11.Endingoflife:euthanasia,assistedsuicideandpaliativecare

GeorgeCristian Curca MD,Ph.D.Prof.demedicina legala si etica medicala

Discipl.Medicina legala si Bioetica,FacultateaMedicina UMFCD

Definitions• Etimologically euthanasia comes from “euthanatos” (that one who dies

happily, eu = good and “tanatos” = death). A good death could be a death without pain, lucid with all beloved near the dying person.

• Euthanasia, E, represents the act to induce the death of a competent patient who:

• (1) voluntarily• (2) repeatedly, • (3) explicitly • (4) asks and request to• (5) his doctor • (6) to be compassionate and • (7) to finish his life • (8) because of his/hers unbearable pain and distress suffering • (9) in the final stage of a lethal disease which brings no hope or cure for

treatment

Clasification1.Consider the voluntariness:

vE. Voluntary:with the consent of the patientvE. involuntary :without the direct consent of the patient butwith proxi consent.vE. Non-voluntary: against one’swill

2.With/without assistance:

uMedical assistance present / Medical assistance absent

3. Consider the action:

ØActive (action)ØAgressive (lethalmedication)

ØSingle effect: unique lethal doseØDouble effect: double dose: the first effect is analgesia with relaxation and stop of the painfollowed immediately by completing the dose in lethal dose with the purpose of euthanasia)

ØNon-agressive (stopping the assistance support)ØPassive (lack of specific actionwhich might prolong life)

EAPC (European Association for Palliative Care) considers that all these classifications are inappropriate.EAPC considers that E is always active because actively the patient dies under doctor ’s actions with shortening of the disease span.EAPC considers that E is always voluntarily. A non-voluntary or involuntary E is murder because what is essential to the understanding

of the case is the patient asking for his death.

WMA(WorldMedicalAssociation)ResolutiononEuthanasia,Adoptedbythe53rdWMAGeneralAssembly,Washington,DC,USA,October 2002andreaffirmedwithminorrevisionbythe194thWMACouncilSession,Bali,Indonesia,April2013

“TheWorldMedicalAssociation'sDeclarationonEuthanasia,adoptedbythe38th WorldMedicalAssembly,Madrid,Spain,October1987andreaffirmedby

the170thWMACouncilSession,Divonne-les-Bains,France,May2005 states:"Euthanasia, thatistheactofdeliberatelyending thelifeofapatient,evenatthepatient'sownrequestoratthe requestofcloserelatives,is

unethical.Thisdoesnotprevent thephysicianfromrespecting thedesireofapatienttoallowthenaturalprocessofdeath tofollowitscoursein the

terminalphaseofsickness."

TheWMAStatementonPhysician-AssistedSuicide,adoptedby the44th WorldMedicalAssembly,Marbella,Spain,September1992andeditoriallyrevised

bythe170thWMACouncilSession,Divonne-les-Bains,France,May2005likewisestates:"Physicians-assistedsuicide, likeeuthanasia, isunethicalandmustbecondemned bythemedicalprofession.Wheretheassistanceofthe

physicianisintentionallyanddeliberatelydirectedatenablinganindividual toendhisorherownlife,thephysicianactsunethically. Howevertherightto

declinemedicaltreatmentisabasicrightofthepatientand thephysiciandoesnotactunethicallyevenifrespectingsuchawishresultsinthedeathof

thepatient."

TheWorldMedicalAssociationhasnotedthatthepracticeofactiveeuthanasiawithphysicianassistance,hasbeenadopted intolawinsomecountries.

BEITRESOLVEDthat:TheWorldMedicalAssociationreaffirmsitsstrongbeliefthateuthanasiaisinconflictwithbasicethicalprinciplesofmedicalpractice,andTheWorldMedicalAssociationstronglyencouragesallNationalMedicalAssociationsandphysicianstorefrainfromparticipating ineuthanasia,

evenifnationallawallowsitordecriminalizesitundercertainconditions.”

