CHN News roundup  Netherlands, Scotland, France, - Assisted suicide, euthanasia - end of life issues: Quoting, Inside this report

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"QUOTING"

Euthanasia: going Dutch? Twycross-RG

My experience in 25 years as a hospice doctor have reinforced my belief that when everything is taken into account--physical, psychological, social and spiritual--euthanasia is not the answer. This belief is enhanced by what I see happening in the Netherlands. However, lest it be thought that I have become hardened and indifferent to suffering let me add that, although firmly opposed to euthanasia, I consider that: (i) a doctor who has never been tempted to kill a patient probably has had limited clinical experience or is not able to empathize with those who suffer (ii) a doctor who leaves a patient to suffer intolerably is morally more reprehensible than the doctor who performs euthanasia A doctor has twin obligations to preserve life and to relieve suffering. Preserving life is increasingly meaningless when a terminally ill patient is close to death, and the emphasis on relieving suffering becomes paramount. Even here, however, the doctor is obliged to achieve his objective with minimum risk to the patient's life. This means that treatment to relieve pain and suffering which coincidentally might bring forward the moment of death by a few hours or days is acceptable (the principle of double effect), but administering a drug such as potassium or curare, with the primary intention of causing death, is not.

Twycross-RG
J-R-Soc-Med. 1996 Feb; 89(2): 61-3

Over the past two decades, the Netherlands has moved from assisted suicide to euthanasia, from euthanasia for the terminally ill to euthanasia for the chronically ill, from euthanasia for physical illness to euthanasia for psychological distress and from voluntary euthanasia to nonvoluntary and involuntary euthanasia.

Once the Dutch accepted assisted suicide it was not possible legally or morally to deny more active medical help i.e. euthanasia to those who could not effect their own deaths. Nor could they deny assisted suicide or euthanasia to the chronically ill who have longer to suffer than the terminally ill or to those who have psychological pain not associated with physical disease. To do so would be a form of discrimination. Involuntary euthanasia has been justified as necessitated by the need to make decisions for patients not competent to choose for themselves.

Taken from: Lessons From the Dutch Experience by Herbert Hendin, M.D.

 "The theme of dignity is widely exploited. We are also told that one way to die in dignity is to let oneself be killed by a professional! A special soothing language is used to make it easier for the public to accept euthanasia: documents intended to hasten death are given the name of "living wills," and killing the patients with injections is called "aid in dying."

The acceptation of euthanasia involves a new and different role for medicine, and a new and different vision of the world. The striving of libertarians for expanded rights and unlimited freedom of the individual is producing the opposite: compulsion to die, denial of the right to live, and replacement of the human community we know, by a new Killing Society. Every effort should be applied to prevent this from happening."

Dr. R. Fenigsen. Taken from:" Euthanasia in the Netherlands and What It Means to the U.S." Dr. Richard Fenigsen, a Dutch citizen, is a retired cardiologist. 

 

INSIDE THIS REPORT:

bullet Euthanasia debate in Europe  focuses on children up to 12 years old 
bullet Dutch euthanasia law should apply to patients "suffering through living," report says
bullet Dutch doctors euthanize newborns 
bullet Dutch doctor proud he killed 4 newborns
bullet NETHERLANDS: Dutch doctors call for new approach to reporting "mercy killings"
bullet DUTCH:  doctor violated euthanasia laws
bullet Lessons From the Dutch Experience Herbert Hendin, M.D.  An American psychiatrist who believes in "do no harm"
bullet SCOTLAND: Debate call after euthanasia poll 
bullet FRANCE: considers euthanasia law
bullet FRANCE: France seeking definition of end of life care
bullet Depression and euthanasia  - The Dutch view

 

 

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Euthanasia debate in Europe focuses on children up to 12 years old 



Knight Ridder Newspapers

 Posted on Fri, Oct. 08, 2004 

AMSTERDAM, Netherlands - Four times in recent months, Dutch doctors have pumped lethal doses of drugs into newborns they believe are terminally ill, setting off a new phase in a growing European debate over when, if ever, it's acceptable to hasten death for the critically ill.

Few details of the four newborns' deaths have been made public. Official investigations have found that the doctors made appropriate and professional decisions under an experimental policy allowing child euthanasia that's known as the Groningen University Hospital protocol.

But the children's deaths, and the possibility that the protocol will become standard practice throughout the Netherlands, have sparked heated discussion about whether the idea of assisting adults who seek to die should ever be applied to children and others who are incapable of making, or understanding, such a request.

"Applying euthanasia to children is another step down the slope in this debate," said Henk Jochemsen, the director of Holland's Lindeboom Institute, which studies medical ethics. "Not everybody agrees, obviously, but when we broaden the application from those who actively and repeatedly seek to end their lives to those for whom someone else determines death is a better option, we are treading in dangerous territory."

The Dutch debate is being closely watched throughout the continent. Belgium has laws similar to those in the Netherlands, and a bill permitting child euthanasia is before its Parliament. No date has been set for debate.

Great Britain is considering legalizing assisted suicide for the terminally ill, amid reports that doctors already may be helping thousands of patients to die each year.

"Assisted dying is a fact," said Hazel Biggs, the director of medical law at the University of Kent, who's about to publish a report estimating the number of assisted deaths in Britain at 18,000 annually. "We have to regulate it, to ensure that vulnerable people are being protected."

Under the Groningen protocol, if doctors at the hospital think a child is suffering unbearably from a terminal condition, they have the authority to end the child's life. The protocol is likely to be used primarily for newborns, but it covers any child up to age 12.

The hospital, beyond confirming the protocol in general terms, refused to discuss its details.

"It is for very sad cases," said a hospital spokesman, who declined to be identified. "After years of discussions, we made our own protocol to cover the small number of infants born with such severe disabilities that doctors can see they have extreme pain and no hope for life. Our estimate is that it will not be used but 10 to 15 times a year."

A parent's role is limited under the protocol. While experts and critics familiar with the policy said a parent's wishes to let a child live or die naturally most likely would be considered, they note that the decision must be professional, so rests with doctors.

The protocol was written by hospital doctors and officials, with help from Dutch prosecutors. It's being studied by lawmakers as potential law.

Under the protocol, assisted infant deaths are investigated, but so far all of them have been determined to have been in the patients' best interests.

Euthanasia has been legal in the Netherlands since 1994. Under the law, any critically ill patient older than 12 can request an assisted death, including adults in the early stages of dementia.

