Should patient assisted suicide be allowed? Under what circumstances?

1. Should patient assisted suicide be allowed? Under what circumstances? Where do we draw the line for Euthanasia? Mekhala Acharya Jennifer Barb March 6, 2007 Jeff Solka BINF705

2. What is Euthanasia? Euthanasia is inducing the painless death of a person for reasons assumed to be merciful. Euthanasia is the intentional killing by act or omission of a dependent human being for his or her alleged benefit. The key word here is "intentional". If death is not intended, it is not an act of euthanasia. (Henrickson and Martin 24)

3. What Euthanasia is NOT There is no euthanasia unless the death is intentionally caused by what was done or not done. Thus, some medical actions that are often labeled "passive euthanasia" are no form of euthanasia, since the intention to take life is lacking. http://www.euthanasia.com/definitions.html

4. These are NOT euthanasia: • Not commencing treatment that would not provide a benefit to the patient. • Withdrawing treatment that has been shown to be ineffective, too burdensome or is unwanted. • The giving of high doses of pain-killers that may endanger life, when they have been shown to be necessary.

5. Whats the right answer?

6. Timeline • About 400 B.C. - The Hippocratic Oath: “I will give no deadly medicine to any one if asked, nor suggest any such counsel • 14th through 20th Century English Common Law: "the Anglo American common law tradition disapproved of both suicide and assisting suicide." • 19th Century United States: That suicide remained a grievous but nonfelonious. • 1828 - Earliest American statute explicitly to outlaw assisting suicide • 1920 The book "Permitting the Destruction of Life not Worthy of Life" was published: This book helped support involuntary euthanasia by Nazi Germany. • 1935: Voluntary Euthanasia Society was started. • 1938: United States Hemlock Society established • 1939:Nazi Germany: In October of 1939 amid the turmoil of the outbreak of war Hitler ordered widespread "mercy killing" of the sick and disabled. • 1995: Australia's Northern Territory approved a euthanasia bill • 1998: U.S. state of Oregon legalizes assisted suicide • 1999: Dr. Jack Kevorkian sentenced to a 10-25 year prison term. • 2000: The Netherlands legalizes euthanasia • 2002: Belgium legalizes euthanasia • 2007:Italy No Disciplinary Action For Doctor In Right-To-Die Case http://www.euthanasia.com/historyeuthanasia.html

7. Difference between euthanasia and assisted suicide • One way to distinguish them is to look at the last act – the act without which death would not occur. • Using this distinction, if a third party performs the last act that intentionally causes a patient’s death, euthanasia has occurred. For example, giving a patient a lethal injection or putting a plastic bag over her head to suffocate her would be considered euthanasia. • On the other hand, if the person who dies performs the last act, assisted suicide has taken place. Thus it would be assisted suicide if a person swallows an overdose of drugs that has been provided by a doctor for the purpose of causing death. It would also be assisted suicide if a patient pushes a switch to trigger a fatal injection after the doctor has inserted an intravenous needle into the patient’s vein. http://www.internationaltaskforce.org/faq.htm

8. Where is euthanasia legal Oregon, the Netherlands, Belgium • Oregon permits only assisted suicide • The Netherlands and Belgium permit euthanasia and assisted suicide In 1995 Australia’s Northern Territory approved a euthanasia bill.  It went into effect in 1996 but was overturned by the Australian Parliament in 1997. Also, in 1997, Colombia’s Supreme Court ruled that penalties for mercy killing should be removed. However the ruling does not go into effect until guidelines, still to be drafted, are approved by the Colombian Congress. http://www.religioustolerance.org/euth1.htm

9. Some reasons why people may want to end their life • Depression - permanent solution to a temporary problem • Chronic pain - poverty or lack health of health care • Terminal illness - can’t cover medical expenses • Serious disorder or disease - quality of life is very low • Continual care is needed - no longer can sustain their own responsibilities and maintain their own life • Been told that they will die soon - why wait? • Future concerns with health – suicide is an option

10. Euthanasia terminology • Assisted Suicide: providing a person with the means to end his or her life. • Active euthanasia: taking a specific action to end a person's life. (lethal injection) • Passive Euthanasia : withholding or withdrawing life support, nutrition, or water without a person's consent, with the specific intention of ending that person's life. • Doctor-assisted death: this term includes both physician-assisted suicide and active euthanasia performed by a physician. http://www.leaderu.com/orgs/tul/ott-euthanasia.html

11. Its in the Movies: Is the movie “Million Dollar Baby”propaganda for Euthanasia? How it happens: …Hoping to bleed to death, Maggie attempts suicide by biting her tongue. She is unsuccessful. However, enough is enough and Frankie makes the decision to do the “right” thing and end Maggie’s suffering. Frankie enters his friend’s room at night. He kisses Maggie on the forehead, disconnects her breathing tube and injects a large does of adrenaline into her I.V. He slips out of the room and Maggie dies… http://www.prisonplanet.com/articles/february2005/030205euthanasiapropaganda.htm

