The world medical community considers both euthanasia and assisted suicide to be in conflict with basic ethical principles of medical practice. The World Medical Association, with members representing medical associations (including the American Medical Association) from eighty-two countries, has adopted strong resolutions condemning both practices and urging all national medical associations and physicians to refrain from participating in them even if national law allows or decriminalizes the practices.(1)
“Euthanasia, that is the act of deliberately ending the life of a patient, even at the patient’s own request or at the request of close relatives, is unethical. This does not prevent the physician from respecting the desire of a patient to allow the natural process of death to follow its course in the terminal phase of sickness.”(2)
“Physician-assisted suicide, like euthanasia is unethical and must be condemned by the medical profession. Where the assistance of the physician is intentionally and deliberately directed at enabling an individual to end his or her own life, the physician acts unethically. However, the right to decline medical treatment is a basic right of the patient and the physician does not act unethically even if respecting such a wish results in the death of the patient.”(3)
Furthermore, in deciding an assisted-suicide case, the European Court of Human Rights found that its “prohibition on the use of lethal force or other conduct that might lead to the death of a human being did not confer any claim on an individual to require a State to permit or facilitate his or her death.”(4) The European Court judges described the prohibition as a measure intended to protect the weak and the vulnerable.
In spite of the nearly universal rejection of assisted suicide and euthanasia because they are outside of the bounds of legitimate medical practice, several jurisdictions, in addition to the state of Oregon, have or did permit either or both euthanasia and assisted suicide in recent years.
In 1995, with the passage of the “Rights of the Terminally Ill (ROTI) Act,”(5) Australia’s Northern Territory became the only jurisdiction in the world with both legalized assisted suicide and euthanasia. The law went into effect in July 1996. It was repealed on March 25, 1997. The Australian Medical Association opposed the Northern Territory legislation while it was in effect(6) and continues to oppose both euthanasia and assisted suicide.(7)
The law’s repeal stemmed from the relationship between the national (Commonwealth) Parliament and the government of the Northern Territory. Under that relationship, the Commonwealth can review and repeal a Northern Territory Act if the Act can be shown to be in conflict with national views.(8)
During the eight months the law was in effect, four deaths occurred under its assisted-suicide provision. Dr. Philip Nitschke, a long-time activist and campaigner for assisted suicide and euthanasia, was listed as a certifying physician under the law(9) and facilitated all four deaths. Before his involvement with euthanasia, Nitschke had not been involved in caring for terminally ill people nor was he a part of any medical or palliative care network in the Northern Territory.(10)
The method used to end the lives of the four patients was a far cry from what would be considered an accepted medical procedure. It was appropriately described as “death-by-laptop.”(11) To facilitate the deaths, Nitschke made house calls. He carried an old grey suitcase that held his three-year-old laptop computer, plastic tubing, and a pump-driven syringe filled with barbiturates.(12) The computer was equipped with an interactive suicide software program. After the patient was hooked up to an intravenous line connected to the computer and the program was turned on, a series of three questions appeared on the computer screen:
1. Are you aware that if you go ahead to the last screen and press the ‘yes’ button, you will be given a lethal dose of medicine and die? Yes / No
2. Are you certain you understand that if you proceed and press the ‘yes’ button on the next screen, you will die? Yes / No
3. In 15 seconds you will be given a lethal injection. Yes / No
Clicking “yes” for each of three questions, activated a syringe driver and a sequential delivery of death-inducing drugs.(13) The method meant that the doctor did not directly administer the fatal dose.