The law doesn't allow involuntary euthanasia nor does it apply to children younger than 12, who aren't considered aware enough to make a life-or-death choice.

Dutch doctors have some intentional role in 3.4 percent of all deaths, according to statistics published in the medical journal The Lancet. About 0.6 percent are patients who didn't ask to be euthanized, the journal said.

Dutch courts often treat those cases leniently if an investigation determines that the doctor acted out of concern for the patient's well-being.

Opponents of expanding euthanasia to the young cite a recent Dutch court ruling against punishment for a doctor who injected fatal drugs into an elderly woman after she told him she didn't want to die.

The court determined that he'd made "an error of judgment," but had acted "honorably and according to conscience."

News reports say that since that decision some elderly hospital patients are carrying written appeals not to be euthanized. A German company has proposed a nursing home just across the border from the Netherlands that would be promoted to aging Dutch residents as a safe haven in a country where euthanasia is illegal and likely to remain so.

What happens to vulnerable people is a particularly sharp issue in a continent where birthrates have declined, populations have aged and five nations have more old than young. Euthanasia opponents fear that as costs increase for long-term intensive care and health-care budgets become more strained, financial reasons could creep into euthanasia debates.

"The danger, of course, is ensuring a debate on the right to die does not become one on a duty to die," said Urban Wiesing, the chair for ethics in medicine at Germany's prestigious Eberhard Karls Tuebingen University.

The issue is a particularly delicate one in Germany, where euthanasia was used by the Nazis as cover for wide-scale murders of the disabled, among others. Germany is one of the few countries where there's no serious push to legalize assisted suicide.

European advocates of expanding euthanasia laws say they're acting in the best humanitarian tradition to halt intolerable suffering. Belgian Sens. Jeannine Leduc and Paul Wille noted that motive in their proposed law: "Their suffering is as great, the situation they face is as intolerable and inhumane."

But others worry that after children, who will be next?

"I do accept that there are very difficult cases, very rare cases where a baby is in such pain that death would be the humane option," Dutch ethicist Jochemsen said. "But hard cases make bad laws. As soon as a law is passed, it will expand the number of those who are considered extreme cases."

There's little evidence that permitting euthanasia has had much impact on the number of assisted deaths, argued Rotterdam epidemiologist Agnes van der Heide, who's measured euthanasia in Europe for 10 years.

She said her research indicated that the number of assisted deaths in the Netherlands had increased only slightly in 10 years of legalization. She said the inclusion under the law of such groups as those in the beginning stages of dementia and terminally ill 12- to 16-year-olds accounted for only a few cases nationwide each year, similar to predictions on child euthanasia.

"And the fact remains, euthanasia typically shortens life by one month against life expectancy," she said. "There are no trends showing an increase in that number, or in the estimation that quality of life in these cases is so poor that life should not continue. I know the debate focuses on worst-case scenarios, and abuse. There's no evidence of those things taking place."

bulletSource http://www.realcities.com/mld/krwashington/9872007.htm

BMJ  2005;330:61 (8 January), doi:10.1136/bmj.330.7482.61

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Dutch euthanasia law should apply to patients "suffering through living," report says

Utrecht Tony Sheldon

Doctors can help patients who ask for help to die even though they may not be ill but "suffering through living," concludes a three year inquiry commissioned by the Royal Dutch Medical Association. The report argues that no reason can be given to exclude situations of such suffering from a doctor?s area of competence.

The conclusion has reopened a fierce debate over what constitutes grounds for requesting euthanasia, as it contradicts a landmark Supreme Court decision that a patient must have a "classifiable physical or mental condition." The 2002 ruling upheld a guilty verdict on a GP for helping his 86 year old patient die, even though he was not technically ill but obsessed with his physical decline and hopeless existence (BMJ 2003;326:71).

The Dutch euthanasia law does not specifically state that a patient must have a physical or mental condition, only that a patient must be "suffering hopelessly and unbearably."

The new report does not rule on how doctors should respond if a patient without a classifiable condition should approach them for help but says that doctors believe that some cases of "suffering through living" could be judged "unbearable and hopeless" and therefore fall within the boundaries of the existing euthanasia law.

The report argues that the Supreme Court criteria are unhelpful in defining the limits of medical practice in varied and complex cases. It is "an illusion," it argues, to suggest that a patient?s suffering can be "unambiguously measured according to his illness."

Jos Dijkhuis, the emeritus professor of clinical psychology who led the inquiry, said that it was "evident to us that Dutch doctors would not consider euthanasia from a patient who is simply ?tired of, or through with, life,?" (terms used in the original court case). Instead his committee chose the term "suffering through living," where a patient may present a variety of physical and mental complaints.

He said there was "enormous protest" from doctors to the Supreme Court?s ruling. "In more than half of cases we considered, doctors were not confronted with a classifiable disease. In practice the medical domain of doctors is far broader ? We see a doctor?s task is to reduce suffering, therefore we can?t exclude these cases in advance. We must now look further to see if we can draw a line and if so where."

His report recommends caution, saying that doctors currently lack sufficient expertise and that their roles remain unclear. It recommends drawing up protocols by which to judge "suffering through living" cases and collecting and analysing further data. In the meantime it recommends an "extra phase" to treatment, where therapeutic and social solutions can first be sought.

Henk Jochemsen, director of the anti-euthanasia Lindeboom Institute for Medical Ethics, said that the report has dangerous signs, to the effect that "we as a society should say to people who feel their life has lost meaning: right you had better go away."

The association plans to continue the debate, believing that such cases could become more common. Research shows that 30% of doctors have had patients request euthanasia even though they do not have "a serious physical or psychiatric condition." (Lancet 2003;362:395-9)

Op zoek naar normen voor het handelen van artsen bij vragen om hulp bij levensbe?nding in geval van lijden aan het leven (In Search of Standards for the Treatment by Doctors of Requests for Help in Ending Life Because of Suffering Through Living) is accessible on the website of the Royal Dutch Medical Association, www.knmg.nl
(Note - I visited that site but can't read Dutch!  Cheryl, CHN)
 
Other related articles in BMJ:

News Being "tired of life" is not grounds for euthanasia.

