Chapter 11: Deliberate Termination of Life and Physician Assisted Suicide : Aid in Dying

Section 2.  Social Context
Physician Assisted Suicide and the Deliberate termination of life are deaths that do involve issues related to suicide and to voluntary euthanasia. The use of the phrasing "Physician Assisted Suicide" while being very popular casts a negative connotation over the discussion of its moral status as the word "suicide" is in the West considered morally incorrect in the traditions of Judaism, Christianity and Islam.  Perhaps a phrase that would be accurate and less prejudicial would be "aid in dying" that would include deliberate efforts to hasten a death in a less painful manner than otherwise leaving the diseases to take their course.

READ: http://en.wikipedia.org/wiki/Physician_assisted_suicide

READ: http://en.wikipedia.org/wiki/Suicide

This section was organized, prepared and written by Mark Riddagh (SCCC, 2006) using Ronald Munson's Intervention and Reflection as a guide.

Oregon Becomes the First State to Recognize Physician-Assisted Suicide :Oregon Ballot Measure 16 (1994) READ http://en.wikipedia.org/wiki/Oregon_Ballot_Measure_16_%281994%29

In 1994, the state of Oregon passed a law that stated one could present a "Written Request for Medication to End One’s Life in a Humane and Dignified Manner". (Munson – 192) The Law was dubbed the "Death with Dignity Act" and was the first of such laws passed in the United States. The law clearly specifies the conditions that must exist and which actions are acceptable for legal physician assistance in ending the life of a patient.

There are five-main points that the law requires. They are:

1. A primary-care physician and a consulting physician must both agree that the patient has 6-months or less to live.

2. The patient must make two oral requests (at least forty-eight hour apart) for drugs to use to terminate his or her life.

3. The patient must wait at least fifteen days after the initial oral request, then make a written request to the physician.

4. If either physician thinks the patient has a mental disorder or is suffering from impaired judgment from depression, they must recommend the patient for counseling.

5. The patient can terminate the request at any time during the process. (Munson – 192)

Additionally, the physician can only prescribe the medication and indicate the means for it to become lethal. No direct involvement can be provided to assist in the person’s suicide. Lethal injection, as well as other similar means of physician-assisted suicide remains illegal.

Although only by a slight margin, 52 to 48 percent of the vote, the bill was passed into law in 1994. In 1997, opponents of the "Death with Dignity Act" found the means to appeal, but alas, their efforts were in vain. The law was again approved by a 60 to 40 percentage and remained a legal part of the Oregon medical profession.

Ironically, physicians, although protected by law, were hesitant to support a patient’s right to die. The Drug Enforcement Agency (DEA) claimed that severe sanctions would be imposed upon any physician who engaged in assisting a patient with suicide. This announcement did not boost physician confidence in their legal protection and although their licenses were in no way threatened, the DEA has no authority to cancel a physician’s license to practice; the organization could, however cancel a physician’s license to prescribe medication. Nevertheless, in 1998, the Attorney General, Janet Reno overruled the DEA’s decision to threaten physician who upheld and practiced as state law deemed appropriate. She claimed that the DEA had no authority to intervene in issues of morality at the state level.

Although the law did effectively protect physicians who assisted patients in ending their lives, it did not extend that protection to other health care professionals. Nurses, who frequently assist patients with taking medication, were never mentioned in the law. Since nurses are responsible for giving medication to those who are physically unable to take it themselves, is the threat of prosecution a foreseen reality? Additionally, are pharmacists who fill such prescriptions potentially liable for dispensing a lethal dose of medication? They too were never given consideration in the original law.

Other obstacles have hindered the practice of the "Death with Dignity Act". Despite the Supreme Court’s decision in the Cruzan case a few years prior, many physicians and other health care professionals refuse to acknowledge this option for their patients. In fact, many physicians admittedly ignore patients’ oral instructions concerning their treatment. "In one study of over 4000 seriously ill patients, researchers found that although 33 percent of the patients asked not to be revived by cardiopulmonary resuscitation, 50 percent of the time ‘Do Not Resuscitate’ was never written in their charts." (Munson – 194) Additionally, "In a 1997 study of 4804 terminally ill patients, only 688 had written directives, and only 22 of these contained instructions explicit enough to guide the care they received. Even these instructions were ignored about 50 percent of the time, and physicians knew about the patient’s instructions only about 25 percent of the time." (Munson – 194) Furthermore, in many cases, the written directives of patients were never recoded in their medical charts, resulting in patients receiving the precise care that they have unequivocally rejected in writing.

One final obstacle that has violated patients’ legal right to control their treatment, or lack of it, is the intervention of family members who do not share the same views. Often, a close relative will override a patient’s desire to end treatment or imposed nutrition and hydration. Likewise, medical professionals are likely to respect the wishes of the family over the wishes of the patient because in reality, even though the patient overrides the family when it comes to treatment, "Families never sue because of the overtreatment of a patient, but they do sue because of withholding or discontinuing treatment." (Munson – 194)

One major opponent of physician-assisted suicide is the American Medical Association (AMA). According to the Code of Medical Ethics, the practice conflicts with a physician’s primary role as a healer. Rather than assist a patient in ending his or her life, the physician is responsible for providing the best care possible as a patient nears death. This "best care possible" would include respect for autonomy, emotional support, comfort provisions and proper communication as well as medical care and pain relief.

