I. DEFINITIONS

EUTHANASIA

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
• Widening the indications
  • 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)

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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.

3. NUMBERS

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

	1990	1995	2001	2005	2010	2015
Euthanasia	1.7	2.4	2.6	1.7	2.8	4.5
Physician-assisted suicide	0.2	0.2	0.2	0.1	0.1	0.1
Ending of life without specific request	0.8	0.7	0.7	0.4	0.2	0.3
Intensified alleviation of symptoms	18.8	19.1	20.1	24.7	36.4	35.8
Withholding/withdrawal of treatment	17.9	20.2	20.2	15.6	18.2	17.4
Continuous deep sedation			5.6	8.2	12.3	18.3

From van der Heide et al, 2017

Euthanasia

• 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).
• Under Dutch law, palliative sedation is not euthanasia and is classified as ‘normal medical practice’ that ‘must be clearly distinguished from the ending of life’ (de Graeff and Dean, 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).
• The number of patients treated by continuous deep sedation until death has increased rapidly from 5.6% of all deaths in 2001 to 18.3% in 2015 (see Table 1).
  • 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 intensified treatment of pain and symptoms, it is reported that it was performed with the intention of hastening death or ending life in 6% of cases (1990) and 16% (1995) (van der Maas et al, 1991; van der Maas et al, 1996). Wyers (quoting data published in Dutch) indicates the intention rate declined from 21% in 1990 to 3% in 2010 (Weyers, 2014). Using a conservative ‘intention rate’ decreasing from 10% in 1990 to 1.5% in 2015 indicates that of the order of 36,900 people may have died after intensified treatment of pain and symptoms performed with the intention of hastening death or ending life (Table 2).

• 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

Euthanasia	91,500
Physician-assisted suicide	5,400
Termination of life without explicit request	18,400
Intensified treatment of pain and symptoms	36,900
with the intention of hastening death
Withholding/withdrawing treatment with the intention of hastening death	285,000
Continuous sedation until death with the intention of hastening death	12,100
TOTAL	449,300

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

• Thousands of patients have had their lives terminated without request (see above).
  • 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).
• For some patients treated by withholding or withdrawing medication, where it was performed with the intention of hastening death, it had not been discussed with them and was therefore not requested.
  • 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).
• For some patients treated with continuous deep sedation until death (CSD), where the treatment was given with the intention of hastening death, it had not been discussed with them and was therefore not requested.
  • 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).
• Dutch physicians have been accused of not being knowledgeable regarding palliative care (Zylicz, 2002).
  • 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).

Provide a report to the appropriate authority.

• Reporting of euthanasia and physician-assisted suicide has improved from 18% in 1990 to 81% in 2015 (van der Wal et al, 1996; Rurup et al, 2008; Onwuteaka-Philipsen, 2018).
  • 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).
• Expansion of eligibility
  • 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.
• Now that it is legal for physicians to perform euthanasia, it is reported that nurses are doing it as well (Volker, 2015).
• 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).

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)

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
• (iv). HIV
• (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

(i). ‘Normalization’ of euthanasia

• Insufficiently precise or strict were inevitably stretched, and there has been unrelenting progression toward 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).

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

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 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 Review Committees have now admitted that that incapacitated people are being surreptitiously killed (Chabot, 2017).
• Others express a different view:
  • 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)

Dementia

• 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).
• Euthanasia is legal for patients with dementia and a written advance directive (de Boer et al, 2011; Kouwenhoven et al, 2015).
  • 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)

(iv). HIV

• 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)

(v). Children

• 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).

(vi). Amyotrophic lateral sclerosis (ALS)

• 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).

(vii). Lack of physical disease

• 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 toward feared dependence (van Wijngaarden et al, 2015).

(viii). Euthanasia using opioids

• 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.
• Others believe that opioids don’t hasten death.
  • 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).

(ix). Amount of life lost

• 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).
• In most Dutch reports, there is insufficient clinical information for one to judge the estimations of life lost. However, in the report of euthanasia for homosexual men with AIDS (Bindels et al, 1996), it is stated ‘in the judgement of the physicians, most of these patients would have died naturally within one month…no person would have lived more than an additional three months.’
  • 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).

(x). Contradiction of autonomy

• 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.
• It is the doctor, not the patient, who decides whether the patient will have PAS or euthanasia by injection.
  • PAS (c.f. euthanasia) emphasizes patient autonomy and responsibility, but the option is rarely discussed with patients (Kouwenhoven et al, 2014).
  • 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).

(xii). Arrogance

• 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 toward 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)

1. BACKGROUND

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.

2. GUIDELINES

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.

3. NUMBERS

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

(i). Depression

• 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)

1. BACKGROUND

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

• It is usually stated that more than half the population of Oregon voted in favor of the Act, but
  • 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)

2. GUIDELINES

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

• Is 18 years of age or older;
• Is competent;
  • 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

• Two oral requests, separated by a minimum of 15 days.
  • 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.

3. NUMBERS

• 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).

In 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.

1997-2017

• 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%).
• Most frequently reported reasons for request: losing autonomy (91%), decreasing ability to participate in activities that made life enjoyable (90%), and loss of dignity (76%).
  • 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

Year	No. of Deaths
1998	16
2002	38
2007	49
2012	85
2017	143

Drugs used

• 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.

4. DO THEY MEET THEIR OWN GUIDELINES?

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 doctor is expected to evaluate patient decision-making capacity and judgment without a requirement for psychiatric expertise or consultation (Hendin and Foley, 2008).
  • 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).
• A significant number of patients live beyond their 6-month prognosis (see Oregon Death with Dignity Act).
  • 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.

5. ARE THE SYSTEMS OF REGULATION AND SAFEGUARDS EFFECTIVE?

• 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.
• The OHA has no jurisdiction to investigate any reported case of PAS or any case of alleged abuse reported in the media. ‘We are not given the resources to investigate [assisted suicide cases] and…we do not have any legal authority to insert ourselves.’
  • 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).

6. IS THERE EVIDENCE OF A SLIPPERY SLOPE?

• 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).

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

• 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).

8. OTHER ISSUES/CONCERNS

• (i). Depression
• (ii). Lack of physical suffering
• (iii). ALS
• (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)

(i). Depression

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

Incidence

• Ganzini claims that the prevalence of depression in individuals requesting PAS is no higher than in terminally ill patients not requesting it (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).

Diagnosis

• 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).

Relevance

• 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

• The guideline that patients with depression that might be affecting their decisional competence should be referred to a mental health specialist is a nonsense. The ordinary medical practitioner:
  • 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).
• 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.
  • 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).

Summing up

• 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 toward 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).
• For years it was claimed there were no complications of the PAS procedures (Keown, 2013), even though
  • 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).
• Reviewing the data to the end of 2012, Ganzini reported that six patients (of presumably around 290 for whom information would have been available) had regained consciousness after ingestion of the medication (Ganzini, 2014).
  • 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

• There is concern about the prescribing physicians not knowing the patient well enough or for long enough (Ganzini et al, 2000b).
  • 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

• Kim Callinan, CEO of Compassion and Choices, presents the organization as supportive of research (Callinan and Silva, 2018).
  • 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).

(x). Oregon Health Plan Bastardry

• 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).

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

• A study of VRFF reported a very good median quality of death of 8 (on a scale of 0-9) (Ganzini et al, 2003b).

9. SOME FINAL WORDS

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)

D. BELGIUM

1. BACKGROUND

• 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;
• The physician must obtain the opinion of another independent physician, who is qualified to give an opinion about the disorder in question, who must see the patient and provide a written report.
  • 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

• The request must be in writing
  • 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;
• Advance Directives can be used in lieu of requests, provided:
  • The patient suffers from a serious and incurable disorder;
  • The patient is no longer conscious;
  • The unconsciousness and underlying condition are irreversible.

Reporting

• 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.

3. NUMBERS

Euthanasia

• 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

	2003	2004	2013
Percentage of all deaths	0.2	0.5	1.7

From Dierickx et al, 2016

Table 5. Frequency of physician assistance in dying - Flanders

	2001	2007	2013
% of all deaths
Euthanasia	0.3	1.9	4.6
Physician-assisted suicide	0.01	0.07	0.05
Ending of life without explicit request	1.5	1.8	1.7
Intensified alleviation of symptoms	22	26.7	24.2
Withholding/withdrawing of treatment	14.6	17.4	17.2
Continuous deep sedation until death	8.2	14.5	12

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).

Ending of life without the patient’s explicit request

• As in Holland, euthanasia is defined as being requested, so cases of life termination without explicit request have to be counted separately.
• Life termination without explicit request comprised 1.7% of all deaths in Flanders in 2013, amounting to more than 1,000 deaths (Table 5) (Bilsen et al, 2009; Chambaere et al, 2015b).
  • 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

• 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

• 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.
• In Flanders, withholding or withdrawing of therapy was involved in 14.6% of all deaths in 2001, 17.4% in 2007, and 17.2% in 2013 (Table 5) (Bilsen et al, 2009; Chambaere et al, 2015b).
  • 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.
• In Flanders, CSD was involved in 8.2% of all deaths in 2001, 14.5% in 2007, and 12.0% in 2013 (Table 5) (Chambaere et al, 2015b; Robijn et al, 2016).
  • 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).

4. DO THEY MEET THEIR OWN GUIDELINES?

That the procedure is requested

• As in Holland, the definition of euthanasia is that it is requested.
• Life termination without explicit request accounted for 1.5-1.8% of all deaths in Flanders, equivalent to between 840 and 1050 deaths per year (Meeussen et al, 2010; Chambaere et al, 2010 & 2015b).
  • 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.
• Few doctors, other than psychiatrists, are familiar with formal assessment of decision-making capacity (Fairman and Irwin, 2016).

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.’
• The underling causes of the unbearable suffering leading to euthanasia in 2014-2015, and accepted by the Commission (see Institut), were
  • cancer (68%)
  • ‘polypathology’ (10%) – explained as ‘the coexistence of several serious and incurable disorders linked to different dysfunctions that are sometimes associated with old age, and therefore not necessarily fatal’. Examples cited in the Commission’s report include
    • 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).

Provide a report to the appropriate authority.

• 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).

5. ARE THE SYSTEMS OF REGULATION AND SAFEGUARDS EFFECTIVE?

Life End Information Foundation (LEIF)

• 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).
• Pro-euthanasia neurologist, Dr Ludo Vanopdenbosch, resigned from the 16-member Federal Commission in September 2017, accusing the Commission of failing to refer a case to the public prosecutor concerning a man who had euthanasia at his family’s request. He also asserted that any critical debate within the Commission was muzzled, and that many of the doctors on the Commission were leading euthanasia practitioners, who supported each other to defend euthanasia at all costs. Tlie accusations were strongly denied by the co-chair of the Commission, Dr Wim Distelmans.

• 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’.

6. IS THERE EVIDENCE OF A SLIPPERY SLOPE?

• 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.
• There is increasing use of CSD with the explicit intention of hastening death:
  • ‘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)

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

• 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).

8. OTHER ISSUES/CONCERNS

• (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

(i). The ‘normalization’ of euthanasia

• 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))

(ii). Euthanasia for children

• In 2014, Belgium became the first country in the world to legislate euthanasia for children.
• Euthanasia is permissible if the child has a ‘reasonable understanding of the consequences’ of their requesting a lethal injection, i.e. the child's capacity to understand disease, dying and death is supposedly a prerequisite to the implementation of the request.
  • 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).

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

• 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).

(iv). Continuous sedation until death (CSD)

• 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).
• Other studies confirm the increasing use of CSD with the explicit intention of hastening death:
  • ‘frequently’ in adults (Rys et al, 2014a).
  • 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)

(v). Euthanasia and palliative care

• 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.

(vi). Attempts to prohibit conscientious objection

• 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.

