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The Arguments for Euthanasia: a Critical Analysis

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Published: Sep 7, 2023

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Introduction, autonomy and self-determination: a fundamental right, relief of suffering: a compassionate response, protection of personal choice: preserving individual freedom.

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We have a right to die with dignity. The medical profession has a duty to assist

Distinguished Professor of Philosophy and Director: Centre for Applied Ethics, Stellenbosch University

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Anton van Niekerk is director of the Centre for Applied Ethics and Head of the Unit for Bioethics in that Centre. The Unit receives an annual contribution from Mediclinic, but that is not for the exclusive use of Anton van Niekerk.

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Euthanasia represents one of the oldest issues in medical ethics. It is forbidden in the original Hippocratic Oath, and has consistently been opposed by most religious traditions since antiquity – other than, incidentally, abortion, which has only been formally banned by the Catholic Church since the middle of the 19th century.

Euthanasia is a wide topic with many dimensions. I will limit myself in this article to the issue of assisted death, which seems to me to be one of the most pressing issues of our time.

Desmond Tutu, emeritus archbishop of Cape Town, raised it again on his 85th birthday in an article in the Washington Post. He wrote:

I have prepared for my death and have made it clear that I do not wish to be kept alive at all costs. I hope I am treated with compassion and allowed to pass onto the next phase of life’s journey in the manner of my choice.

Assisted death can take the form of physician assisted suicide (PAS) . Here a suffering and terminal patient is assisted by a physician to gain access to a lethal substance which the patient himself or herself takes or administers. If incapable of doing so, the physician – on request of the patient – administers the lethal substance which terminates the patient’s life.

The latter procedure is also referred to as “voluntary active euthanasia” (VAE). I will not deal with the issue of involuntary euthanasia –where the suffering patient’s life is terminated without their explicit consent -– a procedure which, to my mind, is ethically much more problematic.

Passive form of euthanasia

The term “voluntary active euthanasia” suggests that there also is a passive form of euthanasia. It is passive in the sense that nothing is “actively” done to kill the patient, but that nothing is done to deter the process of dying either, and that the termination of life-support which is clearly futile, is permitted.

However, the moral significance of the distinction between “active” and “passive” euthanasia is increasingly questioned by ethicists. The reason simply is the credibility of arguing that administering a lethal agent is “active”, but terminating life support (for example switching off a ventilator) is “passive”. Both clearly are observable and describable actions, and both are the direct causes of the patient’s death.

There are a number of reasons for the opposition to physician assisted suicide or voluntary active euthanasia. The value bestowed on human life in all religious traditions and almost all cultures, such as the prohibition on murder is so pervasive that it is an element of common, and not statutory, law.

Objections from the medical profession to being seen or utilised as “killers” rather than saviours of human life, as well as the sometimes well-founded fear of the possible abuse of physician assisted suicide or voluntary active euthanasia, is a further reason. The main victims of such possible abuse could well be the most vulnerable and indigent members of society: the poor, the disabled and the like. Those who cannot pay for prolonged accommodation in expensive health care facilities and intensive care units.

Death with dignity

In support of physician assisted suicide or voluntary active euthanasia, the argument is often made that, as people have the right to live with dignity, they also have the right to die with dignity. Some medical conditions are simply so painful and unnecessarily prolonged that the capability of the medical profession to alleviate suffering by means of palliative care is surpassed.

Intractable terminal suffering robs the victims of most of their dignity. In addition, medical science and practice is currently capable of an unprecedented prolongation of human life. It can be a prolongation that too often results in a concomitant prolongation of unnecessary and pointless suffering.

Enormous pressure is placed upon both families and the health care system to spend time and very costly resources on patients that have little or no chance of recovery and are irrevocably destined to die. It is, so the argument goes, not inhumane or irreverent to assist such patients – particularly if they clearly and repeatedly so request – to bring their lives to an end.

I am personally much more in favour of the pro-PAS and pro-VAE positions, although the arguments against do raise issues that need to be addressed. Most of those issues (for example the danger of the exploitation of vulnerable patients) I believe, can be satisfactorily dealt with by regulation.

Argument in favour of assisted suicide

The most compelling argument in favour of physician assisted suicide or voluntary active euthanasia is the argument in support of committing suicide in a democracy. The right to commit suicide is, as far as I am concerned, simply one of the prices we have to be willing to pay as citizens of a democracy.

We do not have the right, and we play no discernible role, in coming into existence. But we do have the right to decide how long we remain in existence. The fact that we have the right to suicide, does not mean that it is always (morally) right to execute that right.

It is hard to deny the right of an 85-year-old with terminal cancer of the pancreas and almost no family and friends left, to commit suicide or ask for assisted death. In this case, he or she both has the right, and will be in the right if exercising that right.

Compare that with the situation of a 40-year-old man, a husband and father of three young children, who has embezzled company funds and now has to face the music in court. He, also, has the right to commit suicide. But, I would argue, it would not be morally right for him to do so, given the dire consequences for his family. To have a right, does not imply that it is always right to execute that right.

My argument in favour of physician assisted suicide or voluntary active euthanasia is thus grounded in the right to suicide, which I think is fundamental to a democracy.

Take the case of a competent person who is terminally ill, who will die within the next six months and has no prospect of relief or cure. This person suffers intolerably and/or intractably, often because of an irreversible dependence on life-support. This patient repeatedly, say at least twice a week, requests that his/her life be terminated. I am convinced that to perform physician assisted suicide or voluntary active euthanasia in this situation is not only the humane and respectful, but the morally justified way to go.

The primary task of the medical profession is not to prolong life or to promote health, but to relieve suffering. We have a right to die with dignity, and the medical profession has a duty to assist in that regard.

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How To Write A Vivid Euthanasia Argumentative Essay?

Table of Contents

Euthanasia (good death from Greek) is the practice of intentional life ending aiming to relieve patients’ pain and suffering. The topic of its use is fiercely debated all over the world.

People have divided into two camps: some say Euthanasia is the matter of choice, even when it comes to choosing death. Another group claims that doctors mustn’t be empowered to offer death to people who may not even realize the decision they make.

Every country where Euthanasia is legal has its own specific legislative base of its use. Nevertheless, there is one aspect of this topic that unites all the people together: the issue is considered from the moral and ethical perspective.

Euthanasia argumentative essay: the basics

The topics for an argumentative essay writing are usually two-sided: voting for or against the topic, agree or disagree with the statement, choose one option or another.

Writing any argumentative assay requires highlighting both possible points of view, no matter what is your own. Remember, you should explain both sides equally correct and impartial.

So let’s take a closer look into the details…

How to write a Euthanasia thesis statement?

Before writing an essay on Euthanasia you have to think about your own attitude towards the topic. It will help you write a good thesis statement.

…Why you need it?

The thesis is the representation of the essay’s main idea. You’ll have to clarify both sides of the topic, sure. Still, you also need to express your own point of view. And that is made with the thesis statement in the first place.

You may clearly state your opinion in the thesis, like:

“Injecting a medication to a hopeless patient is a murder.”

“Taking life from a person who wants to end up sufferings is mercy.”

Also, you can try to intrigue your readers and present your thesis as a question with no answer provided right away. Like:

“Helping people die: is it murder or mercy?”

“Would you personally use your right for euthanasia if there was no chance to get better?”

Variations are welcomed.

Euthanasia essay introduction: general recommendations

Most professional essay writing services agree that writing an introduction is always the hardest thing. You get the fear of the blank paper, writer’s block, and the stress from remembering all the requirements you should ideally follow.

… Sounds familiar?

There are no reasons to be that stressed, actually. The web is full of info, interesting statistics, law variations, and personal stories.

A combination of those would be both, catchy and informative, that’s all you need for a perfect intro.

Start with some background information to help your reader understand the subject better.

What kind of info would be relevant?

• A brief definition of Euthanasia.
• When it might be allowed.
• Laws of the countries where it is permitted.
• Personal stories of friends/relatives.
• Stories of doctors and nurses.

All of that can be easily found online. Your goal here would rewrite it in your style, make it appealing to read and combined logically. End your introduction with the thesis statement. You already know how it’s done.

Specifics of Euthanasia essay main body

The main body for an argumentative essay should consist of two parts, one for each point of view. Once you express your point of view in the introduction, then it would be logical to start the main body from it.

Still, it is far from being obligatory. You may start with whatever you find more comfortable.

Like, f.e., you decide to start by talking about the positive aspects of Euthanasia. List the statements using words “firstly,” “secondly,” “moreover,” etc. Begin with the weakest argument and move up to the most solid one you have.

Provide the reader with some positive examples, including personal stories, if they fit in, try to find shreds of evidence of euthanasia practice in your country.

Here are some ideas for statements in favor of Euthanasia:

• A patient’s life can be worse than death.
• It is better to die from Euthanasia than from suicide.
• Euthanasia can help in saving budget funds. Saved money may help somebody else.
• Some people don’t want to see how their relatives suffer hopelessly.
• Death from Euthanasia can be more humane than natural.

Once you finish with the arguments for the first part, go on representing the opposite point of view. A good idea to begin the second paragraph with phrases like “on the other hand,” “the other side of the coin is,” “however,” etc.

List a couple of statements against Euthanasia. You may also search for some scandals including the illegal activity of doctors who made such decision without consulting the patient’s relatives.

Here are several ideas that might be helpful.

• Life is the primary integral right and can’t be taken away.
• If there are many organizations and measures to prevent suicides, why should we offer death to someone?
• Each aspect of Euthanasia can’t be foreseen in the law.
• It’s impossible to define who may/may not be offered the Euthanasia.
• What if the person who chose Euthanasia could recover and live the life to its fullest?

What to write in Euthanasia essay conclusion?

In conclusion, you sum up all the ideas highlighted in your essay, without adding new ones. Start with phrases like “to sum up,” “to conclude,” “in conclusion,” “on balance,” “in a nutshell,” etc.

Here you should also express your point of view and paraphrase the thesis you used in the introduction. For uttering your point, use inputs like “my point of view is,” “I strongly believe,” “I am convinced,” “to tell you the truth,” and so on.

How to create a Euthanasia essay outline?

An outline is a brief sketch of your essay. If you need to write it, select the main ideas of your work and write them down in a couple of sentences.

The sketch outline for an essay on Euthanasia may be like:

“Th work is about the problem of Euthanasia. I highlight some statements for and against the use of Euthanasia and support them with top examples. In conclusion, I explain my personal position on this question.”

The full version of an outline would look something like this…

Introduction

• Hook sentence
• Thesis statement
• Transition to Main Body
• History of Euthanasia
• Euthanasia statistics in countries where it is legal
• Impact of legal Euthanasia on people’s life
• Negative consequences of illegal Euthanasia
• Transition to Conclusion
• Unexpected twist or a final argument
• Food for thought

The use of Euthanasia argumentative essay example

This topic is pretty vast. It can be both good and bad for you. Due to the variety of topics within the issue of Euthanasia, it might be easy to find something you are genuinely interested in.

On the other hand, there are dozens of various materials, thousands of articles, and billions of opinions you should consider before writing. Sometimes it might be difficult for you to get a full picture.

Therefore, a sample of the essay on this topic is presented here. It follows all the standards of an argumentative essay and shows you how this type of work may be completed.

On balance…

I’d say that it’s great to work with such an ambiguous topic. You’ll definitely benefit from training your persuasive and analytical skills while working on this essay.

Hope you’ve found some inspiration here, good luck!

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Structuring of an argumentative essay on euthanasia

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Euthanasia and assisted dying: the illusion of autonomy—an essay by Ole Hartling

Read our coverage of the assisted dying debate.

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As a medical doctor I have, with some worry, followed the assisted dying debate that regularly hits headlines in many parts of the world. The main arguments for legalisation are respecting self-determination and alleviating suffering. Since those arguments appear self-evident, my book Euthanasia and the Ethics of a Doctor’s Decisions—An Argument Against Assisted Dying 1 aimed to contribute to the international debate on this matter.

I found it worthwhile to look into the arguments for legalisation more closely, with the hope of sowing a little doubt in the minds of those who exhibit absolute certainty in the matter. This essay focuses on one point: the concept of “autonomy.”

(While there are several definitions of voluntary, involuntary, and non-voluntary euthanasia as well as assisted dying, assisted suicide, and physician assisted suicide, for the purposes of brevity in this essay, I use “assisted dying” throughout.)

Currently, in richer countries, arguments for legalising assisted dying frequently refer to the right to self-determination—or autonomy and free will. Our ability to self-determine seems to be unlimited and our right to it inviolable. The public’s response to opinion poll questions on voluntary euthanasia show that people can scarcely imagine not being able to make up their own minds, nor can they imagine not having the choice. Moreover, a healthy person answering a poll may have difficulty imagining being in a predicament where they simply would not wish to be given the choice.

I question whether self-determination is genuinely possible when choosing your own death. In my book, I explain that the choice will always be made in the context of a non-autonomous assessment of your quality of life—that is, an assessment outside your control. 1

All essential decisions that we make are made in relation to other people. Our decisions are affected by other people, and …

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Home > Books > Euthanasia - The "Good Death" Controversy in Humans and Animals

Everything Under Control: How and When to Die - A Critical Analysis of the Arguments for Euthanasia

Submitted: 26 October 2010 Published: 15 September 2011

DOI: 10.5772/18271

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Euthanasia - The "Good Death" Controversy in Humans and Animals

Edited by Josef Kuře

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Josef kuře *.

• University Centre for Bioethics & Department of Medical Ethics, Masaryk University, Brno, Czech Republic

*Address all correspondence to:

1. Introduction

The proposed title for this article was originally “Euthanasia pro et contra: Analytical synopsis of argumentations for and against euthanasia”. Its aim was to provide a synoptic and comparative analysis of both types of arguments used for support or refusal of euthanasia. However it soon became clear that such an approach transcends the format of one book chapter. So instead of a very short analysis of all arguments for and against euthanasia, only five leading arguments for euthanasia have been critically scrutinized.

The debates about both the morality and legality of euthanasia have been a significant phenomenon of the last decades of the twentieth century and one can expect that they will remain a source of powerful controversies well into the twenty first century. Within these debates, euthanasia is often replaced by “(physician-)assisted dying” ( Quill & Battin, 2004 ; Young, 2007 ), or extended to an “assisted death” ( Lewis, 2007 ; Lewy, 2011 ), a broad term under which both euthanasia and assisted suicide are subsumed. The general term “assisted death” is not understood as euthanasia in the sense used both by legislation in the countries in which euthanasia has been legalized and by its debaters who use this quite precise notion of euthanasia. Finally the term “assisted death” is not conceived in the sense as the term “euthanasia” as being used in this article. The use of the broad notion of euthanasia leads to the fact that many diverse situations are discussed under the term “euthanasia”. So John Keown identifies the problem when he notes that “much of the confusion which besets the contemporary euthanasia debate can be traced to an unfortunate imprecision in definition. Lack of clarity has hitherto helped to ensure that much of the debate has been frustrating and sterile.” ( Keown, 2002 , p. 16). For its similarity with “assisted death”, euthanasia is being frequently discussed within similar but distinct contexts such as assisted suicide, medical futility, life sustaining treatment and (other) end-of-life decisions ( Bauer-Maglin &Perry, 2010 ; Onwuteaka-Philipsen, 2003 ; van der Maas, 1991 ). It is obvious that the decisions in clinical medicine- both in palliative and intensive care- encompass a much broader spectrum than just the issue of euthanasia ( Battin et al., 2007 ; Kinzbrunner & Policzer, 2010 ; Wanzer & Glenmullen, 2007 ; Wennberg, 1989 ). As such, if two people are discussing whether ‘euthanasia’ should be legalized or criminalized and by the same word they understand two quite different things, their discussion will be fruitless and meaningless; they will be addressing each other without being able to reach any common ground, instead developing two distinct monologues.

Although for euthanasia and assisted suicide the same or similar arguments can be used, for the purpose of this book it is held that euthanasia and assisted suicide are two diverse entities –from both a moral and legal point of view ( Watts & Howell, 1992 ; Beech, 1995 ). Consequently in discussions on issues raised by those two concepts, two distinct notions should be used. To this effect, the debates on both assisted suicide and physician assisted suicide and the arguments used in this context will be not included in this chapter. The scope is demarked by the topic “euthanasia”, although the same or similar arguments are used in assisted suicide debates as well.

Despite the fact that in some current debates taking place under the term “euthanasia”, “assisted suicide” is discussed, “euthanasia” in this chapter is semantically understood not as a notion common for both “euthanasia” and “assisted suicide”. The term “euthanasia” within this chapter means that one person brings about the death of another person because the first person believes that the life of the second person, who has asked for euthanasia, is so miserable that it would be better for him/her to be dead. More precisely, A kills B upon the request of B for the sake of B . The motive of A, who commits the act of euthanasia, is to benefit B . In contrast, assisted suicide is basically a suicide: B kills B ; A is solely providing help, not taking the life of B . Albeit the help provided by A is an essential element in the death of B ( B probably would be not able to kill him/her self without this help of A ), B still has the possibility and freedom not to complete the act and not to kill him/her self. B remains the author and originator of his/her act even though his/her free volition may be diminished.

The term “termination of life” (instead of “killing”) has been used as a neutral description, which is open to diverse value-laden interpretations, including “taking life”, “killing” or “homicide”.

The “passive action” of allowing to die can include not only passivity in the sense of diverse avoiding of treatment (e.g. withholding or withdrawing); it can also include “active actions” such as the psychological or spiritual accompaniment of a dying person or the support by those close to the patient.

“Non-voluntary euthanasia” and “involuntary euthanasia” will be included mainly in the role of counter-argumentation.

So within the following analysis of arguments, the focus is on active voluntary euthanasia. All sub-forms such as euthanasia of minors (e.g. terminal stage of cancer in small children) or euthanasia of (extremely immature) newborn children with abnormalities has naturally to be discussed, however some of the arguments would have a different and modified form, taking into account the particular context (e.g. parents as decision-makers), but maintaining a certain congruence. A distinct argumentative framework would be appropriate for involuntary euthanasia, also for killing a person despite an explicit expression of his/her opposition towards euthanasia. Such a framework is not elaborated in this chapter.

Beauchamp, 1996 ; Behnke & Bok 1975 ; Bernards, 1989 ; Biggar, 2004 ; Brody, 1989 ; Cohen-Almagor, 2001 ; Dworkin, 1993 ; Dworkin et al. 1998 ; Engdahl, 2007 ; Gentles, 1995 ; Grisez & Boyle, 1979 ; Harris, 2005 ; Keown, 1995 , 2002 ; Leone, 1999 ; Medina, 2005 ; Moreno, 1995 ; Morgan, 1996 ; Oosthuizen et al., 1978 ; Rachels, 1986 ; Roberts & Gorman, 1996 ; Snyder 2006 ; Torr, 2000 ; Wekesser, 1995 ; Young, 2007a .

Various numbers of arguments for and against euthanasia are listed within current literature. Similarly, different categories of arguments are used in euthanasia debates - for instance arguments based on rights, philosophical arguments (the universality of moral rules vs. tolerable exceptions), practical approaches (regulation of euthanasia by law) or religious belief (only God can give and take life). It is practically impossible to list the arguments for euthanasia as pure arguments for euthanasia, while at the same time giving another inventory of arguments against euthanasia, as if both lists were mutually exclusive and reciprocally independent. The opposite is true. Many of the pro arguments can simultaneously be contra arguments and vice versa. So the resultant categorization of arguments derives from the precondition that the individual arguments can be assigned as to their prevalent use as arguments for (e.g. autonomy) or as arguments against (e.g. slippery slope). It has to be noted that some other arguments are so truly “ambidextrous” i.e. the base of the same argument can be used both for and against euthanasia, that assigning them according one camp is fleeting at best. Some aspects of the arguments can be utilized or even manipulated in different ways or have an inverse complement in the form of counterargument - for example autonomy as one of the primary arguments for euthanasia can be challenged by one of the serious counter-arguments, namely that of competence (to which extent a terminally ill or unbearably suffering person is competent to make an autonomous choice).

• For purposes of this study, only the first five leading for arguments have been examined.

Synopsis of arguments for and against euthanasia

Some of the arguments complement each other (e.g. autonomy and competence). Other arguments, located on the same line, illustrate the respective sides of a viewpoint. The added value of such a matrix is the emphasis on complexity. In euthanasia debates, arguments usually have an either/or, either for or against structure. This matrix seeks to “interweave” diverse arguments, putting them into a fabric of dualities. For instance, proponents would argue for the decriminalization of euthanasia in the following way: let us regulate what is being done anyway, regulated euthanasia is better then the grey zone in which it is occurring today. But the legalization of euthanasia would also affect the public role of the physician, who would become both healer and killer in the same person, with the potential to put vulnerable patients under social pressure. And these aspects have to be considered as well.

2. The arguments for euthanasia

According to the methodology described above, some of the main arguments for euthanasia will be analyzed. The remaining pro arguments will be scrutinized less intensively. It has to be highlighted that all arguments have their objections and counter-objections; so all of the pro arguments can simultaneously be used as contra arguments. Therefore, while dealing with the objections to the pro arguments, the contra argumentation is in fact scrutinized inherently.

The following structure of analysis of the arguments has been adopted:

Introduction

Description

Contextualization

Presuppositions

2.1. Autonomy

2.1.1. introduction.

Autonomy is frequently given as one of the main arguments for euthanasia ( Achille & Ogloff, 1997 ; Begley, 1998 , 2008 ; Brock, 1992 ; Quill et al., 1997 ; Smith, 1989 ; Tulloch, 2008 ), usually in conjunction with the right to die ( Dworkin, 1993 ; Finkel et al., 1993 ; Ogden, 1994 ; Smook & de Vos-Schippers, 1990 ). As per its proponents‘ arguments, a ban on euthanasia imposes a considerable restriction on the options of an individual to govern his/her life, denying a competent individual’s ability to shape his/her own death. Opponents‘ arguments are based on different interpretations of autonomy and its role in the life of individuals: self-determination regarding one’s own death (euthanasia) would be a false autonomy. Other opponents argue that the positive principle of autonomy (and self-determination) cannot outweigh the prohibitive (and therefore negative) principle of not killing. The essence of the euthanasia controversy is the tension between the values of life and individual liberty.

2.1.2. Description

Autonomy is certainly one of the essential values of Western societies and is therefore worthy of protection. The autonomy argument states that a person, while asking for euthanasia, expresses his/her personal choice, realizing his/her autonomy. The request for euthanasia is part of the human freedom to terminate one’s own life ( Dworkin, 1993 ; Russell, 1975 ). Thus the euthanasia request of a competent individual is a basic freedom to define the framework and conditions of his/her life, more precisely it is a decision about how that life should be lived and ended. To ask for euthanasia means to end one’s own life in a prearranged way, without loosing control over one’s own process of dying and death. From this point of view, euthanasia is the execution of control over one’s life and death. Therefore euthanasia can and has to be practiced and has to be legalized, because the legalization of euthanasia protects and promotes the autonomy of an individual. Euthanasia not prohibited by law or legislatively decriminalized is an essential element for the execution of autonomy. On the other hand the criminalization of euthanasia results in a restriction of autonomy. The legalization of euthanasia also eliminates unnecessary or inadmissible barriers to the right to die.

This terminology is not usually used in euthanasia debates and it can rightly be criticized. For the purposes of this study, the terms liberal and libertarian have been used instead of saying ‘less liberal’ and ‘more liberal’.

Within the libertarian approach, decriminalization of euthanasia is an imperative of autonomy; euthanasia has to be legal, individuals have the right to request euthanasia, physicians have the duty to administrate euthanasia and in some radical approaches, individuals have not only the freedom but even a moral duty to request euthanasia in situations where the suffering is unbearable, the quality of life too low and dissatisfying and the dignity of person hurt, when in short to die is better than to live. Thus the demand of liberty would predetermine a call for euthanasia. The initiation of the use of force by one individual against another is contradictory to libertarian understanding. The libertarian approach would postulate the suspension of laws banning euthanasia. This radical (ideological) form of duty to request euthanasia (in certain situations) would be close to authoritarian and totalitarian thinking. Ironically, these extreme perspectives on both sides are very close each other.

2.1.3. Contextualization

As a prerequisite to the concept of autonomy one of the central features of liberal political philosophy can be found: a commitment to respect the dignity of persons. This states that it is not sufficient to do good for patients and to forestall their harm. Doing good could endanger their dignity ( Childress, 2000 ). Therefore the primary concern is that the persons are respected in their dignity; dignity is the base for autonomy, or in other words, dignity is expressed in the form of autonomy. From the respect for persons as the first principle, it follows that a person has the right to make his/her own life shorter in order to maintain a certain quality of life (shorter but better), while keeping or protecting dignity. Thus making life shorter is a necessary means of making it better as a whole ( Velleman, 1999 ). James Childress describes this typical feature of Anglo-American thinking in the following way: “Autonomy does not imply that an individual’s life plan is his or her own creation and that it excludes interest in others. The first implication focuses on the source, the second on the object of autonomy. Neither implication holds. Autonomy simply means that a person chooses and acts freely and rationally out of her own life plan, however ill-defined. […] Thus, personal autonomy does not imply an asocial or a historical approach to life plans. It only means that whatever the life plan, and whatever its source, an individual takes it as his own”. ( Childress, 2000 , p. 149). With regard to death and dying, personal autonomy in the form of shaping one’s own life and imparting sense and meaning to it is even more relevant than in everyday life. “The way people die is of great importance to individuals' overall perception and understanding of their existence.” ( The Danish Council of Ethics, 2006 ). We do not have any better alternative to autonomy in Western societies but we have diverse societal and cultural contexts in which autonomy is realized.

2.1.4. Presuppositions

• Autonomy in the continental European tradition can be represented by Immanuel Kant (Grundlegung zur Metaphysik der Sitten). The notion of autonomy in the Anglo-Saxon tradition is based on authors such as Jeremy Bentham, John Start Mill or Isaiah Berlin. For Kant, autonomy is (a freely accepted) commitment to the universal law given by the maxim of the will (autonomy is expressed by the Categorical Imperative). For Kant, autonomy is the highest (and the only acceptable) principle of morality; any heteronymous morality has to be rejected. In contrast, autonomy is for Mill an individual free choice, free from any social or political control or constraint. Autonomy for Mill coincides with liberty and independence (On Liberty). For Mill, autonomy is an issue of (subjective) liberty; for Kant, autonomy is an issue of (objective) reason.

Autonomy follows from liberal theories which put the individual, fundamentally free and rational, into the centre; the individual not state legislation knows better what is good for his/her life. The individual, not state institutions, has to decide in which way to die. The autonomy argument is based on the liberal notion of freedom: as long as one is not causing harm to another he/she can (and has to) exercise his/her freedom. Autonomy in euthanasia debates presupposes the following structure of argument: If an action does not violate the moral rights of another individual and promotes the good of the person concerned, then that action is morally good. Since euthanasia does not violate the moral rights of others and promotes the good of the persons concerned (of everyone involved) euthanasia is morally good. Thus euthanasia is not only an action which could or should be tolerated, it is much more so an action which has to be performed, promoted and protected.

The sense of autonomy comes from the notion of positive freedom. Not only must I not be coerced by someone (negative freedom) but as an individual I want to be my own master: “I wish my life and decisions to depend on myself, not on external forces of whatever kind.” ( Berlin, 1969 , p. 131) Once the right of a person to make his/her life shorter (and better) is recognized, the second presumption consists of being in favour of deferring to an individual’s judgement regarding his/her own good. This presumption means that an individual has the right to life and to die in his/her own way, by his/her own convictions about which life is better for him/her. ( Velleman, 1999 ). In contrast “making someone die in a way that others approve, but he believes to be a horrifying contradiction of his life, is a devastating, odious form of tyranny” ( Dworkin, 1993 , p. 217).

The next condition of autonomy is the freedom to choose between several options for an action. The patient (moral agent) has a preference for performing the elected act ( preference autonomy ). From this point of view euthanasia is a preferred autonomous choice, for instance the patient prefers euthanasia to palliative care and to suffering. The principle of autonomy as a basic faculty of self-determination presupposes that every moral agent is an autonomous agent. This means that not only the patient has his/her autonomy but so does the physician. To be autonomous agents is a precondition for the defence and protection of self-interests. Therewithal the principle of autonomy presupposes more than that an individual is an autonomous agent, but also a rational agent able of decision making and of (moral) action. The autonomy argument assumes that the individual is fully capable of autonomy.

In summary autonomy presupposes capacities such as understanding, reasoning, deliberateness, freedom of choice and self-governance.

2.1.5. Analysis

As has been demonstrated, the core concept of the autonomy argument is based on freedom: one wants to be the author of his/her life, who in turn shapes his/her death and dying, while making an autonomous choice as to how to die (rational self-governance). A request for euthanasia is an expression of the fundamental value to have one’s own life and its circumstances under one’s own control. The contrary would be a fatalistic belief that delegates the right and duty of control over one’s own life and its course to some external power. Some people would argue that to repudiate control over one’s own life is irresponsible, while on the other hand to realize autonomy regarding the final stage of life is regarded as a form of responsibility. A petition for euthanasia would be an act of proper responsibility, being both within the faculty and quality of a person who attempts to influence the design of his/her life by making efforts in accordance with his/her best convictions. In his analysis of the right of self-termination, David Velleman, he himself suffering from cancer, argues that the person living his/her life is therefore the best judge of the value that its continuation would afford him/her — despite the fallibility of his/her judgement. A person’s judgement, being usually more reliable than anyone else’s, and based on his/her values, tends to be self-fulfilling because it can respond to its own set of values. The justification for deferring to a person’s judgment about serving his/her own good goes beyond her reliability as a judge. Respect for a person’s autonomy requires that we defer to the well considered judgment about his/her own good even when we have reason to regard that judgment as erroneous. Thus, if an individual is capable of making the autonomous choice of asking for the termination of life which he/she deems to be not worth living, then he/she has the right to be guided by his/her own judgment. ( Velleman, 1999 ). The question of whether the person asked to provide euthanasia has therefore a duty to conduct euthanasia will be discussed later.

Preference autonomy has been introduced as one of the conditions for autonomy. However many authors argue that preference autonomy is a necessary but not sufficient condition for an autonomous action, emphasizing the relevance of preference building. The preference is very much influenced by society, by its dominant morality and by societal expectations, and by the stage of psychological and moral development of the concrete person. So preference autonomy could easily mislead the real and authentic preference of the person asking for euthanasia. Thus for some authors the determining condition for autonomy is dispositional autonomy : the autonomous agent is able to reflect on his/her preferences, and be able to change his/her first-order preferences ( Holm, 1998 ). “If disposal autonomy requires preferences that are fully self-chosen and authentic in the way described by Camus, Sartre, and other French existentialists, very few persons would ever be autonomous.” ( Holm, 1998 , p. 270) It can also happen that a person is autonomous in one area, while not being autonomous in another area. The autonomous person who has self-governing capacities sometimes fails to govern him/herself due to temporary constrains caused by illness, depression or other conditions that restrict his/her options ( Beauchamp & Childress, 2001 ). Autonomy can also be understood as an ideal, something very important and worthy to possess that however, not everybody achieves in his/her lifetime. In euthanasia debates the autonomy argument is used as a non-idealist moral requirement, rather one based on real situations. So as the decisive criterion for autonomy the following determiner has been proposed: autonomous is a person who is substantially autonomous; then autonomy is understood as substantial autonomy ( Beauchamp & Childress, 2001 , p. 60). Autonomy in these debates is also a faculty of a mature person who has the basic understanding of the circumstances of his/her life, who chooses and acts intentionally and who, free of constrains, is determining his/her life and death.

With regard to some of the psychological concepts of personal development (J. Piaget, E. Erikson, L. Kohlberg), autonomy is taking various faces and roles during one’s life. In relation to developmental psychology, autonomy can also be understood gradualistically: autonomy is something what we progressively acquire, develop and lose. Then the question of to what extent a dying person has real autonomy is reciprocal to the question of to what extent has this person lost his/her autonomy (understood as full autonomy, as dispositional autonomy or as substantial autonomy). Thus any claim of autonomy (autonomous choice) is valid only if the person concerned (patient) still posses the necessary degree of autonomy. In some clinical situations such as a terminal or pre-terminal stage, there is a high probability that the person does not possess full autonomy; the question which has to be clarified is whether there exists a dispositional or substantial autonomy.

• The competence of a dying person would be a part of the counter-argument.

The counter-objection to the objection which states that true autonomy of a dying person is not possible at all or rarely possible is the following: Even if the choices of many persons asking for euthanasia are psychologically and socially shaped and conditioned, they must be respected as real choices. ( Battin, 2003 ).

• The compassion argument is discussed below.
• Social pressure as a negative consequence of legal euthanasia is a strong objection to this argument.

Finally there is a fundamental objection to the autonomy argument: Based on the previous analysis of autonomy in the context of an autonomous request for euthanasia and despite the broad consent that autonomy is an essential value to person‘s life, it is not obvious that legalization of euthanasia would automatically promote the individual’s scope for practising autonomy as authentic self-determination. ( The Danish Council of Ethics, 2006 ).

Therefore, critics would re-qualify autonomy as something that not only has to do with self-conception (as architect of one’s own life) but also with self-identity, interpersonal recognition and the vulnerability of a dying person.

2.1.6. Evaluation

In euthanasia debates, arguments based on autonomy often erroneously presuppose that we all use one and the same concept of autonomy; autonomy in these debates is predominantly identical with autonomy in the sense of Anglo-Saxon liberal political philosophy. However, there is a significant difference between the meaning (and history) of autonomy in moral philosophy and the appropriation of the term in euthanasia debates ( Schneewind, 1998 ). This difference is frequently overlooked in euthanasia debates.

Furthermore, an autonomy argument based on dignity (or related to dignity) implies a diverse notion of dignity (for example dignity characterized by empirical features as it is the case in philosophical Empiricism or dignity as it is understood in philosophical Personalism). Therefore some autonomy arguments are rather collateral discussions than a dia -logical enterprise.

A specific category is built by the arguments based on an ideological concept of autonomy ( Ells, 2001 ). Eventually the relationship between the meaning of autonomy in moral philosophy (ethics) and its usage in euthanasia debates is highly selective and tenuous ( Jennings, 2007 ). The prevalent concept of autonomy used in euthanasia debates is the concept derived from Berlin’s negative liberty: negative liberty here being a necessary condition for autonomy, sometime identified with autonomous action. This approach mirrors the liberal individualistic culture of the Anglo-Saxon world, while relating less to other cultural settings and their respective philosophical traditions. Autonomy, a prerequisite for moral standing and basic moral values, has been criticized in particular by many European and other non-Anglo-Saxon authors, by feminists (e.g. Ethics of Care) and Communitarians. These authors criticize the emphasis on autonomy as a product of American society (different from values such as vulnerability or solidarity, as emphasized in the European tradition), the masculine tradition in moral philosophy, which neglects feminine moral experiences (the fact that less women than men ask for euthanasia) and its stress on atomic individualism (Communitarians).

Respect for the autonomy of the individual has always been given as the principal argument for euthanasia, understood as an active medical intervention to intentionally terminate life at the explicit request of the patient in the Dutch debates ( Gunning, 1991 ; ten Have & Welie, 1992 , ten Have, 2001 ). However, there have been a number of cases occurring without the explicit request of the patient (ten Have, 2001), without respect for the autonomy of the individual. So the theoretical autonomy argument is being invalidated by some instances of practice.

Autonomy indisputably should be considered a necessary but not a sufficient condition for a moral life ( Callahan, 1984 ); what is needed as well is a broader perspective that includes interpersonal relations and interdependence ( Christman & Anderson, 2009 ; Gaylin & Jennings, 2003 ). These aspects are usually neglected in euthanasia debates that adopt autonomy as its main argument.

2.1.7. Conclusion

Despite the fact that no single concept has been more relevant in contemporary bioethics than the concept of autonomy and that the autonomy argument has played a pivotal role as the principal argument for euthanasia, autonomy can be used in euthanasia arguments in both support for and rejection of euthanasia. In this context the competence of the patient requesting euthanasia must be recognised as one of the main counter-arguments.

2.2. The right to die

2.2.1. introduction.

Bernards, 1989 ; Blocher, 1999 ; Cosic, 2003 ; Haley, 1999; Moreno, 1995 ; Ogden, 1994 ; Rebman, 2002 ; Russell, 1975 ; Scherer & Simon, 1999 ; Tada, 1992 ; Uhlman, 1998 .

2.2.2. Description

The usual form of this argument is based on the moral fundament of the right to die ( Feinberg, 1992 ). This moral right can be expressed as the right to control one’s own body and life and consequently to determine at what time, in what way, and with whose help one will die. The other form of the right to die is the right in a legal sense, a right which either exists (or should exist) as a specific right or can be derived from other rights such as from the right to life.

In the debates about the right to die (euthanasia) one important distinction has to be made, namely between the positive and negative right to die (right to self-determination). “A positive right of self-determination implies that a person can demand to have euthanasia carried out, providing the criteria for being able to request euthanasia are otherwise met.” ( The Danish Council of Ethics, 2006 ). Thus the positive right of self-determination implies that there is an objective duty to conduct euthanasia if requested; B requesting euthanasia imposes an obligation to perform euthanasia on A . While a negative right does not imply any entitlement to demand to conduct euthanasia. “Legalization here would merely mean that euthanasia is an action that is not illegal. No one is obliged to comply with the request for euthanasia, but it is legal to carry out euthanasia if the individual meets the qualifying criteria for having euthanasia carried out.” ( The Danish Council of Ethics, 2006 ). There are diverse practical implications if euthanasia is understood as a positive or negative right.

2.2.3. Contextualization

• The key declarations for the furthering of human rights development, which have been the background for euthanasia as the right to die, were The UN Declaration of Human Rights (1948), The European Convention of the Protection of Human Rights and Fundamental Freedoms (1950) and The International Covenants on Economic, Social and Cultural Rights and on Civil and Political Rights (1976).

The “Patient’s Bill of Rights” (which includes the right to reject medical treatment even if such refusal causes death) was adopted by the American Hospital Association in 1973. The American Society for the Right to Die (the former Euthanasia Society of America) has promoted the legalization of a living will (1974) which includes refusal of treatment (called “passive euthanasia”). The Patient Self-Determination Act (1990) has implemented the right to die (refusal of treatment) by legally requiring all health care institutions to provide patients on admission with information regarding their rights to make decisions about medical treatment (to accept it or to refuse it); this right (to die) has been confirmed by the U.S. Supreme Court (1990) based on constitutional liberty rights.

• In this chapter only the right to die in the context of the right to be killed (active voluntary euthanasia) is discussed. The right to die as the right of a competent patient to refuse (futile) medical treatment even if it results in death (letting die) is not covered here as the right to euthanasia. The argumentations about passively hastening death, forgoing life-sustaining treatment as they have been discussed since the Karen Ann Quinlan case (1975), as well as the forgoing of artificial nutrition and hydration and legalisation of physician assisted suicide have not been included. The focus is on actively hastening death by (active) euthanasia.

Two different settings of the right to die can be identified: a moral claim and legal claim. These two settings and two different forms of right are often intermixed in euthanasia debates. Therefore which type of reasoning used should be distinguished in euthanasia debates. There are at least four different types of reasoning based on the right to die: moral reasoning (euthanasia as a moral right), legal reasoning (euthanasia as a legal right), euthanasia as a positive right and euthanasia as a negative right.

2.2.4. Presuppositions

The right to die presupposes that such a right exists and that this right can be exercised by a competent (autonomous) person who is terminally ill or who is suffering unbearably. The basic presumption is that in order to exercise the right, two conditions have to be met: an external and internal one. The first condition lies in the absence of any external pressure on the person exercising this right. The second condition is defined by the lucidity of the person concerned. This internal condition means that the person (patient) is fully competent with a clear intention regarding euthanasia.

The right to die derives from the idea that humans should be as free as possible and as little suppressed as possible; unnecessary restrains on human rights are in principle bad. In contemporary euthanasia debates this link between right and freedom can be found very often, although not always in an explicit way. So the “right” argument and can be transformed into a “freedom” argument (autonomy) and vice versa. It is important to emphasize that one can acknowledge the right to die without necessarily agreeing to its legal codification.

2.2.5. Analysis

Within this chapter, if the right to die has been defined as the justifiable claim of a competent, terminally ill person to avoid excruciating suffering by embracing a timely and dignified death; then euthanasia is a moral right based on ordered liberty.

There are diverse constructions how to derive the right to die (which does not exist as such in the form of a positive law) from the existing legal provisions. Some argue that the fundamental human right to life equally includes the right to die. So the right to die does not have to be created or acknowledged as a specific right. Insofar as human beings have the right to life, which is more than just a right to exist but also covers a minimum quality of life, then he/she has the right to influence the process of dying which, in difference to death, is part of life (active voluntary euthanasia) ( Downing, 1970 ; Downing & Smoker, 1986 ; Wilshaw, 1974 ). Since dying, despite the tabooization of death and dying in our culture, is one of the most significant events in human life, one has the right to make his/her dying as good and meaningful as possible.

Another attempt to deduce the right to die is to derive it from the rights to privacy and freedom of belief. However this deduction, using a specific concept of privacy which also encompasses the right to die as the private issue (under the presupposition that death is inherently a private issue) is more debatable than the deduction of the right to die from the right to life.

Some people deduce the right to die from the worthlessness of life: on the grounds that life is not worth living one has the right to die. Opponents remind that such argument has been used for justification of eugenic euthanasia by the Nazis ( lebensunwertes Leben ). This deduction presupposes that life may be worth living in one case, being worthless in another. This results in the value of life becoming relative, depending on specific situations and changeable factors - as it was in the Nazi period.

From another background comes the utilitarian argument, justifying the abridgement of life (and the dying process as part of life) if the dying process is unpleasant and exceedingly painful. By shortening the dying process then both the unpleasantness and suffering of this process are reduced. In this way the right to shorten one’s own life (dying) is established and justified. The utilitarian argument based on a reduction of unhappiness and suffering is very often used in euthanasia debates – not only to support the right to die (and the right to shorten one’s own dying/life) but also in arguments based on compassion and suffering. The utilitarian argument of a reduction of suffering provides the justification for the right to die. So the right to die is not solely the right of an individual to self-determination but also a right which affects the social benefits of all persons involved (relatives, health care personnel); it also reduces their unhappiness and suffering. Despite its social utilitarianism, the right to die does not imply a physician’s duty to kill the patient. As an individual right the right to die should be exercised solely by its bearer - that is to say by the person requesting euthanasia only. However the right to die (as an individual right) can be converted into a social right which empowers society to reduce unhappiness and suffering by administrating euthanasia without request.

In difference to suicide where a person is killing him/herself, claiming he/she has the right to do so (and he/she certainly has the right to do so in the sense that he/she is at the same time the bearer of such right and the one who is exercising that right), the person who claims the right to be killed as the bearer of such right is not the person who is realizing this right. From this follows that no physician can be forced to administrate euthanasia on a patient who claims the right to be killed since such a claim does not constitute a duty of the physician to realize this specific right that the patient is claiming. If the patient’s right to be killed would be a standard patient’s right within the reciprocity of right and duty framework ( A has a right, B has a duty towards A ), then physicians would have an objective duty to administrate euthanasia in patients who claim this right (or possibly even in patients who do not claim this right but who fulfil the criteria for realization of this right, e.g. intensive suffering, futile clinical prognosis) ( Smith, 2006 ). The only exemption from such an objective duty of the physician would be one of conscientious objection. One should distinguish whether euthanasia as the right to die belongs to the introduced right-duty framework or not. To avoid the right-duty framework some authors suggest distinguishing between rights/liberties and privileges. As such, then the right to die would be a specific form of privilege. A privilege does not imply a duty for anyone else ( Williams, 1977 ).

In some specific areas such as neonatal and child euthanasia, the right to die is especially problematic; as the origin, scope, justification and purpose of parental rights are unclear ( Chervenak, 2006 ; de Vries & Verhagen, 2008 ; Lindemann, 2008 ; Moreno Villares, 2005 ; Schneider, 1988 ; Verhagen & Sauer, 2005 ).

2.2.6. Evaluation

The differentiation between euthanasia as a negative and positive right is crucial:

“If arguing for the legalization of euthanasia as a negative right, the practical implementation of euthanasia will depend on there being some people among those able/entitled to carry out killing on request under such a law who are willing to do so. If arguing for the legalization of euthanasia as a positive right, a legitimate request for euthanasia will result in individuals or institutions being obliged to accommodate that request. But the positive right can be graduated in terms of the authorities or persons in whom that obligation is vested. In one radical variant, it is possible to envisage all doctors being obliged to carry out euthanasia. A less restrictive variant might mean that the health services as such were obliged to arrange for euthanasia to be carried out, while leaving the individual doctor free to choose whether he or she wishes to perform euthanasia. […] A positive right of self-determination regarding euthanasia cannot be introduced without simultaneously acknowledging that, in certain cases provided for in law, society is duty-bound to take the life of a human being. A negative right of self-determination regarding euthanasia, on the other hand, can be introduced on the grounds that euthanasia, under certain circumstances provided for in law, is a matter for the judgement and conscience of the individual. The fundamental difference is that the first form of legalization, more so than the second, turns euthanasia into a communal, general matter, which must be acknowledged by society as a whole as being worthy of aspiring to ethically.” ( The Danish Council of Ethics, 2006 ).

Some authors reject the right to die argument on the grounds of benefit and harm ( Velleman, 1999 ). The common religious counter-argument states that the right to decide when and how to die belongs to God. ( Gill, 1998 ; Larson & Amundsen, 1998 ; Manning, 1998 ). The common secular counter-argument is doubly based on obligation. First the right to die does not imply a legal obligation of another person to conduct euthanasia. Secondly our rights are limited by our obligations. One may have a right to die however one has also obligations to other people such as our partners, family, friends, healthcare professionals ( Finkel et al., 1993 ). The enactment of the right to die (euthanasia) would affect other people so we must consider the consequences such an exercising of the right to die would have on them (grief, sorrow, guilt, anger). The enactment of the right to die could affect the professional integrity of the physician who would conduct euthanasia. All these consequences have to be measured against our right to die and the individual rights have to be balanced against the good/consequences of the community and society in general. ( Sullivan, 2005 ). Regardless of the fact that these consequences might seem to be practical (the dying process of a person suffering extremely has been made easier), one of the negative consequences is the risk of vulnerable persons’ integrity being undermined, whereby the principal argument is switched from one of autonomy and right (voluntary euthanasia) to compassion (possible involuntary euthanasia).

The limitations of the right to die are provided not only by the obligations to society but also by the rights and duties of other persons who are requested to provide euthanasia. There is not an evident moral right to kill a person even upon his/her explicit request. Likewise there is not an objective moral duty to conduct euthanasia upon explicit request. It is obvious that a legal obligation to administrate euthanasia does not exist; the establishment of such a legal obligation would require a substantial transformation of our democratic society, based on fundamental rights and liberties.

2.2.7. Conclusion

The right to die is one of the main arguments for euthanasia. It is closely related to autonomy and to the principle of respect for autonomy. So in some discussions both arguments (right to die and respect for autonomy) are intertwined into the right to autonomy. However, there is no unanimous consent that the right to die exists (that it can be derived from other rights such as from the right to life), and the right to die argument can also be used as an objection to euthanasia, in that this right does not exist. Despite its moral or legal appeal it serves poorly as a medium for debate as common argumentative precepts are difficult to establish.

2.3. Unbearable suffering

2.3.1. introduction.

Unbearable suffering is one of the criteria required by Dutch and Belgian legislation on euthanasia. One would assume that the right to die argument is not a sufficient legal requirement for the decriminalization of euthanasia since there is no broad consent that such right exists or that it can be derived from other rights in a very convincing way. Similarly the autonomy argument alone is not strong enough an argument to justify legal euthanasia. No doubt every competent person has his/her autonomy, however to justify autonomous choice in the case of euthanasia would require some additional conditions. Otherwise any competent person would be able to request euthanasia - regardless of the circumstances they find themselves in - as a legitimate tool to terminate his/her life. The only validator would be a reference to his/her autonomy. So when legislators were specifying some additional conditions under which the autonomous choice could be decriminalized there was the evocative condition “unbearable suffering”, which made sense, as all else being equal, no person in their right mind would prefer to die in a painful way or with immense suffering. So among the circumstances that could lead one to choose death for him/her self and/or for a loved one, unbearable suffering occupies the prime position. The expression “unbearable suffering” clearly states that not every painful process within health care entitles one to ask for euthanasia but only great ongoing pain and suffering which trespass one’s faculty to tolerate it can be a legitimate reason to request euthanasia. Proponents of euthanasia defend the decriminalization of killing on request in well defined situations as a kind of last resort and under serious conditions.

It comes as no surprise that both proponents and opponents of euthanasia agree that the prevention and alleviation of people’s suffering has been one of the noble goals of medicine from ancient times and that compassion is a valued emotion in general and in health care in particular. However, they heartily disagree about the extent to which the means can be justified by the end (alleviation of pain and suffering). ( The Danish Council of Ethics, 2006 ). While proponents argue that the alleviation of terrible suffering in desperate situations justifies killing a person on her request, opponents do not tolerate alleviation of suffering by removal of its cause (a suffering human being), arguing that pain and suffering have to be controlled medically (pain killers, terminal sedation), but not by killing.

2.3.2. Description

The suffering argument can be briefly described in the following way: Once a person is suffering to an extent which is beyond her will and capacity to tolerate such a degree of pain and suffering, having become “unbearable”, than he/she should not have to bear it. Moreover, all medical attempts to relieve this unbearable suffering have been unsuccessful and unsatisfactory to this person. Then the basic rule about impossibilities which do not establish moral commitment would apply: ad impossibilis nemo tenetur (no one is obliged to do what is not possible). Thus, as a last option, it is morally right to help this person not to suffer unbearably and on compassionate grounds to terminate her suffering and life.

2.3.3. Contextualization

With regard to suffering, it is a paradox of contemporary medicine that thanks to powerful technological advances the lives of many people have been saved but an additional suffering of many other people is being produced and prolonged. Despite the fundamental physicians’ obligation to relieve suffering, little attention is explicitly given to the issue of suffering in medical practice; it is not unusual for suffering to occur not only as an implication of disease but as a result of its treatment. ( Cassell, 2004 ).