Describing his sentiments about the first such death, Nitschke said, “I felt at the end of it enhanced by the experience. I did not feel in any way that I have done the wrong thing.”(14) Yet he later acknowledged, “You can’t help but feel like an executioner.” “You get to know people,” he said, “and then you just end up one day killing them.”(15)
Nitschke and Des Carne, the computer programmer with whom he designed the “Self Deliverance” program, offered the software to others over the Internet as freeware. According to Nitschke, he made it available on the Internet to demystify computer death and to expedite processes carried out by others.(16)
Nitschke noted that the “procedure” was inexpensive since patients paid about $100 for the drugs and the cost of consultations was paid under the Australian Medicare system.(17)
Even while the Northern Territory law was in effect, Nitschke was designing another death-inducing machine that would use carbon monoxide and an oxygen mask, thus eliminating the need for drugs. He said such a device would enable people to end their lives without needing someone to insert intravenous tubes and would be better for older people. “When people get too old and frail it can be very difficult to get access to veins and gas is a much easier way to go,” he said.(18)
After repeal of the Northern Territory law, he stepped up his efforts to design the perfect assisted-suicide method. The Hemlock Society (now known as Compassion and Choices) provided tens of thousands of dollars for his various projects.(19) In addition to the carbon monoxide method, he researched substances that had never been approved for patient use because they had been found to be harmful. Those, he claimed, could form the basis for a new pill and, since they would not be medications, the ingredients and directions for mixing them could be sold in kit form over the Internet.(20) When asked, at a 1999 Hemlock conference, if that didn’t raise the possibility of teen access to suicide kits, Nitschke said that the specter of teen access could be used to pressure politicians. One could, he said, tell politicians: Pass the laws we want or we’ll sell suicide kits to your kids.(21)
Although Nitschke recognized that some would feel threatened by the prospect of making suicide materials available to teens, he does not see a problem. “At a certain age you become old enough to understand about death and if your life is no longer worth living according to your estimation, you have the right to give it away,” he said on an Australian radio program.(22)
Nitschke has continued his “research” in recent years. In July 2002, he announced the production of plastic bags with drawstrings that people could put over their heads to commit suicide.(23) The following December he unveiled the “COGen” machine, a more elaborate model of his earlier carbon monoxide and face mask method.(24) The device generates carbon monoxide delivered to the recipient through nasal prongs.
As the celebrity speaker at Hemlock’s 13th Biennial Conference held in San Diego, Nitschke told a cheering audience, “You don’t need a doctor! You can die without one! You can do it! You can do it yourself!”(25)
Nitschke’s acknowledgment that a doctor is not needed underscores the fact that, although it may be carried out by a physician, assisted suicide is not a medical act. And, although drugs may be used in some assisted suicides, their use for assisted suicide constitutes a life-ending, not a medical, purpose.
In June 2004, he explained that a “peaceful pill,” was in the testing process. He described it as one large pill that could be made from readily available compounds that could be distilled using “pretty elementary laboratory-type moves.” The process would cost less that $200 and the pill could be stored in the refrigerator indefinitely.(26)
Several months later, he announced that he would conduct workshops where participants would use an on-site laboratory to make their own “peaceful pill.”(27) (Although he still called it the peaceful pill, the concoction had evolved into a liquid formula.) Nitschke said the people would be learning to make the drink, but would not be taking it, at the workshop. When they do take it, he said, “They drink it and go to sleep and quickly die.”(28)
Philip Nitschke, who was the only doctor to carry out assisted suicide during the months in which it was legal in Australia, represents the non-medical nature of death by assisted suicide.
Euthanasia and assisted suicide have been widely practiced in the Netherlands for a number of years. Unlike their professional counterparts in other nations, Dutch physicians have led the way in permitting the practices – practices that illustrate how physician-advocacy of induced death can expand and be used to justify virtually unlimited euthanasia and assisted suicide.
Both euthanasia and assisted suicide have been widely practiced in the Netherlands since 1973 although they were against the law until 2002. The Dutch situation between 1973 and 2002 was an outgrowth of a series of court decisions and medical association guidelines, beginning with a 1973 District Court case in which Geertruida Postma, a Dutch physician, was convicted of the crime of euthanasia after she ended the life of her seriously ill mother.(29) The conditions under which the elderly woman died might have never come to the attention of authorities had it not been for Dr. Postma’s insistence that her actions be made public.(30) Her admission that she had given her mother a lethal injection seemed calculated to force public and legal reconsideration of the laws against assisted suicide(31) and euthanasia.(32)
The highly visible case became a rallying point for those seeking to change the law. Doctors in the province signed an open letter to the Netherlands Minister of Justice stating that euthanasia was commonly practiced.(33)
While finding Dr. Postma guilty of the crime of mercy killing that was punishable by imprisonment for a maximum of 12 years, the court imposed a one-week suspended sentence and a week’s probation. The Dutch court relied heavily on expert testimony by the District’s medical inspector who set forth certain conditions under which the average physician thought euthanasia should be considered acceptable. Inclusion of those conditions(34) formed the basis for subsequent acceptance of euthanasia and assisted suicide in the Netherlands.