(viii). Definition of euthanasia

• 19% of Belgian physicians did not label a death following the deliberate administration of neuromuscular relaxants as 'euthanasia'(Smets et al, 2012).

(ix). ICU patients

• 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).

(x). Arrogance

• 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).

9. SOME FINAL WORDS

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)

E. CANADA

1. BACKGROUND

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 unanimity in the title of the NEJM editorial—‘Unanimity on Death with Dignity’—refers to the justices, not the population or the health care professionals (Attaran, 2015).
  • 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).

2. GUIDELINES

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;
• Has a grievous and irremediable medical condition and meets all of the following criteria:
  • 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.

Procedure

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.

Reporting

• 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).

3. NUMBERS

• 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

	2016	2017
Number of deaths	803	2704

From Canadian Government Statistics (see Government of Canada)

4. DO THEY MEET THEIR OWN GUIDELINES?

That the patient has a grievous and irremediable medical condition

• The report from Toronto (Li et al, 2017) indicates that loss of autonomy was the primary reason for requests.
  • 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.

5. ARE THE SYSTEMS OF REGULATION AND SAFEGUARDS EFFECTIVE?

• 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.

6. IS THERE EVIDENCE OF A SLIPPERY SLOPE?

• 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.

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

• It is too early for any assessment.

8. OTHER ISSUES/CONCERNS

• (i). Palliative care
• (ii). Moves to remove safeguards
• (iii). Calls for inclusion expansion
• (iv). Prohibition of conscientious objection
• (v). Psychiatric issues
• (vi). ALS
• (vii). Organ Donation

(i). Palliative care

• 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).

(iii). Calls for inclusion expansion

• 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).

(iv). Prohibition of conscientious objection

• 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).

(v). Psychiatric issues

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).

(vi). ALS

• 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).

(vii). Organ Donation

• The possibility of combining assisted dying with organ donation is being discussed, as a kind of homage to autonomy (Allard and Fortin, 2017).

9. SOME FINAL WORDS

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…’
• ‘Canada’s largest medical regulator demands that physicians who are unwilling to personally provide euthanasia or assisted suicide must collaborate in homicide and suicide by referring patients to colleagues who are willing to do so.’ The non-negotiable need for an ‘Effective Referral’, and what such referral comprises are set out on the CPSO website (see CPSO).
  • 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

1. BACKGROUND

• 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.

2. GUIDELINES

Under Swiss law

• Euthanasia is not legal.
• Termination of life without explicit request is not legal.
• Assisted suicide from non-selfish motives is not illegal.
  • 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.
• The guidelines are loose and open to interpretation.
  • Exit: ‘Poor prognosis, unbearable suffering, or unreasonable disability.’
  • Dignitas: ‘Fatal disease or unacceptable disability.’

3. NUMBERS

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

	2001	2013
% of all deaths
Euthanasia	0.2	0.3
Assisted suicide	0.3	1.1
Ending of life without explicit request	0.5	0.8
Intensified alleviation of symptoms	22.3	21.3
Withholding/withdrawal of treatment	28.7	35.2
Continuous deep sedation	4.7	17.5

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).

4. DO THEY MEET THEIR OWN GUIDELINES?

• 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).

5. ARE THE SYSTEMS OF REGULATION AND SAFEGUARDS EFFECTIVE?

• 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).
• Increasing numbers
  • 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).
• Widening of eligibility criteria
  • 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

(i). Disregarding psychosocial matters

• 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).

(ii). IV & PEG infusions for assisted suicide

• 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.

(iii). ALS

• 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).

(iv). Psychological morbidity for relatives

• 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).

(vii). Problems related to suicide tourism

• 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.

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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—

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

To which they may add—

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

But they don’t mention—

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

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

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.

In reply-

• 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?

1.1 But…autonomy is not absolute.

• 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 medicine, there is no reason for autonomy to be absolute.
  • 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).

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

• 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)

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

Depression

• Potentially treatable major depression is under-diagnosed and under-treated in patients with advanced disease (Breitbart et al, 2010a).
• Major depression can be reliably diagnosed in 10-25% of patients with advanced cancer (Breitbart et al, 2000; Hotopf et al, 2002).
  • 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).
• 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).
• 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 toward 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).

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

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.
• That some decisions about euthanasia may be due inadequate information.
  • 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.
• But it is being used for psychological (‘to be in control’) and social (‘tired of life’) reasons (Rurup et al, 2005a; Sulmasy, 2017; Keown, 2018).
  • 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).
• Proponents of assisted dying regard the relief of suffering as beneficence.
  • But such beneficence deprives them of their very existence.
• Compassion leads to non-voluntary euthanasia.
  • 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.

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 toward 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)

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

The polls

• 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 polls

• 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).
• There is a definite non-responder factor.
  • 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 perceived need for the legalization of assisted dying is inversely proportional to clinical experience in the management of the terminally ill (Portenoy et al, 1997).
  • 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).
• 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).

5.2 Oregon

• 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).

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.

To which they may add—

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)

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)

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).
• The assertion that vulnerable groups are not adversely affected by assisted dying (Battin et al, 2007) has been challenged (Finlay and George, 2011).
• 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 toward [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.

• There is an increasing voice that no doctor has any moral right to refuse to participate in medically-assisted death (Rivera-Lopez, 2017; Schuklenk and Smalling, 2017; Savulescu and Schuklenk, 2017). Even worse, ‘Medical schools should carefully…screen for conscientious objection.’ (Savulescu and Schuklenk, 2017).
  • More tolerant views have been expressed. (Maclure and Dumont, 2017; Trigg, 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).
• 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.
• Both the quality and quantity of palliative care in the Netherlands are clearly deficient (Zylicz, 2002).
  • 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).

But they don’t mention—

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

• ‘There has been unrelenting progression toward 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).
• The diagnosis of depression is frequently missed in routine (non-psychiatric) clinical practice (Pignone et al, 2002).
• 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).

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.
• Any physician is qualified to assess capacity, although in practice few doctors, other than psychiatrists, are familiar with formal assessment of decision-making capacity (Fairman and Irwin, 2016).
  • 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.
• ‘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)
• 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)
• Killing is wrong because of the intrinsic dignity or intrinsic worth in every human being (Sulmasy, 2016).
  • 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.
• 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.
• 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)

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IV. WHAT OTHERS SAY - SOME BOOK REVIEWS

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

1999
Neuberger	DYING WELL. A Guide to Enabling a Good Death
2002
Foley & Hendin	THE CASE AGAINST ASSISTED SUICIDE.
Keown	EUTHANASIA, ETHICS AND PUBLIC POLICY.
2004
Neuberger	DYING WELL. A Guide to Enabling a Good Death 2e
Quill & Battin	PHYSICIAN-ASSISTED DYING.
2005
Battin	ENDING LIFE: Ethics and the Way We Die
Blank & Merrick	END-OF-LIFE DECISION MAKING.
Smith	FORCED EXIT.
Ten Have & Welie	DEATH AND POWER.
2006
Colby	UNPLUGGED. Reclaiming Our Right To Die in America
Gorsuch	THE FUTURE OF ASSISTED SUICIDE AND EUTHANASIA
Kelly	MEDICAL CARE AT THE END OF LIFE.
Kiernan	LAST RITES.
2007
Horne	DYING. A Memoir
Shannon & Faso	LET THEM GO FREE. A Guide to Withdrawing Life Support
Wanzer & Glenmullen	TO DIE WELL. Your right to comfort, calm, and choice
Lewis	MEDICINE AND CARE OF THE DYING
2008
Griffiths et al	EUTHANASIA AND LAW IN EUROPE
Hastings Center	CHOOSING DEATH.
Syme	A GOOD DEATH. An Argument for Voluntary Euthanasia
Warnock & Macdonald	EASEFUL DEATH. Is There A Case For Assisted Dying?
2009
Foster	CHOOSING LIFE, CHOOSING DEATH.
Jeffrey	AGAINST PHYSICIAN ASSISTED SUICIDE.
Randall & Downie	END OF LIFE CHOICES. Consensus and Controversy
2010
Goodman	THE CASE OF TERRI SCHIAVO.
2011
Qualls & Kasl-Godley	END-OF-LIFE ISSUES, GRIEF, AND BEREAVEMENT.
Goldberg	DEATH WITH DIGNITY.
Orfali	DEATH WITH DIGNITY.
Lewy	ASSISTED DEATH IN EUROPE AND AMERICA.
2012
Byock	THE BEST CARE POSSIBLE. A Physician’s Quest to Transform
Jackson & Keown	DEBATING EUTHANASIA
Youngner & Kimsma	PHYSICIAN-ASSISTED DEATH IN PERSPECTIVE.
2013
Berlinger et al	THE HASTINGS CENTER GUIDELINES FOR DECISIONS ON CARE NEAR THE END OF LIFE 2e
Hagger & Woods	A GOOD DEATH? Law and Ethics in Practice
Johnstone	ALZHEIMER’S DISEASE AND THE POLITICS OF EUTHANASIA
Keown	THE LAW AND ETHICS OF MEDICINE.
2014
Gawande	BEING MORTAL. Medicine and What Matters in the End
IOM	DYING IN AMERICA.
Quill & Miller	PALLIATIVE CARE AND ETHICS
Sumner	ASSISTED DEATH. A Study in Ethics and Law
2015
Renz	DYING. A Transition
Rehmann-Sutter et al	THE PATIENT’S WISH TO DIE.
Taboada	SEDATION AT THE END-OF-LIFE.
Dugdale	DYING IN THE TWENTY-FIRST CENTURY.
2016
Taylor	DYING. A Memoir
Dwyer	CONVERSATIONS ON DYING.
Stercks et al	CONTINUOUS SEDATION AT THE END OF LIFE.
Youngner & Arnold	THE OXFORD HANDBOOK OF ETHICS AT THE END OF LIFE
2017
Gemmell	AFTER
Syme	TIME TO DIE
Roscoe & Schenck	COMMUNICATION AND BIOETHICS AT THE END OF LIFE.
Jones et al	EUTHANASIA AND ASSISTED SUICIDE. Lessons from Belgium
2018
Mannix	WITH THE END IN MIND.
English et al	PHYSICIAN-ASSISTED DEATH: SCANNING THE LANDSCAPE.
Macauley	ETHICS IN PALLIATIVE CARE
Keown	EUTHANASIA, ETHICS AND PUBLIC POLICY 2e.

THE REVIEWS

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)

2002

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

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)

2004

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)

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)

2005

A Dutchman came to see me last week. In his 80s, but mentally very on the ball. Toward 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 toward legalizing physician-assisted dying? Not a bit.

Roger Woodruff, November 2005

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

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.

1. Is there a deep and dividing need for this proposed revolutionary change that cannot be met through other means?
2. Are the expected benefits of the change worth the foreseeable risks of the change?
3. 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)

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)

2006

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)

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)

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.

Roger Woodruff (June 2007)

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

2007

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)

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.

Roger Woodruff(April 2007)

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.

Roger Woodruff (January 2008)

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)

2008

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)

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)

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

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.

Roger Woodruff July 2008

2009

‘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)

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.

Roger Woodruff (February 2010)

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

2010

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.

Roger Woodruff (March 2010)

2011

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)

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)

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

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.

Roger Woodruff August 2011

2012

‘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)

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)

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)

2013

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)

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)

‘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)

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.’

…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…’

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.

Roger Woodruff (November 2013)

2014

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)

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)

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

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.

Roger Woodruff (February 2015)

2015

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)

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 toward 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)

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)

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.

Roger Woodruff (November 2015)

2016

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)

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)

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)

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)

2017

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)

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) toward 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.

Roger Woodruff (February 2017)

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)

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.

Roger Woodruff

(January 2019)

2018

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.

Roger Woodruff

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

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)

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 toward 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.

Roger Woodruff

(January, 2019)

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V. REFERENCES

Abrahao A, Downar J, Pinto H, et al. Physician-assisted death: A Canada-wide survey of ALS health care providers.Neurology 2016; 87: 1152-60.