Tony Sheldon
BMJ 2003 326: 71. [Extract] [Full text]  
Read all Rapid Responses Dutch "euthanasia law" applies to physicians, not patients
Mira de Vries
bmj.com, 7 Jan 2005 [Full text]


Editor's note:  This report Dutch doctors euthanize newborns  differs only in the last few paragraphs, cf:Euthanasia debate in Europe focuses on children up to 12 years old

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Dutch doctors euthanize newborns 

Published Tuesday October 12, 2004 

 Netherlands -   Four times in recent months, Dutch doctors have pumped lethal doses of drugs into newborns they believed to be terminally ill, setting off a new phase in a European debate over when, if ever, it's acceptable to hasten death for the critically ill.

Few details of the babies' deaths have been made public. Official investigations have ruled that the doctors made appropriate decisions under an experimental policy allowing child euthanasia.

But the deaths, and the possibility that the policy will become standard throughout the Netherlands, have set off a heated discussion. It is focused on whether the idea of assisting adults who want to die - controversial in itself - should ever be applied to those, like children, who are incapable of making or understanding such a request.

"Applying euthanasia to children is another step down the slope in this debate," said Henk Jochemsen, the director of Holland's Lindeboom Institute, which studies medical ethics. "Not everybody agrees, obviously, but when we broaden the application from those who actively and repeatedly seek to end their lives to those for whom someone else determines death is a better option, we are treading in dangerous territory."

The Dutch debate is being closely watched throughout Europe and abroad. In the United States, assisted suicide is legal only in Oregon. Belgium has laws similar to those in the Netherlands and is considering a bill to permit child euthanasia. Great Britain is considering legalizing assisted suicide for the terminally ill, amid reports that doctors already are helping many patients die each year.

"Assisted dying is a fact," said Hazel Biggs, the director of medical law at the University of Kent, who is publishing a report estimating the assisted deaths in Britain at 18,000 annually. "We have to regulate it, to ensure that vulnerable people are being protected."

Under the experimental Dutch policy, known as the Groningen University Hospital protocol, if doctors at the hospital think a child is suffering unbearably from a terminal condition, they have the authority to end the child's life. The policy is most likely to be used for newborns, but it covers any child up to age 12.

The hospital, beyond confirming the protocol in general terms, refused to discuss its details.

"It is for very sad cases," said a spokesman. "After years of discussions, we made our own protocol to cover the small number of infants born with such severe disabilities that doctors can see they have extreme pain and no hope for life. Our estimate is that it will not be used but 10 to 15 times a year."

A parent's role is limited under the protocol. Experts and critics familiar with the policy said a parent's wishes most likely would be considered but said the decision is designed to be a professional one, and so rests with doctors.

The protocol was written by hospital doctors and officials, with help from Dutch prosecutors. Legislators are studying it with a view toward making it law.

Opponents of expanding euthanasia cite a recent Dutch court ruling against punishment for a doctor who injected fatal drugs into an elderly woman after she told him she didn't want to die. The court determined that he'd made "an error of judgment," but had acted "honorably and according to conscience."

Since that ruling, news reports say, some elderly hospital patients are carrying written appeals not to be euthanized.

"The danger, of course, is ensuring that a debate on the right to die does not become one on a duty to die," said Urban Wiesing, the chairman for ethics in medicine at Germany's Eberhard Karls Tuebingen University.

 

Source: KNIGHT RIDDER NEWSPAPERS AMSTERDAM  http://www.omaha.com/index.php?u_np=0&u_pg=1642&u_sid=1228008

 

 

bulletDutch doctor proud he killed 4 newborns

WorldNet Daily Sat, 25 Dec 2004 10:04 PM PST

Officials from the Dutch Ministry of Justice say the legislature of the Netherlands is preparing a new protocol designed to protect doctors who euthanize newborns with severe disabilities, according to Dr. Eduard Verhagen, the head of pediatrics at Groningen Hospital.

MATTERS OF LIFE AND DEATH

Dutch doctor defiant over killing newborns

Government to approve new protocol protecting physicians who euthanize

Posted: December 26, 2004 1:00 a.m. Eastern 2004 WorldNetDaily.com

 Officials from the Dutch Ministry of Justice say the legislature of the Netherlands is preparing a new protocol designed to protect doctors who euthanize newborns with severe disabilities, according to Dr. Eduard Verhagen, the head of pediatrics at Groningen Hospital.

Verhagen is an outspoken advocate for killing seriously deformed babies, a procedure he admits he's performed four times in the past 16 months.

"There is a small group of children for whom no treatment is possible for the congenital disease and malformations they are born with," Verhagen told the London Telegraph, explaining why he had chosen to break the law. "Asking doctors to take away the pain easily and allow the child to die quietly is the natural reaction.

"For the incurable to die early requires that we do this or they enter a starvation phase and what suffering is more unbearable than a minor left to die from natural causes such as these."

While prosecutors have declined to take action against the doctor, various pro-life groups have condemned him. The Vatican labeled Verhagen and other physicians involved in medical killings of infants as little better than the Nazi medical workers who killed defective newborns to create Hitler's master race.

"This is a Darwinian nightmare and a grave violation of the laws of God," a spokesman for Wim Eijk, the Roman Catholic bishop in Groningen said last week. "It is crossing a boundary thus far prohibited in every code. Euthanasia for children in circumstances where it is not possible to seek or secure the consent of those affected. It is a slippery slope that will give doctors the right to impose life or death, and will lead to an argument that it should be extended to all."

Currently, Dutch doctors who support Dr. Verhagen are regularly reporting "neo-natal" deaths to the national prosecutor's office in the Hague in an attempt to force a prosecution and confrontation over the practice in the courts. The lack of prosecution, thus far, is being used to support their claim that the practice is humane and that it should no longer be done in secret, but openly, with government protection for doctors.

Voluntary euthanasia is already legal in the Netherlands for anyone above the age of 12. Between 4,000 and 5,000 people have been euthanized since 2002.

"It makes you shiver to see babies suffer such enormous pain caused by their deformities, especially when you know that life expectancy is extremely low," says Verhagen. "Right now in all countries doctors are forced to find a solution behind the curtain. We want to shine a spotlight on this, to have clear rules so that no doctor is left facing a murder charge."

In 1997, tacit legal permission to euthanize was granted when the government refused to sentence a doctor found guilty of medically killing an infant. But Verhagen and other doctors want explicit permission and that's why they've been reporting their "crimes" to the authorities.

Verhagen concludes: "We want what is acceptable and unacceptable to be in the open. That it should be brought forward like this fits into the structure of Dutch society and the legal system. We deal with these problems that every country shares."

Cry-for-Life, a pro-life lobbying group promises to resist any change in the law that will remove the threat of prosecution from doctors who kill handicapped infants.