Suffering is usually associated with pain. However suffering is not identical to pain. Pain, being caused physically (e.g. by injury or metastatic cancer), can be onerously assessed: one cannot see pain, but feel its manifestation. As clinical findings demonstrate, the amount of pain a person reports is not directly related to the degree of disease. There are important psychological factors which help to explain why people perceive, report and give meaning to pain in different ways. Pain, perceived as hurt, is a highly subjective experience, affected by mood, morale and other conditioners. ( Skevington, 2002 ). In spite of the fact that the current pain therapy can provide continuous pain relief up to the very end of life in more than 90% of cases, these new therapeutic tools are not yet widely known and practiced by physicians. In addition, suffering is much more difficult to treat than physical pain. Severe pain can lead to suffering which cannot be easily controlled. Paradoxically a patient whose pain is managed well may still suffer. The suffering, as an individual sensation of discomfort and malaise, may continue for a very long period of time without any specific correlation to the physical pain. Heavy suffering can violate one’s integrity as a person; the self may become unravelled, fragmented, and disintegrated by massive suffering ( Ben Mitchell, 2010 ). There are feelings such as hopelessness, loneliness, alienation, pointlessness or unworthiness which may occur even if pain is being relieved properly, making suffering intolerable and unbearable.

While pain is more related to a physical condition, suffering can be caused by both physical and non-physical factors. There is no consonant approach to pain and suffering. While some authors sharply distinguish suffering from physically caused pain, other authors regard physically caused pain as one of the many forms of suffering. Some people believe that suffering is person-centric ( Cassell, 2004 a). That suffering, dissimilar to the physical symptoms, is a personal phenomenon which cannot be accessed by a third-person view; suffering as the personal (subjective) phenomenon cannot be objectified. Other people believe that suffering has different forms which, in addition, can be objectively described. Since there is no consensus about the nature of suffering, diverse hermeneutics of suffering would have diverse consequences in an assessment of suffering.

Within the biological model, suffering can result from disease; where pain is the source of the suffering. Suffering can also arise from the impact disease is having on the person’s life. This type of the suffering will depend on the attitudes and objectives of the suffering person – to what extent the person is able to modify attitudes and to adjust objectives to the new situation. Finally suffering can also be found on the existential level; some people reduce the existential level to spirituality ( Peck, 1997 ), however it should be noted that not only religious persons have their existential needs- more precisely “non-believers” can have existential questions as well and do not call them “spirituality”.

It is important in arguments based on suffering to distinguish between physical, psychological, social and existential (which includes spiritual) suffering. With regard to unbearable suffering it is important to distinguish if suffering is understood as a personal phenomenon (that only the person concerned is able to determine the level of “unbearable suffering”) or as an objective phenomenon (then “unbearable suffering” can be assessed by external criteria and by other persons). It is important to define “unbearable suffering”. Dutch law states as a criterion merely “unbearable suffering”, while Belgian law holds it to be “unbearable physical or mental suffering”. Besides suffering, similar specifications of other conditions related to suffering but distinct, such as being in a terminal stage of disease are relevant to warranting euthanasia.

2.3.4. Presuppositions

“Suffering as a criterion for access to euthanasia is based on an approach that is taken for granted and regarded as self-evident” ( The Danish Council of Ethics, 2006 ).

2.3.5. Analysis

Suffering can be considered both an objective and subjective phenomenon. However the unbearableness of suffering is rather a personal phenomenon and therefore a subjective criterion. Once the suffering has become “unbearable” for an individual then this suffering is intolerable, insupportable and insufferable and only the suffering person can know at what point or when this state has been realised. No one acting as an external (and “objective”) observer can assign the unbearably suffering person to tolerate such suffering. If we would regard the unbearableness of suffering as an objective criterion then this threshold could only be determined after a palliative care trial or after a committee or inquiry, after which some group would have authority to say “You are entitled to die” or “You are not allowed to die”, which would be in contradiction both to autonomy and the right to die arguments. It seems that the praxis in the Netherlands tends to assume that the unbearableness of suffering is a subjective criterion which is validated by a longstanding declared wish to die rather than by some exact empirical tools. Furthermore it remains unclear if for instance the mental torment as documented in the Dr. Chabot case is included in unbearable suffering ( Sheldon, 1994 ) or if suffering would also cover situations like “tired of life” which can be existential and very afflictive but not necessary qualifying as grounds for a euthanasia request ( Sheldon, 2003 ). Surely it is easier to medically measure pain than suffering. The level of both pain and suffering can be measured – albeit such assessment is problematic if pain is not reduced to the physical entity and if suffering is taken in its complexity – while it can be taken for granted that “unbearable” suffering can be assessed by the individual concerned solely. Even two accounts of very heavy and awful suffering, which according to an external evaluation would be graded as almost the same could be perceived as “unbearable” for one person and as “bearable” by another person.

Proponents of euthanasia argue that unbearable suffering is more that sufficient reason to request euthanasia. Their other supportive arguments are compassion, respect for human dignity, the patient’s best interest, quality of life, autonomy and the right to die.

Opponents of euthanasia refuse the suffering argument as such, saying that suffering, even “unbearable “, is not sufficient grounds for killing a person. Their counter-objections mostly refer to compassion in the sense of psychological support, efficacious relieve of suffering, good palliative care and human proximity; to care in the sense of avoiding alienation, shame, helplessness, emotional and social burdens and dealing with needs, such as worthiness and being treated as a person- not as a non-person or as a no person anymore.

Some authors argue that the desire for euthanasia cannot be interpreted at face value. The meaning of the desire for euthanasia is not related to the reality of physical disintegration or physical and psychological suffering from the effects of disease such as cancer, but includes anxiety, fears, existential concerns and desires for respect, care, and connectedness interpreted within the context of the patients’ whole lived experience. ( Mak & Elvyn, 2005 ).

For some adherents of euthanasia, unbearable suffering is a necessary but not the sufficient condition for a patient’s eligibility to request euthanasia. They argue that unbearable suffering is the minimal requirement and some objective criteria of the patient’s conditions must have been met before the desire to die can be fulfilled. Such additional and more objective criteria, such as being in the terminal stage of an illness, can be medically assessed more exactly than the subjective evaluation of unbearable suffering.

Opponents of euthanasia point out the ambiguity of pain and suffering: “If the pain and suffering are by definition unbearable, then it seems clear enough that the decision to die is not freely chosen but is compelled by the pain. […] Under the conditions of unbearable pain and suffering, then, if the concern of the agent is to alleviate the pain it seems to be a mistake to speak of voluntary choices. The natural conclusion to draw from this is that there can be no such thing as voluntary euthanasia, or, at the very least, that we have no means to ensure that the patient’s request to die was not compelled.” ( Campbell, 1999 , p. 243). Thus in situations where the decision to terminate one’s own life is made while experiencing unbearable suffering, the possibility that such a choice was not made freely has to be taken seriously. Opponents also argue that effective pain control can alleviate the suffering. The counter-objection is focused on the fact that not all pain is manageable in terminally ill patients, stressing the difference between pain and suffering. Suffering is inevitably a solitary condition and always involves self-conflict, since, among others, the meaning is essential to suffering. ( Cassell, 2004 a). In addition, in cases where the disease is progressing and state of health worsening, even the best pain therapy can prove to be unsatisfactory, leaving the person suffering to an intensity that the other person, imagining such suffering, neither has suffered nor could possibly imagine suffering.

Proponents argue that it is more in accordance with human dignity to relieve suffering by termination of life then to incapacitate the patient with high doses of drugs (analgesics and sedatives) and to keep the patient in a state of unconsciousness so that he/she does not have to consciously suffer (palliative sedation, terminal sedation). Then if there is an option between existence with suffering and unconsciousness without suffering, it is more appropriate to choose death instead of continuing such an unconscious existence (or choose life alternating between suffering and sleep). They conclude that such a way of living (caused by medical intervention) is pointless, harmful and inhuman and such “medical suffering” should be avoided.

Some people, with reference to the fact that the full autonomy of a person requesting euthanasia may be doubtful, propose the use of a similar framework as the ones we use in other areas of end-of-life decision making, such as the withholding or withdrawing life support treatment for incompetent patients, in particular in the context where there is doubt as to the genuine autonomous choice of the terminally ill patient. This would involve a cascading process of assessment. Then the first condition would be a clear wish to die expressed in a qualified and authentic way repeatedly. The next condition would be the assessment of the patient’s unbearable suffering as a reason for choosing death. Then the external social controls would apply (medical evaluation done by the therapeutic team, proxy evaluation). When all relevant facts and circumstances are weighted and assessed and all persons involved agree then choosing death at a chosen time is better option than continuing unbearable suffering.

2.3.6. Evaluation

Suffering is an ambiguous phenomenon in our contemporary world. On the one hand there is a strong tendency not only to avoid suffering but also to negate it as such since suffering does not fit into the picture of a young, healthy, wealthy and successful person. In current Western culture, pain and suffering as symptoms of disease and illness, are perceived as contrary to a healthy life, corporeal performance and the cult of youth. On the other hand suffering is glorified by some popular (and in fact unorthodox) versions of Christianity which can be characterized as “dolorous Christianity” (Christ has suffered, therefore you have to suffer; the more you suffer the more you are loved by God). Suffering, denied or glorified, overlooks the positive aspects of suffering as part of our personal development. However it is neither easy nor appropriate to say to the person suffering unbearably, who does not see any sense of such terrible suffering and of her destroyed life, that suffering has its place in the process of personal development. Whatever the case, a lack and/or superficiality of analysis from the patient’s perspective should temper calls to make euthanasia legal ( Mak & Elvyn, 2005 ).

The argument “unbearable suffering” should not be taken in its “simplified version”: they suffer unbearably, therefore let us legalize euthanasia. There are many hidden existential concerns of the terminally ill and horribly suffering patient’s that should be addressed and discussed. And the patient’s personal perspective has to be taken more into account.

Some authors are hesitant to address suffering as a determiner for eligibility to euthanasia as they criticize the medical world’s objectification of patients. They believe our dominant biomedical model should be modified, improved and re-oriented to the patient’s personhood ( Mak & Elvyn, 2005 ). It is not only the patient’s mental competency that is at the stake but also a new professional moral competency of health care personnel; such professional competency, not entirely fitting into the biomedical model, would ensure appropriate existential care, exploring the covert meaning of “a good death” and dealing with the authentic desires of patients rather than mechanically applying arguments of autonomy or suffering. As many studies demonstrate, the desire to die (due to unbearable suffering or due to personal preference not to have to go through the final, painful, hopeless and possibly meaningless passage of own life), in many situations, is not so much a request for death as a request for help ( Lesley, 2006 ).

With regard to the medical practice of euthanasia in the Netherlands, “the ethical justification has been shifting from respect for autonomy to relief of suffering . But this has created a tension within the justificatory strategies regarding euthanasia. The two arguments are mutually exclusive. It only makes sense to talk about respect for autonomy if a physician refrains from making judgements about the patient’s benefits.” ( ten Have, 2001 , p. 477).

Another question which has to be clarified is about “suffering” and “unbearable suffering” as the only criterion for euthanasia (the autonomy argument is very problematic in a situation of terrible suffering). There are two approaches to this question: either unbearable suffering as a purely subjective phenomenon is understood in a broad sense, as any physical, psychological, social or existential suffering, and, once claimed as “unbearable” (and only the patient can decide whether his/her suffering has become unbearable) becomes the necessary and sufficient grounds for euthanasia (and any patient including psychiatric ones would have the right to euthanasia on the grounds of “unbearable suffering”) or “unbearable suffering” is a necessary but not self-standing condition and some additional criteria such as terminal stage illness or consent of all persons concerned would need to apply.

2.3.7. Conclusion

The unbearable suffering argument is based on the patient’s perspective and perception. Many feel that only the patient can assess his/her intolerable suffering. Unbearable suffering is in line with the right to die and with (one of the interpretations of) human dignity to ask for euthanasia in such a humanly devastating situation assessed as unbearable suffering. Regardless of whether one is able to determine where the suffering threshold is, and if that is therefore grounds for euthanasia, the issue of whether it serves as the sole ground for such also serves to divide opinion.

2.4. Compassion

2.4.1. introduction.

While the suffering argument stems from the patient’s perspective, the compassion argument comes from the other person’s perspective. Compassion is a kind of external response to that devastating suffering. One feels morally obliged to help, to relieve such suffering and to save the intolerably suffering person ( Begley, 2008 ).

2.4.2. Description

The compassion argument is usually used in euthanasia debates as “mercy killing”. Under the presupposition that no person should be obliged to endure interminable suffering perceived as pointless, and supposed that the intolerable suffering cannot be relieved by medical tools and the only way to avoid such suffering is by death of the patient, then such a death may be brought about as an act of mercy. ( Battin, 2003 ). From this perspective, euthanasia is not to be applied based on an evaluation of the suffering by a second or third person (in order to determinate if the suffering is unbearable) but about the response of the health care professionals and family members, who draw attention to the suffering person and to the distress and misery of such a situation. As an act of humanity and showing mercy they terminate the life of the suffering person. The counter-argument is based on false interpretation of compassion and mercy: killing is not compassion. To show compassion in such a situation would mean to take care of the suffering person, but not to kill him/her ( Schotsmans & Gastmans, 2009 ).

2.4.3. Contextualization

In animals it would be regarded as inhuman to allow a dog or horse to suffer not just a terminal illness but also conditions such as a broken leg in the wild. As such, one could use animal euthanasia as an argument, making it an a fortiori argument: if we euthanize animals on the grounds of compassion, all the more so we have to act with compassion towards suffering humans by providing a merciful death. As such, euthanasia is an expression of humanity.

2.4.4. Presuppositions

The compassion argument comes from the general belief that the desire to relieve suffering and feeling compassion are highly regarded human values which also include volitional elements. Compassion by definition motivates one to action. Another presupposition is based on the old medical tradition of beneficence. At present the utilitarian arguments similarly presume beneficence as the justification for euthanasia ( Kohl, 1975 ; Rosenblatt, 1992 ). Compassion can also be a condition for legal assisted dying ( Kay, 2006 ).

2.4.5. Analysis

Under the condition that there exist no effective means to relieve (unbearable) suffering, euthanasia may be justified as the only remaining option available, or even required by the principle of beneficence. The commitment to act with regard to the benefit of the patient is still one of the most relevant principles in medical ethics. Thus on such grounds of beneficence physicians would have to ensure that a peaceful and painless death is offered to patients who are suffering while dying in a horrible way. On such grounds physicians may be even obliged to administrate euthanasia due to the virtue of compassion, which seeks beneficence rather than to observe impassively and inactively as a patient dies in a horrible way with his/her painful death prolonged ( Van Zyl, 2000 ). Such an “omission” could be qualified as contrary to basic human values such as sympathy and mercifulness.

The beneficence argument can be reinforced by utilitarianism. The killing of a patient may be contrary to the sanctity of life doctrine but as such is morally good because the consequence of such an action is good: suffering has been eliminated and the death has been achieved in a desirable way (painless and peaceful). Naturally this moral assessment of an action in accordance with its good or bad consequences can be applied not solely to physical pain and suffering but also to mental suffering such as feelings of unworthiness, loss of self-control and self-sufficiency or complete dependence on others for their assistance in daily activities starting with hygiene and food. Utilitarians argue “that frustration of being unable to perform everyday tasks for oneself, and the erosion of dignity as personal and previously private tasks have to be performed by someone else as one reverts to behaviour not experienced since infancy.” ( Draper, 1998 , p. 184). The utilitarian argument of beneficence will be potentiated in situations where no alternative exists to the miserable death the patient is experiencing, when the suffering is ceaseless and increasing by its protraction and death is imminent. Then compassion would override that little of (very miserable) life which is lost by the act of euthanasia. The utilitarian argument of beneficence caused by compassion is an external criterion for euthanasia: the autonomous patient is not making the decision to die but another person, on grounds of sym-pathy (etymologically to suffer with), decides about the death of the suffering patient. By this argument euthanasia of incompetent patients (both of adults and children) can be justified. The common utilitarian argument would not usually justify involuntary euthanasia of a competent person. Once liberty is granted as one of the basic values, then the autonomy of individuals has to be respected. However, once the patient is no longer able to express his/her autonomy and freedom, his/her way of dying can be determined by feelings of compassion. It is very valuable if a person, moved by compassion, is seeking to act and to defeat suffering and if the sense of compassion is not limited to feeling alone. ( Ramsey, 1997 ).

A specific target of the relief of suffering is that of terminal suffering. It could be argued that since virtually all pain can be treated pharmaceutically, compassion is not an applicable issue. However, ‘virtually all’ pain is not ‘all’. Thus some pain and suffering remain to be treated though it cannot be treated medically and the usage of terminal sedation is justified. However terminal sedation as complete sedation is complete obtundation as well (the patient can no longer perceive and communicate) being almost the same as causing death, thus making their use questionable. Some people argue that pain and suffering as part of the dying process can be a valuable, positive and transformative experience leading to personal and spiritual growth. Nevertheless it should be said that there is no guarantee of such a positive, valuable and transformative experience. ( Battin, 2003 ). Moreover experience of such terminal suffering is far more likely to become a very negative, horrifying experience.

2.4.6. Evaluation

Once compassion is taken as the competence which decides for the good of the patient, then the competence of the patient concerned doesn’t necessarily have to be taken into account, thus compassion becomes the normative upon which decisions are made and for the incompetent patient, even in some cases for the competent one, more for the other person’s self-esteem and peace of mind than for the good of the suffering patient, who did not express his/her wish to be terminated. Here the compassion argument is attacked by the slippery slope argument: from autonomous euthanasia to non-autonomous mercy killing. “The ethical acceptability of one person taking the life of another at the latter's request and based on a feeling of compassion will depend, as a minimum, on the situation involved being one of extraordinary suffering and agony that cannot be relieved” ( The Danish Council of Ethics, 2006 ).

The ethical evaluation of compassion directly depends on the understanding of the moral significance of compassion. If compassion is ranked as a primary human virtue then the compassion argument plays a different role in the euthanasia debate than when compassion, with a focus on its unsteady and non-rational nature, is ranked as a secondary moral faculty.

2.4.7. Conclusion

The compassion argument is surrounded by many emotions which place it between compassion as the response to unbearable suffering (only the suffering person can say what suffering is not bearable) and mercy killing based not on the patient’s perspective and request but on the feelings of mercy of the person who is providing a “good death”; the “good death” being interpreted exclusively by that other person.

2.5. Human dignity

2.5.1. introduction.

For the meaning and history of dignity see Meyer, 1995 .

2.5.2. Description

The human dignity argument in euthanasia debates can be articulated in two simple but contradictory theses:

Euthanasia is in line with human dignity.

Euthanasia is a violation of human dignity.

The first thesis supposes that human dignity has to be protected and harm to dignity should be avoided. Since the enormous suffering of a dying person would wound the dignity of that person, it is justified to protect human dignity by the act of euthanasia – either on grounds of autonomy and right to die (voluntary euthanasia) or on grounds of compassion (non-voluntary/involuntary euthanasia).

The second thesis is similarly based on the preservation of human dignity, using a contrary argument: euthanasia is contrary to human dignity; euthanasia cannot be performed because not only the dignity of the person requesting euthanasia would be violated but also the dignity of the person who performs euthanasia (regardless of whether it was requested or not).

2.5.3. Contextualization

Human dignity is usually given as the philosophico-anthropological essence of human rights ( Schachter, 1983 ). Thus one of the goals of human rights is to protect human dignity (respect for the inherent dignity of the human person). Consequently the right to die is not only a positive or negative right of self-determination but also a tool by which human dignity is protected. ( Swarup, 2009 ; Cohen-Almagor, 2001 ). Once a person reaches the conclusion that his/her dignity would be affected by great (or unbearable) suffering and inhumane dying then the person has to take steps to protect his/her human dignity. There are plenty of historical examples of such scenarios starting with Stoa ( autothanatos ), when the person suffering in an indignant way was obliged to avoid or to end such a devaluing and dehumanizing situation by suicide.

This becomes contextualized in the form of medical futility, whereby clinical situations arise in the form of reduced therapy such as withdrawing and withholding life-sustaining treatment or termination of artificial hydration and nutrition and the relevant decision-making processes. It creates a paradigm of medically futile treatment which technically can be administrated and continued but also, from the patient perspective, such reduced treatment is justified by the respect for human dignity: it would be against human dignity (and against the patient’s best interest) to produce suffering and to prolong dying if there is no other perspective than the imminent death of the patient. Since there are areas within medical practice that are already governed by measures for the protection of human dignity (e.g. advance directives) ( Cantor, 1993 ), this protection has to be extended to other areas of end-of-life decisions such as voluntary euthanasia ( Hillyard& Dombrink, 2001 ).

2.5.4. Presuppositions

There are two completely different philosophical presuppositions in euthanasia debates about human dignity which are very rarely revealed and addressed. One presupposition assumes that human dignity is by its nature a changeable faculty which can be developed during the life of human being. Thus human dignity is an empirical entity which can be assessed and measured by external criteria such as level of consciousness. So while for some people human dignity is given by birth (or even before); the newborn child already has its human dignity, other people assume that human dignity has to be acquired in the course of a lifetime (after birth), when the person has developed abilities of perception, awareness, self-interest etc. As an example of this philosophical assumption Peter Singer and his approach can be given. Within this understanding, human dignity is something what we gradually acquire, develop and lose. Thus the human dignity of a terminally ill or terribly suffering person who is devastated by his/her biological and physiological condition is “on retreat” because the person is in the process of loosing his/her dignity or may have lost it to a various extent.

A different presupposition is grounded in the metaphysics of the person, which understands human dignity as a constant entity which human beings possess continuously: to be human means to have human dignity. So dignity does not belong to some aspect of a person but to the person as such, being that which is essential to the person ( Ramsey, 1997 ). In this sense dignity is not what one has (diverse faculties and capacities) but what one is . Human dignity as a whole can be harmed (for instance by killing) but not taken away or lost. Thus both newborn child and dying person have the same human dignity which cannot be diminished or augmented.

2.5.5. Analysis

There is no doubt that as human beings are mortal, everybody wishes for a “death with dignity”. However there are huge controversies about the meaning of dignity and its implication for dying. So for one group, “death with dignity” means legal reform which accommodates active voluntary euthanasia as an appropriate response to a perceived need for the option called “death with dignity” ( Paust, 1995 ). While for the other group, “death with dignity” amalgamates with palliative care, hospice and spiritual care which have to replace the request for euthanasia; death with dignity seems a mutation of the original concept of human dignity and therefore euthanasia being indignant.

For the first group “being dignified is having a sense of the importance of one’s life or achievements and appearing and behaving, before oneself and others, in the light of these. To lack this sense of importance or to fail to (or be unable to) present oneself in accordance with it is undignified. This lack of dignity is properly a humiliating thing for the subject, and connected to lack or loss of self-esteem, or even of the sense of self-worth.” ( Ramsey, 1997 , p. 48). Then to live such a diminished life or to suffer such diminishment or impoverishment is sufficient to conclude that such life ought to be ended ( Quill, 1993 ; Ramsey, 1997 ). Thus personal dignity is part of personal liberty which includes the ability to choose to die more or less quickly; dignity and self-determination are virtually interchangeable. It is matter of personal dignity to decide the time and way of one’s death. As a supportive argument, quality of life is used: if the person decides that the quality of his/her life is too low and not acceptable to him/her then he/she has the right to choose death while one’s dignity is still (relatively) intact. Some argue that dignity, being complex and unique to each person, includes not only physical and physiological aspects, but also emotional, intellectual, spiritual and existential ones ( Quill, 1993 ).

For the second group, dignity belongs to human nature: we posses it in the mode which is not limited and therefore dignity cannot be denied or damaged. They argue that the (rational) nature of humankind cannot be attacked as such, only some aspect can be hidden: an incurable disease affects one’s life but not one’s nature. Dignity to them consists of the intrinsic worth of human nature ( Ramsey, 1997 ). So despite pain and heavy suffering, there is dignity in such a case; human dignity cannot be undermined. It is obvious that such a hermeneutic of dignity is based on certain metaphysical presumptions which can be taken as granted or refused as false.

From a clinical point of view, contemporary medicine can impose medical technology on a dying person to the extent to which it can be seen as incompatible with and contradictory to human dignity. This has been recently described by an Iranian neurosurgeon in the following way: “Rob a human being of his dignity and you have robbed him of the essence of being human. Confine him, immobilize him, make him dependant, deprive him of hope and then inflict pain upon him and you have all the ingredients of the highest form of torture.” ( Nayernouri, 2011 , p. 55)

2.5.6. Evaluation

On one hand a patient’s choices, limited by existing legal constrains which do not allow a physician to comply with the patient’s request for euthanasia as a deliberately hastened death, result in a violation and/or loss of dignity. On the other hand a patient’s choices in many countries are limited by insufficient palliative care; this results in a violation of human dignity because persons have to die in indignant conditions.

2.5.7. Conclusion

Any conclusion regarding human dignity depends on the meaning given to the term “human dignity”.

2.6. Patient’s best interest

The argument of the patient’s best interest is related to the argument of dignity. In the later case it was human dignity which demanded a dignified death; in some situations the respect for human dignity could justify termination of the life of a person suffering in a way which violates human dignity (when understood as a changeable feature of human beings). Here it is on the grounds of the patient’s best interest that euthanasia is justified. It is either the patient self who is interpreting his/her best interest or another person (physician, nurse, relative) who is assessing the patient’s best interest and who acts in the patient’s best interest. Some people think that euthanasia does not go against the goals of medicine, considering it to be possibly in the patient’s best overall interest. Some authors relate euthanasia to eudaimonia (living well, flourishing) of the Aristotelian tradition, arguing that in virtue ethics, euthanasia can be regarded as a continuation of eudaimonia insofar as euthanasia facilitates good dying (dying is a part of life), avoiding bad dying which would be frustrating and not a vibrant way to finish life. ( Begley, 2008 ). Therefore medical and other health care professionals have to balance their own integrity with professional concerns and patients’ interests. In this way they will recognize good and be able to realize it. Finally, helping another will lead, from a teleological perspective, to human flourishing. ( Begley, 2008 ). So if euthanasia is understood as the upholding of a patient’s best interest, then it is a catalyst to human flourishing.

The counter-argument points out that if a patient’s best interest is interpreted by another person such as a health care professional, then such an interpretation will be paternalistic. Another objection does not deny the legitimacy of the patient’s best interest, however in scenarios involving killing, it is not given precedence.

2.7. Quality of life

The quality of life argument is related to the patient’s best interest argument in the way that it is the patient’s best interest to live a life which has certain qualitative features, which are valuable and worthwhile. Quality of life is therefore an indicator as to how these qualitative features can be assessed by the patient. In contrast to the patient’s best interest, quality of life is purely subjective and can be measured by the patient only. There is an affinity with the suffering argument: once suffering becomes unbearable, quality of life is very low, possibly so low that the patient does not want to live a life of such poor quality, giving euthanasia a role and upon the patient’s evaluation of his/her life, a good death can be administrated.

Insofar as death is a part of life, quality of life can be referred to the quality of dying. As there has been an enormous emphasis on the quality of life in all areas of medicine in the last decades, the same impetus should be given to death and dying. ( Hoffmann, 2009 ; Nordenfelt, 1994 ; Walter & Shannon, 1990 ). Quality of life can become a secondary argument of autonomy (as the primary argument): Once the quality of life or dying is too low and no longer acceptable or intolerable, the patient can express his/her autonomy by requesting euthanasia.

The counter-argument to the quality of life argument is based on a critique of the concept of quality of life in health care. This critique emphasizes life as a gift which is valuable as such and which should not be measured by subjective criteria of quality. In a comparable way as the dignity of life cannot be measured, the value of life cannot be assessed. Although quality of life is very important both individually and for society as a whole, quality of life in itself cannot be the reason to terminate those suffering low quality of life or life which is not deemed worthy of being lived. And this line of counter-argument could continue with references to the Nazi period (the killing of people with low quality of life and with unworthy life).

2.8. Health care costs

It is a trivial statement that health care resources are limited. Since some treatments (e.g. intensive care or in oncology) are very expensive, they should be used with good justification in order to prevent that health care resources are not used in an unfair and irresponsible way but in the ways in which the criteria of social justice are satisfied.

From an economic standpoint, one package of morphine costs a few Euros while one day in an Intensive Care Unit can cost thousands of Euros. On top of that if the treatment is futile anyway and the patient’s prospect is one mainly of pain, suffering and dying then not only principles such as autonomy or dignity apply but also principles like justice, solidarity (which would not justify futile treatment) and health care costs as distribution of limited resources criteria have to be taken into account.

There are various scenarios for the economical calculation in this context; from very liberal ones to those based more on social coherence and social solidarity (which has its limits as well). Then euthanasia could become a smooth solution for generally expensive health care and for health care systems suffering from financial deficiency. It should be mentioned that palliative care is much less expensive than many medically aggressive, technically advanced and economically costly treatments.

The counter-argument is based on the impropriety of a financial argument in the context of dying patients. The counter-objection stresses the fact of limited resources for health care and the validity of health care cost calculations. The middle-ground position argues that care for terminally ill and dying patient certainly cannot be limited to economic calculations however health care costs do have to be considered.

2.9. Regulation - legalization

The basic form of the regulation argument concerns the legalization of euthanasia. Proponents argue, while referring to autonomy, right to die, compassion and dignity, that euthanasia should be a legal right for everyone; the criminalization of euthanasia is contrary to the many arguments for which euthanasia should be decriminalized. The fear of decriminalization of euthanasia has the consequence that euthanasia will be practised “in the shadows”, beyond any social control. The legalization argument is more policy oriented, focusing more on social and legislative strategies than on morality as such.

Opponents argue that the right to die cannot be legally acknowledged since such a right does not exist, moreover such a legal provision would violate human rights, in particular the right to life. Even opponents who would otherwise condone legal voluntary euthanasia under certain conditions argue that once legalized, euthanasia would be abused. Referring to the Dutch practice where not all performed cases of euthanasia have been reported, they argue that there is a slippery slope from active voluntary euthanasia to involuntary euthanasia which, again, can be proven empirically. ( Keown, 1995 , 2002 ).

A pragmatic view on regulation appreciates a legal provision on euthanasia under the argument “regulation is better as no regulation at all”. Once regulated, obligatory rules have been established and they provide an enforceable framework. The alternative scenario of no regulation is much worse because euthanasia will be performed anyway but in the chaotic and confused setting of a grey zone.

Those who hold euthanasia as wrong in principle argue that an immoral practice cannot be transformed into a moral one by legalization: immorality cannot be legalized.

2.10. Transparency

The transparency argument is associated with the regulation argument. As is generally known, euthanasia is being practiced in many countries in which it is illegal. So the transparency argument states as follows: let us be transparent, let us continue doing what we are doing anyway in the open and honest way, let us terminate hypocrisy (criticising euthanasia in Benelux, not being able to address the issue in our home countries, behaving as if euthanasia is not presently being practised in our cities).

The argument to the contrary holds that if euthanasia is completely wrong, then transparency only serves to corrupt existing morality. A similar objection as above would apply.

3. Conclusion

In the analysis of this chapter, it became clear that for any argumentation on euthanasia, regardless of whether for or against, the first crucial step is clarity in terminology: what exactly do we mean by the term “euthanasia”. So to avoid confusion, misunderstanding and frustration, it is crucial to start with clear semantics. Within this analytical study, euthanasia, having been distinguished from assisted suicide and from other instances of the end-of-life decisions such as withholding, withdrawing or terminal sedation, was defined as a deliberate act of termination of the life of B by A upon an explicit request of B for the sake of B . This means that the term euthanasia is understood to be so-called active voluntary euthanasia. Moreover, for a precise definition, some additional criteria apply such as terminal stage of the illness, unbearable suffering, enduring and voluntary wish to die (expressed repeatedly), and the act of euthanasia being performed by a physician.

In the discussions on euthanasia various numbers of arguments are listed. Similarly different types of argumentations can be identified which use different or the same arguments taken from different fields and contexts; so one and the same argument is used within diverse argumentations. In summary, philosophical, legal, religious and social types of argumentations on euthanasia should be distinguished. So if, for instance, an argument is made on the basis of a “right”, while one argumentation uses the argument of “right” in the legal sense (e.g. human rights), another uses the argument of “right” in the sense of moral right (moral claim, not based on specific legislation). The next one uses the argument of “right” in a theological way (God’s right over life) or in a psychological way (one’s right to an authentic expression of his/her self).

It became evident that there are no unequivocal arguments for or against euthanasia. Any list of arguments for euthanasia is, to a large extent, at the same time also a list of the arguments against euthanasia in the sense that another list of objections to these pro arguments has to be considered. Some of the pro arguments are simultaneously contra arguments and vice versa (e.g. dignity). Despite this fact, some arguments are prevalently arguments pro (e.g. autonomy) while the other ones are arguments against (e.g. slippery slope). If the argumentation is not to be biased, it has also to deal with the argument’s contra position in an intellectually honest way.

The analysis demonstrated that some arguments which at first glance seemed quite convincing were found to be not so if questioned and analyzed critically, and once their weak points are also brought to light. So for instance the autonomy argument (autonomy of the dying person asking for euthanasia) is not as convincing as its proponents argue, being replaced or invalidated by the argument of compassion - unless there is clear evidence that euthanasia was the genuine choice and authentic option of the person concerned. While the autonomy argument has its justifications and explanatory powers, it is however diminished by other arguments such as competence or social pressure which affect the authenticity of an autonomous choice.

As an auxiliary tool, a matrix of arguments ( Fig. 1) demonstrating the interconnectedness of the individual arguments was provided. The matrix shows both the prevalent dichotomy “pro et contra” and complementariness. As the main arguments for euthanasia, autonomy, the right to die, unbearable suffering, compassion, dignity, the patient’s best interest, quality of life, health care costs, policy arguments of legalization (regulation) and transparency have been identified. By contrast, as the arguments against euthanasia, the following ones have been listed: competence, inviolability of human life, prohibition of killing, abuse, slippery slope, quality palliative care, physician’s role, vulnerability, and social pressure. All these arguments have to be placed into the operational framework of the proposed matrix whose purpose is to illustrate the correlation of individual arguments. Some arguments can be used simultaneously both ways, for or against euthanasia; each of them has its own different explanatory and justifying power; some of them remain mutually exclusive (e.g. autonomy, compassion).

There is an immense interrelation between the arguments which sometimes goes unnoticed but what can be described by comparative analysis based on the proposed matrix. Many arguments rely on specific meaning or interpretations, as derived by the semantics of a singular term, or by a specific philosophical approach upon which the argument is based (e.g. dignity); last but not least the arguments also rely on their use in a particular cultural and/or religious context.

Such an understanding of the backgrounds, mechanisms and strategies of the arguments on euthanasia contributes significantly to a meaningful and respectful discussion of the controversial issue of euthanasia, which will surely continue into the coming decades.

• 27. The Danish Council of Ethics (Det Etiske Råd). 2006 End of Life- Ethical Challenges and Problems.
• 68. Maas, van der P.J. et al. 1991 Euthanasia and Other Medical Decisions Concerning the End of Life, Lancet , 335 8767 September 1991), 669 773 0140-6736
• The proposed title for this article was originally “Euthanasia pro et contra: Analytical synopsis of argumentations for and against euthanasia”. Its aim was to provide a synoptic and comparative analysis of both types of arguments used for support or refusal of euthanasia. However it soon became clear that such an approach transcends the format of one book chapter. So instead of a very short analysis of all arguments for and against euthanasia, only five leading arguments for euthanasia have been critically scrutinized.
• The term “termination of life” (instead of “killing”) has been used as a neutral description, which is open to diverse value-laden interpretations, including “taking life”, “killing” or “homicide”.
• The “passive action” of allowing to die can include not only passivity in the sense of diverse avoiding of treatment (e.g. withholding or withdrawing); it can also include “active actions” such as the psychological or spiritual accompaniment of a dying person or the support by those close to the patient.
• “Non-voluntary euthanasia” and “involuntary euthanasia” will be included mainly in the role of counter-argumentation.
• Beauchamp, 1996; Behnke & Bok 1975; Bernards, 1989; Biggar, 2004; Brody, 1989; Cohen-Almagor, 2001; Dworkin, 1993; Dworkin et al. 1998; Engdahl, 2007; Gentles, 1995; Grisez & Boyle, 1979; Harris, 2005; Keown, 1995, 2002; Leone, 1999; Medina, 2005; Moreno, 1995; Morgan, 1996; Oosthuizen et al., 1978; Rachels, 1986; Roberts & Gorman, 1996; Snyder 2006; Torr, 2000; Wekesser, 1995; Young, 2007a.
• The vocalization of the presuppositions is of significance for mutual understanding in euthanasia discussions. Otherwise these starting points, often based not only on certain ethical theories but on personal beliefs, or on various dogmas and ideologies which (even as non-identified) play a pivotal role in the debate, if not revealed cannot be addressed, rendering the debate both more difficult and superficial and inconclusive.
• This terminology is not usually used in euthanasia debates and it can rightly be criticized. For the purposes of this study, the terms liberal and libertarian have been used instead of saying ‘less liberal’ and ‘more liberal’.
• Bernards, 1989; Blocher, 1999; Cosic, 2003; Haley, 1999; Moreno, 1995; Ogden, 1994; Rebman, 2002; Russell, 1975; Scherer & Simon, 1999; Tada, 1992; Uhlman, 1998.
• The “Patient’s Bill of Rights” (which includes the right to reject medical treatment even if such refusal causes death) was adopted by the American Hospital Association in 1973. The American Society for the Right to Die (the former Euthanasia Society of America) has promoted the legalization of a living will (1974) which includes refusal of treatment (called “passive euthanasia”). The Patient Self-Determination Act (1990) has implemented the right to die (refusal of treatment) by legally requiring all health care institutions to provide patients on admission with information regarding their rights to make decisions about medical treatment (to accept it or to refuse it); this right (to die) has been confirmed by the U.S. Supreme Court (1990) based on constitutional liberty rights.
• “Suffering as a criterion for access to euthanasia is based on an approach that is taken for granted and regarded as self-evident” (The Danish Council of Ethics, 2006).
• For the meaning and history of dignity see Meyer, 1995.

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Debating Euthanasia

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Jennifer Edwards, Debating Euthanasia, Medical Law Review , Volume 21, Issue 4, Autumn 2013, Pages 632–641, https://doi.org/10.1093/medlaw/fwt007

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Debating Euthanasia is a collaborative work authored by Professors Emily Jackson and John Keown, published as part of Hart Publishing's Debating Law series. This series aims to explore topical areas of law and policy by presenting ‘[t]wo essays … written from opposite points of view’ (Series Editor's Preface). In keeping with this premise, Debating Euthanasia comprises two self-contained, 30, 000 word essays which represent the authors' contrasting viewpoints on the question of whether euthanasia could, and indeed should, be legalised. The Debating Law series is designed to cater to a wide readership. Consequently, the essays used to illustrate contrasting viewpoints on the topic in question must be ‘accessibly written and only lightly end-noted’ (Series Editor's Preface), and Debating Euthanasia adheres to these requirements well. Both Jackson's and Keown's contributions are clearly presented and succinct, and provide learned representations of the polarised perspectives taken in the euthanasia debate.

As they are canvassing opposing sides of the same debate, their pieces cover similar topics in presenting their arguments for and against legalising euthanasia. The most prominent example of this is the use of the slippery slope argument. Jackson uses it, coupled with evidence from the Netherlands, Australia, Belgium, England and Wales, and Oregon, to allege that it is ‘clearly false that a blanket ban is the optimum response to concerns about a practice's potential misapplication’ (p 62). Keown, on the other hand, argues that in view of evidence from Oregon and the Netherlands the mechanisms the legislation those jurisdictions utilise have already allowed the slide along the slippery slope to occur (p 118–136). Both too have six broad headings which outline the basic shape of their respective theses. Jackson's are Introduction; Why We Should Try; The Status Quo is Indefensible; Why Might Anyone Think We Shouldn't Try?; What Might an Assisted Dying Law Look Like?, and What Are The Consequences of not Trying? Keown's, by comparison, are Introduction; Definitions; Ten Arguments For Decriminalisation; Professor Jackson's Arguments; The Joffe Bill, and Conclusions. This duality does not negatively affect the flow of the book; indeed, it makes the piece a better tool for reference as it allows the reader to easily compare the two contrasting arguments.

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• v.111(11); 2018 Nov

Euthanasia and assisted dying: what is the current position and what are the key arguments informing the debate?

Andreas fontalis.

1 St George's University Hospitals NHS Foundation Trust, London SW17 0QT, UK

Efthymia Prousali

2 Aristotle University of Thessaloniki, 54124 Thessaloniki Greece

Kunal Kulkarni

3 University Hospitals of Leicester NHS Trust, Infirmary Square, Leicester, LE1 5WW, UK

Assisted dying is a highly controversial moral issue incorporating both physician-assisted dying (PAD) and voluntary active euthanasia. End-of-life practices are debated in many countries, with assisted dying receiving different consideration across various jurisdictions. In this paper, we provide an analytic framework of the current position and the main arguments related to the rights and moral principles concerning assisted dying. Assisted dying proponents focus on the respect of autonomy, self-determination and forestalling suffering. On the other hand, concerns are raised regarding the interpretation of the constitutional right to life and balancing this with the premise of assisted dying, alongside the impacts of assisted dying on the doctor–patient relationship, which is fundamentally based on trust, mutual respect and the premise of ‘first do no harm’. Our review is underpinning the interpretation of constitutional rights and the Hippocratic Oath with the premise of assisted dying, alongside the impacts of assisted dying on the doctor–patient relationship. Most clinicians remain untrained in such decision making, with fears against crossing key ethical divides. Due to the increasing number of cases of assisted dying and lack of consensus, our review enables the integration of ethical and legal aspects and facilitates decision making.

Introduction

Assisted dying remains a highly controversial moral issue, with clinical, legal, political, religious and ethical considerations playing an important role. Lack of consensus and ongoing debate are features of modern life, while the law generally sustains a broader, pluralist outlook. Advances in both life-prolonging treatments and palliative care in recent years are inextricably intertwined with this complex topic, resulting in the continuing demand for amendments on current legislations. 1 This review presents an overview of the current status of this topical debate.

Definition and current legal framework

Assisted dying is a general term that incorporates both physician-assisted dying and voluntary active euthanasia . Voluntary active euthanasia includes a physician (or third person) intentionally ending a person’s life normally through the administration of drugs, at that person’s voluntary and competent request. 2 , 3 Facilitating a person’s death without their prior consent incorporates both non-voluntary euthanasia (when the patient is not capable of providing informed consent, e.g. vegetative state, young child) and involuntary euthanasia (against patient’s will). Physician-assisted dying is defined as follows: a physician intentionally helping a person to terminate their life by providing drugs for self-administration, at that person’s voluntary and competent request. 2 , 3 Consequently, in the first case a third person acts resulting in patient’s death, whereas in physician-assisted dying the action is undertaken by the patient who is given lethal medication by a physician. 2

Discussion regarding withholding or withdrawing treatment and requesting assisted death has emerged in association with the simultaneous expansion of palliative care across the world. The World Health Organization defines palliative care is an approach that

improves the quality of life of patients and their families facing the problem associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual. 4

It intends to neither hasten nor postpone death. Nonetheless, in practice, terminally ill patients – often with full mental capacity – may develop a loss of self-determination as their condition deteriorates and express a desire for assisted dying to alleviate intractable physical symptoms.

Assisted dying is an emotionally and ethically challenging subject, which understandably receives varying degrees of acceptance among different global jurisdictions. Currently, there is legal provision for assisted dying (or variants) in only four European countries (the Netherlands, Belgium, Switzerland and Luxemburg), Canada, Colombia and the United States of America (USA) states of Oregon, Washington, Montana, Vermont, California, Colorado and Washington, DC, representing nearly 18% of the US population. 5 , 6 Switzerland is the only country which permits the act of assisted dying performed by a non-physician. Moreover, non-Swiss citizens can exploit the Swiss law by visiting Switzerland in order to access assisted dying. 7 In these more tolerant jurisdictions, palliative care is seen as an important link in the same chain as assisted dying in caring for terminally ill individuals, rather than an alternative. Elsewhere in the world, an assisted death remains a criminal offence, prosecutable through various legal routes. For example, in the UK, all forms of assisted dying remain illegal and can be considered under criminal laws of manslaughter or murder, or under the Suicide Act (1961), depending on the circumstances. 6 Prosecution guidelines were first issued by the Director of Public Prosecutions in 2009 following House of Lords ruling in the case of Debbie Purdy, which stated that there was ambiguous guidance regarding when people would be prosecuted for encouraging or assisting suicide. The guidelines suggest that while each case will be assessed on its relative merits, individuals acting in the capacity of a healthcare professional are more likely to be prosecuted for assisting or encouraging suicide, although to date no report-providing doctor or accompanying individual has been prosecuted for helping patients to travel abroad from the UK to end their life. 8 In England and Scotland, three assisted dying bills have been proposed and debated, largely based on the Oregon Death with Dignity Act (1997) from the USA, which permits assisted dying; none were passed.

We performed a systematic search of MEDLINE and EMBASE databases from conception to January 2018. The search terms used were ‘euthanasia’, ‘assisted dying OR death’, ‘assisted suicide’, ‘medical ethics’, ‘autonomy’, ‘end of life’ and ‘sanctity of life’. We also combined free text searching with Medical Subject Headings (MeSH) terms and no restrictions were set in publication date, study design and publication status.

Principles of bioethics

Autonomy and right to life.

Beauchamp and Childress developed a standard approach to bioethics and advocated for four principles that lie at the heart of healthcare ethics and underpin decision-making. 9 , 10 Respect for autonomy is one of the fundamental concepts, in combination with justice , beneficence and non-maleficence .

In medical practice, autonomy describes the right of competent adults to make informed decisions about their own medical care, prior to any investigation or treatment taking place. For a physician, respect for autonomy includes acknowledging and preserving a patient’s right to self-determination and providing the necessary guidance, which would allow for an informed and independent choice, free of coercion.

However, autonomy is far from a straightforward consideration. Onora O'Neill, in an attempt to scrutinise the context of autonomy in her Gifford lectures, makes a clear and compelling distinction between the approach of John Stuart Mill and Kant regarding the subject of autonomy. 11 As O’Neill vividly describes, Mill stretches the bound of choice and ‘sees individuals not merely as choosing to implement whatever desires they happen to have at a given moment, but as taking charge of those desires, as reflecting on and selecting among them in distinctive ways’. 11 The Kantian version of autonomy is guided by a ‘practical reason’. Kant views autonomy as ‘a matter of acting on certain sorts of principles, and specifically on principles of obligation’ rather than a form of self-expression and supports that ‘there can be no possibility of freedom for any one individual if that person acts without reference to all other moral agents’. 12 O’Neill embraces the Kantian view and contextualises it as ‘principled autonomy’ compared to ‘individualistic autonomy’. O’Neill’s work vigorously illustrates the fragility of the concept of autonomy and its contingency on a number of other considerations, particularly the network of human relationships within which it features.

The greatest expression of autonomous self-determination is the right of ‘capacitous’ adults to refuse any proposed intervention (irrespective of rationality), even if this decision could result in harm or death, provided they are capable of freely reaching a decision in the above manner. For this reason, obtaining informed consent from a patient after they have been offered all the relevant information regarding their situation is of paramount importance. During the past decades, the development of liberal democracies has highlighted the significance of self-determination, with healthcare systems increasingly adopting more patient-centred approaches to care decisions. The right to bodily autonomy has also been enshrined under Article 8 ( Table 1 ) of the European Convention on Human Rights (ECHR).

Article 8: Right to respect for private and family life.

Taking the above into consideration, Article 8 encompasses inter alia the right to personal development. In a technical legal sense within the jurisdiction of Swiss law, it includes a patient’s choice to avoid what they consider an undignified and severe end to their life. 14 Proponents of this highly contentious argument claim that seriously ill patients should have a choice in whether or not they wish to continue living with a condition that undermines their inherent dignity and personal identity, 15 without violating the principle of sanctity of life. Therefore, it can be argued that respecting autonomy inherently involves the prima facie right of a patient to control the circumstances and time of death by requesting help in dying. This could minimise the suffering of an individual or their family and improve the quality of the end of the patient’s life, as their wishes would be respected and dignity would be preserved. 16 , 17

A further dimension that can be considered is the treating clinician’s ethical beliefs and values. During their training, most practising clinicians have not experienced the concept of assisted dying as an expected duty in the context of patients’ autonomy. 18 Nevertheless, it is important to consider the magnitude of patients’ autonomy within modern society. Individual liberty ought not to be viewed as absolute and exceptions to Article 8 should be provided in favour of preservation and reverence to life. 17 , 18

The right to life is guaranteed by Article 2 ( Table 2 ) of the European Convention on Human Rights. Under Article 2, the State is enjoined to abstain from the deliberate and illicit taking of life, as well as to protect vulnerable people against actions by which they could jeopardise their lives. The principle of sanctity of life emerges frequently in modern discussion, particularly in Anglo-American bioethics, surrounding public controversy about end of life and abortion issues. Yet, its moral foundation is rarely unriddled and understood. The sanctity of life position asserts that life has sanctity and its value prevails all other values. No individual’s life deserves priority, and sanctity is attributed to life regardless of the physiological status, imminence of death, suffering or individual’s wishes to live or die. 19

Article 2: Right to life.

This argument is often associated, but not fully equated, with religious and cultural traditions that generally object to assisted death, because human life is viewed as God’s sovereign creation. From a religious perspective, God is considered the only one who can determine the beginning and end of human life. The sanctity of life is a value also clearly mirrored under Article 9 of the European Convention on Human Rights, which refers to freedom of thought, conscience and religion. 13 It is notable, though, that Article 2 does not encompass assisted dying, i.e. in situations where a person’s decision to end their life has been taken independently and with absolute perception of what it implied.

The crucial issue is therefore one of balance . Patient autonomy has to be balanced against the principle of sanctity of life. It should be acknowledged though that the autonomy argument is secondary in its applicability on whether assisted dying is ethically permissible and cannot solely guide decisions on what is morally impermissible, as it constitutes only a piece of the puzzle. The right to end a life that an individual finds intolerable has to be considered in association with its resulting impact on other rights, regulations and the responsibilities of healthcare professionals in facilitating assisted dying. 18

As discussed, justice constitutes one of the main four fundamental principles of medical ethics. All individuals in a society should be treated equally and impartially. One of the arguments that has monopolised the debate concerning assisted dying is the ‘slippery slope’. According to this, should assisted suicide be established, then it might be applied in circumstances that fall outside the scope of morally permissible cases, such as in patients who may not be fully competent. 17 Furthermore, if a person is motivated by means other than his own will, for example through external coercion, then patient autonomy is infringed.