Albers G, de Vet HC, Pasman HR, et al. Personal dignity in the terminally ill from the perspective of caregivers: a survey among trained volunteers and physicians. J Palliat Med 2013; 16: 1108-14.

Aldridge MD, Kelley AS. The Myth Regarding the High Cost of End-of-Life CareAm J Public Health 2015; 105: 2411-5.

Allard J, Fortin MC. Organ donation after medical assistance in dying or cessation of life-sustaining treatment requested by conscious patients: the Canadian context.J Med Ethics 2017; 43: 601-605.

Angell M. (1996) Euthanasia in the Netherlands – good news or bad? N Engl J Med 1996; 335: 1676-8.

Angell M. (1997)The Supreme Court and physician-assisted suicide – the ultimate right. N Engl J Med 1997; 336: 50-3.

Annas GJ. Death by prescription. The Oregon initiative. N Engl J Med 1994; 331: 1240-3

Anquinet L, Rietjens JA, Van den Block L, et al. General practitioners' report of continuous deep sedation until death for patients dying at home: a descriptive study from Belgium.Eur J Gen Pract 2011; 17: 5-13.

ANZSPM (Australian and New Zealand Society of Palliative Medicine). Statement on Euthanasia and Assisted Suicide (2017). Available at www.anzspm.org.au/

Appel JM. A suicide right for the mentally ill? A Swiss case opens a new debate. Hastings Cent Rep 2007; 37: 21-3.

Aranda S, O'Conner M. Euthanasia, nursing and care of the dying: rethinking Kuhse and Singer. Aust Nurs J 1995; 3: 18-21.

Attaran A. Unanimity on Death with Dignity — Legalizing Physician-Assisted Dying in Canada. N Engl J Med 2015; 372: 2080-2

Austriaco N. Biomedicine and Beatitude: An Introduction to Catholic Bioethics The Catholic University of America Press, 2011.

Bachman JG, Alcser KH, Doukas DJ et al. Attitudes of Michigan physicians and the public toward legalising physician-assisted suicide and voluntary euthanasia. N Engl J Med 1996; 334 : 303-9

Bannink M, Van Gool AR, van der Heide A, et al. Psychiatric consultation and quality of decision making in euthanasia.Lancet 2000; 356: 2067-8.

Battin MP, van der Heide A, Ganzini L, et al. Legal physician-assisted dying in Oregon and the Netherlands: evidence concerning the impact on patients in "vulnerable" groups. J Med Ethics 2007; 33: 591-7.

Battin MP. Ending Life. Ethics and the way we die. Oxford University Press, 2005.

Baume P, O'Malley E. Euthanasia: attitudes and practices of medical practitioners. Med J Aust 1994; 161: 137-44.

Bazan A et al. Remove Euthanasia on the Basis of Purely Psychological Suffering from the Legislation. Available at trudolemmens.wordpress.com December 9, 2015

BCCLA (British Columbia Civil Liberties Association). Available at https://bccla.org/category/medically-assisted-dying/

Bernheim JL, Raus K. Euthanasia embedded in palliative care. Responses to essentialistic criticisms of the Belgian model of integral end-of-life care.J Med Ethics 2017; 43: 489-94.

Beuselinck B. 2002-2016: Fourteen Years of Euthanasia in Belgium. First-Line Observations by an Oncologist, in Jones et al (eds) Euthanasia and Assisted Suicide. Lessons from Belgium. Cambridge University Press, 2017.

Biller-Andorno N. Physician-Assisted Suicide Should Be Permitted. N Engl J Med 2013; 368: 1451-2.

Bilsen J, Cohen J, Chambaere K, et al. (2009)Medical End-of-Life Practices under the Euthanasia Law in Belgium. N Engl J Med 2009; 361:1119-21.

Bilsen J, Stichele RV, Mortier F, et al. (2004a)The incidence and characteristics of end-of-life decisions by GPs in Belgium.Fam Pract 2004; 21: 282-9.

Bilsen JJ, Vander Stichele RH, Mortier F, et al. (2004b)Involvement of nurses in physician-assisted dying.J Adv Nurs 2004; 47: 583-91.

Bindels PJ, Krol A, van Ameijden E, et al. Euthanasia and physician-assisted suicide in homosexual men with AIDS. Lancet 1996; 347: 499-504

Blanke C, LeBlanc M, Hershman D, et al. Characterizing 18 Years of the Death With Dignity Act in Oregon. JAMA Oncol 2017; 3: 1403-1406.

Boer TA. (2014) Transcript of oral presentation to NZ parliament. Available at https://www.parliament.nz/resource/en-NZ/51SCHE_EVI_51DBHOH_PET63268_1_A552008/2b6233222c2d602995aac158d3a9313cbaf8721d

Boer TA. (2016) Report on Euthanasia and Physician Assisted Suicide in the Netherlands. Available at https://www.pthu.nl/Over_PThU/Organisatie/Medewerkers/t.a.boer/downloads/2016-boer-south-africa-affidavit-euthanasia-netherlands.pdf

Boer TA. (2017) Does euthanasia have a dampening effect on suicide rates? Recent experiences from the Netherlands. Journal of Ethics in Mental Health 2017; 10: 1-9. Available at https://www.jemh.ca/

Bollen J, Ten Hoopen R, Ysebaert D, et al. Legal and ethical aspects of organ donation after euthanasia in Belgium and the Netherlands.J Med Ethics 2016; 42: 486-9.

Bolt EE, Flens EQ, Pasman HR, et al. Physician-assisted dying for children is conceivable for most Dutch paediatricians, irrespective of the patient's age or competence to decide. Acta Paediatr 2017; 106: 668-675.

Bosshard G, Fischer S, van der Heide A, et al. (2006)Intentional hastening by withholding or withdrawing treatment. Wein Klin Wochenschr 2006: 118: 322-6.

Bosshard G, Ulrich E, Bär W. (2003)748 cases of suicide assisted by a Swiss right-to-die organisation. Swiss Med Wkly 2003; 133: 310-7.

Bosshard G, Ulrich E, Ziegler SJ, et al. (2008a)Assessment of requests for assisted suicide by a Swiss right-to-die society. Death Stud 2008; 32: 646-57.

Bosshard G, Zellweger U, Bopp M, et al. (2016) Medical End-of-Life Practices in Switzerland: A Comparison of 2001 and 2013. JAMA Intern Med 2016; 176: 555-6.

Bosshard G. (2008b) Switzerland, in Griffiths J, Weyers H, Adams M. (eds) Euthanasia and Law in Europe. Hart Publishing, 2008

Boudreau JD, Somerville MA. Physician-Assisted Suicide Should Not Be Permitted. N Engl J Med 2013; 368: 1450-1.

Boyle J. The Relevance of Double Effect to Decisions About Sedation at the End of Life, in Taboada P (ed.). Sedation at the End-of-life: An Interdisciplinary Approach. Springer, 2015.

Breitbart W, Chochinov M, Passik S. (2010a)Psychiatric symptoms in palliative medicine, in Hanks G et al (eds.) Oxford Textbook of Palliative Medicine 4e. Oxford University Press, 2010.

Breitbart W, Rosenfeld B, Gibson C, et al. (2010b)Impact of treatment for depression on desire for hastened death in patients with advanced AIDS. Psychosomatics 2010; 51: 98-105.

Breitbart W, Rosenfeld B, Pessin H, et al. Depression, hopelessness, and desire for hastened death in terminally ill patients with cancer.JAMA 2000; 284: 2907-11.

Bridge DT et al. Medical assistance in dying: a disruption of therapeutic relationships Med J Aust 2019; 210: 189.

Brinkkemper T, Klinkenberg M, Deliens L, et al. Palliative sedation at home in the Netherlands: a nationwide survey among nurses. J Adv Nurs 2011; 67: 1719-28.

Bruinsma SM, Rietjens JA, Swart SJ, et al. Estimating the potential life-shortening effect of continuous sedation until death: a comparison between two approaches.J Med Ethics 2014; 40: 458-62.

Buiting H, van Delden J, Onwuteaka-Philpsen B, et al. Reporting of euthanasia and physician-assisted suicide in the Netherlands: descriptive study.BMC Med Ethics 2009; 10: 18.

Byock I. The Best Care Possible Avery, 2012

Byock I. The Case Against Physician-Assisted Suicide and Euthanasia, in Youngner SJ, Arnold RM (eds.). The Oxford Handbook of Ethics at the End of Life. Oxford University Press, 2016.

Callahan D. Organized obfuscation: advocacy for physician-assisted suicide. Hastings Cent Rep 2008; 38: 30-2.

Callahan D. Values and Ethics in Conversations About Physician-Assisted Death, in Physician-Assisted Death. Scanning the Landscape: Proceedings of a Workshop (2018). National Academies Press. Available at http://nap.edu/25131

Callinan K, Silva O. Advocating for the Option of Physician-Assisted Death, in English RA et al (Rapporteurs) Physician-Assisted Death: Scanning the Landscape. Proceedings of a Workshop. National Academies Press, 2018. Available at http://nap.edu/25131.

Campbell CS, Black MA. Dignity, death, and dilemmas: a study of Washington hospices and physician-assisted death.J Pain Symptom Manage 2014; 47: 137-53.

Campbell CS, Cox JC. Hospice-assisted death? A study of Oregon hospices on death with dignity.Am J Hosp Palliat Care 2012; 29: 227-35.

Centeno C, Clark D, Lynch T, et al. Facts and indicators on palliative care development in 52 countries of the WHO European region: Results of an EAPC Task Force. Palliat Med 2007: 21: 463-471.

Chabot B. (2012) Hastening Death Through Cessation of Eating and Drinking. In Youngner SJ and Kimsma GK (eds.) Physician-Assisted Death in Perspective. Assessing the Dutch Experience. Cambridge University Press, 2012.

Chabot B. (2017) Worrisome Culture Shift in the context of Self-Selected Death. Available at trudolemmens.wordpress.com June 19, 2017.

Chambaere K, Bilsen J, Cohen J, et al. Physician-assisted deaths under the euthanasia law in Belgium: a population-based survey.CMAJ 2010; 182: 895-901.

Chambaere K, Cohen J, Robijn L, et al. (2015a)End-of-life decisions in individuals dying with dementia in Belgium.J Am Geriatr Soc 2015; 63: 290-6.

Chambaere K, Vander Stichele R, Mortier F, et al. (2015b) Recent trends in euthanasia and other end of life practices in Belgium. N Engl J Med 2015; 372: 1179-81.

Chan B, Somerville M. Converting the 'Right to Life' to the 'Right to Physician-Assisted Suicide and Euthanasia'. Med Law Rev 2016; 24: 143-75.

Cherny NI, Radbruch L, Board of the European Association for Palliative Care. European Association for Palliative Care (EAPC) recommended framework for the use of sedation in palliative care. Palliat Med 2009; 23: 581-93.

Chin AE, Hedberg K, Higginson GK, et al. Legalized physician-assisted suicide in Oregon--the first year's experience. N Engl J Med 1999; 340: 577-83.

Chochinov HM, Hack T, Hassard T, et al. Dignity therapy: a novel psychotherapeutic intervention for patients near the end of life. J Clin Oncol 2005; 23: 5520-5.

Chochinov HM, Tataryn D, Clinch JJ, et al. Will to live in the terminally ill. Lancet 1999; 354: 816-9.

Chochinov HM, Wilson KG, Enns M, et al. Desire for death in the terminally ill.Am J Psychiatry 1995; 152: 1185-91.

CHPCA (Canadian Hospice Palliative Care Association). Hospice Palliative Care and Medical Assistance in Dying (MAiD) in Canada. Available at www.chpca.net/media/540325/chpca-maid-booklet-eng-12page-final-web.pdf

Claessens P, Menten J, Schotsmans P, et al. Palliative sedation: a review of the research literature. J Pain Symptom Manage 2008; 36: 310-33.

