Euthanasia*

Forensic and Legal Medicine R 135Lecture XVII

June, 2009

* This replaces the lecture originally labelled lecture XVII

2 April 28, 2023

Euthanasia - DefinitionBelgium menerima the Dutch definition: “euthanasia is the intentional taking of someone’s life

by another, on her request”. Berikut ini adalah tidak berlaku pada kasus dimana

dengan orang yang tidak kompeten; ada usulan penggunaan terminologi dengan “penghentian kehidupan pada orang yg tidak kompeten”

Lebih penting lagi, tindakan untuk menghentikan terapi yang sia-sia (futile) ini adalah bukan euthanasia dan pada kasus ini disebut “passive euthanasia”

Apapun yang disebut “indirect euthanasia”, memaksa untuk menggunakan analgesik dengan efek yang memperpendek kehidupan ini juga secara jelas dibedakan dari euthanasia yang sebenarnya.

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Belgian Euthanasia Law

On January 20, 2001 the euthanasia commission of Belgium’s upper house, the Senate,memvoting usulan UU euthanasia bahwa euthanasia tidak lagi dihukum oleh undang-undang bila syarat2 tertentu dipenuhi.

Sembilan bulan kemudian October 25, 2001 Belgium’s Senate menyetujui prpoposal undang2 euthanasia tersebut secara mayoritas

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Pembagian (…are the part / mean of the debate!) euthanasia – (from Greek - “good death”): killing (terminating

the life) of a person (or an animal) in a presumably painless or minimally painful way

assisted suicide – providing means and/or the help to a person, who want to terminate his/her life

----------------------------------------------------------------------------------------------- euthanasia by means [e.g. insulin in a diabetic]

– “active” “aggressive” – using lethal dose of medicaments, or

lethal substance/s, or force to kill “non-aggressive” – withdrawing life support

– “passive” – withholding common treatments/giving a medication to relieve pain, knowing that it may also result in death

euthanasia by consent – voluntary – with the person’s direct consent– non-voluntary – without the person’s direct consent (e.g.

someone not legally competent, or unable to make the decision), decision made by a proxy

– involuntary – against someone’s will -------------------------------------------------------------------------------------- ‘terminal sedation’ ‘letting die’, futile treatments,…

Places in the World Where Euthanasia or Assisted Suicide are Legal: Netherlands (Green), Belgium (Red), Oregon and Washington (Yellow)

Accepted:

• Switzerland• USA (state of Oregon)

Accepted under specific conditions:• Columbia• Spain• France

Case Studies

• Robert Latimer is a Canadian farmer sentenced to 10 years in prison for the murder of his daughter, Tracy, which occurred on October 24, 1993.

• Latimer says that he killed his daughter because she had severe mental and physical disabilities and ongoing health problems as a result of cerebral palsy and he believed that the next surgery she was to have, to remove a permanently disconnected hip, would only add to her suffering.

• Supporters of Latimer said that this was a mercy killing which should not be punished as harshly as other murders. (10 years is the minimum sentence for murder). The jury that convicted him felt that he should spend 1 year in jail and another under house arrest.

• However, disability rights advocates said that killing a severely disabled child like Tracy should carry the same penalty as killing a non-disabled child. To do otherwise would devalue the lives of disabled people and thereby increase the risk of more "mercy killings" by their caregivers.http://en.wikipedia.org/wiki/Robert_Latimer

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WMA Declaration on Euthanasia

“Euthanasia, that is the act of deliberately ending the life of a patient, even at the patient’s own request or at the request of close relatives, is unethical.

This does not prevent the physician from respecting the desire of a patient to allow the natural process of death to follow its course in the terminal phase of sickness.”

WMA, 2002

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History

Hippocratic Oath (400 – 300 BC) “To please no one will I prescribe a deadly drug nor give advice which may cause his death.”

