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When Morphine Fails to Kill By GINA KOLATA

Death Due to Withdrawal from Narcotics


How The Courts Allowed Euthanasia

Physician-Assisted Suicide: What's Legal and What's Professional?

Suicide statistics (USA)

U.S. advocates of assisted suicide will find no help from the Netherlands

Palliative care

Must assisted suicide be only doctor assisted?



Dutch voting today to permit euthanasia  First country to do so: Critics point out child could be killed if parents agree

Dutch senators pass mercy-killing bill A long-standing practice



CEREBRAL PALSY:  Continuous fetal heart rate monitoring . . . does not lead to the reduction in the incidence of cerebral palsy



Death Due to Withdrawal from Narcotics

"There is a widespread impression among both the general public and physicians that withdrawal from narcotics is extremely hazardous and that death is a not infrequent consequence. Inasmuch as our clinical impressions and research experience pertaining to opiate withdrawal did not coincide with this general opinion, we decided to undertake a critical review of the question of death occurring as a consequence of withdrawal. The present chapter reports the findings of this study."    

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British Ignite Debate in U.S. on Drugs and Suicide

New York Times, December 16, 2003

Many American psychiatrists were taken by surprise last week when British drug regulators told doctors to stop writing prescriptions for all but one of a newer generation of antidepressant drugs to treat depressed children under 18.

Now the psychiatrists are trying to figure out how to advise the parents of the young patients who come to them for help. Some parents, the doctors say, are calling to ask if the drugs their children are taking are really safe.

"The news has certainly generated anxiety, concern and questions," said Dr. Flemming Graae, the chief of child and adolescent psychiatry at Westchester Medical Center in Valhalla, N.Y.

For parents and psychiatrists alike, the issue is not an easy one to sort out.

The British regulators said that for adults, the benefits of the antidepressants, most belonging to the class called selective serotonin reuptake inhibitors or S.S.R.I.'s, clearly outweigh their risks.

But after reviewing 11 studies of the drugs in treating depressed children and adolescents, the regulators concluded that for most of the medications, the potential for harmful side effects including suicidal thoughts and behavior, as well as hostility was greater than the evidence for their effectiveness. Doctors should not prescribe the medications except in certain circumstances, the regulators said.

The drugs included Paxil, from GlaxoSmithKline; Zoloft, from Pfizer; Effexor, from Wyeth; Celexa and Lexapro, from Forest Laboratories Inc.; and Luvox, from Solvay. Prozac, by Eli Lilly, was exempted from the advisory. (Effexor is a serotonin-norepinephrine inhibitor.)

Few psychiatrists dispute that little is known about how well the drugs work and how they affect the developing brain: the number of large-scale studies of S.S.R.I.'s in children is small, many of the findings are less than impressive, and some drugs have yet to be tested.

And some mental health professionals believe that, given the limited knowledge, antidepressants are being prescribed too widely and too casually by doctors, many of them general practitioners rather than psychiatrists.

But medical experts have sharply divergent opinions on whether governments should intervene in the way that Britain did.

Dr. Richard Harrington, a professor of child and adolescent psychiatry at the University of Manchester in England, said he thought that, on balance, the British regulators did the right thing.

"The broad story seems to be that the drugs don't work and they have some side effects," Dr. Harrington said. "If we're going to practice evidence-based medicine and if the basic evidence is negative, then why prescribe them?"

But some American psychiatrists say the British regulators acted hastily and went too far.

"Everybody scientists, parents and advocates needs an answer to this question," said Dr. John March, the chief of child and adolescent psychiatry at Duke University Medical Center. But the British regulators, he said, "prematurely closed the story."

Dr. March and other experts argue that the cost of leaving depressed children and teenagers untreated is high: depression itself can be a lethal illness. And some psychiatrists say that they have seen "indisputable proof" in their practices that the drugs help seriously ill children.

Most of the experts said they would continue to use S.S.R.I.'s to treat children and teenagers. But they added that doctors and parents should closely monitor children for signs of restlessness, agitation, recklessness, unusual behavior or thoughts of suicide, especially during the first weeks of drug treatment and after any increase in dosage. Some anecdotal evidence suggests that suicidal or aggressive behavior, if it is tied to the drugs, occurs within the first weeks after the drug treatment is started.