In an effort to prevent the uncontrolled migration of terminal patients into Oregon borders, the law specifies that it apply only to Oregon residents, therefore eliminating a physician’s responsibility to provide lethal doses of medication to visitors of the state. This detail may have been unnecessary however, as only 15 people ended their lives by lethal prescription during the first year the law was in affect. Supporter of the law have proposed this statistic to support it’s necessity, claiming that people just want to know that the option is available to them should they ever want to consider the self-determination to end their life.

Euthanasia

From Wikipedia, the free encyclopedia  http://en.wikipedia.org/wiki/Euthanasia

Euthanasia (from Greek: ευθανασία -ευ, eu, "good", θάνατος, thanatos, death) is the practice of terminating the life of a person or animal in a painless or minimally painful way.

Laws around the world vary greatly with regard to euthanasia and are constantly subject to change as cultural values shift and better palliative care or treatments become available. It is legal in some nations, while in others it may be criminalized. Due to the gravity of the issue, strict restrictions and proceedings are enforced regardless of legal status. Euthanasia is a controversial issue because of conflicting moral feelings both for the individual and between different cultures, ethnicities, religions and other groups. The subject is explored by the mass media, authors, film makers and philosophers, and is the source of ongoing debate and emotion. Euthanasia of humans as a topic is often highly-charged. Terminology, religions and laws change over time, geographically and globally, causing a great deal of confusion

Terminology

It is often difficult to discuss euthanasia because there are so many different views:

 Euthanasia by means

There is passive, non-aggressive, and aggressive. Passive euthanasia is withholding common treatments (such as antibiotics, drugs, or surgery) or giving a medication (such as morphine) to relieve pain, knowing that it may also result in death (principle of double effect). Passive euthanasia is currently the most accepted form as it is currently common practice in most hospitals. Non-aggressive Euthanasia is the practice of withdrawing life support and is more controversial. Aggressive Euthanasia is using lethal substances or force to kill and is the most controversial means.[1][2]

 Euthanasia by consent

There is involuntary, non-voluntary, and voluntary. Involuntary euthanasia is euthanasia against someone’s will and equates to murder. This kind of euthanasia is almost always considered wrong by both sides and is rarely debated. Non-voluntary euthanasia is when the person is not competent to or unable to make a decision and it is thus left to a proxy like in the Terri Schiavo case. This is highly controversial, especially because multiple proxies may claim the authority to decide for the patient. Voluntary euthanasia is euthanasia with the person’s direct consent, but is still controversial as can be seen by the arguments section below.[2]

 Other designations

There are also the designations of mercy killing, animal euthanasia, and physician-assisted suicide which is a term for aggressive voluntary euthanasia.[1]

 History

The term euthanasia comes from the Greek words “eu” and “thanatos” which combined means “good death”. Hippocrates mentions euthanasia in the Hippocratic Oath, which was written between 400 and 300 B.C. The original Oath states: “To please no one will I prescribe a deadly drug nor give advice which may cause his death.”[3] Despite this, the ancient Greeks and Romans generally did not believe that life needed to be preserved at any cost and were, in consequence, tolerant of suicide in cases where no relief could be offered to the dying or, in the case of the Stoics and Epicureans, where a person no longer cared for his life.[2]

The English Common Law from the 1300’s until today also disapproved of both suicide and assisting suicide. However, in the 1500s, Thomas More, in describing a utopian community, envisaged such a community as one that would facilitate the death of those whose lives had become burdensome as a result of "torturing and lingering pain".[2] In 1828, euthanasia was explicitly outlawed in the U.S. Support grew in the 1900’s for euthanasia, however. Societies were formed in England in 1935 and in the U.S.A. in 1938 to promote aggressive Euthanasia. In 1937, doctor-assisted euthanasia was declared legal in Switzerland as long as the person ending the life has nothing to gain.[1][3]

In 1939, Nazis, in what was code named Action T4, euthanized children under three who exhibited mental retardation, physical deformity, or other debilitating problems whom they considered "life unworthy of life”. This program was later extended to include older children and adults.[3]

In 1977, California legalized living wills and other states soon followed suit. In 1990, Dr. Jack Kevorkian, a Michigan physician, became infamous for encouraging and assisting people in committing suicide which resulted in a Michigan law against the practice in 1992. Kevorkian was tried and convicted in 1999 for a murder displayed on television.[1][3] In 1990, the Supreme Court approved the use of non-aggressive euthanasia.[4]

In 1994, Oregon voters approved doctor-assisted suicide and the Supreme Court allowed such laws in 1997.[2] The Bush administration failed in its attempt to use drug law to stop Oregon in 2001.[1] In 1999, non-aggressive euthanasia was permitted in Texas.