English Common Law – since 1300’s until today disapproved suicide and assisted suicide

1828 – euthanasia explicitly outlawed in the USA 1900’s – growing support in some ‘intellectual circles’ 1935 – society to promote euthanasia in England 1937 – doctor-assisted suicide legal in Switzerland 1938 – society to promote euthanasia in USA 1939 – Action T4 – Nazi Germany 1948 – Nuremberg trial 1977 – “living wills” in California (later on in other states of USA)

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History 1990 – Dr. Jack Kevorkian (Michigan, USA) – encouraging

and assisting people in committing suicide, tried and convicted in 1999 for a murder displayed on television (to be paroled 2007!)

1993 – Netherlands – decriminalization of doctor-assisted suicide

1994 – Oregon (USA) – Death with Dignity Act (US Supreme Court decision 1997, attempts to stop the law by amendment of the drug law failed 2001)

1995 – Northern Territory (Australia): euthanasia bill; overturned by Australia’s legislative branch 1997

1999 – Texas (USA) – Futile Care Law passed 2002 – euthanasia laws in the Netherlands, in Belgium 2005 – Terri Schiavo case 2005 – Groningen Protocol (euthanasia in children) … … … … … and the history continues nowadays!

Case Studies

• Robert Latimer is a Canadian farmer sentenced to 10 years in prison for the murder of his daughter, Tracy, which occurred on October 24, 1993.

• Latimer says that he killed his daughter because she had severe mental and physical disabilities and ongoing health problems as a result of cerebral palsy and he believed that the next surgery she was to have, to remove a permanently disconnected hip, would only add to her suffering.

• Supporters of Latimer said that this was a mercy killing which should not be punished as harshly as other murders. (10 years is the minimum sentence for murder). The jury that convicted him felt that he should spend 1 year in jail and another under house arrest.

• However, disability rights advocates said that killing a severely disabled child like Tracy should carry the same penalty as killing a non-disabled child. To do otherwise would devalue the lives of disabled people and thereby increase the risk of more "mercy killings" by their caregivers.http://en.wikipedia.org/wiki/Robert_Latimer

Kapan dilakukan Euthanasia

Euthanasia is mainly taken out when one is terminally ill and wants to die without pain and end their suffering.

Tetapi survey membuktikan bahwa kurang dari sepertiga saja yang melakukan euthanasia karena unbearable pain.

Hukum mengijinkan review dewan dokter untuk menghentikan penuntutan yang dilakukan dokter yang melakukan euthanasia bila masing-masing kondisi ini dipenuhi:

Pasien yang menderita penyakit yg tak tertahankan tanpa prospek dari peningkatan dari penyembuhan penyakitnya itu.

Atas permintaan pasien untuk euthanasia harus sukarela dan bersikeras sepanjang waktu (permintaan tersebut tidak dapat diberikan apabila di bawah pengaruh orang lain, atau obat penyakit psikologis)

Pasien harus menyadari sepenuhnya tentang kondisi penyakitnya, prospek dan pilihan lainnya

Hukum mengijinkan review dewan dokter untuk menghentikan penuntutan yang dilakukan dokter yang melakukan euthanasia bila masing-masing kondisi ini dipenuhi:

Harus ada konsultasi dengan setidaknya satu dokter independen lain yang perlu mengkonfirmasi kondisi yang disebutkan di atas

Kematian harus dilakukan dalam mode medis sesuai dengan dokter atau pasien, dalam hal ini dokter harus hadir

Pasien sekurang-kurangnya 12 tahun (pasien antara 12 dan 16 tahun memerlukan persetujuan dari orang tua mereka)

Is Euthanasia Ever Morally OK?

– E.g., Tn B mederita kanker stad terminal dan semua tx telah gagal utk menyembuhkannya

– Tanpa tx dia akan mati lagi dlm beberapa hari– Ada penelitian obat yg menjanjikan utk tx kanker spt

ini tetapi dengan side efek yg tdk menyenangkan– Apakah tim medis yang merawat Tn B tdk bermoral bl

bila berharap agar Tn B menolak terapi baru tsb.