Clearkin RJ. Mis-selling Euthanasia BMJ 2017; 358: j3566

Cohen J, Van Wesemael Y, Smets T, et al. Cultural differences affecting euthanasia practice in Belgium: one law but different attitudes and practices in Flanders and Wallonia.Soc Sci Med 2012; 75: 845-53.

Cohen J, Van Wesemael Y, Smets T, et al. Nationwide survey to evaluate the decision-making process in euthanasia requests in Belgium: do specifically trained 2nd physicians improve quality of consultation? BMC Health Serv Res 2014; 14: 307.

Cohen JS, Fihn SD, Boyko EJ et al. Attitudes toward assisted suicide and euthanasia among physicians in Washington State. N Engl J Med 1994; 331: 89-94.

Cohen-Almagor R. Euthanisinz People Who Are 'Tired of Life', in Jones et al (eds) Euthanasia and Assisted Suicide. Lessons from Belgium. Cambridge University Press, 2017.

Cohen-Almagor R. Should the Euthanasia Act in Belgium Include Minors?Perspect Biol Med 2018; 61: 230-48.

Compassion and Choices. Medical Aid in Dying Fact Sheet (December 2016). Available at https://compassionandchoices.org/

Cook M. A Dutch euthanasia pioneer surveys the wreckage and despairs. MercatorNet June 20, 2017. Available at https://www.mercatornet.com/

CPSO (College of Physicians and Surgeons of Ontario). Effective Referral. Available at https://www.cpso.on.ca/cpso/media/documents/policies/policy-items/medical-assistance-in-dying-effective-referral-factsheet.pdf

Craine PB. Former Dutch Health Minister admits error of legalizing euthanasia. LifeSiteNews Dec 2, 2009. Available at https://www.lifesitenews.com/

Cuman G, Gastmans C. Minors and euthanasia: a systematic review of argument-based ethics literature. Eur J Pediatr 2017; 176: 837-47.

de Beaufort ID, van de Vathorst S. Dementia and assisted suicide and euthanasia.J Neurol 2016; 263: 1463-7.

de Boer ME, Dröes RM, Jonker C, et al. Advance directives for euthanasia in dementia: how do they affect resident care in Dutch nursing homes? Experiences of physicians and relatives. J Am Geriatr Soc 2011; 59: 989-96.

de Graeff A, Dean M. Palliative sedation therapy in the last weeks of life: a literature review and recommendations for standards. J Palliat Med 2007; 10: 67-85.

de Jong A, van Dijk G. Euthanasia in the Netherlands: balancing autonomy and compassion. World Medical Journal 2017; 63: 10-15. Available at www.knmg.nl>publications

Dees M, et al. Unbearable suffering of patients with a request for euthanasia or physician-assisted suicide: an integrative review.Psychooncology 2010; 19: 339-52.

Denton A. (1) An address on assisted dying laws. Available at https://www.ourcommunity.com.au/cic/speakers/?speaker=Andrew%20Denton

Denton A. (2) Better off dead. Available at www.wheelercentre.com

Diaz D. Brittany Maynard, in English RA et al (Rapporteurs) Physician-Assisted Death: Scanning the Landscape. Proceedings of a Workshop. National Academies Press, 2018. Available at http://nap.edu/25131.

Dierickx S, Deliens L, Cohen J, et al. Euthanasia for people with psychiatric disorders or dementia in Belgium: analysis of officially reported cases. BMC Psychiatry 2017; 17: 203.

Dierickx S, Deliens L, Cohen J, et al. Euthanasia in Belgium: trends in reported cases between 2003 and 2013. CMAJ 2016; 188: E407-E414.

Dierickx S, Deliens L, Cohen J, et al. Involvement of palliative care in euthanasia practice in a context of legalized euthanasia: A population-based mortality follow-back study.Palliat Med 2018; 32: 114-122.

Doernberg SN, Peteet JR, Kim SY. Capacity Evaluations of Psychiatric Patients Requesting Assisted Death in the Netherlands.Psychosomatics 2016; 57: 556-565.

Dore MK. ‘Death With Dignity’: A Recipe for Elder Abuse and Homicide (Albeit Not by Name). Marquette Elder's Advisor 2010; 11: 387-400. Available at: http://scholarship.law.marquette.edu/elders/vol11/iss2/8

Dorrepaal KL, Aaronson NK, van Dam FS. Pain experience and pain management among hospitalized cancer patients. A clinical study. Cancer 1989; 63: 593-8.

Doukas DJ, Waterhouse D, Gorenflo DW, et al. Attitudes and behaviours on physician-assisted death: a study of Michigan oncologists. J Clin Oncol 1995; 13: 1055-61.

Downie J. (2017)In a Nutshell II: Ontario Court Decision and MAID. Available at https://bioethics.georgetown.edu/2017/07/in-a-nutshell-ii-ontario-court-decision-maid/

DREDF (Disability Rights Education & Defense Fund). Some Oregon and Washington State Assisted Suicide Abuses and Complications. Available at https://www.dredf.org

Drum CE, White G, Taitano G, et al. The Oregon Death with Dignity Act: results of a literature review and naturalistic inquiry.Disabil Health J 2010; 3: 3-15.

Dworkin R. Life's Dominion. Alfred Knopf, 1993

Dwyer P. Conversations on Dying. A Palliative Care Pioneer Faces His Own Death. Dundurn Press, 2016.

Eggertson L. Most palliative physicians want no role in assisted death.CMAJ 2015; 187: E177.

Emanuel EJ, Battin MP. (1998b) What are the potential cost savings from legalizing physician-assisted suicide?N Engl J Med 1998; 339: 167-72.

Emanuel EJ, Daniels ER, Fairclough DL, et al. (1998a)The practice of euthanasia and physician-assisted suicide in the United States. JAMA 1998; 280: 507-13

Emanuel EJ, Fairclough DL, Daniels ER, et al. Euthanasia and physician-assisted suicide:attitudes and experiences of oncology patients, oncologists, and the public. Lancet 1996; 347:1805-10.

Emanuel EJ, Fairclough DL, Emanuel LL. Attitudes and desires related to euthanasia and physician-assisted suicide among terminally ill patients and their caregivers. JAMA 2000; 284: 2460-8.

Euthanasia in Switzerland. Available at https://en.wikipedia.org/wiki/Euthanasia_in_Switzerland

Fairman N, Irwin S. Depression and the Desire to Die Near the End of Life, in Youngner SJ, Arnold RM (eds.). The Oxford Handbook of Ethics at the End of Life. Oxford University Press, 2016.

Fenigsen R. A case against Dutch euthanasia. Hastings Cent Rep 1989; 19: S22-30.

Fenigsen R. Dutch euthanasia revisited. Issues Law Med 1997; 13: 301-11

Fergusson A, George R, Norris P, et al. Euthanasia. Lancet 1991; 338: 1010-11.

Finlay IG, George R. Legal physician-assisted suicide in Oregon and The Netherlands: evidence concerning the impact on patients in vulnerable groups--another perspective on Oregon's data. J Med Ethics 2011; 37:171-4.

Fischer S, Huber CA, Furter M, et al. Reasons why people in Switzerland seek assisted suicide: the view of patients and physicians. Swiss Med Wkly 2009; 139: 333-8.

Fischer S, Huber CA, Imhof L, et al. Suicide assisted by two Swiss right-to-die organisations.J Med Ethics 2008; 34: 810-4.

Fischer S, Miccinesi G, Hornung R, et al. Responders and non-responders in a study on medical end-of-life decisions in Denmark, the Netherlands, Sweden and Switzerland. Soz Praventivmed 2006; 51: 24-33.

Fitzpatrick K. Should the law on assisted dying be changed? No. BMJ 2011; 342: d1883.

Foley K, Hendin H. The Oregon Experiment, in Foley K, Hendin H (eds.). The Case Against Assisted Suicide. For the Right to End-of-Life Care. Johns Hopkins University Press, 2002.

Foley K, Hendin H. The Oregon Report. Don’t Ask, Don’t Tell. Hastings Center Report 1999; 29: 37-42.

Foster C. Choosing Life, Choosing Death. The Tyranny of Autonomy in Medical Ethics and Law. Hart Publishing, 2009.

Frei A, Schenker TA, Finzen A, et al. Assisted suicide as conducted by a "Right-to-Die"-society in Switzerland: a descriptive analysis of 43 consecutive cases. Swiss Med Wkly 2001; 131: 375-80.

Gamondi C, Pott M, Forbes K, et al. Exploring the experiences of bereaved families involved in assisted suicide in Southern Switzerland: a qualitative study.BMJ Support Palliat Care 2015; 5: 146-52.

Ganzini L and Block S. (2002) Physician-assisted death – a last resort? N Engl J Med 2002; 346: 1663-5.

Ganzini L, Dobscha SK, Heintz RT, et al. (2003a) Oregon physicians' perceptions of patients who request assisted suicide and their families. J Palliat Med 2003; 6: 381-90.

Ganzini L, Fenn DS, Lee MA, et al. (1996)Attitudes of Oregon psychiatrists toward physician-assisted suicide. Am J Psychiatry 1996; 153: 1469-75.

Ganzini L, Goy ER, Dobscha SK, et al. (2009a)Mental health outcomes of family members of Oregonians who request physician aid in dying.J Pain Symptom Manage 2009; 38: 807-15.

Ganzini L, Goy ER, Dobscha SK. (2008)Prevalence of depression and anxiety in patients requesting physicians' aid in dying: cross sectional survey. BMJ 2008; 337: 973-5.

Ganzini L, Goy ER, Dobscha SK. (2009b) Oregonians' reasons for requesting physician aid in dying. Arch Intern Med 2009; 169: 489-92.

Ganzini L, Goy ER, Miller LL, et al. (2003b) Nurses’ experiences with hospice patients who refuse food and fluids to hasten death. N Engl J Med 2003; 349: 359-65.

Ganzini L, Hedberg K. (2018) Statistics and Research Results on Physician-Assisted death in Oregon, in English RA et al (Rapporteurs) Physician-Assisted Death: Scanning the Landscape. Proceedings of a Workshop. National Academies Press, 2018. Available at http://nap.edu/25131.

Ganzini L, Lee MA, Heinz RT, et al. (1994) The effect of depression treatment on elderly patients' preferences for life-sustaining medical therapy. Am J Psychiatry 1994;151: 1631-36.

Ganzini L, Nelson HD, Schmidt TA, et al. (2000a)Evaluation of competence to consent to assisted suicide: views of forensic psychiatrists.Am J Psychiatry 2000; 157: 595-600.

Ganzini L, Nelson HD, Schmidt TA, et al. (2000b)Physicians' experiences with the Oregon Death with Dignity Act. N Engl J Med 2000;342: 557-63.

Ganzini L. (2014) Lessons from Legalized Physician-Assisted Death in Oregon and Washington, in Quill T and Miller F (eds.) Palliative Care and Ethics, Oxford University Press, 2014.

Ganzini L. (2016) Legalised Physician-Assisted Death in Oregon. QUT Law Review 2016; 16: 76-83. Available at https://lr.law.qut.edu.au

Gauthier S. Mausbach J, Reisch T, et al. Suicide tourism: a pilot study on the Swiss phenomenon. J Med Ethics 2015; 41: 611-7.

Gemmel N. After. Fourth Estate, 2017.

George RJ, Finlay IG, Jeffrey D. Legalised euthanasia will violate the rights of vulnerable patients. BMJ 2005; 331: 684-5.

Glare P, Virik K, Jones M, et al. A systematic review of physicians' survival predictions in terminally ill cancer patients. BMJ 2003; 327: 195-8.

Glick SM. Euthanasia: an unbiased decision? Am J Med 1997; 102: 294-6.

Gordon M, Singer PA. Decisions and care at the end of life. Lancet 1995; 346: 163-6.