In 1993, the Netherlands decriminalized doctor-assisted suicide, and in 2002, restrictions were loosened. During that year, physician-assisted suicide was approved in Belgium. An Australian province approved a euthanasia bill in 1995, but that was overturned by Australia’s legislative branch in 1997.[1][2][3]

Most recently, amid government roadblocks and controversy, Terri Schiavo, a Floridian who was believed to have been in a vegetative state since 1990, had her feeding tube removed in 2005. Her husband had won the right to take her off life support, which he claimed she would want but was difficult to confirm as she had no living will and the rest of her family claimed otherwise.[1]

Arguments for and against Voluntary Euthanasia

Reasons given for Voluntary Euthanasia:

  • Choice: Choice is a fundamental democratic principle and is the basis of the Free Enterprise system.[2]
  • Financial: It is a burden to keep people alive past the point they can contribute to society. See also Utilitarianism.
  • Quality of Life: The pain and suffering a person feels during a disease can be incomprehensible, even with pain relievers, to a person who has not gone through it. Even without considering the physical pain, it is often difficult for patients to overcome the emotional pain of losing their independence. Society should not be able to force them to endure such hardship.[2] The German Government of the late 1930s and early 1940s used this argument in the form of the mentally ill having lives without living.
  • Resources: Today in many countries there is a shortage of hospital space. The energy of doctors and hospital beds could be used for people whose lives could be saved instead of continuing the life of those who want to die which increases the general quality of care and shortens hospital waiting lists.

Reasons given against Voluntary Euthanasia:

  • Hippocratic Oath: Every doctor must swear upon some variation of it, and the original version explicitly excludes euthanasia.[5]
  • Moral: Some people consider euthanasia of some or all types to be morally unacceptable.[2] This view usually treats euthanasia to be a type of murder and voluntary euthanasia as a type of suicide, the morality of which is the subject of active debate.
  • Theological: Many religions and modern religious interpretations explicitly regard both euthanasia and suicide as sinful acts (see Religious views of suicide).
  • Competence: Euthanasia can only be considered "voluntary" if a patient is mentally competent to make the decision, i.e., has a rational understanding of options and consequences. Competence can be difficult to determine or even define.[2]
  • Necessity: If there is some reason to believe the cause of a patient's illness or suffering is or will soon be curable, the correct action is sometimes considered to be attempting to bring about a cure or engage in palliative care.[2]
  • Wishes of Family: Family members often desire to spend as much time with their loved ones as possible before they die.
  • Pressure: All the arguments listed for voluntary euthanasia can be used by hospital personnel to form a terrible and continuing psychological pressure on people to consent to voluntary euthanasia.[6] In countries with social systems like those in Britain, the hospital personnel would have targets to meet. Some people find this a terrifying prospect.[7]

 

Influence of various factors on opinion regarding euthanasia

Religion

Some of the differences in public attitudes towards the right to die debate stem from the diversity of religion in the United States. The United States contains a wide array of religious views, and these views seem to correlate with whether euthanasia was supported. Using the results from past General Social Surveys performed, some patterns can be found. Respondents that did not affiliate with a religion were found to support euthanasia more than those who did.

Of the religious groups that were studied, which were mostly Christian in this particular study, (including Southern Baptists, Pentecostals, and Evangelicals) and Catholics were more opposed to euthanasia than non-affiliates and the other religious groups.

Moderate Protestants (including Lutherans and Methodists)showed mixed views concerning end of life decisions in general. Both of these groups showed less support than non-affiliates, but were less opposed to it than conservative Protestants. Moderate Protestants are less likely to take a literal interpretation to Bible than their conservative counterparts, and some leaderships tend to take a less oppositional view on the issue. Despite the fact that the Catholic Church has come out in firm opposition to physician-assisted suicide, they share the nearly same level of support as moderate Protestants.

The liberal Protestants (including some Presbyterians and Episcopalians) were the most supportive of the groups. In general, they had looser affiliations with religious institutions and their views were similar to those of non-affiliates. Within all these groups, religiosity (identified as being frequency of church attendance and self-evaluation) also affected their level of opposition towards euthanasia. Individuals who attended church regularly and more frequently and considered themselves more religious were found to be more opposed than to those who had a lower level of religiosity.[8]

In Theravada Buddhism, a monk can be expelled for praising the advantages of death, even if they simply describe the miseries of life or the bliss of the after-life in a way that might inspire a person to commit suicide or pine away to death. In caring for the terminally ill, one is forbidden to treat a patient so as to bring on death faster than would occur if the disease were allowed to run its natural course.[9]

Jainism is worth of mention when it comes to this topic, as Mahavira Varadhman, it's founder, is unique in explicitly allowing suicide.