In this regard, concerns are raised about vulnerable populations, such as the terminally ill, the mentally incapacitated and the elderly. There remains the understandable fear that assisted dying could potentially lead society toward an attitude that suffering should not be a part of life, interdependency is a burden and the lives of disabled of terminally ill individuals are not worth living. 20 The implications of such an attitude on vulnerable populations is clear, with individuals potentially forced or coerced into assisted dying for reasons other than their own free will.

The slippery slope argument is inordinately complex and controversial evidence exists in the literature in favour of both sides. Cases of assisted dying in the Netherlands grew from 1882 in 2002 to 5306 in 2014. 21 Eight-one cases were concerned with dementia and 41 with mental health-related reasons only in 2014. 6 In the light of data from Holland, the slippery slope argument is supported in a number of respects, e.g. concerns about legislation ‘creep’, lack of availability of good palliative care and fears in the vulnerable and elderly. Early data published from Oregon were also concordant. The number of physician-assisted deaths progressively rose from 16 in 1998 to 71 during 2011; loss of autonomy (88.7%) and ability to participate in enjoyable activities (90.1%) were the two most commonly reported end-of life concerns. 22 In increasingly financially constrained health and social care systems, fears have also been raised regarding the impact of budget-cutting trends and their potential impact on terminally ill individuals for whom the alternatives are only high-cost life-prolonging or quality-enhancing (rather than curative) treatments.

However, recent data summarising the 20 years’ experience in Oregon suggest the opposite. According to the authors, patients requesting an assisted death allegedly belong to a higher than average socioeconomic class and have a higher than average education level. 23 Oregon, the first state in the US to allow assisted dying, employed strict criteria that had an influential role in other jurisdictions. 5 The criteria comprised the agreement of another doctor, the assessment of the patient’s mental capacity and the presence of a terminal illness with less than six months to live. 24 Additional measures to ensure an informed and unforced decision involved adequate pain relief and access to end-of-life care. 25 Assisted dying proponents support that safeguards and regulations in place are very powerful since only one in 50 terminally ill patients have a discussion about the process with their doctor and even fewer complete it. 26

Rhetoric from opponents has raised concerns of whether such safeguards could ever be adequate, which appears to be a key argument in the debate in some jurisdictions as well. Consequently, any future legal permissibility of assisted dying should be developed in conjunction with clear regulatory safeguards to ensure the abuse of assisted dying and protect vulnerable individuals from coercion. 3 . Such safeguards must also preserve societal justice and ensure equitability and availability of healthcare is not a deciding factor in assisted dying decision-making.

The Hippocratic Oath and the principles of beneficence and non-maleficence

The principles of beneficence and non-maleficence , plainly described in the Hippocratic Oath, have been the foundation of medical ethics for many centuries. Beneficence states that a doctor should act in the best interest of the patient. Non-maleficence states ‘first, do no harm’ – ‘ primum non nocere ’. 27 Conformation to these fundamental principles is enshrined within Hippocratic Oath, which involve aiming to benefit, or perhaps most importantly, not doing any harm to a patient. Moreover, modern medical education in most countries follows legal and cultural opposition to an assisted death. Healthcare professionals are therefore currently not adequately trained to participate in assisted dying. Professional opinion also remains divided on whether further involvement would benefit or damage public perception of the profession, given the potential conflict between these two ethical principles. The UK’s medical representative body, the British Medical Association (BMA), has acknowledged this lack of consensus, but clearly concludes with their view that assisted dying should not be made legal in the UK. 28

However, the evolution of decision-making processes in modern medicine, particularly regarding end-of-life decisions, and with patients increasingly at the heart of shared decision-making (e.g. the UK NHS’ ‘no decision about me, without me’ policy), have applied pressure on clinicians to reconsider their collective professional stance on assisted dying. Indeed, an increasing number of legal challenges from patients and assisted dying representative organisations are taking place worldwide to challenge local legislation against an assisted death.

Assisted dying therefore challenges the conflict faced between the ultimate purpose of modern medical and social care and its founding ethical principles. Relief of suffering through an assisted death can be argued as a distinct entity to palliative care, with the former – if safely and carefully considered – potentially an important way of fulfilling a clinician’s duty to preserve autonomy and do good for a patient – for example, in cases where alternatives are treatments which provide no benefit or do not prolong or improve the quality of life of a terminally ill patient. 27 , 29 A further consideration is that of an individual doctor’s ethical and moral beliefs, which are also an important factor should a patient request an assisted death; indeed, the British Medical Association has proposed that should assisted dying legislation be derived, then there should be a clear demarcation between those physicians who do and do not offer this option. 30

Freedom of thought, conscience and religion

A further controversial issue is raised by Article 9 of the European Convention on Human Rights, which protects the rights of freedom of thought, conscience and religion. Its impact on the assisted dying debate centres on whether requesting an assisted, dignified death constitutes a manifestation of belief, therefore falling within the remit of Article 9. Several European Court decisions have determined that individual views are entitled to protection only if they ‘attain a certain level of cogency, seriousness, cohesion and importance’. 31

Seriousness and importance are undoubtedly justified when considering an individual’s decision to end their life. On the other hand, an informed desire to die with dignity may well constitute a coherent and cogent view. For instance, it remains debatable whether approaching death through a solely palliative care lens constitutes a less dignified way to die than assisted dying. 31 Article 9 may therefore provide a preferable framework for decisions relating to the right to die with dignity than Article 8, which focuses on a patients’ autonomy; while the former aims to protect truly coherent and cogent decisions, it may be argued that the latter in isolation could potentially open a bigger door to a broader attitude towards assisted dying. 13

Furthermore, Article 3 should also be considered as a safeguard, as this prohibits torture and degrading treatment. 17 Ultimately, each potential assisted dying case is unique and its various facets should therefore be approached carefully under the scope of relevant legislation (e.g. European Convention on Human Rights Articles 2, 3, 8 and 9), and individual/societal ethical and moral perspectives ( Tables 1 ​ 1 ​ to ​ to4 4 ).

Article 3: Prohibition of torture.

Article 9: Freedom of thought, conscience and religion.

Implications of assisted dying in the doctor–patient relationship

As discussed, a key concern of the medical profession remains the impact of legalisation of assisted dying on the doctor–patient relationship. This relationship is fundamentally based on trust. Although aspects of assisted dying may be considered in conflict with certain underlying ethical obligations placed upon doctors, considering a patient’s autonomous wishes, alongside the moral perspectives of the doctor, is also an important aspect of this relationship. 32 , 33 This quandary is recognised by the Swiss Academy of Medical Sciences in their ethical guidelines, which acknowledges that ‘in certain special cases a doctor’s personal decision to assist a dying patient to commit suicide is in accordance with his or her conscience and has to be respected’. 18

The delicate balance between the views of patients, doctors and society can pose an ethical dilemma, with the potential to serve a disruptive influence on the sanctity of the doctor–patient relationship and negatively distorting how society perceives the role and motives of healthcare professionals. For example, as previously considered, particularly in healthcare systems where doctors play the role of gatekeeper to healthcare, a doctor’s support for an assisted death for a terminally ill individual might be negatively interpreted as a conflict of interest, with a desire to help relieve the social and economic burden of a patient’s illness upon society overriding the patient’s individual interests. Ultimately, should appropriate safeguarding measures be deployed alongside relevant legislation, assisted dying may risk eroding doctors’ professional integrity. 34

Current position of doctors’ professional groups in the UK and the USA

As expected, the discussion around adopting assisted dying has caused much controversy among the doctors’ professional groups and bodies. Several professional organisations in the UK have clearly expressed their opposing views to assisted dying such as the British Medical Association, the Royal College of General Practitioners and the Royal College of Surgeons of England, whereas others maintain a neutral position including the Royal College of Nursing, the Royal College of Psychiatrists and the Royal Pharmaceutical Society. 5 The Royal Society of Medicine has no policy on the issue since ‘its remit is the education of doctors and health professionals and the promotion of debate, not the making of policy’. 35

In the US, the American Medical Association, representing nearly 250,000 members, vehemently opposes legalisation of assisted dying as does the American College of Physicians with more than 150,000 members. 6

Conclusions

The debate surrounding assisted dying is never far from the headlines, particularly while its legal status in most jurisdictions remains inadequate and discursive. However, alongside the evolution of palliative care, there appears to be an increasingly vocal desire for legislation to support assisted dying in selected cases. 21 Developing a sensitive balance between established cultural norms and a progressive, well-balanced, transparent and safe attitude towards assisted dying is key. 24 More patient-centred attitudes towards health and social care increasingly place patients – quite rightly – at the heart of everything health professionals do. Patients’ needs, attitudes and beliefs must be therefore at the forefront of decision-making. However, when considering these alongside the fundamental principles of bioethics as well as legislation and doctors’ own beliefs, conflict can arise, thereby leaving the assisted dying debate in a state of limbo. Whether assisted dying should be legalised (albeit with stringent controls) remains controversial; as considered in this essay, even the basic moral principles can conflict when considering the arguments for and against supporting an assisted death, making consensus building far from straightforward.

Ultimately, individual patients’ autonomy should be balanced with a fundamental right to life, impacts on the individual doctor–patient relationship and wider society and the safeguards required to prevent misuse of any assisted dying regulations. The challenge remains for society to decide where this balance lies, guided by regional religious, cultural and legislative perspectives.

Developing the required ethical competencies among medical professionals is also key; given the current absence of legal support for assisted dying in most jurisdictions, most clinicians remain untrained in such decision-making. Indeed with understandable fears against crossing key ethical divides, physician support for an assisted death tends to be lower than that of patients. 36 Dying is a natural part of human life. With growing demand worldwide, the assisted dying debate will increasingly come to the fore – something healthcare professionals, politicians and legislators cannot ignore.

Declarations

Competing interests.

None declared.

Ethics approval

Ethics approval was not required for this review.

Contributorship

AF and EP conceived, designed the study and performed the literature search. All authors analysed the data and drafted the manuscript. All authors contributed to and approved the final version of the manuscript.

Acknowledgements

Not commissioned; peer-reviewed by David Misselbrook.

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Inside The Fight For The Right To Die: Logistical And Ethical Challenges

Terry Gross

Katie Engelhart details the right-to-die movement in her new book, The Inevitable . She says that many patients in the U.S. are forced to act alone, without telling friends and family, because they fear their loved ones will be prosecuted after the fact. Germán Vogel/Getty Images hide caption

Katie Engelhart details the right-to-die movement in her new book, The Inevitable . She says that many patients in the U.S. are forced to act alone, without telling friends and family, because they fear their loved ones will be prosecuted after the fact.

When you have a dog or a cat that is in pain and near the end of life, you have the option of putting down your beloved pet. Some people who fear loss of function — mental or physical — would like a similar option for ending their own lives in a safe, peaceful and legal manner.

Journalist Katie Engelhart explores the "right to die" movement in her new book, The Inevitable. Engelhart says individuals seeking death on their own terms sometimes resort to ordering lethal veterinary drugs from Mexico or China.

"When I started reporting the book, I heard this phrase over and over ... 'I'd rather die like a dog,' " Engelhart says. "A lot of people spoke to me about euthanizing beloved pets in their past. They talked about [euthanizing their pets] as being acts of mercy and acts of love — and all they wanted was the same option for themselves."

The Two-Way

As planned, right-to-die advocate brittany maynard ends her life.

Engelhart's book focuses on six individuals — two doctors and four patients — who represent different aspects of the debate about physician-assisted death. She notes that in the U.S., physician-assisted death or medical aid in dying is legal in only a handful of states and Washington, D.C. — and there are strict measures regulating which patients qualify. Some people assume that patients who choose to end their own lives do so because they are in physical agony, but Engelhart says her research shows that's not necessarily the case.

New Zealand Supports The Right To Die, But Rejects The Right To Get High

"Most people who choose to end their lives at a preplanned moment are more concerned with things like dignity ... autonomy," she says. "They're worried less about the physical pain than the loss of themselves, though that's not to say that pain doesn't enter the equation."

Interview Highlights

On who qualifies for physician-assisted death

The law [on who qualifies] is very strict in the United States. ... A person must be terminally ill, within six months of a natural death according to two doctors. Prognostication is a kind of fuzzy science, but two doctors need to agree that six months or less is a reasonable time frame. And the person needs to have the mental capacity to be making the decision. If that's in doubt, the patient's usually referred for a psychiatric assessment.

That's very different from what the laws look like in other places. ...

Physician-assisted death is legal across [Canada] and the criteria are looser. So instead of having this hard six-months-or-less time frame, patients are required to be suffering "unbearably and irremediably," and their death is required to be reasonably foreseeable, which some doctors interpret as being 10 or even 20 years away. ... So it opens up the law to patients who, say, have multiple sclerosis, who were on a predictable physical downhill slope but who are unlikely to die in the immediate short term. And, in fact, the Canadian government now is considering several amendments to the law, which would open it up to people who are mentally ill but not suffering physically and to people who have dementia. And there are several countries in Europe that already allow euthanasia for both of those conditions.

On how the states that do permit medically assisted death don't give specific guidance on what drugs to use

We invent veterinary drugs specifically to kill pets, in some instances, [but] we don't design drugs to kill people. We design drugs to alleviate pain or to sedate. And, in fact, though physician-assisted death is legal in a number of states, the laws don't specifically outline what drugs should be used and what combination and what timing — that's been left up to doctors to decide and sort out.

So doctors have, in fact, come up with a kind of cocktail of respiratory and cardiac drugs that will work to end life. The timing will vary from 20 minutes to a couple of hours, depending on the patient and her condition. But [figuring out the doses and timing in those situations is] actually a much more difficult process than I think a lot of people would have imagined. And again, that's specific to the United States. In most countries where aid in dying is legal, people choose to die by an injection given by a physician. And that's swift and quite straightforward.

Shots - Health News

Despite sweeping aid-in-dying law, few will have that option.

On the "euthanasia underground"

Congress Moves To Overturn D.C. 'Death With Dignity Law'

The more I researched, the more I realized that people were organizing outside of the law, in some cases within family units and in some cases through quite organized groups committed to guiding people through the dying process. This really surprised me in my reporting, but I don't think it should have. I'm very loathe to make comparisons with the abortion movement, but there is one relevant point of comparison here. We know that groups like the Jane Collective existed before Roe v. Wade — they provided safe abortion access before it was legal. And there are groups big and small that sort of do an equivalent for the end of life. ... I probably should have expected that people find a way when they feel abandoned by the law and by medicine. So I ended up profiling a number of those groups. Some are quite informal — we're talking more about websites that refer people to different means of procuring lethal drugs — and some are very organized.

On the risk of prosecution if a friend or family member helps someone end their own life

Family Struggles With Father's Wish To Die

I think there is concern that an accomplice or an aide might be somehow pushing a person toward death, that this might veer into some sort of murder, homicide. But certainly it puts people in a difficult situation. I met a lot of men and women who were working very hard to obtain either drugs or materials that would help them end their lives and were being forced to do it alone without their loved ones' knowledge, because they just worried so much about their loved ones being prosecuted after the fact.

And in fact, some of the "euthanasia underground" groups that I profiled in my book offer quite detailed guidance to families who are trying to help their loved ones in a sort of furtive way. So they'll say something like: After your loved one ends her life, make sure you go to a grocery store, go shopping, get a receipt with a time stamp on it, bring it home, have an alibi. I think that can be sad in a lot of situations for a lot of families because people want to be there for their loved ones. The idea that their parents would die alone and in fear because they're worried about future prosecutions is a difficult one.

If You Have Dementia, Can You Hasten Death As You Wished?

On the complications patients with dementia face in planning physician-assisted death (which is not allowed for people with dementia in the U.S.)

For anyone who's been close to dementia, it's not like there's an on/off switch that you can see coming. There are good days and bad days and then there are fewer good days and more bad days — and then one day, a bad day stays a bad day forever. In the Netherlands, the law actually goes further. So a person can say when she's diagnosed, "I want to be euthanized when I reach X, Y, Z moment, say, when I don't recognize my husband anymore or when I lose the ability to speak and to eat." But these cases are very difficult too. And doctors are often very reluctant to be part of them, because what those deaths could mean, effectively, is that a patient could be smiling, a patient could seem happy on the day of her death. And the doctor is still required to euthanize her because of what she specified potentially months and years earlier.

'I Look Forward' To Ending My Life, Assisted Suicide Backer Says Before Dying

On the "suicide tourism" in Switzerland

Switzerland does have quite liberal aid-in-dying laws and, unusually, they're open to nonresidents. So there are a few clinics that have formed that serve visitors from abroad who want to to come and end their lives there. The Swiss even speak of "suicide tourism" to the country. And these clinics require that patients be suffering unbearably, that they are sick with something that will at some point reasonably soon end their lives. So anyone [from any country] can qualify to go. But again, I find that people end up traveling to Switzerland and dying before they really want to, because they have to be healthy enough to get on a plane to travel around Zurich or Bern and to complete the process for getting final approval.

On the ethical issues Engelhart grappled with while researching her book

Katie Engelhart has worked as a correspondent for Vice News and NBC News in New York. She won a George Polk Award for her article about the nursing home in Kirkland, Wash., that became the first COVID-19 hotspot in the U.S. Owain Rich/Macmillan hide caption

I was very careful with who I spoke to, and some of this was just born of a self-preservation instinct. I didn't want to get in trouble. I didn't want to be in a situation where I was speaking to someone who I fundamentally didn't think was stable. So in almost every instance, I would only speak to someone at length if I could also speak to their loved ones, their family, their friends, their colleagues, their clinicians, their therapists — if I could have access to their medical notes. So I really didn't want to feel like I was speaking to someone in, kind of, obscurity. I wanted the people around them to know that I was there. And that, of course, would open the opportunity for someone around the person to say to me, "this is a bad idea" or "I think you're making things worse."

And then I also was just very careful in my interactions with people. So I said at length, probably excessively, something along the lines of, "I appreciate you for talking to me, but just because we're having this conversation doesn't mean we have to have more. You can choose at any moment to stop talking to me and that's OK. You can let me know if you don't want to continue the conversations, or if that's too uncomfortable for you, you can just ignore my calls and emails and I will get the point and I will leave you alone." So I definitely left that option open. And in a couple of instances, people took it. I was very aware I didn't want anyone to die for the sake of a story and certainly not for my story.

Amy Salit and Seth Kelley produced and edited the audio of this interview. Bridget Bentz, Molly Seavy-Nesper and Deborah Franklin adapted it for the Web.

• right to die
• physician-assisted suicide

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The NHS defines Euthanasia as “Euthanasia is the act of deliberately ending a person’s life to relieve suffering.” The word “euthanasia” derives from the Greek ‘eu’ signifying ‘good’ and ‘Thanatos’ meaning ‘death.’ Countries such as Canada, Switzerland, Belgium, Luxembourg, France, America, and the Neverlands have legalized euthanasia. However, at present...

The NHS defines Euthanasia as “Euthanasia is the act of deliberately ending a person’s life to relieve suffering.” The word “euthanasia” derives from the Greek ‘eu’ signifying ‘good’ and ‘Thanatos’ meaning ‘death.’ Countries such as Canada, Switzerland, Belgium, Luxembourg, France, America, and the Neverlands have legalized euthanasia. However, at present Euthanasia remains illegal in the UK. Euthanasia is intensely debated due to its moral, ethical, and emotional complexities. Due to modern medical advances, people can live longer, so the question of euthanasia becoming legalized is raised. There are various arguments supporting and opposing legalizing euthanasia within the UK. This essay will outline the differing arguments for and against euthanasia. Highlighting, the ethical and moral debates and the implications of euthanasia being legal.

“Many of us would like to have some control over the time and manner of our deaths, should we find ourselves in a condition so hopeless that there is no point in going on…” (Thomas Nagel, London Review of Books. 2011.) One supporting argument for legalizing Euthanasia is having the choice. “It’s important to give people with dementia choice and control over their life whenever possible.” (George McNamara, Head of Policy at the Alzheimer’s Society, 2013.) This argument suggests, a person should have the choice of choosing when they die. This argument is based on the principles of human rights. It is suggested that a person has the basic human right to live, they should also have the right to choose when to die. If it is your body, it should be your preference. Furthermore, it raises the question is it right to keep someone alive if they want to die due to excruciating pain?

Secondly, an argument often debated in favor of euthanasia is allowing a patient to die with self-respect. “In refusing dying people the right to die with dignity, we fail to demonstrate the compassion that lies at the heart of Christian values.” (Archbishop Desmond Tutu, Washington Post 2010.) The argument for authorizing euthanasia suggests Euthanasia gives a sense of control to a dying person consequently; they feel comforted that their wishes will be met. What is more, relatives feel comforted as the patient’s suffering and pain have ended. Euthanasia will enable a person to die with dignity. In addition, terminally ill people often become bedridden with terminal illnesses. Legalizing euthanasia in the UK would enable terminally ill people to die comfortably in a monitored environment. It offers a sense of control to the patient; it allows them to decide how they want to be remembered by relatives. Furthermore, patients no longer fear the pain and suffering they would endure without the option of euthanasia.

Additionally, Legalising euthanasia will enable the person to avoid caregiver guilt. For example, someone who does not want to continue to live with a debilitating terminal disease would opt for euthanasia to relieve themselves of being a financial burden or burden to relatives who would care for them. Euthanasia would also allow a patient to die in their own country without having to travel.

Furthermore, and conceivably the strongest argument supporting Euthanasia being legalized in the UK, is the ending of pain and suffering for the terminally ill. By enabling euthanasia to be legalized within the UK, it will enable a person to die without having to endure potential years or months of suffering. As Stephen Hawkins stated, “We don’t let animals suffer, so why humans?’

On the other hand, one counterargument for legalizing euthanasia for the terminally ill is terminal diagnosis is not always accurate. The argument disputes it difficulty of determining a person’s life expectancy. In 2005 a study conducted by the Mayo Clinic found one in five people had an accurate diagnosis. Some people live longer. Therefore, legalizing Euthanasia it has the potential to end a person’s life prematurely.

In addition, the argument regarding consent is highly debated. This argument expresses the issues regarding a person’s frame of mind in order to give consent. For example, a person in extreme pain may opt for euthanasia without fully understanding and considering consequences and other options of care.

Moreover, the argument of the potential misuse of euthanasia is often conveyed. A disadvantage to legalizing euthanasia for the terminally ill is the potential for misuse and abuse of the vulnerable. This argument suggests a patient may be subject to pressure from the family or doctors to opt for euthanasia. Patients may feel as though they are a burden to family and doctors. Research conducted through Age UK has indicated that about 500,000 elderly individuals are mistreated each year in the UK. Consequently, the argument against Euthanasia expresses the point of protecting the vulnerable. Would patients feel protected?

Finally, Palliative care is an argument opposing euthanasia. It is disputed that a terminally ill person can have a good quality of life in their final months and weeks due to palliative care. In addition, a patient should not feel as though they are being persuaded into euthanasia. A doctor is meant to heal a patient and aid them in their time of need, to prolong and protect life not cut life short. The argument expresses that doctors should act in a patient’s best interests, but with a nation obsessed with the cost of the NHS would people be talked into Euthanasia to save money?

In conclusion, Euthanasia is a highly passionate debate with many moral and ethical complexities. The debate on legalizing euthanasia is continuous due to the advances in medicine people are living longer with debilitating terminal illnesses. The question regarding legalizing euthanasia remains. The implications of legalizing euthanasia could be good or bad depending on your personal stance. The potential consequences of legalizing euthanasia in the UK for the terminally ill is hard to ignore. Safeguarding issues and protecting the vulnerable is one of the potential challenges. Nevertheless, it is near impossible to deny a person in pain the right to opt for euthanasia.

Bibliography

• Aaron Scherer. (2020). A brief history of euthanasia. Available: https:www.theodysseyonline.combrief-history-of-euthanasia. Last accessed 100121.
• BBC publication. (2014). Euthanasia and physician-assisted suicide. Available: http:www.bbc.co.ukethicseuthanasia. Last accessed 100121.
• NHS Publication. (2020). Euthanasia and assisted suicide. Available: https:www.carenotkilling.org.ukarticlesmps-speeches-the-arguments. Last accessed 100121.
• Paul Goodman. (2011). Euthanasia Pros and Cons: should people have the right to die? Available: https:soapboxie.comsocial-issuesEuthanasia-pros-and-cons-Should-people-have-the-right-to-die#:~:text= Pros of Euthanasia 1 People should,if they are not conscious, it…. Last accessed 100121.
• Publication, My death my decision. (2018). My Death, My Decision (MDMD). Available: https:www.mydeath-mydecision.org.uk. Last accessed 100121.
• Publication. (unknown). Medical Diagnosis and Prognosis are often Wrong. Available: https:euthanasiadebate.org.nzresourcesdiagnosis-and-prognosis-are-often-wrong#:~:text=A study of doctors’ prognoses for terminally ill, disease over time and the ch. Last accessed 100121.
• Sarah Bosley. (2013). Professor Stephen Hawking backs the right to die for the terminally ill. Available: https:www.theguardian.comscience2013sep17stephen-hawking-right-to-die. Last accessed 100121.
• unknown. (2015). MP’S Speeches: the arguments. Available: https:www.carenotkilling.org.ukarticlesmps-speeches-the-arguments. Last accessed 100121.

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Essay on Euthanasia: 100, 200 and 300 Words Samples

• Updated on  
• Feb 22, 2024

Essay on Euthanasia: Euthanasia refers to the act of killing a person without any emotions or mercy. Euthanasia is an ethnically complex and controversial topic, with different perspectives and legal regulations on different topics. School students and individuals preparing for competitive exams are given assigned topics like essays on euthanasia. The objective of such topics is to check the candidate’s perspectives and what punishment should be morally and legally right according to them. 

If you are assigned an essay on euthanasia, it means your examiner or teacher wants to know your level of understanding of the topic. In this article, we will provide you with some samples of essays on euthanasia. Feel free to take ideas from the essays discussed below.

Master the art of essay writing with our blog on How to Write an Essay in English .

Table of Contents

• 1 Essay on Euthanasia in 150 Words
• 2.1 Euthanasia Vs Physician-Assisted Suicide
• 2.2 Euthanasia Classification
• 3 Is Euthanasia Bad?

Essay on Euthanasia in 150 Words

Euthanasia or mercy killing is the act of deliberately ending a person’s life.  This term was coined by Sir Francis Bacon. Different countries have their perspectives and laws against such harmful acts. The Government of India, 2016, drafted a bill on passive euthanasia and called it ‘The Medical Treatment of Terminally Ill Patient’s Bill (Protection of Patients and Medical Practitioners). 

Euthanasia is divided into different classifications: Voluntary, Involuntary and Non-Voluntary. Voluntary euthanasia is legal in countries like Belgium and the Netherlands, with the patient’s consent. On one side, some supporters argue for an individual’s right to autonomy and a dignified death. On the other hand, the opponents raise concerns about the sanctity of life, the potential for abuse, and the slippery slope towards devaluing human existence. The ethical debate extends to questions of consent, quality of life, and societal implications.

Also Read: Essay on National Science Day for Students in English

Essay on Euthanasia in 350 Words

The term ‘Euthanasia’ was first coined by Sir Francis Bacon, who referred to an easy and painless death, without necessarily implying intentional or assisted actions. In recent years, different countries have come up with different approaches, and legal regulations against euthanasia have been put forward. 

In 2016, the government of India drafted a bill, where euthanasia was categorised as a punishable offence. According to Sections 309 and 306 of the Indian Penal Code, any attempt to commit suicide and abetment of suicide is a punishable offence. However, if a person is brain dead, only then he or she can be taken off life support only with the help of family members.

Euthanasia Vs Physician-Assisted Suicide

Euthanasia is the act of intentionally causing the death of a person to relieve their suffering, typically due to a terminal illness or unbearable pain. 

Physician-assisted suicide involves a medical professional providing the means or information necessary for a person to end their own life, typically by prescribing a lethal dose of medication.

In euthanasia, a third party, often a healthcare professional, administers a lethal substance or performs an action directly causing the person’s death.

It is the final decision of the patient that brings out the decision of their death.

Euthanasia Classification

Voluntary Euthanasia

It refers to the situation when the person who is suffering explicitly requests or consents to euthanasia. A patient with a terminal illness may express his or her clear and informed desire to end their life to a medical professional.

Involuntary

It refers to the situation when euthanasia is performed without the explicit consent of the person, often due to the individual being unable to communicate their wishes.

Non-Voluntary

In this situation, euthanasia is performed without the explicit consent of the person, and the person’s wishes are unknown.

Active euthanasia refers to the deliberate action of causing a person’s death, such as administering a lethal dose of medication.

It means allowing a person to die by withholding or withdrawing treatment or life-sustaining measures.

Euthanasia and assisted suicide are a defeat for all. We are called never to abandon those who are suffering, never giving up but caring and loving to restore hope. — Pope Francis (@Pontifex) June 5, 2019

Also Read: Essay on Cleanliness

Is Euthanasia Bad?

Euthanasia is a subjective term and its perspectives vary from person to person. Different cultures, countries and religions have their own set of values and beliefs. Life is sacred and gifted to us by god or nature. Therefore, intentionally causing death goes against moral and religious beliefs. 

However, some people have raised concerns about the potential for a slippery slope, where the acceptance of euthanasia could lead to the devaluation of human life, involuntary euthanasia, or abuse of the practice. Some even argue that euthanasia conflicts with their traditional medical ethics of preserving life and prioritizing the well-being of the patient.

Today, countries like the Netherlands and Belgium have legalised euthanasia. In India, the USA and the UK, it is a punishable offence with varying sentences and fines. Euthanasia is a complex and controversial topic and creating a law against or for it requires a comprehensive study by experts and the opinions of all sections of society. 

Ans: Euthanasia refers to the act of killing a person without any emotions or mercy. Euthanasia is an ethnically complex and controversial topic, with different perspectives and legal regulations on different topics.

Ans: The term ‘Euthanasia’ was first coined by Sir Francis Bacon, who referred to an easy and painless death, without necessarily implying intentional or assisted actions. In recent years, different countries have come up with different approaches, and legal regulations against euthanasia have been put forward.  In 2016, the government of India drafted a bill, where euthanasia was categorised as a punishable offence. According to Sections 309 and 306 of the Indian Penal Code, any attempt to commit suicide and abetment of suicide is a punishable offence. However, if a person is brain dead, only then he or she can be taken off life support only with the help of family members.

Ans: Belgium and the Netherlands have legalised euthanasia. However, it is banned in India.

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• Euthanasia and Physician Assisted Suicide - Are they clinically necessary or desirable?
• Policy and Ethics
• Ethical Issues
• Essays and articles

Euthanasia and Physician Assisted Suicide

Are they clinically necessary or desirable, by dr. roger woodruff, this book is available for free in pdf format for iahpc members.

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Any opinions are those of the author and not necessarily those of IAHPC

Copyright © 2019 Roger Woodruff

© All rights reserved. IAHPC permits educational and scientific use of this publication. IAHPC prohibits the commercial use or reproduction and distribution of this material without authorization.

Published by IAHPC Press 5535 Memorial Drive, Suite F- 509, Houston TX, 77007, USA

I. DEFINITIONS

Euthanasia is ‘a deliberate intervention undertaken with the express intention of ending a life so as to relieve intractable suffering’ (House of Lords, 1994; Walton, 1995). If it is performed at the dying person's request, it is voluntary; otherwise, it is non-voluntary. The terms ‘active’ and ‘passive’ may be misleading (Walton, 1995).

PHYSICIAN-ASSISTED SUICIDE

Physician-assisted suicide (PAS) is defined as the provision of help by a doctor to a competent patient who has formed a desire to end his or her life (Walton, 1995). In PAS, the physician provides the necessary knowledge and means (equipment, drugs) but the act is completed by the patient. It is similarly a deliberate act with the express intention of ending life and is not ethically or morally distinguishable from euthanasia.

The performance of assisted suicide by persons other than physicians, as occurs in Switzerland, is ethically and morally equivalent to PAS.

TERMINATION OF LIFE WITHOUT EXPLICIT REQUEST

In Holland and Belgium, euthanasia is defined as being at the patient’s request, so cases of ‘ending of life without the patient’s explicit request’ have to be counted separately. It is ethically and morally no different to euthanasia.

INTENSIFIED TREATMENT OF PAIN AND SYMPTOMS

Intensified treatment of pain and symptoms may be entirely clinically appropriate, the possibility of life-shortening being acknowledged, but not intended.

In contrast, intensified treatment of pain and symptoms performed with the intention of hastening death or ending life, is no different to euthanasia—these are deaths caused by the active intervention of the physician.

WITHHOLDING/WITHDRAWING TREATMENT

Withholding or withdrawing therapy may be entirely clinically appropriate, the possibility of life-shortening being acknowledged, but not intended.

In contrast, withholding or withdrawing therapy performed with the intention of hastening death or ending life, is no different to euthanasia—these are deaths caused by the active intervention of the physician.

TERMINAL SEDATION

Continuous sedation until death (CSD) for the management of severe and refractory symptoms in the last days or week of life may be entirely clinically appropriate therapy, the possibility of life-shortening being acknowledged, but not intended.

In contrast, CSD performed with the intention of hastening death or ending life is no different to euthanasia—these are deaths caused by the active intervention of the physician.

THE SLIPPERY SLOPE

The ‘slippery slope’ is the gradual extension of assisted suicide to widening groups of patients after it is legally permitted for patients designated as terminally ill (Hendin, 1997a).

Manifestations include

• Increased numbers of deaths per year
• Increased proportion of requests granted
• Terminally ill to not terminally ill
• Unbearable suffering to ‘tired of life’
• Adults to children
• Inclusion of patients with dementia or psychiatric disease

Henk Jochemsen (Director, Lindeboom Institute for Medical Ethics, the Netherlands): ‘The Dutch experience shows that once the termination of patients’ lives is practised and that practice wins official toleration or approval, the practice develops a dynamic of its own that resists effective control.’ (Jochemsen, 1994)

Herbert Hendin (Medical Director of Suicide Prevention Initiatives (SPI) and Professor of Psychiatry at New York Medical College): ‘Virtually every guideline set up by the Dutch—a voluntary, well considered, persistent request; intolerable suffering that cannot be relieved; consultation; and reporting of cases—has failed to protect patients or has been modified or violated.’ (Hendin, 2002)

José Pereira (Head of Palliative Care at the University of Ottawa): ‘Abuse of guidelines has occurred in every jurisdiction around the world where assisted dying has been legalized.’ (Pereira, 2011)

TERMINOLOGY

A range of euphemisms have been developed to avoid the terms euthanasia and PAS, particularly the stigma of the word ‘suicide’. These include ‘death with dignity’, ‘medical assistance in dying’, and ‘the peaceful alternative’. But these terms do not alter the nature of the act and, where possible, are avoided.

Daniel Callahan (co-founder and President Emeritus of The Hastings Center): ‘The advocates for physician-assisted suicide make use of a favourite method from the spin-tool box, that of obfuscation, defined in dictionaries as an effort to render something unclear, evasive, or confusing.’ (Callahan, 2008)

Robert Twycross (Reader, Oxford University): ‘[The pro lobby’s] attempt to ‘prettify’ the language of death by not using terms such as assisted suicide, euthanasia, and killing…’ (Twycross, 1990)

Wesley J. Smith (journalist and author of Forced Exit): ‘According to Compassion & Choices, when a terminally ill patient swallows an intentionally prescribed lethal overdose of barbiturates, it isn’t really suicide. Why? Because the word ‘suicide’ has negative connotations, and C&C wants people to feel positive about some self-killings.’ (Smith, 2013)

II. WHAT’S HAPPENED

During the last 30 years, euthanasia and/or physician-assisted suicide (PAS) have been legalized in a number of countries. In chronological order, these are The Netherlands, the Northern Territory of Australia, Oregon (USA), Belgium, and Canada. Legal change was not required to allow assisted suicide in Switzerland.

A. THE NETHERLANDS

1. background.

‘The 1960s and 1970s were a watershed for Dutch society. From a conservative, tradition-bound country, the Netherlands transformed itself into a hotbed of social and cultural experimentation’ (Weyers, 2012). Amongst these were the ideals of patient autonomy and assisted dying (Angell, 1996). There are a number of good accounts of the saga of Dutch euthanasia (Hendin, 1997b; Hendin, 2002; Ten Have and Welie, 2005; Griffiths et al, 2008; Youngner and Kimsma, 2012; Keown, 2018).

In about 1990, formalized guidelines for the practice of euthanasia and physician-assisted suicide were issued (Walton, 1995). These were:

• The request for euthanasia must come only from the patient and must be entirely free and voluntary;
• The patient's request must be well considered, durable and persistent;
• The patient must be experiencing intolerable suffering with no prospect of improvement;
• Alternatives to alleviate the patient's suffering must have been considered and found wanting;
• Euthanasia must be performed by a doctor;
• The doctor must consult an independent colleague, before performing euthanasia;
• The doctor must submit a written report to the appropriate authority.

In 2002, the practices became legally regulated with the passage of the Termination of Life on Request and Assisted Suicide (Review Procedures) Act by the Dutch Parliament (see Parliament of the Netherlands).

End of Life Clinic

In 2012, the Dutch Association for Voluntary Euthanasia (NVVE) founded the End-of-Life Clinic or Levenseindekliniek (see Levenseindekliniek).

• It comprises teams of doctors and nurses who visit patients at home (‘the mobile life-ending clinics’) (Snijdewind et al, 2015).
• It provides euthanasia or PAS for patients who meet all the legal requirements but whose regular physician rejected their request.
• There is no prior doctor-patient relationship and they provide no palliative care.
• In the first twelve months of operation, the Clinic received 645 requests, of which 162 (25%) were granted (Snijdewind et al, 2015). The proportion of requests granted were 33% for patients with somatic complaints, 38% for cognitive decline, 5% for psychological disorders, and 28% for being ‘tired of life’.
• The number of patients receiving euthanasia from the Clinic increased from 53 in 2012 to over 400 in 2016 (Boer, 2016; see Levenseindekliniek).
• The End-of-Life Clinic has made application to health insurance companies to fund 30 more teams (Kimsma, 2016).

2. GUIDELINES

The current (2015) Regional Euthanasia Review Committees Code of Practice (see Regional Euthanasia Review Committees Code of Practice) states the physician must:

• Be satisfied that the patient’s request is voluntary and well-considered;
• Be satisfied that the patient is suffering unbearably, with no prospect of improvement;
• Have informed the patient about their situation and prognosis;
• Have concluded, together with the patient, that there is no reasonable alternative in the patient’s situation;
• Have consulted an independent physician, who must see the patient and provide a written opinion;
• Exercise due medical care in performing euthanasia; and

Provide a report to the appropriate authority.

In the accompanying notes, it explains:

• The patient does not have to have a terminal illness - the patient’s life-expectancy is not relevant;
• The physician and the patient do not need to be in a treatment relationship;
• There is no need for a written request;
• The request must be well-considered, but it need not be persistent;
• The request must be voluntary, without undue influence of others;
• Palliative sedation is not a ‘reasonable alternative’ within the meaning of the Act; palliative sedation is defined as ‘normal medical practice’ and is not euthanasia;
• It is not a requirement that the patient’s family be informed - their consent is not required;
• It applies to anyone aged 12 and over - parental consent is required for ages 12-15;
• Only a physician can perform euthanasia;
• The patient must be ‘decisionally competent’;
• For patients with psychiatric disorders, there is no requirement for psychiatric review;
• For patients who lack decisional competence and those with dementia, aphasia, reduced conscious state or in a coma, the physician can proceed with euthanasia provided there is a clear, written advance directive.

The Dutch have reported their practices each 5 years since 1990 (Table 1) (van der Maas et al, 1991; van der Maas et al, 1996; Onwuteaka-Philipsen et al, 2003; van der Heide et al, 2007; Onwuteaka-Philipsen et al, 2012b; van der Heide et al, 2017). The figures are also available from The Royal Dutch Medical Association (KNMG) website (see KNMG). Reports for 2016 and 2017 are available (see Regional Euthanasia Review Committees. Annual Reports).

Table 1. Frequency of Physician Assistance in Dying in the Netherlands - expressed as a percentage of all deaths

From van der Heide et al, 2017

• During the period 1990 to 2015, the incidence of euthanasia has risen from 1.7% to 4.5% of all deaths, or from about 2,190 to 6,000 cases per year (van der Heide et al, 2017).

Physician-assisted suicide

• A smaller number of patients undergo physician-assisted suicide, which has remained fairly constant over the years (van der Heide et al, 2017).

Ending of life without the patient’s explicit request

• In Holland, euthanasia is defined as being at the patient’s request, so cases of ‘ending of life without the patient’s explicit request’ are counted separately (Pijnenborg et al, 1993; Rietjens et al, 2007).
• Throughout the 1990s, there were 900-1,000 cases per year (van der Heide et al, 2007); the number has come down more recently, but there were still 440 deaths in 2015 (van der Heide, 2012; van der Heide et al, 2017).
• The following chart shows the approximate total number of deaths due to euthanasia, physician-assisted suicide, and life termination without explicit request.

Intensified treatment of pain and symptoms

• Intensified treatment for pain and symptoms was performed with the intention of ending life in 6% of cases in 1990 (van der Maas et al, 1991; Gunning, 1991; Keown 2002), and in 16% of cases in 1995 (van der Maas et al, 1996).
• Weyers (quoting from a Dutch publication) indicates the intention rate (explicit plus subsidiary) declined from 21% in 1990 to 3% in 2010 (Weyers, 2014).

Withholding or withdrawing therapy

• In the 1990 study, the number of patients in whom therapy was withheld or withdrawn, with the intention of ending life, was variously reported to be 12% or 16% of cases (van der Maas et al, 1991; Gunning, 1991).
• A 2006 study reported that withholding and withdrawing of therapy was performed with the explicit intention of hastening death in 45% of cases (Bosshard et al, 2006).
• The percentage of all deaths attributable to withholding/withdrawal of treatment performed with the explicit intention of hastening death during the period 1990 to 2010 varied between 8 and 13% (Weyers, 2014).

Continuous deep sedation until death (CSD)

• There is considerable variation as to what constitutes palliative sedation or terminal sedation (Krakauer and Quinn, 2010; Papavasiliou et al, 2014a; Taboda, 2015; Seymour et al, 2015; Henry, 2015; Sterckx et al, 2016).
• Guidelines for palliative sedation have been proposed (Cherny et al, 2009; Legemaate et al, 2007; Verkerk et al, 2007).
• Others question that distinction (Rady and Verheijde, 2010; Janssens et al, 2012; Boyle, 2015).
• CSD has the advantage that it requires no second opinion, does not have to be reported to authorities, and carries no risk of prosecution. Doctors have admitted they are using it with the intention of hastening death or ending life, i.e. it is euthanasia ‘in disguise’ (Rietjens et al, 2004; Griffiths et al, 2008; Taboda, 2015; Sterckx et al, 2016).
• Quoting data published in Dutch, Griffiths states that CSD was performed with the intention of hastening death in 5% of cases (Griffiths et al, 2008).
• In two separate studies, it was reported that CSD was performed with the intention of hastening death in 17% and 1% of cases (Rietjens et al, 2004 & 2006; Swart, 2013).

Totals for 1990-2015

Estimating the magnitude of the Dutch experiment with euthanasia and PAS is an informative exercise.

• Starting with the figures in Table 1 and using the total number of annual deaths from Statistics Netherlands (see Statistics Netherlands), it is possible to estimate the numbers for each form of assisted dying for each year 1990 to 2015; it is assumed that any increases or decreases between the 5-yearly observations were relatively smooth.
• The figures for euthanasia, physician-assisted suicide, and termination of life without explicit request are shown in Table 2 and add up to 115,000 deaths.
• For deaths associated with withholding/withdrawal of treatment, it is reported that it is performed with the intention of hastening death or ending life in 45% of cases (Bosshard et al, 2006), which averages out at about 8.3% of all deaths per year. Weyers reports that withholding/withdrawal of treatment with the explicit intention of hastening death or ending life accounted for between 8 and 13% of all deaths during the period 1990 to 2010 (Weyers, 2014). Using a conservative rate of 8% reveals that of the order of 285,000 people (Table 2) may have died after the withholding/withdrawal of treatment performed with the intention of hastening death.
• For deaths associated with continuous sedation until death (CSD), it is reported that this is performed with the intention of hastening death in 5-17% of cases (Griffiths et al, 2008; Rietjens et al, 2004). Using a conservative rate of 5% reveals that of the order of 12,100 people (Table 2) may have died after continuous sedation until death (CSD), performed with the intention of hastening death.

Table 2. Estimate of total numbers of deaths 1990-2015

The figures in Table 2 are calculated from the Dutch data. They are an approximation, given the limitations of the published data, but they suggest of the order of 450,000 people may have been involved in the Dutch experiment.

4. DO THEY MEET THEIR OWN GUIDELINES?

Be satisfied that it is requested

In the Netherlands, euthanasia is by definition requested, but

• It is stated that the decision to terminate life was not discussed with the patients because most of them were incompetent (van der Maas et al, 1991). But, 37% (1990) and 21% (1995) of them were reported to be competent (van der Maas et al, 1996; Jochemsen and Keown, 1999; Hendin, 2002).
• Some regard these deaths as simply part of ‘normal end-of-life medical practice’ (Rietjens et al, 2007).
• Others claim it is the doctor’s duty to ensure that his patient dies a ‘humane’ or ‘dignified’ death (Griffiths et al, 2008; Keown, 2013).
• ‘In 15% of cases where no discussion took place but could have, the doctor did not discuss the termination of life because the doctor thought that the termination of the patient’s life was clearly in the patient’s best interests.’ (Jochemsen and Keown, 1999).
• Keown provides some eye-opening quotes from Dutch doctors regarding these deaths without request: ‘It is the patient who is now responsible in the Netherlands for avoiding termination of his life; if he does not wish to be killed by his doctor then he must state it clearly, orally and in writing, well in advance.’ And ‘Due consideration should be given to the question how termination of life without explicit request can be prevented. It should be the responsibility of the patients…’ (Keown, 2013).
• For some patients given intensified treatment of pain and symptoms, where the treatment was given with the intention of hastening death, it had not been discussed with them and was therefore not requested (Jochemsen and Keown, 1999).
• The decision was made without any patient involvement in 50-60% of cases, mainly because of incompetence, although in 20% of the cases there was no discussion for ‘paternalistic’ reasons (Pijnenborg et al, 1994 & 1995).
• There was no discussion with the patient in 17% of cases treated by withholding/withdrawal of therapy, where it was done with the intention of hastening death (Groenewoud et al, 2000a).
• Terminal sedation was not discussed with the patient in 41% of cases (Rietjens et al, 2004).
• ‘The decision to use [continuous palliative] sedation was discussed with all competent patients, but in 18% this merely involved informing the patient.’ (Swart et al, 2012)

Be satisfied that the patient’s request is voluntary and free of coercion

• More than 50% of physicians believe it is appropriate for the physician to initiate the discussion or suggest euthanasia as an option (Hendin et al, 1997a; Hendin, 2002; Ten Have and Welie, 2005).
• 15% of nursing home physicians initiated the discussion of euthanasia (Muller et al, 1994).
• The pressures that make patients’ requests anything but voluntary and free of coercion are being ignored. As a member of a Regional Euthanasia Review Committee, Boer estimated that 10% of requests were seriously influenced by family issues, and that 50% of approaches to the End of Life Clinic were initiated by a relative of the patient (Boer, 2016).
• ‘A Dutch general practitioner had urged an unwilling patient to have euthanasia. To get away from such pressure, the woman engineered an inpatient admission. On the GP's return from holidays, he visited the patient and urged her to return home so that she could have euthanasia.’ (Twycross, 1996)
• ‘An elderly husband was dying of cancer and he and his wife agreed that euthanasia was not an option they wanted. Visiting friends and neighbours, however, put subtle pressure on the couple by expressing surprise that the husband had not yet opted for euthanasia.’ (Twycross, 1996)
• ‘A Dutch wife who no longer wished to care for her sick husband gave him a choice between euthanasia and admission to a home for the chronically ill. The man, afraid of being left to the mercy of strangers in an unfamiliar place, chose to be killed.’ (Hendin et al, 1997a)

Be satisfied that the patient’s request is well-considered

• An American anthropologist who studied euthanasia in the Netherlands painted a glowing picture of the time taken and devotion shown by Dutch physicians when it comes to euthanasia: ‘Euthanasia in the Netherlands involves discussions taking place over weeks, months, and sometimes years and does not largely focus on the final day itself.’ (Norwood, 2018)
• But a Dutch report stated: ‘The period of time between the first discussion of the subject and the actual administration varied from less than a day to…’ i.e. some people had euthanasia on the same day it was first spoken about (Muller et al, 1994).

Be satisfied that the patient is suffering unbearably

• Suffering is totally subjective and judgement of it is very variable (Rietjens et al, 2009; van Tol et al, 2010; Kimsma, 2012c).
• Attempts at a definition and scoring system add no objectivity (Dees et al, 2010; Ruijs et al, 2012).
• Unbearable suffering has come to include psychological and existential suffering, including ‘tiredness of life’.
• Of patients requesting euthanasia, 57% and 46% described unbearable suffering as ‘to prevent the loss of dignity’ and ‘unworthy dying’ (Jochemsen and Keown, 1999).

Be satisfied that there were no reasonable (therapeutic) alternatives

• Therapeutic alternatives were available in 17-35% of cases (van der Maas et al, 1991; van der Maas et al, 1996; Jochemsen and Keown, 1999; Hendin, 2002; Jansen-van der Weide et al, 2006; Buiting et al, 2009).
• The Euthanasia Review Committees were interested in the presence or absence of therapeutic alternative in only 1% of cases (Buiting et al, 2009).
• Pain management was independently assessed as inadequate in 54% of patients at the Netherlands Cancer Institute (Dorrepaal et al, 1989).
• The medical director of a hospice testified (c. 2004) that hospitals in general were ‘totally devoid of input from palliative care specialists’ (Keown, 2013).
• Of 450 patients referred to Hospice Rozenheuvel, 126 (28%) made an explicit request for euthanasia, but in the end only two patients were transferred to hospital to have euthanasia performed (Zylicz and Janssens, 1998).
• The discussion of ‘no realistic prospect of improvement’ must depend greatly on the knowledge and expertise of the physician in question.