Dr. Graae and others say they start children on very low doses of the medications and that in some cases a low dose is all that is needed.

Most American experts do not rule out the possibility that in some young people, the antidepressants may somehow increase the risk of suicidal thinking or self-harm, though they believe a link remains unproved.

But even if an association were shown, some say, they would favor stronger warning labels rather than a recommendation that the drugs not be used.

Some researchers said they believed that the Food and Drug Administration, which is conducting its own intensive review of the drugs and will hold public hearings on Feb. 2, has taken a more careful and comprehensive approach to investigating the medications' safety.

Dr. March and other experts said the committee that reviewed the studies for the British Medicines and Healthcare Products Regulatory Agency, the British equivalent of the F.D.A., failed to adequately take into account the complexity of the data and the difficulty of comparing studies done with varying methodologies and with subjects who suffered from different degrees of illness. The British agency has posted summaries on its Web site ( of all the studies reviewed.

The British regulators, some experts said, also did not give proper weight to the high frequency of suicidal thoughts and attempts among depressed adolescents in general. A study in 2000 by Norwegian researchers of close to 10,000 children ages 12 to 20, for example, found that 30 percent of those who met criteria for a diagnosis of depression at the beginning of the study had made a suicide attempt two years later.

Some researchers also questioned the logic of singling out one drug as better or safer than the others.

Dr. Graham Emslie, a professor of psychiatry at the University of Texas Southwestern Medical Center and the lead investigator on the studies of Prozac that the British regulators found convincing, said that because the studies of different drugs use different measures and are based on significantly varying numbers of subjects, the discrepancies in their findings may mean little.

"Any relative difference in effectiveness between S.S.R.I.'s is probably best explained by methodological differences and not by specific differences in the medications," Dr. Emslie said.

The F.D.A., psychiatrists familiar with the agency's investigation said, is requesting more information from drug companies than was given to the British drug agency, and has asked outside researchers to trace back and recode by hand the raw data used in some studies.

The experts said the agency hoped to determine how many of the reports of suicidal thinking or behavior were real. The F.D.A. also hopes to tell if the greater incidence of suicidal tendencies found in some studies among children taking the drugs is meaningful or is simply an artifact of how the children were assigned to the drug or placebo groups, the experts said. No suicides were reported in any of the studies.

If a link is found between some of the drugs and suicidal tendencies, scientists will then have to figure out how many children and adolescents may be affected most experts believe the number would be very small and how the drugs produce such behavior.

While emphasizing that any attempt to explain what might be going on was pure speculation, some experts have offered hypotheses. One is that some children may have a "paradoxical" reaction to the drugs that causes them to become extremely restless, agitated or impulsive. Dr. Graae said that he had treated more than 2,000 children with S.S.R.I.'s and had not seen a case where he thought the drugs produced suicidal thoughts or behavior. But he said that he had seen cases of children who had shown "a level of recklessness or risk taking, not necessarily aimed at injuring oneself."

Another is that the drugs may produce an unstable emotional state in some children who actually suffer from manic depression that has gone undiagnosed.

A third idea is that some incidents may occur in children who are taking their medication irregularly or who have just stopped the drug. Some S.S.R.I.'s are metabolized by the body very quickly. When they are stopped abruptly they can produce a variety of reactions, including shifts in mood, lightheadedness, flulike symptoms and what some patients have described as "electrical zapping sensations." Children, experts said, metabolize drugs more quickly than adults, and may be more susceptible to such reactions. In three studies of Paxil examined by the British regulators, 20 of 34 events "possibly related to suicidality" occurred during the 30 days after the children stopped taking the drug, compared with 8 out of 17 in the placebo group in the same period.

The British action appears to have already made some American parents more cautious about starting their children on antidepressants. Dr. Graae said that one couple he saw decided to postpone their child's treatment with an S.S.R.I. until they could discuss the issue further.

But for many parents, the pronouncements of government officials has less impact than their own personal experiences with the drugs.

A woman in Westchester County whose 12-year-old son has taken Zoloft for several months, for example, said that she resorted to medication only because she feared her son was on the edge of a serious breakdown.

"I knew my child was in deep trouble," the mother said. She added that on the drug her son had improved greatly.