In Hinduism, the Law of Karma states that any bad action happening in one lifetime will be reflected in the next. Euthanasia could be seen as murder, and releasing the Atman before it's time. However, when a body is in a vegetative state, and with no quality of life, it could be seen that the Atman has already left. When avatars come down to earth they normally do so to help out mankind. Since they have already attained Moksha they choose when they want to leave.

Ethnicity

In the specific case of euthanasia, recent studies have shown European-Americans to be more accepting than African-Americans. They are also more likely to have advance directives and to use other end of life measures.[10] African-Americans are almost 3 times more likely to oppose euthanasia than European-Americans. The main reason for this discrepancy is attributed to the lower levels of trust in the medical establishment.[11] Researchers believe that past history of abuses towards minority in medicine (such as the Tuskegee Syphilis Study) have made minority groups less trustful of the level of care they receive. Studies have also found that there are significant disparities in the medical treatment and pain management that European-Americans and other Americans receive.[12]

Among African-Americans, education correlates to support for euthanasia. African-Americans without a four-year degree are twice as likely to oppose euthanasia than those with at least that much education. Level of education, however, does not significantly influence other racial groups in the US. Some researchers suggest that African-Americans tend to be more religious, a claim that is difficult to substantiate and define.[13] Only African and European Americans have been studied in extensive detail. Although it has been found that non European-American groups are less supportive of euthanasia than European-Americans, there is still some ambiguity as to what degree this is true.

 Gender

The research has not found sex to be a significant factor in predicting opinion about euthanasia. However, some studies have shown that there are differences in views between males and females. A recent Gallup Poll found that 84% of males supported euthanasia compared to 64% of females.[14] Some cite the prior studies showing that women have a higher level of religiosity and moral conservatism as an explanation. Within both sexes, there are differences in attitudes towards euthanasia due to other influences. For example, one study found that African-American women are 2.37 times more likely to oppose euthanasia than European-American women. African-American men are 3.61 times more likely to oppose euthanasia than European-American men.[15]

 Country examples

 Switzerland

In Switzerland, deadly drugs may be prescribed to a Swiss person or to a foreigner, where the recipient takes an active role in the drug administration. More generally, article 115 of the Swiss penal code, which came into effect in 1942 (having been written in 1937), considers assisting suicide a crime if and only if the motive is selfish. The code does not give physicians a special status in assisting suicide; however, they are most likely to have access to suitable drugs and the medical establishment have prohibited highly liberal physicians from prescribing deadly drugs further. When an assisted suicide is declared, a police inquiry may be started. Since no crime has been committed in the absence of a selfish motive, these are mostly open and shut cases. Prosecution happens if doubts are raised on the patient's competence to make an autonomous choice. This is rare.

Article 115 was only interpreted as legal permission to set up organisations administering life-ending medicine in the 1980s, 40 years after its introduction.

These organisations have been widely used by foreigners - most notably Germans - as well as the Swiss. Around half of the people helped to die by the organisation DIGNITAS have been Germans.

United States

Euthanasia is illegal in most of the United States. A recent Gallup Poll survey showed that 60% of Americans supported euthanasia.[16] Attempts to legalize euthanasia and assisted suicide resulted in ballot initiatives and legislation bills within the United States in the last 20 years. For example, Washington voters saw Ballot Initiative 119 in 1991, California placed Proposition 161 on the ballot in 1992, Michigan included Proposal B in their ballot in 1998, and Oregon passed the Death with Dignity Act.

 The Netherlands

In 2002, The Netherlands legalized euthanasia. The law codified a twenty year old convention of not persecuting doctors who have committed euthanasia in very specific cases, under very specific circumstances. The Ministry of Public Health, Wellbeing and Sports claims that this practice "allows a person to end their life in dignity after having received every available type of palliative care."[17]

 Legal framework

Termination of Life on Request and Assisted Suicide (Review Procedures) Act took effect on April 1, 2002. It legalizes euthanasia and physician assistance in dying in very specific cases, under very specific circumstances. The law was proposed by Els Borst, the D66 minister of Health. The procedures codified in the law had been a convention of the medical community for over twenty years.

The law allows medical review board to suspend prosecution of doctors who performed euthanasia when each of the following conditions is fulfilled:

  • the patient's suffering is unbearable with no prospect of improvement
  • the patient's request for euthanasia must be voluntary and persist over time (the request can not be granted when under the influence of others, psychological illness or drugs)
  • the patient must be fully aware of his/her condition, prospects and options
  • there must be consultation with at least one other independent doctor who needs to confirm the conditions mentioned above
  • the death must be carried out in a medically appropriate fashion by the doctor or patient, in which case the doctor must be present
  • the patient is at least 12 years old (patients between 12 and 16 years of age require the consent of their parents)

The doctor must also report the cause of death to the municipal coroner in accordance with the relevant provisions of the Burial and Cremation Act. A regional review committee assesses whether a case of termination of life on request or assisted suicide complies with the due care criteria. Depending on its findings, the case will either be closed or, if the conditions are not met brought to the attention of the Public Prosecutor. Finally, the legislation offers an explicit recognition of the validity of a written declaration of will of the patient regarding euthanasia (a "euthanasia directive"). Such declarations can be used when a patient is in a coma or otherwise unable to state whether they want euthanasia or not.