History(quickelements)ØHippocraticOath(cca.400bC):“Iwillneithergiveadeadlydrugtoanybodyifaskedforit,norwillImakeasuggestiontothiseffect”.

ØEnglishCommonLaw–1300criticsEandassistedsuicideØ1828– EisoutofthelawinUSAØ1900’s– sustainingoftheproElobbiesinsomecirclesØ1935– theconceptofEisaccepted inEnglandØ1937– assistedsuicide islegally inSwitzerland(‘onewayticketstoZurich’)Ø1938– theconceptofEisaccepted inUSAØ1939– ActionT4– NazyGermanyØ1948–NurembergtrialØ1977– the“livingwill” aftertheQuinlan case(almostayearoftrial)Ø1990– Dr.JackKevorkian(Michigan,USA)– encouragedE,actingproEonelderpeople,condemnedØ1990 –NancyCruzan case(almost8yearsoftrial)Ø1993– Holland– EisdecriminalizedØ1994– Oregon(USA)–DeathwithDignityAct (USSupremeCourtdecision1997,attemptstostopthelawbyamendmentofthedruglawadmittedin2001)

Ø1995– NorthernTerritory (Australia):euthanasiabill;overturnedbyAustralia’slegislative branch1997Ø1999– Texas(USA)– FutileCareLaw admittedØ2002– ElawinHollandØ2002- ElawinBelgiumØ2005–Terri Schiavo case(almost15yearsoftrial)Ø2005– GroningenProtocol(euthanasiainchildren)Ø2005Leonetti lawinFrance(choiceofthepatienttoletdie)Ø2006- CompassionateChoicesAct,California, overturned,Cehia,Franta,AngliaoverturnedØ2011ElawinFranceoverturned

ArgumentsagainstE1. Religionargument:Lifeasadivinegift.2. Philosophicalargument:valueofthehumanlife.Pricelesshumanlife.Respectforhumanity.

Respectforthehumanlife-Imm.Kant3. Culturalargument:penitence,sufferanceasbothaculturalvalueandindividualvalue.4. Legalarguments;

1. Thereisnolegalpossibilityforeexceptoflegalizingtherighttodeath:buttherecouldnotbearighttodeathbecausetherecouldnotexistsoneachpersonstwoantitheticrightsimplyingtwoantitheticactionstoprovide.Therighttolifeisuniversalandafundamentalrightbecauseitisfromthebirth.Therightofdeathwhateverkindofrightmaybecannotexistsfrombirththereforeisnotfundamental,thereforeisinferior,submergingtotherightoflife.

2. Anypositiveright(suchastherightoflife)createsobligationsofcorrelativityforallthecitizens.Iftherightofdeathisapositiverightalso(itcannotbeelsehowbecausefollowthepatient’srequest)itcreatesalsocorrelativityforallcitizens:thereforelimitsthelibertyofthosecitizenswiththeoptioncontrarytoEwhichmaybeobligedtoaction.

3. Therightoflifecreatesobligationforallcitizensincludingthedoctorsbecauseitisafundamentalright(directedforall).Therightofdeathhoweverisnotdirectedforallbutonlyforthoseaskingforitandputinactiononlybydoctorsasexecutionerpersons(discriminativeright)

5. Riscuri:Dreptul lamoarte poate fiabuzat (abuzuri criminale).S-aupetrecut cafapt istoric(actiunea T4dinperioada nazista 1939-1942)

Important authors: The Bible, The Coran, Religious authors of different religious currents, Writings ofthe Christian Church (Pope Pius XII Testament), Nat Hentoff, Leon R. Kass, Ronald Dworkin

ArgumentsproE1.Philosophical arguments:

a.Mercy and compassion: Society has the duty to manifest mercy and compassion facing the agony and pain of one’shuman being having no medical hope (Counterargument: doctors are not directed to express mercy killing andsociety needs: actually their role is contrary, to save humans and to protect human life; doctors are not societybutchers)

b.Value of the human life. Respect for humanity. Respect for the human life- utilitarian perspective (actually human lifeis preserve by keeping the patient alive and respect for humanity keeping the patient under pain alleviation onpalliation treatment; doctors duty is to protect patient health as his first consideration, Geneve Declaration1947)