"This is the product of lobbying by doctors who feel they should be free to do what they want to do," says spokesman Bert Dorenbos. "If the condition of handicapped-born babies is really incurable, it should not be necessary to kill them but to treat them humanely until their passing. There will be more children who will die because of these changes."

=====================

SOURCE:  http://www.worldnetdaily.com/news/article.asp?ARTICLE_ID=42109

 

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Netherlands: Dutch doctors call for new approach to reporting "mercy killings"

Utrecht Tony Sheldon

Dutch paediatricians are urging that all decisions taken to hasten the death of babies born with severe multiple handicaps should be reported initially to committees of doctors and lawyers after the child’s death rather than directly to the coroner’s office, as currently required under Dutch law.

The Dutch Paediatric Society believes this approach would be less threatening than the current requirement, and thinks it would encourage the more frequent reporting of cases, thus achieving greater transparency and supervision of what currently remains a largely secretive practice.

Mercy killing of new born babies, along with any patient deemed incompetent to express their wishes, is not covered by Dutch law permitting euthanasia, as a key requirement of the law on euthanasia is a request from the patient.

Research suggests that in about 100 cases each year paediatricians make decisions that result in the death of babies with severe multiple handicaps. Most decisions involve instituting palliative care only, or withholding treatment, but in about 20 of these cases the paediatrician will, after consultation with both parents, choose to end the child’s life with a fatal injection.

Only two or three cases are reported each year to a local coroner, even though the current law requires all such cases to be reported. In 10 years, only two cases have reached the courts.

The Dutch Society of Paediatrics believes that its proposed approach would be less threatening and would encourage reporting of what remains a largely secretive practice. This would provide greater transparency, permitting external supervision.

Louis Kollée, professor of paediatrics at the University Medical Centre Saint Radboud, Nijmegen, chairs the society’s ethics committee and fears that currently all forms of life ending treatment are “invisible.”

Professor Kollée believes that decisions are taken carefully but that they are made by doctors, nurses, and parents: “We think society also has a right to know what is happening. Such societal control can guarantee the quality of decisions.”

The proposal, which embraces withdrawing or withholding treatment and increasing pain relief as well actively ending life, is contained in a letter from the Royal Dutch Medical Association’s chairman, Dr Peter Holland, to the state secretary for health, Clémence Ross.

Dr Holland argues that an “adequate procedure” for judging all “life ending treatment without a request” is lacking. Over the past 15 years the Royal Dutch Medical Association and the Dutch Society of Paediatrics have developed guidelines for careful practice in this area. But without greater transparency the profession cannot ensure they are applied or brought up to date, he says.

The association believes a multidisciplinary committee of doctors, lawyers, and ethicists could achieve this transparency. Professor Kollée says that if all cases went through such a committee, which in turn anonymously published its decisions, it could act as an important point of reference both for doctors and parents. “We don’t want to change the law. The public prosecutor can always have the last word. We just want to screen cases so that doctors stick to the requirements of good medical practice,” he argued.

The government is committed to reviewing its whole policy regarding doctors “ending life without a request” before the end of the year. Research commissioned by the government into its euthanasia policy indicates about 900 such cases year. These include all patients not able to make a request, such as coma patients or elderly people who are terminally ill with hours to live, as well as severely handicapped newborn babies 

Source: BMJ  2004;329:591 (11 September), doi:10.1136/bmj.329.7466.591-a
 (Lancet 2003;263:395-9).

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Dutch doctor violated euthanasia laws

By Karen Birchard

THE HAGUE – The Dutch supreme court has upheld the country's strict guidelines governing euthanasia.

In a case that was closely followed by the medical community and euthanasia advocates, the court ruled that Dr. Philip Sutorius, who helped a relatively healthy elderly man who was "tired of living" to die, breached the euthanasia law that covers terminally ill patients.

The court said the doctor was guilty of assisted suicide, which had been the verdict of a lower court in a test case. Dr. Sutorius had appealed that verdict, despite the fact he had received no punishment because the lower court felt the transgression was minor and he had acted out of compassion.

But the supreme court said there is a common sense line between doctors treating sickness and suffering, and doctors acting where there is no sickness.

The case began in 1998 when Dr. Sutorius gave 86-year-old former Dutch senate member Edward Brongersma a lethal cocktail of drugs, which the patient administered to himself. Brongersma, who had incontinence and dizziness that affected his mobility, had said he did not want to go on living.

However, to qualify for euthanasia under the law, patients must face interminable and unbearable pain with no hope of recovery, and the doctor must obtain a second, concurring medical opinion. Each case is then reviewed by a commission comprised of at least one lawyer, one doctor and one expert on medical ethics.

The Dutch medical federation said the decision had not clarified the issue of psychological suffering, which has been the subject of much debate within the profession. It said the public has also been asking questions about how doctors should handle requests for euthanasia from patients who are tired of life.

"In practice, this is a grey area and in many cases it is not clear into which category a euthanasia request should be classified," the Dutch medical federation said in a statement.

In contrast, Belgium allows psychological suffering as a reason for a patient to seek euthanasia.

Source: http://www.medicalpost.com/mpcontent/article.jsp?content=20030203_150640_2616

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Lessons From the Dutch Experience Herbert Hendin, M.D. 

Summary for Congressional Subcommittee on the Constitution
Suicide, Assisted Suicide and Euthanasia:
Lessons From the Dutch Experience
Herbert Hendin, M.D.

Does our need to care for people who are terminally ill and to reduce their suffering require us to give physicians the right to end patients' lives?

Asking this question helps make us aware that neither legalizing nor forbidding physician-assisted suicide or euthanasia addresses the much larger problem of providing humane care for those who are terminally ill. To some degree the call for legalization is a symptom of our failure to develop a better response to the problems of dying and the fear of unbearable pain or artificial prolongation of life in intolerable circumstances.

The uninitiated are apt to assume that the seriously or terminally ill who wish to end their lives are different than those who are otherwise suicidal. The first reaction of many patients to the knowledge of serious illness and possible death, however, is terror, depression, and a wish to die. Such patients are not significantly different than patients who react to other crises in their lives with the desire to end the crisis by ending their lives.

Many patients and physicians displace anxieties about death onto the circumstances of dying: pain, dependence, loss of dignity, and the unpleasant side effects of medical treatments. Focusing on or becoming enraged at the process distracts from the fear of death itself.