Euthanasia remains a criminal offense in cases not meeting the law's specific conditions, with the exception of several situations that are not subject to the restrictions of the law at all, because they are considered normal medical practice:

  • stopping or not starting a medically useless (futile) treatment
  • stopping or not starting a treatment at the patient's request
  • speeding up death as a side-effect of treatment necessary for alleviating serious suffering

Euthanasia of children under the age of 12 remains technically illegal; however, Dr. Eduard Verhagen has documented several cases and, together with colleagues and prosecutors, has developed a protocol to be followed in those cases. Prosecutors will refrain from pressing charges if this Groningen protocol is followed.

Practice in The Netherlands

In 2003, in the Netherlands, 1626 cases were officially reported of euthanasia in the sense of a physician assisting the death (1.2% of all deaths). Usually the sedative sodium thiopental is intravenously administered to induce a coma. Once it is certain that the patient is in a deep coma, typically after some minutes, Pancuronium is administered to stop the breathing and cause death.

Officially reported were also 148 cases of physician assisted dying (0.14% of all deaths), usually by drinking a strong (10g) barbiturate potion. The doctor is required to be present for two reasons:

  • to make sure the potion is not taken by a different person, by accident (or, theoretically, for "unauthorized" suicide or perhaps even murder)
  • to monitor the process and be available to apply the combined procedure mentioned below, if necessary

In two cases the doctor was reprimanded for not being present while the patient drank the potion. They said they had not realized that this was required.

Forty-one cases were reported to combine the two procedures: usually in these cases the patient drinks the potion, but this does not cause death. After a few hours, or earlier in the case of vomiting, the muscle relaxant is administered to cause death.

By far, most reported cases concerned cancer patients. Also, in most cases the procedure was applied at home.

 Social debate within The Netherlands

The legislation has wide support among the socially libertarian Dutch, who have one of the world's highest life expectancies. There is, however, persistent opposition, mainly from the orthodox protestant Political Reformed Party and the ChristianUnion, which call for more attention for palliative care and the eventual illegalization of the procedure.

In 1992, Huib Drion, a member of the Dutch high court proposed to develop and legalize a drug, which is now known as Drion's pill. This fictional drug would be a set of 2 pills. The first pill could be taken without any harm; the second pill would have to be taken a couple of days later (and only then would work). This would give the patient the time to think things over. The main goal of this drug would be to allow people who have unbearable psychological suffering to end their life, especially old people who feel their life is finished. The drug was never developed. The proposal, however, indirectly started up the discussion of euthanasia in Netherlands.

Australia

Euthanasia was legalised in Australia's Northern Territory, by the Rights of the Terminally Ill Act 1995. Soon after, the law was voided by an amendment by the Commonwealth to the Northern Territory (Self-Government) Act 1978. The powers of the Northern Territory legislature, unlike those of the State legislatures, are not guaranteed by the Australian constitution. However, before the Commonwealth government made this amendment, three people had already been legally euthanised. The first person was a taxi driver, Bob Dent, who died on 22 September 1996.

Although it is a crime in most Australian states to assist in euthanasia, prosecutions have been rare. In 2002, relatives and friends who provided moral support to an elderly woman who committed suicide were extensively investigated by police, but no charges were laid. The Commonwealth government subsequently tried to hinder euthanasia with the passage of the Criminal Code Amendment (Suicide Related Materials Offences) Bill 2004. In Tasmania in 2005 a nurse was convicted of assisting in the death of her elderly mother and father who were both suffering from illnesses. She was sentenced to two and a half years in jail but the judge later suspended the conviction because he believed the community did not want the woman put behind bars. This sparked debate about decriminalising euthanasia.

 Belgium

The Belgian parliament legalized euthanasia in late September 2002. Proponents of euthanasia state that prior to the law, several thousand illegal acts of euthanasia were carried out in Belgium each year. According to proponents, the legislation incorporated a complicated process, which has been criticized as an attempt to establish a "bureaucracy of death".

The United Kingdom

On November 5, 2006, Britain's Royal College of Obstetricians and Gynaecologists submitted a proposal to the Nuffield Council on Bioethics calling for consideration of permitting the euthanasia of disabled newborns.[18] The report does not address the current illegality of euthanasia in the United Kingdom, but rather calls for reconsideration of its viability as a legitimate medical practice.
 

In contrast there is increasing evidence that doctors in the UK are hardening their attitude against euthanasia or physician assisted suicide:
 

  • UK doctors are particularly cautious about decisions to shorten life.[19]
  • Compared with countries where euthanasia is illegal (eg. Italy, Sweden, Denmark), UK doctors are more open about discussing end-of-life decisions (ELD) with patients and relatives.[19]
  • Compared with countries where euthanasia or physician assisted suicide is legal (eg. Belgium, Netherlands, Switzerland), UK doctors are the same or more likely to report discussions on ELD with medical and nursing colleagues.[19]
  • 94% of UK specialist doctors in palliative care are against a change in the law.[20]
  • In 2006 both the Royal College of Physicians and the Royal College of General Practitioners voted against a change in the law.