2. Legal arguments;

a.One’s right to self determination and autonomy (any citizen rights do not may over imposed upon others; no onehuman being has more rights than another human being; legalization impose obligation for the state and his agentsin this case of euthanasia legalization, doctors)

b.The right to life is however a right and not an obligation. May life be an obligation before being a right? Actually not.But being a right is not anymore an obligation. And becoming a right may not become an obligation to another onewhich will be bare of autonomy, professional independence and free option of choice

c.The right to death. The right to a dignify death. The right to death is not antithetic to the right of life but synergic:the right to death follow the right of life therefore is evident that there may not be since the birth. The right of lifeaction in rem but the right to death action individually because the person is autonomous: if one person has the rightto live how may and by whose power be left without the right to die?May the human being be obliged by the societyto live till his natural death without any kind of contract with the society making him obliged to do so? Actually theright to die is antithetic: the right to live is not just in rem but in re also because it needs from everyone involveddirect and active measures in order to be promotes and sustained (active right) in asmuch as the right to die which ifa right needs appropriate and active measures to be fulfilled. Every one has both rights then everyone is entitle for tobe sustained as to be fulfilled and then doctors , as agents o f society, will be legally unable to promote theirethics(professional ethics and individual ethics) because of the synergy between those two antithetic rights every onerequiring desperate different measure, i.e. completely opposed.

Important authors: Timothy Quill ("Deathand Dignity," 1991), Richard Selzer, BettyRollin, Sidney Hook

Slipperyslope

All persons having not a full engagement in society and weakened by any condition especially in authoritative societies (vulnerable persons) are prone to abuses under a pro E concept or an E law of such societies.Ø ElderØ MinoritiesØ Persons with disabilitiesØ Tipically discriminate groups: ethnic, social,

economical, etc.Ø etc.

Philosophicalmodels

UtilitarianmodelPutthebaseontheglobalinterests,communityinterest,consequencesofactions,utilityofactions,equalutility,multiplyingthegoodWhoisindecision?Thesocietydefiningandfightingforitsgood

Kantianmodel• Putthebaseonindividualityofthe

humanbeing:autonomy,rights,respect,thegoodoftheindividualaspartofthesocietyasawhole.

• Whoisindecision?Theindividualdefiningandfightingforhisgood

• Autonomy- atriplemanifestationofitsconceptuality:

– Moralconceptuality:Aprinciple (Imm.Kant,bioethics):autonomyvs.heteronomy

– Biological conceptuality:Conceptualcharacteristic ofthepsychiccapacity:autonomyisinside thepsychiccapacityandincludevoluntariness,understandinganddecisioncapacity

– Legalconceptuality :conceptualmaterializationofone’slegal competence (psychiccompetence)takingintoexercise therighttoselfdetermination.

Jeremy Bentham: A good death is a death without pain

John Stuart Mill: A good death is a happy death

-Howmuchcoststhesufferingandtheelderness? 40%justinthelastmonth.30%spend almosteverythingonexpenses noninsured.80%ofamericans dyingiinhealthfacilities.

-Moneythataretakenawayfromthefamilyrestingwithoutsuccessor goodscallingforsocietyhelp.

-Medicalfutility

-Awaytoenrichthirdparties

vThere is a huge psychologicaldifference between to admitdeath and to kill, differenceso important for workers inthe intensive therapy (freetranslation).

vThere is a huge differencefor pediatricians betweennot using an incubator toheld in life a baby born with600 gr. or to perform a killinginjection, no matter theresult may be similar.(Campbell and Downie,Modern pediatrician practice,1989), (free translation).