On the initiative of physicians and with the support of the Dutch Medical Association, other cases followed, each widening the boundaries and further liberalizing the conditions under which euthanasia and assisted suicide, although remaining illegal, would not be punished.(35)
Under the guidelines in effect for ending a life on request, euthanasia and assisted suicide continued to be punishable but were not prosecuted if the guidelines were followed. The burden of proof was on the physician who was required to justify the death to an evaluation commission that could, if it deemed fit, bring the case to the public prosecutor.
In an effort to determine the frequency of assisted suicide and euthanasia, two national studies were undertaken. To obtain the most complete and accurate information, physicians were granted both immunity and anonymity related to their responses. The first study released by the Dutch government on September 10, 1991, found that physician-induced deaths accounted for more than 9.1 percent of annual deaths. Of those deaths, 2,300 were from requested euthanasia, 400 were assisted suicide and 1,040 (an average of approximately 3 per day) died from euthanasia which was administered without the patients’ knowledge or consent.(36) Similar results were found in a follow up study five years later.(37)
In addition, the 1990 study also determined that 50 percent of Dutch physicians suggested euthanasia to patients.(38) Both the 1990 and 1995 studies found that, although reporting of physician-assisted suicide deaths was required by law, the majority of such deaths went unreported.(39)
Generally, Dutch physicians seem certain that there is no need for any real oversight of their activities. At a 1990 right-to-die conference held in the Netherlands, Dr. H.S. Cohen, a Dutch general practitioner who has often carried out euthanasia, was asked if there was ever any abuse related to the practice of euthanasia. Cohen dismissed the possibility, saying that the Dutch medical establishment is of such high integrity that it is “not corruptible.”(40)
On April 10, 2001, the Dutch Parliament approved the “Termination of Life on Request and Assisted Suicide (Review Procedures) Act.”(41) It amended sections of the criminal code, specifically stating that the offenses of euthanasia and assisted suicide are not punishable if they have been “committed by a physician who has met the requirements of due care” that are described in the act and if they have informed the municipal “autopsist” in accordance with the Burial and Cremation Act.
The inclusion of “due care” requirements transformed the crimes into medical treatments as physicians had advocated. Under the new law, minors between sixteen and eighteen may request that their lives be terminated and, although parents or guardians must be consulted, they have no authority to prevent the requested death.(42) Children between the ages of twelve and sixteen may request euthanasia or assisted suicide but a parent or guardian must agree with the decision.(43)
In addition, the law recognizes the right of a physician to carry out euthanasia based on a written advance request for death of a currently incapacitated patient who is 16 years old or older.(44)s (Although the person must be at least 16 years old to be euthanized there is no requirement that one be at least 16 when the request is put in writing.)
Under the previous system, doctors had been reluctant to report their death-inducing activities. According to the Dutch government, the primary reason for changing the law was “to bring matters into the open, to apply uniform criteria in assessing every case in which a doctor terminates life, and hence to ensure that maximum care is exercised in such cases.”(45) This assumed that legalization would make doctors more forthcoming, more accurate and more careful. But that did not happen.
In fact, Dutch doctors felt that the formalities contained in the new law were “too much fuss” and, consequently, fewer, not more, cases of physician-induced death were reported,(46) leading to consideration of possible penalties for non-reporting.(47)Nonetheless, Dutch physicians and medical professionals continued to expand the boundaries of acceptable euthanasia.
Within days of the new law’s passage, Dutch Health Minister Els Borst, who had guided the bill through parliament said the government should consider introducing a suicide pill for patients who are healthy but are ready to die. Borst said this would be carefully regulated.(48) On December 16, 2004, a report commissioned by the Royal Dutch Medical Association (KNMG) argued that the criteria in place for euthanasia were unhelpful in defining the limits of medical practice.(49) Stating that the guidelines were “an illusion,”(50) it concluded that euthanasia should be allowed for virtually anyone who didn’t want to live.