Suicidal patients are also prone to make conditions on life: I won't live ..."without my husband,"..."if I lose my looks, power, prestige or health," or "if I am going to die soon." They are afflicted by the need to make demands on life that cannot be fulfilled. Determining the time, place, and circumstances of their death is the most dramatic expression of their need for control.

Depression, often precipitated by discovering a serious illness, exaggerates the tendency toward seeing problems in black-or-white terms. When a patient finds a doctor who shares the view that life is only worth living if certain conditions are met, the patient's rigidity is reinforced.

Patients are not alone in their inability to tolerate situations they cannot control. From the physician's viewpoint, Lewis Thomas has written insightfully about the sense of failure and helplessness that doctors may experience in the face of death; such feelings might explain why doctors have such difficulty discussing terminal illness with patients. A majority of doctors avoid such discussions, while most patients would prefer frank talk. These feelings might also explain both doctors' tendency to use excessive measures to maintain life and their need to make death a physician's decision. By deciding when patients die, by making death a medical decision, the physician preserves the illusion of mastery over the disease and the accompanying feelings of helplessness. The physician, not the illness, is responsible for the death. Assisting suicide and providing euthanasia become ways of dealing with the frustration of being unable to cure the disease.

The request for assisted suicide is also usually made with as much ambivalence as are most suicide attempts. If the doctor does not recognize that ambivalence as well as the anxiety and depression that underlie the patient's request for death, the patient may become trapped by that request and die in a state of unrecognized terror.

A few years ago, a young professional in his early thirties who had acute myelocytic leukemia was referred to me for consultation. With medical treatment, Tim was given a 25 percent chance of survival; without it, he was told, he would die in a few months.

Tim, an ambitious executive whose focus on career success had led him to neglect his relationships with his wife and family, was stunned. His immediate reaction was a desperate, angry preoccupation with suicide and a request for support in carrying it out. He was worried about becoming dependent and feared both the symptoms of his disease and the side effects of treatment.

Tim's anxieties about the painful circumstances that would surround his death were not irrational, but all his fears about dying amplified them. Once Tim and I could talk about the possibility or likelihood of his dying--what separation from his family and the destruction of his body meant to him--his desperation subsided. He accepted medical treatment and used the remaining months of his life to become closer to his wife and parents. Two days before he died, Tim talked about what he would have missed without the opportunity for a loving parting.

If assisted suicide were legal, as an Oregon law now being contested in the courts would make it, Tim probably would have asked a doctor's help in taking his own life. Because he was mentally competent, he would have qualified for assisted suicide and would surely have found a doctor who would have agreed to his request.

I have just completed a study of assisted suicide and euthanasia in the Netherlands where both are accepted practice. Early in my work, in a film, Appointment with Death, intended to promote euthanasia that I was shown by the Dutch Voluntary Euthanasia Society, I was reminded of Tim by seeing an example of how a physician's failure to deal with a patient's fear of death led to a premature ending of the patient's life.

A forty-two year old man was diagnosed as HIV positive. He had no physical symptoms, but had seen others suffer with them and wanted his physician's assistance in dying. The doctor compassionately explained to him that he might live for some years symptom-free.

Over time the patient repeated his request for euthanasia and eventually his doctor acceded to it. The man was clearly depressed and overwhelmed by the news of his situation. The doctor kept establishing that the patient was persistent in his request and competent to make the decision - criteria a Dutch patient must meet - but did not address the terror that underlay it.

Consultation in the case was pro forma. A colleague of the doctor's saw the patient briefly to confirm his wishes. In many cases the consultant does not see the patient at all. With a psychologically sensitive physicians looking for more than justification to respond to the request to die, more likely in a culture not so accepting of euthanasia, this man would not have needed to be put to death.

In the cases presented to me by physicians in the Netherlands, and in cases I have reviewed in this country, I saw such examples many times over. Patients whose fear of death precipitates them into seeking assisted suicide or euthanasia may be quite different than those who are concerned that they may suffer unduly in the last days of their lives.

Whenever, as in the Netherlands, or in the recent Oregon law now under challenge in the courts, there is legal sanction for assisted suicide for patients who are not in the last weeks of their lives, the two groups of patients become hopelessly confused. In such a situation basically suicidal patients become the willing victims of euthanasia practitioners.

In the past decade by making assisted suicide and euthanasia easily available, the Dutch have significantly reduced the suicide rate of those over fifty in the population. The likelihood that patients would end their own lives if euthanasia was not available to them was one of the justifications given by Dutch doctors for providing such help.

Of course, euthanasia advocates can maintain that making suicide "unnecessary" for those over fifty who are physically ill is a benefit of legalization rather than a sign of abuse. Such an attitude depends, of course, on whether one believes that there are alternatives to assisted suicide or euthanasia for dealing with the problems of older people who become ill. Among an older population physical illness of all types is common, and many who have trouble coping with physical illness became suicidal. In a culture accepting of euthanasia their distress may be accepted as a legitimate reason for euthanasia. It may be more than ironic to describe euthanasia as the Dutch cure for suicide.

That seems even more true since the Dutch have recently accepted mental suffering without physical illness as justification for assisted suicide and euthanasia. How this acceptance translates into practice with a psychiatric patient is evident in a case that has received a good deal of international attention since it was the case that formally established in the Netherlands that mental suffering was sufficient justification for assisted suicide.

In the spring of 1993 a Dutch court in Assen ruled that a psychiatrist was justified in assisting in the suicide of his patient, a physically healthy but grief-stricken 50-year-old social worker who was mourning the death of her son and who came to the psychiatrist saying she wanted death, not treatment. I had a chance to spend about seven hours interviewing the psychiatrist involved. Without going into the details of the case which I have discussed elsewhere, it is worth noting that the psychiatrist assisted in the patient's suicide a little over two months after she came to see him, about four months after her younger son died of cancer at 20. Discussion of the case centered around whether the psychiatrist, supported by experts, was right in his contention that the woman suffered from an understandable and untreatable grief. Although no one should underestimate the grief of a mother who has lost a beloved child, life offers ways to cope with such grief and time alone was likely to have altered her mood.

The Dutch Supreme Court which ruled on the Assen Case in June 1994 agreed with the lower courts in affirming that mental suffering can be grounds for euthanasia, but felt that in the absence of physical illness a psychiatric consultant should have actually seen the patient. Since it felt that in all other regards the psychiatrist had behaved responsibly it imposed no punishment. Since the consultation can easily be obtained from a sympathetic colleague, it offers the patient little protection. The case was seen as a triumph by euthanasia advocates since it legally established mental suffering as a basis for euthanasia.