•Case1:Smith intentionallydrownshissix-year-oldcousininthebathandmakesitlooklikeanaccidentinordertoreceivealargeinheritance.•Case2:Joneswillalsoreceivealargeinheritanceifhissix-year-oldcousindiesandsohesneaks intothebathroomwhilesheisbathingwiththeintentionofdrowningher.However,asJonesenterthebathroom,thechildslips,hitsherhead,andbeginstodrownonherown.Jonesstandsoverthebathandisreadytopushherheadbackdownifsheshouldraiseitfromthewater.Sheneverdoesanddrownsallonherownwithout anyinterferencefromJones

Thuskillingisnotmorallyworsethanlettingdieandthatthereforeactiveeuthanasiaisnotmorallyworsethanpassiveeuthanasia.

ReflectionsonEthics,Identity,andEpistemology,2012

[http://repugnantconclusions.wordpress.com/2012/07/06/james-rachels-on-euthanasia/]

Arguments that promotes the lack of difference

between killing and letting die: J. Rachel

Arguments that promotes the difference between killing and letting die:

Assistedsuicide• TheHippocraticOathisofteninvokedagainstthemoralityofphysicianinvolvement

indeathsofpatients.Thatoathdeclares:“Iwillneithergiveadeadlydrugtoanybodyifaskedforit,norwillImakeasuggestiontothiseffect.”NumerouschurchessharetheopinionoftheAmericanMedicalAssociationthatthiskindofinvolvementinthedeathofpatients isunacceptableforphysicians.

• Acentralquestionthatfacestheprofessionistherelationshipofassistedsuicidetothefundamentalgoalsandvaluesoftheprofessionitself.Asnotedabove,theA.M.A.holdsthatitisdetrimentaltomedicine itself.Thereareotherviews.Somecommentatorshavesupportedassistedsuicidebutstillarguedthatitfallsoutsidethedomainofmoralmedicalpractice:theyarguethereoughttobeothers(non-physicians)whoassist indeathofthiskind.Othercommentatorsnotethatthereisapluralityofviewswithinthemedicalprofession,andthegoalsoftheprofessionoughttorespectthatdiversity.Theprofessiontoleratesdifferencesofopinionabout,forexample,thepracticeofabortion.Whyshoulditnot,goestheargument,alsotoleratediversityinrespectofphysician-assisted suicide?

• Eventhetermtobeusedwhendiscussingphysicianinvolvementinhasteningapatient’sdeathisamatterofdebate.Differentcommentatorsusethefollowingtermstodifferentpurposes:“euthanasia,”“physician-assistedsuicide,”oreven“physician-assistanceindeath.”

• Ethicshasdrawnupaspecificvocabularyinordertoclarifydifferentkindsofaction.Aphysician'sinvolvementinthedeathofpatientscanfallintothefollowingcategories:

• active,involuntary:thephysicianintentionallykillsapatientcontrarytothewishesofthepatient• active,voluntary:thephysicianintentionallykillsthepatientinaccordancewiththewishesofthe

patient• passive,involuntary:thephysicianletsthepatientdiebyrefrainingfrominterventions,contraryto

thewishesofthepatient• passive,voluntary:thephysicianletsthepatientdiebyrefrainingfrominterventionswhichwould

beuselessinanycase,inaccordancewiththewishesofthepatient• Medicalethicshastraditionallyaccepted(d)asmoralonthegroundsthat itisdiseaseandnotthe

physicianwhoisdoingthekilling,treatmentforthedyingpatientisthought tobepointless inanycase,andapatientshould notbesubjectedto interventionsthatbringaboutmoreharmthanbenefit.

• Theformallystatedopinionsofmedicalethicshavetraditionallydeniedthelegitimacyof(a),(b),and(c).Forexample,theAmericanMedicalAssociationhassaid:“...permittingphysicianstoengageineuthanasiawouldultimatelycasemoreharmthangood.Euthanasiaisfundamentallyincompatiblewiththephysician’sroleashealer,wouldbedifficulttocontrol,andwouldposeserioussocietalrisks.”(CodeofEthics,2.21)