"It's been night and day," she said.

But Sara Bostock, who says she believes that Paxil caused her 25-year-old daughter to commit suicide a few weeks after starting the drug, sees the British action as the first step toward recognizing what she calls the dangers of S.S.R.I.'s. Ms. Bostock has campaigned for the pharmaceutical companies to open privately held data to the public.

"I admit to anger and outrage over what I believe was a serious wrong done to my beloved daughter," Ms. Bostock said in an e-mail message, "and this ban does represent some vindication for me."

In fact, the British regulators stopped short of an outright ban, saying that for some children, including those who were already doing well on an S.S.R.I. and those who could not tolerate Prozac, their use might still be warranted.

What everyone agrees on is that only more research and more detailed analysis of the studies that exist will be able to provide answers to parents and clinicians.

"We should let the data tell the story," Dr. March said.

Source The New York Times Company



The Netherlands has become the first country in the world where euthanasia is formally allowed. By approving the new bill, the Dutch parliament set down in law a practice that had been tolerated for years. Pro-euthanasia campaigners worldwide rejoiced, but opposition to the law in other countries is widespread. Some countries even claim The Netherlands now violates one of the basic human rights: the right to life.

How The Courts Allowed Euthanasia
by Arjan Schippers, 23 July 2001

Euthanasia has been openly practiced in the Netherlands, as courts have always been very sensitive to the general mood in society and therefore very hesitant to send doctors to jail for granting patients' wishes to die. Case law on the due care requirements gradually evolved through a series of landmark rulings.

It all started in 1973 when the Leeuwarden criminal court sentenced a doctor to only a one week suspended sentence, for administering a lethal dose of morphine to her terminally ill mother. She had repeatedly asked her daughter to put an end to her life. It was the first court case where a number of requirements were
summed up: the patient had to be terminally ill, suffer unbearably and request to die.

Force Majeure
The next landmark ruling came in 1983, when the Dutch Supreme Court overturned a conviction. The doctor had terminated the life of a 95-year-old woman who had been unable to eat or drink and had requested euthanasia. A lower court had convicted him because the woman suffered from a chronic, and not a terminal, illness. But the Supreme Court agreed that the doctor faced a conflict between his duty to preserve life and his duty to alleviate suffering. It allowed him to invoke force majeure.

In 1991 the famous Chabot case implicitly included psychological suffering as a valid ground for euthanasia. The psychiatrist Chabot had assisted a 50-year-old woman in committing suicide. The woman suffered
from severe depression, and after the death of her two sons and the break-up of her marriage she did not want to live any longer. Dr. Chabot invoked force majeure. This was not granted, because none of the
colleagues that Dr. Chabot had consulted had actually examined the woman. But the Court also held that invoking force majeure could be allowed in cases where the suffering is purely psychological.

In 1995 a nurse was handed a suspended prison sentence of two months for terminating the life of a friend who suffered from aids. She had consulted a doctor who had supplied her with the means. The court ruled that only doctors could perform euthanasia.

In that same year the Amsterdam Court ruled in a case concerning a patient who was not able to express a wish to die. The Court acquitted a gynaecologist who had administered a lethal injection to a three-day old
baby suffering from spina bifida and hydrocephalus. The baby was in extreme pain and was expected to live no longer than six months. The parents had requested euthanasia. The gynaecologist successfully invoked force majeure.

In 2000 a doctor was acquitted after he had assisted an 86-year-old man in committing suicide. The patient, former senator Edward Brongersma, was simply tired of life. The court ruled the doctor had acted with



The Right To Die Vs. The Right To Life
Euthanasia in the New Law
Medical Decisions in the Terminal
Stages of Life
Euthanasia Before 2001
How the Courts Allowed Euthanasia
The Big Issues
The Opponents
The Right to Die
The Dutch Voluntary Euthanasia Society
The Outside World
The Next Debate

Personal Stories
Mrs de Hullu
Dr Buck


End-of-life Care Ethics January 2001: Physician-Assisted Suicide: What's Legal and What's Professional?