Gorsuch NM. The Future of Assisted Suicide and Euthanasia. Princeton University Press, 2006.

Government of Canada. Medical assistance in dying. Available at https://www.canada.ca/en/health-canada/services/medical-assistance-dying.html

Griffiths J, Weyers H, Adams M. (2008) Euthanasia and Law in Europe. Hart Publishing, 2008

Groenewoud JH, van der Heide A, Kester JG, et al. (2000a)A nationwide study of decisions to forego life-prolonging treatment in Dutch medical practice. Arch Intern Med 2000; 160: 357-63.

Groenewoud JH, van der Heide A, Onwuteaka-Philipsen BD, et al. (2000b) Clinical problems with the performance of euthanasia and physician-assisted suicide in The Netherlands. N Engl J Med 2000; 342: 551-6.

Groenewoud JH, Van Der Heide A, Tholen AJ, et al. (2004)Psychiatric consultation with regard to requests for euthanasia or physician-assisted suicide. Gen Hosp Psychiatry 2004; 26: 323-30.

Groenewoud JH, van der Maas PJ, van der Wal G, et al. (1997)Physician-assisted death in psychiatric practice in the Netherlands. N Engl J Med 1997; 336: 1795-801.

Gunning KF. (1991) Euthanasia. Lancet 1991; 338:1010.

Hagelin J, Nilstun T, Hau J, et al. Surveys on attitudes toward legalisation of euthanasia: importance of question phrasing. J Med Ethics 2004; 30: 521-3.

Hamilton NG. Oregon’s Culture of Silence, in Foley K, Hendin H (eds.). The Case Against Assisted Suicide. For the Right to End-of-Life Care. Johns Hopkins University Press, 2002.

Harman S. Hospice and Palliative Care, in English RA et al (rapporteurs) Physician-Assisted Death: Scanning the Landscape. Proceedings of a Workshop. National Academies Press, 2018. Available at http://nap.edu/25131.

Harris J. Euthanasia and the value of life, in Keown J (ed) Euthanasia Examined. Cambridge University Press, 1995

Hartling OJ. Euthanasia--the illusion of autonomy. Med Law 2006; 25: 189-99.

Haverkate I, van der Heide A, Onwuteaka-Philipsen BD, et al. The emotional impact on physicians of hastening the death of a patient.Med J Aust 2001; 175: 519-22.

Hedberg K, Hopkins D, Kohn M. Five years of legal physician-assisted suicide in Oregon.N Engl J Med 2003; 348: 961-4.

Hedberg K, Hopkins D, Southwick K. Legalized physician-assisted suicide in Oregon, 2001. N Engl J Med 2002; 346: 450-2.

Hendin H, Foley K, White M. Physician-assisted suicide: reflections on Oregon's first case. Issues Law Med 1998; 14: 243-70.

Hendin H, Foley K. Physician-assisted suicide in Oregon: a medical perspective.Mich Law Rev 2008; 106: 1613-40.

Hendin H, Rutenfrans C, Zylicz Z. (1997a)Physician-assisted suicide and euthanasia in the Netherlands. Lessons from the Dutch.JAMA 1997; 277: 1720-2.

Hendin H. (1997b) Seduced by Death. Doctors, Patients and the Dutch Cure. New York, WW Norton, 1997.

Hendin H. (2002)The Dutch Experience, in Foley K, Hendin H (eds.). The Case Against Assisted Suicide. For the Right to End-of-Life Care. Johns Hopkins University Press, 2002.

Hendin H. Euthanasia Consultants or Facilitators? Med J Aust 1999; 170: 351-2.

Henry B. Clinical Guidelines for the Use of Palliative Sedation: Moving from Contention to Consensus, in Taboada P (ed.). Sedation at the End-of-life: An Interdisciplinary Approach. Springer, 2015.

Hooper SC, Vaughan KJ, Tennant CC, et al. Major depression and refusal of life-sustaining medical treatment in the elderly. Med J Aust 1996; 165: 416-9.

Hotopf M, Chidgey J, Addington-Hall J, et al. Depression in advanced disease: a systematic review Part 1. Prevalence and case finding. Palliat Med 2002; 16: 81-97.

House of Lords. (1994) Report of the Select Committee on Medical Ethics. Session 1993-94, HL Paper 21-I. London, HMSO, 1994.

House of Lords. (2005)Report of the Select Committee on the Assisted Dying for the Terminally Ill Bill. Session 2004-05, HL Paper 86-I. London, HMSO, 2005.

Humphrey D, Clement M. Freedom to Die: People, Politics and the Right-to-Die Movement. St Martin’s Press, 2000.

Hurst S, Auron A. Assisted suicide and euthanasia in Switzerland: allowing a role for non-physicians. BMJ 2003; 326: 271–273.

IAHPC (International Association for Hospice and Palliative Care). Global Statements on Euthanasia and Physician Assisted Suicide. Available athttps://iahpc.org/policy-and-ethics/ethical-issues/statements-on-euthanasia-and-physician-assisted-suicide/

Inghelbrecht E, Bilsen J, Mortier F, et al. The role of nurses in physician-assisted deaths in Belgium.CMAJ 2010; 182: 905-10.

Institut Eurpeén de Bioéthique. Analysis of the Seventh Report of the Federal Commission for Euthanasia Control and Evaluation. Available at www.ieb-eib.org

Jansen-van der Weide MC, Onwuteaka-Philipsen BD, van der Wal G. (2004)Implementation of the project 'Support and Consultation on Euthanasia in The Netherlands' (SCEN).Health Policy 2004; 69: 365-73.

Jansen-van der Weide MC, Onwuteaka-Philipsen BD, van der Wal G. (2005)Granted, undecided, withdrawn, and refused requests for euthanasia and physician-assisted suicide. Arch Intern Med 2005; 165: 1698-704.

Jansen-van der Weide MC, Onwuteaka-Philipsen BD, van der Wal G. (2006)Requests for euthanasia and physician-assisted suicide and the availability and application of palliative options.Palliat Support Care 2006; 4: 399-406.

Jansen-van der Weide MC, Onwuteaka-Philipsen BD, van der Wal G. (2007)Quality of consultation and the project 'Support and Consultation on Euthanasia in the Netherlands' (SCEN).Health Policy 2007; 80: 97-106.

Janssens R, van Delden JJ, Widdershoven GA. Palliative sedation: not just normal medical practice. Ethical reflections on the Royal Dutch Medical Association's guideline on palliative sedation. J Med Ethics 2012; 38: 664-8.

Jeffrey D. Against Physician Assisted Suicide. A Palliative Care Perspective. Radcliffe Publishing, 2009.

Jochemsen H, Keown J. (1999) Voluntary euthanasia under control? Further empirical evidence from The Netherlands.J Med Ethics 1999; 25: 16-21.

Jochemsen H. (1994) Euthanasia in Holland: an ethical critique of the new law. J Med Ethics 1994; 20: 212-7.

Johnston W. Canadianhospices are being bullied into hosting euthanasia. Mercatornet Feb 2 2018. Available at www.mercatornet.com

Jones DA, et al (eds) Euthanasia and Assisted Suicide. Lessons from Belgium. Cambridge University Press, 2017.

Jones DA, Paton D. How Does Legalization of Physician-Assisted Suicide Affect Rates of Suicide?South Med J 2015; 108: 599-604.

Jones DA. Euthanasia and Assisted Suicide in Belgium, in Jones et al (eds) Euthanasia and Assisted Suicide. Lessons from Belgium. Cambridge University Press, 2017.

Kaczor C. Against euthanasia for children: a response to Bovens. J Med Ethics 2016; 42: 57-8.

Kekewich MA. Market liberalism in health care: a dysfunctional view of respecting "consumer" autonomy.J Bioeth Inq 2014; 11: 21-9.

Kelly BJ, Pelusi D, Burnett PC, et al. The prevalence of psychiatric disorder and the wish to hasten death among terminally ill cancer patients.Palliat Support Care 2004; 2: 163-9.

Kelly BJ, Varghese FT. Assisted suicide and euthanasia: what about the clinical issues? Aust N Z J Psychiatry 1996; 30: 3-8.

Kelly BJ, Varghese FT. The Seduction of Autonomy: Countertransference and Physician Aid in Dying, in Katz RS and Johnson TA (eds) When Professionals Weep. Emotional and Countertransference Responses in Palliative and End-of-Life Care 2e, Routledge, 2016.

Keown J. (2002) Euthanasia, Ethics and Public Policy. An Argument Against Legalisation. Cambridge University Press, 2002.

Keown J. (2012)Against Decriminalising Euthanasia; For Improving Care, in Jackson E, Keown J. Debating Euthanasia. Hart Publishing, 2012.

Keown J. (2013) The Law and Ethics of Medicine. Essays on the Inviolability of Human Life. Oxford University Press, 2013.

Keown J. (2018) Euthanasia, Ethics and Public Policy. An Argument Against Legalisation 2e. Cambridge University Press, 2018.

Kim SY, De Vries RG, Peteet JR. Euthanasia and Assisted Suicide of Patients With Psychiatric Disorders in the Netherlands 2011 to 2014. JAMA Psychiatry 2016; 73: 362-8.

Kimsma GK, Clark C. (2012a)Shared Obligations and ‘Medical Friendships’ in Assisted Dying. Moral and Psychological Repercussions Reconsidered, in Younger S and Kimsma G (eds.) Physician-Assisted Death in Perspective – Assessing the Dutch Experience. Cambridge University Press, 2012.

Kimsma GK, van Leeuwen E. (2012b) Reviews after the Act: The Role and Work of the Regional Euthanasia Committees, in Youngner SJ, Kimsma GK (eds.). Physician-Assisted Death in Perspective. Assessing the Dutch Experience. Cambridge University Press, 2012.

Kimsma GK. (2012c)Assessment of Unbearable and Hopeless Suffering in Evaluating a Request to End Life, in Youngner SJ, Kimsma GK (eds.). Physician-Assisted Death in Perspective. Assessing the Dutch Experience. Cambridge University Press, 2012.

Kimsma GK. (2016)Physician-Assisted Death in The Netherlands, in Youngner and Arnold (eds.) The Oxford Handbook of Ethics at the End of Life. Oxford University Press, 2016

Kissane D. Deadly Days in Darwin, in Foley K, Hendin H (eds.). The Case Against Assisted Suicide. For the Right to End-of-Life Care. Johns Hopkins University Press, 2002.

Kissane DW, Kelly BJ. Demoralisation, depression and desire for death: problems with the Dutch guidelines for euthanasia of the mentally ill. Aust N Z J Psychiatry 2000; 34: 325-33.

Kissane DW, Street A, Nitschke P. Seven deaths in Darwin: case studies under the Rights of the Terminally Ill Act, Northern Territory, Australia. Lancet 1998; 352: 1097-102.

KNMG. Euthanasia in figures. Available at www.knmg.nl

Koch T. Living Versus ‘Dying With Dignity’. Camb Q Healthc Ethics 1996; 5: 50-61.

Kouwenhoven PS, Raijmakers NJ, van Delden JJ, et al. Opinions about euthanasia and advanced dementia: a qualitative study among Dutch physicians and members of the general public.BMC Med Ethics 2015; 16: 7.

Krakauer EL, Quinn TE. Sedation in Palliative medicine, in Hanks G et al (eds.) Oxford Textbook of Palliative Medicine 4e. Oxford University Press, 2010.

Kugaya A, Akechi T, Nakano T, et al. Successful antidepressant treatment for five terminally ill cancer patients with major depression, suicidal ideation and a desire for death.Support Care Cancer 1999; 7: 432-6.

Kuhse H, Singer P, Baume P, et al. End-of-life decisions in Australian medical practice.Med J Aust 1997; 166: 191-6.

Lamme V. The practice of euthanasia has landed on a slippery slope. Available at www.trudolemmens.wordpress.com February 28, 2016.