Euthanasia protocol

See Lethal Injection for more information.

A machine that can facilitate euthanasia through heavy doses of drugs. It is possible in this image to see the laptop screen that leads the user through a series of steps and questions, to the final injection, which is done by motors controlled by the computer. This series of questions is supposedly to prevent unprepared users from undergoing Euthanasia.

A machine that can facilitate euthanasia through heavy doses of drugs. It is possible in this image to see the laptop screen that leads the user through a series of steps and questions, to the final injection, which is done by motors controlled by the computer. This series of questions is supposedly to prevent unprepared users from undergoing Euthanasia.[21]

Euthanasia can be accomplished either through an oral, intravenous, or intramuscular administration of drugs. In individuals who are incapable of swallowing lethal doses of medication, an intravenous route is preferred. The following is a Dutch protocol for parenteral (intravenous) administration to obtain euthanasia:

Intravenous administration is the most reliable and rapid way to accomplish euthanasia and therefore can be safely recommended. A coma is first induced by intravenous administration of 20 mg/kg thiopental sodium (Nesdonal) in a small volume (10 ml physiological saline). Then a triple intravenous dose of a non-depolarizing neuromuscular muscle relaxant is given, such as 20 mg pancuronium dibromide (Pavulon) or 20 mg vecuronium bromide (Norcuron). The muscle relaxant should preferably be given intravenously, in order to ensure optimal availability. Only for pancuronium dibromide (Pavulon) are there substantial indications that the agent may also be given intramuscularly in a dosage of 40 mg.[22]

Some people approve of some forms of euthanasia in principle, but fear that if some forms of euthanasia are legalized other forms of euthanasia that they do not support will come into practice.

With regards to nonvoluntary euthanasia, the cases where the person could consent but was not asked are often viewed differently from those where the person could not consent. Some people raise issues regarding stereotypes of disability that can lead to non-disabled or less disabled people overestimating the person's suffering, or assuming it to be unchangeable when it could be changed. For example, many disability rights advocates responded to Tracy Latimer's murder by pointing out that her parents had refused a hip surgery that could have greatly reduced or eliminated the physical pain Tracy experienced. Also, they point out that a severely disabled person need not be in emotional pain at their situation, and claim that the emotional pain, if present, is due to societal prejudice rather than the disability, analogous to a black person wanting to die because they have internalized negative stereotypes about being black. Another example of this is Keith McCormick, a New Zealander Paralympian who was "mercy-killed" by his caregiver [23], and Matthew Sutton[24].

With regards to voluntary euthanasia, many people argue that 'equal access' should apply to access to suicide as well, so therefore disabled people who cannot kill themselves should have access to voluntary euthanasia.

Others respond to this argument by pointing out that if a nondisabled person attempts suicide, all measures possible are taken to save their lives. Suicidal people are often given involuntary medical treatment so that they will not die. This argument states that it is due to societal prejudice, namely that disabled people are of lower worth and that any unhappiness must be due to the disability, which results in greater support of voluntary euthanasia by disabled people than suicide by nondisabled people.

 See also

 VIDEOS:

Mercy or Murder?- Holland   http://www.youtube.com/watch?v=Mbh46XzC4-w

Physician Assisted Suicide    http://www.youtube.com/watch?v=Rk3ri1ADIsI

Kevorkian: I Helped Over 130 People Die

http://www.youtube.com/watch?v=EQmyo6EvUY8&feature=channel

Dying Man Opposes Assisted Suicide    http://www.youtube.com/watch?v=5Qr9_hzVfYI

References

  1. ^ a b c d e f g http://www.bartleby.com/65/eu/euthanas.html
  2. ^ a b c d e f g h i j k http://plato.stanford.edu/entries/euthanasia-voluntary/ An overview of voluntary euthanasia
  3. ^ a b c d e http://www.euthanasia.com/historyeuthanasia.html
  4. ^ Cruzan v. Director, Missouri Department of Health
  5. ^ Hippocratic Oath
  6. ^ "Terminally ill patients often fear being a burden to others and may feel they ought to request euthanasia to relieve their relatives from distress." letter to the editor of the Financial Times by Dr David Jeffrey, published 11 Jan 2003.
  7. ^ "If euthanasia became socially acceptable, the sick would no longer be able to trust either doctors or their relatives: many of those earnestly counselling a painless, 'dignified' death would be doing so mainly on financial grounds. Euthanasia would become a euphemism for assisted murder." FT WEEKEND - THE FRONT LINE: Don't take liberties with the right to die by Michael Prowse, Financial Times, 4th Jan 2003
  8. ^ Burdette, Amy M; Hill, Terrence D; Moulton, Benjamin E. Religion and Attitudes toward Physician-Assisted Suicide and Terminal Palliative Care. Journal for the Scientific Study of Religion, 2005, 44, 1, Mar, 79-93.
  9. ^ Thanissaro Bhikkhu, "Buddhist Monastic Code I: Chapter 4"
  10. ^ Werth Jr., James L.; Blevins, Dean; Toussaint, Karine L.; Durham, Martha R. The influence of cultural diversity on end-of-life care and decisions. The American Behavioral Scientist; Oct 2002; 46, 2; pg 204-219.
  11. ^ Jennings, Patricia K.,Talley, Clarence R.. A Good Death?: White Privilege and Public Opinion. Race, Gender, & Class. New Orleans: Jul 31, 2003. Vol. 10, Iss. 3; pg. 42.
  12. ^ Werth Jr., James L.; Blevins, Dean; Toussaint, Karine L.; Durham, Martha R. The influence of cultural diversity on end-of-life care and decisions. The American Behavioral Scientist; Oct 2002; 46, 2; pg 204-219
  13. ^ Jennings, Patricia K.,Talley, Clarence R.. A Good Death?: White Privilege and Public Opinion. Race, Gender, & Class. New Orleans: Jul 31, 2003. Vol. 10, Iss. 3; pg. 42.
  14. ^ Moore, D. (2005 May 17). “Three in Four Americans Support Euthanasia.” The Gallup Organization.
  15. ^ Jennings, Patricia K.,Talley, Clarence R.. A Good Death?: White Privilege and Public Opinion. Race, Gender, & Class. New Orleans: Jul 31, 2003. Vol. 10, Iss. 3; pg. 42. the public opinion
  16. ^ Carroll, Joseph (2006, June 19). Public Continues to Support Right-to-Die for Terminally Ill Patients. Retrieved on January 16, 2007, from The Gallup Poll Web site: http://www.galluppoll.com/content/?ci=23356&pg=1
  17. ^ discussion of euthanasia on the site of the Dutch ministry of Health, Welfare and Sports
  18. ^ Templeton, Sarah-Kate. "Doctors: let us kill disabled babies". Retrieved on 2007-02-05.
  19. ^ a b c Seale C. Characteristics of end-of-life decisions: survey of UK medical practitioners. Palliative Medicine 2006; 20(7): 653-9.
  20. ^ Survey. Association of Palliative Medicine, 2006.
  21. ^ http://www.smh.com.au/articles/2003/01/10/1041990085855.html
  22. ^ http://www.wweek.com/html/euthanasics.html
  23. ^ http://www.nzherald.co.nz/search/story.cfm?storyid=0002EB73-8358-1464-B02B83027AF1010E
  24. ^ http://www.abc.net.au/news/newsitems/200704/s1889400.htm

External links

 Neutral

Support

 Opposition

Wikipedia  Document License Information: http://en.wikipedia.org/wiki/Wikipedia:Text_of_the_GNU_Free_Documentation_License

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Summary by James Rowe, QCC, 2005

Dutch Euthanasia: 

            The Dutch Parliament passed a law in 2000 which established the rules to allow physicians to assist in the suicide of those who are terminally kill without risking any criminal prosecution, a practice which has been routinely performed in the Netherlands for 15 years antecedent to the law passing. In 1993, an act from the Dutch parliament upheld the illegality of assisting in the suicide of a patient or ending his life, but physicians would not be charged so long as they followed the law.

            The specifics of the 200 law require the physician to adhere to a checklist to avoid persecution, which is summarized as followed: 

  1. Patient initiated request.
  2. Patient competence.
  3. Patient understanding
  4. Informed to alternatives
  5. Enduring decision
  6. Unbearable suffering
  7. Professional consultation
  8. Medically appropriate
  9. Government report.

To further protect the doctor, the patient must sign before witnesses an explicit authorization for acts to be performed. Minors were later excluded from the law, but initially allowed. The law also allows any doctor to refuse to perform euthanasia.

            Statistics taken by the Dutch government show that in 1990, 2300 deaths by voluntary euthanasia and 400 cases of assisted suicide, representing two percent of all the deaths in the Netherlands, occurred that year, and although 9000 requests for euthanasia were made, the majority of such were denied. Moreover, from 1990 through 1995, although euthanasia cases rose from 1.8 percent to 2.4 percent of the total deaths in the Netherlands, assisted suicide rates remained the state. Preliminary reports also indicate that 2215 patients were given physician assistance in the matter of their deaths in 1999, although it is thought that the number likely hovers near 5000, for it is held as a truth that only half of physician-assisted suicides are report, with 9 out of 10 of all cases being related to the final stages of cancer. Physicians, however, remain reluctant in its practice, with surveys showing that almost two thirds of people who petition physicians to end their life are turned down. Public opinion in 2000 revealed that about only ten percent of the Dutch people and 10 percent of Dutch physicians are vehemently against the legalization.