Physician-assisted suicide claimed front-page status again as the year 2000 drew to a close. In late November, the Dutch Parliament approved a bill legalizing euthanasia and physician-assisted suicide, making the Netherlands the first country to do so formally. Earlier that month, US voters in Maine considered legalizing physician-assisted suicide in their state. Question One on their referendum ballot asked succinctly and in plain English: "Should a terminally ill adult who is of sound mind be allowed to ask for and receive a doctor's help to die?" Maine voters said "no" (meekly) by a vote of 51.5 percent to 48.5 percent

For complete article go to

bulletThe Center for Disease Control and Prevention (CDC) USA  

According to the Center for Disease Control and Prevention (CDC) USA more people die from suicide than from homicide in the United States. Every day approximately 86 Americans commit suicide, and 1,500 people attempt to commit suicide. . . . Suicide is the eighth leading cause of death for all Americans. Suicide rates are the highest among people age 65 and older, and suicide is the third leading cause of death for people ages 15 to 24. Among youths 10 to 14 years old, suicide rates increased 100 percent from 1980 to 1996.

For more information, visit

bulletU.S. advocates of assisted suicide will find no help from the Netherlands
U.S. advocates of assisted suicide will find no help from the Netherlands.  Euthanasia is about to become legal -- not just tolerated -- in the Netherlands. But will assisted-suicide activists in this country want to point to it as an enlightened example? Editorial. Jan. 15, 2001.  Complete article:

bullet Palliative care

 Palliative care: Mainstream model Efforts to change the culture of dying in acute care settings are no longer on the fringes of medicine. Some physicians have proven that hospice-like care can coexist -- and even cohabit -- with hospitals. For complete article go to

bulletMust assisted suicide be only doctor assisted?

Must assisted suicide be only doctor assisted? A panel of clinicians and ethicists reaches common ground on this and other questions on assisted suicide.   By Vida Foubister, AM News staff. April 10, 2000 For complete article go to

bulletHealthScout Fibromyalgia: 

"The controversy continues New disagreements over pain syndrome" by Janice Billingsley HealthScout Reporter March 3, 2001 Shirley Mynatt's debilitating neck, shoulder, hip and leg pains were diagnosed five years ago as fibromyalgia. She's grateful for that, surprisingly. "It was another way of saying, 'Yes, this isn't in your head,' . . .  "  For complete article go to:

bulletHurting All Over Patients suffering from fibromyalgia used to be told that it was all in their head. Not anymore BY IAN K. SMITH, M.D.   Thursday, April 5, 2001  TIME.COM

 Fibromyalgia is a mysterious illness with a long name and a bad reputation. For years, patients who went to their doctors complaining of inexplicable pain, stiffness and fatigue were told that they were depressed or stressed out and their symptoms were psychosomatic. More recently, fibromyalgia has been linked to chronic-fatigue syndrome and the aftereffects of Lyme disease, which in some medical circles is enough to give any ailment a bad name. But the reputation is undeserved.

 Fibromyalgia is a real medical syndrome that is being taken more seriously these days, thanks to a study out of the University of Alabama that has found what may be the underlying causes: a reduced blood flow to the parts of the brain that process pain and twice the normal level of a brain chemical called substance P, which helps nervous-system cells send pain messages to the brain. Not only do patients now have scientific support to prove they're not crazy but doctors also have more reason to take their complaints seriously.

The complaints are serious indeed, from swelling, tingling, numbness and stiffness in the soft tissues (muscles, tendons, ligaments) to achy, throbbing pain that is worse in the morning, intensifies again at night and has been known to drive sufferers to suicide. Fatigue is a common complaint (reported in as many as 9 out of 10 cases), caused perhaps by disturbances in the deep-sleep phase the body needs to get properly refreshed at night. Patients have told me that they feel so heavy in the morning they can hardly get out of bed and that they often find it difficult to concentrate on even minor tasks. For reasons that are not known, women get fibromyalgia seven times as often as men, but the ailment can strike anyone at any age.