Have consulted an independent physician, who must see the patient and provide a written opinion

• Consultation took place in only around half of all cases (Jochemsen and Keown, 1999; Hendin, 2002).
• For euthanasia in nursing homes, 15% of physicians did not seek a second opinion (Muller et al, 1994).
• Consultation occurred in 80% of reported cases, but in only 11% of unreported cases and 3% of cases involving termination of life without explicit request (Hendin, 2002).
• Consulting physicians were not independent in 60% of cases (Buiting et al, 2009).
• Consultation occurred in 85% of cases of euthanasia for patients with mental handicap, but it was often by another physician from the same nursing home (Muller et al, 1994).
• In another study of end-of-life decisions for mentally handicapped patients, only 46% of physicians sought a second opinion (van Thiel et al, 1997).
• Independence was compromised by repeated cross-referral between the same pairs of physicians, for convenience (Hendin, 1999; Onwuteaka-Philipsen et al, 1999).
• In one study, consultants did not see the patient in 12% of cases (Hendin, 1999).
• A special service—Support and Consultation on Euthanasia in the Netherlands (SCEN)—provides consultants who are independent in 85% of cases in which they are involved (Jansen-van der Weide et al, 2004 & 2007).
• But these reporting figures do not include the patients whose life was terminated without explicit request or those receiving intensified treatment of pain and symptoms, or withholding/withdrawal of therapy, or continuous deep sedation, performed with the specific intention of hastening death (Jochemsen and Keown, 1999; Hendin, 2002).
• In cases where life was terminated without explicit request 2 out of 1000 cases were reported in 1990 and 3 out of 900 in 1995, i.e. 0.26% (Lewy, 2011).

Euthanasia is performed only by medical doctors

• In a hospital study, nurses administered the euthanatics in 15% of cases (van Bruchem et al, 2008).
• The doctor was not present at the time of starting palliative sedation in one-third of cases (Brinkkemper et al, 2011).
• Now that it is legal for physicians to perform euthanasia, it is reported that nurses are doing it as well (Volker, 2015).

In summary , the Dutch themselves have documented that they have broken every one of their own guidelines.

5. ARE THE SYSTEMS OF REGULATION AND SAFEGUARDS EFFECTIVE?

Support and Consultation on Euthanasia in the Netherlands (SCEN)

• Starting in 2000, the Dutch established a network of specially trained SCEN physicians to whom GPs could turn for support, assistance and, when requested, to provide an independent consultant (Jansen-van der Weide et al, 2004 & 2007).
• SCEN physicians were found to put less emphasis on the psychological and social aspects of suffering (Albers et al, 2013).
• Uniformity of assessment between SCEN physicians was poor. (Ypma and Hoekstra, 2015)
• One specially trained SCEN physician, Dr Wilfred van Oijen, was convicted of murder for killing an 84-year-old woman who had not requested euthanasia and who was in a coma and not suffering unbearably. Although convicted of murder, his penalty was a one-week jail sentence, suspended for two years (Keown, 2012 & 2013).

Euthanasia Review Committees

• Five regional multidisciplinary Euthanasia Review Committees, comprising a judicial expert, a physician, and an ethicist have been in operation since 1998 (Kimsma and van Leeuwen, 2012b).
• The Committee reports are published (see Regional Euthanasia Review Committees Reports).
• One Dutch authority who supports euthanasia, John Griffiths, observed that a regime which relies on voluntary self-reporting by doctors ‘is by its very nature ineffective’ (Keown, 2013).
• ‘The Dutch [Euthanasia Review Committees] do not focus on whether patients should have received euthanasia or assisted suicide, but instead primarily gauge whether doctors conducted the euthanasia or assisted suicide in a thorough, professional manner. To what extent this constitutes enforcement of strict safeguards, especially when cases contain controversial features, is not clear.’ (Miller and Kim, 2017)
• During the period 2002-14, 75 cases were referred to the Public Prosecutor, none of which led to prosecution (Boer, 2016).
• A consultant’s failure to see the patient, a negative opinion by a consultant, or a failure to consult an independent consultant, is unlikely to trigger prosecution, because the Review Committees interpret the law in a ‘flexible way’ (Griffiths et al, 2008; Keown, 2012).
• The Review Committees have more recently come under attack for concealing the fact that incapacitated people were being surreptitiously killed. ‘The surreptitious administration of medication has previously occurred, but has never been mentioned in an annual report…Remaining silent about the precise way of execution appears very far removed from the transparency that the committee expects of doctors.’ (Chabot, 2017)

Henk ten Have (Professor of Medical Ethics at the University Medical Centre of Njmegen) and Jos Welie (Professor of Health Policy and Ethics, Creighton University, Omaha): ‘The important lesson to be learned from the Dutch experiment is the virtual impossibility of regulating the practice of euthanasia and PAS through public debate, laws and policies.’ (Ten Have and Welie, 2005)

Neil M Gorsuch (Associate Justice of the Supreme Court of the United States and author of The Future of Assisted Suicide): Does a regime dependent on self-reporting by physicians who have no interest in recording any case falling outside the guidelines adequately protect against lives taken erroneously, mistakenly, or as a result of abuse or coercion? How would we ever know? (Gorsuch, 2006)

6. IS THERE EVIDENCE OF A SLIPPERY SLOPE?

The ‘slippery slope’ is the gradual extension of assisted suicide to widening groups of patients after it is legally permitted for patients designated as terminally ill (Hendin et al, 1997a).

Paul van der Maas (Department of Public Health, Erasmus University, Rotterdam): ‘…whether the acceptance of euthanasia or assisted suicide when it is specifically requested by a greatly suffering, terminally ill, competent patient is the first step on a slippery slope that will lead to an unintended and undesirable increase in the number of cases of less careful end-of-life decision making and to the gradual social acceptance of euthanasia performed for morally unacceptable reasons.’ (van der Maas et al, 1996).

The data for the period 1990 to 2015 show

• Voluntary euthanasia for terminal disease has progressed to non-voluntary and involuntary euthanasia (‘life termination without explicit request’).
• Euthanasia numbers (deaths per year) continue to increase.
• The proportion of the requests for euthanasia that are being granted has increased from 26% in 1990 to 55% in 2015 (van der Maas et al, 1991; Onwuteaka-Philipsen, 2018).
• When voluntary euthanasia for terminal illness was allowed, Dutch doctors performed euthanasia on patients with non-terminal illnesses including psychiatric disorders and mental handicap (Groenewoud et al, 1997; van Thiel et al, 1997).
• It is now no longer necessary for the patient to have terminal or incurable illness. Euthanasia is available to anyone with suffering, no matter what their life expectancy may be.
• Suffering includes psychosocial suffering, including ‘being tired of life’ and ‘loss of dignity’.
• Euthanasia for psychiatric disorders and dementia are now accepted.
• Euthanasia is available for 12-year-olds.
• Euthanasia is permitted on the basis of advance directives for patients who lack decisional capacity.
• The assertion that vulnerable groups are not adversely affected by assisted dying (Battin et al, 2007) has been challenged (Finlay and George, 2011).
• There are assertions that terminal sedation is being used instead of euthanasia because it does not require a second opinion, it does not have to be reported, and it carries no risk of prosecution (Rietjens et al, 2004; Griffiths et al, 2008; Sterckx et al, 2016).

The Dutch view

One of the better descriptions of the ‘slippery slope’, written in 2017, went as follows: ‘The core of this argument is that as soon as euthanasia is allowed at all, even if only under certain conditions, it will necessarily follow that euthanasia will in future be performed under less stringent conditions and will eventually degenerate into an absolutely abject form of euthanasia, such as killing people involuntarily.’

• I thought that was not a bad description of what the Dutch tell us has happened in the Netherlands.
• However, the authors of the above description vehemently deny that anything like that has happened in the Netherlands. They are both Consultants (in Health Law and Bioethics) to the pro-euthanasia Royal Dutch Medical Association (KNMG) (de Jong and van Dijk, 2017).
• Many Dutch publications claim that their reports show absolutely no evidence of a slippery slope, a view shared by some overseas commentators (Angell, 1996; Battin, 2005; Battin et al, 2007).
• One Dutch authority regards the slippery slope argument as ‘intrinsically incoherent’ and declares the Netherlands has slithered up the slippery slope, ‘slipping into more control and into more careful practice’ (Griffiths et al, 2008).

The alternative view

It is not possible to list all the publications attesting to the existence of a slippery slope, but I include several good reviews that I have seen (Hendin, 1997a; Jochemsen and Keown, 1999; Hendin, 2002; Keown, 2002; Ten Have and Welie, 2005; Randall and Downie, 2009; Keown, 2012 & 2013; Sprung et al, 2018; Keown, 2018).

Richard Fenigsen (Dutch cardiologist): ‘Dutch doctors who practice euthanasia are not on the slippery slope. From the very beginning, they have been at the bottom.’ (Fenigsen, 1997)

Karl Gunning (Director of the (anti-euthanasia) Dutch Physicians Union): ‘Once you start looking at killing as a means to solve problems, you’ll find more and more problems where killing may be the solution.’ (Koch, 1996)

Tom Koch (University of British Columbia, Vancouver, Canada): ‘Limited and closely regulated euthanasia for persons with a terminal illness [c. 1990] has been an expanding field that now [c.1995] includes patients with chronic conditions—for example ALS, Down’s syndrome, clinical depression, and anorexia nervosa—and those in the earlier or chronic phase of illnesses that may eventually prove terminal: Alzheimer disease, Parkinson’s disease, multiple sclerosis and AIDS.’ (Koch, 1996)

José Pereira (Head of the Division of Palliative Care, University of Ottawa): ‘In 30 years, the Netherlands has moved from euthanasia of people who are terminally ill, to euthanasia for those who are chronically Ill; from euthanasia for physical illness, to euthanasia for mental illness; from euthanasia for mental illness, to euthanasia for psychological distress or mental suffering—and now to euthanasia simply if a person is over the age of 70 and ‘tired of living’.’ (Pereira, 2011)

Margaret Somerville (Professor of Bioethics at University of Notre Dame in Australia) describes two types of slope: the “practical slippery slope”—which involves abuses of euthanasia once it is seen as legally acceptable, and the “logical slippery slope”—on which the people eligible for euthanasia and the circumstances in which it may be provided inevitably expand (Somerville, 2016).

Robert Twycross (Emeritus Reader, Oxford University): ‘Once the barrier of legislation is passed, medically assisted dying takes on a dynamic of its own and extends beyond the original intent, despite earlier explicit assurances that this would not happen.’ (Twycross, 2016)

7. DOES IT REDUCE THE (NON-ASSISTED) SUICIDE RATE?

• ‘In many publications offered by advocates of a more liberal government policy on PAD [physician-assisted death], PAD is said to be an alternative for patients who otherwise would choose to have a suicide.’ (Boer, 2016)
• The suicide rate in the Netherlands went from 8.3 per 100,000 (1,353 deaths) in 2007 to 11.1 per 100,000 (1,871 deaths) in 2015 (see Statistics Netherlands).
• So, not only did the suicide rate increase by 38%, but it did so since 2007 when assisted dying became more accessible for the categories of people that commit suicide—the people with chronic diseases, including psychiatric diseases, dementia, and others (Boer, 2014).
• The suicide rates in the Netherlands are the fastest growing when compared to surrounding European countries, most of which lack the option of euthanasia (Boer, 2017).

8. OTHER ISSUES/CONCERNS

(i). ‘Normalization’ of euthanasia

• (ii). End of life Clinic

(iii). Management of patients with psychiatric disorders or dementia

(v). Children

(vi). Amyotrophic lateral sclerosis (ALS)

(vii). Lack of physical disease

(viii). Euthanasia using opioids

(ix). Amount of life lost

(x). Contradiction of autonomy

• (xi). Voluntary refusal of food and fluids

(xii). Arrogance

• (xiii). Existential suffering for patients en route to assisted dying
• Insufficiently precise or strict were inevitably stretched, and there has been unrelenting progression towards euthanasia being ‘normalized’—euthanasia has become just another option, perhaps even the default one, and has progressed from an exceptional act to a legal right (Keown, 2018).
• ‘In the Netherlands, there has been a shift from PAD [physician-assisted dying] as a last resort to PAD as a default way to die…PAD is increasingly becoming a patient’s right, a default way to die, and a default way to deal with life’s difficulties.’ (Boer, 2016)

(ii) End of Life Clinic

• The End of Life Clinic, where there is no therapeutic relationship between doctor and patient, was responsible for 75% of the chronic psychiatric patients who underwent euthanasia in 2016 (Cook, 2017).
• The doctors working within the End of Life Clinic consider themselves at the ‘forefront’ and call the clinic a ‘centre of expertise’ (Chabot, 2017).
• Within the clinic, a group culture has emerged in which euthanasia is considered to be ‘virtuous labor’, especially in severe dementia and chronic psychiatric patients (Chabot, 2017).

Psychiatric examination of those requesting assisted dying

• Only 3% of persons requesting euthanasia were referred to a psychiatrist (Hendin, 2002).
• Psychiatric examination may reveal undiagnosed psychiatric issues in patients requesting euthanasia: 5 of 22 cancer patients were refused euthanasia for psychiatric reasons (Bannink et al, 2000).
• 56% of patients who requested euthanasia, and who were then subjected to psychiatric evaluation, had their request denied due to the existence of a treatable mental disorder, because the decision was not well considered, or the decision-making was influenced by transference and countertransference (Groenewoud et al, 2004).
• In a study of 128 cancer patients with less than 3 months to live, depression was 4.1 times more common in those requesting euthanasia (van der Lee et al, 2005).
• A study of patients withdrawing a request for euthanasia reported that they had more mental health problems and less mental clarity (Marcoux et al, 2005).

Assisted dying for people with psychiatric disorders

• In 1994, the Dutch Supreme Court ruled that euthanasia or assisted suicide were justifiable for a patient with severe psychic suffering due to a depressive illness and in the absence of a physical disorder or a terminal condition (Ogilvie and Potts, 1994).
• 64% Dutch psychiatrists were supportive of assisted dying for patients with a mental disorder in the absence of physical illness (Groenewoud et al, 1997).
• Patients having euthanasia for psychiatric disorders were predominantly women, 55% were depressed; other conditions included eating disorders, prolonged grief, and autism (Kim et al, 2016).
• The number of patients with chronic psychiatric conditions undergoing euthanasia increased sharply from 2009 to 2016 (Cook, 2017).
• The Review Committees have now admitted that that incapacitated people are being surreptitiously killed (Chabot, 2017).
• Decisions about euthanasia for patients with psychiatric disease are made difficult by the impossibility of being certain about incurability and the therapist’s inability to assess the patient’s wish to die (Schoevers et al, 1998).
• The Dutch guidelines for physician-assisted suicide in the mentally ill do not take into account the uncertainty of prognosis, the potential variability of outcome of treatments of suicidality, and the boundary violations that are involved for the psychiatrist (Kissane and Kelly, 2000).
• Examination of the details (as submitted to the Euthanasia Review Committee) of the capacity examination of psychiatric patients who underwent euthanasia suggests the examination was frequently inadequate and that a high threshold for the assessment of capacity was not required for granting euthanasia (Doernberg et al, 2016).
• In a report on six patients with an intellectual disability and/or autism spectrum disorder, tests of decisional capacity did not seem stringent enough (Tuffrey-Wijne et al, 2018).

Dr Boudewijn Chabot (psychiatrist and father figure of Dutch euthanasia): ‘The euthanasia practice is running amok because the legal requirements which doctors can reasonably apply in the context of physically ill people, are being declared equally applicable without limitation in the context of vulnerable patients with incurable brain diseases. In psychiatry, an essential limitation disappeared when the existence of a treatment relationship was no longer required. In the case of dementia, such a restriction disappeared by making the written advance request equivalent to an actual oral request. And lastly, it really went off the tracks when the review committee concealed that incapacitated people were surreptitiously killed.’ (Cook, 2017)

• There are increasing numbers of patients with dementia who are requesting euthanasia, but management remains controversial (Rurup et al, 2005c; de Beaufort and van de Vathorst, 2016).
• There has been a rapid increase in the numbers of patients with dementia undergoing euthanasia, from 12 in 2009 to 141 in 2016 (Cook, 2017).
• There should be no doubt regarding the genuineness of the advance directive.
• But Dutch law does not require the directives to be signed or witnessed, and patients’ families have been suspected of manufacturing the directives (Griffiths et al, 2008; Keown, 2012).

Victor Lamme (Professor of Cognitive Neuroscience at the University of Amsterdam): Referring to the treatment of the demented Hannie Goudriaan by the End of Life Clinic —‘the euthanasia doctor found in her pronunciation of the word ‘huppakee’ [hoppity] sufficient evidence for a clear and present desire to die.’ (Lamme, 2016)

Dr Boudewijn Chabot (psychiatrist and father figure of Dutch euthanasia): ‘In 2016, there were three reports of euthanasia of deep-demented persons who could not confirm their death wish. One of the three was identified as having been done without due care; her advance request could be interpreted in different ways. The execution was also done without due care; the doctor had first put a sedative in her coffee. When the patient was lying drowsily on her bed and was about to be given a high dose, she got up with fear in her eyes and had to be held down by family members. The doctor stated that she had continued the procedure very consciously.’ (Chabot, 2017)

• Of all deaths due to AIDS during the period 1984-93, euthanasia and assisted suicide accounted for an increasing proportion – up to 23% in 1993 (Bindels et al, 1996; Onwuteaka-Philipsen and van der Wal, 1998).
• 70% of euthanasia and assisted suicide for AIDS were performed by general practitioners (Onwuteaka-Philipsen and van der Wal, 1998); I remember the management of AIDS at that time as being a rapidly changing specialty, both in terms of effective palliative care and the new antiviral therapies, neither of which I would have expected a GP to be fully abreast of.
• The Dutch figures indicate a lack of knowledge and expertise in palliative care of the physicians concerned and/or the lack of palliative care services as, in contrast, there was only one request for euthanasia in 1800 admissions to the Mildmay Mission Hospital (AIDS Hospice) in London over a three-year period (McKeogh, 1997).
• The criticisms in McKeogh’s paper are primarily directed at the physician’s in the San Francisco Bay Area, a majority of whom admitted to physician assisted suicide for patients with AIDS (Slome et al, 1997), but are equally applicable to the Dutch: ‘The reasons for the patient’s request for a lethal prescription is not raised. Is he afraid of pain, the process of dying, or a loss of dignity? Has he witnessed the painful death of someone close to him? Would holistic care attentilie to his symptoms and also his psychological, social, and spiritual needs, as well as those of his care givers, have obviated the need for a lethal prescription?’ (McKeogh, 1997)
• The justification for allowing euthanasia in minors is buttressed mostly by the principles of beneficence and respect for autonomy (Cuman and Gastmans, 2017).
• There are cogent arguments against the practice (Kaczor, 2016).
• Euthanasia for children was conceivable to 81% of paediatricians. The paediatricians interviewed felt a duty to relieve suffering, irrespective of the patient's age or competency to decide (Bolt et al, 2017).
• In the Netherlands,seriously ill children who experience ‘constant and unbearable suffering’ may request death by lethal injection if they convey a ‘reasonable understanding of the consequences’ of that request. I would take that to mean that the child has significant insight regarding dying and death, which would therefore be a prerequisite to the implementation of the request.
• Modern neuro-psychological and fMRI (functional Magnetic Resonance Imaging) studies of the relationship between the neuro-anatomical development of the brain in human beings and their emotional and experiential capacity demonstrates that both are not fully developed until the early 20s for girls and mid-20s for boys (Mendelson and Haywood, 2014).
• In 2002, 20% of ALS deaths were by euthanasia (Veldink et al, 2002).
• In 2009, 17% of deaths were by euthanasia and 15% by continuous deep sedation until death (Maessen et al, 2009).
• In another study, the most frequently reported reason for claiming unbearable suffering was ‘fear of choking to death’ (Maessen et al, 2010), although a large German/English study did not report this as a clinical issue in the last 24 hours of life (Neudert et al, 2001).
• A recent review described the European experience with ALS and assisted dying as ‘disconcerting’ (Russell and Simmons, 2018).
• The three symptoms that were cited most frequently when requesting assisted suicide were 'feeling bad', 'tired', and 'not active' (Rurup et al, 2005b).
• The most frequently mentioned reasons for requesting euthanasia were ‘pointless suffering’, ‘loss of dignity’, and ‘weakness’ (Jansen-van der Weide et al, 2005).
• Being ‘tired of living’ accounts for 17% of requests for euthanasia, 28% of whom have no other serious disease (Rurup et al, 2005a & 2005b).
• A proportion of Dutch physicians will consider euthanasia for elderly patients without severe disease but who are ‘weary of life’ (Rurup et al, 2005a).
• We are informed that the syndrome of ‘life being completed and no longer worth living’ can be objectively diagnosed by the presence of its five constituent elements: a sense of aching loneliness, the pain of not mattering, the inability to express oneself, multidimensional tiredness, and aversion towards feared dependence (van Wijngaarden et al, 2015).
• Dutch euthanasia deaths caused by opioids are not being reported and the numbers are unknown (Rurup et al, 2008 & 2009; Onwuteaka-Philipsen, 2012a).
• Some physicians believe deliberate ending of life with opioids falls within ‘normal medical practice’ and doesn’t constitute euthanasia.
• This is based on the reports that careful use of opioids in terminal care was not associated with shortening of life (Thorns and Sykes, 2000; Sykes and Thorns, 2003), but ignores the well-known fact that opioids used in higher doses are very effective at causing death.
• The use of opioids in standard euthanasia fell from 39% in 1995 to 16% in 2005, although an opioid remained the drug of choice for ending life without explicit request (Rurup et al, 2009).
• Many Dutch publications include earnest arguments about how little loss of life is associated with euthanasia and other life-ending procedures. This is meaningless nonsense as our ability to accurately predict the life expectancy of an individual patient, except in the last few days of life, is quite inexact (Glare et al, 2003; Randall and Downie, 2009).
• Common sense suggests you would tend to underestimate the amount of life lost for the person whose life you had just terminated.
• Two methods of estimating life lost with continuous sedation gave discordant results (Bruinsma et al, 2014).
• But five of the patients underwent euthanasia at the time of the initial AIDS-defining illness when, according to the current evidence at that time, the average life expectancy was two to three years (Marriott and McMurchie, 1996).
• Advocates of assisted dying hold patient autonomy to be sacred.
• But it is the doctor, not the patient, who decides whether or not the patient will have assisted dying.
• Euthanasia is used more frequently than PAS (see Tables 1 & 2).
• Attempted PAS required a lethal injection in 18% of cases (Groenewoud et al, 2000b).
• ‘Patients' perception of total control over this type of death [euthanasia and physician-assisted suicide] is illusory.’ (George et al, 2005)

(xi). Voluntary refusal of food and fluids (VRFF)

• This topic is not discussed at length in the Dutch literature.
• One published study showed it was well tolerated, even in the elderly; thirst was not a problem provided the mucus membranes of the mouth were lubricated (Chabot, 2012).
• It is claimed that euthanasia had been discussed previously with the majority of the patients who lacked decisional competence and had their life terminated without explicit request (van der Maas et al, 1991 & 1996; van der Heide et al, 2007).
• Dutch patients, we are told, frequently discuss assisted dying with their doctor early in the course of a serious illness. ‘Many patients want an assurance that their doctor will assist them to die should suffering become unbearable…[But] we found that about two-thirds of these requests never end up as a serious or persistent request [for euthanasia] at a later stage of the disease.’ (van der Maas et al, 1991)
• This means that the fact that euthanasia was mentioned in passing months or years earlier is used by Dutch doctors to legitimize their performance of life termination without request, although if the patients had been competent, perhaps two-thirds of them would not have been requesting euthanasia.
• It has been alleged that ‘Dutch doctors lie about their actions when not taking part in an anonymous study with guaranteed legal immunity’ (Fergusson et al, 1991).

(xiii). Existential suffering for patients en route to euthanasia

• Little attention is paid to what may be considerable existential suffering of elderly patients between choosing to have euthanasia and having it done (van Wijngaarden et al, 2016).

9. SOME FINAL WORDS

• Johannes van Delden (Professor of Medical Ethics, University Medical Center, Utrecht): It is difficult to relate the numbers and the increases over time with the statement ‘The Dutch medical profession itself believes that euthanasia must always remain an exception. Euthanasia…must always be the last resort.’ (van Delden et al, 2004)
• Richard Fenigsen (Dutch cardiologist): ‘”Voluntary” euthanasia also brings an ominous change in society because of the message it sends to the elderly and sick, the weak and the dependent.’ (Fenigsen, 1989)
• Theo Boer (Professor of Health Care Ethics at Kampen Theological University in the Netherlands, who was previously pro-euthanasia and served on a Regional Euthanasia Review Committee from 2005 to 2014): ‘I have become painfully aware [of] the possibility [that] euthanasia and assisted suicide increasingly contributes to a culture of death. I am deeply convinced that this leaning towards death increasingly influences severely impaired, deeply suffering, and elderly people to consider active killing as their only way out.’ (Boer, 2014)
• Els Borst (the doctor/Health Minister who guided the euthanasia legislation through the Dutch parliament). She admitted in 2009 that the government did not give enough attention to palliative care and support for the dying, that the legalization of euthanasia came ‘far too early’, and that there had been a decline in the quality of care for the terminally ill since then (Craine, 2009; Keown, 2012).
• Gerrit Kimsma (Associate Professor of Medical Philosophy, Free University Center for Ethics and Philosophy, Amsterdam): ‘Some physicians practice assisted dying without the emotional and moral sensitivity that we have argued is necessary to restrain the practice.’ (Kisma and Clark, 2012a)
• Margo Trappenburg (Associate Professor of Governance at Utrecht University, and someone who has been very involved in the development of Holland’s euthanasia policies): ‘Perhaps we should be allowed to be smug about our euthanasia policy, as something we managed to accomplish, something we really did right.’ (Trappenburg, 2012)
• Boudewijn Chabot (psychiatrist and father figure of Dutch euthanasia): ‘I don’t see how we can get the genie back in the bottle. It would already mean a lot if we’d acknowledge he’s out.’ (Cook, 2017)

B. THE NORTHERN TERRITORY (AUSTRALIA)

The Rights of the Terminally Ill (ROTI) Act was passed by the parliament of Australia’s Northern Territory in May 1995. This was the first time, anywhere in the world, that euthanasia and physician-assisted suicide were made legal (Ryan and Kaye, 1996a).

The Act came into effect in July 1996 and was repealed in March 1997 by the federal Australian Government.

The ROTI Act was for patients who were terminally ill, required consultation with specialists in both psychiatry and palliative care, and involved a 2-week waiting period.

During the 9 months of operation, seven patients sought euthanasia under the Act. Two died before it was enacted and one after it was repealed. Four patients died from euthanasia. They all had cancer. Pain was not a prominent symptom and fatigue, frailty, depression and social isolation contributed more to the suffering of the patients (Kissane et al, 1998).

4. OTHER ISSUES/CONCERNS

(i). Depression

• (ii). Influence of the media
• The clinical studies illustrated the difficulties diagnosing and assessing depression in the terminally ill (Kissane et al, 1998).
• The patients’ stories highlighted the importance of demoralization as a significant mental state influencing the choices these patients made (Kissane and Kelly, 2000; Kissane, 2002).
• Despite an Australian study documenting the link between depression and a wish to die (Hooper et al, 1996), as well as a review of the difficulties that may be experienced in diagnosing depression in the terminally ill (Ryan, 1996b), the politician responsible for the introduction of the ROTI legislation, Marshall Perron, stated ‘I understand severe depression to be fairly readily recognizable. You don’t have to have a huge string of qualifications.’ (Perron, 1996).

(ii). The influence of media

• The ROTI legislation provoked much discussion in the Australian media.

Fran McInerney (Professor of Aged Care, Australian Catholic University, studied the representations of death, dying and medicine during the period 1995-1997): ‘The media's predilection for reporting dramatic and unusual death coincided with the [requested death] movement's construction of contemporary dying as horrific, intractable, and intolerable…The framing of requested death activists as heroes, and of requested death itself as a redeeming and transforming act for those seeking it, were preeminent in press portrayals.’ (McInerney, 2006)

C. OREGON (USA)

The Oregon Death with Dignity Act (DWDA), legalizing physician-assisted suicide (PAS), was passed by a voter referendum in November 1994.

• Only 1,254,265 people voted that day, with 51% voting in favor of the DWDA (see OSOS);
• Which means the Act was supported by only 34.9% of registered voters.
• Because of a series of legal challenges, the DWDA was not enacted until 1997.

A 1995 survey of Oregon physicians showed that 60% favored legalization of PAS, but less than half (46%) said they might possibly participate (Lee et al, 1996).

• Over 50% of Oregon physicians were not confident they could predict a prognosis of 6 months or less (Lee et al, 1996).
• There were concerns about the possible complications of the procedure.

A national survey reported 3% of physicians had participated in PAS (Meier et al, 1998).

• Patients requesting assistance were seriously ill, near death, and had a significant burden of pain and physical discomfort.
• Nearly half were described as depressed at the time of the request.
• Patients with severe pain or physical discomfort were more likely to have their request granted (Meier et al, 2003).

A legal dissection of the Oregon and Washington State Acts concluded ‘[The Acts] are not about patient "choice" and "control." These laws instead enable people to pressure others to an early death or to even cause that death on an involuntary basis.’ (Dore, 2010)

The DWDA (see Oregon Death With Dignity Act) provides for a person who

• Is 18 years of age or older;
• If there is concern that depression may be interfering with decisional competence, they must be referred to a mental health specialist;
• Is a resident of Oregon;
• Is suffering from a terminal disease with a life expectancy of 6 months or less;
• Has voluntarily expressed his or her wish to die, and
• Has made a written request, witnessed by two others.

The DWDA requires

• The first is to the ‘attending physician’.
• The second is to the ‘consulting physician’ who must confirm the patient has a terminal illness, is capable, and has made the request voluntarily.
• One written request, witnessed by two others.
• A minimum waiting period of 15 days from first request to procedure.
• The lethal medication must be self-administered by the patient.
• The certified cause of death is the underlying disease, and assistance in dying is not included on the Death Certificate.
• A summary of the data for 2017 and for the first 20 years are available at the Oregon Health Authority website (see Oregon Death with Dignity Act).
• Progress reports have appeared in the medical literature (Chin et al, 1999; Sullivan et al, 2000 & 2001; Hedberg et al, 2002 & 2003; Blanke et al, 2017).
• 218 patients received lethal prescriptions, written by 92 physicians.
• There were 143 deaths, including 14 individuals given a prescription in previous years.
• Patient age, type of disease and reason for request were similar to previous years.
• Only five patients (2.3%) were referred for psychological or psychiatric evaluation.
• 1,967 patients have received lethal prescriptions.
• 1,275 have died from ingesting the medication.
• The number of DWDA deaths has increased each year (1998: 16; 2017: 143) and the rate of change has increased significantly in the last five years (Table 3) (see Oregon Death with Dignity Act).
• Only 4.9% were referred for psychological or psychiatric evaluation.
• 72% of patients were 65 years or older.
• Underlying disease: cancer (78%), neurological disease including ALS (11%), respiratory disease (5%), and cardiovascular disease (4%).
• Inadequate pain control or concerns about it were cited in only 26% of cases.
• In a list of the 7 most frequent reasons for requesting PAS, pain or fear of future pain ranked 6th.

Table 3. Number of PAS deaths in Oregon, 1998-2017

• In 2017, morphine was used more frequently than in previous years: (see Oregon Death with Dignity Act)
• 1997-2016: barbiturates were used in 94% of cases and morphine in 6%;
• 2017: 54% barbiturates and 46% morphine.

That it was requested

• In contrast to Holland and Belgium, no attempt has been made to assess whether any patients had suffered ‘life termination without request’. Officially, what is not reported to the Oregon Health Authority does not exist.

That the request was voluntary, without coercion

• The doctor is expected to judge voluntariness without any requirement to interview those close to the patient or make any other relevant enquiries (Hendin and Foley, 2008).
• 43.7% of patients cited external pressures—‘being a burden to family, friends/caregivers’—as a reason for requesting PAS (see Living and Dying Well).
• A list of alleged abuses of the DWDA has been compiled by the Disability Rights Education and Defense Fund (see DREDF) and the Physicians for Compassionate Care Education Foundation (see PCCEF).
• The pro-assisted suicide organization, Compassion and Choices, was reported to be involved with 97% of assisted suicides in Oregon in 2009 (see Patients Rights Council).

That the patient requesting was competent

• The diagnosis of depression may well be missed (Pignone et al, 2002; Brietbart et al, 2010a).
• Few doctors, other than psychiatrists, are familiar with formal assessment of decision-making capacity (Fairman and Irwin, 2016).
• Whilst patients may be competent at the time they receive their lethal prescription, no attempt is made to ensure they are competent at the time they elect to use it (Ganzini, 2014).

That the patient had a terminal illness

• The DWDA’s definition of terminal illness can include chronic, treatable conditions like insulin-dependent diabetes, which if not treated may lead to the death of the patient (see Living and Dying Well).
• It is noted that lethal prescriptions have been issued for reasons of caregiver burden and so as not to disappoint the family (Foley and Hendin, 2002; Keown, 2013).

That the patient had a prognosis of 6 months or less

• Estimating prognoses of 6 months or less is difficult, more so in patients with non-malignant disease (Glare et al, 2003; Randall and Downie, 2009).
• Lynn has pointed out the ambiguity of the 6-month rule—it could mean that a person is nearly certain to die within 6 months, is very likely to die, or that 51 percent of people with a similar condition will be dead within 6 months (Lynn, 2018).
• The median interval between initial request and death was 48 days, but with a range of 14-1009 days (0.5-33 months).
• In every year except the first, some patients have survived beyond 6 months.

That there was discussion of alternatives, including palliative care

• The doctor is expected to inform patients that alternatives are possible without being required to be knowledgeable about such alternatives or to consult with someone who is (Hendin and Foley, 2008).
• There are reported cases in which the presentation of alternatives, including palliative care, were manifestly inadequate (Hendin and Foley, 2008).
• A palliative care consultation was recommended for only 13% of patients requesting PAS (Ganzini et al, 2000b).
• The availability and quality of palliative care in Oregon have been criticized (Hendin and Foley, 2008).
• The more physicians know about palliative care, the less they favor assisted suicide; the less they know, the more they favor it (Portenoy et al, 1997).

The consulting physician

• There is no information regarding the independence of the second or consulting physician, or their attitude to assisted dying. Are they known advocates for assisted dying, recommended by Compassion and Choices, who provide pro forma/rubber stamp second opinions?

The self-administration of medication

• Self-administration was touted as one of the key safeguards of the Oregon law.
• There is no information as to whether the medication was self-administered in the 60% of cases where no health care provider was known to be present (see Oregon Death With Dignity; see Patients Rights Council; see Not Dead Yet).
• For the same 60%, there is no information regarding the psychological state at the time at the time the lethal medication was taken.
• For the same 60%, there is no information regarding coercion at the time of taking the medication. (It is an offence to coerce a patient to request assisted suicide, but not to coerce them to take the lethal medication).
• There are reports of patients being actively ‘assisted’ with taking the lethal medication (Hamilton, 2002; Keown, 2013).
• In 1999, the deputy attorney general of Oregon issued an official opinion, indicating that lethal injection may need to be accepted in order not to violate the Americans with Disabilities Act (Hamilton, 2002). There is no further statement as to whether or not euthanasia by lethal injection is being used in Oregon.
• The role of the Oregon Health Authority (OHA) is simply the passive recording of information, without any active surveillance or investigation (see Oregon Health Authority).
• All reporting of cases is by the physician who prescribed the lethal medication, who has every incentive to report that all is well.
• The monitoring process in Oregon has been described as a case of ‘Don’t Ask, Don’t Tell’, designed to cover up rather than reveal problems, and yielding only limited data which does not reveal what happened in any particular case (Foley and Hendin, 1999).
• The OHA has only very limited data and what it has is largely kept secret, which has been referred to as a ‘veil of confidentiality’ and a ‘culture of silence’ (Foley and Hendin, 2002; Hamilton, 2002; Keown, 2013).
• The prohibition of any reference to assisted dying on Death Certificates makes any meaningful review impossible.
• There is no information to document that the patients met the guidelines as set out above, including having decisional competence and an illness that is terminal.
• This includes cases in which it is alleged nurses performed assisted dying but were not prosecuted.
• A review of the DWDA by a group representing people with disabilities commented on inadequate demographic profiling of DWD requesting patients, inadequate mental health evaluations, insufficient duration of physician-patient relationships, potential inaccuracy of the six-month prognosis, and inadequate exploration of alternative treatment. It concluded that the DWDA lacked sufficient safeguards (Drum et al, 2010).

In summary, one has to agree with the accusation that the Oregon law provides inadequate safeguards and lacks any enforcement of safeguards (Ganzini, 2016).

• The number of lethal prescriptions provided (1998: 24; 2017: 218) and the number of DWDA deaths (1998: 16; 2017: 143) have both increased nine-fold during the period 1998-2017. The rate of change has increased significantly in the last five years (see Oregon Death With Dignity).
• The restriction to a prognosis of 6 months has been challenged (see Patients Rights).
• There are calls for more liberal laws with regard to mental health (Ganzini, 2016).
• According to some, the supporters of the DWDA have been encouraged not to seek extension of the law because of concerns that it ‘would send the wrong message to lawmakers considering similar laws in other states’ (see Living and Dying Well).
• Kim Callinan (CEO of the pro-euthanasia organization, Compassion and Choices), suggests that assisted dying laws allow the terminally ill to access assisted suicide, which in turn will lead to a reduction in non-assisted suicides (Callinan and Silva, 2018).
• The suicide rate in Oregon in 2012 was 42% higher than the national average (Shen and Millet, 2012).
• During the period 1998-2012 (during which time the DWDA was operative), the non-assisted suicide rate increased from under 14 to 17.7 per 100,000 (Shen and Millet, 2012; Jones and Paton, 2015).
• (ii). Lack of physical suffering
• (iv). Vulnerable groups
• (v). Complications of the procedure
• (vi). Relatives’ mental health
• (vii). Interface between PAS and palliative care
• (viii). Duration of physician/patient relationship
• (ix). Compassion and Choices disgraces

(x). Oregon Health Plan Bastardry

• (xi).Voluntary refusal of food and fluids (VRFF)

The DWDA does not exclude patients with depression, just those in whom depression is impairing their judgement around desire for death (Ganzini, 2014).

• This is in sharp contrast to most other reports that show a strong correlation between depression and the wish to die (Breitbart et al, 2000; Rosenfeld et al, 2000 & 2006; Fairman and Irwin, 2016).
• Ganzini maintains the incidence of depression is low, based on her study in which social workers (not physicians, never mind psychiatrists) were asked to give a gut-feeling score for depression on a scale of 1 to 5, without bothering to use any of the clinically validated instruments for the diagnosis of depression (Ganzini and Hedberg, 2018).
• Ganzini reported that for patients given a prescription for lethal medication, those with depression were significantly more likely to use it (3/3 patients vs. 9/15) (Ganzini et al, 2008).
• In patients with advanced disease, major depression is under-diagnosed and under-treated (Breitbart et al, 2010a).
• The diagnosis of depression is frequently missed in routine (non-psychiatric) clinical practice (Pignone et al, 2002).
• ‘Only 6% of Oregon psychiatrists were confident that in a single evaluation they could adequately assess whether a psychiatric disorder was impairing the judgement of a patient requesting assisted suicide.’ (Ganzini et al, 1996)
• Some don’t ask: two doctors associated with Compassion in Dying (now Compassion and Choices) approved a man’s request for a lethal prescription, having failed to elicit his long past history of depression and multiple attempted suicides (Hendin and Foley, 2008).
• Ganzini argues that there is no reason to stop patients with depression (except those with impaired competence) from accessing PAS (Ganzini, 2014), despite evidence from her own studies show that the treatment of depression may reduce the wish to die (Ganzini et al, 1994, 2000b & 2008).

Depression causing impaired competence

• May well miss the diagnosis of depression (Pignone et al, 2002; Breitbart et al, 2010a).
• Is not likely to be familiar with formal assessment of decision-making capacity (Fairman and Irwin, 2016).
• 73% indicated that 2 independent examinations were needed to determine competence.
• 58% believed major depression should result in an automatic finding of incompetence.
• Ganzini regarded these attitudes as unacceptable as they were contrary to the patients’ rights to autonomy. She attributed them to the ethical views and morals of the psychiatrists concerned, rather than their psychiatric skills (Ganzini et al, 2000a).
• There is admission that the DWD system may fail to protect some patients with major depression from getting prescriptions for lethal medication (Ganzini et al, 2008).
• In 2014, Ganzini discussed mandatory psychiatric assessment (which might protect some vulnerable patients) but argued that it should not be considered as it would impair or impede the goal to ‘advance patient autonomy’ (Ganzini, 2014).
• In 2016, commenting on one of her own studies, Ganzini wrote ‘this finding supports the need for more active and systematic screening and surveillance for depression…’ (Ganzini, 2016)

(ii). Lack of Physical Suffering

• PAS was sold to the voters as reasonable treatment for patients with unrelievable physical suffering (Foley and Hendin, 2002).
• ‘Many, if not most, of those who want PAS want it not to relieve suffering as ordinarily understood but to maintain control over their dying, something that may not correlate at all with suffering from illness and disease…’ (White and Callahan, 2000).
• A 2015 study showed PAS requesters had higher levels of depression, hopelessness and dismissive attachment (Smith et al, 2015).
• These patients wanted to control the timing and manner of death and to avoid dependence on others (Ganzini et al, 2003a & 2008).
• Whilst there may be concerns about future pain, current pain and other physical symptoms were rated as unimportant (Ganzini et al, 2009b).

Daniel Sulmasy (Medical Ethicist, Kennedy Institute of Ethics and the Edmund D. Pellegrino Center for Clinical Bioethics, Georgetown University): ‘Rather than having severe physical or mental suffering, patients who follow through on PAS in the USA appear to have a distinct personality type, characterized by a need for control and a dismissive attitude towards other persons. They represent only about 0.5% of the US population, and the question arises whether the risks to the other 99.5% of the population justify acceding to the wishes of this small minority.’ (Sulmasy, 2017)

(iii). Amyotrophic Lateral Sclerosis (ALS)

• 5% of ALS deaths were PAS, c.f. 0.4% of cancer deaths (Ganzini and Block, 2002).
• There is evidence that depression, sialorrhea, hypoventilation, and dysphagia were undertreated; their proper treatment might improve the quality of life and reduce interest in assisted dying (Ganzini and Block, 2002).
• There was no relationship between cognitive impairment, depression, and interest in assisted death in a larger cohort (Rabkin et al, 2016).

(iv). Vulnerable Groups

• The high incidence of psychological and non-somatic symptoms suggests ‘that abuse of the vulnerable will likely occur in Oregon over time.’ (White and Callahan, 2000).
• Some regard the increased numbers of patients with depression as exploitation of a vulnerable group (Ganzini et al, 2008).
• A report claimed no evidence of any effect on vulnerable groups in Oregon (Battin et al, 2007), although this has been challenged (Finlay and George, 2011).
• The statistical observation of no increased numbers from vulnerable groups does not necessarily mean their vulnerability has not been exploited, or that their deaths were not the result of malice or mistake (Keown, 2013).

(v). Complications of the Procedure

• For the approximately 600 patients for whom information is available, the time to unconsciousness after taking the medication was 1-240 minutes, but the time to death varied from I minute to 104 hours (see Oregon Death With Dignity; Ganzini and Hedberg, 2018).
• A survey of American oncologists reported that PAS failed in 15% of cases (Emanuel et al, 1998a).
• PAS in the Netherlands required intervention (i.e. euthanasia by injection) in 18% of cases (Groenewould et al, 2000b).
• Their subsequent course is described thus: ‘for some it was minimal level of awareness with death occurring within a few days, whereas another individual awoke after 3 days and lived for 3 more months.’
• 25 patients were reported to have suffered difficulty ingesting and/or regurgitation of the medication (see Oregon Death With Dignity).
• It should be noted that in 60% of the cases, where a health care provider was not present, there is no information about complications (see Patients Rights Council).
• The cost of the medications has increased to around $4,000-5,000.

(vi). Relatives’ Mental Health

• A report on relatives of patients requesting PAS, 14 months after the suicide, reported 11% major depression, 2% prolonged grief reaction and 38% had required mental health care. It was claimed that PAS had no negative effect on the mental health of family members (Ganzini et al, 2009a).

(vii). Interface between PAS and Palliative Care

• According to ‘a recognized expert in palliative care, bioethics and health care communication skills’, palliative care teams can be fully participatory in programs of assisted dying, although writing prescriptions for lethal medication would be left to someone else (Harman, 2018).
• This is the model promoted by the Belgians in which euthanasia is seen as an integral and necessary part of palliative care.
• Over many years, I have repeatedly been impressed when one or other member of the palliative care team has made that extra effort, gone the extra mile, to deal with a patient’s suffering. That will never happen if it is likely (or possible) that the patient will have euthanasia in a week’s time.
• The difficulties in trying to integrate palliative care and assisted dying programs are substantial (Campbell and Cox, 2012; Campbell and Black, 2014; Harman, 2018).
• It is noteworthy that 46% of patients requesting PAS changed their mind after a substantive palliative intervention (Ganzini et al, 2000b).
• But most physicians are not adequately trained in palliative care and hence are unable to effectively present alternatives to patients requesting assisted suicide (Hendin et al, 1998; Hendin, 2002; Hendin and Foley, 2008).
• The OHA maintains that patients requesting PAS were receiving adequate end of life care (see Oregon Health Authority); information from a number of sources does not support this contention (Hendin and Foley, 2008).

(viii). Duration of the physician/patient relationship

• The prescribing physicians had known the patient for a median duration of 13 weeks (range 0-2138) before the patient’s suicide (see Oregon Death With Dignity).

(ix). Compassion and Choices Duplicity

• But when approached by Ganzini to participate in a study of whether receiving a prescription resulted in reduction of anxiety and increased sense of peace (which I thought was a worthy question), Compassion and Choices refused (Ganzini, 2014).
• The are multiple reports of patients with a terminal illness receiving letters from the Oregon Heath Plan, refusing cover for the costs of treatment of their underlying disease, but informing them they would be covered for doctor-prescribed suicide (Dore, 2010; Keown, 2012; see Patients Rights Council).
• A study of VRFF reported a very good median quality of death of 8 (on a scale of 0-9) (Ganzini et al, 2003b).

Dan Diaz (member of the Latino Leadership Council of Compassion and Choices) is quoted as saying that all PAD [physician-assisted dying] deaths are ‘gentle, peaceful’, whilst all non-PAD deaths are ‘struggling and in pain’ (Diaz, 2018).

Compassion & Choices Medical Aid in Dying Fact Sheet (December 2016):

‘Medical aid in dying is a safe and trusted medical practice because the eligibility requirements ensure that only mentally capable, terminally ill adults with a prognosis of six months or less who want the choice of a peaceful death are able to request and obtain aid-in-dying medication…Almost two decades of rigorously observed and documented experience in Oregon shows us the law has worked as intended, with none of the problems opponents had predicted.’ (see Compassion and Choices)

Daniel Callahan (co-founder and President Emeritus of The Hastings Center): He described the safeguards in Oregon as ‘regulatory obfuscation. They look good, sound good, feel good, but have nothing behind them.’ (Callahan, 2008)

John Keown (Professor in the Kennedy Institute of Ethics at Georgetown University): ‘The next steps in Oregon…seem predictable. If autonomy and beneficence justify ‘terminally ill ’ patients obtaining prescriptions for lethal drugs then they justify non-terminally ill patients obtaining them, not least as they may have many years and not just a predicted six months of illness to endure. It is only a matter of time until the requirement of a ‘ terminal illness ’ is removed by legislation or struck down by a court as unjustifiably discriminatory…Moreover, if autonomy and beneficence justify lethal prescriptions they also justify lethal injections, especially for those too disabled to lift or swallow a lethal cocktail. It is, again, only a matter of time before a right to a lethal injection is upheld, either by legislation or by a court holding that their prohibition discriminates against the disabled…’ (Keown, 2018)

• The Belgian Parliament passed the Law on Euthanasia in May 2002. An unofficial English translation is available (Jones et al, 2017). A further law was passed in February 2014, legalizing euthanasia for children.
• A public opinion poll by the daily newspaper La Libre Belgique in 2001 reported 72% in favor of legalization of euthanasia (Griffiths et al, 2008).
• A study from the Flanders region of Belgium reported 65% of physicians to be in favor of legalization of euthanasia (Miccinesi et al, 2005).
• In contrast to the Royal Dutch Medical Association (KNMG), the equivalent professional organization in Belgium, the Order of Physicians, ‘has shown no willingness to bear any responsibility for either the content or the maintenance of the new norms’, for which it has been strongly criticized (Griffiths et al, 2008).

Life End Information Foundation ( LEIF)

• Following legalization, the Life End Information Foundation (LEIF) was formed to provide specifically trained physicians to act as consultants with euthanasia requests (Cohen et al, 2014).

Federal Control and Evaluation Commission on Euthanasia (FCECE)

• All reported cases of euthanasia are reviewed by the Commission.

2. THE GUIDELINES

I was unable to find any governmental document listing the legal requirements in English. The following is largely taken from Griffiths (Griffiths et al, 2008).

If the patient expected to die in near future

• The patient must be 18 years or older;
• The patient must be legally competent and conscious at the time of request;
• The request must be voluntary, well considered, repeated, and not the result of external pressure;
• The patient must have persistent and unbearable physical or mental suffering that cannot be alleviated, resulting from a serious and incurable disorder caused by illness or accident;
• The physician must discuss the condition and life expectancy, including the possibilities of other treatments and palliative care, and must have several conversations with the patient over a reasonable period of time;
• It should be noted that there is no legal requirement for the two doctors to agree (Nys, 2017).