12. The movie:“One True Thing” The terminally ill mother with cancer dies from a morphine overdose “…finding a new respect for her mother and the life she led, Ellen finds herself contemplating euthanasia when Kate’s pain reaches unbearable pain and her love for life is extinguished. All of this sets the stage for the interview with a district attorney over her mother’s death, which serves as the movie’s framework narrative…”

13. Another movie:The English Patient A burn victim receives an overdose of morphine from his care giving nurse Why didn't we notice euthanasia in "The English Patient ?" How it happens: …when it's time for him to get another dose of pain medication, he flicks a few extra vials sitting on the night table toward Hana. She looks at him and says nothing. Crying, she draws the overdose and gives it. He dies, freeing her from her nursing duties and allowing her to leave just at the time her new lover has been transferred… http://en.wikipedia.org/wiki/The_English_Patient_(film)

14. It’s in the News We all remember the Terry Schiavo case: • Was this acceptable? • Should they have disconnected her feeding tube?

15. Terri and assisted death Theresa Marie "Terri" Schiavo, died at 41 yrs old -St. Petersburg, Florida, United States -1990 – she collapsed and experienced cardiac and respiratory arrest in her home -suffered brain damage - dependent on a feeding tube for 15 years -Her diagnosis- persistent vegetative state (PVS) “In 1998, Michael Schiavo, her husband and guardian, petitioned the Pinellas County Circuit Court to remove her feeding tube.” http://en.wikipedia.org/wiki/Terri_Schiavo

16. Terri • By March 2005, the legal history around the Schiavo case included fourteen appeals and numerous motions, petitions, and hearings in the Florida courts; five suits in Federal District Court; Florida legislation struck down by the Supreme Court of Florida; a subpoena by a congressional committee to qualify Schiavo for witness protection; federal legislation (Palm Sunday Compromise); and four denials of certiorari from the Supreme Court of the United States.[1] • She died at a Pinellas Park hospice on March 31, 2005, at the age of 41.

17. A PBS frontline specialand 60 Minutes

18. Dr. Jack Kevorkian • Dr. Kevorkian – an Armenian American pathologist • advertised about death counseling in Michigan newspapers in 1987 • The right to die – he assisted in 130 patient suicides between 1990-1998 – voluntary euthanasia • His most famous quote: “dying is not a crime” http://en.wikipedia.org/wiki/Jack_Kevorkian

19. Thomas Youk and Kevorkian • Youk - an adult male with full decisional capacity who was in the final stages of Amyotrophic lateral sclerosis (ALS- a progressive, fatal neurodegenerative disease) • Youk provided his fully-informed consent on September 17, 1998, Kevorkian administered a lethal injection • Kevorkian was sentenced to 10 to 25 years for second-degree murder in the 1998 poisoning of Thomas Youk, 52, of Oakland County, Michigan. • Kevorkian filmed the procedure and the death and submitted it for broadcast on 60 Minutes WAS THIS ACCEPTABLE? Should he have been sentenced to 10-25 years in prison?? http://en.wikipedia.org/wiki/Jack_Kevorkian

20. The debate continues "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." ... Richard Fenigsen, Dutch cardiologist”

21. Joffe bill The Assisted Dying for the Terminally Ill Bill seeks to allow doctors to assist a patient who is requesting suicide to do so. Those opposed to the bill - among them Care Not Killing - believe it will simply put vulnerable people at risk of early death. The Joffe bill if passed it will enable 'an adult who has capacity and who is suffering unbearably as a result of a terminal illness to receive medical assistance to die at his own considered and persistent request'. Put simply it seeks to legalize physician assisted suicide (PAS), along the lines of the Oregon Death with Dignity Act

22. The film http://www.carenotkilling.org.uk/?show=315

23. Case study • Although euthanasia is illegal in the UK, there are some grey areas. A doctor can legally give a person an overdose of an opiate like morphine - even if they know it will kill the patient. • As long as the intention is to ease suffering, they cannot be prosecuted for murder. Known as the principle of "double effect", many doctors admit that they have done this - even that their motives were mixed. http://news.bbc.co.uk/2/hi/health/1983457.stm

24. The Diane Pretty case • Diane Pretty was said to be terminally ill with motor neuron disease . She was in extreme pain and regularly begged for her life to be ended. She had lost her ability to move her muscles - including, eventually, those controlling speech and breathing. The 42-year-old wanted to end her life – but because of the immobilizing nature of motor neuron, despite the clarity of her thoughts, she lacked the capacity to perform the act.

