Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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An even greater distraction
- Peter Singer (8 June 2001)
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Correct but Incomplete
- Roger Albin (8 June 2001)
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The Concept of 'Why Not?'
- William P Gruzenski (9 June 2001)
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enforcing values
- J Calinas-Correia (9 June 2001)
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paternalism reinvented
- Wim Ceelen (11 June 2001)
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Re: enforcing values
- Joseph Watine (11 June 2001)
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A one-sided argument?
- Roger M Goss (17 June 2001)
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Euthanasia already exists
- Jeremy Dearling (19 June 2001)
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Euthanasia
- Steve Brennan (23 June 2001)
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Euthanasia already happens
- Jeremy Dearling (26 June 2001)
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Parental values.
- Vaishali Mona Verma (2 July 2001)
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Include "slow euthanasia" data
- Michael H K Irwin (6 July 2001)
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Peter Singer, Sun Life Financial Chair and Director University of Toronto Joint Centre for Bioethics
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Hooray, Zeke got this exactly right! His argument is that euthanasia is a distraction from the real issue -- quality end of life care. An even greater distraction is that virtually the entire focus of efforts in end of life care is on the 8 miliion deaths per year in high income countries, with almost no attention to the 46 million deaths in middle and low income countries. Of the many articles published on end of life care, only a handful address the quality of this silent majority of deaths. Just another example of the most pressing ethical challenge in the world: the inequities in global health. |
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Roger Albin, Professor of Neurology University of Michigan
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Dr. Emanuel's cogent essay misses an important point about physician assisted suicide and physician mediated euthanasia. For many individuals, it is likely that that the key issue is not pain and suffering but rather the loss of autonomy produced by serious illness. The option of suicide or euthanasia is a means to reassert personal autonomy. Improving end of life care, a highly desirable goal, will not alter this this fundamental existensial problem. |
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William P Gruzenski, Chief of Clinical Services Clarks Summit State Hospital
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Dear Sir: Why not? It is very difficult for one to have the 'vision' of seeing something neutral. Yet, science is neutral. The rest we apparently color. Facts are neutral and perception is not fact but choice. Ask yourself 'why not?' If the answer you come up with has that neutrality then by all means grasp hard onto this. If not, consider that an open mind might be more useful for us at the present time. William Gruzenski |
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J Calinas-Correia, medical practitioner Cornwall
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Editor, I believe the editorial by Ezekiel Emanuel to be a disservice to the cause he purports to defend. The relevance of euthanasia is assessed against crude mortality. This is an extremely biased presentation of the issue. First, one has to exclude all deaths in which medicine plays no role or a very minor one. What relevance is there in saying that euthanasia plays no role in sudden death? Thank you, we already knew that, and it adds nothing to the discussion. We are talking about deaths where there is time to see death coming, about established and protracted suffering with time to explore - and exhaust - therapeutic options. The Dutch study states that only 42% of all deaths in the Netherlands involved medical decisions. There is also a fallacy in the assertion that euthanasia is counterproductive. The idea that with more or less comfort, there is nothing to be done about the length of the terminal period allows some complacent attitudes, which stand in the way of high quality terminal care. The claim that euthanasia is a shortcut to avoid expensive palliative care ignores that it is real people, with real feelings, who is involved in the deaths of loved ones or of their patients. The claim that the normal person will accept even considering euthanasia without satisfying him or herself that all that could be offered was indeed offered is a very cynical view of humankind. Indeed, I would see euthanasia as pressing the cause of high quality palliative care. To address, even to consider the possibility of euthanasia with the patient and his or her relatives, without being prepared to address all possible alternatives and the use made of them in each particular case, would invite severe disciplinary and legal consequences, and above all would be morally indefensible. This is supported by the Dutch study quoted: “Indeed, the increased frequency of consultation and better documentation of cases can be considered to indicate better decision making.” Euthanasia can only exist within a system providing high quality palliative care, otherwise we are discussing death as a means to escape avoidable torture, and the perpetrator will be guilty of both crimes. However, I am not a supporter of euthanasia. I would not rule it out, but I would like to be satisfied that there was some kind of physical incapacity preventing suicide, so that the hands of another person were called to perform the actions intended by the patient. This would probably restrict euthanasia to a much rarer occasion than presently happens in the Netherlands. Obviously, I have no such qualms regarding physician-assisted suicide. At the end, why would anyone want to die amidst attempts to control one's Clostridium difficile diarrhoea which drenches the bed several times a day, or with that pain that is always a step ahead of the ever increasing analgesic doses/interventions, or slowly observe one's body fading away and becoming a living corpse? Different people tolerate in different ways the different processes of dying. It is interesting to note that the Oregon study states that higher education was a predictive factor to choose physician-assisted suicide. As pointed by Dr Albin, it is not just pain, but the loss of control over one's body, with the loss of dignity it implies, that drives patients into hastening the time to die. While medicalising death, we are also getting our patients trapped within the system of values which operates in medical institutions, and it seems we are becoming ever more eager not to allow the patient to escape from those values we decided