Over the past two decades, the Netherlands has moved from assisted suicide to euthanasia, from euthanasia for the terminally ill to euthanasia for the chronically ill, from euthanasia for physical illness to euthanasia for psychological distress and from voluntary euthanasia to nonvoluntary and involuntary euthanasia.

Once the Dutch accepted assisted suicide it was not possible legally or morally to deny more active medical help i.e. euthanasia to those who could not effect their own deaths. Nor could they deny assisted suicide or euthanasia to the chronically ill who have longer to suffer than the terminally ill or to those who have psychological pain not associated with physical disease. To do so would be a form of discrimination. Involuntary euthanasia has been justified as necessitated by the need to make decisions for patients not competent to choose for themselves.

That it is often the doctor and not the patient who determines the choice for death was underlined by the documentation of "involuntary euthanasia" in the Remmelink report - the Dutch government's commissioned study of the problem. "Involuntary euthanasia" is a term that is disturbing to the Dutch. The Dutch define euthanasia as the ending of the life of one person by another at the first person's request. If life is ended without request they do not consider it to be euthanasia. The Remmelink report uses the equally troubling expression "termination of the patient without explicit request" to refer to euthanasia performed without consent on competent, partially competent, and incompetent patients.

The report revealed that in over 1,000 cases, of the 130,000 deaths in the Netherlands each year, physicians admitted they actively caused or hastened death without any request from the patient. In about 25,000 cases, medical decisions were made at the end of life that might or were intended to end the life of the patient without consulting the patient. In nearly 20,000 of these cases (about 80 percent) physicians gave the patient's impaired ability to communicate as their justification for not seeking consent.

This left about 5,000 cases in which physicians made decisions that might or were intended to end the lives of competent patients without consulting them. In 13 percent of these cases, physicians who did not communicate with competent patients concerning decisions that might or were intended to end their lives gave as a reason for not doing so that they had previously had some discussion of the subject with the patient. Yet it seems incomprehensible that a physician would terminate the life of a competent patient on the basis of some prior discussion without checking if the patient still felt the same way.

A number of Dutch euthanasia advocates have admitted that practicing euthanasia with legal sanction has encouraged doctors to feel that they can make life or death decisions without consulting patients. Many advocates privately defend the need for doctors to end the lives of competent patients without discussion with them. An attorney who represents the Dutch Voluntary Euthanasia Society gave me as an example a case in which a doctor had terminated the life of a nun a few days before she would have died because she was in excruciating pain but her religious convictions did not permit her to ask for death. He did not argue when I asked why she should not have been permitted to die in the way she wanted.

Even when the patient requests or consents to euthanasia, in cases presented to me in the Netherlands and cases I have reviewed in this country, assisted suicide and euthanasia were usually the result of an interaction in which the needs and character of family, friends, and doctor play as big and often bigger role than those of the patient.

In a study of euthanasia done in Dutch hospitals, doctors and nurses reported that more requests for euthanasia came from families than from patients themselves. The investigator concluded that the families, the doctors, and the nurses were involved in pressuring patients to request euthanasia.

A Dutch medical journal noted an example of a wife who no longer wished to care for her sick husband; she 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. The doctor, although aware of the coercion, ended the man's life.

The Remmelink report revealed that more than half of Dutch physicians considered it appropriate to introduce the subject of euthanasia to their patients. Virtually all the medical advocates of euthanasia that I spoke to in the Netherlands saw this as enabling the patient to consider an option that he or she may have felt inhibited about bringing up, rather than a form of coercion. They seemed not to recognize that the doctor was also telling the patient that his or her life was not worth living, a message that would have a powerful effect on the patient's outlook and decision.

The Dutch experience illustrates how social sanction promotes a culture that transforms suicide into assisted suicide and euthanasia and encourages patients and doctors to see assisted suicide and euthanasia--intended as an unfortunate necessity in exceptional cases--as almost a routine way of dealing with serious or terminal illness.

Pressure for improved palliative care appears to have evaporated in the Netherlands. Discussion of care for the terminally ill is dominated by how and when to extend assisted suicide and euthanasia to increasing groups of patients. Given the inequities in our own health care system and the inadequacies of our care of those who are terminally ill, palliative care would be an even more likely casualty of euthanasia in this country. Euthanasia will become a way for all of us to ignore the genuine needs of terminally ill people.

The public has the illusion that legalizing assisted suicide and euthanasia will give them greater autonomy. If the Dutch experience teaches us anything it is that the reverse is true. In practice it is still the doctor who decides whether to perform euthanasia. He can suggest it, not give patients obvious alternatives, ignore patients' ambivalence, and even put to death patients who have not requested it. Euthanasia enhances the power and control of doctors, not patients.

People assume that the doctor encouraging or supporting assisted suicide is making as objective a judgment as a radiologist reading an x-ray. The decisive role of the physician's needs and values in the decision for euthanasia are not apparent to them.

Virtually every guideline set up by the Dutch to regulate euthanasia has been modified or violated with impunity. Despite their best efforts, the Dutch have been able to get only 60 percent of their doctors to report their euthanasia cases (and there is reason from the Remmelink Report to question whether all of them are reporting truthfully). Since following the legal guidelines would free from the risk of prosecution the 40 percent of Dutch doctors who admit to not reporting their cases and the 20 percent who say that under no circumstances will they do so, it is a reasonable assumption that these doctors are not following the guidelines. The cases presented to me and to Dr. Carlos Gomez bear this out. Dr. Gomez and I went to the Netherlands at different times and with totally different perspectives, since he is a palliative care specialist and I am a psychiatrist. Yet after hearing detailed cases of euthanasia presented by Dutch physicians, we independently came to the same conclusion: that it is not possible to sanction and regulate euthanasia within any prescribed guidelines.

A supervisory system intended to protect patients would require an ombudsman to look at the overall situation including the family, the patient, the doctor, and, above all, the interaction among them prior to the performance of assisted suicide or euthanasia. This would involve an intrusion into the relationship between patient and doctor that most patients would not want and most doctors would not accept.

Without such intrusion before the fact, there is no law or set of guidelines that can protect patients. After euthanasia has been performed, since only the patient and the doctor may know the actual facts of the case, and since only the doctor is alive to relate them, any medical, legal, or interdisciplinary review committee will, as in the Netherlands, only know what the doctor chooses to tell them. Legal sanction creates a permissive atmosphere that seems to foster not taking the guidelines too seriously. The notion that those American doctors-- who are admittedly breaking some serious laws in now assisting in a suicide--would follow guidelines if assisted suicide were legalized is not borne out by the Dutch experience; nor is it likely given the failure of American practitioners of assisted suicide to follow elementary safeguards in cases they have published.