Reasons for Euthanasia1. Unbearable Pain

• Major argument in favour of euthanasia is that the person is in a great deal of pain and can no longer live with it. (orang tersebut menderita sakit yg tak terahankan dan tak lahi mempunyai harapan untuk kesembuhannya).

• Rasa sakit yang tidak dapat dihilangkan dengan obat-obat penghilang rasa sakit

• Sudah melakukan kosultasi dengan beberapa dokter spesialis yang dapat memberikan support kpd pasien karena emosi dan depressi yang berhubungan dengan sakit fisik

• Beberapa pasien memerlukan euthanasia walaupun tdk menderita sakit agar dapat mati secara bermartabat

• how do we measure dignity?

Reasons for Euthanasia2. Right to commit suicide

• Many people think that each person should have the right to control how they die and in what way and by whose hand he or she will die.

• The Suicide Act (1961) made it legal for people to take their own lives, hence there is a right to die but not a right to kill (an assisted suicide cannot be carried out).

3. People should not be forced to stay alive

• Keeping a person alive when he or she wants to die would be cruel and inhumane.

• There comes a time when continued attempts to cure are not compassionate or wise and maybe this is where euthanasia comes in play.

Arguments against Euthanasia• Euthanasia adalah penolakan terhadap

pentingnya dan nilai kehidupan manusia

• Euthanasia biasanya dilihat dari sudut pandang orang yang ingin mati, tetapi efeknya terhadap orang lain juga harus dipertimbangkan, dan hak-hak mereka juga harus dipertimbangkan.

Arguments against Euthanasia• Euthanasia memungkinkan dokter dan perawat

merusak komitmen mereka menyelamatkan hidup, ini juga menyebabkan mereka tidak mau mencari pengobatan atau perawatan pasien dengan terminal ill

• Mungkin ada cara lain yg undang-undang yang mengatur euthanasia tetapi tidak dapat menghentikan orang untuk melaksanakan euthanasia utk motIf yang tidak baik

Arguments against Euthanasia

• Para pakar mengakui bahwa hampir mustahil untuk memperkirakan harapan hidup seorang pasien tertentu. Beberapa orang didiagnosis sebagai terminally ill tetapi tidak mati selama bertahun-tahun

• Menerima Euthanasia secara otomatis akan menerima kenyataan bahwa beberapa kehidupan yang lebih baik dari orang lain karena itu semua orang yang tidak sama.

Case Studies

A controversial American medical doctor. He is famous for advocating patient's "right to die" and assisting in the suicides of terminally ill people.

Kevorkian membantu lebih dari 100 orang yg mati melalui assisted suicides selama 1990 an, dia bahkan memperlihatkan hal ini didepan sebuah siaran stasiun TV terhadap salah seorang pasiennya. Kervokian kmd dituntut melakukan pembunuhan derajad ke 2 dan dimasukkan ke dalam penjara. Sekarang ini dia berada di lapas Michigan, untuk menjalani 15 – 25 th hukuman. Dia akan menjalani pembebasan bersyarat pada tahun 2007.

Dr Jack Kevorkianhttp://en.wikipedia.org/wiki/Jack_Kevorkian

Arguments against Euthanasia Orang beragama percaya bahwa setiap

manusia adalah ciptaan Tuhan, dan ini yang menyebabkan batas-batas tertentu pada kami. Maka hidup tidak boleh dengan melakukan apa yang kita kehendaki

"...drugs used in assisted suicide cost only about $40, but that it could take $40,000 to treat a patient properly so that they don't want the "choice" of assisted suicide..."