If the patient is not expected to die in the near future

In addition to the requirements listed above—

• The physician must obtain the opinion of a second, independent physician, who is a psychiatrist or a specialist in the disorder in question, who must see the patient and provide a written report;
• Allow at least one month after receipt of the request.

The request

• If the patient is not able, it must be written by a person designated by the patient, who must be 18 years or older and have no material interests in the death;
• The patient suffers from a serious and incurable disorder;
• The patient is no longer conscious;
• The unconsciousness and underlying condition are irreversible.
• Physicians performing euthanasia must notify the Federal Control and Evaluation Commission on Euthanasia.

The 2014 law allowing euthanasia for children (Raus, 2016)

• For children experiencing ‘constant and unbearable suffering’;
• Requires the child’s own voluntary and explicit request;
• Requires parental consent;
• Requires verification of the child’s ‘capacity to judge’ (capacité de discernment).
• There are no age limits;
• Children with an intellectual disability or mental illness are excluded.
• The number of cases of euthanasia reported to the Commission has increased each year, from 0.2% of all deaths in 2003 to 1.7% in 2013 (Table 4) (Dierickx et al, 2016).
• The 2014-2015 Report of the Commission shows the annual totals to have gone up further, to 1,928 in 2014 and to 2,022 in 2015 (see Institut).
• The Commission Report indicates a total of 12,726 deaths from euthanasia between 2002 and 2015, rising from 235 in 2003 to 2,022 in 2015 (see Institut).
• However, the reports of the physician questionnaires in Flanders (the Dutch-speaking half of Belgium) reveal higher numbers and indicate the number of cases of euthanasia has increased from 0.3% of all deaths in 2001 to 4.6% in 2013 (Table 5) (Bilsen et al, 2009; Chambaere et al, 2015b).
• This indicates that in 2013 were approximately 2,800 deaths from euthanasia in Flanders alone (Chambaere et al, 2015b).

Table 4. Frequency of reported cases of euthanasia - whole of Belgium

From Dierickx et al, 2016

Table 5. Frequency of physician assistance in dying - Flanders

From Bilsen et al, 2009 and Chambaere et al 2015

Physician-assisted suicide (PAS)

• PAS is not included in the Euthanasia Law of 2002 and is technically not legal.
• Cases of PAS reported to the Commission are accepted (because the law does not specify the manner in which euthanasia must be performed) and counted with the euthanasia cases.
• The data from the surveys of physicians in Flanders indicates very few cases of PAS: 0.05% of all deaths in 2013, or about 3 cases (Chambaere et al, 2015b).
• As in Holland, euthanasia is defined as being requested, so cases of life termination without explicit request have to be counted separately.
• This rate of life termination without explicit request in Flanders is more than double the rate in the Netherlands (Chambaere et al, 2015b).
• There are currently calls to legalize life-ending without request (Jones, 2017).
• Intensified treatment of pain and symptoms may be entirely clinically appropriate, with the possibility of life-shortening being acknowledged, but not intended.
• In contrast, intensified treatment of pain and symptoms performed with the intention of ending life, is no different to euthanasia—these are deaths caused by the active intervention of the physician.
• Intensified therapy for pain and symptoms was involved in 22% of all deaths in 2001, 26.7% in 2007, and 24.2% in 2013 (Table 5) (Bilsen et al, 2009; Chambaere et al, 2015b).
• Withholding or withdrawing therapy may be entirely clinically appropriate, with the possibility of life-shortening being acknowledged, but not intended.
• In contrast, withholding or withdrawing therapy performed with the intention of ending life, is no different to euthanasia—these are deaths caused by the active intervention of the physician.
• A single study reports that withholding or withdrawing of treatment was performed with the explicit of hastening the end of the patient’s life in 38% of cases (Bosshard et al, 2006).

Continuous sedation until death (CSD)

• CSD for severe and refractory symptoms in the last days or week of life may be entirely clinically appropriate therapy, with the possibility of life-shortening being acknowledged, but not intended.
• There are many inconsistencies between different studies as to exactly what constitutes CSD (Claessens et al, 2008; Taboda, 2015; Stierckx et al, 2016).
• CSD performed with the intention of hastening death or ending life is no different to euthanasia—these are deaths caused by the active intervention of the physician.
• Reports indicate that CSD was performed with the specific intention of hastening death in 3-24% of cases [Pousset et al, 2011; Papavasiliou et al, 2014a; Rys et al, 2014a).
• Another report indicates CSD is used where there is personal, family or institutional reluctance regarding euthanasia (Sterckx and Raus, 2017).
• CSD was initiated without consent or request, either of the patient or of the family, in 28% of cases (Sterckx and Raus, 2017).

That the procedure is requested

• As in Holland, the definition of euthanasia is that it is requested.
• A 2007 study reported life termination without explicit request was not discussed with the patient in 78% of cases (Chambaere et al, 2010).
• Intensified treatment of pain and symptoms is sometimes employeded with the specific intention of hastening death, and may not be discussed with the patient; no discussion implies no request (Bilsen et al, 2004a).
• Withholding or withdrawing of therapy is sometimes performed with the specific intention of hastening death, and may not be discussed with the patient; no discussion implies no request (Bilsen et al, 2004a; Bosshard et al, 2006).
• CSD was not discussed with some patients who were competent; no discussion implies no request (Anquinet et al, 2011).

That the request is in writing

• Requests were not in writing for 50% of reported cases in 2007 and 31% of cases in 2013 (Chambaere et al, 2015b).
• In the unreported cases, 88% lacked a written request (Smets et al, 2010).

That the person is competent and conscious

• There is no requirement for psychiatric or psychological examination.

That the patient has a serious and incurable disorder causing persistent and unbearable suffering

• The euthanasia law requires ‘persistent and unbearable physical or mental suffering that cannot be alleviated, resulting from a serious and incurable disorder caused by illness or accident.’
• cancer (68%)
• disorders of gait and mobility due to osteoporosis;
• limitation of movement resulting in a loss of autonomy;
• eye disorders, resulting in inability to read a newspaper or watch TV, causing social isolation;
• hearing impairment, preventing social contact;
• cardiac disease reducing the patient’s real living space, leading to loneliness;
• the onset of dementia.
• neurological disease (7%)
• cardiovascular disease (5%)
• mental and behavioral disorders (3%) – including dementia
• The 2015 report admits the law is being interpreted in a liberal or flexible manner to include ‘polypathologies’ and behavioral disorders.

There is discussion of treatment possibilities, including palliative care

• Few physicians have expertise in palliative care, severely limiting the palliative alternatives they might offer.

There is an independent second opinion

• A 2004 study reported that when life termination without explicit request was performed by GPs, it was often done without obtaining an independent second opinion (Bilsen et al, 2004a).
• In the reported cases, there is a second opinion in between 70 and 93% of cases (Cohen et al, 2014; Chambaere et al, 2015b).
• In unreported cases, only 55% had a second opinion (Smets et al, 2010).
• A 2007 national study reported 47% of cases of euthanasia were not reported (Smets et al, 2010).
• A 2009 study reported that 27% of cases of euthanasia in Flanders and 42% in Wallonia were not reported (Cohen et al, 2012).

The euthanasia is performed only by medical doctors

• Nurses administered the lethal medication in 59% of euthanasia cases occurring in institutions and 21% of such cases at home; these figures rose to 83% and 25%, respectively, where life was terminated without patient request (Bilsen et al, 2004b).
• In institutions, nurses mostly administered the lethal medication without the attendance of the doctor who had prescribed it (Bilsen et al, 2004b).
• Another study reported that nurses administered the lethal medication in 12% of cases of euthanasia and in 45% of life termination without explicit request, mostly in the absence of the prescribing physician (Inghelbrecht et al, 2010).

In summary, the Belgians themselves have documented that they have broken every one of their own guidelines (Jones et al, 2017; Keown, 2018).

• LEIF consultants were employed in one-third of cases in which a second opinion was sought (Cohen et al, 2014).
• LEIF consultants were more likely to be genuinely independent, but provided no other advantages (Cohen et al, 2014).

The Federal Control and Evaluation Commission on Euthanasia (FCECE)

• All cases of euthanasia are to be reported to the Commission.
• Regulation depends on self-reporting, and a significant proportion of cases are not reported (Montero, 2017; Keown, 2018).
• Reporting of euthanasia in Belgium is anonymous and the lack of transparency has been acknowledged (Smets et al, 2009).
• It is reported that the Commission has less than one hour to review all aspects of each case.
• The Commission found fault with 24.7% of the reports submitted, but accepted the reports if they felt there was compliance with the essential requirements of the law; they have been accused of interpreting the law in a liberal or flexible way.
• There has been only one referral to the public prosecutor during the period 2002-2015.
• The Belgian system stands accused of being ineffective (Jones et al, 2017; Keown, 2018).
• The Commission has been accused of illegitimately reinterpreting the law (Keown, 2018).
• Dr Distelmans, Google informs me, operates a euthanasia clinic in Belgium and is known for his involvement in controversial euthanasia deaths including: depressed women, twins who feared becoming blind, a woman with anorexia nervosa who was suffering psychologically after being sexually exploited, and Nathan Verhelst who died by euthanasia after a botched sex-change operation. He also conducts study tours to the Nazi death camp, Auschwitz, which he describes as ‘inspiring’.
• There are increasing numbers of euthanasia cases over time.
• There are increasing numbers of life terminations without request over time.
• An increasing proportion of requests are being granted: 56% in 2007, 77% in 2013 (Chambaere et al, 2015b).
• There is generous interpretation of the meaning of unbearable suffering to include ‘polypathologies’ and behavioral disorders.
• There are increasing numbers of non-terminally ill and older patients (Dierickx et al, 2016).
• There are increasing numbers of patients with a psychiatric disorder or dementia: 0.5% in 2002, 3.0% in 2013 (Dierickx et al, 2017).
• There is now euthanasia for children.
• ‘frequently’ in adults (Rys et al, 2014a).
• in 22% of a series of children (Pousset et al, 2011).
• The Belgians proudly declare there is no evidence of any slippery slope (Bernheim and Raus, 2017).

Etienne Montero (Faculty of Law, University of Namur, Belgium): ‘The indications for euthanasia are constantly multiplying, despite the legislators’ initial statements and intentions.’ (Montero, 2017)

• In Belgium, the number of suicides remained stable during the period 1998 to 2012 at 1.9%, i.e. there was no reduction in the suicide rate after passage of the Euthanasia Law (see Statbel).

(i). The ‘normalization’ of euthanasia

(ii). Euthanasia for children

(iii). Euthanasia for psychiatric patients and those with dementia

(iv). Continuous sedation until death (CSD)

(v). Euthanasia and palliative care

(vi). Attempts to prohibit conscientious objection

• (vii). Euthanasia and organ donation

(viii). Definition of euthanasia

(ix). ICU patients

(x). Arrogance

• A more sinister aspect of Belgian euthanasia is that in just 12 years, it has gone from being an exceptional act to the norm (the ‘normalization’ of euthanasia) (Montero, 2017)
• Then it became a right— there is information in official documents and in the media regarding a ‘right to euthanasia’
• Following which, supply creates demand (MacKellar, 2017; Keown, 2018))
• In 2014, Belgium became the first country in the world to legislate euthanasia for children.
• Adults may choose euthanasia for reasons such as loss of autonomy, being dependent, or social isolation, but children and adolescents lack the experiential knowledge and sense of self to make those decisions.
• The only description I found of this ‘capacity to judge’ (capacité de discernment) was vague (van Gool and de Lepeleire, 2017). I noted the criteria quoted for psychosocial development were dated 1968, and those for cognitive operations 1971.
• Modern neuro-psychological and fMRI (functional Magnetic Resonance Imaging) studies of the relationship between the neuro-anatomical development of the brain in human beings and their emotional and experiential capacity demonstrates that both are not fully developed until the early 20s for girls and mid-20s for boys (Mendelson and Haywood).
• I found the statement about children with serious illness sensing their own mortality and therefore having a clear understanding of death, quite sinister (van Gool and de Lepeleire, 2017). It’s a bit like saying: ‘This child is going to die, therefore he has good insight into dying and death.’
• Euthanasia for children has been criticized. ‘In the case of the new Belgian law, children seem to be asked to choose between unbearable suffering on the one hand and death on the other.’ (Siegel et al, 2014).
• Other reasons invoked against pediatric euthanasia besides capability of discernment, include pressure and abuse, and sufficiency of palliative care (Kaczor, 2016; Cohen-Almagor, 2018).
• In a report of 165 childhood deaths (ages 1-17), 22% had CSD. In 23.5% of these cases, the physician’s intention was to hasten death (Pousset et al, 2011).
• Euthanasia for patients with psychiatric disorders or dementia comprised 0.5% of all cases in 2002-7, rising to 3.0% in 2013 (Dierickx et al, 2017).
• Euthanasia for patients with psychiatric disorders or dementia is permissible on the basis of an advance euthanasia directive if the patient is in a coma (Dierickx et al, 2017).
• Decisions regarding euthanasia for patients with dementia typically involve the prospects of the individual with dementia as opposed to the severity of their present situation (Chambaere et al, 2015a).
• A study of 100 patients with psychiatric disorders who requested euthanasia reported the request was accepted in 48, who by definition must have had unrelievable, unbearable suffering. But 8 of the 48 (17%) withdrew, ‘because simply having this option gave them enough peace of mind to continue living’ (Thienpont et al, 2015).
• Concern is expressed about assessing the voluntariness and well-considered nature of the request—how to ‘differentiate between a death wish that is merely a symptom of depression, and one that can be canonized as an expression of free will’ (Lemmens, 2017).
• Dr Distelmans, who is convinced euthanasia should be seen as a form of suicide prevention, believes a physician can distinguish, in an objective manner, a merely symptomatic death wish from a patient’s genuine, rational wish to die by euthanasia (Lemmens, 2017).
• But this is not consistent with the statement that psychiatrists in Flanders follow the directive of the Dutch Association of Psychiatrists ‘that stipulates that in cases of chronic depression, a wish to die can become durable and should be considered the expression of the well-considered rational choice of the patient’ (Lemmens, 2017).
• In 2015, 65 Belgian psychiatrists, clinical psychologists and others, wrote to a Flemish newspaper to request that the option of euthanasia solely on the basis of "psychological suffering" be removed from the legislation, since they argued, it was promoting the "trivialization" of euthanasia; and being wholly subjective and incapable of objective verification was through its promotion of 'death as therapy', undermining the entire field of mental health (Bazan, 2015).
• In Flanders, 5 to 10 years after the introduction of the Belgian model, CSD accounted for 12 to 14.5% of all deaths (Chambaere et al, 2015b).
• In a study of 28 cases of CSD, 6 patients were competent, but the procedure was discussed with none of them (Anquinet et al, 2011).
• CSD was commenced without the consent of patient or family in 5% of cases by GPs and in 28% of cases by specialists (Papavasiliou et al, 2014b; Sterckx and Raus, 2017).
• 9 of 28 patients treated with CSD were not suffering persistently or unbearably (Anquinet et al, 2011).
• Another study reports that ‘in nursing homes in Flanders, CSD is frequently used to hasten the patient’s death. In some cases, CSD can even be considered a substitute for legal euthanasia.’ (Rys et al, 2014a)
• Of 249 cases of CSD in nursing homes in Flanders, 33% had dementia and 66% lacked competence (Rys et al, 2014b)
• In one study, CSD was performed with the explicit intention of hastening the patient’s death in 3-4% of cases (Papavasiliou et al, 2014b).
• in 24% of a series of children (Pousset et al, 2011).
• CSD is used for getting around personal, family or institutional reluctance regarding euthanasia (Sterckx and Raus, 2017)
• The Belgians have promoted the concept that euthanasia is an integral and necessary part of palliative care. They talk of ‘integral palliative care’, where ‘palliative care and euthanasia are neither alternatives nor opposites’ (Materstvedt and Bosshard, 2010; Bernheim and Raus, 2017; Dierickx et al, 2018).
• We are told that the caring practice of ‘euthanasia accompaniment’ (euthanasiebegeleiding) is now part of the daily work of palliative care professionals (Vanden Berghe et al, 2017).
• It is said that whilst palliative care professionals had originally been opposed to euthanasia, over time they came to appreciate its advantages, ‘which convinced palliative care professionals that euthanasia could be part of genuinely good care.’ (Vanden Berghe et al, 2017)
• It is stated that ‘palliative care was not harmed but strengthened’ by the introduction of euthanasia (Vanden Berghe et al, 2017).
• The integrated Belgian model of palliative care is said to give Belgium a guiding role for the rest of the world (Bernheim and Raus, 2017).
• Patients needing supportive palliative care may resist referral to palliative care for fear of euthanasia (Beuselinck, 2017).
• I cannot comprehend providing optimal palliative care (as I understand it) one week, and terminating their life by lethal injection the next.
• There have been several legislative attempts to force doctors who refuse to perform euthanasia to refer the patient another physician favorable to this practice (Nys, 2017; Keown, 2018).

(vii). Euthanasia and Organ Donation.

• It is recommended that this should be encouraged as there are good medical results in the transplant recipients, and it may help relieve the problems related to organ supply (Bollen et al, 2016).
• It is suggested that the ‘dead donor’ rule, the requirement that the patient be dead before organs are harvested, should be lifted and replaced by ‘euthanasia by removal of vital organs’ (Wilkinson and Savulescu, 2012; Bollen et al, 2016; Stammers, 2017).
• A symposium entitled ‘Euthanasia and Organ Donation’ was held in Brussels in 2012, partly sponsored by LEIF.
• 19% of Belgian physicians did not label a death following the deliberate administration of neuromuscular relaxants as 'euthanasia'(Smets et al, 2012).
• A statement of the Belgian Society of Intensive Care Medicine advocates the deliberate shortening of the dying process (what they call ‘the process of terminal palliative care’) in patients with no prospect of a meaningful recovery, by the administration of analgesic or sedative agents, even in the absence of discomfort. The recommendation applies to children as well as adults (Vincent et al, 2014).
• When there was a public outcry by some (adult) children who had not been informed prior to their parents’ euthanasia, two euthanasia experts publicly declared them to have ‘pathological mourning’ and to be in need of psychiatric care (Beuselinck, 2017; Lemmens, 2017).

Wesley J. Smith (journalist and author of Forced Exit): ‘Euthanasia in Belgium has gone completely out of control—including as just two examples—doctors killing the mentally ill and conjoining the death procedure with voluntary organ harvesting, as well as joint euthanasia deaths of elderly couples who ask to die for fear of future widowhood.’ (Smith, 2018)

Willem Lemmens (Department of Philosophy, University of Antwerp): ‘[The] fundamentally problematic feature of the Belgian euthanasia social experiment…[is] a too exclusive and uncritical propagation of the ethical principle of respect for autonomy and self-determination.’ (Lemmens, 2017)

Etienne Montero (Faculty of Law, University of Namur, Belgium): ‘Since euthanasia was legalized in Belgium in 2002, experience demonstrates that it is an illusion to believe that euthanasia can be permitted as a narrowly circumscribed, well-defined exceptional practice to which ‘strict conditions’ apply and which is under rigorous control. Once euthanasia is allowed, the limiting conditions established under the law fall away, one after the other, and it appears practically impossible to maintain a strict interpretation of the statutory conditions and to prevent the extension of the law…Indications for euthanasia are constantly multiplying, despite the legislators’ initial statements and intentions.’ (Montero, 2017)

Raphael Cohen-Almagor (School of Law and Politics, University of Hull): ‘The scope of tolerance toward the practice is enlarged so that yesterday’s red light becomes obsolete today. As the restrictions are removed, practitioners and law-makers are already debating the next step and the additional groups to be included in the more liberal euthanasia policy as if the restrictive logic behind the Euthanasia Act were no longer valid. This is quite astonishing because human lives are at stake.’ (Cohen-Almagor, 2017)

Willem Lemmens (Department of Philosophy, University of Antwerp): asks why ‘none of the pro-euthanasia experts ever seems to consider the possibility that there might be something wrong with a law that creates such emotional and existential havoc.’ (Lemmens, 2017)

Benoit Beuselinck (Oncologist, University Hospitals, Leuven, Belgium): ‘…the legalization of euthanasia has put a burden on doctors, families, palliative care services and has put in danger the patient’s own life. Together with several colleagues, we believe that the law on euthanasia has created more problems and difficulties than solutions…It is the core business of doctors to offer genuine palliative care and alleviate the physical suffering of a patient while taking care for the mental, social and spiritual aspects of his or her suffering.’ (Beuselinck, 2017)

In February 2015, the Supreme Court of Canada’s decision in the Carter v Canada case overturned the ban on doctor-assisted suicide (Chan and Somerville, 2016). The decision has been questioned on judicial grounds (Keown, 2018).

• The editorial was written by an enthusing lawyer who believes strongly in the right to assisted dying and seems to believe that a dignified death can only be achieved with assisted dying.

In June 2016, federal legislation was enacted to allow assisted dying, referred to in Canada as medical assistance in dying (MAiD) (see Government of Canada).

Availability of palliative care

• I was surprised to learn that ‘If you die in Canada today [2016], it is much more likely than not that palliative care won’t be available for you. Between 70 and 84% of all Canadians die without receiving, or having access to, palliative or end-of-life-care services.’ (Dwyer, 2016)
• The Canadian Health Minister has acknowledged that only 15% of Canadians have access to quality palliative care (see Patients Rights).

Eligibility

The law provides for a person who

• Is eligible for Canadian government-funded health services;
• Is 18 years of age or older and capable of making decisions with respect to their health;
• They have a serious illness, disease or disability;
• They are in an advanced state of irreversible decline in capability;
• They experience unbearable physical or mental suffering that cannot be relieved under conditions that they consider acceptable; and
• Their natural death has become reasonably foreseeable [not further specified].
• Has made a voluntary request for medical assistance in dying, free of any external pressure; and
• Has given informed consent to receive medical assistance in dying after having been informed of the other means that are available to relieve their suffering, including palliative care.
• The law excludes children, those with mental illness, and the use of advance directives.

The physician or nurse practitioner must

• Ensure the person meets all of the eligibility criteria;
• Ensure the request is in writing and signed by two independent witnesses;
• Ensure the person is informed they may, at any time, withdraw the request;
• Arrange for the person to be seen by a second, independent physician or nurse practitioner, to provide a written report confirming the presence of ‘a grievous and irremediable medical condition’;
• Allow 10 clear days between request and procedure (unless the physicians/nurse practitioners agree that the loss of the capacity to provide informed consent is imminent).
• Ensure that, immediately before the procedure, the person is given an opportunity to withdraw their request and, failing that, give express consent to the procedure.
• Although assisted dying became legal in June 2016, the reporting requirements only came into effect at the beginning of November, 2018 (see Government of Canada).
• The physician or nurse practitioner must report every written request received; this report includes what happened after the request if it did not result in an assisted death (see Government of Canada).
• The physician or nurse practitioner must submit a second report if they perform assisted dying (see Government of Canada).
• In the first two years, the number of deaths by euthanasia and physician-assisted suicide appear to have increased rapidly (Table 6) (see Government of Canada).
• It appears that almost 100% of these deaths were by euthanasia with very few (self-administered) assisted suicides.

Table 6. Number of cases of euthanasia and assisted suicide: Canada 2016-17

From Canadian Government Statistics (see Government of Canada)

That the patient has a grievous and irremediable medical condition

• Other common reasons included the wish to avoid burdening others, losing dignity, and the intolerability of not being able to enjoy one’s life.
• Few patients cited inadequate control of pain or other symptoms.
• An Ontario Court ruled that a 77-year-old woman with inflammatory arthritis faced death in the “foreseeable future” and was eligible for MAiD, even though her life expectancy was about 10 years and she was still an avid hiker (Downie, 2017).

That ‘their natural death has become reasonably foreseeable’

• This is medically meaningless, as it is reasonably foreseeable that we will all die.
• Reporting requirements only came into effect in November, 2018.
• Some claim the laws were intentionally drafted with ‘purposeful flexibility’—using language you cannot define—to facilitate future widening of the regulations. This will make regulation more difficult.
• The increase in the number of euthanasia cases in the second year is impressive.
• There are already reports of calls for indication expansions (see below).
• There are no reports (yet) of life termination without request.
• There are no reports (yet) of failing to report.
• It is too early for any assessment.

(i). Palliative care

• (ii). Moves to remove safeguards

(iii). Calls for inclusion expansion

(iv). Prohibition of conscientious objection

(v). Psychiatric issues

(vii). Organ Donation

• CHPCA (Canadian Hospice and Palliative Care Association) has produced a booklet for health care professionals and volunteers about the coexistence of palliative care and assisted dying (see CHPCA).
• There is‘Provincial foot-dragging on plans to expand palliative care services substantially…that was promised in the shift to MAiD’ (Stockland, 2018).
• There are reports from Quebec’s Collège des Médicins, about ‘hearing increasing concerns from its member doctors about re-direction of already scarce resources from palliative care to Medical Aid in Dying, which [is] a violation of both the letter and the spirit of Quebec’s law governing end of life care.’ (Stockland, 2018)
• The Quebec College of Physicians have written to the Health Minister expressing concern that patients may be turning to lethal injections because of the lack of palliative care (Stockland, 2018)
• The Canadian Health Minister has acknowledged that only 15% of Canadians have access to quality palliative care, although special travelling teams are being considered to deliver physician-assisted death in the country’s remote regions (see Patients Rights).
• Most palliative physicians want no role in assisted death (Eggertson, 2015).
• Pro-euthanasia advocate, Kathryn Morrison, says, ‘If PCUs [palliative care units] conscientiously object to MAID…then they are neglecting to fulfil their responsibility to honor their own missions and values.’ She is demanding that any palliative care service that declines to perform medically-assisted dying should be ‘outed’ and publicly named. Not a big step then to have their funding revoked (Morrison, 2017b & c).
• There are other reports of palliative care services and hospices being severely pressured to perform MAiD (Johnston, 2018).

(ii). Moves to reduce safeguards

• At the present time, immediately before the procedure, the person must be mentally competent and give express consent to the procedure. There are moves to have this rescinded for reasons to do with autonomy and human rights (Somerville, 2018).
• The exclusion of psychiatric patients is described as totally unfounded and as arbitrary discrimination (Rooney et al, 2017).
• Euthanasia advocate Kathryn Morrison is campaigning for adolescents to be eligible for assisted death (Morrison, 2017a).
• The British Columbia Civil Liberties Association is suing the government, arguing that the current law that only allows physician-assisted death only for people suffering from terminal physical illnesses whose death is imminent, is unconstitutional and should be repealed (see BCCLA).
• Two Montrealers with degenerative diseases are challenging the federal laws which they say are too limiting in their criteria of access and are against their charter rights (Stevenson, 2017).
• UNICEF has lobbied the Canadian Parliament to introduce euthanasia for children (see UNICEF).
• There are calls for the prohibition of conscientious objection, which is referred to as just arbitrary dislikes (Schuklenk and Smalling, 2017; Savulescu and Schuklenk, 2017).
• Wiser minds say conscience matters and physicians should not be coerced into involvement of any kind in what they regard as wrong (Trigg, 2017; Maclure and Dumont, 2017).
• The College of Physicians and Surgeons of Ontario has decreed that if a doctor is unwilling to perform euthanasia or physician-assisted dying, they must provide an ‘Effective Referral’ to a doctor who will, i.e. the College does not consider providing the patient with an ‘effective referral’ as ‘assisting’ in providing medical assistance in dying (see CPSO; Keown, 2018).

Difficulties with psychiatric disorders and assisted dying in Canada are emphasized by the work of Harvey Chochinov and his colleagues.

• Psychiatric morbidity among patients requesting physician-hastened death is considerable (Chochinov et al, 1995).
• In 200 terminally ill patients, 17 (8.5%) had a serious desire for death, which correlated with measures of depression. Of patients wanting to die, 59% were depressed, compared to 8% among the rest (Chochinov et al, 1995).
• Among dying patients, the will to live shows substantial fluctuation (Chochinov et al, 1999).
• Of 379 patients receiving palliative care for cancer, 63% said assisted dying should be legalized, but only 40% said they might consider it for themselves, and only 6% actually wanted it (Wilson et al, 2007).
• When terminally ill patients received dignity therapy, 47% reported an increased will to live as well as less desire to die (Chochinov et al, 2005).
• Of palliative care patients with a genuine desire for assisted dying, 52% were diagnosed with a mental health disorder (Wilson et al, 2016).
• While 64% of ALS physicians supported the legalization of assisted dying, less than one-third of them were willing to actively participate. Most wanted a psychiatric review, a second opinion regarding eligibility, and referral to a third party for the actual assisted dying (Abrahao et al, 2016).
• The possibility of combining assisted dying with organ donation is being discussed, as a kind of homage to autonomy (Allard and Fortin, 2017).

The final words rest with seven Canadian physicians who provide troubling insights into what is really happening (Leiva et al, 2018).

• The redefinition of euthanasia and assisted suicide as ‘medical care’, to which all citizens are entitled, leads to euthanasia and assisted suicide being seen as a tax-paid entitlement, and being described as a ‘constitutionally protected civil and human right’. And doctors who do not co-operate are accused of violating human rights and even called bigots.
• Within a year of the original legislation, ‘the pressure for “Carter Plus” had become so great that the federal government legally committed itself to consider allowing euthanasia and assisted suicide for adolescents and children, for mental illness, and by advanced directive for those who lack capacity…’
• A challenge to this policy by the Christian Medical and Dental Society of Canada was dismissed by the Ontario Divisional Court (Keown, 2018).
• ‘[In Quebec], all public health care institutions (…including palliative care units) are required to provide or arrange for euthanasia…McGill University Health Centre complied with the law by arranging to transfer patients from the palliative care unit to be lethally injected elsewhere in the facility. [But] the Quebec Minister of Health forced euthanasia into the palliative care unit, citing ‘patients’ lawful right to receive end-of-life care’.
• ‘Quebec law allows hospices to opt out of providing euthanasia, but when Quebec hospices opted out, the Minister for Health denounced them for “administrative fundamentalism,” declaring their refusal “incomprehensible”.’ There are calls for the withdrawal of public subsidies for hospice and palliative care in Quebec and other provinces.
• ‘…Public calls from influential voices have been heard for those medical students who are personally opposed to the euthanasia imperative, to either abandon, or refrain from applying for, medical training.’ In the words of those influential voices: ‘Medical schools should carefully…screen for conscientious objection.’ (Savulescu and Schuklenk, 2017).
• ‘We are disturbed and grieved by the story of a 25-year-old disabled woman in acute crisis in an Emergency ward, pressured to consider assisted suicide by an attending physician, who called her mother “selfish” for protecting her.’
• ‘We are disturbed and angered to hear that hospital authorities denied a chronically ill, severely disabled patient the care he needed, suggesting euthanasia or assisted suicide instead.’
• ‘We were astonished to hear that some emergency physicians in Quebec were…letting suicide victims die even though they could have saved their lives.’
• And then there is the Orthodox Jewish nursing home that forbade euthanasia and assisted suicide on its premises out of respect for Jewish beliefs and concerns for its residents (who include Holocaust survivors). Dr Ellen Wiebe is alleged to have crept in at night and lethally injected a resident. When challenged, she regarded her actions as praiseworthy in that she had allowed him to die at home.

G. SWITZERLAND

• Under the Swiss Criminal Code of 1937, assisted suicide from non-selfish motives is not illegal.
• In Switzerland, assistance in suicide is seen as an issue of human rights rather than as a health care issue, and it is clearly separated from mainstream health issues (Bosshard, 2008b).
• The 2005 report of the Swiss National Advisory Commission on Biomedical Ethics emphasized that assisted suicide should be distinguished from euthanasia (Bosshard, 2008b).
• The 2005 revised guideline of the Swiss Academy of Medical Sciences (SAMS) reveals a shift from the medical criterion (the end of life is near) to a focus on patients’ rights and decisional capacity (Reiter-Theil et al, 2018).

The Right-to-Die Organizations

• The great majority of assisted suicides in Switzerland are organized and performed by the right-to-die organizations.
• There are 3 main organizations—Exit Deutsche Schweiz (known as Exit) in Zurich and Exit ADMD in Geneva, both of which cater for Swiss residents, and Dignitas, which caters for non-residents.
• The volunteers who perform assisted dying are non-physicians (Hurst and Auron, 2003).
• The doctor’s role is to see the patient (to assess their medical reports and to examine their competence) and, if appropriate, provide a prescription for pentobarbital.

Under Swiss law

• Euthanasia is not legal.
• Termination of life without explicit request is not legal.
• Assisted suicide from selfish motives (e.g. monetary gain) is illegal.
• Physicians may participate in altruistic assisted suicide, but most leave it to the right-to-die organizations (Hurst and Auron, 2003).
• Intensified treatment of pain and symptoms, withholding or withdrawal of therapy, and continuous sedation until death (CSD), with which it is acknowledged there may possibly be some shortening of life, are considered as normal medical therapy.

Guidelines of the right-to-die organizations

• Exit and Dignitas have their own guidelines regarding patient eligibility.
• Exit: ‘Poor prognosis, unbearable suffering, or unreasonable disability.’
• Dignitas: ‘Fatal disease or unacceptable disability.’

The frequency of assisted suicide in the German-speaking part of Switzerland in 2001 and 2013 are shown in Table 7 (van der Heide et al, 2003; Bosshard et al, 2016).

Table 7. Physician Decisions Regarding Dying in German-speaking Switzerland

From van der Heide et al, 2003 and Bosshard et al, 2016

• The annual number of assisted suicides involving Exit tripled between 1990 and 2000 (Bosshard et al, 2003).
• The numbers of assisted suicides more than tripled again during the period 2003-2014 (Steck et al, 2018).
• Assisted suicide accounted for 0.32% of all deaths in 2003, rising to 1.30% of all deaths in 2014 (Steck et al, 2018).
• A report on assisted suicide for non-residents by Dignitas, so-called ‘suicide tourism’, indicated 611 cases in the 5 years 2008-12 (Gauthier et al, 2015).
• In 2014, there were 742 assisted suicides, which was a 250% increase compared to 2009 (see Euthanasia in Switzerland).
• There are small but increasing numbers of (illegal) euthanasia: 8 in 2001 and 11 in 2013 (Bosshard et al, 2016).
• There are small but increasing numbers of (illegal) termination of life without explicit request: 15 in 2001 and 25 in 2013 (Bosshard et al, 2016).
• Continuous deep sedation until death increased markedly, involving 4.7% of all deaths in 2001 and 17.5% in 2013 (Bosshard et al, 2016; Ziegler et al, 2018).
• The majority of assisted suicides are reported—the number admitted to by physicians is about the same as the number of death certificates of non-natural deaths (Bosshard, 2008b).
• In Switzerland, there is no requirement to report assisted suicides to a central registry.

6. IS THERE A SLIPPERY SLOPE?

• Compared to 1990s, there are increasing numbers of older patients (mean age: 69.3, increasing to 76.9), females (52%, increasing to 65%), and people without a serious medical condition (22%, increasing to 34%) (Fischer et al, 2008).
• Rapidly increasing numbers of assisted suicides
• Small but increasing numbers of euthanasia (Bosshard et al, 2016).
• Small but increasing numbers of termination of life without explicit request (Bosshard et al, 2016).
• 21% of people receiving assistance by Dignitas and 65% of women attending Exit do not have a terminal or progressive illness (Fischer et al, 2008).
• Social loss (or fear of) was reason for requesting suicide in 5/43 patients (Frei et al, 2001).
• Increasing numbers of non-residents with non-terminal conditions. (Gauthier et al, 2015).
• A precedent has been set regarding assisted suicide for the mentally ill (Appel, 2007).

7. OTHER ISSUES/CONCERNS

(i). Disregarding psychosocial matters

(ii). IV & PEG infusions for assisted suicide

• (iii). Amyotrophic lateral sclerosis (ALS)

(iv). Psychological morbidity for relatives

• (v). Palliative care
• (vi). Organ donation

(vii). Problems related to suicide tourism

• 14% of an Exit sample had formerly been in psychiatric care, but this was not mentioned in their files (Frei et al, 2001).
• There is evidence that psychiatric or social factors were not an obstacle for Exit to assist with suicide (Frei et al, 2001).
• Depression was reported in 31 (27%) of a group of 114 Exit patients, but disregarded (Bosshard et al, 2008a).
• Reasons for assisted suicide such as control over circumstances of death, loss of dignity, and less able to engage in activities that make life enjoyable, were significantly more often mentioned by patients than by the physicians (Fischer et al, 2009).
• In 2006, the Swiss Federal Supreme Court upheld the right of those suffering from ‘incurable, permanent, severe psychological disorders’ to terminate their own lives (Appel, 2007).
• The arguments in favor of assisted suicide (c.f. euthanasia) are that it is in keeping with patient autonomy and also increases the patient’s responsibility.
• However, by 2000, 14% of assisted suicides in Switzerland were administered via IV infusion or PEG catheter (Bosshard et al, 2003). This was considered satisfactory provided it was the patient who was seen to switch the infusion on.
• A study of patients with ALS showed the wish to hasten death was predicted by depression, anxiety, loneliness, perceiving to be a burden to others, and a low quality of life.
• Some suggested that physicians should consider proactive discussion of assisted suicide with such patients (Stutzki et al, 2014).
• Increased posttraumatic stress disorder (PTSD), complicated grief, and depression were reported after assisted suicide (Wagner et al, 2012a & b).
• Relatives reported feeling socially isolated and did not openly disclose assisted suicide as the cause of death for fear of social stigma (Gamondi et al, 2015).

(v). Palliative Care

• Right-to-die organization personnel are now allowed into some teaching hospitals, which has caused major conflicts for staff on the palliative care services (Pereira et al, 2008).

(vi). Organ Donation

• Consideration of organ donation after assisted suicide is recommended as a potential solution to the organ scarcity problem (Shaw, 2014).
• Have to travel to Zurich when one is still fit enough, leading to deaths occurring sooner than one might have wished.
• Fewer safeguards, particularly regarding psychiatric conditions and depression.
• Have to die in a foreign country instead of your own home.
• Costs about €4000.

III. WHAT NOW?

Arguments for and against assisted dying.

The arguments for and against euthanasia and physician-assisted suicide have been summarized (Biller-Andorno, 2013; Boudreau and Somerville, 2013; Byock, 2016; Keown, 2018; Sulmasy et al, 2018).

Many medical and nursing organizations have published position statements on euthanasia and physician-assisted suicide (see IAHPC). Recently, a number have adopted a position of neutrality, which is seen by proponents and the public and politicians as supportive of assisted dying (Sulmasy et al, 2018). ‘If a medical association declares neutrality on this important issue, it squanders the precious role such associations have in providing guidance to the public and political sphere.’ (Bridge et al, 2019)

Protagonists will tell you the main reasons why assisted dying must be legalized are—

• Because we must respect the autonomy of the individual.
• Because it is needed for patients with unbearable pain or suffering.
• Because polls show a majority of the public are in favor.
• Because more and more health care professionals support it.
• Because legalization stops people committing suicide.
• Because it would be better controlled ‘out in the open’.

To which they may add—

• There is no evidence of a ‘slippery slope’.
• Legalization poses no risk to ‘vulnerable’ patients.
• There is no moral difference between allowing to die and euthanasia.
• Doctors opposed to assisted dying do not have to participate.
• Legalization is associated with improvement in palliative care.

But they don’t mention—

• That legalization leads to ‘normalization’ of assisted dying.
• That palliative care reduces requests for euthanasia.
• That the diagnosis of depression is often missed.
• That the assessment of competence may be inadequate.
• That assisted dying is contrary to ethos of medicine.
• That it damages the doctor patient relationship.
• That it may be harmful to doctors and nurses.
• That it has a bad effect on palliative care.
• That organ donation be part of assisted dying.
• That economic interests are behind the push for assisted dying.

1. BECAUSE WE MUST RESPECT THE AUTONOMY OF THE INDIVIDUAL

• Patients have a right to be involved in any decisions regarding their medical care. True.
• Patients have the right to refuse treatment, even if there is a risk to life. True.
• Patients have the right to make their own decisions about the time and manner of their death. True.
• The patient has a right to assistance to achieve that death, the so-called legal or human ‘right to die’. False.

Ronald Dworkin (Professor of Law and Philosophy, New York University): ‘Making someone die in a way that others approve, but he believes a horrifying contradiction of his life, is a devastating, odious form of tyranny.’ (Dworkin, 1993)

John Harris (Professor of Bioethics and Applied Philosophy, University of Manchester): ‘Euthanasia should be permitted…simply because to deny a person control of what, on any analysis, must be one of the most important decisions of life, is a form of tyranny, which like all acts of tyranny is an ultimate denial of respect for persons.’ (Harris, 1995)

Marcia Angell (former Editor, NEJM): ‘The most important ethical principle in medicine is respect for the patient’s autonomy and when this principle conflicts with others, it should almost always take precedence.’ (Angell, 1997)

Richard Smith (former Editor, BMJ): ‘…the three themes that emerged…were control, autonomy, and independence.’ (Smith, 2000)

Compassion and Choices: My Life. My Death. My choice.

1.1 But…autonomy is not absolute.

1.2 But…aren’t ‘autonomous decisions’ subject to outside influences?

1.3 But…can’t ‘autonomous decisions’ be influenced by psychological factors?

1.4 But…is autonomy used to justify progressive widening of the indications?

• 1.5 But…are there not contradictions between autonomy and assisted dying?
• In modern society, there are innumerable examples of limitations of personal autonomy, e.g. you cannot drive whilst drunk, or freely sell yourself into slavery.
• In some cases, it is because other individuals might be harmed.
• In other situations, potential danger to others is not involved, e.g. the compulsory treatment for acute mental illness.
• Autonomy gives a right to refuse treatments, but it does not give a right to demand them, e.g. assisted death.
• Advocates of euthanasia want recasting of the right to die as a right to have a physician facilitate one’s death (O’Rouke, 2017).

Edmund Pellegrino (Director of the Kennedy Institute of Ethics at Georgetown University): ‘In the last 25 years, patient autonomy has displaced physician beneficence as a dominant principle in medical ethics. This has enhanced the moral right of patients to refuse unwanted treatment and to participate in clinical decisions. But now, in some cases, patient autonomy is being absolutized. The right to refuse is becoming a right to demand treatment.’ (Pellegrino, 1994)

Charles Foster (London barrister who teaches medical law and ethics at the University of Oxford): ‘Autonomy is a vital principle in medical law and ethics, but there is a dangerous presumption that it should have the only vote, or at least the casting vote.’ (Foster, 2009)

Michael Kekewich (Clinical Ethicist, Ottawa) ‘The principle of respect for autonomy has for many patients evolved into a positive right to request treatments and expect accommodation’…which he describes as dysfunctional (Kekewich, 2014).

• Evidence from The Netherlands demonstrates that there is societal pressure to go down the assisted dying path (Twycross, 1996).
• As a member of a Dutch Regional Euthanasia Review Committee, Boer estimated that 10% of requests were seriously influenced by family issues, and that 50% of approaches to the End of Life Clinic were initiated by a relative of the patient (Boer, 2016).
• In Oregon, 43.7% of patients cited external pressures—‘being a burden to family, friends/caregivers’—as a reason for requesting PAS (see Living and Dying Well).

Robert Twycross (Emeritus Reader, Oxford University): ‘Every person asking for assisted death brings with them the attitudes and feelings of their family, their socioeconomic problems, and whether or not they feel they are a burden.’ (Twycross, 1996)

Shimon Glick (Jakobovits Center for Jewish Medical Ethics, Ben-Gurion University Faculty of Health Sciences, Beer-Sheva, Israel): ‘Can a decision for suicide or euthanasia be truly autonomous? Can a vulnerable, sick, suffering person be truly capable of a truly autonomous decision in an environment where the media, the medical community, the bioethicists, the caregivers, and the family overtly and covertly convey the message that the time has come to die.’ (Glick, 1997)

• Potentially treatable major depression is under-diagnosed and under-treated in patients with advanced disease (Breitbart et al, 2010a) .
• The argument that depressive symptoms in the terminally ill are ‘normal sadness’ or ‘understandable depression’, and that they are not amenable to treatment (Syme, 2008), is false.
• There is a strong correlation between depression and the wish to hasten death in the terminally ill (Chochinov et al, 1995; Tieman et al, 2002; Kelly et al, 2004; van der Lee et al, 2005; Fairman and Irwin, 2016).
• Major depression associated with terminal illness is potentially treatable and, if successful, there will be a significant reduction in the wish to hasten death (Ganzini et al, 1994; Kugaya et al, 1999; Breitbart et al, 2010b; Ng et al, 2014).

Other psychological matters

• A Dutch study of cancer patients requesting euthanasia in which a psychiatric review was undertaken reported that 5 of 22 patients had psychiatric problems sufficient to deny their request (Bannink et al, 2000).
• A Canadian study reported that 24/46 (52%) of palliative care cancer patients with a wish to hasten death had a mental health problem (Wilson et al, 2016).
• Careful examination of the psychodynamic issues that may be involved in making and receiving requests for assisted dying (all the potential influences on what is going on in the patient’s head, the doctor’s mind, and all the interactions between the two), makes a nonsense of the yes/no attitude towards patient autonomy and the right to assisted dying (Kelly and Varghese, 2016).

Brian Kelly and Francis Varghese (Professor of Psychiatry at the University of Newcastle, Australia and the University of Queensland, respectively): ‘The reasons for a patient seeking suicide as a treatment are complex and go beyond questions of a patient's right to die. The request for euthanasia needs to be seen in the context of the patient's circumstances, including relationships with and attitudes of carers and health professionals, along with patterns of psychiatric disorder and psychiatric symptoms in the medically ill (Kelly and Varghese, 1996).

Etienne Montero (Faculty of Law, University of Namur, Belgium): ‘ In keeping with the philosophy of autonomy, it seems logical and even natural that, sooner or later, the ‘strict’ legal conditions weigh less than the firm and specific wishes of the patient.’ (Montero, 2017)

Michael Cook (editor of BioEdge and founder of MercatorNet): In Holland, the law requires ‘(1) the request must be voluntary and deliberate; (2) there must be unbearable suffering with no hope of improvement; and (3) there must be no reasonable alternative to euthanasia…[But] patients define what is unbearable and they define what is a reasonable alternative…Autonomy has trumped medicine…’ (Cook, 2017)

1.5 But…are there not apparent contradictions between autonomy and assisted dying?

• That killing (assisted death) is the ultimate violation of another’s autonomy; a dead person has no autonomy (Jeffrey, 2009).
• That some decisions about euthanasia may reflect inadequate or non-existent palliative care.
• That some decisions about euthanasia may be prompted by depression.
• Dianne Pretty wanted an assisted death because of her fear of choking to death; choking may occur with motor neuron disease but can be palliated and is not a cause of death (Foster, 2009).
• For all the talk about patient autonomy, the actual decision makers are the physicians (Ten Have and Welie, 2005).

John Keown (Professor at the Kennedy Institute of Ethics at Georgetown University, Washington DC.): ‘[The argument for assisted dying] that it respects individual autonomy, is too often advanced as if it were an obvious conclusion rather than a controversial proposition. The counter-argument is that many requests for [assisted dying] are not truly autonomous but result from depression or inadequate palliative care.’ (Keown, 2002 & 2018)

Kathryn Mannix (Palliative Care Physician, Newcastle, UK): ‘…to legalize assistance with dying arises from the argument that to deny assistance is to deny the autonomy, or right to choose, of an individual. Proponents describe this denial as dehumanizing, as though exercise of autonomy alone is the mark of human personhood. The humanizing aspect of choice is its potential for nobility: as humans, we can reflect on our being and on the consequences of our choices. The right to choose to die with medical assistance, when placed in this context, must be weighed against the nobility of relinquishing this right if its commission would damage other, possibly more vulnerable, members of our society.’(Mannix, 2005)

Charles Foster (London barrister who teaches medical law and ethics at the University of Oxford): ‘Autonomy grew up as a street fighter, and was bloodied in some genuinely noble battles against medical paternalism. But like so many rulers with this sort of pedigree, it has quickly forgotten its democratic roots, and grown fat and brutal in power.’ (Foster, 2009)

OJ Hartling (The Danish Council of Ethics, Copenhagen): ‘The illusion of autonomy—the choice is meant to be free, but the patient is not free to make the choice; a choice that seeks to alleviate suffering and improve life by annihilating it is irrational; autonomy as to one's own death is hardly exercised freely. Even an otherwise competent person may not be competent in deciding on his own death on account of despair, hopelessness, fear or maybe a feeling of being weak, superfluous and unwanted.’ (Hartling, 2006)

Robert George (Bioethicist, University College, London) et al: ‘Therapeutic killing without explicit request, or of those lacking capacity, is the ultimate violation of autonomy.’ (George et al, 2005)

Numerous others have made a case for the overriding importance of patient autonomy, including Margaret Battin (Professor of Philosophy, University of Utah) (Battin, 2005), Timothy Quill (palliative care physician) (Quill and Battin, 2004; Quill and Miller, 2014), Baroness Warnock (Philosopher) (Warnock and Macdonald, 2008), Guenter Lewy (Emeritus Professor of Political Science, University of Massachusetts) (Lewy, 2011), L. W. Sumner (Emeritus Professor of Philosophy, University of Toronto) (Sumner, 2011), and Rodney Syme (retired urologist, former president of Dying With Dignity Victoria) (Syme, 2008 & 2016).

2. BECAUSE IT IS NEEDED FOR PATIENTS WITH UNBEARABLE PAIN OR SUFFERING.

• Assisted dying was sold to the public for the management of unbearable pain and symptoms in the terminally ill.
• In Oregon, the most frequently reported reasons for request were losing autonomy, decreasing ability to participate in activities that made life enjoyable, and loss of dignity. In a list of the 7 most frequent reasons for requesting PAS, pain or fear of future pain ranked 6th. (see Oregon Death with Dignity Act; Ganzini, 2014).
• In Canada, the most frequent reasons for request were loss of autonomy, the wish to avoid burdening others, and the intolerability of not being able to enjoy one’s life. Few patients cited inadequate control of pain or other symptoms. (Li et al, 2017).
• The study from Washington State reported the most frequent reasons for request were loss of autonomy, inability to engage in enjoyable activities and loss of dignity, rather than disease-related symptoms (Loggers et al, 2013).
• Physical pain and other symptoms can almost always be alleviated (Sulmasy, 2016).
• But such beneficence deprives them of their very existence.
• If a doctor is permitted perform euthanasia or assisted suicide for the terminally ill on request, then by the same reasoning he should be able to perform euthanasia or assisted suicide if he sees similar suffering, even though the patient may be unable to request it (Keown, 2012).
• The next step is to perform euthanasia or assisted suicide for people with similar suffering who are not terminally ill.