Doctors are at a disadvantage in diagnosing fibromyalgia because many of its symptoms are shared by other illnesses. Compounding the problem is the fact that even with these recent findings, there are still no definitive fibromyalgia markers. X rays and blood tests can be used only to rule out other illnesses. To facilitate diagnosis, the American College of Rheumatology established a procedure for examining 18 tender points on a patient's body. If the muscles feel very sore when pressed in 11 of these 18 points, a tentative diagnosis of fibromyalgia can be made. Although there is no known cure, there are treatments that work. In fact, many patients have managed the disease successfully with a combination of simple exercises and medication. Heat treatments, massage and regular stretching have been of benefit, as have such aerobic exercises as cycling and jogging. Though many patients say these exercises only worsen the pain, working through the discomfort can eventually bring relief. Tricyclic antidepressants such as amitriptyline and cyclobenzaprine are sometimes prescribed to improve sleep and relax muscles. Some patients opt for temporary pain relief via local anesthetic or steroid injections. There's no single regimen that helps everyone. Just keep trying until you find one that works for you. And don't let anyone tell you it's all in your mind. Dr. Ian is a correspondent for NBC's Today show. For more on fibromyalgia, see  Source:,9171,98959,00.html


 Painkiller OxyContin a factor in 120 deaths The drug's producer did not adequately inform physicians about potential for abuse, critics say  News  Published Monday, March 5, 2001 by Barry Meier and Melody Petersen NEW YORK TIMES  For complete article go to

April 10, 2001

Dutch voting today to permit euthanasia  First country to do so: Critics point out child could be killed if parents agree

Philip Johnston
The Daily Telegraph

THE HAGUE - After 38 courses of radiotherapy and four of chemotherapy, Petra Brockmoller is resigned to her death. A mother of three, she has made arrangements that when the pain of cancer becomes unbearable, her doctor should kill her.

"I want to be the director of my own life and of my own treatment," says Mrs. Brockmoller, 66. Today that wish will be incorporated into Dutch law, when the upper house of Parliament votes to enact the world's first national euthanasia legislation. Last year, the lower house voted in favour of decriminalizing mercy killing provided it is carried out under strict conditions.

Doctors in Holland have performed euthanasia for almot 30 years but have always run the risk of prosecution for murder.

Court cases have laid down the rules by which doctors can help people die without risking jail. The new law places these safeguards on a statutory basis.

Under the law, prosecuting authorities will no longer have to be notified of all cases of euthanasia --about 3,000 a year. Instead, one of five new regional review teams must be informed and the criminal justice system will become involved only if something is considered amiss.

The law has few opponents. The main Christian Democrat opposition party has declined to support the bill -- not because it opposes euthanasia but because it is unhappy with some technical aspects. Only the small religious parties oppose the bill outright. They are considered "extremists" for their opposition to abortion and same-sex marriages, which Holland recently legalized.

Andre Rouvoet, of the RPF, an evangelical parliamentary coalition, said: "We think life is God-given and that people should not take their own lives let alone have a doctor take it."

"It is the primary duty of a government to protect the lives of its citizens, even when those citizens don't want to live any longer," Mr. Rouvoet said.

He noted that it will be possible for a child to be euthanized if his parents agree. A proposal that was excluded from the bill would have allowed children as young as 12 to request euthanasia without parental permission.

Under the legislation, the patient does not have to be terminally ill, as was once the case. The test now is that they are "suffering unbearably." A court case several years ago established that a woman in despair after the deaths of her two children was justified in requesting euthanasia.

Traditionally one of the most contentious factors has been consent, with an obvious problem arising when a patient is unconscious or senile.

The new law explicitly recognizes the validity of "living wills" -- advance declarations of a desire to undergo euthanasia in certain defined circumstances. They must be updated regularly and discussed with doctors.

The law's supporters, who include most parliamentarians, a majority of voters and nearly all doctors, are adamant there is no danger of people suffering from Alzheimer's being killed unless they have given explicit permission when they were lucid.

Rob Jonquiere, leader of the Dutch voluntary euthanasia society, believes other European countries will follow Holland's lead and is irritated that the Dutch were recently branded murderers in the European Parliament.

Nico Mensing, of the Royal Dutch Medical Association, believes doctors elsewhere in Europe wish to function under similar circumstances.

"If you talk to them privately, your doctors are jealous of our laws,'' he said. "This is now on the agenda elsewhere, especially in Belgium and in France.''

Henk Leenen, a medical ethicist who was a guiding hand behind the new legislation, said: "Physicians the world over administer pain-killing drugs to terminally ill patients that have the effect of killing them. The difference is that we do it openly.''