Euthanasia can become a means of health care cost containment

Di Amerika Serikat, ribuan orang yang tidak memiliki asuransi kesehatan; penelitian telah menunjukkan bahwa masyarakat miskin dan minoritas umumnya tidak mempunyai akses untuk tempat yang menyediakan pain kontrol, dan fasilitas pelayanan kesehatan yang dikelola menawarkan dokter bonus tunai jika mereka tidak menyediakan perawatan untuk pasien . Dengan penekanan yang lebih besar yang diletakkan pada fasilitas perawatan, banyak dokter mempunyai risiko pada keuangan bila mereka memberikan pengobatan bagi pasien. Dengan melegalkan euthanasia menimbulkan potensi yang berbahaya pada situasi di mana dokter dapat menemukan sendiri jauh lebih makmur finansial serius jika orang sakit atau cacat "memilih" untuk mati daripada menerima perawatan jangka panjang.

Much of these answers are taken from the International Task Force on Euthanasia and Assisted Suicide's "Frequently Asked Questions" web page.

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Belgium - Worrisome Data Sebelum hukum, penelitian telah

menunjukkan bahwa lebih dari satu di antara 10 kematian di negeri ini 10 juta orang adalah hasil dari “euthanasia informal“ , dimana dokter memberikan obat untuk pasien mereka menyegerakan kematian.

Tiga di lebih dari 100 kematian di Flemish Belgia utara dari setiap tahun adalah hasil dari letal suntikan tanpa permintaan pasien.

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The Netherlands - Data Evaluasi Terakhir ttg legislasi euthanasia (2007)

menunjukkan bahwa jumlah kasus euthanasia telah menurun selama beberapa tahun. – Pada tahun 2005, 1,7% dari semua kematian di

Belanda (2.297 orang) adalah hasil dari euthanasia, sepertiga lebih rendah dari 3.500 kasus pada tahun 2001.

– 113 pasien yang meninggal sebagai akibat dari dokter-dibantu bunuh diri. Dalam kedua 2005 dan 2001, nilai tertinggi yang euthanasia assisted suicide atau bunuh diri yang ditemukan untuk pasien berusia 64 tahun atau lebih muda, untuk laki-laki, dan untuk pasien dengan kanker.

– Selain itu, sebagian besar tindakan mati ringan atau dibantu bunuh diri yang dilakukan oleh dokter umum .*   * Agnes van der Heide, Bregje D. Onwuteaka-Philipsen dkk., Â € œEnd Praktik Kehidupan di Belanda di bawah mati ringan Log €, Baru Eng. J. of Med., Vol. 356, No 19 (10 Mei 2007): 1957-1965.

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Belgium - Data Pada bulan September 2004, yang pertama studi utama

dalam efek dari Belgia dari undang-undang baru yang telah mengijinkan euthanasia pada sekitar 20 orang terminally ill per bulan memohon kepada dokter untuk membantu mereka mati. Studi ini menemukan bahwa 259 tindakan euthanasia legal yang dilaksanakan di Belgia sampai akhir 2003.

Federal dan Evaluasi Komisi untuk euthanasia menghitung rata-rata tercatat 17 kasus euthanasia per bulan. Sekitar 60 persen dari kasus-kasus yang euthanasia tercatat di rumah sakit; sisanya umumnya terjadi pada pasien rumah.

Euthanasia will become non-voluntary Tekanan emosional dan psikologis dapat

memberikan pengaruh yang sangat kuat untuk tertekan atau tergantung orang.

Jika euthanasia dianggap menjadi pilihan yang baik sebagai sebuah keputusan untuk menerima perawatan, banyak orang akan merasa bersalah untuk tidak memilih kematian akhirnya menjadi tdk dengan sukarela

Pertimbangan keuangan, ditambah dengan kekhawatiran tentang "menjadi beban," dapat dijadikan sebagai kekuatan yang kuat akan membawa seseorang untuk "memilih“ euthanasia atau assisted suicide.