Lee MA, Nelson HD, Tilden VP, et al. Legalizing assisted suicide--views of physicians in Oregon. N Engl J Med 1996; 334: 310-5.

Legal and Social Issues Committee, Parliament of Victoria. Inquiry into end of life choices. Final report. Available at www.parliament.vic.gov.au/lsic

Legemaate J, Verkerk M, van Wijlick E, et al. Palliative sedation in the Netherlands: starting-points and contents of a national guideline. Eur J Health Law 2007; 14: 61-73.

Leiva R, Cottle MM, Ferrier C, et al. Euthanasia in Canada: a Cautionary Tale. World Medical Journal 2018; 64: 17-23. Available at https://www.wma.net/publications/

Lemmens W. Psychiatric Patients and the Culture of Euthanasia in Belgium, in Jones et al (eds) Euthanasia and Assisted Suicide. Lessons from Belgium. Cambridge University Press, 2017.

Levenseindekliniek (End-of-Life Clinic). See https://www.levenseindekliniek.nl/en/

Lewy G. Assisted Death in Europe and America. Four Regimes and Their Lessons. Oxford University Press, 2011.

Li M, Watt S, Escaf M, et al. Medical Assistance in Dying – Implementing a Hospital-Based Program in Canada. N Engl J Med 2017; 376: 2082-8.

Living and Dying Well. Oregon – Twenty Years of Assisted Suicide – Looking at the Evidence. Available at www.livinganddyingwell.org.uk

Loggers ET, et al. Implementing a Death With Dignity Program at a Comprehensive Cancer Center N Engj J Med 2013; 368: 1417-24.

Lynn J. Terminal Illness and the 6-Month Prognosis, in English RA et al (Rapporteurs) Physician-Assisted Death:Scanning the Landscape. Proceedings of a Workshop. National Academies Press, 2018. Available at www.nap.edu/25131.

MacKellar C. Some Possible Consequences Arising from the Normalisation of Euthanasia in Belgium, in Jones et al (eds) Euthanasia and Assisted Suicide. Lessons from Belgium. Cambridge University Press, 2017.

Maclure J, Dumont I. Selling conscience short: a response to Schuklenk and Smalling on conscientious objections by medical professionals. J Med Ethics 2017; 43: 241-244.

Maessen M, Veldink JH, Onwuteaka-Philipsen BD, et al. Trends and determinants of end-of-life practices in ALS in the Netherlands. Neurology 2009; 73: 954-61.

Maessen M, Veldink JH, van den Berg LH, et al. Requests for euthanasia: origin of suffering in ALS, heart failure, and cancer patients. J Neurol 2010; 257: 1192-8.

Magelssen M, Supphellen M, Nortvedt P, et al. Attitudes toward assisted dying are influenced by question wording and order: a survey experiment. BMC Med Ethics 2016; 17: 24.

Mann PS. Meanings of death, in Battin MP et al (eds) Physician-Assisted Suicide. Routledge, 1998.

Mannix K. The Gaurdian 12 October, 2005.

Marcoux I, Onwuteaka-Philipsen BD, Jansen-van der Weide MC, et al. Withdrawing an explicit request for euthanasia or physician-assisted suicide: a retrospective study on the influence of mental health status and other patient characteristics. Psychol Med 2005; 35: 1265-74.

Marriott D and McMurchie M. HIV and advanced immune deficiency. Med J Aust 1996; 164: 111-2.

Materstvedt LJ, Bosshard G. Euthanasia and physician-assisted suicide, in Hanks G et al (eds.) Oxford Textbook of Palliative Medicine 4e. Oxford University Press, 2010.

McInerney F. Heroic frames: discursive constructions around the requested death movement in Australia in the late-1990s. Soc Sci Med 2006; 62: 654-67.

McKeogh M. Physician-assisted suicide and patients with HIV disease. N Engl J Med. 1997; 337: 56.

Meeussen K, Van den Block L, Bossuyt N, et al. Physician reports of medication use with explicit intention of hastening the end of life in the absence of explicit patient request in general practice in Belgium.BMC Public Health 2010; 10: 186.

Meier DE, Emmons CA, Litke A, et al. Characteristics of patients requesting and receiving physician-assisted death. Arch Intern Med 2003; 163: 1537-42.

Meier DE, Emmons CA, Wallenstein S, et al. A national survey of physician-assisted suicide and euthanasia in the United States. N Engl J Med 1998; 338: 1193-201.

Mendelson D, Haywood I. Minors' decision-making capacity to refuse life-saving and life-sustaining treatment: legal and psychiatric perspectives.J Law Med 2014; 21: 762-73.

Miccinesi G, Fischer S, Paci E, et al. Physicians' attitudes toward end-of-life decisions: a comparison between seven countries. Soc Sci Med 2005; 60: 1961-74.

Miller DG, Kim SYH. Euthanasia and physician-assisted suicide not meeting due care criteria in the Netherlands: a qualitative review of review committee judgements. BMJ Open 2017; 7: e017628.

Montero E. The Belgian Experience of Euthanasia Since Its Legal Implementation in 2002, in Jones et al (eds) Euthanasia and Assisted Suicide. Lessons from Belgium. Cambridge University Press, 2017.

Morrison K. (2017a) Presuming Mature Minor Competency for MAID? Available at http://eol.law.dal.ca/wp-content/uploads/2017/11/FR-CS-4-303-KathrynMorrison.pdf

Morrison K. (2017b)Medical assistance in dying, in Henry et al (eds.) Palliative Care. Psychosocial and Ethical Considerations. Nova Biomedical, 2017.

Morrison K. (2017c) Finding a home (somewhere) for medical aid in dying. J Pain Manage 2017; 10: 9-13.

Muller MT, Van der Wal G, van Eijk JT, et al. Voluntary active euthanasia and physician-assisted suicide in Dutch nursing homes: are the requirements for prudent practice properly met? J Am Geriatr Soc 1994; 42: 624-9.

Neudert C, Oliver D, Wasner M et al. The course of the terminal phase in patients with amyotrophic lateral sclerosis. J Neurol 2001; 248: 612-6.

New York State Task Force on Life and the Law. When Death is Sought: Assisted Suicide and Euthanasia in the Medical Context, 1994. Available at www.health.ny.gov

Ng CG, Boks MP, Roes KC, et al. Rapid response to methylphenidate as an add-on therapy to mirtazapine in the treatment of major depressive disorder in terminally ill cancer patients: a four-week, randomized, double-blinded, placebo-controlled study.Eur Neuropsychopharmacol 2014; 24: 491-8.

Nitschke P. Available at https://exitinternational.net

Norwood F. Euthanasia in the Netherlands, in English RA et al (Rapporteurs) Physician-Assisted Death: Scanning the Landscape. Proceedings of a Workshop. National Academies Press, 2018. Available at http://nap.edu/25131.

Not Dead Yet. Oregon State Assisted Suicide Reports Substantiate Critics' Concerns. Available at notdeadyet.org/

Nys H. Discussion of the Legal Rules on Euthanasia in Belgium, in Jones et al (eds) Euthanasia and Assisted Suicide. Lessons from Belgium. Cambridge University Press, 2017.

O’Neill O. A Note on Autonomy and Assisted Dying (memorandum circulated to members of the House of Lords when considering the Joffe Bill), 2006.

O’Rourke MA et al. Reasons to Reject Physician Assisted Suicide/Physician Aid in Dying. J Oncol Pract 2017; 13: 683-6. Available at www.ascopubs.org/journal/jop/

Ogilvie AD, Potts SG. Assisted suicide for depression: the slippery slope in action? BMJ 1994; 309: 492-3.

Onwuteaka-Philipsen BD and van der Wal G. Cases of euthanasia and physician-assisted suicide among AIDS patients reported to the Public Prosecutor in North Holland. Public Health. 1998; 112: 53-6.

Onwuteaka-Philipsen BD, Brinkman-Stoppelenburg A, Penning C, et al. (2012b)Trends in end-of-life practices before and after the enactment of the euthanasia law in the Netherlands from 1990 to 2010: a repeated cross-sectional survey. Lancet 2012; 380: 908-15.

Onwuteaka-Philipsen BD, Muller MT, van der Wal, et al. Active voluntary euthanasia or physician-assisted suicide? JAGS 1997; 45: 1208-13.

Onwuteaka-Philipsen BD, van der Heide A, Koper D, et al. (2003) Euthanasia and other end-of-life decisions in the Netherlands in 1990, 1995, and 2001. Lancet 2003; 362: 395-9.

Onwuteaka-Philipsen BD, van der Wal G, Kostense PJ, et al. Consultants in cases of intended euthanasia or assisted suicide in The Netherlands. Med J Aust 1999; 170: 360-3.

Onwuteaka-Philipsen BD. (2012a) The Unreported Cases, in Youngner SJ, Kimsma GK (eds.). Physician-Assisted Death in Perspective. Assessing the Dutch Experience. Cambridge University Press, 2012.

Onwuteaka-Philipsen BD. Euthanasia in the Netherlands, in Physician-Assisted Death. Scanning the Landscape: Proceedings of a Workshop (2018). National Academies Press. Available at http://nap.edu/25131

Oregon Death with Dignity Act. 2017 Data Summary. http://www.healthoregon.org/dwd

Oregon Health Authority. http://www.oregon.gov/oha

OSOS (Oregon Secretary of State). https://sos.oregon.gov/elections/Documents/Voter_Turnout_History_General_Election.pdf

Papavasiliou EE, Chambaere K, Deliens L, et al. (2014b)Physician-reported practices on continuous deep sedation until death: A descriptive and comparative study. Palliat Med 2014; 28: 491-500.

Papavasiliou EE, Payne S, Brearley S. (2014a) Current debates on end-of-life sedation: an international expert elicitation study. Support Care Cancer 2014; 22: 2141-9.

Parkinson L, Rainbird K, Kerridge I, et al. Cancer patients' attitudes toward euthanasia and physician-assisted suicide: the influence of question wording and patients' own definitions on responses. J Bioeth Inq 2005; 2: 82-9.

Parliament of the Netherlands. Termination of Life on Request and Assisted Suicide (Review Procedures) Act, 2002. https://www.eutanasia.ws/leyes/leyholandesa2002.pdf

Patients Rights Council. Available atwww.patientsrightscouncil.org

PCCEF (Physicians for Compassionate Care Education Foundation). Five Oregonians to Remember. Available at www.pccef.org/articles/art60.htm

Pellegrino ED. Patient autonomy and the physician's ethics. Ann R Coll Physicians Surg Can 1994; 27: 171-3.

Pereira J, Laurent P, Cantin B, et al. The response of a Swiss university hospital's palliative care consult team to assisted suicide within the institution.Palliat Med 2008; 22: 659-67.

Pereira J. Legalizing euthanasia or assisted suicide: the illusion of safeguards and controls. Curr Oncol 2011; 18: e38-45.

Perron M. in Parsons I and Newell C (eds.) Managing Mortality – Euthanasia on Trial. Villamanta Publishing, 1996.

Pignone M, Gaynes BN, Rushton JL, et al, Screening for depression in adults: a summary of the evidence for the U.S. Preventive Services Task Force. Ann Intern Med 2002; 136: 765-76.

Pijnenborg L, van Delden JJ, Kardaun JW, et al. (1994) Nationwide study of decisions concerning the end of life in general practice in The Netherlands. BMJ 1994; 309: 1209-12.

Pijnenborg L, van der Maas PJ, Kardaun JW, et al. (1995) Withdrawal or withholding of treatment at the end of life. Results of a nationwide study. Arch Intern Med 1995; 155: 286-92.

Pijnenborg L, van der Maas PJ, van Delden JJ, et al. (1993) Life-terminating acts without explicit request of patient. Lancet 1993; 341: 1196-9.

Portenoy RK, Coyle N, Kash KM, et al. Determinants of the willingness to endorse assisted suicide. A survey of physicians, nurses, and social workers. Psychosomatics 1997; 38: 277-87.