• StandardArgumentsagainstPhysician-AssistedSuicide• Thereareanumberofargumentsthatarerepeatedintheargumentagainst

physician-assistedsuicide:1. suicideiswronginandofitselfevenfortheill2. itisincompatiblewiththehealinggoalsofmedicine3. givenappropriatepalliativecare,itisunnecessary4. requestsfordeathareinducedbypoorcareand/orunrecognized

psychologicalneeds5. thepracticedamagesphysiciansbydesensitizingthemtohumanneeds6. itleadsdownaslipperyslopetoindiscriminatekillingoftheill,weak,and

disabled,amongothers7. Takeneitherseparatelyorinsomecombination,theseargumentsareoften

foundpowerfulandconvincingbyphysicians,moralists,andthepublicalike.• Atpresent,theA.M.A.declarestheprofessionentirelyopposedtophysician-

assistedsuicide:“Physician-assistedsuicideisfundamentallyinconsistentwiththephysician'sprofessionalrole.”Insteadofphysicianinvolvementinassistingthedeathofpatients,theA.M.A.counselsphysicianstotendassiduouslytothepainanddiscomfortofthedying.

• StandardArgumentsinfavorofPhysician-AssistedSuicide• Asisthecasewiththecaseagainstphysician-assistedsuicide, certainargumentsare

repeatedinthesemovementsfavoringphysician-assistedsuicide:• itprotectspeoplewhodonotwanttosufferlingering, painfuldeaths• itisinkeeping withrespectforpatientautonomy• itisdefensibleaspolicybecauseitrespectssocialdiversity• itprotectsagainstphysicianpaternalismandunwantedtreatment• itprotectsagainstdebilitatingconditionsnoteasilymanagedbymedicine• thestatehasnointerestinginforcing theprolongation oflifeofsomeone inpainwho

wantstodie• Thereisnomoralorlegalsupport forphysicianassistanceinanykindofinvoluntarydeath.

Noseriousadvocateofphysician-assistedsuicidehasarguedthatphysiciansmusttakepartinassistingindeath.Proponents ofphysician-assistedsuiciderecognizetherightofindividualphysicianstodeclinetoparticipateforreligiousormoralreasons.Itisthoughsometimesargued thatphysiciansshould, regardlessoftheirownmoralviewsaboutassisteddeath,offerreferralofpatientstophysicianswhowillhelptheminthedesiredway

http://www.uic.edu/depts/mcam/ethics/suicide.htm

PalliativecarevPC are medical care beyond curativ treatment addressed to

physical, psychological, spiritual issues for persons being ill withlethal diseases (WMO, 2002).

vPatient issues: pain, sufference, uncertainty, lonliness, marginalization, lack of hope, etc.

• Thepackageofpalliationisbroughtinthetreatmentofthepatientandnotafterthetreatmentofthepatient).

WHO, Better Palliative Care for Older People, ed. Elizabeth Davies and Irene J Higginson, Floriani Foundation, 2004)

Futilemeansnotwithoutthemeaningoflifebutwithoutefficiencyforcure.

Palliation is not E when :

(1) a futile treatment is stopped

(2) a futile treatment is not started

(3) terminal sedation is applied with the scope to bring pain relief and to protectlife

PALLIATION v.EUTANASIA

PALLIATIONvIntention:pain relief

vProcedure :touseadrug forpainrelief(paincontrol)

vScope:immediate pain relief

vVerifing indicators:painreliefdiagnosis

INEUTANASiIAvIntention :toinducedeath

vProcedure:touseadrug toinducedeath(deathcontrol)

vScope:immediate death

vVerifing indicators :deathdiagnosis

Voluntary medicalization in order to bring death is E. Nonvoluntarymedicalization is murder.

Albrecht Durer:Ceipatrucavaleriaiapocalipsei

Michael Kearl’s Guide to Sociological Thanatalogy: http://www.trinity.edu/~mkearl/death.htmlPeter Metcalf, Richard HuntingtonCelebrations of Death: The

Anthropology of Mortuary Rituals.Leo Tolstoy, “The Death of Ivan Illych”D. J. Enright, The Oxford Book of DeathSherwin Nuland, How We DieElizabeth Kübler-Ross, On Death and Dying

Further reading