[Active euthanasia, or assisted suicide?] / Aktív eutanázia vagy asszisztált öngyilkosság?

INTRODUCTION: Both active euthanasia and assisted suicide are legal in The Netherlands, Belgium, Luxemburg and, most recently, in Canada. AIM: Examination of national legislations of countries where both active euthanasia and assisted suicide are legal. The number of accomplished active euthanasia cases and that of assisted suicide cases. METHOD: Analysis of national statistical data. Comparison of statistical data before and after 2010. Comparison of the related practices in the surveyed countries. RESULTS: The number of active euthanasia cases markedly predominates over the number of assisted suicide cases. Cancer is a main reason for active euthanasia, or assisted suicide. In countries with a larger population, the number of active euthanasia cases is higher than that in countries with a smaller population. CONCLUSIONS: Regarding the fact that the applicants for active euthanasia withdraw their requests in a smaller number than the applicants for assisted suicide, patients prefer the choice of active euthanasia. Since the related legislative product is too recent in Canada at present, it may be only presumed that a certain preference will also develop in the related practices in Canada. Orv. Hetil., 2016, 157(40), 1595-1600.

Eutanasia activa, una mirada a la situación internacional / Active euthanasia, a view of international situation

International situation on euthanasia varies among countries. Even though in most of the countries worldwide active euthanasia is forbidden by law, to the date four countries (The Netherlands, Belgium, Luxembourg and Colombia) have approved and regulated by law active euthanasia (defined as “physician’s intentionally administering a treatment -usually medication- to cause the patient’s death, with the patient’s full, informed consent”). For a country like Chile, in which all types of euthanasia are forbidden by law, it is important to look forward to the international situation, in order to enrich public policy debate, based on the international empirical experience.

[Euthanasia outside Europe]. / Eutanázia Európán kívül.

The passive form of euthanasia is legalized almost in every civilized country. Its active form is not a generally accepted legal institution. In Europe, active euthanasia is legalized only in The Netherlands, Belgium, Luxembourg and Switzerland. In Australia, the Act on the Rights of the Terminally Ill of 1995 legalized the institution of assisted suicide, which is not identical to active euthanasia. The difference lies in the fact that legalized active euthanasia means that the author of a murder is not punishable (under certain circumstances), whilst assisted suicide is not about murder, rather about suicide. In the first case, the patient is killed on his or her request by someone else. In the second case, the patient himself or herself executes the act of self-killing (by the assistance of a healthcare worker). In Australia, the institution of assisted suicide was repealed in 1997. Assisted suicide is legal in four USA member states: in Vermont, Washington, Montana and Oregon. In Uruguay, the active form of euthanasia has been legal since 1932.

Premises and evidence in the rhetoric of assisted suicide and euthanasia.

In debates about euthanasia and assisted suicide, it is rare to find an article that begins with an expression of neutral interest and then proceeds to examine the various arguments and data before drawing conclusions based upon the results of a scholarly investigation. Although authors frequently give the impression of being impartial in their introduction, they invariably reach their prior conclusions. Positions tend to be clearly dichotomized: either one believes that the practice of euthanasia or assisted suicide is totally acceptable or completely unacceptable in a just and moral society. Where there is some admission of a gray zone of incertitude, authors attempt to persuade us that their beliefs (preferences) are the only sensible way to resolve outstanding dilemmas. The practice of vehemently promoting a "pro" or "con" position may be useful when societies must decide to either legalize certain practices or not. Although only a handful of countries have thus far accepted the legal practice of euthanasia or assisted suicide (Belgium, Luxembourg, The Netherlands, the U.S. states of Montana, Oregon, Vermont and Washington, and Switzerland), scholarly articles in recent trends mainly promote legalization, to the point of recommending expansion of the current practices. Is this a case of the philosophers being ahead of their time in promoting and rationalizing the wave of the future? Alternatively, does the small number of countries that have legalized these practices indicate a substantial gap between the beliefs and desires of common citizens and the universe of the 'abstracted realm'? For the time being, what we do know is that more countries and states are debating legalization of euthanasia or assisted suicide, the nature of laws and legal practices vary greatly and both ethical and empirical assessments of current practices are the subject of much controversy. This article presents an examination of the premises and evidence in the rhetoric of assisted suicide and euthanasia. Inasmuch as any analysis cannot be totally impartial, we do not contend that our analysis is without influence from our experiences and philosophical affinities. Notwithstanding this caveat, we venture to propose that our scrutiny of the arguments and empirical data may offer some guidance to individuals who are attempting to reach practical conclusions based upon the available evidence, whether empirical or rationalized.

A survey of the perspectives of patients who are seriously ill regarding end-of-life decisions in some medical institutions of Korea, China and Japan.