3. BECAUSE POLLS SHOW A MAJORITY OF THE PUBLIC ARE IN FAVOUR.

• Independent research conducted for the Mackay Committee of public and professional polls concluded they were of ‘limited value’ and ‘could not be accepted at face value as an authentic account’ of opinion (Keown, 2012).
• The majority of people questioned would have had little knowledge about terminal illness and dying, except for what the assisted dying movement had told them—that the treatment of pain and suffering is frequently ineffective.
• The results may be influenced by how the questions were worded (Hagelin et al, 2004; Parkinson et al, 2005), the order in which the questions were asked (Magelssen et al, 2016), or by limited (two-way forced choice) options to answer (Aranda and O’Connor, 1995). The questions themselves may be biased or superficial (Annas, 1994; Bachman et al, 1996).
• There is also a credibility gap in the way mass media reports matters to do with assisted dying (McInerny, 2006; Seale, 2010).

Fran McInerney (Professor of Aged Care, Australian Catholic University): ‘The framing of requested death activists as heroes, and of requested death itself as a redeeming and transforming act for those seeking it, were preeminent in press portrayals.’ (McInerny, 2006)

The polls are asking about legalization

• The polls are saying the majority of the population are in favor of legalization. A question about whether they wish to undergo assisted dying themselves would produce a very different response.
• A study of nearly one thousand terminally ill patients in the USA reported 60% to be supportive of the legalization of assisted dying, but only 11% had seriously considered it for themselves (Emanuel et al, 2000).
• In two studies of Canadian cancer patients receiving palliative care, 63-73% were in favor of legalization, but only 6-8% said they would request it if it were legal (Wilson et al, 2000 & 2007).
• In Oregon there are about 7,500 cancer deaths per year, or 150,000 since the DWDA started. If 35% of the adult population voted in favour of the DWDA, that should have resulted in 52,500 assisted deaths from cancer alone. Of the 1275 patients to 2017, 68% (867) had cancer. This means only 0.6% of all patients dying of cancer (and only 1.6% of patients dying of cancer who presumably voted in favor of the DWDA), chose an assisted death (see Oregon Health Authority).
• Evidence from clinical practice suggests the desire for assisted death is extremely low. Experience with 9,000 dying patients yielded only two explicit requests for euthanasia (Saul, 2015). I have been associated with a similar number of dying patients, but never received a request.
• Sulmasy estimates the personality trait that demands PAS to represent 0.5% of the population in the USA (Sulmasy, 2017).
• The supposition that all the people in favor of legalizing euthanasia will want to have euthanasia themselves, what Syme refers to as ‘The Momentum’ (Syme, 2016), is totally unfounded.
• The clinical ‘need’ and public ‘demand’ are much exaggerated.

The Mackay Report (House of Lords): ‘There was general agreement among our witnesses that the number of people who might be regarded as serious about ending their lives, who are not psychiatrically ill and who are unlikely to be deflected from their purpose is very small indeed and comprises to a large extent terminally ill people who have strong personalities and a history of being in control of their lives and whose suffering derives more from the fact of their terminal illness and from the loss of control which this involves than from the symptoms of their disease.’ (House of Lords, 2005)

4. BECAUSE MORE AND MORE HEALTH CARE PROFESSIONALS SUPPORT IT

• The assessment of the professional polls is fraught with difficulty. They depend on the interpretation of definitions, participant’s responses and actions, and whether there are palliative care options included (Aranda and O'Connor, 1995; Waddell et al, 1996; Bachman et al, 1996; Emanuel et al, 1996; Slome et al, 1997; Meier et al, 1998; Emanuel et al, 1998a).
• Of the 75% of doctors who responded to a survey, 59% agreed with assisted dying; of the 25% who did not respond but were subsequently contacted by telephone, only 18% agreed (Baume and O'Malley, 1994).
• A European survey reported that agreement with assisted dying was statistically more likely in survey responders than non-responders (Fischer et al, 2006).
• The early Australian studies were deliberately ambiguous, so that doctors who admitted they had given a patient opioids that might possibly have hastened death (but of which they had no intention) were classified as intentional euthanasia (Kuhse et al, 1997).

It depends on the population surveyed

• The lowest approval rate came from oncologists and palliative care doctors (Waddell et al, 1996; Meier et al, 1998).
• Psychiatrists have the highest approval rates (Cohen et al, 1994; Shah et al, 1998).

The responses are about legalization, not performance

• In a study of physicians, 60% were in favor of legalization of PAS, but only 46% would consider performing it (Lee et al, 1996).
• In a study of oncologists, 21% were in favor of legalization, but only 8% would consider performing it (Doukas et al, 1995).
• A survey of Australian palliative care physicians showed 7% were in favor of euthanasia, but only 2% would participate in doing it (Sheahan, 2016; ANZSPM, 2017).

5. BECAUSE LEGALIZATION STOPS PEOPLE COMMITTING SUICIDE

• Proponents argue that the legalization of assisted dying provides an alternative for people with a terminal illness who might otherwise turn to ‘impulsive, irrational and often violent’ suicides. (Boer, 2016; Callinan and Silva, 2018; Tarzian, 2018)
• But data is emerging that the number of ‘ordinary’ (non-assisted) suicides increases when assisted suicide is legalized (Callahan, 2018).
• This is possibly suicide contagion, the increase in suicide that that accompanies publicity about suicide, which is a well-recognised phenomenon (Sulmasy, 2017).
• In the State of Victoria , a big deal was made of the Coroner’s deposition, detailing all the suicides in persons who had ‘experienced an irreversible deterioration in physical health’, which proponents said would be eliminated by assisted dying legislation (see Legal and Social Issues Committee).

5.1 The Netherlands

• The suicide rate in the Netherlands went from 8.3 per 100,000 (1353 deaths) in 2007 to 11.1 per 100,000 (1871 deaths) in 2015 (see Statistics Netherlands).
• This 38% increase has occurred since 2007, at a time when assisted dying became more accessible for the categories of people that commit suicide—the people with chronic diseases, including psychiatric diseases, dementia, and others (Boer, 2014).

5.3 Belgium

• The suicide rate in Belgium is the highest in Western Europe (see Statbel).
• In Belgium, the number of suicides remained stable during the period 1998 to 2012 at 1.9%, i.e. there was no reduction in the (non-assisted) suicide rate after passage of the Euthanasia Law (see Statbel).

6. BECAUSE IT WOULD BE BETTER CONTROLLED ‘OUT IN THE OPEN’

6.1 But…is it really being widely practiced?

• There is no evidence that assisted dying is being practiced widely in the UK or USA (Meier et al, 1998 & 2003; Seale, 2006 & 2009).

6.2 But…would bringing it out in the open lead to more effective regulation?

• The confidential surveys in the Netherlands and Flanders indicate euthanasia without request, non-reporting, and abuse of the guidelines continue unabated.
• There is no information available to assess abuse in the Oregon system.

7. THERE IS NO EVIDENCE OF A ‘SLIPPERY SLOPE’

• There is evidence that the laws and safeguards are regularly ignored and transgressed in all the jurisdictions where assisted dying is sanctioned (Pereira, 2011).
• In the Netherlands and Belgium, the rapidly increasing numbers of assisted deaths, the increased proportion of requests granted, the cases of euthanasia without request, and the rapid expansion of indications from adults with a terminal illness to any suffering associated with non-terminal disease, dementia, psychiatric disease, ‘tiredness of life’, and children, all attest to the existence of a ‘slippery slope’ (Sprung et al, 2018).
• In Oregon, the numbers are increasing more rapidly, but there is essentially no information about whether or not the guidelines are being abused. The system is not designed to detect abuse; what is not reported does not exist.
• In Canada, almost before the assisted dying legislation was enacted, pressure on the federal government led it to legally commit itself to consider allowing euthanasia and assisted suicide for adolescents and children, for mental illness, and by advanced directive for those who lack capacity (Leiva et al, 2018).
• ‘Whenever [euthanasia or physician-assisted suicide] exceeds the safeguards of the law, it is the law that changes to accommodate the practice, while the practitioner escapes without censure.’ (Clearkin, 2017)

Peter Singer (Professor of Medicine and bioethicist, University of Toronto): ‘Of all the arguments against voluntary euthanasia, the most influential is the slippery slope: once we allow doctors to kill patients, we will not be able to limit the killing to those who want to die.’

Wesley Smith (journalist and author of Forced Exit): ‘It took the Dutch almost 30 years for their medical practices to fall to the point that Dutch doctors are able to engage in the kind of euthanasia activities that got some German doctors hanged after Nuremberg. For those who object to this assertion by claiming that German doctors killed disabled babies during World War II without consent of parents, so too do many Dutch doctors: Approximately 21% of the infant euthanasia deaths occurred without request or consent of parents.’ (Smith 2004)

Daniel Sulmasy (Medical Ethicist, Kennedy Institute of Ethics and the Edmund D. Pellegrino Center for Clinical Bioethics, Georgetown University): There is a slippery slope, the final end being the legalizing of euthanasia for anyone for any reason or no reason (Sulmasy, 2014).

8. LEGALIZATION POSES NO RISK TO ‘VULNERABLE’ PATIENTS

• There is an insoluble ethical conflict between meeting individuals' demands for therapeutic death and ensuring that incapable, vulnerable, or voiceless patients will not have lethal treatment prescribed as their best interest (George et al, 2005).
• The risk of abuse outweighs the potential for individual benefit. Vulnerable persons, especially the frail elderly, require protection (Gordon and Singer, 1995).
• But there is a much wider spectrum of vulnerability—the frail, the elderly, the dying, and those with disabilities, who may feel they are a physical or psychological or financial burden and who may feel some obligation to request assisted death.

The Walton Committee (House of Lords): ‘We do not think it possible to set secure limits on voluntary euthanasia…We are also concerned that vulnerable people – the elderly, lonely, sick, or distressed – would feel pressure, whether real or imagined, to request early death.’ (House of Lords, 1994)

The New York State Task Force on Life and the Law (Some members of this committee were supporters of euthanasia and assisted dying, but they ended up with a unanimous recommendation not to legalize assisted dying): ‘…legalizing assisted suicide and euthanasia would be profoundly dangerous for many individuals who are ill and vulnerable. The risks would be most severe for those who are elderly, socially disadvantaged, or without access to good medical care.’ (New York Task Force, 1994)

Patricia Mann (Department of Philosophy, Hofstra University): ‘There will be social expectations for individuals to choose PAS as soon as their capabilities decline to a point where they become dependent upon others in an expensive inconvenient way.’

(Mann, 1998)

Baroness Onora O’Neill (Professor Emeritus of Philosophy): ‘Legalizing assisted dying places a huge burden on the vulnerable…[it] amounts to adopting a principle of indifference towards [the vulnerable], in order to allow a few independent folk to get others to kill them on demand…Laws are written for all of us in all situations.’ (O’Neill, 2006)

John Keown (Professor of Ethics in the Kennedy Institute of Ethics at Georgetown University): ‘The ‘right to die’ would surely in time become more of a ‘duty to die’, not least given the burgeoning costs of caring for a growing, elderly and demented population …decriminalization [of assisted dying] could easily by itself signal to vulnerable groups, directly or indirectly, not only that they may seek an earlier death, but that they should.’ (Keown, 2012)

Richard Fenigsen (Dutch cardiologist): ‘The fundamental question about euthanasia: Whether it is a libertarian movement for human freedom and the right of choice, or an aggressive drive to exterminate the weak, the old, and the different, this question can now be answered. It is both.’

9. THERE IS NO MORAL DIFFERENCE BETWEEN ALLOWING TO DIE AND ASSISTED DYING

9.1 But…what about intention?

• In palliating symptoms with treatment that may possibly shorten life (which is acknowledged, although not intended), the intention is to relieve symptoms.
• With assisted dying, the intention is to bring about death.
• A medication administered to palliate symptoms that inadvertently causes death is ethical and profoundly different from a prescription designed to bring about death (O’Rourke et al, 2017).

9.2 But…the cause of death is different.

• Patients allowed to die are dying of their underlying condition.
• With assisted dying, the cause of death is the lethal medication.

10. DOCTORS OPPOSED TO ASSISTED DYING DO NOT HAVE TO PARTICIPATE

An individual doctor’s conscientious objection, for whatever reason, should be respected and this includes referral to another practitioner who performs euthanasia and physician-assisted suicide. Some doctors do not believe assisted dying is morally right, whether for religious or other reasons.

• More tolerant views have been expressed. (Maclure and Dumont, 2017; Trigg, 2017)
• In Belgium, there have been several legislative attempts to force doctors who refuse to perform euthanasia to refer the patient another physician favorable to the practice (Nys, 2017; Keown, 2018).

11. LEGALIZATION IS ASSOCIATED WITH IMPROVEMENT IN PALLIATIVE CARE

• A 2007 study listed The Netherlands as one of the three countries with ‘the most vital palliative care movements’ (Centeno et al, 2007). This was based on measures including the number of congresses attended, and there was no attempt to measure the quality of care delivered.
• The medical director of a Dutch hospice testified (c. 2004) that hospitals in general were ‘totally devoid of input from palliative care specialists’ (Keown, 2013).
• The Belgians claim the inclusion of euthanasia strengthened and did not harm palliative care (Vanden Berghe et al, 2017).
• In Canada, where 85% of the population do not have access to palliative care, there are accusations the promised increase in palliative care funding has not eventuated, and that palliative care funds are being diverted to assisted dying programs (Leiva et al, 2018).

Els Borst (the doctor/Health Minister who guided the euthanasia legislation through the Dutch parliament) admitted in 2009 that the government did not give enough attention to palliative care and support for the dying, that the legalization came ‘far too early’, and that a decline in the quality of care for the terminally ill had followed (Craine, 2009; Keown, 2012).

12. THAT LEGALIZATION LEADS TO ‘NORMALIZATION’ OF ASSISTED DYING

• ‘There has been unrelenting progression towards euthanasia being ‘normalized’—euthanasia has become just another option, perhaps even the default one, and has progressed from an exceptional act to a legal right (Keown, 2018).
• In the Netherlands, there has been a shift from PAD [physician-assisted dying] as a last resort to PAD as a default way to die…PAD is increasingly becoming a patient’s right, a default way to die, and a default way to deal with life’s difficulties.’ (Boer, 2016)
• Euthanasia went from being an exceptional act to the norm (Montero, 2017).
• Then it became a right—the ‘right to euthanasia’
• Once normalized, supply creates demand (MacKellar, 2017; Keown, 2018).

Victor Lamme (Professor of Cognitive Neuroscience, University of Amsterdam): ‘The "normalisation" of euthanasia means that it is seen as an acceptable solution to the problem of the elderly who are felt to have outstayed their welcome, or who feel they are a burden to their families.’ (Lamme, 2016)

13. THAT PALLIATIVE CARE REDUCES REQUESTS FOR EUTHANASIA

Quality palliative care will reduce the wish for hastened death.

• Of 126 patients who made an explicit request for euthanasia at the time of admission to a Dutch palliative care unit, only 2 persisted with their request (Zylicz and Janssens, 1998).
• For patients requesting PAS in Oregon, 46% of patients changed their mind after a substantive palliative intervention (Ganzini et al, 2000b).

14. THAT THE DIAGNOSIS OF DEPRESSION IS OFTEN MISSED

• Potentially treatable major depression is under-diagnosed and under-treated in patients with advanced disease (Breitbart et al, 2010a).

Marshall Perron (former Chief Minister of the Australian Northern Territory and the politician responsible for the introduction of the assisted dying legislation): ‘I understand severe depression to be fairly readily recognizable. You don’t have to have a huge string of qualifications.’ (Perron, 1996)

15. THAT THE ASSESSMENT OF COMPETENCE MAY BE INADEQUATE

• It is assumed that the examination of decision-making capacity is easy. It may be, but frequently is not.
• Assessment of decision-making capacity is not the same as obtaining informed consent for treatment.
• There is agreement on the importance of mental capacity with regards to euthanasia and physician-assisted suicide, but there remains significant variation in views of what does or does not constitute mental capacity (Price et al, 2014).
• The decision-making capacity of a significant number of patients with advanced disease will fall in the grey area, due to due to a range of causes including intercurrent illness, medications, and dementia.
• A survey of forensic psychiatrists (Ganzini et al, 2000a) reported that 78% recommended a stringent standard of competence, 73% indicated that 2 independent examinations were needed to determine competence, and 58% believed major depression should result in an automatic finding of incompetence.

16. THAT ASSISTED DYING IS CONTRARY TO THE ETHOS OF MEDICINE

Killing is inherently wrong; there is an inherent value in human life.

• Religious views aside, most people regard killing as wrong.
• Killing another person is the most extreme abuse of their autonomy. (Jeffrey, 2009)
• Martin Luther King said that he learned this from his grandmother who told him, “Martin, don’t let anybody ever tell you you’re not a Somebody”.
• This ‘some-bodiness’ is our intrinsic worth.
• Everybody is somebody. Euthanasia means it is morally acceptable to turn a somebody into a nobody.

Killing is contrary to the ethos of medicine

• Participation in assisted dying ‘flatly contradicts what it means to be a doctor’. (Randall and Downie, 2010).
• Assisted dying is the absolute antithesis of the healing vocation of doctors.
• In their practice, in training, doctors tend to see themselves as agents of hope and healing and comfort, and certainly not as agents of death.
• PAS is fundamentally inconsistent with the physician’s role as professional and trusted healer (O’Rouke et al, 2017)
• Euthanasia is contrary to the professional ethic of compassionate service of the patient who is vulnerable, wounded, sick, alone, alienated, afraid—it violates professional integrity.
• Euthanasia diverts attention from the real medical issues in the care of dying patients, and strikes at the very heart of what it means to be a physician. The time-honored ‘prohibition against it has been fundamental to the medical profession and has served as a moral absolute for both patients and physicians’. (Singer and Siegler 1990)
• ‘[Euthanasia and physician-assisted suicide] creates irreconcilable conflicts with our responsibilities to our patients.’ (Bridge et al, 2019)

Robert Twycross (Emeritus Reader, University of Oxford): ‘I am bound by the cardinal medical ethical principle that I must achieve my treatment goal with the least risk to the patient’s life.’ (Twycross, 1990)

Daniel Sulmasy (Medical Ethicist, Kennedy Institute of Ethics and the Edmund D. Pellegrino Center for Clinical Bioethics, Georgetown University): ‘The traditional Hippocratic ban on physicians killing patients makes sense from the perspective of the psychodynamics of the patient-physician relationship. The preconditions of trust that constitute the safety of the interpersonal space in which the patient can expose his or her vulnerability to the physician in order to be healed would seem to include, at a minimum, that the physician pledge to the patient, ‘I will not kill you.’’ (Sulmasy, 2017)

Robert Twycross (Emeritus Reader, University of Oxford): ‘A gap…between the philosophical sophisticates and those who are involved daily in the care of the dying. When viewed from the academic (or editorial) ivory tower the arguments in favour of legalized euthanasia may well seem logical and powerful. At the bedside, however, the arguments against are overwhelming.’ (Twycross, 1995)

17. THAT IT DAMAGES THE DOCTOR-PATIENT RELATIONSHIP

The practice of assisted dying has adverse consequences for the patient-doctor relationship in terms of physician integrity and patient trust.

• Euthanasia and physician-assisted suicide would undermine the medical profession by eroding the trust of patients in their physicians as caregivers (Austriaco, 2011).
• ‘[PAS] is problematic given the nature of the patient-physician relationship, affects trust in the relationship and in the profession, and fundamentally alters the medical profession’s role in society.’ (Snyder Sulmasy et al, 2017)
• The public perception is still that the Hippocratic tradition is an important indicator that the patient in his or her vulnerability can put trust in the physician. Euthanasia by physicians undermines that trust (Austriaco, 2011).
• ‘Many elderly people in the Netherlands are so fearful of euthanasia that they carry cards around with them saying that they do not want it.’ (Fitzpatrick, 2011)
• ‘Many Dutch patients, before they will check themselves into hospitals, insist on writing contracts assuring that they will not be killed without their explicit consent.’ (Austriaco, 2011)
• ‘Will your doctor kill you if he or she thinks you are too ill or in too much pain or unconscious?’ (Sulmasy, 2014)

18. THAT IT MAY BE HARMFUL TO DOCTORS AND NURSES

• 42% physicians involved with any form of assisted dying reported feelings of discomfort, most frequently referred to as ‘emotional’ and ‘burdensome’. The discomfort rate went up to 75% with euthanasia. (Haverkate et al, 2001)
• Many doctors who have participated in euthanasia and/or PAS are adversely affected emotionally and psychologically by their experiences. (Stevens, 2006)
• Nurses who believed they had hastened death described feelings of guilt and moral distress (Schwarz, 2004).

Kenneth Stevens (Emeritus Professor of Radiation Oncology, Oregon Health and Science University, Portland): ‘The physician is centrally involved in PAS and euthanasia, and the emotional and psychological effects on the participating physician can be substantial. The shift away from the fundamental values of medicine to heal and promote human wholeness can have significant effects on many participating physicians. Doctors describe being profoundly adversely affected, being shocked by the suddenness of the death, being caught up in the patient’s drive for assisted suicide, having a sense of powerlessness, and feeling isolated. There is evidence of pressure on and intimidation of doctors by some patients to assist in suicide. The effect of countertransference in the doctor-patient relationship may influence physician involvement in PAS and euthanasia.’ (Stevens, 2006)

19. THAT IT HAS A BAD EFFECT ON PALLIATIVE CARE

Palliative care services are being forced to perform euthanasia and physician-assisted dying

• In Canada, state-funded institutions are being forced to perform MAID.
• Also, in Canada, palliative care services are being forced to perform euthanasia in the palliative care unit and are not allowed to transfer euthanasia patients to a different part of the institution (Leiva et al, 2018).

Funding of palliative care services is threatened (Leiva et al, 2018)

• In Canada, there are calls for the withdrawal of public subsidies for hospice and palliative care (Leiva et al, 2018).
• ‘If PCUs [palliative care units] conscientiously object to MAID [medical assistance in dying] …then they are neglecting to fulfil their responsibility to honor their own missions and values.’ Not a big step to then try and have their funding revoked (Morrison, 2017c).

The Belgian model of palliative care is advocated

• In which euthanasia is an integral part of palliative care (Materstvedt and Bosshard, 2010; Vanden Berghe et al, 2017).
• I, for one, would not be able to work in a unit that provided compassionate ‘palliative care’ until such time as the patients underwent euthanasia.
• Robert Twycross said something similar: ‘The opportunity to opt out [to opt for assisted dying] will probably discourage the patient and clinical staff from pursuing all other available avenues.’ (Twycross, 1990)

Palliative care staff and services may be challenged by the introduction of assisted dying programs.

Considerable difficulties have been reported establishing assisted dying programs, including the relationship with the palliative care services in the same institutions (Loggers et al, 2013; Campbell and Black, 2014; Li et al, 2017; Pereira et al, 2008).

Offensive remarks are made

Rodney Syme (retired urologist, former president of Dying With Dignity Victoria):

‘There is scant evidence to support the effectiveness of specialised palliative care for patients with terminal illness in terms of quality of life, patient or care giver satisfaction, or economic cost.’ (Syme, 2016)

He describes the palliative care process as intrusive for the patient and family, and palliative care professionals with ‘the mind-set’ (i.e. not agreeing with his views) as hypocrites (Syme, 2008).

Philip Nitschke (founder and director Exit International):

He told author Nikki Gemmell that her mother’s physician-assisted suicide (which he helped arrange) amounted to ‘empowerment’, and that anyone opposing his views was either not mature or was suffering ‘religious claptrap’ (Gemmel, 2017; see Nitscke).

Andrew Denton (former TV personality and comedian):

‘Palliative care doctors are poorly informed, unreflective and opposed to euthanasia for out-dated, ideological/religious reasons.’ (Denton (2))

He accused Catholic palliative care doctors of delaying palliative symptom relief because they believed in the redemptive benefits of suffering. ‘If a doctor has this core religious belief then there’s a limit to how much and how quickly they’re going to help you.’ (Denton (1))

20. THAT ORGAN DONATION SHOULD BE PART OF ASSISTED DYING

• Voices around the world are talking about the benefits of combining organ donation with euthanasia and physician-assisted suicide (Shaw, 2014; Bollen et al, 2016; Allard and Fortin, 2017).
• It is described as augmenting the autonomy and being of beneficence to the donor (even though he’s dead) (Wilkinson and Savulescu, 2012).
• An argument is made to change the ‘dead donor’ rule (that the patient must be dead before organs are harvested) and allow ‘euthanasia by removal of the vital organs’.
• Would the benefits of donation be used to strengthen the case for euthanasia?

21. THAT ECONOMIC INTERESTS ARE BEHIND THE PUSH FOR ASSISTED DYING

Reducing health care expenditure is a priority in most developed countries. Which brings up the inevitable question of how much money might be saved (by the insurance organizations, the state, and the families of the dying) by the introduction of assisted dying?

• A theoretical study estimated that it might save $627 million p.a. in the USA (Emanuel and Battin, 1998).
• A Canadian study estimated a program of medical assistance in dying might save between $35 and $139 million (Trachtenberg and Manns, 2017).
• An analysis performed for the Institute of Medicine showed that 13% of the 1.6 trillion dollars spent on personal health care in the USA in 2011 was devoted to care of individuals in their last year of life, i.e. 208 billion dollars (Aldridge and Kelley, 2015). But if something happened, like programs of assisted dying perhaps, that reduced the costs by 10%, the savings would be enormous—20.8 billion dollars.

The State and the health insurance companies stand to make major savings.

• Patients in Oregon are being told that the Oregon Health Plan will not pay for treatment of their underlying condition, although it will pay for assisted suicide. (see Patients Rights; Keown, 2012)
• The Dutch End of Life Clinic is said to have approached the health insurance companies to fund a number of new teams

Derek Humphrey (co-founder of the Hemlock Society, the Final Exit Network, and Compassion and Choices): ‘In the final analysis, economics, not the quest for broadened individual liberties or increased autonomy, will drive assisted suicide to the plateau of acceptable practice.’ (Humphrey and Clement, 2000)

ON REFLECTION…

The way we manage the dying leaves much to be desired…

The doctor comfortably accompanying his patient, providing appropriate physical and emotional comfort…the patient informed, and content that they will be not abandoned.

• But many doctors don’t like talking about dying and death because it’s depressing, it’s difficult, and it takes up too much time…
• Patients are not prepared because we live in a death-denying society…
• Some doctors cope poorly with dying and death. ‘There’s nothing more that can be done!’ The patient is abandoned…
• Some patients deny or are blind to death and expect treatment to continue forever…
• The doctor who sees death as a medical failure will pursue relentless therapy…
• And some patients have no access to palliative care…

There is much that needs to be done…

But is euthanasia and physician-assisted suicide the answer?

• The grounds for it are shaky…the autonomy of the individual is not absolute.
• The need is greatly exaggerated—70% of people approve it being legalized, but less than 10% (<1% in Oregon) want assisted dying for themselves.
• Legalization is always accompanied by a ‘slippery slope’, the indications for assisted dying expanding all the time, despite earlier explicit reassurances that this would not occur.
• Legalization of assisted dying will always catch the vulnerable, the disadvantaged, and the disabled—not only may they seek an earlier death, but whether or not they should.
• Life termination without request seems endemic in the Netherlands and Belgium. There is no information as to whether or not the same is happening in Oregon.
• And if you do it enough, and if it is available for just about any complaint, it becomes ‘normalized’ or just another option. From being an exceptional act, it becomes the norm. Then supply creates demand and more and more people do it.
• ‘Participation in assisted dying flatly contradicts what it means to be a doctor.’ (Randall and Downie, 2009)

Much change is needed, but not the introduction of medical assistance in dying.

SOME FINAL QUOTATIONS

Ira Byock (palliative care physician, author and Professor of Medicine at the Geisel School of Medicine, Dartmouth, New Hampshire):

‘From its very inception, the profession of medicine has formally prohibited its members from using their special knowledge to cause death or harm to others. This was – and is – a necessary protection so that the power of medicine is not used against vulnerable people.’

‘Physician-assisted suicide weakens the moral grounding and structural integrity of the medical profession in service to society. This damage is particularly acute for the specialty of hospice and palliative medicine in sowing confusion among the public and in diverting the discipline’s research and policy foci away from alleviating persistent suffering.’

‘In these adversarial arenas, the fight over physician-assisted suicide makes it appear as if a cultural chasm divides Americans. In fact, the chasm is a mirage, an artefact…Our differences are dwarfed by the common high ground of values, shared wishes for care…It is on this common ground that we can build better systems of medical care and social support and realize our full social potential. (Byock, 2012)

René Girard (French historian and social philosopher, 1923-2015): ‘The experience of death is going to get more and more painful, contrary to what many people believe. The forthcoming euthanasia will make it more rather than less painful because it will put the emphasis on personal decision in a way which was blissfully alien to the whole problem of dying in former times. It will make death even more subjectively intolerable, for people will feel responsible for their own deaths and morally obligated to rid their relatives of their unwanted presence. Euthanasia will further intensify all the problems its advocates think it will solve.’

Barbara Karnes (American nurse, educator and author of A Time to Live): ‘Dying a gradual death makes us the fortunate ones. We have been given the opportunity to say I love you, to amend the mistakes, to ride the rollercoaster, to say good-bye.’

Elisabeth Kübler-Ross (Swiss-born American psychiatrist, 1926-2004): ‘Lots of my dying patients say they grow in bounds and leaps, and finish all the unfinished business. But assisting a suicide is cheating them of these lessons, like taking a student out of school before final exams. That's not love, it's projecting your own unfinished business.’

Michigan's Religious Leaders Forum (a group of Christian, Jewish and Muslim leaders): ‘Those who promote this last, fatal escape as a "right" should remember that such a "right" may quickly become an expectation and, finally, even a "duty" to die.’

Dame Cicely Saunders (nurse, almoner, palliative care physician and founder of the modern hospice movement, 1918-2005):

You don’t have to kill the patient to kill the pain. There is no such thing as intractable pain, only intractable doctors.

You matter because you are you, and you matter to the end of your life. We will do all we can not only to help you die peacefully, but also to live until you die.

I remain committed to helping people find meaning in the end of life and not to helping them to a hastened death. (Saunders, 2002)

IV. WHAT OTHERS SAY - SOME BOOK REVIEWS

Here are my reviews of books dealing with euthanasia and assisted-suicide.

THE REVIEWS

Guide to Enabling a Good Death

Julia Neuberger

Radcliffe Medical Press, 1999

Brilliant! In 171 clearly-written pages, I found out about the origins of the attitudes to death and bereavement with which I grew up; I learned about the teachings and customs regarding death of the world’s great religions and how palliative care professionals can best deal with them; I was treated to an erudite discussion on the meaning of a “good death”, covering everything from common sense to euthanasia; and how we, whether we are health care professionals, family members, clergy, or friends, can help people achieve it; and finally, a description of our society’s approach to grief and bereavement that does not shy away from pointing out what is wrong and why.

Anyone who works in hospice and palliative care should read this book. And, as it is written both for health care professionals and the general public, it should be available to be loaned out to people caring for loved ones through a terminal illness.

Rabbi Julia Neuberger has served as the Rabbi of a South London Liberal Synagogue for twelve years, is Chief Executive of the King’s Fund, and is a Vice-President of the Royal College of Nursing and the National Carers Association.

Highly recommended.

Roger Woodruff (May 2004)

THE CASE AGAINST ASSISTED SUICIDE

For the Right to End-of-Life Care

Kathleen Foley and Herbert Hendin

Johns Hopkins University Press, 2002

ISBN 0-8018-6792-4

This book cogently sets out the medical, ethical, philosophical and legal arguments against the legalization of physician-assisted suicide and, just as importantly, describes how palliative care needs to be developed so that we can uphold the right of the terminally ill not to suffer. The contributors are distinguished experts in medical ethics, palliative care, and law.

The book is divided into four sections. In the first - Autonomy, Compassion and Rational Suicide - Kass, Pellegrino, Callahan and Kamisar provide ethical, philosophical and legal arguments that neither of the major justifications for assisted suicide, autonomy and compassion, provides an adequate basis for legalizing the practice. And, in the words of the ethicist Sissela Bok, if you do legalize it “no country has yet worked out the hardest questions of how to help those patients who desire to die, without endangering others who do not”.

The second section - Practice versus Theory - includes chapters on the practice of assisted suicide and euthanasia in the Netherlands, Oregon and the Australian Northern Territory. Hendin’s extensive knowledge and insight is evident in his review of the Dutch practices and includes the remarkable statement by one of the authors of the 1995 Dutch report “that the person responsible for avoiding involuntary termination of life is the patient”. Ben Zylicz describes working in palliative care in the Netherlands, where its development has been severely hampered by the easy availability of euthanasia; one feels a tug as he describes being prevented from seeing terminally ill patients with treatable symptoms, and patients for whom palliative care might offer so much being taken away to hospital for euthanasia. Foley and Hendin review the Oregon experiment and catalogue the lack of legal safeguards and the paucity of information that has been made available. The Northern Territory deaths are described and discussed by David Kissane.

The third section - Reason to be Concerned - discusses assisted suicide and palliative care in relation to patients who are disabled, vulnerable (minority groups, the elderly and the financially disadvantaged), or depressed. The chapter by Cohn and Lynn clearly and categorically refutes the claims seen almost constantly in the lay press and should be required reading for any journalist contemplating writing anything about assisted suicide.

The last section - A Better Way - includes chapters by Dame Cicely Saunders and Kathleen Foley, examining the state of palliative care and what needs to be done to improve it so that it provides better end-of-life care, for all those people who need it.

This book adequately accomplishes its goal of providing an open and tolerant discussion of both the case against assisted suicide and the case for palliative care. The book also provides some powerful insights into the shortcomings of the palliative care system and how it might be improved. The discussions are well written and are practical and clinically relevant. This excellent book will be a valuable resource for anybody interested in the delivery of better end-of-life care, whether they are clinicians, ethicists, or health care policymakers.

Roger Woodruff

EUTHANASIA, ETHICS AND PUBLIC POLICY

An Argument Against Legalisation

Cambridge University Press, 2002

ISBN 0-521-00933-2

As indicated by the subtitle, this book is unashamedly against the legalization of euthanasia and physician-assisted suicide, but it is written in a moderate and reasoned tone and in a manner easily understood whether you are a health care professional, lawyer, politician or just an interested member of the public.

Keown first explores the inexactitudes and ambiguities that abound in the euthanasia debate, and then dissects the arguments for and against. This includes a description of the doctrine of double effects, although more recently published information suggests that it may not need to be invoked; Sykes et al (Lancet Oncology 2003; 4:312) found no evidence that initiation of opioid or sedative therapy is associated with the precipitation of death.

The second part of the book is an in-depth assessment of the practices in The Netherlands, the Northern Territory of Australia, and the U.S. State of Oregon, and includes a clear illumination of the inadequacy of the much-vaunted legal safeguards against abuse. Despite all their talk, the most recent data published by the Dutch (Onwuteaka-Philipsen et al. Lancet 2003;362:395) shows no sign of any reduction in the incidence of non-voluntary euthanasia or euthanasia without request. It is to be hoped that Cambridge University Press will invite Keown to prepare an up-dated edition as more information and data becomes available from The Netherlands and Oregon. The third part of the book critically reviews the findings of various expert committees, associations and the courts.

By no means everyone will agree with the conclusions and opinions expressed in this book, but it should be required reading for anyone who intends to make a public statement in the euthanasia debate.

Roger Woodruff(May 2004)

A Guide to Enabling a Good Death (2nd edition)

Radcliffe Publishing 2004

ISBN 1-85775-940-0

This is the second edition of Julia Neuberger’s book that was first published in 1999. The order of the material has been shuffled a bit and the discussion has been expanded and brought up to date with the discussions that are occurring in both professional and lay societies.

As for the first edition (although the order has been altered), ‘I found out about the origins of the attitudes to death and bereavement with which I grew up; I learned about the teachings and customs regarding death of the world’s major religions and how palliative care professionals can best deal with them; I was treated to an erudite discussion on the meaning of a “good death”, covering everything from common sense to euthanasia; and how we, whether we are health care professionals, family members, clergy, or friends, can help achieve it; and finally, a description of our society’s approach to grief and bereavement that does not shy away from pointing out what is wrong and why.’

Reading this book will be both enjoyable and beneficial to anyone who works in hospice and palliative care.

Roger Woodruff(June 2005)

PHYSICIAN-ASSISTED DYING

The case for palliative care and patient choice

Timothy E. Quill and Margaret P. Battin (Eds)

Johns Hopkins University Press, 2004

ISBN 0-8018-8070-X

This book was compiled in response to the volume edited by Kathleen Foley and Herbert Hendin (The Case Against Assisted Suicide; For the Right to End-of-Life Care, Johns Hopkins University Press, 2002; see review) and to stress what the authors see as the positive aspects of Physician-Assisted Dying.

The tone is set in the introduction. Those in favor of Physician-Assisted Dying champion the causes of patient autonomy, mercy (the relief of pain and suffering), and patient non-abandonment (all very positive), whilst those who oppose it are worried about the wrongness of killing, diminished integrity of physicians, and the risk of abuse (all very negative).

The book is divided into four parts. The first examines the critical values of autonomy and mercy. The second explores the clinical, philosophical, and religious issues that underlie end-of-life practices. Part three examines practice in Oregon and the Netherlands. The last section deals with some of the legal and political turmoil that has surrounded the debate on Physician-Assisted Dying in the United States.

The opening chapter by Marcia Angell in an impassioned statement, based around the tragic circumstances of her father’s suicide, that Physician-Assisted Dying should be legalized and that “many people would choose [it]”. But in Chapter 11, where Linda Ganzini reviews the Oregon data, it is seen that only between one-third and one-half of one percent of patients dying of cancer in Oregon have availed themselves of the State’s legalized Physician-Assisted Dying.

The chapter on patient autonomy deals with just that, and does not adequately address what effect legalizing Physician-Assisted Dying might have on the autonomy and rights of other people in society.

There are several chapters that discuss the Dutch practices, focusing particularly on the one thousand patients a year who are euthanased without specific request. [The fact that, according to the figures published by the Dutch, the incidence of non-voluntary euthanasia is a multiple of that number is not discussed]. But back to the one thousand. We are told that these patients had either expressed a wish for euthanasia at some time in the past (current wishes were not important) or they were incompetent. That’s not what the published data says. We are also told “In a number of cases [in which patients were euthanased without explicit request] the decision had been discussed with the patient.” That’s a new twist.

Mention is made in several chapters that, as a result of the open and honest system they have, the incidence of non-voluntary euthanasia is lower in The Netherlands than in other less advanced countries, including Australia. These studies (e.g. Kuhse et al) are based on deliberately ambiguous questions that have been publicly discredited. I received a questionnaire last year, based on the Dutch format, for the International Collaborative Study on End-of-Life Decisions in Medical Practice. It asked the question regarding a patient in pain “Would you intensify the alleviation of symptoms by using drugs, taking into account the possibility or certainty that this could hasten the end of the patient’s life?” So a good doctor, practicing good medicine, carefully titrating drugs to improve patient comfort, could or would be recorded as taking active steps to hasten death. So much for all those reports.

This is a worthwhile book and, given that any discussion has more than one side, I would recommend it to anybody with an interest in the debate about Euthanasia and Physician-Assisted Dying. But it did nothing to change my views, particularly about the Dutch practices. There are repeated references throughout the book that, if you just think about it properly, there is really no difference between hastening death and letting die. Death is a natural end to a life and will come to us all. Killing is something else. Or that’s what I think.

Roger Woodruff (May 2005)

ENDING LIFE: Ethics and the Way We Die

Margaret Pabst Battin

Oxford University Press, 2005

ISBN 0-19-514027-3

A Dutchman came to see me last week. In his 80s, but mentally very on the ball. Towards the end of our meeting, he said, ‘I want you to know that I am a very strong proponent of euthanasia.’ This, it turned out, evolved from watching his father die slowly over a ten-year period in a nursing home, blind and deaf. It sounded awful to me but I avoided asking how many courses of antibiotics and other life-prolonging measures had been administered during that time. When I suggested that modern palliative care might go a long way to preventing the pain and psychosocial suffering associated with a terminal illness, he was unmoved. He was both a fervent autonomist and scared of dying the way his father had.

This book is about the way philosopher Professor Margaret Pabst Battin thinks we should now move on from the currently polarized debate about physician assisted-dying, and along the way she presents a lot of interesting information about the way people die. She starts with the present for-and-against debate, exploring some of the issues in depth. The middle section of the book describes the influences of historical, religious and cultural concerns, touching on a wide variety of topics from serpent-handling to suicide bombing. The final section is titled ‘Dilemmas about Dying in a Global Future’ and deals with issues related to increased life expectancy, genetic prognostication, and ‘NuTech’ methods for committing suicide, before coming to the predictable conclusion that physician-assisted dying will come to be accepted as our culture changes.

In her introduction, Battin urged me not to address the issues surrounding physician-assisted dying in ‘all or nothing’ terms. But I failed to reach the required standard. I felt that her description of the Dutch practices was somewhat selective. I was encouraged to pass over the ‘notorious 1000’ patients who are euthanased each year without current request or consent. The clinical facts, as published by the Dutch authorities, is that the true number is a multiple of this when you include deaths related to treatment of pain and symptoms given with the intention of hastening death and deaths related to withholding or withdrawal of treatment done with the intention of hastening death, many of whom were euthanased without request or consent. A more detailed appraisal of Dutch practices can be found in John Keown’s Euthanasia, Ethics and Public Policy (Cambridge, 2002) and The Case Against Assisted Suicide edited by Foley and Hendin (Johns Hopkins, 2002), but I couldn’t find reference to either volume. And just to set the record straight, the Australian data on physician-assisted dying published by Kuhse, which is quoted, was based on unethical and ambiguous questions and was discredited years ago.

On the other side is the possession of personal autonomy. I am somewhat bemused that this is such an important and central tenet in the physician-assisted dying debate when we all relinquish bits of personal autonomy all the time, every day, because we live in a society. And what about the data from Oregon, where it is legal to exert your personal autonomy and receive physician-assisted suicide? During the four-year period 1998-2001, there were about 20,000 deaths from cancer in Oregon. Now if 60% of Oregonians voted in favour of legalizing physician-assisted suicide that might lead to as many as 12,000 requests. But during that period there were only 70 deaths by physician-assisted suicide of patients with cancer – which is one-third of one percent. There are more complex issues at work.

And just a word about suicide bombing. Forgetting the historical context from centuries ago, should we really “see these actions as defensible cases of martyrdom” in the twenty-first century? This might be appropriate analytical thinking for philosophy departments, but I wonder whether a lot of people down here on earth would agree.

This book is well-written and certainly thought-provoking. I would not hesitate to recommend it to anyone with an interest in the debate about physician-assisted dying or the historical and cultural origins of the way people die. I learned a lot of interesting things along the way and was entertained by Battin’s fictional essays. But would something as simple as improving pain control lead to fewer and fewer requests for physician-assisted dying? My Dutchman expects perfect pain control and euthanasia. And was I swayed towards legalizing physician-assisted dying? Not a bit.

Roger Woodruff, November 2005

END-OF-LIFE DECISION MAKING

A Cross-National Study

Robert H. Blank and Janna C. Merrick (Eds)

MIT Press, 2005

ISBN 0262524732

This is a collection of expert reports on end-of-life issues from twelve disparate countries – Brazil, China, Germany, India, Israel, Japan, Kenya, the Netherlands, Taiwan, Turkey, the UK and the USA – representing East and West, developed and developing countries. The topics covered in each chapter include health care costs, where people die, the use of advance directives, the cut-off point for aggressive care, and policies regarding euthanasia and physician-assisted suicide, allowing the reader to make comparisons. Particularly interesting is the influence that history, culture and religion bring to care of the dying and, in more recent times, the HIV/AIDS epidemic.

Many interesting questions are raised. Have structural adjustments mandated by the World Bank and the International Monetary Fund, that place more emphasis on curative care than on public health programs, actually reduce the standard of health care in places like Kenya? As is to be expected, the quantity and quality of the data varied widely across the spectrum of countries.

Needless to say, I read the chapter on the Netherlands with keen interest. Overall, ten Have provides a balanced discussion but to argue that euthanasia is controversial and not an established practice does not sit well with all the data that has come out of Holland in the last 20 years. And for the Dutch government to insist that the law does not legalise active euthanasia, but merely provides a punishment exclusion ensuring that physicians will not be prosecuted. That doesn’t really wash, either.

But I came away with a new word. Dysthanasia is a Brazilian term for the unnecessary prolongation of life, at all costs, when death is unavoidable.

Roger Woodruff, April 2007

FORCED EXIT

Euthanasia, Assisted Suicide and the New Duty to Die

Wesley J. Smith

Encounter Books, 2005

ISBN 1-59403-119-3

Originally published in 1997, this edition has been up-dated to mid-2005 by American attorney and euthanasia expert, Wesley Smith. He describes the progress of the euthanasia juggernaut, which he describes as a death fundamentalism, and warns against the gradual decay of essential human values. The movement has changed from using the term euthanasia to ‘Aid in dying’, or ‘Deliverance’, or ‘Gentle landing’. Individualism, Choice and Control are the buzzwords. He discusses the deeds of Jack Kevorkian and Australia’s Philip Nitschke, the latter involving the infamous case of Nancy Crick. Said to be suffering from terminal cancer, hers was to be a widely publicized suicide, loudly applauded by the advocates of euthanasia, but at autopsy she didn’t have cancer or any other serious physical illness.

In the next chapter, he goes on to argue that we are creating a caste of disposable people. Nancy Curzon and Terri Schiavo feature here. The question boils down to whether or not life should be preserved for life’s sake, but I worry that after 10 or 15 years of persistent vegetative state, we might be guilty of prolonging suffering.

Smith then turns his sights on the Germans and describes how euthanasia was alive and well long before the Nazis came to power. He draws some worrying comparison with present trends. In his chapter on Dutch practices, which he describes as something much steeper than a slippery slope, he attempts to show how the rules (and now the legislation) were drawn up to legitimize behaviour.

Smith fervently believes that euthanasia betrays the morality inherent in medicine and says that euthanasia together with profit-driven Health Maintenance Organisations, with their emphasis on controlling costs by limiting services, make a deadly combination.

In the final chapter, Smith argues the pros and cons of creating a ‘right to die’ based on three questions.

• Is there a deep and dividing need for this proposed revolutionary change that cannot be met through other means?
• Are the expected benefits of the change worth the foreseeable risks of the change?
• Would the change be progress?

This is a well-written, thoughtful and provocative book. Perhaps a touch over-dramatic in places but the ‘no holds barred’ approach appealed to me.

Roger Woodruff(April 2007)

DEATH AND POWER

An Ethical Analysis of Dutch Euthanasia Practice

Henk ten Have and Jos Welie

Open University Press, 2005

ISBN 978-0-335-217557

This book escaped my notice when it was first published and was brought to my attention by the robots at Amazon.com. The authors, who spent twenty years observing and writing about the Dutch euthanasia movement, studied medicine and philosophy (HtH) and medicine, philosophy and law (JW). It provides a good history of the medical, social and political aspects of the debate, with more background information about what else was going on in Holland at the time than you would find in the medical literature. There are chapters providing a detailed analysis of Dutch euthanasia practices as reported, the response of the legal system, and an assessment of the ethical aspects of the debate. The final chapter is about what lessons can be learned from the Dutch experience, which should be read by more people involved in the debate in other countries. Their description of all the manoeuvrings on the part of the proponents of euthanasia, how medical acts were re-defined, re-classified and re-interpreted over the thirty years, makes fascinating reading.

And the title? It stems from their observation of the paradox that one of the origins of the euthanasia movement was to empower the patient rather than the doctor, but they have ended up with a system in which the doctor is all-powerful.

This book reinforces my views that euthanasia as practised in The Netherlands is neither controlled nor controllable. And remember, this book was published before the recent surge in deaths from terminal sedation reported from Holland. If you have an interest in the euthanasia debate and, like me, you missed this book when it was published, it’s a must read.

Roger Woodruff (October 2014)

UNPLUGGED. Reclaiming Our Right To Die in America

William H. Colby

American Management Association, 2006

ISBN 0-8144-0882-6

William Colby was the lawyer who represented Nancy Cruzan in the first right-to-die case heard by the U.S. Supreme Court. Nancy died after being in a persistent vegetative state for 8 years, but 4 years after her family unanimously agreed that her feeding tube should be removed. Here, Colby dissects the implications of the case of Terri Schiavo, who suffered irreversible brain damage in February 1990 but wasn’t allowed to die until Easter 2005. The first part of the book is about the bitter feud that broke out between Terri’s husband and her family and the years of legal wrangling that ensued. It is very well written and I found it hard to put down. When the courts finally said Terri’s feeding tube could be removed, Florida Governor Jeb Bush stepped in and over-ruled them with legislation that was dubbed ‘Terri’s law’. The law was immediately declared unconstitutional by the courts, but it took another eleven months of appeals before the Florida Supreme Court unanimously ruled it to be so. When that failed, legislation was hastily pushed through the Senate and House of Representatives, which brother George got up to sign at 1.00 in the morning.

But let’s be fair to Colby. This book is about the ramifications of Terri Schiavo’s case and it is well-researched and well written. How does a modern society grapple with cases like this? He provides a good description of the rapid advances made in medical technology over the last 50 years, followed by the advent of Living Wills and the like. He manages to provide a view of the problems from the point of view of ordinary people, health care professionals, spiritual leaders and legislators. The views of Pope Paul II and the infamous Dr. Kevorkian feature too, as does the Oregon physician-assisted suicide program. Hospice and palliative care are described as the jewel in the crown. To his credit, Colby never seems to take sides. He even has empathy with the demonstrator carrying a placard saying “Hospice Auschwitz”. Fascinating reading.