According to Dr. Rob Jonquiere of the Dutch Voluntary Euthanasia Society, the proposal addresses an “existential problem” outside of the medical domain but should, nevertheless, be adopted since it is within the context of ending unbearable suffering.(51) The KNMG said it would “take the lead” in discussing how the issue confronts doctors in practice.(52)
Three months later, the University Medical Centre Groningen, acknowledged that it had been euthanizing infants, not only in the case of terminally ill newborns but also in cases of children who had spina bifida and other disabilities.(53) In publishing its procedures for pediatric euthanasia, the medical center explained that the “approach suits our legal and social culture,” although it acknowledged that it was “unclear to what extent it would be transferable to other countries.”(54)
The Belgian act legalizing euthanasia was passed on May 28, 2002 and went into effect on September 23, 2002.(55) It limits euthanasia to competent adults and emancipated minors.(56) However, only two years later, lawmakers introduced a proposal to extend euthanasia to children and individuals suffering from dementia.(57) According to ruling Flemish Liberal party Senators Jeannine Leduc and Paul Wille who introduced the bill, terminally ill children and teenagers have as much right to choose when they want to die as anyone else.(58) The bill did not pass. However, a later report indicated that physicians in Belgium are, nonetheless, administering lethal drugs to newborns and older infants.(59) This has led to new calls to expand the scope of euthanasia in Belgium.
Embrace of euthanasia by medical professionals has led to the formulation of more convenient ways to end patients’ live. In early 2005, a pharmaceutical company announced that home “euthanasia kits” would be available soon in more than two hundred Belgian pharmacies so that doctors could carry out in-home deaths with greater ease. Reports indicated that the kits will contain a barbiturate, a paralyzing agent, an anesthetic, and instructions for use, and will cost approximately 45 Euros.(60)
As in the Netherlands, the practices of euthanasia and assisted suicide in Belgium illustrate how rapidly induced death, first accepted for difficult cases, expands to death-on-demand and how that actual demand need not be made by the victim.
The practice of assisted suicide in Switzerland has led many people to believe that the practice has been legalized in that country. That is not the case. There is an important distinction between the Swiss situation and that of Oregon, the Netherlands and Belgium where the law considers euthanasia and/or assisted suicide to be “medical treatment.”
According to Swiss law, “Whoever, from selfish motives, induces another to commit suicide or assists him therein shall be punished, if the suicide was successful or attempted, by confinement in a penitentiary for not more than five years or by imprisonment.”(61)
The key words are “from selfish motives.” Thus, in Switzerland, there is no prosecution if the person assisting a suicide successfully claims that he is acting unselfishly. While this results in de facto legalization, assisted suicide is not legal, only unpunishable, unless a selfish motive is proven. It should also be noted that there is no illusion that assisted suicide is a medical practice. The person assisting a suicide need not be a medical professional to escape prosecution.
As in the United States, euthanasia and assisted-suicide advocates will continue to push their agenda throughout the world to make death-on-demand acceptable and legal. Often such advocates hold positions of great influence. Many are known as experts in medical ethics. Few, however, are as outspoken as England’s Baroness Mary Warnock who is universally referred to as Britain’s leading medical ethics expert. In an interview with the London Sunday Times, Warnock explained that is better for elderly people to kill themselves than to be a burden on their families and society. “I don’t see what is so horrible about the motive of not wanting to be an increasing nuisance,” she said.(62) In Warnock’s view, only productive, independent people have value. All others are a “nuisance.”
Her words emphasize the need to maintain laws against euthanasia and assisted suicide. Those laws will only be preserved if all who oppose euthanasia and assisted suicide not only wish to protect people, but also work to do so.
1. World Medical Association Policy: “The World Medical Association Resolution on Euthanasia.” Adopted by the World Medical Association General Assembly, Washington 2002, accessed at http://www.wma.net/e/policy/e13b.htm
6. Belinda Hickman, Katherine Glascott and Jody Scott, “Ethical dilemma,” The Australian, September 27, 1996. “Doctor aids first legal euthanasia act,” British Medical Journal, volume 313, p. 835. October 5, 1996, and Adrian Bradley, “Majority of doctors oppose euthanasia,” The Australian, November 18, 1996.
8. Annette Street and David W. Kissane, “Dispensing Death, Desiring Death: An Exploration of Medical Roles and Patient Motivation during the Period of Legalized Euthanasia in Australia,” OMEGA, Vol. 40(1) 1999-2000, p. 234.