25. Diane • This is what brings her into conflict with the law. Her husband, Brian, wants to help her die, but faces possible prosecution should he do so - with a maximum potential jail term of 14 years? • She decided she couldn't wait for the disease to take its course and face a death she believed would be distressing and deprived of all dignity and control. • After their appeal was dismissed in the British courts, Diane traveled on a nine-hour ambulance journey to the European Court of Human Rights in Strasbourg - to ask for the right to die.

26. What life? • In an interview with BBC, Diane told about her quality of life. • When she wanted to say something she would make a noise something like a cross between a grunt and a moan. Or make a movement with her eyes to indicate what she was after. • Someone to move her arm. Or scratch her eyebrow. Or wipe her eyes. Or suction the saliva out of her mouth because she couldn't clear her own throat. • Or fetch a bowl so she could be sick. Or massage her legs because they'd gone into spasm. Or change her catheter bag or her incontinence pad. • When asked whether life isn't always better than death she replied: "I am dead". When asked about her quality of life, she replied simply: "What life?"

27. Health care providers • One of the most important developments in recent years is the increasing emphasis placed on health care providers to contain costs. • In the United States alone, millions of people have no medical insurance and studies have shown that the elderly, the poor and minorities are often denied access to needed treatment or pain control. • Savings to governments could become a consideration. Drugs for assisted suicide cost about $35 to $45, making them far less expensive than providing medical care. • Legalized euthanasia or assisted suicide raises the potential for a profoundly dangerous situation in which the "choice" of assisted suicide or euthanasia is the only affordable option for some people. Humane Med. 1993 Oct;9(4):320-1.

28. Forced into euthanasia? • There is absolutely nothing in the Oregon law to prevent HMOs, managed care companies, doctors or anyone else from suggesting, encouraging, offering, or bringing up assisted suicide with a patient who has not asked about it. • In 63% of the deaths reported, fear of being a burden was expressed as a reason for requesting assisted suicide. • The concern about "being a burden" could serve as a powerful force that could influence the decision . • Even the smallest gesture could create a gentle nudge into the grave . The Hemlock Society designed cards to be given to those who are terminally ill. It read "I learned you’ll be leaving us soon” http://www.internationaltaskforce.org/faq.htm

29. What about pain? • Everyone – whether a person with a life-threatening illness or a chronic condition – has the right to pain relief. With modern advances in pain control, no patient should ever be in excruciating pain. • If a patient who is under a doctor’s care is in excruciating pain, there’s definitely a need to find a different doctor. But that doctor should be one who will control the pain, not one who will kill the patient. • There are board certified specialists in pain management who can not only help alleviate physical pain but who are also skilled in providing necessary support to deal with emotional suffering and depression that often accompany physical pain. http://www.euthanasia.com/reasonsforeuthanasia.html

30. Predicting death • The assisted suicide bill applies to those with a "terminal disease" that is "incurable and irreversible" and will "produce death within 6 months". • Predicting death is an inexact science at best. Doctors can and do make mistakes. And there is no requirement that death be expected to occur despite provision of lifesaving medical treatment. • Therefore people with diabetes, kidney disease, or respiratory failure (they are terminally ill but will not die within six months) could be candidates for assisted suicide. In other words, the bill could apply to those with permanent disabilities. http://www.mainerighttolife.com/euthanasia.php

31. The right to die • Euthanasia is not simply a question of ending someone's life. The important question is how that person's life ends. If someone can choose euthanasia, they don't have to think about the worry and the suffering only. They can also focus on the things they really want to do, like taking a last trip, or making up a fight with someone in the family, or saying goodbye. The pressure on that person becomes lighter when they know they won't have to go on suffering. Often, people who have chosen euthanasia have such peace of mind that they die naturally anyway. • In fact Dr Gerrit Kimsma, from the Netherlands, supports the option of voluntary euthanasia. He talks to them often about different treatments and ways to relieve their pain, so that they know about all the choices, not just euthanasia. • Dr Kimsma admits that in the case of euthanasia there is a conflict between two of his goals as a doctor: the goal of saving life, and the goal of helping people who are suffering. He believes that helping people is the morally right thing to do. "My patients can be sure that I will not let them suffer unnecessarily alone. That is my goal and duty as a physician.“ "A Careful Death" : New Internationalist April 1997

32. The Impact of Euthanasia on Society • Euthanasia is a complex matter, there are many different types of euthanasia, each of which has it’s own advantages and disadvantages. It can be said that all types of euthanasia have an impact on society - or perhaps society has an impact on them. • People suffering from terminal diseases are often faced with the prospect of experiencing great deals of pain as the disease progressively worsens until it kills them. This prospect may be so frightening for them that they would rather end their lives before they have to face it. • The ethical question is whether people should be given assistance in killing themselves, or if they should be forced to suffer the pain and indignity caused by terminal illness. • If it's only people that want to die that are going to be affected then why should other people be worried? We have certain rights as individuals, but society has rights of it's own as well: the rights of an individual must not interfere with the rights of another. Whipp, M. (2000). Euthanasia - a Good Death? Cambridge: Grove books.