Roger Woodruff (March 2007)

THE FUTURE OF ASSISTED SUICIDE AND EUTHANASIA

Neil M Gorsuch

Princeton University Press, 2006

ISBN: 978-0-691-124582

A Harvard law graduate with a doctorate in legal philosophy from Oxford University, Gorsuch examines in detail all the political, legal and philosophical goings-on surrounding the debate about legalizing physician-assisted suicide and euthanasia in the United States. It is very well researched and clearly written. His arguments are clear and substantiated. His description of practices in The Netherlands is unforgiving, which is exactly how this reviewer thinks it should be. The last part of the book deals with Gorsuch’s moral and legal argument against legalization based on the idea that human life is intrinsically valuable and that intentional killing is always wrong, whilst leaving latitude for patient autonomy. While Gorsuch’s views are clear, his dissections are balanced, and this book should be read by supporters, opponents and the undecided.

Roger Woodruff (June 2007)

MEDICAL CARE AT THE END OF LIFE

A Catholic Perspective

David F. Kelly

Georgetown University Press 2006

ISBN 978-1-58901-112-0

David Kelly is professor emeritus of Theology and Health Care at Duquesne University in Pennsylvania. He brings a rich experience to this discussion of ethics in end-of-life care. I was particularly interested in the historical perspective – one is always a little surprised to be reminded how much things have changed during one’s own professional lifetime. The case of Theresa Shiavo and the Papal allocution of 2004 feature prominently. However, Kelly does not dodge any hurdles and argues cogently for what he believes is ethically correct. He believes strongly that some life-sustaining treatment is ethically optional and may be withheld, and that there is a clear difference between actively killing dying people and allowing them to die. Who should make the decisions, and how they should be made, are discussed at length. This is an excellent guidebook for anyone interested in ethical decision-making in end-of-life care.

LAST RIGHTS

Rescuing the End of Life from the Medical System

Stephen P. Kiernan

St. Martin’s Griffin, 2006

ISBN 978-0-312-37464-8

This book is about how we can help our loved ones die in peace. The focus is on life and ‘how its waning days could be peaceful and pain-free, and how caring for people at their most vulnerable can be an incredibly fulfilling experience’. It is not about physician-assisted death or grief and bereavement or cultural variations, it is about helping people get the most out of the last bit of their lives.

I was impressed. Written by a professional journalist, an enormous amount of research must have gone into writing this book. His investigative insights are sound and it is a good read.

With lots of stories about patients and their families, Kiernan paints a picture of what happens now and what might be, from the perspectives of the families, the patients, and the professionals. There are a range of suggestions for policy makers, the profession, and the public at large as to how things could be improved.

Enjoyable and insightful.

Roger Woodruff September 2011

DYING. A Memoir

Donald Horne

Viking (Penguin) 2007

ISBN 978-0-670-07102-9

Donald Horne (1921-2005) was a well known Australian author and academic who came to prominence in 1964 with the publication of The Lucky Country, an evaluation of Australian society that questioned many attitudes.

Suffering terminal pulmonary fibrosis, Dying is his record of the experience of dying. It is a remarkable journal in which memories of his well-lived years sit alongside his unflinching view of their end. Ever the intellectual, he also recorded his last thoughts on such matters as faith and regret, the rewards of the engaged mind, the Iraq War, and the meaning of democracy, which are included as essays. There is also a poignant memoir of his last few weeks by his wife and long-time editor, Myfanwy.

Roger Woodruff (January 2008)

LET THEM GO FREE

A Guide to Withdrawing Life Support

Thomas A. Shannon and Charles N. Faso, O.F.M.

Georgetown University Press, 2007

ISBN 1-58901-140-6

This little guide is written to help people facing decisions about taking a loved one off life support. Written by an emeritus professor of religion and social ethics from the UK (TS) and a Franciscan friar and Catholic priest from Chicago, Illinois (CF), it clearly sets out the steps that have to be taken. It is written simply and in a very warm and supportive manner. It also includes an ecumenical prayer service, with a variety of readings and prayers from Hebrew and Christian scripture, which could be used before life support is withdrawn.

TO DIE WELL

Your right to comfort, calm, and choice in the last days of life

Sydney Wanzer and Joseph Glenmullen

Da Capo Press, 2007

ISBN 978-0-7382-1083-4

This book is written for the lay reader, presumably the patient with a terminal illness or a member of their immediate family. It covers two broad areas. The first is about appropriate life-prolonging therapy with patients with a terminal illness or conditions like irreversible dementia. Some of the examples given beggar belief. Wanzer’s own totally demented, 92 year old mother, with a documented advance directive against invasive procedures, had a cardiac pacemaker inserted and was sentenced to live on for another five years. The totally demented man who had a hip replacement because he had a fractured neck of femur. Etc, etc. I have no problems with the arguments here.

The second issue relates to the need to legalise physician-assisted dying in the face of intolerable suffering and the presence of a terminal illness. Here I have problems. Wanzer correctly states that this is a situation that one might encounter once or only a few times in a professional lifetime, but I am concerned that a patient or family member reading this would assume that their risk of encountering intolerable suffering was high. And who judges ‘intolerable’? Over the years, I have seen hundreds of patients (if not more), referred with intractable symptoms and unrelieved suffering. But with attention to detail and the help of the multidisciplinary team, their symptoms and suffering were brought under good control. So whilst you might entrust someone as experienced as Dr. Wanzer, to give the same powers to all doctors, many of whom have little experience in symptom control or end-of-life treatment, is a concern. He points out that the experience in Oregon shows no evidence of a slippery slope, but I would contend the Dutch have shown otherwise. He does not point out that the intractable suffering of the Oregon patients was largely psychosocial rather than physical/medical. And, of course, the results of public opinion polls are trotted out in support. As in most countries, these are basically ‘Do you want your loved one to die in agony or legalise physician-assisted suicide?’ No one should die in agony, but my experience is that with good palliative care and multidisciplinary support, the incidence of intolerable suffering is extraordinarily low.

I have no doubts about Dr. Wanzer’s sincerity and he has done a lot to advance the discussion on end-of-life issues within the profession. His arguments about appropriate therapy? Long overdue. But physician-assisted dying? Neither necessary nor desirable.

MEDICINE AND CARE OF THE DYING

Milton J. Lewis

Oxford University Press, 2007

ISBN 0-19-517548-6

Has modern scientific medicine put curing the body before caring for the person? I guess most palliative care workers would think so. The opening chapters trace the historical and religious origins of this issue. Chapter 3 focuses on the treatment of cancer as an example to demonstrate the strengths and weaknesses of modern scientific medicine. The following chapters detail the development of palliative care and pain control. The last chapter is about the history and present status of the euthanasia movement. As has happened before, I did not entirely agree with everything I read in the chapter on euthanasia, but the historical descriptions of what happened in the late 19th and early 20th centuries were most interesting. This book will be of interest to anyone who works in palliative care and anyone interested in end-of-life issues.

Roger Woodruff(July 2007)

EUTHANASIA AND LAW IN EUROPE

John Griffiths, Heleen Weyers and Maurice Adams

Hart Publishing, 2008

ISBN 978-1-84113-700-1

Written by three academic lawyers from the Netherlands and Belgium, this book describes recent trends in the practice of euthanasia and physician-assisted suicide, the evolution of the associated law, and systems of control for these practices. The prime focus is on the Netherlands, with a smaller section on Belgium, where legislation to legalise euthanasia was passed more recently. The third section details what is known about practices in other European countries. The book is detailed and well researched, if not light reading.

This is an excellent book that should be read by anybody with an interest in the debate about euthanasia and physician-assisted suicide, but the data presented does not ease my concerns about practices in the Netherlands. They report a recent reduction in the number of patients treated by euthanasia without request and in the number of euthanasia cases overall. But these seem to be balanced by a rise in deaths associated with ‘palliative’ sedation. (It was called ‘terminal’ sedation, but was changed to ‘palliative’ probably because it sounds nicer). When last surveyed, Dutch doctors said they used ‘palliative’ sedation for the purpose of hastening the patient’s death in 50% of cases. But, in classifying the types of deaths, we are told the Dutch have now moved past worrying about the doctor’s intention. To me, there is a huge difference between giving sedation to a terminally ill patient and carefully titrating it to control clinical symptoms, and using larger doses with the intention of hastening/precipitating the patient’s death. The Dutch need to provide data on patients dying with ‘palliative’ sedation—what drugs were used, what doses were given, and what the intentions were. That would be interesting, very interesting. Could the fact that deaths occurring with ‘palliative’ sedation do not attract the same legal reporting requirements as deaths associated with euthanasia and physician-assisted suicide be relevant?

The other major theme in this book relates to the system of legal control. Griffiths, who is responsible for ‘a substantial research programme on the regulation of socially problematic medical behaviour (RSPMB)’, describes in some detail all the legal and legislative activity that has been designed to tighten the rules. As a physician, not literate in matters legal, I was left wondering whether they were really making headway or whether the Dutch had actually dug themselves a very deep hole. And legal rules need punitive teeth to be effective. When I last reviewed the results of Dutch trials regarding euthanasia/murder, I was amazed at the almost complete lack of punishment for those found guilty. Dr Van Oijen’s case (described on pp 40-41), involved a hearing by the Medical Inspectorate following which he was tried for murder (in the District Court, the Court of Appeals, and finally the Supreme Court) and found guilty, for which he was given a conditional fine of 5,000 guilders (about €2,250).

Roger Woodruff (February 2010)

CHOOSING DEATH

Should medicine’s last ‘last resort’ be legal?

The Hastings Center Report Volume 38, No. 5, September-October 2008

see http://www.thehastingscenter.org/Publications/HCR/

The September-October 2008 issue of The Hastings Center Report has a collection of four essays exploring the issues in the debate on physician-assisted death. Timothy Quill and Margaret Battin give the appearance putting forward balanced arguments, seen from both sides, but this is really a veil and their stance is obvious. Timothy Quill admits physician-assisted death is imperfect, whilst arguing strongly about its necessity. Margaret Battin equates terminal sedation with ‘pulling the sheet over our eyes’. I have not been convinced by their arguments in the past and remain unswayed, but their essays are worth reading for any student of this debate. Susan Wolf’s essay is about her own father’s terminal illness and death and the personal anguish she felt; but on later reflection is very content that physician-assisted death was not employed. The jewel in the collection is Daniel Callahan’s essay on advocacy for physician-assisted suicide, which he describes as ‘organised obfuscation’—an effort to render something unclear, evasive or confusing. This is a pleasure to read, as he clearly and concisely reduces the marketing of physician-assisted death to just that—organised obfuscation. He concludes ‘…the way single-minded advocates can foul the waters of public debate. Stirring up some verbal muck can work wonders for a bad cause.’

Roger Woodruff (July 2009)

A GOOD DEATH

An Argument for Voluntary Euthanasia

Rodney Syme

Melbourne University Press, 2008

ISBN 978-0-522-85503-6

Here is another book to be recommended to anybody involved with the debate about euthanasia and physician-assisted suicide, although many may not agree with what is said. Rodney Syme is a Melbourne urologist who has been at the forefront of the push to legalise physician-assisted death in Victoria and has served as the president of the Voluntary Euthanasia Society of Victoria, now sanitised to Dying With Dignity Victoria. The book recounts some of his clinical experiences over the years, from which he develops his arguments to challenge the legal and legislative fraternities and take a swipe at the palliative care community.

I was a bit put off by the style. The clinical histories are described in a melodramatic way and I didn’t like the repeated use of exaggerated adjectives—anguished signature, progressive ravages, remorseless progression, etc. And the blind lady who bid him farewell as he vanished into the darkness?

I was a little more off-side when labelled a hypocrite because I didn’t agree that ‘the intention of a doctor [using terminal sedation] to relieve intolerable suffering is no different from that of a doctor who provides or administers medication that causes death quickly.’ I beg to differ. He argues that patients treated by ‘pharmacological oblivion’ (his term for terminal sedation) should be subject to coronial enquiry. I was unconvinced by his argument that terminal sedation, not possibly, but always hastens the patient’s death. In contrast, he says our more enlightened Dutch colleagues acknowledge that voluntary euthanasia will hasten death. Should do, if they do it right.

I was a little confused on the autonomy thing, which is a strong theme that runs through the book. He describes Philip Nitschke’s computerised injection technique as ‘allowing that person to control totally the delivery of the lethal medication.’ Not after they click on ‘Yes’. And ‘the Dutch experience’—the 1000 patients a year euthanased without request? I don’t think it was mentioned.

I was more confused by his attitude to palliative care. He states on several occasions how much he supports it, but describes the palliative care process as intrusive for the patient and family, and palliative care professionals with ‘the mindset’ (not agreeing with his views) as hypocrites. He describes as laughable Michael Ashby’s statement that ‘… intentional ending of life is not part of palliative care practice and is different in kind from all other clinical intentions.’

Overall, the book is rather predictable. There are the usual references to polls, the surveys of professional behaviour (since discredited because of ambiguous questions), recounting of terrible end-of-life stories, and quotes from the usual suspects—Timothy Quill and Marcia Angell, for example.

On reflection, Syme gives some good examples of why physician-assisted death should not be legalised. Working alone, facing patients with severe suffering, he repeatedly admits feeling professionally inadequate. What did he do when he visited the family friend, not under Syme’s care, dying of cardiac failure with severe breathlessness? Ordered the nurse to draw up the large dose of morphine (written up by the treating doctor), which he immediately administered by intravenous injection. What, I ask, will happen when doctors with less experience of end-of-life care than Syme are faced with similar suffering?

No sheep’s clothing here.

Roger Woodruff July 2008

EASEFUL DEATH

Is There A Case For Assisted Dying?

Mary Warnock and Elisabeth Macdonald

Oxford University Press, 2008

ISBN 978-0-19-953990-1

This book is to be recommended to anybody involved with the debate about euthanasia, although not all will agree with what is said. Written by a moral philosopher (Baroness Warnock) and a retired cancer specialist, this book sets out to provide a balanced discussion of what would be necessary for the legalization of physician-assisted suicide in the UK, to define what the issues really are. It certainly adds some intellectual tenor to the debate, although my reading was more than a little troubled.

I started off a little off-side when I read that I was one of those who were standing in the way of ‘what society demands’, trying to ‘impose their convictions on the quiet majority’. The 2007 public opinion poll that is cited is not referenced, but when I last reviewed the public opinion polls from around the world, they mostly boiled down to ‘Do you want to die in agony or legalize physician-assisted dying?’ I have had a handful of serious requests for assisted-dying in 30 years of working as a medical oncologist and palliative care physician, which doesn’t support what the newspaper polls tell us.

Then I stumbled at there being no morally relevant difference between killing someone and allowing them to die. I would contend that there is a great difference between accompanying a dying patient, allowing them to die and not artificially prolonging their life, and giving them a premeditated lethal injection. I was quite unconvinced by their philosophical arguments that killing patients was really no different to what I now do and wondered whether theoretical moral philosophy should be confined within ivory towers and kept out of the clinic.

I tripped at their dealing with ‘the Dutch experience’—the 1000 patients who are euthanased without request each year. This was to be neither a concern nor a reason not to change the law in the UK, because the figures were not reliable as information was hard to obtain; but if we had information on the 40-50% of cases of euthanasia that are presently not reported, the figure isn’t going to be less than 1000 patients per year and may possibly be much higher. It was also implied that many of these cases were handicapped babies; my copy of the New England Journal of Medicine indicates that more than 50% of the patients subjected to non-voluntary euthanasia were 65 years or older in the 1995 and the 2001 surveys.

I baulked at their reassurance that there is no evidence of increased assisted dying for vulnerable groups (the disabled, elderly and those with psychiatric illness) in the Netherlands; as we only have information on a little over half of the cases, such a conclusion is speculative. The reports from Darwin and Oregon reveal a preponderance of socially isolated individuals who could be described as a vulnerable group, but this is not discussed.

I was uncertain which way they wanted to go on the slippery slope business. Early in the book, they argue at length that slippery slopes don’t exist but later conclude that future legislation will only succeed if it has guarantees against such slopes.

Does it present balanced arguments? I think not. In the end, I felt this book was a bit of a wolf in sheep’s clothing and wondered whether there was a philosophical position on the honesty of wolves.

CHOOSING LIFE, CHOOSING DEATH

The Tyranny of Autonomy in Medical Ethics and Law

Charles Foster

Hart Publishing, 2009

ISBN 978-1-84113-929-6

‘Autonomy is a vital principle in medical law and ethics, but there is a dangerous presumption that it should have the only vote, or at least the casting vote. This book is an assault on that presumption, and an audit of autonomy’s extraordinary status.’

Written by a London barrister who also teaches medical law and ethics at the University of Oxford, this is a book about medical law, not a treatise on medical ethics. Foster discusses a range of contentious issues from reproductive technology, to abortion, to confidentiality and consent, and, needless to say, euthanasia. In a style both entertaining and informative, Foster turns his gaze on the views of autonomists, pointing out where they are valid and where they have been carried way too far, particularly in relation to the debate about euthanasia and end-of-life decision making. I particularly liked his list of the ‘many reasons why autonomy, if it were consistent, would oppose euthanasia/physician-assisted suicide’.

I had trouble putting this book down. If you have an interest in medical ethics or are involved in the debate about euthanasia/physician-assisted suicide, it comes strongly recommended.

Roger Woodruff (March 2010)

AGAINST PHYSICIAN ASSISTED SUICIDE

A Palliative Care Perspective

David Jeffrey

Radcliffe Publishing, 2009

ISBN 978-184619-186-2

This is a clearly written review, concise but thorough, of the pros and cons of legalising physician-assisted suicide (PAS) in the UK viewed from the perspective of palliative care. Jeffrey does an excellent job of presenting both sides of the argument, but fudging, double-talk and euphemisms are given their due. I hadn’t been aware of the significant recent increase in deaths associated with deep sedation in the Netherlands, possibly related to the fact that such deaths do not attract the same legal reporting requirements as deaths associated with euthanasia and PAS. Anybody who has an interest in the debate about PAS and euthanasia should read this book.

END OF LIFE CHOICES

Consensus and Controversy

Fiona Randall and R. S. Downie

Oxford University Press, 2009

ISBN 978-0-19-954733-3

This book was a pleasure to read. As in their previous volumes, Randall and Downie have the ability to write clearly and to develop arguments that are logical and transparent, all of which is a refreshing departure from a lot of the stuff published on euthanasia and physician-assisted suicide.

The first part of the book is about choices and argues that the best interests of patient are promoted by means of the traditional aims of medicine: to prolong life, to alleviate suffering, and to restore or maintain function, but they draw a clear distinction between patient choice and what might happen if patients are simply regarded as consumers with end-of-life services run on consumerist lines. In their no nonsense way, they state that to understand decision-making in end-of-life care requires us to distinguish between intended and foreseen consequences, between acts and omissions, and between killing and letting die. And the arguments of Mary Warnock and others are chopped up despatched.

Part two of the book is about issues in end-of-life care that are controversial. Is advanced care planning, as we know it today, the right way to go? Does it promote unrealistic patient expectations, does it cause avoidable emotional distress? They asked whether we should be asking a different question regarding the preferred place of care and death. The chapter on physician-assisted suicide and euthanasia debunks the arguments that some morally acceptable practices are equivalent to euthanasia and confronts the ‘dignity’ and ‘right to die’ arguments head-on. The ‘human rights’ issue casts a shadow, but one can argue that it has been taken too far in many fields besides end-of-life care.

A substantial appendix on ethical theories and terms is available on-line.

The material in this book is well-presented and articulate. If you are going to delve into these matters only once this year, this should be the book.

Roger Woodruff August 2011

THE CASE OF TERRI SCHIAVO

Ethics, Politics and Death in the Twenty-first Century

Kenneth W. Goodman (Ed)

Oxford University Press, 2010

ISBN 978-0-19-539908-0

Much has been written about the terrible story of Terri Schiavo, who in 1990 suffered a cardiac arrest that led to a persistent vegetative state, but was not allowed to die until March 2005. In Goodman’s words ‘…when politics intervened, the Terri Schiavo story turned from tragedy to farce … a riot of kooky views and political vehemence.’

But this is a very serious book that sets out to dissect what we can learn about end-of-life care and decision making from this case. The ten essays in this volume are written by a range of experts including ethicists, medical specialists and attorneys and cover the moral, ethical, medical, religious and legal aspects. One can argue that there should not have been a political dimension. The role of the media ‘to agitate and inflame public sentiment’ is rightly criticised in the final chapter.

One little fact that I had not been aware of was that the Congress of the United States subpoenaed the permanently unconscious Ms. Schiavo to appear and testify. Hmmm.

END-OF-LIFE ISSUES, GRIEF, AND BEREAVEMENT

What Clinicians Need to Know

Sara Qualls and Julia Kasl-Godley (Eds)

John Wiley and Sons, 2011

ISBN 978-0-470-40693-9

This is an informative and practical guide to the issues involved in end-of-life care, be they the needs of the patient and family or matters that are of concern to professionals or institutions. It focuses on end-of-life care for our ageing population and is primarily directed at mental health professionals. But much of what is written is applicable to adults of any age and I think it should have a much wider audience than just mental health professionals. I think it would be of interest to palliative care professionals and to anyone involved with end-of-life care for older adults. There are good discussions on spirituality and meaning, advance care planning, grief and bereavement, professional self-care, and changing attitudes and behaviours (with regard to end-of-life care) in communities. I like the book because it was clinically practical, written by practicing clinicians, with due regard to the evidence base (such that it is), but without any long-winded discussion of theory.

I particularly liked Canetto’s clear dissection of the ‘model statute’ that underpins Oregon’s Assisted Suicide legislation, showing it to be ‘far from being carefully crafted.’

Roger Woodruff (April 2011)

DEATH WITH DIGNITY

Legalized Physician-Assisted Death in the United States 2011

Stuart C. Goldberg Esq.

No publisher cited

ISBN 978-1463 65084 1

Written by an attorney, this is a self-help manual for Oregonians and Washingtonians to help them understand and use their (wonderful, new) Death with Dignity Acts, and a guide for people and legislators in the other 48 states who want similar laws. I thought it was a bit macabre, certainly sad.

Viewed from afar, the absolutely miniscule number of people who have committed suicide under the Oregon Act, together with the fact that many were categorised as possibly being able to be helped by other compassionate interventions, brings into question the need for these laws.

In Australia, voting is compulsory. If you are 18 or over, you vote. So, if a referendum for physician-assisted suicide was passed here, I would have to sit back and acknowledge that that was what more than 50% of the population wanted. I have not seen the voter turn-out figures when these Acts were passed, but I suspect they were not high.

I was amused by some of the detail. Were I to give a patient a supply of lethal medication with which they subsequently took their life, the terms ‘suicide’ and ‘assisted suicide’ would certainly come into it. But to call it that is against the law in Oregon. Reminded me of Humpty Dumpty in Through the Looking Glass.

I suppose people working in palliative care need to know the book is out there.

Roger Woodruff (February 2012)

The Case for Legalising Physician-Assisted Dying and Euthanasia

Robert Orfali

Mill City Press, 2011

ISBN 978-1-936780-18-1

I didn’t find anything new in this book. It is a tirade of facts, aligned to demonstrate that he is correct, and I thought the occasional derogatory comment to those who hold a contrary view were unnecessary. There is a lot of trumpeting of the results of public opinion polls; much has been written on how meaningless they may be. To give him his credit, he raises the possibility that the recent increase in palliative sedation in the Netherlands might be doctors practising euthanasia without all the bureaucratic hassles; given the reports that palliative sedation is used with the intention of hastening death, I would have though that to think otherwise would be naïve.

Roger Woodruff March 2011

ASSISTED DEATH IN EUROPE AND AMERICA

Four Regimes and Their Lessons

Gunter Lewy

Oxford University Press, 2011

ISBN 978-0-19-974641-5

This review is written by an octogenarian emeritus professor of political science who states ‘I have arrived at a stage in my life when the issue of dignified and compassionate end-of-life care is of more than theoretical interest.’ The focus is on how the systems are working rather than the pros and cons of euthanasia and physician-assisted suicide.

Lewy seems satisfied with everything in the Netherlands. He doesn’t confront the issue of intent. When the Dutch were challenged about whether intent mattered, they stopped reporting it. He mentions euthanasia without request or consent, but seems to gloss over it. Reading the journals, it would seem that the recent reduction in euthanasia in the Netherlands has been balanced by an increase in ‘terminal sedation’, and in the majority of cases it was the doctors’ intention to hasten death. The difference is that terminal sedation is not subject to the same stringent reporting criteria that apply to euthanasia. In short, it’s pretty much all tulips in the Netherlands.

I was startled by the statement that ‘among European physicians, Dutch doctors are now considered the best trained in [palliative care]’. I thought a few people from across the Channel might have something to say about that.

Lewy’s view of euthanasia in Belgium is up-beat, with few criticisms. What happens in Switzerland is anybody’s business, with Exit and Dignitas coming into conflict with government recommendations. The discussion of physician-assisted suicide in Oregon touches on some of the problems, but does not provide any arguments to counter the criticisms levelled by Kathleen Foley, Herbert Hendin, John Keown and others. I am afraid his last chapter, ‘Assisted Death as a Last Resort’ did not hold much water.

I don’t doubt Lewy’s scholarship or sincerity for one moment, but I found the conclusions he reached were curious. I am uncertain whether this relates to non-medical eyes or to the focus being on the regimes rather than the practices. I would recommend this book to anyone involved in the euthanasia debate as an example of how an intelligent but non-medical person can interpret the data that is out there.

THE BEST CARE POSSIBLE

A Physician’s Quest to Transform Care Through the End of Life

Avery, 2012

ISBN 978-1-58333-459-1

‘Americans are scared to death of dying.’ That is the starting point for Ira Byock, one of the leading voices for palliative care in the USA, to take us through the problems in the health care system and in society that result in so many people dying badly or in suffering. These problems will increase as the older population begins to outnumber the young. Medical suffering aside, I was surprised by the statement that, even before the recent recession, ‘well over a million American families annually filed for bankruptcy due to health care costs.’ Byock, with the use of clinical vignettes and a lot of personal experience, explains how things might be done better, whilst admitting that it would be tantamount to a revolution in health care. His appeal is for better treatment of people with advanced disease and the dying, but he has no problem with the co-existence of medical excellence and tender human caring. Well-told, this book advocates strongly for the need for change in the way we look after people at the end-of-live. And although written about America, many of the matters discussed apply to other ‘developed’ countries. It was a pleasure to hear Byock speaking out about matters that concern many of us.

Roger Woodruff (May 2012)

DEBATING EUTHANASIA

Emily Jackson and John Keown

Hart Publishing, 2012

ISBN 978-1-84946-178-8

Two heavyweights address the question of euthanasia, without knowing what the other has written. Emily Jackson is Professor of Law at the London School of Economics. Professor John Keown, who formerly taught law and the ethics of medicine in the Faculty of Law at Cambridge University, now holds the Rose F. Kennedy Chair in Christian Ethics in the Kennedy Institute of Ethics at Georgetown University.

The argument for change is made by Emily Jackson, who maintains that the case for status quo is indefensible, and I was left feeling she would know a number of ways in which I could be made a better person. She starts with a number of quotations from the emotional, highly-publicised cases, arguing that the law should be changed to accommodate the exceptional few; as a physician, I was led to believe that laws developed on exceptional cases were usually not good law. She argues against the various claims that change would be bad, but her recommended solutions are quite impractical. The need for a consistent request is self-evident, but the way she writes might lead you to think that doctor-patient interactions are black and white, clear-cut, and immune to all outside pressures on either party; the opposite is true. Her caveat that the patient is mentally competent is also self-evident, although how to establish this continues to worry the psychiatrists of Oregon and the UK. She advocates a social support ‘filter’ and a palliative care ‘filter’, but exactly how these would function is not defined. Given that no two patients present the same problems, it would be extraordinarily difficult and expensive to set up; from the clinical standpoint, it would verge on the impossible. I enjoyed reading her well-written and well-argued chapter, but nothing she said led me to think that a change in the law would be a good thing.

In return, John Keown (Euthanasia, Ethics and Public Policy, Cambridge University Press, 2002) quietly addresses the major reasons for changing the law – autonomy, legal hypocrisy, a right to suicide, compassion, and public opinion – and rebuts them all. Discussion of what is happening in the Netherlands and Oregon doesn’t lessen his argument. In particular, he notes that the apparent recent decrease in euthanasia in the Netherlands has been accompanied by a parallel increase in the use of terminal sedation, a procedure that does not involve the same regulatory and red-tape requirements as euthanasia. He goes on to dissect two of Emily Jackson’s recent papers and points out the fundamental flaws of the Joffe Bill.

A concise and excellent summary of the current state of play in the debate about assisted dying.

Roger Woodruff (January 2012)

PHYSICIAN-ASSISTED DEATH IN PERSPECTIVE

Assessing the Dutch Experience

Stuart J. Youngner and Gerrit K. Kimsma (Eds)

Cambridge University Press, 2012

ISBN 978-1-107-00756-7

This is an important book for anyone with an interest in euthanasia and physician-assisted death (PAD). It is a collection of essays written by ‘the leading Dutch scholars and clinicians who shaped euthanasia policy and who have studied, evaluated, and helped regulate it’. So, this is the Dutch themselves telling us why they did it, how they did it, how they regulated it, and how good it is. Once I started reading it, I had trouble putting it down.

The cast of contributors is interesting. Youngner is a psychiatrist from Cleveland, USA. Kimsma describes himself as a ‘practicing physician and philosopher’. Of the other 20, there are six doctors (two neonatologists, one epidemiologist, one ethicist, one psychiatrist and one public health specialist), plus three philosophers, three sociologists, two historians, two lawyers, two political scientists and two psychologists. Not your average crew from the medical coalface, I think they are what Cohen-Almagors (p.100) calls the ‘euthanasia elite’—the people who drive the agenda. I felt none of them would hesitate to tell me how I could be made a better person. People and organisations opposed to euthanasia because of the effect it might have on medicine, law or society are generally regarded as stupid, blind or hung-up on religion—which was one of the downsides of this book for me.

The book is divided into six sections: Background and History, Regulation and Practice Deficiencies, Quality Assurance, Learning from the Practice, the Challenge of Unbearable Suffering, and a concluding Overview.

But for all their talking and all the words here, I remain totally unconvinced that they have done a good thing or that they have got it right.

The unreported cases? Well, they decided there was too much emphasis on the physician’s intentions in the earlier studies and switched to the drugs used. They hide behind the observation that opioids, properly used, may not be life-threatening and so opioid-related deaths are not euthanasia, which brings the proportion of unreported cases down very nicely. My understanding is that the same opioid drugs, improperly used, are lethal.

The rise in palliative sedation? In 2005 it was reported that there had been a fall in the incidence of euthanasia and assisted suicide, but there was a compensatory rise in palliative sedation. Were the Dutch doctors trying to avoid all the legal strings attached to performing euthanasia? Well, ‘the 2005 study… was not designed to examine this [question]’, but suggests that it ‘reflects positive choices in favour of palliative sedation.’ Now, if I had two clinical options that resulted in the same outcome (the death of the patient, in this case) and one required hours of talking and paperwork and carried a remote risk of prosecution, and the other had none of the above…

Euthanasia without explicit request? ‘Observational studies on the characteristics of practice cannot be used to prove that physicians [who euthanase patients without explicit request] were right or wrong.’

The definition of unbearable suffering? This pillar of the Dutch movement is beset with subjectivity, but it is all settled if ‘[the doctor] grasps the public norm concerning unbearableness.’

Much is made of the wonderful Dutch system of general practitioners whom, it says, the patients trust with their lives and their deaths. We are reassured that a request for euthanasia changes the physician-patient relation to an even higher level and that this ‘connection’ allows objectivity in proceeding to euthanasia. This implies Dutch doctors never get tired, never feel anxious or depressed, are immune to all extraneous aggravations and always make calm and perfect judgements in their patients’ interests. Oh, but …‘it is certainly possible that some physicians practice PAD without the emotional sensitivity that we have agreed is necessary…’

Euthanasia is the best form of palliative care? That’s a bit close to the bone! ‘Excellent palliative care and physician-assisted death may go together, both in practice and principle.’

The author of the last chapter acknowledges that most of the heady ideals of the 1970s, when ‘the Dutch saw their country as a shining example for all the world to follow’, have collapsed or backfired. But she declares herself to feel smug about their euthanasia policy, ‘something we did really right.’

Did they? But it’s fascinating reading!

Roger Woodruff (February 2013)

THE HASTINGS CENTER GUIDELINES FOR DECISIONS ON LIFE-SUSTAINING TREATMENT AND CARE NEAR THE END OF LIFE. 2e

Nancy Berlinger, Bruce Jennings, Susan M. Wolf (Eds)

Oxford University Press, 2013

ISBN 978-0-19-997455-9

Reports and publications from the Hastings Center have been influential in shaping and defining our professional attitudes to ethics of clinical care, particularly in regard to euthanasia and physician-assisted suicide (PAS) and other matters related to end-of-life care. This second edition of their Guidelines is very welcome and provides a clear and reasoned approach to the different clinical scenarios.

The book is divided into three parts. The first is about the ethics of good end-of-life care, the education competencies required, the organisational systems that should be in place, as well as socio-economic and legal factors. The second part deals with guidelines on care planning and decision making, including the decision-making process and guidelines for pediatric patients, care transitions, and for institutional policies. The third part is about communication in the support of decision-making and care. In addition to the straightforward cases, it includes interesting sections on supporting the decision-maker when loved ones disagree, how to approach a dying patient who has an implanted defibrillator, and the institution or withdrawal of a range of treatments from cancer chemotherapy to dialysis; it also includes a good discussion on the relatively new topic of palliative sedation.

I didn’t find anything dramatically new or controversial; in fact, I didn’t find anything with which I disagreed. But it’s nice to have it all in one place. It’s a pleasure to read as the material is logically sequenced and each statement or recommendation is justified—you feel each bit has been thought through and care taken to write it clearly. If you have an interest in the ethical underpinnings of what we do, this book is for you. If you teach about ethics and clinical practice, or are responsible for it at your institution, this is required reading.

Roger Woodruff (July 2013)

A GOOD DEATH?

Law and Ethics in Practice

Lynn Hagger and Simon Woods (eds)

Ashgate, 2013

ISBN 978-1-4094-2089-7

This book grew out of a 2008 UK Clinical Ethics Network Conference entitled ‘The Value of Life, the Value of Death.’ The editors, an academic lawyer and a philosopher, present a collection of ten essays written by a multidisciplinary cast, exploring some of the legal, ethical, moral, and social aspects of end-of-life care. The medical and nursing perspectives are not well-represented (or are viewed from an ivory tower), but there is a lot in this book to make you sit up and think. The chapter by Lord Justice Munby on the legal rights of terminally ill patients was a pleasure to read. Daniele Bryden asks whether the diagnosis of death, equating death of the organism with death of the person, needs to be re-defined for end-of-life planning and particularly when organ donation and retrieval are considered. John Erik Troyer explores the implications for end-of-life care of the constitutional changes wanted by the fundamentalist Christian anti-abortion Personhood groups in the USA. Would every patient have to have everything done, until they were dead? Hagger and Rehmann-Sutter advocate the need for liberalising assisted suicide in the UK along the lines of the Swiss model (which ‘reflects clear support for patient autonomy’) and provide help for anyone, regardless of the state of their medical health. Viewed as a clinician who deals with real patients, no two of whom are the same, I think it would be totally unworkable. Vincent Kirkbride discusses the escalating costs of health care in the last year of life, whether or not we should expect a right of access to expensive treatments, and the turbulent history of the National Institute for Health and Clinical Excellence (NICE) restricting the use of expensive new anticancer drugs. Wood’s chapter on palliate care and the ‘good death’ seemed more about philosophy than clinical care. There are another two chapters about end-of-life care for children and a mother’s account of the death of her daughter from Tay-Sachs disease.

Reading these essays will have no effect on your clinical skills, but it is good to be reminded of these other legal, social and philosophical views on end-of-life care. There’s plenty to think about here, although it is a little on the expensive side.

Roger Woodruff (November 2013)

ALZHEIMER’S DISEASE, MEDIA REPRESENTATIONS AND THE POLITICS OF EUTHANASIA

Megan-Jane Johnstone

ISBN 978-1-4094-5192-1

‘The ultimate aim—and hope—of this work is that it will infuse the euthanasia debate with a level of intellectual honesty, transparency and accountability that up until now has largely been missing.’ Great objective, but a big task, I would have thought. But that is the goal for Professor Megan-Jane Johnstone, who is Chair of Nursing at Deakin University in Victoria, Australia and is also a nominated Consultant (in Ethics and Human Rights) to the International Council of Nurses in Geneva.

This book is not about the pros and cons of euthanasia and physician-assisted suicide (it lands on neither side), but about the contorted, manipulated, political debate that is going on using conditions like Alzheimer’s Disease to stoke the fire.

Johnstone provides a description of the disease, including its variable course, and goes on to discuss media constructions and representations of it, described in the Foreword as ‘the best discussion yet available on metaphors, analogy, and the stigmatization or even demonization of the deeply forgetful.’ Johnstone discusses in detail what has contributed to the extraordinary success of the euthanasia activists—their political activity, using propaganda and fallacious reasoning, sophisticated marketing strategies, and much more. This is not to say the anti-euthanasia lobby has not been guilty of the occasional dirty-trick or lie, but what is laid at the feet of the pro-euthanasia people is staggering. Her catalogue of the use of the epidemic, military and predatory thief metaphors is illuminating. I particularly liked her classification of the kinds of narratives used to bolster the illusion that euthanasia is right—‘reassurance’, ‘uncertainty’, ‘helplessness’, ‘choice’, ‘control’, and ‘dignity’. Her analysis of what has appeared in the media seems objective, and at the same time is very worrying.

But I guess I’m biased, having seen thousands of patients dying with cancer whose greatest wish was to live a little longer, a wish so sincere that it would silence the activists who believe in beneficent euthanasia for any one with dementia; that is, if they listened.

So who should read this book? Certainly anyone with an interest in the debate about euthanasia, and in particular anyone who wants to make public comment. Starting with the moral philosophers, sociologists, politicians and other self-styled experts (beautifully categorized in the Foreword as the ‘hyper-cognitives’) who can emphatically address difficult questions like the legalization of euthanasia with certainty and conviction. Unfortunately, knowing all the answers, they are less likely to read it.

I hope Johnstone gets her wish—that euthanasia can be discussed in a more honest and sensible manner. Although reading some of the material in this book makes me worry that the debate has already been dragged down to the level of farce.

Roger Woodruff (December 2013)

THE LAW AND ETHICS OF MEDICINE

Essays on the Inviolability of Human Life

ISBN 978-0-19-958955-5

This book is about the ethical and legal principle of the inviolability of human life, and not some theological discussion. It is divided into three parts. The first is about the history, influence and misunderstanding of the ethical principle, the second discusses aspects of the beginning of life, and the last deals with a number of issues at the end of life.

I found the first section a bit heavy-going, as though it was written for academic lawyers, who in fact are the intended audience. I skimped on the second, but the third part (comprising fully a third of the book) was unputdownable. He provides in-depth but readable reviews of the debate about the decriminalization of euthanasia in the House of Lords, the report from the Council of Europe and there are commentaries on the Pretty, Purdy and Bland cases. In the chapter dealing with the Mackay Report (House of Lords), he describes the debunking of two popular myths—that the great majority of our communities are screaming for legalisation of physician-assisted death now, and that we doctors are doing it all the time in secret. Keown also comes up with numerous pieces of evidence (from material supplied with the Mackay Report) that might have significantly strengthened the case against euthanasia. The evidence obtained about practices in The Netherlands include some eye-opening quotes from Dutch doctors, such as:

‘it is the patient who is now responsible in the Netherlands for avoiding termination of his life; if he does not wish to be killed by his doctor then he must state it clearly orally and in writing, well in advance.’

‘Due consideration should be given to the question how termination of life without explicit request can be prevented. It should be the responsibility of the patients…’

His chapter on palliative care is about not wasting time and energy on the euthanasia debate, but focusing on the legal and professional reforms ‘needed to help the 90% or more of dying patients who will never even vaguely desire euthanasia,’ and includes pertinent discussions of whether palliative care is an ethical duty and a human right.

John Keown is well known in euthanasia circles. His previous contributions include Euthanasia Examined—An Argument Against Legalisation (1995) and Euthanasia, Ethics and Public Policy—Ethical, Clinical and Legal Perspectives (2002), both from Cambridge University Press, and Debating Euthanasia (Hart Publishing, 2011), and are all to be recommended. His attention to detail and clarity of thought are admirable, but he writes in a moderate and reasoned tone and in a manner easily understood whether you are a health care professional, lawyer, politician or just an interested member of the public. The Law and Ethics of Medicine is no exception and is recommended to anyone involved in the discussions about physician-assisted death and perhaps to those thinking about better strategies for advancing palliative care.

BEING MORTAL

Medicine and What Matters in the End

Atul Gawande

Metropolitan Books, Henry Holt and Company, 2014

ISBN 978-0-8050-9515-9

I think this is a remarkable book for a number of reasons. It is medically accurate and believable (Gawande is a surgeon at Brigham and Women’s Hospital in Boston as well as a professor at Harvard Medical School and the Harvard School of Public Health), it is well written (he is a staff writer for The New Yorker), the arguments about what should and should not be our goals in caring for the aged and terminally ill are thoughtful and well constructed, and, most of all, because he describes the human foibles that we see every day in the real world, which can undo even the best-intentioned and careful end-of-life care planning.

Gawande’s thesis is that high-tech modern medicine often fails the elderly or those with terminal illness—people it is supposed to help. ‘The waning days of our lives are given over to treatments that addle our brains and sap our bodies for a sliver’s chance of benefit.’ Using some poignant biographical sketches of family members and a retired geriatrician, he describes the medical and societal changes of the last 50 years or so that have changed our attitude to and experience of aging and dying. He tells the story of the poorhouse, the aged care facility, the nursing home—‘designed to be safe but empty of anything they care about’—a trend perhaps interrupted by the advent of assisted living.

The last three chapters deal with terminal illness and include the tales of several memorable patients including Gawande’s own father with his cervical cord astrocytoma. Gawande paints a true picture of how the patients, their families, and their doctors stumble through the minefield of decisions and choices—sometimes getting it right, sometimes getting it wrong. Palliative care and home-based hospice are well described and their value demonstrated, although the point is made that hospice is often involved only in the last few days. And ‘Which funeral service do you want to use?’ is not a question I ask at the first visit. There is thoughtful discussion about how we should be communicating with these patients and their families, without being paternalistic or expecting patients to make decisions they are not qualified to make, but with guidance—the so-called shared decision making. But done right, it’s never easy.

For anyone who works in palliative care, this book provides a thoughtful discussion about the problems we encounter regularly that rings clinically true. And it’s enjoyable to read.

‘We’ve been wrong about what our job is in medicine. We think our job is to ensure health and survival. But really it is larger than that. It is to enable well-being. And well-being is about the reasons one wishes to be alive.’

Roger Woodruff (November 2014)

DYING IN AMERICA

Improving Quality and Honoring Individual Preferences Near the End of Life

Institute of Medicine

The National Academies Press, 2014

ISBN 978-0-309-303101

This Report, by an expert committee convened by the Institute of Medicine (IOM) of the National Academies is about the universal provision of comprehensive care, including hospice and palliative care, for people with advanced serious illness who are nearing the end of life.

The brief for the committee was daunting. To assess the delivery of medical care, social and other supports to the patient and the family; patient/family/provider communication of values, preferences and beliefs; advance care planning; health care costs, financing and reimbursement; and the education of health professionals, patients, families and the public at large. And to explore approaches to advance the field.

Not surprisingly, they concluded that the U.S. health care system is poorly designed to meet the needs of patients and their families at the end of life and that major changes are needed. However the report suggests that broad improvements in end-of-life care to make it compassionate, affordable, sustainable and high quality are within reach.

I was drawn to the more clinical issues, including advance care planning and how physician education might be changed to improve end-of-life care. For example, Recommendation 2: ‘Professional societies and other organizations that establish quality standards should develop standards for clinician-patient communication and advance care planning that are measurable, actionable and evidence-based.’ That would be a big step forward. In a New England Journal of Medicine Perspective, the co-chairs of the IOM committee note that 80 and 88% of American physicians surveyed in two studies indicated they would choose to forgo high-intensity end-of-life treatment (Pizzo PA and Walker DM: Should we practice what we profess? Care near the end of life. N Engl J Med 372: 595, 2015), and ask why we physicians are not helping more patients express their preferences so that they can make informed decisions about the care they want near the end of life. I liked the discussion of inadequacies in professional training, even going back to the ‘death is seen as a medical failure’ excuse.

Whilst this Report is written about and for the United States, many of the issues discussed are pertinent to other countries, both developed and developing. And there is a wealth of information and thought as the (long) list of problems and barriers is discussed.

The report can be purchased, or read free or downloaded as a free pdf file at www.nap.edu/openbook.php?record_id18748

Roger Woodruff (February 2015)

PALLIATIVE CARE AND ETHICS

Timothy Quill and Franklin Miller (eds)

Oxford University Press, 2014

ISBN 978-0-19-931667-0

Hospice and palliative care is alive with ethical issues and this book, with a commendable list of contributors, sets out to discuss them. The opening chapters discuss hospice and palliative care in general, and ethical issues arising from modes of delivery in particular. Following this are a series of chapters about ethical issues related to pain relief, dyspnea, delirium, and psychosocial and psychiatric suffering.

The nitty-gritty of the book is in the last section—Difficult Decisions Near the Very End of Life. There are good chapters on withholding and withdrawing life-sustaining treatments, voluntarily stopping eating and drinking, and on medical futility. Andrew Billings’ chapter on palliative sedation provides a good description of what we are talking about, where it fits in the ethical scheme of things, and underlines the responsibilities of the physician. The chapter on physician-assisted death by Quill and Miller left me dissatisfied and I did not agree that relieving a patient’s symptoms with treatment that you knew might hasten their death, but in no way intended, was the same as popping them off. The chapter on physician-assisted suicide by Ganzini was interesting but did not add any important new information. I was most interested to read that her proposal for a study on whether receiving a prescription resulted in reduction of anxiety and increased sense of peace (an interesting and worthwhile question) was blocked by the pro-PAS organisation.

The final chapter is about physician-assisted death in Western Europe, The Netherlands in particular. I ran into a few bumps here. She starts with the Dutch data that ignores intention, and follows with the European studies. The Australian study, conducted I believe according to the same Dutch criteria, was deceptive in its ambiguity: if you said you had given a patient medication that you knew might possibly shorten their life, although you had no intention of so doing, you were counted as having intentionally shortened the patient’s life. She tells us that ‘termination of life without request is declining since 1990.’ But the numbers stayed the same during the period 1990-2001, amounting to around one thousand patients a year, euthanased without request; the first significant fall was in the 2004 report. She tells us that palliative care services in The Netherlands are among the best in Europe, based on criteria such as attendances at palliative care conferences. She tells us that reporting levels for euthanasia have increased remarkably, but not that this is due to the fact that doctors no longer have to report opioid-related deaths because someone somewhere else in the world reported that opioids given appropriately were not associated with hastened death; that doesn’t apply if you give a lethal dose, intentionally. I didn’t see any mention of the recent rapid rise in the use of terminal sedation, which some have reported as being used in place of euthanasia (i.e. to intentionally hasten the death of the patient), because it doesn’t have any of the legal connotations of euthanasia.

Overall, this is a good synopsis of the range of ethical issues encountered in palliative care, including the delivery of services, patient suffering and physician-assisted dying. It will be useful in the postgraduate classroom and should be of interest to anybody working in palliative care. Just don’t believe everything you read about euthanasia in The Netherlands.

Roger Woodruff – February 2015

ASSISTED DEATH

A Study in Ethics and Law

L. W. Sumner

ISBN 978-0-19-968747-3

L. W. Sumner is Professor Emeritus of Philosophy at the University of Toronto. This is his admittedly partisan contribution, from an ethical and legal perspective, to the debate about assisted death. I note he describes it as an ethical, social, political and legal debate—medical doesn’t seem to come into it.

The first section is about Ethics. He discusses refusal of life-sustaining treatment, followed by a long discussion about double effects, which he describes as ‘relieving suffering and causing death’. This is the first hole he digs for himself, referring to the treatment of patients with increasing doses of opioids as having a probable or certain chance of hastening death; foreseeing a possibility of hastening death doesn’t come into it. To his credit, he mentions that some maintain that appropriate doses of opioids do not shorten patients’ lives, but I’m not sure he believes it. The Australian study (and similar studies from elsewhere) is trotted out to show that doctors frequently use doses of drugs in terminally ill patients that may hasten death. I was sent a copy of that Australian study, which I failed to complete. The questions were deliberately ambiguous, so that doctors who admitted they had given a patient opioids that might possibly have hastened death (but of which they had no intention) were classified as having intentionally given doses of medications they knew to be lethal. Which is just the result the investigators wanted. Utter rubbish, but the results turned up on the front page of the Sunday newspaper. I can’t remember the headline, but it had to do with doctors and killing. Much is made by Sumner about how much a life might be shortened, perhaps to lessen the psychological impact if only a seemingly trivial amount of time is involved. The truth is that no one can know exactly how much a life is shortened by euthanasia, but the Dutch are notorious in this regard. I remember commenting in the mid-1990s on the euthanasia of a young man with AIDS whose life-expectancy using internationally accepted criteria, and using treatment available at that time, was in excess of two years. The Dutch said his life was shortened by less than a month, at the most.

The next chapter moves on to euthanasia and physician-assisted suicide that, from an ethical perspective, Sumner sees as no different from treatment with the possibility of hastening death. I do not agree. The physician’s job is to relieve suffering, and killing people is not an option. Intention is a big thing.

The last chapter in this section is about deciding for others—the formerly competent and the never competent. Sumner argues that where there are no advance directives and the patient is not competent, the principle of ‘acting in the patient’s best interest’ trumps all other considerations and is sufficient to make decisions about euthanasia. I definitely do not agree, and such an argument brings what happened in Nazi Germany back into the debate. Adopting such attitudes in a palliative care unit, or the geriatric or psychiatric wards, is to me unthinkable. As a doctor, I would consider doing a ward round thinking about who can or should be euthanased would constitute, to use the Dutch term, unbearable suffering.