PURPOSE: The debate about the end-of-life care decision is becoming a serious ethical and legal concern in the Far-Eastern countries of Korea, China and Japan. However, the issues regarding end-of-life care will reflect the cultural background, current medical practices and socioeconomic conditions of the countries, which are different from Western countries and between each other. Understanding the genuine thoughts of patients who are critically ill is the first step in confronting the issues, and a comparative descriptive study of these perspectives was conducted by collaboration between researchers in all three countries. METHODS: Surveys using self-reporting paper questionnaire forms were conducted from December 2008 to April 2009 in Korea (six hospitals in two regions), China (five hospitals in four regions) and Japan (nine hospitals in one region). The subjects were patients who were critically ill who had been diagnosed as having cancer. A total of 235 participants (Korea, 91; China, 62; Japan, 52) were eventually recruited and statistically analysed. RESULTS: Most respondents had sometimes or often thought of their own death, mostly fear of 'separation from loved ones'. They wanted to hear the news regarding their own condition directly and frankly from the physician. A quarter of them preferred making end-of-life care decisions by themselves, while many respondents favoured a 'joint decision' with their family members. The most favoured proxy decision maker was the spouse, followed by the children. Most admitted the necessity of 'advance directives' and agreed with artificial ventilation withdrawal in irreversible conditions. The most common reason was 'artificial prolongation of life is unnecessary'. Most respondents agreed with the concept of active euthanasia; however, significant differences were sometimes observed in the responses according to variables such as patient's country of origin, age, gender and education level. CONCLUSION: Patients in Far-Eastern countries gave various responses regarding end-of-life care decisions. Although familial input is still influential, most patients think of themselves as the major decision maker and accept the necessity of advance directives with Westernization of the society. Artificial ventilation withdrawal and even active euthanasia may be acceptable to them.

Battlefield euthanasia - courageous compassion or war crime?

Issues relating to voluntary euthanasia that are currently being debated by Australian society are distinctly different from those encountered by battlefield doctors. Doctors in war undertake to treat those affected by conflict; their participation in euthanasia challenges the profession's definition of "duty of care". Euthanasia must be distinguished from "triage" and medical withdrawal of care (which are decided within a medical facility where, although resources may be limited, comfort care can be provided in the face of treatment futility). Battlefield euthanasia is a decision made, often immediately after hostile action, in the face of apparently overwhelming injuries; there is often limited availability of pain relief, support systems or palliation that would be available in a civilian environment. The battlefield situation is further complicated by issues of personal danger, the immediacy of decision making and difficulties with distinguishing civilians from combatants. Regardless of the circumstances on a battlefield, doctors, whether they are civilians or members of a defence force, are subject to the laws of armed conflict, the special provisions of the Geneva Conventions and the ethical codes of the medical profession.

Physician reports of medication use with explicit intention of hastening the end of life in the absence of explicit patient request in general practice in Belgium.

BACKGROUND: Although the incidence of the use of life-ending drugs without explicit patient request has been estimated in several studies, in-depth empirical research on this controversial practice is nonexistent. Based on face-to-face interviews with the clinicians involved in cases where patients died following such a decision in general practice in Belgium, we investigated the clinical characteristics of the patients, the decision-making process, and the way the practice was conducted. METHODS: Mortality follow-back study in 2005-2006 using the nationwide Sentinel Network of General Practitioners, a surveillance instrument representative of all GPs in Belgium. Standardised face-to-face interviews were conducted with all GPs who reported a non-sudden death in their practice, at home or in a care home, which was preceded by the use of a drug prescribed, supplied or administered by a physician without an explicit patient request. RESULTS: Of the 2690 deaths registered by the GPs, 17 were eligible to be included in the study. Thirteen interviews were conducted. GPs indicated that at the time of the decision all patients were without prospect of improvement, with persistent and unbearable suffering to a (very) high degree in nine cases. Twelve patients were judged to lack the competence to make decisions. GPs were unaware of their patient's end-of-life wishes in nine cases, but always discussed the practice with other caregivers and/or the patient's relatives. All but one patient received opioids to hasten death. All GPs believed that end-of-life quality had been "improved considerably". CONCLUSIONS: The practice of using life-ending drugs without explicit patient request in general practice in Belgium mainly involves non-competent patients experiencing persistent and unbearable suffering whose end-of-life wishes can no longer be ascertained. GPs do not act as isolated decision-makers and they believe they act in the best interests of the patient. Advance care planning could help to inform GPs about patients' wishes prior to their loss of competence.

Euthanasia and other end-of-life decisions: a mortality follow-back study in Belgium.

BACKGROUND: This study compares prevalence and types of medical end-of-life decisions between the Dutch-speaking and French-speaking communities of Belgium. This is the first nationwide study that can make these comparisons and the first measurement after implementation of the euthanasia law (2002). METHODS: We performed a mortality follow-back study in 2005-2006. Data were collected via the nationwide Sentinel Network of General Practitioners, an epidemiological surveillance system representative of all Belgian GPs.Weekly, all GPs reported the medical end-of-life decisions among all non-sudden deaths of patients in their practice. We compared the northern Dutch-speaking (60%) and southern French-speaking communities (40%) controlling for population differences. RESULTS: We analysed 1690 non-sudden deaths. An end-of-life decision with possible life-shortening effect was made in 50% of patients in the Dutch-speaking community and 41% of patients in the French-speaking community (OR 1.4; 95%CI, 1.2 to 1.8). Continuous deep sedation until death occurred in 8% and 15% respectively (OR 0.5; 95%CI, 0.4 to 0.7). Community differences regarding the prevalence of euthanasia or physician-assisted suicide were not significant.Community differences were more present among home/care home than among hospital deaths: non-treatment decisions with explicit life-shortening intention were made more often in the Dutch-speaking than in the French-speaking community settings (OR 2.2; 95%CI, 1.2 to 3.9); while continuous deep sedation occurred less often in the Dutch-speaking community settings (OR 0.5; 95%CI, 0.3 to 0.9). CONCLUSION: Even though legal and general healthcare systems are the same for the whole country, there are considerable variations between the communities in type and prevalence of certain end-of-life decisions, even after controlling for population differences.