Diskusi

Discussion of this issue often turns on the type of euthanasia involved:

– Active vs. Passive Euthanasia– Voluntary vs. Non-voluntary Euthanasia– Assisted Suicide

Active vs. Passive Euthanasia Active - roughly, involves killing a patient

– E.g., administering a fatal dose of morphine to a terminally ill cancer patient

– This is often what people have in mind when they simply speak of euthanasia

– Be careful to distinguish killing from murdering (‘wrongful killing’) – not all killings are murders

Passive - roughly, involves letting a patient die

– E.g., failing to revive a patient who has signed a DNR order

Two Kinds of Passive Euthanasia

(i) Withholding of Treatment e.g., not performing a needed surgery or not administering a needed drug

(ii) Cessation of Treatment e.g., turning off a respirator

Question:  While i above seems clearly passive, why is cessation of treatment passive?

– Rachels: "what is the cessation of treatment ... if it is not 'the intentional termination of the life of one human being by another'?" (375)

– Answers to this question tend to rest on claims about ‘naturalness’

Voluntary vs. Non-voluntary Euthanasia Voluntary - killing or letting die a competent

person who has expressed a desire for this (usually over a sustained period of time).

Non-voluntary - killing or letting die when the patient is unable to express such a desire

– Note: there is a difference between involuntary and non-voluntary

– Involuntary euthanasia is not a seriously considered possibility

Assisted Suicide

Not actually euthanasia, since the 'patient' ultimately kills himself or herself.

The line between the two can, however, become very thin.   – e.g., Dr. Jack Kevorkian's 'Mercitron'  

Many of the same issues arise in considering assisted suicide as in considering euthanasia,

– e.g., the Sue Rodriguez case (pp. 366-372)

The Law Very roughly, the following summarizes the Canadian

legal situation re. euthanasia

• voluntary passive euthanasia = legal • in fact, required

• voluntary active euthanasia = illegal• although see ‘The Doctrine of Double Effect’

• non-voluntary passive euthanasia = legal • under appropriate proxy decision

• non-voluntary active euthanasia = illegal• although again see ‘The Doctrine of Double Effect’

• assisted suicide = illegal• see the Sue Rodriguez case (pp. 366-372)

Voluntary Passive Euthanasia

As noted, this is the least controversial form of euthanasia 

It is now a well established principle that a competent patient has a right to refuse treatment, including lifesaving treatment

– But why?

– The short answer: because of the central role of informed consent – no consent, no treatment

A Longer Answer: The Autonomy/ Dignity Argument for VPE P1:  A weakened, dying patient has lost control over

her life in a significant way.

P2:  Allowing the patient control over how her life ends provides a way of preserving her autonomy and her dignity (as far as is possible).

P3:  Dignity and autonomy are very important values.

C:  In order to preserve the patient's dignity and autonomy, a terminally ill patient should be allowed to choose when treatment will be withheld or withdrawn.

Two Questions about the Autonomy/Dignity Argument

1. Does this argument apply only to terminally ill patients?  If autonomy is so important then why shouldn't the patient's wishes be respected even if she is not terminally ill?

– E.g., The anorexic patient who refuses force-feeding– A rational, healthy patient who simply wants to be allowed to

starve himself to death.

Because of the stress placed on informed consent, issues of competence are often raised.

– Those who think a request for cessation of treatment will be easily agreed to are often mistaken, particularly when the family or medical staff don’t agree

Two Questions about the Autonomy/Dignity Argument2. Does this argument also support assisted suicide or

active euthanasia?   – A common response:  ‘No.  There is a morally significant

difference between killing and letting die.  While autonomy provides a ground for allowing the person to die.  It provides no grounds for active killing.’  

– The American Medical Association (1973):  While "[t]he cessation of the employment of extraordinary means to prolong the life of the body ... is the decision of the patient and/or his immediate family," "mercy killing ... is contrary to that for which the medical profession stands." (372)

James Rachels challenges this view.  He claims the distinction between killing and letting die is morally irrelevant. (372-376)

Rachels on Active vs. Passive Euthanasia "once the initial decision not to prolong his [i.e., a

patient with incurable cancer] agony has been made, active euthanasia is actually preferable to passive euthanasia". (373)

– Objection: But killing is morally worse than letting die!

