see an increase.”

Out of all those who died in 2015 in the Netherlands, roughly 8% asked for help dying.

Scott Kim, a bioethicist at the U.S. National Institutes of Health, expressed his concern, stating, “These are old people who may have health problems, but none of them are life-threatening. They’re old, they can’t get around, their friends are dead and their children don’t visit anymore. This kind of trend cries out for a discussion. Do we think their lives are still worthwhile?”

Euthanasia is legal in Belgium, Canada, Colombia, Luxembourg, Switzerland, Germany and six U.S. states: Colorado, California, Montana, Vermont, Washington state and the District of Columbia.