Patients who request euthanasia are usually asking in the strongest way they know for mental and physical relief from suffering. When that request is made to a caring, sensitive, and knowledgeable physician who can address their fear, relieve their suffering, and assure them that he or she will remain with them to the end, most patients no longer want to die and are grateful for the time remaining to them.

Advances in our knowledge of palliative care in the past twenty years make clear that humane care for the terminally ill does not require us to legalize assisted suicide and euthanasia. Study has shown that the more physicians know about palliative care the less apt they are to favor legalizing assisted suicide and euthanasia. Our challenge is to bring that knowledge and that care to all patients who are terminally ill.

Our success in meeting the challenge of providing palliative care for those who are terminally ill will do much to preserve our social humanity. If we do not provide such care, legalization of assisted suicide and euthanasia will become the simplistic answer to the problems of dying. If legalization prevails, we will lose more lives to suicide (although we will call the deaths by a different name) than can be saved by the efforts of the American Suicide Foundation and those of all the other institutions working to prevent suicide in this country.

The tragedy that will befall depressed suicidal patients will be matched by what will happen to terminally ill people, particularly older poor people. Assisted suicide and euthanasia will become routine ways of dealing with serious and terminal illness just as they have in the Netherlands; those without means will be under particular pressure to accept the euthanasia option. In the process, palliative care will be undercut for everyone.

Euthanasia advocates have come to see suicide as a cure for disease and a way of appropriating death's power over the human capacity for control. They have detoured what could be a constructive effort to manage the final phase of life in more varied and individualistic ways. Our social policy must be based on a larger and more positive concern for people who are terminally ill. It must reflect an expansive determination to relieve their physical pain, to discover the nature of their fears, and to diminish suffering by providing meaningful reassurance of the life that has been lived and is still going on.

References

1. H. Hendin, and G. Klerman, "Physician-Assisted Suicide: The Dangers of Legalization," American Journal of Psychiatry, 1993

2. H. Hendin, Suicide in America, New York: W. W. Norton, 1995.

3. Ibid.

4. L. Thomas, "Dying as Failure?," American Political Science Review, 1984,444:1-4.

5. D. Hendin, Death as a Fact of Life, New York: W.W. Norton, 1973, citing H. Feifel "Physicians Consider Death," unpublished manuscript presented at 1967 meeting of the American Psychological Association.

6. H. Hendin, "Selling Death and Dignity," Hastings Center Report,

7. An Appointment with Death, K.A. Productions, 1993.

8. H. Hendin, "Assisted Suicide, Euthanasia and Suicide Prevention: The Implications of the Dutch Experience," Suicide and Life-Threatening Behavior, 1995; 25:193-203.

9. H. Hendin, "Seduced by Death: Doctors, Patients and the Dutch Cure," Issues in Law and Medicine, 1994; 10:123-168.

10. P.J. van Der Maas, W. van Delden, and L. Pijnenborg, Euthanasia and Other Medical Decisions Concerning the End of Life, New York: Elsevier, 1992.

11. H.W. Hilhorst, Euthanasie in het Ziekenhuis [Euthanasia in the Hospital,] Lochem: De Tijdstroom, 1983.

12. H. Ten Have and G. Kimsma, Geneeskunde: Tussen Droom en Drama [Medical Science: Between Dream and Drama,] Kampen: R.O.K. Agora, 1985, pp. 83-84.

13. C. Gomez, Regulating Death: Euthanasia and the Case of the Netherlands, New York: The Free Press, 1991.

14. R.K. Portenoy, N. Coyle, K.M. Kash, F. Brescia, C. Scanlon, D. O'Hare, R.I. Misbin, J. Holland, K.M. Foley, "Determinants of the Willingness to Endorse Assisted Suicide: A Survey of Physicians, Nurses and Social Workers," unpublished manuscript, 1995.

15. H. Hendin, Seduced by Death:Doctors, Patients, and the Dutch Cure, New York, W. W. Norton, 1996 (October).

bulletSource http://www.house.gov/judiciary/2169.htm

 
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  Scotland: Debate call after euthanasia poll 

A poll has suggested that four out of 10 people in Scotland would break the existing law to help loved ones die.

The Voluntary Euthanasia Society, which carried out the UK-wide interview of 790 adults, said the Scottish Executive should sponsor a debate on the subject.

But the long-held view of ministers has been that relaxing the law would weaken the protection to society.

Westminster is looking at a Euthanasia Bill, but it would not apply in Scotland as it is a devolved matter.

Dr Richard Simpson, a former Scottish minister, said it was time for a reasoned debate.

He said that the Adults with Incapacity Act (Scotland) 2000, which was one of the first pieces of legislation passed by the Scottish Parliament, promoted a very strong debate on euthanasia.

"There hasn't been a debate for the last four years because the issue was resolved and the wishes of parliament were made clear, but it is time for another debate," said Dr Simpson.

POLL - SCOTLAND BREAKDOWN 

He pointed out that the current legislation provided terminally ill patients with a right to make "living wills".

That comprises a set of rules about what a practitioner can or cannot administer.

A Scottish Executive spokesperson said that ministers had no plans to change the present law.

She added: "Our policy has been and remains that, while it is right that terminally ill patients should receive the best palliative care available, the deliberate taking of life cannot be condoned and should remain illegal."

Sheila McLean, who is professor of medical ethics at Glasgow University, said everyone had an entitlement to expect a level of "certainty, cogency and clarity" about the law on euthanasia.

But she felt that was not being given at a Scotland or a UK-wide level.

'End it all'

Ms McLean said: "We have many situations in which people can choose death with medical assistance, but the one group of people to whom that is not available are those who competently and contemporaneously ask for assistance and I think that is very inconsistent.

"I did a survey in 1996 in which we found that the majority of doctors - we interviewed 1,000 doctors and pharmacists - were actually prepared, in fact enthusiastic, about assisted suicide and euthanasia, and most opinion polls of doctors suggest doctors and nurses are interested at least in the debate coming forward again."

Dr Simpson believed the opinion of doctors was shifting.

"Those of my generation may not be in favour. But I think living wills and the advancement in palliative care and the dealing with suffering in the terminal stages goes a long way to dealing with the problem.