– Response:  Rachels claims that we have been misled by the fact that most actual cases of killing are morally worse than most actual cases of letting die

– Because of this, we have made the mistake of concluding that there is some deep moral difference between killing and letting die.

Cases

(i) A unconscious patient will almost certainly die unless paced on a respirator. His family explain he has expressed a clear desire not to be placed on one. He is treated according to those wishes and dies.

(ii) Case i, but the man is placed on the respirator before his family arrive. After his wishes are explained, he is removed from the respirator and dies.   – Are these cases of killing or letting die? – Are these cases morally different?

Cases

(1) A man drowns his young cousin so that he won't have to split an inheritance with him.

(2) Case #1, except, before he can kill him, the cousin slips and falls face down in the bathtub. The man just has to watch his cousin drown.   – Are these cases of killing or letting die? – Are these cases morally different?

Cases

(a) In accordance with an ALS patient's wishes the doctors remove her from her respirator. She dies.

(b) A greedy son removes an ALS patient from her respirator because he wants to collect his inheritance. She dies.

– Are these cases of killing or letting die? – Are these cases morally different?

Is Rachels Right?

Do the cases make a convincing argument that the difference between active and passive euthanasia is morally irrelevant?

If so, then what is morally relevant?

Non-voluntary Euthanasia Until relatively recently, NPE & NAE were largely

looked upon as morally unacceptable

Two ways in which NPE has become somewhat accepted

– By appeal to standards of personhood When the person is ‘gone’, NPE is generally accepted E.g., ‘Harvard Brain Death’ = loss of virtually all brain activity

including brain stem

– By proxy Under certain conditions, a proxy decision to refuse or suspend

treatment is generally accepted even if the person is still arguably there

But recall Re. S.D. from lecture on consent, there are limitations on these decisions

The Case of Karen Quinlan 1975 - Quinlan goes into a drug induced coma Suffers anoxia (loss of oxygen to the brain) causing irreversible

brain damage Required a ventilator/respirator to live Not brain dead, but in a persistent vegetative state

(unconscious) Quinlan’s sister - "If Karen could ever see herself like this, it

would be the worst thing in the world for her." Hospital - '1 in a million' chance of recovery Family sought to have her removed from the respirator, doctors

& hospital refused. 1976 - N.J. Supreme Court overturns a lower court decision and

rules in favour of the Quinlans. Doctors 'weaned' her off the respirator in a successful attempt to

keep her alive. Died of pneumonia - June 13, 1986

The Case of Nancy Cruzan June 11, 1983 - Cruzan, 24, suffers anoxia as a result of a car crash,

enters a p.v.s.

Kept alive by a feeding tube

Parents sought permission to disconnect their daughter's feeding tube

June, 1990 - U.S. Supreme Court rules that in the absence of 'clear and compelling' evidence of Cruzan’s wishes, it may not be disconnected.

Publicity brings new witnesses (who knew her as Nancy Davis, her married name). 

In a new trial, a lower court rules the 'clear and compelling' standard has now been met.

Dec. 14, 1990 - N.C. is disconnected & subsequently dies

– Many commentators thought that the fact that Cruzan required only a feeding tube (not a respirator) made a significant moral difference

Limits on Non-Voluntary Euthanasia

NAE is still very controversial– E.g., the Robert Latimer case

The limits of NPE are also controversial– E.g., Re. S.D. – Robert Wendland (Topic of Groupwork)

A Continuum of Conditions

Coma– Brain activity, but no consciousness or

wakefulness. Persistent Vegetative State (PVS)

– Wakefulness, but no awareness Minimally Conscious State (MCS)

– Wakefulness and minimal awareness Quite Different: Locked-in Syndrome

– Full consciousness, but extreme paralysis

Minimally Conscious State

“a condition of severely altered consciousness in which minimal, but definite, behavioral evidence of self or environmental awareness is demonstrated.”