Pousset G, Bilsen J, Cohen J, et al. Continuous deep sedation at the end of life of children in Flanders, Belgium. J Pain Symptom Manage 2011; 41: 449-55.

Price A, McCormack R, Wiseman T, et al. Concepts of mental capacity for patients requesting assisted suicide: a qualitative analysis of expert evidence presented to the Commission on Assisted Dying.BMC Med Ethics 2014; 15: 32.

Quill T, Battin M (eds.). Physician-Assisted Dying. The case for palliative care and patient choice. Johns Hopkins University Press, 2004.

Quill T, Miller F (eds.). Palliative Care and Ethics. Oxford University Press, 2014.

Rabkin J, Goetz R, Murphy JM, et al. Cognitive impairment, behavioral impairment, depression, and wish to die in an ALS cohort.Neurology 2016; 87: 1320-8.

Rady MY, Verheijde JL. Continuous deep sedation until death: palliation or physician-assisted death?Am J Hosp Palliat Care 2010; 27: 205-14.

Randall F, Downie R. Assisted suicide and voluntary euthanasia: role contradictions for physicians. Clin Med (Lond) 2010; 10: 323-5.

Randall F, Downie R. End of Life Choices. Consensus and Controversy. Oxford University Press, 2009.

Raus K. The Extension of Belgium's Euthanasia Law to Include Competent Minors.J Bioeth Inq 2016; 13: 305-15.

Regional Euthanasia Review Committees Code of Practice (2015). Available at https://english.euthanasiecommissie.nl/

Regional Euthanasia Review Committees. Annual Reports. Available at https://english.euthanasiecommissie.nl/the-committees/annual-reports

Reiter-Theil S, Wetterauer C, Frei IA. Taking One's Own Life in Hospital? Patients and Health Care Professionals Vis-à-Vis the Tension between Assisted Suicide and Suicide Prevention in Switzerland.Int J Environ Res Public Health 2018; 15. pii: E1272.

Rietjens JA, Bilsen J, Fischer S, et al. (2007)Using drugs to end life without an explicit request of the patient. Death Stud 2007; 31: 205-21.

Rietjens JA, van Delden JJ, van der Heide A, et al. (2006)Terminal sedation and euthanasia: a comparison of clinical practices. Arch Intern Med 2006; 166: 749-53.

Rietjens JA, van der Heide A, Vrakking AM, et al. (2004)Physician reports of terminal sedation without hydration or nutrition for patients nearing death in the Netherlands.Ann Intern Med 2004; 141: 178-85.

Rietjens JA, van Tol DG, Schermer M, et al. (2009) Judgement of suffering in the case of a euthanasia request in The Netherlands. J Med Ethics 2009; 35: 502-7.

Rivera-López E. Is medically assisted death a special obligation?J Med Ethics 2017; 43: 401-406.

Robijn L, Cohen J, Rietjens J, et al. Trends in Continuous Deep Sedation until Death between 2007 and 2013: A Repeated Nationwide Survey. PLoS One 2016; 11: e0158188.

Rooney W, Schuklenk U, van de Vathorst S. Are Concerns About Irremediableness, Vulnerability, or Competence Sufficient to Justify Excluding All Psychiatric Patients from Medical Aid in Dying? Health Care Anal. 2017 Jun 17. doi: 10.1007/s10728-017-0344-8. [Epub ahead of print]

Rosenfeld B, Breitbart W, Galietta M, et al. The schedule of attitudes toward hastened death: Measuring desire for death in terminally ill cancer patients. Cancer 2000; 88: 2868-75.

Rosenfeld B, Breitbart W, Gibson C, et al. Desire for hastened death among patients with advanced AIDS.Psychosomatics 2006; 47: 504-12.

Ruijs CD, Kerkhof AJ, van der Wal G, et al. The broad spectrum of unbearable suffering in end-of-life cancer studied in Dutch primary care. BMC Palliat Care 2012; 11:12.

Rurup ML, Borgsteede SD, van der Heide A, et al. Trends in the use of opioids at the end of life and the expected effects on hastening death. J Pain Symptom Manage 2009; 37: 144-55.

Rurup ML, Buiting HM, Pasman HR, et al. The reporting rate of euthanasia and physician-assisted suicide: a study of the trends.Med Care 2008; 46: 1198-202.

Rurup ML, Muller MT, Onwuteaka-Philipsen BD, et al. (2005a)Requests for euthanasia or physician-assisted suicide from older persons who do not have a severe disease: an interview study. Psychol Med 2005; 35: 665-71.

Rurup ML, Onwuteaka-Philipsen BD, Jansen-van der Weide MC, et al. (2005b)When being 'tired of living' plays an important role in a request for euthanasia or physician-assisted suicide: patient characteristics and the physician's decision. Health Policy 2005; 74: 157-66.

Rurup ML, Onwuteaka-Philipsen BD, van der Heide A, et al. (2005c)Physicians' experiences with demented patients with advance euthanasia directives in the Netherlands. J Am Geriatr Soc 2005; 53: 1138-44.

Russell JA, Simmons Z. Hastened death: Physician-assisted suicide and euthanasia in ALS. In Pagnini F et al (eds.) Amyotrophic Lateral Sclerosis - Understanding and Optimizing Quality of Life and Psychological Well-Being. Oxford University Press, 2018.

Ryan CJ, Kaye M. (1996a) Euthanasia in Australia--the Northern Territory Rights of the Terminally Ill Act.N Engl J Med 1996; 334: 326-8.

Ryan CJ. (1996b) Depression, decisions and the desire to die. Med J Aust 1996; 165: 411.

Rys S, Deschepper R, Mortier F, et al. (2014a)Continuous sedation until death with or without the intention to hasten death--a nationwide study in nursing homes in Flanders, Belgium.J Am Med Dir Assoc 2014; 15: 570-5.

Rys S, Mortier F, Deliens L, et al. (2014b)The practice of continuous sedation until death in nursing homes in Flanders, Belgium: a nationwide study. J Am Geriatr Soc 2014; 62: 1869-76.

Saul P. (2015) From ‘Right to Die’ to ‘Right to Choose the Way You Die’ – The Shifting Euthanasia Debate. Available at www.achr.org.au/

Saunders C. A Hospice Perspective, in Foley K, Hendin H (eds.). The Case Against Assisted Suicide. For the Right to End-of-Life Care. Johns Hopkins University Press, 2002.

Savulescu J, Schuklenk U. Doctors Have no Right to Refuse Medical Assistance in Dying, Abortion or Contraception. Bioethics 2017; 31: 162-170.

Schoevers RA, Asmus FP, Van Tilburg W. Physician-assisted suicide in psychiatry: developments in The Netherlands. Psychiatr Serv 1998; 49: 1475-80.

Schuklenk U, Smalling R. Why medical professionals have no moral claim to conscientious objection accommodation in liberal democracies. J Med Ethics 2017; 43: 234-240.

Schwarz JK. Understanding and responding to patients' requests for assistance in dying. Int J Palliat Nurs 2004; 10: 225-35.

Seale C. End-of-life decisions in the UK involving medical practitioners. Palliat Med 2009; 23: 198-204.

Seale C. How the mass media report social statistics: a case study concerning research on end-of-life decisions.Soc Sci Med 2010; 71: 861-8.

Seale C. National survey of end-of-life decisions made by UK medical practitioners. Palliat Med 2006; 20: 3-10.

Seymour J, Rietjens J, Bruinsma S, et al. Using continuous sedation until death for cancer patients: a qualitative interview study of physicians' and nurses' practice in three European countries. Palliat Med 2015; 29: 48-59.

Shah N, Warner J, Blizard B, et al. National survey of UK psychiatrists' attitudes to euthanasia. Lancet 1998; 352: 1360.

Shaw DM. Organ donation after assisted suicide: a potential solution to the organ scarcity problem. Transplantation 2014; 98: 247-51.

Sheahan L. Exploring the interface between 'physician-assisted death' and palliative care: cross-sectional data from Australasian palliative care specialists.Intern Med J 2016; 46: 443-51.

Shen X, Millet L. Suicides in Oregon: Trends and Associated Factors. 2003-2012. Oregon Health Authority, Portland, Oregon. Available at http://public.health.oregon.gov/DiseasesConditions/InjuryFatalityData/Pages/nvdrs.aspx

Siegel AM, Sisti DA, Caplan AL. Pediatric euthanasia in Belgium: disturbing developments. JAMA 2014; 311: 1963-4.

Singer PA, Siegler M. Euthanasia--a critique. N Engl J Med 1990; 322: 1881-3.

Slome LR, Mitchell TF, Charlebois E, et al. Physician-assisted suicide and patients with human immunodeficiency virus disease. N Engl J Med 1997; 336: 417-21.

Smets T, Bilsen J, Cohen J, et al. Reporting of euthanasia in medical practice in Flanders, Belgium: cross sectional analysis of reported and unreported cases. BMJ 2010; 341: c5174.

Smets T, Bilsen J, Cohen J, et al. The medical practice of euthanasia in Belgium and The Netherlands: legal notification, control and evaluation procedures. Health Policy 2009; 90: 181-7.

Smets T, Cohen J, Bilsen J, et al. The labelling and reporting of euthanasia by Belgian physicians: a study of hypothetical cases.Eur J Public Health 2012; 22: 19-26.

Smith KA, Harvath TA, Goy ER, et al. Predictors of pursuit of physician-assisted death.J Pain Symptom Manage 2015; 49: 555-61.

Smith R. A good death. An important aim for health services and for us all. BMJ 2000; 320: 129-30.

Smith WJ. (2004) Now they want to euthanize children. The Weekly Standard, September 13, 2004. Available at http://www.weeklystandard.com/Content/Public/Articles/000/000/004/616jszlg.asp.

Smith WJ. (2013) Euthanasia's Euphemisms. First Things, 2013. Available at www.firstthings.com

Smith WJ. (2018) Belgian euthanasia corruption exposed.National Review, February 19, 2018. Available at https://www.nationalreviewcom/corner/belgian-euthanasia-corruption-exposed/

Snijdewind MC, Willems DL, Deliens L, et al. (2015) A Study of the First Year of the End-of-Life Clinic for Physician-Assisted Dying in the Netherlands. JAMA Intern Med 2015; 175: 1633-40.

Snyder Sulmasy L, Mueller PS; Ethics, Professionalism and Human Rights Committee of the American College of Physicians. Ethics and the Legalization of Physician-Assisted Suicide: An American College of Physicians Position Paper. Ann Intern Med 2017; 167: 576-578.

Somerville MA. Submission to the Special Joint Committee on Physician-Assisted Dying. Parliament of Canada. 4th February, 2016.

Somerville MA. The Canadian euthanasia express rolls on. Mercatornet Nov 9 2018. Available at www.mercatornet.com

Sprung CL, Somerville MA, Radbruch L, et al. Physician-Assisted Suicide and Euthanasia: Emerging Issues From a Global Perspective. J Palliat Care 2018; 33: 197-203.

Stammers T. A Last Act of Grace? Organ Donation and Euthanasia in Belgium, in Jones et al (eds) Euthanasia and Assisted Suicide. Lessons from Belgium. Cambridge University Press, 2017.

Statbel. (Belgian Statistical Office). Available at www.statbel.fgov.be

Statistics Netherlands (CBS). Available at https://www.cbs.nl/en-gb

Steck N, Junker C, Zwahlen M; Swiss National Cohort. Increase in assisted suicide in Switzerland: did the socioeconomic predictors change? Results from the Swiss National Cohort.BMJ Open 2018; 8: e020992.

Sterckx S and Raus K. The Practice of Continuous Sedation at the End of Life in Belgium, in Jones et al (eds) Euthanasia and Assisted Suicide. Lessons from Belgium. Cambridge University Press, 2017.