"However, we are left with a small group of people with generative diseases where life and the quality of life is so poor that they wish to end it."

The House of Lords Select Committee is taking evidence on Lord Joffe's Assisted Dying for the Terminally Ill Bill.

It proposes a lifting of the UK ban to "enable a competent adult who is suffering unbearably as a result of a terminal illness to receive medical assistance to die at his own considered and persistent request".

But the Westminster debate will not have a bearing on what happens in Scotland and that is why Jeremy Purvis MSP is proposing a member's bill on the matter.

The Liberal Democrat member for Tweeddale, Ettrick & Lauderdale said there was considerable public support for a change in the law.

Julia Millington, the political director of the ProLife Party, said the survey should not be interpreted as representing public opinion.

She said: "They have surveyed not 1% or even half a percent but 0.00066% of the population.

"However, the issues at stake here are extremely serious.

"What we haven't been shown are the many patients who are benefiting from first rate palliative care and who completely reject the idea of euthanasia."

Source: http://news.bbc.co.uk/2/hi/uk_news/scotland/3640438.stm

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France considers euthanasia law

By Karen Birchard 

PARIS – The French parliament will start debating a new law on  euthanasia before the end of the year, according to the government. The decision comes in the wake of a landmark cross-party parliamentary report on the rights of terminally ill patients.

Health Minister Philippe Douste-Blazy said such patients should have "the right to die in dignity" but the government's bill will not allow active euthanasia by doctors, as is the case in The Netherlands and Belgium.

He admitted that palliative care in France is almost non-existent and the new approach will see palliative care become a part of the health system.

The draft legislation is being welcomed by doctors' organizations. It would change the code of medical ethics in France and regulations in the public health code to allow life-support machines to be switched off. Currently, this action could result in a murder charge.

France has been involved in a public debate over the right of terminally ill people to decide their fate for the past 18 months, following the death of a young firefighter. Vincent Humbert, who had been injured in an accident, was completely paralysed, deaf and blind. He asked for a court to order that his life support be turned off and then later wrote an open letter to President Chirac.

His mother and doctor are now under police investigation for removing his life support.

Source: http://www.medicalpost.com/mpcontent/article.jsp?content=20040926_182338_4824

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FRANCE SEEKING DEFINITION OF END OF LIFE CARE

PARIS (AFP) - French Health Minister Philippe Douste-Blazy reopened the thorny debate on euthanasia by calling for a law that would ensure the "right to die in dignity", but ruled out the legalization of mercy killing.


In an interview published in Le Figaro newspaper, Douste-Blazy said the lower-house National Assembly would examine a draft law before year's end on "end-of-life" care that would define the legal options for the terminally ill.

"The law must allow doctors to offer a cancer patient, when it is certain that his condition cannot be reversed, the choice between one more chemotherapy treatment or palliative care and the morphine drip," the minister said.

"In the world of medicine, there is a moment when the truth becomes obvious, when we know that the patient only has a few days left," added Douste-Blazy, a cardiologist by training.

"I am going to ask the prime minister (Jean-Pierre Raffarin) to launch a sweeping nationwide debate, under conditions that have not yet been defined, on end-of-life care, so that everyone can express themselves," he said.

The debate in France over euthanasia came to the forefront in September 2003 following the death of Vincent Humbert, a 22-year-old fireman who was left blind, mute and paralyzed after a road accident in 2000.

His mother Marie, who with her son had campaigned in vain for his right to die, administered an overdose of sedatives to her son, who lapsed into a coma. His doctors switched off his life support system two days later.

A special parliamentary commission formed in the wake of the Humbert case to analyze the complex issue in June recommended that the law on "end-of-life" care be clarified, but did not go so far as to condone mercy killing.

Euthanasia or physician-assisted suicide is legal in the Netherlands and in Belgium. In Switzerland, a doctor can offer passive assistance to a terminally ill person by prescribing a fatal dose of a drug, but actively helping someone to die, as by giving a fatal injection, is illegal.

Euthanasia remains illegal in several European countries like Britain, France and Italy.

Douste-Blazy told Le Figaro that it was "necessary to show that euthanasia should be avoided. We must draw an inviolable line between those for whom there is no longer any hope and those for whom we know there is still hope."

The minister said it was time to "put an end to the hypocrisy going on right now, which is unacceptable," noting that 150,000 life-support machines a year are unplugged on doctors' orders outside the confines of any formal framework.

"We must clarify the law," he told Le Figaro, recommending that the medical code of ethics and public health regulations be altered with respect to end-of-life care, so as to protect doctors from prosecution.

"The law will establish the right to die in dignity. Respect for life is respect for death," Douste-Blazy said.

Former Socialist health minister Bernard Kouchner, who himself did not touch the complex moral and legal issue of euthanasia, hailed Douste-Blazy's comments, saying France "needed to move forward" on the question.

Source: http://news.yahoo.com/news?tmpl=story&u=/afp/20040827/hl_afp/france_euthanasia_040827163630

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Depression and euthanasia  The Dutch view:

Depression we are told, is treatable and curable.  Believe it or not but Dutch physicians are now able to legally assist the suicide of patients who are diagnosed as having depression.  Many other disturbing reports have come from the Netherlands regarding the practice of euthanasia.  Aside from articles posted here and elsewhere, medical journals are some of the best sources of information -   Here follow just a few articles, titles and source only - for your additional personal research:

End of life decisions in mentally disabled people [editorial]
van-der-Maas-P
BMJ. 1997 Jul 12; 315(7100): 73

Dutch euthanasia rules relaxed
Sheldon-T
BMJ. 1997 Feb 1; 314(7077): 325

Mental suffering as justification for euthanasia in the Netherlands
Spanjer-M
Lancet 1994; 343:1630


[The Remmelink report is not the only source. Cryptothanasia in the Netherlands--sufficiently documented]
Bischofberger-E
Lakartidningen. 1993 May 19; 90(20): 1924-5

Life-prolonging and life-terminating treatment of severely handicapped newborn babies: a discussion of the Report of the Royal Dutch Society of Medicine on "Life-Terminating Actions with Incompetent Patients: Part I: Severely Handicapped Newborns".
Jochemsen-H
Issues-Law-Med. 1992 Fall; 8(2): 167-81

[Life-terminating activities without express request by the patient and the viewpoint of the cabinet in relation to medical decisions concerning life's end]
van-Delden-JJ
Ned-Tijdschr-Geneeskd. 1992 Mar 28; 136(13): 644-8

 

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