Having argued to this point, I suppose Sumner has no reason to worry about euthanasia without request (one thousand patients a year in The Netherlands), euthanasia for treatable conditions like depression, or the recent marked rise in the use of terminal sedation in The Netherlands, which some report as being used as an alternative to euthanasia (i.e. for the intentional hastening of death) that does not carry any of the legal connotations of euthanasia.

Having satisfied himself that all forms of assisted death are morally permissible in given circumstances, the second half of the book is about legal matters, but I am not a lawyer and my interest had waned. I am sure Sumner will have come up with a means to make euthanasia legal, but not one to control it. Control was not a major issue in the ethics section.

The problem here is that the clear-cut theoretical case studies used are all very well for discussions held in ivory towers, but do not come close to covering the myriad variations (of patients, families, medical situations, and health care professionals, not to mention differing cultural values and beliefs) seen in the real-world ward or clinic. Sumner refers to people holding views opposite to his as having the Conventional View, although I was left wondering whether the capitalisation represented respect or the opposite. I also noted that in his discussions, the patient subject is always referred to as ‘her’.

This book is well written and I would recommend it to anyone interested in the debate about assisted dying. It’s just that I do not agree with some of the things it says.

A Transition

Monika Renz

Translated by Mark Kyburz and John Peck

Columbia University Press, 2015

ISBN 978-0-231-17088-8

Monika Renz is a psychotherapist, music therapist, theologian and spiritual caregiver, with doctorates in both psychology and theology, who has been the head of psycho-oncology at the Kantonsspital St. Gallen in Switzerland since 1998.

Whilst most books dealing with palliative care cover a significant portion of the illness trajectory, Renz has taken a magnifying glass to the spiritual and psychological happenings in the last minutes or hours (days, at most), of patients’ lives. She studied more than 600 patients dying of cancer, recording what happened (or did not happen) after each therapy intervention or encounter, including things both verbal and nonverbal. Analysis of this data is the underpinning of her hypothesis that the dying undergo transition into another state of consciousness, or another way of experiencing being, beyond anxiety, ego and pain. I am not going to attempt to summarize her description of the nature and meaning of these transition processes. But it results in her recommendations about how we might provide better end-of-life care.

I found this book pretty intense, but very interesting. I frequently had to reread a paragraph to understand the real meaning, but I have to say that what Renz (and her translators) say is perfectly clear; perhaps it is that I am not used to thinking in terms of Jungian psychology at the bedside. I was impressed by the similarities to some of the topics discussed by Patricia Pearson in Opening Heaven’s Door, particularly regarding nearing death awareness and premortem serenity, although they are discussed here from a psychological, almost psycho-analytic, perspective. Many of the things she describes ring true, and perhaps this is a better way to describe and treat our dying patients. I would recommend this to anyone who works in palliative care and has an interest in the spiritual and psychological processes in dying patients, or anyone who simply wants to know more.

Roger Woodruff (November 2015)

THE PATIENT’S WISH TO DIE

Research, Ethics, and Palliative Care

Rehmann-Sutter, Gudat and Ohnsorge (eds)

Oxford University Press, 2015

ISBN 978-0-19-871398-2

This book is about terminally ill patients’ wishes that do not just cover the circumstances of their death, but include the wish for death to come. There is an emphasis towards the psychosocial and ethical aspects of care.

The first part of the book explores the state of empirical psychosocial research on wishes to die. Included here is the 2004 paper by Nessa Coyle and Lois Sculco on expressed desire for hastened death; a new afterword by Nessa Coyle provides interesting insight into the changes that have occurred (and are continuing) in palliative care practice over the last ten years. The second part provides four different perspectives on the ethics of practically responding to wishes to die. In the third section, practical issues are discussed as they are encountered in palliative care for patients at the end of life who express wishes to die.

If you want to know more about the genesis of wishes to die, and some guidance as to how we might best deal with them, both as individual healthcare practitioners and as a society, then you will find this book of interest.

Roger Woodruff (November 2016)

SEDATION AT THE END-OF-LIFE: AN INTERDISCIPLINARY APPROACH

Paulina Taboada (ed.)

Springer, 2015

ISBN 9789401791069

The purpose of this book is to analyse several clinical, ethical, and legal questions related to the use of sedation at the end-of-life, also termed palliative sedation (PS). In her introduction, Taboada explains that it is focused on seven questions: is PS ethically different to euthanasia and physician-assisted suicide; is it necessary to invoke the principle of double effect to justify PS; is PS ethical in patients not imminently dying; are decisions about nutrition and hydration independent of decisions regarding PS; is PS appropriate for psycho-spiritual symptoms and existential suffering; is PS ethical for patients unable to give informed consent; and, are clinical guidelines for PS desirable.

I was impressed by the standard of the contributions to this book, which seemed thoughtful and well organised. The uniformity of presentation suggested good editing. Whilst considered answers are offered to some of the questions, an alternate view never seems far away. No one would argue about the minefield of different terms, concepts and definitions. Should there be indications for PS, or should it be based on the wider ‘goals of care’ that we use in palliative care? The question of PS for existential suffering raises further questions of how you define and assess that type of suffering. Much is said about the principle of double effects, which if used properly does differentiate PS from euthanasia; at the same time it is admitted that some uses of PS may in fact be intentional killing. When it comes to guidelines, one expert argues in favour, whilst another decries their use because they have a very negative effect on judicious medical decision-making.

I was particularly taken by the cogent arguments, by John Keown and others, regarding autonomy. “In spite of the undeniable importance of respect for ‘autonomy’, both for patients and also for health professionals, respect for autonomy should always be subordinated to the respect we owe to the ‘basic human goods’ of which the first and most important one is life itself.” Hear, hear! And it’s been known and believed for a long time—it’s not something that has just been discovered. But the parliamentarians in my home State of Victoria are much wiser and have passed legislation to legalize euthanasia and physician-assisted suicide for the sole purpose of giving the power of autonomy to the individual.

If you work in palliative care and are interested in the ethics of end-of-life care and palliative sedation in particular, this book provides a lot of information and even more to think about.

Paulina Taboada is from the Center for Bioethics and Department of Internal Medicine at Pontificia Universeidad Católica de Chile in Santiago, Chile. The other contributors, experts in bioethics or palliative care, were from Canada (8), Chile (2), and the USA (2).

I must again complain that Springer will not supply review copies of their books, and that I feel that reviewing e-books on line is very difficult and probably does not do the authors credit.

Roger Woodruff (December 2017)

DYING IN THE TWENTY-FIRST CENTURY

Toward a New Ethical Framework for the Art of Dying Well

Lydia Dugdale (ed.)

MIT Press, 2015

ISBN 978-0-262-02912-4

The Ars moriendi (‘The art of dying’) appeared in about 1460 after the Black Death (c.1340-1400) of bubonic plague had killed between one- and two-thirds of the population of Europe, and provided the layperson with guidance about the preparation for death according to the customs of the Church at that time. This book, with contributions from physicians, philosophers, theologians and bioethicists, asks what would be needed to create a contemporary Ars moriendi or ‘art of dying well’ in a society like the USA as it exists today.

Big questions are tackled. Recategorizing death from unmentionable to mentionable, even anticipated. Human finitude. What does and does not constitute a ‘good death’. Do hospice and palliative care provide an answer? The second part of the book deals with the substance of dying well—rituals and practices, spiritual preparation, and the role of community. The final section is about children, the elderly and demented, and people with HIV/AIDS.

I enjoyed this book, which I found informative, thoughtful and stimulating, but it wasn’t light reading. Bioethicists will lap it up, but it also asks questions that are relevant to the practice of palliative care on the ground today, such as what is meant by dying well, and how hospice and palliative care should be aiming to try and achieve that.

Cory Taylor

Text Publishing, 2016

ISBN 978-1-925355772

Cory Taylor is an Australian writer who has the great misfortune to have metastatic melanoma that is no longer responsive to therapy. This is her memoir, which I have to say is pretty clear-eyed and unsentimental.

Part of the book is a reflection on her personal and family life and her thoughts about the joys, the sorrows and the precariousness of life. The other is about what it means to be dying and her arguments for the right to choose the circumstances of her own death. Doctors and other health professionals get bad press for not talking about death and dying; religious beliefs (Christian, at least) are declared irrelevant; but her stash of (illegally imported) suicide medicine and the regular meetings of her local branch of Exit International, fare much better. The only thing stopping her, she says, is guilt about the selfishness of suicide and the collateral damage it may cause her family.

I was both provoked and disturbed reading this book. My objection to the legalisation of assisted dying has nothing to do with religious beliefs, but I find the attitude of the new sectarians, who apparently know everything there is to know about human suffering and insist that anything to do with any religious belief be banned from the discussion, to be both inappropriate and intolerant. The problem with legalised assisted dying is that it implies that every doctor will make the perfect decision, every time. But doctors are human.

Roger Woodruff (August 2016)

CONVERSATIONS ON DYING

A Palliative Care Pioneer Faces His Own Death

Dundurn Press (Toronto), 2016

ISBN 978-1-4597-3193-6

Well-known Canadian palliative care physician, Dr Larry Librach, died of pancreatic cancer in 2013, aged 67 years.

This is the story about his terminal illness, put together by author and journalist, Phil Dwyer. It includes some jewels about doctor-patient communication, the meaning of families, being at home, being a burden, hope, and a lot more. ‘Larry had spent a lifetime teaching others that the best way to deal with this particular unwelcome guest [a terminal illness] is to acknowledge him, invite him into the circle, and address him openly. Share the doubts, the fears, the tears.’

There are also some pertinent comments about physician-assisted death. As a physician, he was against it; as a patient, he was against it. But when running CHPCA, he set up a working party to look at the issues, and I think came to the conclusion that the tiny number of patients who could never be satisfied by the best that palliative care could offer, would result in the legalisation of physician-assisted dying.

Larry’s story is interspersed with Dwyer’s recollections of his own brother’s terminal illness—he died of throat cancer in the UK in 2010. Despite all that we hear about the wonderful Macmillan Nurses and the fantastic system of hospices and palliative care, the system of palliative care in Manchester described by Dwyer is woeful; neglect and disinterest are words that come to mind.

Another fact that raised my eyebrows. ‘If you die in Canada today, it is much more likely than not that palliative care won’t be available for you. Between 70 and 84% of all Canadians die without receiving, or having access to, palliative or end-of-life-care services.’ So they are introducing medically assisted dying when only 16-30% of the population have access to palliative care?

I enjoyed this book, which has lots to think about.

Roger Woodruff (February 2017)

CONTINUOUS SEDATION AT THE END OF LIFE

Ethical, Clinical and Legal Perspectives

Sigrid Sterckx, Kasper Raus and Freddy Mortier (eds.)

Cambridge University Press, 2016 (pb)

ISBN 978-1-107-03921-6

This book and I did not get off to a good start. It was advertised on amazon.co.uk as being newly published in December 2016. There was no mention that it had appeared as a hardback in 2013. But I didn’t even get the paper edition; I was told to make do with the e-book, which I think makes the job of renewing doubly difficult. To cut a long story short, I wasted a lot of time dealing with stuff written for geeks, but was unable to download the book. When I tried a fourth time, the site snapped into action and told me I had used the maximum number of attempts allowed, and that I must report immediately to Cambridge University Press.

But this is meant to be about their book. In the introduction, on p 3, I read ‘Suffice it is to say in 2004 Serge suffered a ‘grand mal’ (type of epilepsy) that was caused by a frontal brain lesion and by lung lesions that were treated by craniotomy.’ I felt troubled. Lung lesions rarely cause epileptic seizures, and lung lesions are definitely not treated by craniotomy. It goes on to say, ‘It is absolutely certain that, without the benefits of [continuous sedation], Serge would have died a horrible death.’ I thought that statement was utter rubbish. I was losing patience.

Sterckx and Mortier are professors of ethics at Ghent University in Belgium; Raus is identified as a postdoctoral researcher at the same university.

The opening chapter, written by the three editors, is long-winded and repetitive to the point of being tedious. They were at pains to emphasise how controversial continuous sedation was, but it seemed like a lot of hot air to me. I realised that I had never considered how professors of ethics fill their working week. The chapter ends with a review of the content of the other 14 chapters. But instead of providing a short, sharp synopsis of each contribution, they attempt to summarise everything each author says, cross-referencing what was said by any of the other 13 on any particular point. I thought it was a useless mess that ground on for 11 pages.

The message that I got from skimming some of the other chapters was that there was absolutely no consensus about terminology and definitions, and that there were an almost unlimited number of clinical variations, which meant that no two people using the words ‘continuous sedation’ or ‘palliative sedation’ were talking about exactly the same thing, and that meaningful comparison of different reports was not possible. There were a number of good contributions about these variations and, viewed from a slightly different angle, they provide insight into the myriad considerations involved with terminal sedation. There were also a few contributions raging about the controversial nature of the subject (mainly from ethicists). The best chapter was by Dr Nigel Sykes from St Christopher’s Hospice in London, who provides a clinically sensible description of the history of sedation in palliative care, what benefits it brings, cuts across the business of artificial hydration and nutrition (they are not relevant in appropriate patients), and really asks what all the hype and rage (by ethicists) is about.

The last chapter is by Margaret Battin, a professor of philosophy from Salt Lake City. A vocal advocate of physician-assisted dying, she seems to be expressing concern about terminal sedation that, ‘once the process has begun, the patient no longer has a way of controlling the course of events on the way to death.’ I felt a bit confused.

I remain concerned that the almost meteoric rise in the use of terminal sedation in The Netherlands represents euthanasia in disguise, and has the advantages of being free of the administrative hassles and legal risks associated with euthanasia. That sedation is being used to shorten life is addressed in several of the presentations in this book, but I could not find any quantitative estimates; however, in Griffiths et al Euthanasia and Law in Europe (Hart Publishing, 2008), there is a statement to the effect that Dutch doctors reported that in 50% of cases in which palliative sedation was employed, the intention was to shorten the patient’s life.

Roger Woodruff (May 2017)

THE OXFORD HANDBOOK OF ETHICS AT THE END OF LIFE

Stuart Younger and Robert Arnold (eds.)

Oxford University Press, 2016

ISBN 978-0-19-997441-2

This book comes not that long after Palliative Care and Ethics (Oxford University Press, 2014). However, the earlier book was very focused on palliative care, and had the advantage that the majority of contributors were medically (or nursing) qualified, which I feel leads to much more meaningful and clinically applicable discussion. The present volume takes a much wider purview of end of life issues and includes contributions from bioethicists, lawyers, sociologists, and philosophers, with a much smaller proportion medically qualified. As I have got older, I have become less tolerant of the Professors of Philosophy who pontificate from their ivory towers about clinical matters of which they have zero practical experience; the noise they make is really just a pain.

The first section is about clinical and legal issues, and covers an interesting range of topics. I tripped up on the report from Holland about continuous sedation at the end of life, written by an ethicist and a philosopher. There are pages about double effects and other extraneous matters. I don’t have a problem—a dying patient has intractable suffering, only way to relieve suffering is by sedation, use sedation. Yes, you can invoke the principle of double effect if you want. But what is not even mentioned in the article is the use of terminal sedation to hasten the patient’s death, which has been reported by the Dutch themselves. In other words, it is euthanasia in disguise, and has the advantage that it doesn’t have to be reported to authorities.

The second section is about theoretical, cultural and psychosocial issues. Eric Cassell on The Nature of Suffering and David Barnard’s On Our Difficulties Speaking to and About the Dying were a pleasure.

Section III is about physician-assisted death. The chapter on The Netherlands is written by Gerrit Kimsma, Professor of Metamedicine at Vrije Universiteit; I had never heard of Metamedicine, but a Google search informed me that conventional medicine does not know the cause of 99% of illnesses, but Metamedicine had all the answers, and for a large fee would be of value to complementary practitioners, chiropractors and homeopaths. As previously (Younger and Kimsma, Physician-Assisted Death in Perspective, Cambridge University Press, 2012), he describes the long legal, professional and political struggles that have resulted in a wonderful societal emancipation. But he only tells the fraction of the truth that is convenient. What about the unreported cases? They can tell you how many cases of euthanasia are reported, but have no clue how many go unreported, especially now that euthanasia using opioids does not have to be reported. What about the meteoric rise in the use of palliative sedation? It’s just ‘normal medicine’; not if, as reported by the Dutch, it is being employed to hasten death (‘euthanasia in disguise’). What about euthanasia without explicit request (a thousand patients a year)? Observational studies cannot be used to prove that physicians (who euthanased patients without request) were right or wrong. What about the common failure to obtain the independent second opinion required by law? Not discussed. I remain totally unconvinced that they did a good thing or that they have got it right.

Ira Byock’s The Case Against Physician-Assisted Suicide and Euthanasia was a breath of fresh air.

The article by Margaret Battin (Distinguished Professor of Philosophy at the University of Utah) is entitled Goodbye, Thomas. After her previous diatribe (Battin, Ending Life, Oxford University Press, 2005), this is a mere six pages. It says her arguments for physician-assisted dying are indisputable, there are no valid arguments against, and that anyone who thinks that way is hung up on the thirteenth century thinking of Thomas Aquinas (1225-1274). The rejection of suicide by Aquinas way back then would not have included the sort of decisions involved in 21st century end of life care, and I thought the association somewhat farcical.

The last section is about the emergence of palliative care and includes a good

review by David Clark and Robert Arnold’s Potential Perils to the Promise of Specialty Palliative Care.

Good book. Just don’t believe everything you read about euthanasia in The Netherlands. And be wary of Professors of Philosophy.

Roger Woodruff (March 2017)

Nikki Gemmell

Fourth Estate, 2017

ISBN 978-1-4607-5305-7

Nikki Gemmell is a successful Australian writer with a string of novels and children’s books to her credit.

This book is about the tsunami of emotional, psychological and physical problems after her mother ‘euthanised’ herself; Gemmell doesn’t like ‘suicide’ because it implies the unhinged and irrational. Gemmell’s mother had problems with intractable, unresponsive pain, which left her dependent and crippled.

Gemmell’s relationship with her mother was tumultuous. ‘If I had my life over I never would have had kids,’ her mother said. Later in the book, the daughter admits that she wished her mother dead at times. Interestingly, Gemmell notes that un-maternal mothers do exist, but says they should not be judged. And despite the years of antagonism, she feels no relief after her mother’s death; she describes her life as hell. The abandonment. We didn’t listen enough. The words unsaid. Everything is upended. Catapulted into crisis. ‘With her final act [mother] has altered my future. She has been attempting to do this since my teenage years…But finally, with this…she has crushed me.’

Philip Nitschke, long-time advocate of euthanasia and assisted dying tells Gemmell that her mother contacted his organisation Exit International and that she had (illegally) imported nembutal. He describes this as empowerment. And he adds that anyone opposing his views is either not mature or is suffering ‘religious claptrap’.

Gemmell wrote about these issues in her weekly column in the national newspaper The Australian, and was inundated with responses. A selection of these is presented in the book, providing pithy insights into the problems with laws and with the medical system. Like the woman who said her husband’s advanced cancer ‘threw him into the willing arms of the medical fraternity who don’t know when to stop.’

Gemmell goes on to provide what I thought was a reasonably balanced discussion about assisted dying. Coming from the autonomy/choice position, she comes to the conclusion that assisted dying should be legalized, stating that the embracing of individual choice is the mark of a mature nation. ‘If the perpetrator’s family cannot, by law, be involved in the wishes of the person wanting to die, you are condemning that person to a horrendously bleak and lonely death. And there will be many people left reeling in the wake of that death.’

I don’t necessarily disagree with those sentiments, but I will never support the legalization of assisted dying because of what it brings with it. In every jurisdiction where assisted dying has been legalized, there has been disregard for the laws and safeguards that were put in place to prevent abuse and misuse of these practices. I have concerns that the majority of the medical profession are not adequately trained to formally assess decision-making capacity, and lack the psychiatrist’s skills to make sure no patients with treatable conditions like depression go down the assisted dying path (and that includes me, on both counts). Many doctors cope poorly with severe pain or suffering and rapidly resort to the ‘nothing more can be done’ position, which is half way to assisted dying. How can you be sure the person is not being pressured by family or socioeconomic issues? How do you manage people who feel a burden or who are ‘tired of life’? Where do you draw the line? ‘Euthanasia creep’ is inevitable—when legalization of assisted dying for a very limited group of people in very limited circumstances is expanded to include more people in more situations. In the words of Robert Twycross: ‘Once the barrier of legislation is passed, medically assisted dying takes on a dynamic of its own and extends beyond the original intent, despite earlier explicit assurances that this would not happen.’ Or Herbert Hendin: ‘Virtually every guideline set up by the Dutch—a voluntary, well considered, persistent request; intolerable suffering that cannot be relieved; consultation; and reporting of cases—has failed to protect patients or has been modified or violated.’ Remember the one thousand patients a year that were euthanased without request, never mind consent, in the Netherlands? Now the Dutch doctors say that in 50% of the cases where palliative or terminal sedation is used, the intention is to hasten the death of the patient, i.e. it is euthanasia. The Belgians have championed the cause that euthanasia is a normal part of palliative care, and there are now moves afoot in Canada to censure any palliative care service that declines to provide assisted dying.

Gemmell’s book is excellent and I had trouble putting it down. It is a dreadful story and extremely personal. But she writes so well and the emotional aspects of the turmoil are vividly portrayed. I would happily recommend this book to anyone who works in palliative care. You will be drawn into her story and it provides a raft of issues on which to reflect—where the current system doesn’t work, where it’s doing harm. On the legalization issue, Gemmell and I start from different positions and with different data and, not surprisingly, come to different conclusions. Again, lots to think about.

Roger Woodruff (June 2017)

TIME TO DIE

Melbourne University Press, 2017

ISBN 978-0-522-87093-0

Rodney Syme is a urological surgeon in Melbourne, Australia. He has been an advocate of medically assisted dying for many years, working with the Voluntary Euthanasia Society of Victoria, now re-branded as Dying With Dignity Victoria.

Syme opens with the story of an unfortunate individual who died of laryngeal cancer. As it is described, his written advance directives were disregarded and he of course had unrelieved pain, suboptimal symptom control and suffered significant side effects of the medications he received. We are told repeatedly that this occurred under the care of a Catholic palliative care team in a Catholic hospice. In this and the other tales of woe, his language is dramatic, wringing every last emotional drop from his stories: suffering was always intolerable and unrelievable, no symptoms responded to therapy, etc, etc. But anyway, hard cases are said to make bad law.

He implies that vast numbers of people are now requesting medically assisted death (‘the momentum’), which I dispute. In my practice as an oncologist and palliative care physician, I have dealt with at least ten times the number of patients with advanced disease that Syme has seen and I have never received one request for assisted dying; and, no, patients were always given plenty of opportunity to ask anything they wanted. I wonder whether the polls reported are based on asking people whether they want their loved ones or themselves to die in agony or vote for assisted dying; if that were the situation, I would probably vote for euthanasia.

In his discussion of palliative care, Syme states that it ‘is one of the most important developments in modern medicine’, but this is followed by ‘there is scant evidence to support the effectiveness of specialised palliative care for patients with terminal illness in terms of quality of life, patient or care giver satisfaction, or economic cost.’ Sounds a bit contradictory to me, but I think Syme feels assisted dying trumps palliative care every time. A more sinister thread comes to light in this chapter—that he believes it is the strong religious beliefs of some of the pioneers in the field of palliative care (Christianity, Catholicism in particular) that is preventing palliative care associations and the profession in general from embracing assisted dying; having worked with several of the individuals named, I found this quite disrespectful. He also says it is hypocrisy to oppose assisted dying whilst employing terminal sedation, which I think he regards as a slow and somewhat clumsy form of assisted dying.

Syme’s discussions of dignity, vulnerability and burden are predictably slanted to his obsession for assisted dying. With regard to autonomy, Syme states that all doctors have a fundamental and overriding legal and ethical duty to respect patient choice—if they ask for assisted dying, there isn’t any discussion; I do not go along with that. As noted recently in this column, there is a good paper written by two Australian psychiatrists, Brian Kelly and Francis Varghese, The Seduction of Autonomy: Countertransference and Physician Aid in Dying, which is a careful examination of the innumerable psychological issues and interactions involved with requests for assisted death and makes an absolute nonsense of yes/no attitude of our politicians (and Syme) towards patient autonomy and the right to assisted dying.

Interestingly, Syme finds euthanasia by lethal injection ‘distasteful’ and claims he would never do it. Making a date and time to give someone a lethal injection would be ‘unconscionable’. But…well…if there was a question about ingesting or absorbing the medication, or paralysis,…then it would be OK.

Much of the last part of the book is about the legislation to be brought before the parliament of the State of Victoria to legalise medically assisted death. Syme thinks the proposed guidelines are excellent, although he would spread the net to include patients with ‘advanced incurable illness’. In contrast, I think the guidelines are vague, clinically impractical and open to abuse. [www.parliament.vic.gov.au/file_ uploads/LSIC_pF3XBb2L.pdf].

The other issue with the guidelines, which is not discussed by Syme, is that doctors, like patients (and politicians, perhaps), are human. They vary. Some are good, some are less good. There are good ones who have bad days. There are some who cannot cope with a lot of pain and suffering and resort quickly to the ‘nothing more can be done’ position, which is half way to assisted dying.

Reading this book and the parliamentary report, I am flabbergasted that there is no mention of any problems with assisted dying in The Netherlands. Not whether some patients benefited, but the widespread abuse of the system. No one knows exactly how many cases of assisted dying are not reported, but it is believed to be significant. There is no mention that Dutch doctors often do not consult a colleague for a second opinion, even though it is required under the law. There is no mention that when voluntary euthanasia for terminal illness was condoned, Dutch doctors performed euthanasia on patients with psychiatric illnesses and mental handicap. There is no mention that throughout the 1990s, about one thousand patients a year were euthanased without request, never mind consent. Over the last few years, the number of patients undergoing euthanasia has continued to increase (5500 in 2015), in addition to which there has been a dramatic rise in the use of terminal sedation. Deaths involving palliative/terminal sedation jumped 150% in the five years to 2010. It has the advantage that it does not have to be reported to authorities and doctors have admitted they are using it to end patients’ lives (i.e. ‘euthanasia in disguise’).

This is an important book, and I do not doubt Syme’s sincerity for one moment. I agree with him that people in our society want and deserve better dying. I think that this involves things like health professionals talking more honestly about death and dying, getting people to think in advance about what they want (‘having the conversation’—100% of them are going to die), and trying to limit futile therapy that simply prolongs suffering. I disagree with Syme that handing out lots of suicide sachets of Nembutal will fix the problem and worry that it may bring a whole lot of new problems.

COMMUNICATION AND BIOETHICS AT THE END OF LIFE

Real Cases, Real Dilemmas

Lori Roscoe and David Schenck

Springer International Publishing AG, 2017

199 pp, hardcover; also available as an e-book

ISBN 978-3-319-70919-2

This is a collection of 16 real-life cases exploring the complex range of issues inherent in end-of-life medical care. The authors are at pains to emphasise how complicated things can get, although I doubt anyone reading this Newsletter needs any convincing.

It is divided into three sections. The first deals with complex issues related to pregnancy, newborns, and young children—the woman dying of tongue cancer who was pregnant, young parents facing difficult decisions regarding treatment for neonates with congenital abnormalities that may be further complicated by religious or cultural views, the 4-year-old with incurable cancer whose parents insisted on on-going intensive therapy, and a story involving post-mortem sperm retrieval. In each, there is the clinical history and a list of suggested discussion points, followed by two critiques—one focused on the ethical problems, the other on communication issues.

The second section concerns issues related to family involvement in decision-making—the woman who refused to believe that her young daughter was brain dead and that her life support could be discontinued, the mother of a young man with widespread colon cancer who forbade the involvement of the palliative care team, the 25-year-old woman dying of cardiomyopathy whose advance directive was successfully contested by her schizophrenic mother, and several more grievous tales.

The last section is about autonomy and balancing benefits and burdens—the Jehovah’s Witness who refused permission for his fiancé to be transfused when surgery was unexpectedly complicated by haemorrhage, to treat or not to treat a man with advanced head and neck cancer, the alcohol- and drug-abusing man with life-threatening infection and the patient’s right to treatment, and the man who had cared for his disabled wife for many years until he became depressed and unable to continue his caring due to self-neglect.

Based on the multiplicity and magnitude of difficulties, all the stories here score nine or ten on a scale of ten. What about the 19-year-old Hindu girl rendered quadriplegic and ventilator-dependent in an automobile accident, whose uncle told the medical staff that in their culture it is the family and not the patient who makes decisions, and that the life support should be stopped because her injuries were a result of bad karma from a previous life? In the end, I wished the authors had turned their blowtorch on the sort of problems we see everyday in palliative care: Mr or Mrs Ordinary with a single major issue.

In the introduction, it is noted that 20% of Americans live in a state where physician-assisted suicide is legal, but euthanasia and physician-assisted suicide do not get a mention after that, which I thought was an important omission. Dealing with the communication and ethical issues associated with physician-assisted dying will be one of the big challenges of the next ten years.

I found the text heavy going in places, but if you work in palliative care you will benefit from reading the stories and asking ‘what went wrong?’ and ‘what could have been done better?’ I thought the critiques provided good insight into how the experts think about these issues.

Lori Roscoe and David Schenck are from the University of Southern Florida in Tampa.

Roger Woodruff (March 2018)

EUTHANASIA AND ASSISTED SUICIDE

Lessons from Belgium

Jones, Gastma and MacKellar (eds.)

Cambridge University Press, 2017

363 pp, softback; also available as an e-book

ISBN 978-1316648353

This volume aims to provide an overview of Belgian euthanasia, including the legal, philosophical, bioethical, and clinical aspects.

As far as the system is concerned, we are told the law is reasonably strict, bit it cannot be regulated or policed. The system relies on self-reporting, but only about 50% of cases are reported. Then there is the second consultation, but there is no legal requirement for there to be unanimity of opinion. There are currently calls to legalise life-ending without request.

The Belgian data show there is a continuing rise in the number of patients having euthanasia each year, and the indications have been increased to include the psychiatrically ill and patients with non-terminal conditions. In the words of one commentator, ‘The indications for euthanasia are constantly multiplying, despite the legislators’ initial statements and intentions.’ Sterckx and Raus report that continuous sedation until death (CSD) is used where there is personal, family or institutional reluctance regarding euthanasia. It is also noted that CSD was initiated without consent or request, either of the patient or of the family, in 28% of cases.

A more sinister aspect of Belgian euthanasia is that in just 12 years, it has gone from an exceptional act to the norm (the ‘normalisation’ of euthanasia); then it became a right— there is information in official documents and in the media regarding a ‘right to euthanasia’. Following which, supply creates demand.

I crashed when I came to the chapter on palliative care. I knew the Belgians believed that euthanasia was an integral part of palliative care, but I was surprised when I was told the caring practice of ‘euthanasia accompaniment’ (euthanasiebegeleiding) is now part of the daily work of palliative care professionals. Then I think I was told (by someone sympathetic to euthanasia) that when euthanasia was introduced, palliative care professionals saw the limitations of palliative care (compared to euthanasia), ‘which convinced palliative care professionals that euthanasia could be part of genuinely good care.’ And that ‘palliative care was not harmed but strengthened’ by the introduction of euthanasia. I note the 2014 review of the integrated model (one co-author of which was Dr Distelmans) as giving Belgium a guiding role for the rest of the world.

I struggled with the chapter on euthanasia for children. The author went to lengths to tell me what a monumental amount of work and thought had gone into this. I noted the criteria quoted for psychosocial development were dated 1968, and those for cognitive operations 1971. The neuroimaging stuff is unconvincing and I think it will be a number of years before fMRI (or anything else) will be able to tell you if a particular child has a clear concept of dying and death. I found the statement about children with serious illness sensing their own mortality and therefore having a sense of death, quite sinister. It’s a bit like saying: This child is going to die, therefore he has good insight into dying and death.

The chapter by oncologist Benoit Beuselinck was much better. He noted that requests for euthanasia were very uncommon with the cancer patients in his clinic and pointed out the problems for palliative care (patients in need of palliative care support are reluctant to be referred for fear of euthanasia), and concludes that ‘the legalisation of euthanasia has put a burden on doctors, families, palliative care services and has put in danger the patient’s own life.’

The discussions about managing patients with psychiatric disorders left me confused. On the one hand they talk about the difficulty differentiating ‘between a death wish that is merely a symptom of depression, and one that can be canonised as an expression of free will’ Euthanasia advocate Dr Distelmans believes such distinction can be performed in an objective manner. But I wondered if it mattered, as they said they adhere to the directive of the Dutch Association of Psychiatrists ‘that stipulates that in cases of chronic depression, a wish to die can become durable and should be considered the expression of the well-considered rational choice of the patient.’ Dr Distelmans is the co-chairman of the Federal Euthanasia Control Commission and is said to be convinced that euthanasia should be seen as a form of suicide prevention. I also learned from Google that he conducts study tours to the Nazi death camp, Auschwitz, which he describes as ‘inspiring’.

There was an undertone of arrogance and insensitivity that I did not like. One commentator, Willem Lemmens, asked why ‘none of the pro-euthanasia experts ever seems to consider the possibility that there might be something wrong with a law that creates such emotional and existential havoc.’ When there was a public outcry by some (adult) children who had not been informed prior to their parents’ euthanasia, two euthanasia experts publicly declared them to have ‘pathological mourning’ and to be in need of psychiatric care.

This book provides a thought-provoking look at what has gone on in Belgium, with an appropriate variety of perspectives and opinions. If you have an interest in the assisted dying debate, this is important reading.

The three editors work in the bioethics field in the UK.

And what do I think about the Belgian euthanasia experiment? Nothing good.

(January 2019)

WITH THE END IN MIND

Dying, Death and Wisdom in an Age of Denial

Kathryn Mannix

William Collins (HarperCollins) (UK), Little Brown (USA), 2018

ISBN 978-0008245597 (UK), 978-0316504485 (USA)

Dr Kathryn Mannix is a Palliative Care consultant based at the Royal Victoria Hospital in Newcastle upon Tyne. It sounds as though her specialist career started in oncology, after which she moved into the new discipline of palliative medicine, a career path that seemed remarkably familiar to me. Having qualified as a Cognitive Behaviour Therapist in 1993, she started the UK’s first CBT clinic exclusively for palliative care patients.

At the outset, Mannix bemoans the lack of talking about death and dying in the second half of the twentieth century. And then it’s down to business: ‘It’s time to talk about dying. This [book] is my way of promoting the conversation…My weapon of choice for this campaign is stories…stories about normal humans, dying normal human deaths...’

The book is essentially made up of 30 clinical stories of people at or nearing the ends of their lives, ‘and the intention is to allow the reader to experience what happens...how they cope; how they live; what matters most; how dying evolves; what a deathbed is like; how families react.’ The stories are grouped under six headings and gradually progress from more objective things (physical changes, patterns of behaviour, and dealing with symptoms) to more abstract concepts like making sense of human impermanence, assessing what has truly been important to a given individual, and our legacy. Written primarily for the lay reader, there is a little explanatory introduction to each story and a short critique at the end of each section.

I thought the stories were well chosen and well told. I enjoyed reading them and learned a little bit about CBT along the way.

I wholly agree with what she is doing, but how do you get the masses to read this type of book, how do you get them to talk about death and dying? Many health care professionals go out of their way to avoid talking about death and dying, and the patients and their families see evidence of miraculous breakthroughs in medical science every night on the TV news.

Anyone who works in palliative care will find this book enjoyable to read and there are a large number of clinical issues to ponder. Whilst I could argue that we as a profession should be somehow advocating this book, it is difficult to know how to go about it.

When I did a little research into Dr Mannix’s background, I came across some comments she made at the time of the euthanasia debate in the House of Lords (The Gaurdian 12 October, 2005). ‘The bill to legalise assistance with dying arises from the argument that to deny assistance is to deny the autonomy, or right to choose, of an individual. Proponents describe this denial as dehumanising, as though exercise of autonomy alone is the mark of human personhood. The humanising aspect of choice is its potential for nobility: as humans, we can reflect on our being and on the consequences of our choices. The right to choose to die with medical assistance, when placed in this context, must be weighed against the nobility of relinquishing this right if its commission would damage other, possibly more vulnerable, members of our society.’ I liked that, and it reflects the same clarity of mind evidenced in her book. But I was writing this during the week that the parliamentarians in my own State of Victoria legislated to approve physician-assisted death and euthanasia, although I suppose words like those of Dr Mannix would have gone straight over their heads. Now the leader of the federal Greens, a medical practitioner who dumped medicine to go into politics, is loudly championing the cause for the legalisation of euthanasia in all Australian States and Territories.

PHYSICIAN-ASSISTED DEATH: SCANNING THE LANDSCAPE

Proceedings of a Workshop

English, Liverman, Cilio and Alper, Rapporteurs

National Academies Press, 2018

ISBN 978-0-309-47695-9

Can be downloaded free at www.nap.edu/25131

Whilst this is certainly the most important palliative care book that crossed my desk in the last month, it is also the most disturbing.

After an introductory chapter, there is discussion of conceptual, legal, and ethical considerations in PAD. A number of important issues are discussed, including the difficulty in determining that a patient’s life expectancy is less than six months, how best to assess capacity and competence (in distinct contrast to what happens now), the contradiction between the proponents who demand PAD in the interests of all the patients with unrelievable pain and physical symptoms and the Oregon patients who pursue it because of existential and not physical reasons, and the concern that no safeguards enacted or proposed to date will be able to stop some people’s lives from ending without their consent through mistakes, coercion, or abuse.

Kim Callinan, CEO of the pro-euthanasia organisation, Compassion and Choices, waved the civil liberties/human rights card and I felt there was a little indignity that anyone might not agree with her; she chided those who sought to make the request process any more onerous. She provides no useful discussion about why opinion polls show the majority of people are in favour of legalisation of euthanasia, but (in Oregon) only a tiny, tiny fraction request PAD for themselves. She doesn’t mention that only a fraction of the physicians who support legalisation say they might be willing to participate in doing it. Lastly, she trots out the prevention of suicide business, and ignores the evidence from Oregon and the Netherlands that the rates of non-assisted suicide have gone up since the legalisation of assisted suicide. I cheered when one participant questioned whether it was appropriate for an advocacy group to attend a scientific meeting.

The next chapter is mainly about PAD in Oregon. Linda Ganzini provides an overview of what has happened over the last 20 years, but I thought she dodged some important issues, depression in particular. There are concerns that significant numbers of patients with potentially treatable depression are getting PAD, but she maintains the incidence of depression is very low based on her study in which social workers (not physicians, never mind psychiatrists) were asked to give a gut-feeling score for depression on a scale of 1 to 5, without bothering to use any of the clinically validated instruments for the diagnosis of depression.

The scientific discussions were again suspended, this time for someone else from Compassion and Choices, to emotionally relate the unfortunate tale of his 29-year-old wife who was diagnosed with glioblastoma multiforme, which led to them moving to Oregon and her dying by assisted suicide. He decries the use of the term ‘suicide’, which he says is insulting. And I note he says all PAD deaths are ‘gentle, peaceful’, whilst all non-PAD deaths are ‘struggling and in pain’. Perhaps he doesn’t know that the Dutch reported that 18% of attempted assisted suicides had to be ‘finished off’ with euthanasia by injection. Perhaps he hadn’t heard about what happened with the seven patients in Oregon who regained consciousness after taking a lethal dose of medication, never mind the poor fellow who woke up after three days and lived for another three months.

Chapter 4 is about PAD elsewhere in the world, mainly in the Netherlands. Bregje Onwuteaka-Philipsen spins the party line that the numbers are low and haven’t changed much and it’s all under perfect control. But between 1990 and 2015, deaths from euthanasia, PAS and termination of life without explicit request have increased from 2.7 to 4.9% of all deaths; between 2001 and 2015, the use of continuous sedation until death jumped from 5.6 to 18.3% of all deaths; and since 1990, there have been of the order of 18,000 cases of termination of life without request and they are still going strong with more than 400 cases each year. She avoids talking specifically about all the cases in which intensified treatment of pain and symptoms, withholding or withdrawal of therapy, or continuous sedation until death were performed with the explicit intention of hastening death.

A presentation by an anthropologist who studied euthanasia in the Netherlands paints a glowing picture of the time taken and devotion shown by Dutch physicians when it comes to euthanasia: ‘Euthanasia in the Netherlands involves discussions taking place over weeks, months, and sometimes years and does not largely focus on the final day itself.’ But a Dutch report I read stated: ‘The period of time between the first discussion [of euthanasia] and the actual administration varied from less than a day to…’ i.e. same-day service.

Chapter 5 discusses implementation and practice of PAD, and includes interesting discussions of the societal, institutional, professional and personal responses to PAD.

The one on which I choked was from ‘a recognized expert in palliative care, bioethics and health care communication skills’, who said that palliative care teams can be fully participatory in programs of PAD. This is the model promoted by the Belgians in which euthanasia is seen as an integral and necessary part of palliative care. I have great trouble comprehending this approach and believe what they are calling palliative care and what I call palliative care are different things. Over the years, I have repeatedly been impressed when one or other members of the palliative care team has made that extra effort, gone the extra mile, to deal with a patient’s suffering. But that will never happen if it is likely (or possible) that the patient will have euthanasia in a week’s time.

Chapter 6 discusses physician-assisted death in the context of other long-term support systems available to patients and the last chapter highlights some of the ideas and questions put forward.

This book has a lot of good material, in addition to the twaddle I have picked on. But what disturbed me most was that it seemed to be about ‘how to do it’ (access, voluntariness, competence, etc.) rather than ‘should we do it?’ What happened to intelligent debate about the limits of autonomy?

Get it and read it! It’s free.

Roger Woodruff (September 201

ETHICS IN PALLIATIVE CARE

A Complete Guide

Robert C Macauley

Oxford University Press, 2018

548 pp, paperback

ISBN 978-0-19-931394-5

Robert Macauley is the Cambia Health Foundation Professor of Pediatric Palliative Care at Oregon Health and Science University.

The book is divided into five sections. The first is a general overview and introduction that includes a description of the evolution of the field of clinical ethics. The second is Ethical Issues in Determining the Plan of Care, covering things like autonomy, advance care planning, surrogate decision-making, and code status. The next is about Death and Dying, which takes up one-quarter of the book and which attracted most of my attention. The fourth is about Pediatric Ethics and Palliative Care. The last is collection of other topics including palliative care for dementia and neurodegenerative disorders, organ donation, and the clinical practice of palliative care. Macauley refers to physician-assisted dying (PAD); I shall continue to call it what it is—physician-assisted suicide (PAS).

I got caught up in the section on Death and Dying. There were long (but accurate) discussions of most aspects of a range of issues, but I felt he avoided expressing his opinion. In the end, I felt he seemed to believe there were reasons for avoiding ‘active’ euthanasia, whilst appearing much more tolerant of PAS. As I have read elsewhere on numerous occasions, we are told that more than half the population of Oregon supported the Death With Dignity Act in November 1994. But according to the Oregon Secretary of State, only 1,254,265 people voted that day, indicating that the DWD Act was supported by only 34.9% of registered voters.

Although rich in theory, I couldn’t find much discussion about the known practical difficulties. What about the Dutch patients given lethal medication without explicit request—a thousand patients a year throughout the 1990s, a significant proportion of whom were competent; I think the 2015 figure was down to 500-odd, or only ten per week. What about the Dutch patients subjected to continuous deep sedation until death (26,400 in 2015, or 18% of all deaths), in 5% of which cases (some say more) it is performed with the specific intention of hastening death?

And it’s not just the Netherlands. Over 20 years, only 5% of candidates for PAS in Oregon have had a psychiatric assessment and there is evidence of patients with potentially treatable depression undergoing PAS. The lack of any oversight of the assessment process has been criticised, as in the cases where lethal prescriptions were issued for reasons of caregiver burden and so as not to disappoint the family. And the lack of any serious complications of the PAS procedure in Oregon (although I note one person took 104 hours or 4.3 days to die)? The Dutch say nearly one in five attempts at PAS ends up with doctor-administered euthanasia. Anyone know the truth?

In the discussions, I found it curious that the patient subject was always described as ‘she’, with her wishes and her rights. This is the same as in Sumner’s Assisted Death (Oxford University Press, 2014), where I thought it might be a subconscious appeal to the innate sentiment to protect, or at least not harm, the fairer sex, whilst selling a horrid message.

Some comparison with Quill T and Miller F (eds.) Palliative Care and Ethics (Oxford University Press, 2014) is appropriate. I had trouble (and still do) with Quill’s denial of the possibility of a double effect when treating pain and symptoms, and Weyer’s discussion of euthanasia in Europe was so selective as to be a disgrace. The current volume has the considerable advantage of being single-authored.

Overall, I thought this book was a remarkable effort and I know it will be a useful reference for anybody who works in palliative care. Even in the sections that I have criticised, I have to

say that the discussions of the pros and cons of various issues (as far as they went) were set out in a calm and even manner.

Roger Woodruff (June 2018)

EUTHANASIA, ETHICS AND PUBLIC POLICY: AN ARGUMENT AGAINST LEGALISATION 2e

Cambridge University Press, 2018

ISBN 978-1107618336

This is the latest addition to John Keown’s library of excellent books to do with euthanasia—Euthanasia Examined (Cambridge, 1995), Euthanasia, Ethics and Public Policy (Cambridge, 2002), Debating Euthanasia (Hart, 2012), and The Law and Ethics of Medicine (Oxford, 2012). Perhaps because a lot has happened in the 16 years since the first edition, I thought this latest was the best.

The book starts with a section on definitions, the clarity (or obfuscation) of which are very important in the debate. Part II outlines the three main arguments for permitting euthanasia and PAS, together with the counter-arguments. His descriptions of the moral issues are clear and the legal matters interesting. Following this there is a good chapter on slippery slopes, both ‘empirical’ and ‘logical’. Part III explores the Dutch experience in detail, following which there are sections on Belgium, the (Australian) Northern Territory, Oregon, and Canada.

In the sections on the Netherlands and Belgium, Keown explains how laws that were insufficiently precise or strict were inevitably stretched, and there has been unrelenting progression towards euthanasia being ‘normalised’—euthanasia has become just another option, perhaps even the default one, and has progressed from an exceptional act to a legal right. He quotes Belgian Professor Etienne Montero: ‘Indications for euthanasia are constantly multiplying, despite the legislators’ initial statements and intentions.’ He carefully and logically dismantles John Griffiths’ and Gerrit Kisma’s defence of Dutch euthanasia, in particular regarding the effectiveness of the regulatory system. I was interested to read about Theo Boer (the Professor of Health Care Ethics who was previously pro-euthanasia and served on a Regional Euthanasia Review Committee from 2005 to 2014), who has now become a leading critic of the system. Boer has published figures showing the suicide rates in the Netherlands are the fastest growing when compared to surrounding European countries, most of which lack the option of euthanasia, and that the big increase from 2007 to 2015 occurred during the time when euthanasia had become more accessible.

The review of Oregon confirms there is no effective regulatory system in place and Keown believes it is only a matter of time before euthanasia by injection is condoned.

Canada, or at least the Canadian Supreme Court, does not get good press. Keown details a list of ‘judicial errors’ and claims ‘the judgement of the Canadian Supreme Court was gravely flawed.’ He asserts that ‘disturbing and well-documented evidence, including that of Professor Montero showing the Belgians skiing past the Dutch down euthanasia’s slippery slope, was waved aside’. He also criticises the use of what he calls fuzzy criteria (e.g. ‘grievous and irremediable medical condition’); for the most meaningless criterion, I chose: ‘their death has become reasonably foreseeable’. And the attempted prohibition of conscientious objection in Canada is ominous. Whilst I believe religious freedoms are preserved under Canada’s Charter, the College of Physicians and Surgeons of Ontario has decreed that if a doctor is unwilling to perform euthanasia or physician-assisted dying, they must provide an ‘Effective Referral’ to a doctor who will, i.e. the College does not consider providing the patient with an ‘effective referral’ as ‘assisting’ in providing medical assistance in dying.

In a short Afterword, Keown details the legislation passed in my home State of Victoria. What he does not tell you is that the parliamentary committee that recommended assisted dying, after a nice tax-payer-funded junket to Holland, Switzerland, Canada and Oregon, cited no evidence of abuse or deficiency in the regulatory systems in any of the jurisdictions visited. And that a big deal (i.e. emotive appeal to the masses) was made of the Coroner’s deposition, detailing all the suicides in persons who had ‘experienced an irreversible deterioration in physical health’, which proponents said would be eliminated by assisted dying legislation; the evidence from Oregon and the Netherlands is unequivocal that the suicide rate goes up after legalisation of assisted dying. And that we were repeatedly promised over a period of at least two years that self-administered oral medication was absolutely the only method being considered; then at the very last second, euthanasia by injection was added for any person who is ‘physically incapable of the self-administration or ingestion’ of the lethal substance; I have predicted that the breadth of interpretation of those words would be breath-taking. I could go on…

Reading the descriptions in this book, one is repeatedly reminded of the rising swell of public support for assisted dying, which Syme (Time to Die, MUP, 2016) refers to as ‘The Momentum’, which unequivocally demands legislation. Polls show 70% (or thereabouts) of ordinary people support legalisation. Polls of people who are terminally ill show that about 70% support legalisation, but less than 10% would request it for themselves if it were legal. And the Oregon experiment? There are about 7,500 deaths from cancer each year, or about 150,000 since the DWDA was enacted. Given that 35% of the adult population voted in favour of the DWDA, that should have resulted in 52,500 assisted deaths from cancer alone. Of the 1275 patients to 2017, 68% (867) had cancer. Which means only 1.6% of patients dying of cancer, who voted in favour of the DWDA, chose an assisted death. Seems to me the clinical ‘need’ and public ‘demand’ are much exaggerated.

This book is the best collection of information regarding euthanasia that I have seen and is strongly recommended if you have any interest in euthanasia and assisted dying debate.

John Keown holds the Rose F. Kennedy Chair in the Kennedy Institute of Ethics at Georgetown University, in Washington DC.

(January, 2019)

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TABLE OF CONTENTS

• DEFINITIONS
• THE NETHERLANDS
• THE NORTHERN TERRITORY (Australia)
• OREGON (USA)
• SWITZERLAND
• Arguments for and against Assisted Dying
• On reflection
• Some Final Quotations
• The reviews