             Problems in the law surround whether or not prior decisions might be overturn by subsequent development of mental illness, but aside from this, the Dutch model is considered ideal, and would likely be modeled after should the United States ever legalize the practice. Significant differences, however, do exist in the medical culture of the United States and the Netherlands, with the Dutch citizenry enjoying almost universal participation in health plans that cover the costs of medical procedures, which is not the case in the United States, which could place financial concerns over the desire for life. Moreover, the Dutch practice does not cover comatose patients, but only those competent to make their own decisions. If nothing else, however, the model that the Netherlands has produced might well serve to demonstrate whether the fears of those against euthanasia, as regards abuse and corruption, are warranted, although even then the matter is likely to remain disputed, as is often the case in the battlegrounds of medical ethics.

Dutch Experience- 1993 Rules to allow physicians to assist or to kill people at their request

28 point check list

1990     2300 deaths that were voluntary and 400 assisted suicides

1. Patient-initiated request

2. Patient Competence

3. Informed about alternatives

4. Enduring Decision

5. Unbearable Suffering

6. Professional Consultation

7. Government Report

8. Signed and Witnessed Authorization

Suppose you’re a doctor and one day, a man enters your office with the assistance of presumably a relative, and tells you quite simply that he wants to die. He is in horrible pain 24/7, he’s handicapped in five different ways, and he can hardly even blink without nearly crying out in agony. His disease is incurable and he may live quite a long time in this horrible state of affairs and simply no longer wishes to endure it. What do you do?  

This is the contentious issue of the Right to Death which covers two related things, namely: 

  1. Physician-Assisted Suicide – This is where a doctor helps the person he is treating commit suicide, but does not actually cause the act of death. Dr. Jack Kevorkian employed this method throughout most of his career.
  2. Euthanasia – Usually owing to the inability of the person to kill themselves, the doctor acts in their place of the person and provides the death directly, through means such as lethal injection.

Ethical Theory Answers to the Right to Death - 

Natural Law under Catholicism: The Catholic Church rejects the Right to Death fully. 

Non-Rule Utilitarianism: The greater happiness would seem to rest in the relieving of suffering, as well as liberating others from the financial burden, both as regards the state and the family

Rule Utilitarianism: Similar to non-rule Utilitarianism, save it must address the matter as to when the rule should go into effect. Rational beings tend to differ on the matter of when life is worthy of being given up, if ever.  

Egoism: Simply, whatever satisfies the individual would be the proper choice. 

Kantian Categorical Imperative: Kantian ethics is somewhat split on the issue, with some arguments based on dignity and what a rational being would want, but all the formulations of the Categorical Imperative (http://en.wikipedia.org/wiki/Categorical_Imperative) seem to indicate that one could not rationally decide death over life.  

Rawl’s Theory of Justice: If one is to assume that the right to end one’s life is given to the majority of people, under the Theory of Justice, to right the inequality, to medically assist the person to end their life, either directly or indirectly, would be justified. 

Will to Power: The embrace of death may be considered a symptom of Nihilism which, as Nietzsche’s arch-nemesis, is essentially incompatible with his theory of the Will to Power. 

Virtue Ethics: As the focus is on building moral character by participation in what is deemed virtuous behaviours, such as justice, courage, et cetera, the question at hand is what promotes a virtuous character? Now, since life is not considered sacred in and of itself in virtue ethics, such as in the case where courage for a proper cause is deemed morally imperative, Virtue Ethics cannot denounce the Right to Death fully. If one were to employ Aristotle’s principle of the Golden Mean, one may view the extremes of life as an unnatural and nihilistic love for death, or a lust for life that does not consider the virtues as important, such as those who would degrade themselves through slavish and base actions in order to save themselves with no sense of shame, and thus the Golden Mean would be a character who whilst not clinging to either life or death, seeks the rational, well thought-out,  proper medium which sees death as a necessity sometime, life at another. Whether the desire for death due to pain, no matter how extreme, is part of the Golden Mean or the harmful extremes is a matter of dispute. 

Those Without the Capacity to Choose: 

Another major issue of contention is how one is to deal with those incapable of making their own decision, such as the comatose, or the severely retarded? What degree of medical help should be given to these people? Unlike in the case of physician assisted suicide or euthanasia, it may not be clear what this person would want to be done with them, confounding the issue with the problem of autonomy. Can we suppose to know what is better for another? Do personal prejudices influence our thought? These and other questions are fervently debated.

http://en.wikipedia.org/wiki/Terry_Schiavo - The most famous recent case revolving around this contentious issue.

 Conclusion: 

As is always the case in medical ethics, a simple answer is not available, and no more is this exemplified than in the matter of Right to Death related issues, specifically as these deal with the irreversible decision of death and crucial matters such as the sovereignty of the individual. With legal battles popping up every day, and only a few countries so far admitting euthanasia and/or assisted suicide as a possibility, it is no doubt to be one of the major issues of 21st century medical ethics, as it was the latter half of the 20th.

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© Copyright Philip A. Pecorino 2002. All Rights reserved.

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