May be temporary or permanent Criteria (at least one of):

– following simple commands – gives yes or no responses, verbally or with gestures– verbalizes intelligibly– demonstrates other purposeful behavior …. in direct

relationship to relevant environmental stimuli

Minimally Conscious State

Unlike PVS, those in a MCS can feel pain, etc. “meaningful, good recovery after 1 year in an

MCS is unlikely” “being nonfunctioning and aware to some

degree is worse than being nonfunctioning and unaware”– Ronald Cranford

“MCS is not a diagnosis; it is a value judgment.” – Diane Coleman, president, Not Dead Yet

The Case of Robert Wendland

NPE is now generally accepted when a patient is in a PVS

Recently there have been controversies about whether NPE is appropriate in other sorts of conditions, specifically for patients in a permanent MCS

– One way of understanding these controversies is as linked to our conception of personhood – the more restrictive the conception, the greater range of cases in which NPE is accepted

Robert Wendland

Suffered brain damage in a car accident in 1993

Wendland was supposedly in a permanent Minimally Conscious State (MCS)

Could respond to simple commands. Wife and children claimed he never

recognized them Mother claimed he would cry and kiss her

hand during visits

Robert Wendland

His mother opposed the attempt by his wife to have Wendland’s feeding and hydration tube removed

Wendland died in July 2001 of pneumonia before California Supreme Court could rule

California Supreme Court eventually ruled against his wife

Question

Assuming his wife’s description of Wendland’s condition was accurate, would NPE of Wendland have been morally acceptable?

Why or why not?

The Doctrine of Double Effect (DDE) Suppose an action (e.g., giving a terminally ill cancer

patient morphine) has some reasonably foreseeable outcome (e.g., quickening the patient’s death) and that it would be unacceptable to perform this action for the purpose of bringing this outcome about.

The DDE claims that it may still be acceptable to perform this action, provided that the action is not performed for the purpose of bringing this outcome about.

– E.g., it may still be acceptable to give the patient the morphine provided that it is given in order to control his pain.

– The DDE is commonly, if not explicitly, appealed to in practice. In this sense, VAE. & NAE. are quite often practiced.

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Role of Physicians Di kedua negara, dokter tidak diwajibkan

untuk melaksanakan praktik ini jika euthanasia bertentangan dengan hati nurani mereka.

Dokter harus merujuk pasien mereka sehingga pasien harus tahu sebelumnya bahwa mereka tidak dapat mengharapkan layanan ini dari mereka.

Dokter merupakan minoritas kecil. Mereka tidak bisa melayani di komite karena

euthanasia ada pada menu yang tersedia praktek medis.

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Role of Physicians

Di kedua negara, dokter diwajibkan untuk mencurahkan tenaga pada pasien dan orang-orang terkasih itu, untuk berkonsultasi dengan spesialis lainnya, menghabiskan waktu dan komunikasi yang baik antara semua orang yang bersangkutan.

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Reporting Di Belanda, semua kasus euthanasia harus dilaporkan

ke komite setempat. Dalam Belgia, semua kasus harus sepenuhnya

didokumentasikan dalam format dan khusus disajikan untuk tetap komite pemantauan, evaluasi dan Nasional Pengendalian Komisi untuk euthanasia, yang didirikan oleh pemerintah pada bulan September 2002.

Kerja sama: The Komite / Komisi perlu kajian yang terdaftar dan sepatutnya euthanasia menyelesaikan dokumen yang diterima dari dokter. Memastikan apakah mereka yang melakukan euthanasia sudah dilakukan sesuai dengan prosedur dan ketentuan yang tercantum dalam undang-undang.

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Reporting

Sementara di Belanda ada lima komisi daerah, di Belgia ada satu komisi.