33. Euthanasia and society • The British Medical Association (BMA) considers that acceptance of euthanasia as an option could exercise a detrimental effect on societal attitudes and on the doctor-patient relationship, jeopardizing in particular, the fate of vulnerable individuals. • Doctors take the Hippocratic oath - pledging to do no harm, the legalization of euthanasia would mean that doctors would take on an additional role, alien to the traditional one of healer. The doctor patient relationship is based on mutual trust, it is feared that this trust may be diminished if euthanasia was legalized. • Patients may fear that their doctor will kill them if it is decided that their life is no longer worth living. There is also a fear of the reverse situation - patients taking greater autonomy over their own treatment and lives will compromise the autonomy of doctors Whipp, M. (2000). Euthanasia - a Good Death? Cambridge: Grove books.

34. Euthanasia and family • The concept of suffering being good for caregivers raises another issue – the effect it has on the family of the patient. Loved ones, friends and family are all going to be involved in the dying process, in the case of slowly progressing diseases they may have to watch the symptoms get worse over a long period of time. • They will be involved right to the end, by which time they may be greatly distressed or traumatized. Doctors and hospital staff have the advantage of being used to seeing such things and having clinical detachment, friends and family do not. If euthanasia were an option, the family of the patient (as well as the patient himself) could be spared a great deal of distress.

35. When do we draw the line? • The consequences of legalizing euthanasia could be profound, but it is thought that only a small number of people would request it, many would be reassured that the option would be available if their condition were to become unbearable later on. When abortion was legalized, however, it was predicted that it too would only be used by a very small number of women. • Advances in medical treatments have enabled us to keep people artificially alive, using respirators and methods of artificial feeding. Drugs used to try and control diseases can be very expensive; chemotherapy treatments used in the fight against cancer, for example, cost a great deal of money. • There comes a point where these treatments are no longer offering therapeutic benefits, and they are merely prolonging the dying process. If the patient were to request euthanasia such treatments would not be given, thus saving a considerable amount of money. This money could be used to provide resources for people who have a chance of surviving, improving hospital facilities, buying more equipment - it could be used in ways that would save lives. People choosing euthanasia would in fact be helping society. Rachels, J. (1986). The End of Life, Euthanasia and Morality. Oxford: Oxford University Press.

36. Safeguards • One of the most worrying issues in this debate is that of the so-called 'slippery slope'. The BMA said that "by removing legal barriers to the previously 'unthinkable' and permitting people to be killed, society would open up new possibilities of action" • Thus what may start out as a safe system which allows terminally ill patients to end their lives on their own terms whilst protecting the vulnerable members of society, may degenerate to a system where "eventually laws will be created to allow the state to kill anyone that it deems to be worthless" • Safeguards would have to be put in place, these would make sure that assistance in committing suicide would only be given to people; with terminal illnesses, who feel that their life is not worth living (because of unbearable pain, loss of dignity, loss of capability), who repeatedly ask for assistance in committing suicide, and who are of sound mind and not depressed. These safeguards should ensure that people aren't requesting it because they feel pressured to, and it might also identify people with depression who would otherwise commit suicide and allow them to be treated. (1997). Last Rights? Assisted Suicide and Euthanasia Debated. (ed. M. Uhlmann).

37. Key points • A request for assisted Suicide is typically a cry for help. • Suicidal Intent is typically transient. Of those who attempt suicide but are stopped, less than 4 percent go on to kill themselves in the next five years; less than 11 percent will commit suicide over the next 35 years. • Terminally Ill patients who desire death are depressed and depression is treatable in those with terminal illness. • Pain is controllable. Modern medicine has the ability to control pain. A person who seeks to kill him or herself to avoid pain does not need legalized assisted suicide but a doctor better trained in alleviating pain. • You don't solve problems by getting rid of the people to whom the problems happen. The more difficult but humane solution to human suffering is to address the problems. Source: Suicide Factsheets, NRLC Dept. of Medical Ethics

38. Do we have a consensus? • In conclusion then, euthanasia is a complex issue. There are many pros and cons towards legalizing euthanasia, it would give people greater autonomy over their own lives and give terminally ill people a chance to avoid great pain and emotional distress. • However, it begins the degradation of the prohibition of murder, and opens up the possibility of further erosion of the system. • The Select Committee report summed up the issue as follows; "The death of a person affects the lives of others, often in ways and to an extent which cannot be foreseen. We believe that the issue of euthanasia is one in which the interest of the individual cannot be separated from the interest of society as a whole". http://www.nt.gov.au/lant/parliament/committees/rotti/rotti.shtml