While the Netherlands will be the first country to legalize mercy killing, physician-assisted suicide has been legal in Oregon for the past three years, and the state of Northern Australia briefly legalized the practice in 1996.

Perhaps indicating the possibility of the Dutch law spreading beyond its borders, Australian doctor Philip Nitschke said he is planning to buy a Dutch-registered ship and practice euthanasia just outside Australian waters as a way of circumventing Australian law.

April 11, 2001

Dutch senators pass mercy-killing bill A long-standing practice

Bruce Wallace
Southam News, with files from Reuters, Agence France-Presse

LONDON - Urging dying patients to "trust in God, not the syringe," a small, anguished minority failed to stop the passage of a bill making the Netherlands the first country where terminally sick and suffering patients can legally ask doctors to end their lives.

About 8,000 protesters turned out last night outside the Dutch senate, which voted 46-28 to give its blessing to the euthanasia bill. Opponents waved petitions with about 60,000 signatures, but nationwide polls have shown 85% of Dutch citizens favour legalizing mercy killings.

The Dutch senate's approval last night ensures the long-standing tacit Dutch practice of doctor- assisted suicide will be legal under controlled conditions.

The bill will not go into force until the lower house formally approves it, which is not expected to happen until the fall.

Its passage closes more than a year of political debate between supporters who contend "the right to life should not be an obligation to life," and critics who argue sanctioning suicide marks a descent into legalized immorality.

But it will change little in the way doctors and patients have operated in the Netherlands since the country's Supreme Court declared voluntary suicides to be acceptable in 1984. It is estimated almost half of Dutch physicians have helped at least one patient end his or her life.

"This law will remove uncertainty for patients and for doctors," Els Borst, the Dutch Health Minister, told the senators.

Under the new law, patients who choose euthanasia must be in "unbearable pain," although their suffering can be either physical or mental. They must also repeatedly and voluntarily express a will to die while of sound mind. The wish can be transmitted in a previously written declaration.

Yet the legislation has still sparked fears of death tourism -- people travelling to the Netherlands for help in ending their lives.

While it has no specific safeguards against this, the strict criteria Dutch doctors must follow insist on a close doctor-patient relationship, effectively preventing foreigners from getting death on demand. Patients must be Dutch residents and have sought a second medical opinion about their conditions. And doctors are prohibited from suggesting assisted suicide as an option.

As they do now, doctors will have to present each potential case to a medical board for authorization to proceed with the mercy killing. They have always been required to inform public prosecutors of impending cases but, as long as jail sentences of up to 12 years were on the books, many doctors balked at disclosure.

The result was many assisted suicides occurred in the medical shadows, with research suggesting as many as two-thirds of all cases were never reported.

A study published in the British Medical Journal concluded one in five Dutch acts of euthanasia in 1995 was done without the patient's explicit permission. Another 1995 study of 649 assisted suicides showed more than one in five did not go smoothly. In some cases, there was additional suffering, and 16% of the time the medication was not fatal.

Dutch lawmakers contend that removing fears of criminal prosecution will ensure the practice is done according to rules.

The government had to back away from one clause that would have allowed children as young as 12 to ask for permission to die.

Health & Science: Federal judge halts removal of woman's feeding tube

The Associated Press

TAMPA, Fla. (April 20, 2001 12:00 p.m. EDT - A federal judge on Friday granted a couple's request to stop the removal of a feeding tube that has kept their comatose daughter alive since 1990.

U.S. District Judge Richard Lazzara issued a stay until 5 p.m. Monday, preventing doctors from withdrawing the feeding tube from Terri Schiavo. The Florida Supreme Court had given permission for her husband, Michael
Schiavo, to have the tube removed at 1 p.m. Friday, three hours after the ruling.

The 37-year-old woman has been in a coma since suffering a heart attack brought on by a blood disorder.

Lazzara's ruling gave Bob and Mary Schindler time to file a federal appeal in Atlanta.

Michael Schiavo has said he wants to remove his wife's feeding tube to end her years of suffering, as he says she wished. It might take a week or more for her to die.

Her parents contend she would want to be kept alive and "has cognition,recognizes them and reacts to them." 
The Schindlers are seeking a new trial. 


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