Di Belanda, nama-nama dokter yang direview dikirimkan ke komite regional. Anggota komite dapat memanggil dokter untuk pertanyaan apakah mereka merasa ada sesuatu dalam proses pengambilan keputusan yang cacat.

Di Belgia, nama-nama dokter tetap anonim. Komisi sebagai aturan umum hanya melihat lbagian yang terbuka dari aporan dokter. Hanya apabila ada keraguan tentang prakteknya, komisi yang dapat memutuskan untuk memberikan suara atau tidak mereka juga harus melihat bagian yang berlainan. Belanda sistem arguably lebih baik lagi karena ada umpan balik antara daerah dan komite dokter.

Komisi di Belgia yang memiliki informasi lebih terbatas.

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Palliative Sedation

One of the worrisome consequences of the Dutch law is increase in the number of patients receiving palliative sedation.

Palliative sedation involves the administration of deep sleep-inducing medication to patients who have at most two weeks to live.

There was a substantive increase in the use of palliative sedation after the introduction of the law from 8,500 to 9,600.*

* Agnes van der Heide, Bregje D. Onwuteaka-Philipsen et al., “End of Life Practices in the Netherlands under the Euthanasia Act”, New Eng. J. of Med., Vol. 356, No. 19 (May 10, 2007): 1957-1965.

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Palliative Sedation

Terminal sedation is not euthanasia, or as some people in Belgium and the Netherlands term “slow euthanasia”.

Euthanasia requires the consent of the patient, while terminal sedation does not by definition requires consent.

The fear of abuse is great. Experts told me that terminal sedation happens frequently in

ICUs. Physicians conceive the practice as the middle approach between euthanasia and withholding treatment.

It is estimated that 8% of all death cases in Belgium in 2001 were cases of terminal sedation, about 4,500 cases in Flanders alone.*

* Johan Bilsen, Robert Vander Stichele, Bert Broeckaert et al., “Changes in Medical End-of-Life Practices during the Legalization Process of Euthanasia in Belgium”, Social Science and Medicine, Vol. 65, Issue 4 (2007): 803-808.

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Palliative Sedation

There is no knowledge whether the patient's consent was sought or given.

At present the Dutch and Belgian physicians do not have clear directives on this.

There is no legal regulation, no public or professional scrutiny to examine to what extent the procedure is careful, and there is no knowledge whether consultation was provided

This situation calls for a change. There should be clear guidelines when it is appropriate, if at all, to resort to this practice.

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Should Physicians Suggest Euthanasia to Their Patients? Dutch study shows that the initiative for discussion

about the action to be performed at the end of life came from the patient in only about half of the cases.*

There is a difference between discussing with the patients what options are available, and suggesting euthanasia.

GP system in both countries, of close relationship between physicians and patient.

Euthanasia in both countries is not a secret, and now it is in the light, within the confines of the law.

* P.J. van der Maas, J.J.M. van Delden, and L. Pijnenborg, Euthanasia and other Medical Decisions Concerning the End of Life, Health Policy Monographs (Amsterdam: Elsevier, 1992), p. 156.

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Should Physicians Suggest Euthanasia to Their Patients? Compromising voluntariness: when euthanasia is

suggested, the very suggestion might undermine the patient’s voluntary wishes.

When all is said and done, all the physician has to offer him is death.

Physicians have great influence over their patients. Indeed, the patients' choices may reflect their physicians' attitude.

Discussion about euthanasia should be conducted with the utmost precaution in order to avoid making the patient feel pushed in a certain direction.

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Definisi Euthanasia• Euthanasia is the deliberate killing of a person for the

benefit of that person.• Sengaja membunuh seseorang untuk kepentingan

orang tersebut

• Banyak negara menentang euthanasia, beberapa negara me lagalkannya. Negara yang menentang euthanasia menganggap ini adalah suatu pembunuhan. Di Ingris orang yang memepertanyakan euthanasia secara hukum berhadapan dengan pengadilan pd waktu mencoba utk melegalisasikannya