Trends in the use of opioids at the end of life and the expected effects on hastening death.

The aim of our study was to describe trends in opioid use and perceptions of having hastened the end of life of a patient. In 2005, a questionnaire was sent to 6860 physicians in The Netherlands who had attended a death. The response rate was 78%. In 1995 and 2001 similar studies were done. Physicians less often administered opioids with the intention to hasten death in 2005 (3.1% of the non-sudden deaths) than in 2001 and in 1995 (7% and 10%, respectively). Physicians gave similar dosages of opioids in 2005, 2001, and 1995, but physicians in 2005 less often thought that life was actually shortened than in 2001 and 1995 (37% in 2005, 50% in 2001, and 53% in 1995). Of the physicians in 2005 who did think that the life of the patient was shortened by opioids, 94% did not give higher dosages than were, in their own opinion, required for pain and symptom management. Physicians in 2005 more often took hastening death into account when they gave higher dosages of opioids when the patient experienced more severe symptoms and with female patients. In older patients (>or=80 years), physicians took the hastening of death into account more often, but the actual dosages of opioids were lower. These data indicate that physicians in The Netherlands less often thought that death was hastened by opioids and less often gave opioids, with the intention to hasten death in 2005 than in 2001 and 1995.

Perfil Jurídico de la lucha médica contra el dolor. Al tiempo, tratamiento de la eutanasia activa indirecta / Juridical arguments of the medical figth against the pain

El presente trabajo se centra en el tratamiento normativo de los cuidados paliativos. Sin rehuir otras ramas del ordenamiento jurídico, se utiliza para ello los instrumentos propios del Derecho penal, incidiendo, pues, en los supuestos patológicos del sistema y, por consiguiente, en los más excepcionales dentro de lo que constituye la práctica médica cotidiana. Se examina, por una parte, el derecho del paciente a obtener un tratamiento médico razonable contra el dolor. Por otra, el deber médico de abstención cuando se produce la negativa del enfermo a someterse a las prescripciones facultativas. El tercer objetivo del trabajo viene constituido por los casos en los que el paciente no puede manifestar su voluntad, lo que implica tratar tanto los supuestos en los que existe un documento de instrucciones previas, como la posibilidad de consentimiento por representación. Por último, se estudian particularmente los supuestos en los que la administración de fármacos produce un acortamiento del periodo natural de la vida, esto es, los casos de eutanasia activa indirecta. Este último fenómeno es analizado llegando a la conclusión, ya alcanzada en otros trabajos y en sintonía con la opinión jurídica dominante, que resulta impune en nuestro país (AU)

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The varying ethical attitudes towards resuscitation in Europe.

OBJECTIVE: This study was conducted to assess the varying attitudes in Europe towards ethical aspects of resuscitation in Europe. METHOD: The ethics of resuscitation is a key discussion topic in the European Resuscitation Council Advanced Life Support (ALS) course. A questionnaire was sent to all leading ALS course directors in 20 European countries. All completed the questionnaire. The results were compiled in March 2004. Views were sought on the following ethical aspects:When not to attempt resuscitation Active euthanasia When to abandon resuscitation efforts The diagnosis of death by non physicians Permission for relatives to be with the patient during resuscitation if they wish Teaching on the recently dead Breaking bad news Results: The results reveal a considerable variation in the interpretation of ethical dilemmas within European countries. It is interesting to note that the results do not necessarily conform to traditional beliefs in the characteristic differences between Northern and Southern Europe. The Mediterranean countries do not all have the same attitudes, any more than the Nordic or Central European countries share the same views. CONCLUSIONS: There remains a widespread divergence of views on ethical aspects of resuscitation with the countries of Europe that are largely unpredictable according to commonly perceived national characteristics. The trend over the past 6 years is towards a more permissive attitude. For many ethical questions there can be no clear and correct didactic answers.

Of euphemisms and euthanasia: the language games of the Nazi doctors and some implications for the modern euthanasia movement.

Euphemisms are place-holders for important concepts. They may disguise a practice which one might abhor if it were given another name. In Nazi Germany during World War II, euphemisms were used to desensitize physicians and society to the horrors of a program of euthanasia. This article examines some of the euphemisms used by the Nazi physicians to redefine medicalized killing, compares the Nazi language games with those of contemporary proponents of medicalized killing, and concludes that the consistent application of euphemisms for medicalized killing significantly weakens arguments against assisted killing.