Sterckx S, Raus K, Mortier F (eds.) Continuous Sedation at the End of Life.Ethical, Clinical and Legal Perspectives. Cambridge University Press, 2016

Stevens KR. Emotional and psychological effects of physician-assisted suicide and euthanasia on participating physicians. Issues Law Med 2006; 21: 187-200.

Stevenson V. Two Montrealers with degenerative diseases challenge medically assisted dying law.CBC News 2017 June14. Available at https://www.cbc.ca/news/canada/montreal/assisted-dying-quebec-canada-legal-challenged-1.4160016

Stockland P. MAiD and modern medicine. Mercatornet Jun 27 2018. Available at www.mercatornet.com

Stutzki R, Weber M, Reiter-Theil S, et al. Attitudes toward hastened death in ALS: a prospective study of patients and family caregivers. Amyotroph Lateral Scler Frontotemporal Degener 2014; 15: 68-76.

Sullivan AD, Hedberg K, Fleming DW. Legalized physician-assisted suicide in Oregon--the second year. N Engl J Med 2000; 342: 598-604.

Sullivan AD, Hedberg K, Hopkins D. Legalized Physician-Assisted Suicide in Oregon 1998-2000. N Engl J Med 2001; 344: 605-6.

Sulmasy DP, Finlay I, Fitzgerald F, et al. Physician-Assisted Suicide: Why Neutrality by Organized Medicine Is Neither Neutral Nor Appropriate.J Gen Intern Med 2018; 2018: 1394-99.

Sulmasy DP. Ethics and the Psychiatric Dimensions of Physician-Assisted Suicide, in Jones et al (eds) Euthanasia and Assisted Suicide. Lessons from Belgium. Cambridge University Press, 2017.

Sulmasy, D et al. Non-faith-based arguments against physician-assisted suicide and euthanasia. The Linacre Quarterly 2016; 83: 246-57. Available at https://journals.sagepub.com/home/lqr

Sumner LW. Assisted Death. A study in Ethics and Law. Oxford University Press, 2011. (Professor Emeritus of Philosophy at the University of Toronto)

Swart SJ, van der Heide A, Brinkkemper T, et al. (2012)Continuous palliative sedation until death: practice after introduction of the Dutch national guideline.BMJ Support Palliat Care 2012; 2: 256-63.

Swart SJ. (2013) The practice of palliative sedation in the Netherlands after the launch of the national guideline. Dissertation, 2013. Available at https://repub.eur.nl/

Sykes N, Thorns A. The use of opioids and sedatives at the end of life. Lancet Oncol 2003; 4: 312-8.

Syme R. A Good Death. An Argument for Voluntary Euthanasia. Melbourne University Press, 2008.

Syme R. Time to Die. Melbourne University Press, 2017.

Taboada P (ed.). Sedation at the End-of-life: An Interdisciplinary Approach. Springer, 2015

Tarzian AJ. Ethical aspects of palliative care, in Matzo M, Sherman DW (eds) Palliative Care Nursing 5e Springer Publishing, 2018.

Ten Have H, Welie J. (2005) Death and Power. An Ethical Analysis of Dutch Euthanasia Practice. Open University Press, 2005.

Thienpont L, Verhofstadt M, Van Loon T, et al. Euthanasia requests, procedures and outcomes for 100 Belgian patients suffering from psychiatric disorders: a retrospective, descriptive study.BMJ Open 2015; 5: e007454.

Thorns A, Sykes N. Opioid use in the last week of life and implications for end-of-life decision-making. Lancet 2000; 356:398-9.

Tieman E, Casey P, O'Boyle C, et al. Relations between desire for early death, depressive symptoms and antidepressant prescribing in terminally ill patients with cancer. J R Soc Med 2002; 95: 386-90.

Trachtenberg AJ, Manns B. Cost analysis of medical assistance in dying in Canada.CMAJ 2017; 189: E101-E105.

Trappenburg M. No regrets, in Youngner SJ, Kimsma GK (eds.). Physician-Assisted Death in Perspective. Assessing the Dutch Experience. Cambridge University Press, 2012.

Trigg R. Conscientious Objection and "Effective Referral". Camb Q Healthc Ethics 2017; 26: 32-43.

Tuffrey-Wijne I, Curfs L, Finlay I, et al. Euthanasia and assisted suicide for people with an intellectual disability and/or autism spectrum disorder: an examination of nine relevant euthanasia cases in the Netherlands (2012-2016).BMC Med Ethics 2018; 19: 17.

Twycross R. Assisted death: a reply. Lancet 1990; 336: 796-8.

Twycross R. Euthanasia: Going Dutch? J R Soc Med 1996; 89: 61-63.

Twycross R. Euthanasia. Lancet 1995; 346: 640.

Twycross R. The Guardian. 6 June 2016.

UNICEF Canada. UNICEF lobbies Canadian Parliament to allow euthanasia for children.

Available at www.lifesitenews.com May 24, 2016.

van Bruchem-van de Scheur GA, van der Arend AJ, Abu-Saad HH, et al. Euthanasia and assisted suicide in Dutch hospitals: the role of nurses. J Clin Nurs 2008; 17:1518-26.

van Delden JJ, Visser JJ, Borst-Eilers E. Thirty Years’experience with Euthanasia in the Netherlands. Focusing on the Patient as a Person, in Quill T, Battin M (eds.) Physician-Assisted Dying. The case for palliative care and patient choice. Johns Hopkins University Press, 2004.

van der Heide A, Deliens L, Faisst K, et al. End-of-life decision-making in six European countries: descriptive study. Lancet 2003; 362: 345-50.

van der Heide A, Onwuteaka-Philipsen BD, Rurup ML, et al. (2007) End-of-life practices in the Netherlands under the Euthanasia Act. N Engl J Med 2007; 356: 1957-63.

van der Heide A, van Delden JJ, Onwuteaka-Philipsen B. (2017) End-of-Life Decisions in the Netherlands over 25 Years.N Engl J Med 2017; 377: 492-494.

van der Heide. (2012) Physician assistance in dying without an explicit request by the patient, in Youngner SJ, Kimsma GK (eds.). Physician-Assisted Death in Perspective. Assessing the Dutch Experience. Cambridge University Press, 2012.

van der Lee ML, van der Bom JG, Swarte NB, et al. Euthanasia and depression: a prospective cohort study among terminally ill cancer patients.J Clin Oncol 2005; 23: 6607-12.

van der Maas PJ, van Delden JJM, Pijnenborg L et al. (1991)Euthanasia and other decisions concerning the end of life. Lancet 1991; 338: 669-74.

van der Maas PJ, van der Wal G, Haverkate I, et al. (1996)Euthanasia, physician-assisted suicide, and other medical practices involving the end of life in the Netherlands, 1990-1995. N Engl J Med 1996; 335: 1699-705.

van der Wal G, van der Maas PJ, Bosma JM, et al. Evaluation of the notification procedure for physician-assisted death in the Netherlands. N Engl J Med 1996; 335: 1706-11.

van Gool S and de Lepeleire. Euthanasia in Children, in Jones et al (eds) Euthanasia and Assisted Suicide. Lessons from Belgium. Cambridge University Press, 2017.

van Thiel GJ, van Delden JJ, de Haan K, et al. Retrospective study of doctors' "end of life decisions" in caring for mentally handicapped people in institutions in The Netherlands. BMJ 1997; 315: 88-91.

van Tol D, Rietjens J, van der Heide A. Judgment of unbearable suffering and willingness to grant a euthanasia request by Dutch general practitioners. Health Policy 2010; 97: 166-72.

van Wijngaarden E, Leget C, Goossensen A. Ready to give up on life: The lived experience of elderly people who feel life is completed and no longer worth living.Soc Sci Med 2015; 138: 257-64.

Vanden Berghe P, et al. Assisted Dying: The Current Situation in Flanders: Euthanasia Embedded in Palliative Care, in Jones et al (eds) Euthanasia and Assisted Suicide. Lessons from Belgium. Cambridge University Press, 2017.

Veldink JH, Wokke JH, van der Wal G, et al. Euthanasia and physician-assisted suicide among patients with amyotrophic lateral sclerosis in the Netherlands. N Engl J Med 2002; 346: 1638-44.

Verkerk M, van Wijlick E, Legemaate J, et al. A national guideline for palliative sedation in the Netherlands. J Pain Symptom Manage 2007; 34: 666-70.

Vincent JL et al. "Piece" of mind: end of life in the intensive care unit statement of the Belgian Society of Intensive Care Medicine J Crit Care 2014;29: 174-5.

Volker DL. Palliative Care and Requests for Assistance in Dying, in Ferrell B et al (eds.) Oxford Textbook of Palliative Nursing. 4e Oxford University Press, 2015.

Waddell C, Clarnette RM, Smith M et al. Treatment decision-making at the end of life : a survey of Australian doctors' attitudes toward patients' wishes and euthanasia. Med J Aust 1996; 165: 540-4.

Wagner B, Keller V, Knaevelsrud C, et al. (2012a)Social acknowledgement as a predictor of post-traumatic stress and complicated grief after witnessing assisted suicide.Int J Soc Psychiatry 2012; 58: 381-5.

Wagner B, Müller J, Maercker A. (2012b)Death by request in Switzerland: posttraumatic stress disorder and complicated grief after witnessing assisted suicide.Eur Psychiatry 2012; 27: 542-6.

Walton, Lord. (1995) Dilemmas of life and death. Parts 1 & 2. J R Soc Med 1995; 88: 311-5 and 372-6.

Warnock M, Macdonald E. Easeful Death. Is there a case for assisted dying? Oxford University Press, 2008. (Former philosopher. Now Life Peer)

Weyers H. (2012) The Legalization of Euthanasia in the Netherlands: Revolutionary Normality, in Younger SJ, Kimsma GK (eds.) Physician-Assisted Death in Perspective. Assessing the Dutch Experience. Cambridge University Press, 2012.

Weyers H. (2014) Physician-Assisted Death in Western Europe: The Legal and Empirical Situation, in Quill T, Miller F (eds.). Palliative Care and Ethics. Oxford University Press, 2014.

White M, Callahan D. Oregon's first year: the medicalization of control. Psychol Public Policy Law 2000; 6: 331-41.

Wilkinson D, Savulescu J. Should we allow organ donation euthanasia? Alternatives for maximizing the number and quality of organs for transplantation.Bioethics 2012; 26: 32-48.

Wilson KG, Chochinov HM, McPherson CJ, et al. Desire for euthanasia or physician-assisted suicide in palliative cancer care. Health Psychol 2007; 26: 314-23.

Wilson KG, Dalgleish TL, Chochinov HM, et al. Mental disorders and the desire for death in patients receiving palliative care for cancer.BMJ Support Palliat Care 2016; 6: 170-7.

Wilson KG, Scott JF, Graham ID,et al. Attitudes of terminally ill patients toward euthanasia and physician-assisted suicide. Arch Intern Med 2000; 160: 2454-60.

Youngner SJ, Kimsma GK (eds.) (2012) Physician-Assisted Death in Perspective. Assessing the Dutch Experience. Cambridge University Press, 2012.

Ypma TD, Hoekstra HL. Assessment of euthanasia request by SCEN physicians [in Dutch]. Ned Tijdschr Geneeskd 2015; 159: A8135.

Ziegler S, Schmid M, Bopp M, et al. Continuous Deep Sedation Until Death-a Swiss Death Certificate Study.J Gen Intern Med 2018; 33: 1053-59.

Zylicz Z, Janssens MJ. Options in palliative care: dealing with those who want to die. Bailliere’s Clinical Anaesthesiology 1998; 12: 121-31.

Zylicz Z. Palliative Care and Euthanasia in the Netherlands: Observations of a Dutch Physician, in Foley K, Hendin H (eds.) The Case Against Assisted Suicide. For the Right to End-of-Life Care. Johns Hopkins University Press, 2002.