34. The guidelines required that the patient must be considered incurable and experiencing subjectively unbearable suffering; the request for termination of life should be in writing and there should be adequate consultation with other physicians before death could be induced. Carlos Gomez, Regulating Death, (1991), p. 30.
35. Among the cases were the Alkmaar case (Nederlandse Jurisprudentie 1985, no. 106) in which a woman died after requesting death because her advancing age and physical condition caused her to be dependent on others, thus leading to psychological suffering. The case gave rise to the 1986 decision by the Hague Court of Appeals recognizing “psychic suffering” and “potential disfigurement of personality” as grounds for induced death. The courts have also exonerated physicians who assisted in the suicides of a young woman with anorexia nervosa(Amelo),Tijdschrift voor Gezondheidsrecht 1992, no. 19, and a woman who was depressed over the death of her two children and the failure of her marriage (Assen) Nederlandse Jurisprudentie 1994, no. 656. For additional discussion of these and other cases, see: Carlos Gomez, Regulating Death (1991); I .J. Keown, “The Law and Practice of Euthanasia in the Netherlands,” 108 Law Quarterly Review (1992), pp. 51-52; Herbert Hendin,Seduced by Death (1997) and Jonathan T. Smies, “The Legalization of Euthanasia in the Netherlands,” Across Borders International Law Journal, 7 (2004) accessed at http://law.gonzaga.edu/borders/Articles/Smies/index.htm, available on LEXIS/NEXIS.
36. Commissie Onderzoek Medische Praktijk inzake Euthanasie, Medische Beslissingen Rond Het Levenseinde, Sdu Unitgeverij Plantijnstraat (1991), vol. 1, p. 13. The study is popularly known as the “Remmelink Report.”
37. Paul J. van der Maas, et al, “Euthanasia, physician-assisted suicide, and other medical practices involving the end of life in the Netherlands, 1990-1995,” New England Journal of Medicine, vol. 335, no. 22 (November 28, 1996), pp. 1699-1705.
38. Herbert Hendin, “Euthanasia and physician-assisted suicide in the Netherlands,” New England Journal of Medicine, vol. 336, no. 19 (May 8, 1997), p. 1385, citing van der Maas et al, Euthanasia and other medical decisions concerning the end of life, (Elsevier, 1992)
45. Netherlands Ministry of Foreign Affairs in cooperation with Ministry of Health, Welfare and Sport and the Ministry of Justice, “Euthanasia: A guide to the Dutch Termination of Life on Request and Assisted Suicide (Review Procedures) Act,” Question 2, accessed at: http://www.minbuza.nl/default.asp?CMS_TCP=tcpAsset&id=A25ED90373454C85B17DF97F96AB8C68.
46. “Dutch television report stirs up euthanasia controversy,” The Lancet, vol. 361, p. 1352 (April 19, 2003) and Tony Sheldon, “Dutch reporting of euthanasia cases falls – despite legal reporting requirements,” British Medical Journal, vol. 328, p.336 (June 5, 2004).
48. Margaret Oostveen, “Ik kan me goed voorstellen dat artsen stervenshulp niet melden,” NRL Handelsblad, April 14, 2001, accessed at: http://www.nrc.n./W2/Nieuws/2001/04/14/Vp/01a.html. English translation available at holbors.htm. .
49. Toby Sterling, “Lifelong suffering can be valid reason for euthanasia, Dutch study finds,” Associated Press, December 16, 2004. Available at LEXIS/NEXIS. The full report of the Dijkhuis Commission is available, in Dutch, at http://knmg.artsennet.nl/uri/?uri=AMGATE_6059_100_TICH_R144638358841695.
51. Amsterdam Forum. “Boundaries of euthanasia: Does unbearable suffering have to be linked to terminal illness?” January 21, 2005, accessed at http://www2.rnw.nl/rnw/en/features/amsterdamforum/050122af
54. Eduard Verhagen and Pieter J.J. Sauer, “The Groningen Protocol – Euthanasia in Severely Ill Newborns,” New England Journal of Medicine, vol. 352, pp. 959-962. Although the Groningen Protocol received international attention, it was not the first acknowledgment by Dutch medical professionals that euthanasia of children was being carried out in the Netherlands. See, for example, “Assisted Suicide: Not for Adults Only?” Available at noa.htm.
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