to enforce. What I cannot see the point of, what I cannot believe to be defensible, is the attitude that one-size-fits -all, that all patients should be grateful and happy with proper and dignifying palliative care. The underlying message is that those who do not, those whose dignity is not preserved by having a stranger washing their body which they cannot control anymore, those who do not feel satisfied with the best we may offer, will have to endure what we decide for them, because we want them to be the living proof of our own values even while they are dying. It was Emanuel who in 1996 presented evidence (Lancet 1996 Jun 29;347(9018):1805-10) that while acceptable to the majority of the public and to the patients, euthanasia and physician- assisted suicide was unacceptable to the majority of oncologists interviewed. There are thus no excuses for his attempted dismissal of the relevance of the issue: he is dismissing patients and public views, to enforce the medical doctrine, and he knows it. The problem with euthanasia is not about its interference with proper care, but about values and judgements to be imposed on the number of patients who may potentially benefit from it according to their own account. The number of deaths prevented by pre-hospital cardiopulmonary resuscitation is small. Using Emanuel's argument one probably should both stop considering euthanasia, and also stop CPR provision in the community, as both may be seen as "diverting effort away from the more mundane but consequential activities necessary to improve end of life care". If we do care about the small number we save with defibrillation in the streets, why can't we care about the small number who does not want to carry on with the best care we can offer? |
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Wim Ceelen, surgeon ghent university hospital, Ghent, Belgium
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Sir In this sensitive area, clear definitions of the discussed practices are essential. Mr Emanuel includes all forms of medical therapy that shorten life as 'euthanasia'. The term is, however, nowadays to be reserved for the (rare) situation in which life is ended by the physician on the explicit and repeated demand of the patient himself. It is therefore, in my opinion, incorrect to refer to the Nazi crimes in this respect. I certainly agree with the author's standpoint about improving the quality of palliative care. This should not, however, lead to a paternalist attitude towards a dying patient's right to self-determination. As already highlighted by Dr Calinas-Correia, this basic right should, in the event of a repeated and informed demand for euthanasia, prevail over the moral, philosophical or religious attitudes of the treating doctor. |
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Joseph Watine Hôpital de Rodez, France
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One of the big problems with legal euthanasia is that it might help some doctors, nurses, or related professionals to better conceal some of their criminal “mistakes” and other “unintentional” murders. |
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Roger M Goss, Consumer member BMJ Editorial Board
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LETTERS TO THE EDITOR 17 June 2001 A one-sided argument? Editor - Emmanuel's use of statistics and choice of examples is misleading and incomplete. (1) His figures do not include the number of lives ended because doctors deemed this in the patients' best interests, rather than at their request. It is this unregulated practice in many countries that may give cause for serious concern. The Belgian Senate is now studying proposals to legalise voluntary euthanasia. A bill was recently introduced in the South Australian parliament. The federal government is considering legislation that would make living wills enforceable throughout Spain. Supporters of voluntary euthanasia or physician assisted suicide may well argue that legislation in this field would promote patient choice and alleviate unavoidable suffering. Whether this is an irrelevant goal for a caring profession is debatable. Improvements in palliative care will hopefully over time reduce the number of people for whom voluntary euthanasia or physician assisted suicide is the only solution to their misery. Meanwhile, shouldn't we at least consider whether depriving them of this option is humane? Roger M. Goss Consumer member BMJ Editorial Board (1) Emmanuel J. Euthanasia: where the Netherlands leads will the world follow? BMJ 2001; 322: 1376-1377 (9 June) |
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Jeremy Dearling, Staff Nurse Stroke Unit, The Queen Elizabeth Hospital, King's Lynn
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Dear Editor, RE: “EUTHANASIA: WHERE THE NETHERLANDS LEADS WILL THE WORLD FOLLOW?”. (1) Mr Emanuel misses the point. The question is not should we debate whether to legalise euthanasia. Euthanasia already happens, and is widely supported,(2). The question is, should we regulate existing practice using the Netherlands model? Yours faithfully, Jeremy Dearling RN(A), RCN, Dip HE(Nursing),
1.Emanuel, E. J. BMJ. 7299, p1376-1377 2. Davis et al 1993, “An international perspective of active euthanasia: attitudes of nurses in seven countries”, International Journal of Nursing Students, 30 (4): 301-310. Di Mola, Borsellino et al 1996, “Attitudes toward euthanasia of physician members of the Italian Society for Palliative Care,” Ann Oncol, November:7(9):907- 11. Folker et al 1996, “Experiences and attitudes towards end of life decisions amongst Danish physicians”, Bioethics,10:3. Grassi, Agostini, and Magnani 1999, “Attitudes of Italian doctors towards euthanasia and assisted suicide for terminally ill patients”, Lancet, 7th November, Grassi, Magnani, and Ercolani 1999, “Attitudes toward euthanasia and physician assisted suicide among Italian primary care physicians”, Journal of Pain Symptom Management, March:17, (3): 188-96. Jowell et al 1996, “British Social Attitudes: the 13th report”, Social and community planning research, Dartmouth. Mclean and Britton 1996, “Sometimes a small victory”, Institute of law and ethics in medicine, University of Glasgow. McCormack 1998 “Quality of life and the right to die: an ethical dilemma”, Journal of Advanced Nursing, Vol 28, no. 1, pp 63-69. Radulovic and Mojsilovic 1998, “Attitudes of oncologists, family doctors, medical students and lawyers to euthanasia”, Support Care Cancer, July; 6 (4):410-5. (Shah, Warner, Blizard and King 1998, “National survey of UK Psychiatrists’ attitudes to euthanasia”, Lancet, 24th Oct. 1998; 352,9137:1360. Schioldborg 1999, “Students attitudes to active euthanasia”, Tidsskr Nor Laegeforen, June 30th; 119 (17):2515-9. Tijmstra, Kempen and Ormel 1997, “End of life and termination of life: opinions of elderly persons with health problems”, Ned Tijdschr Geneeskd, December; 141(50):2444-8. Vega Vega, and Moya Pueyo 1992, “Attitudes towards active euthanasia and its legislation in Spain”, Med Clin (Barc), 98(14):545-8. Vincent 1999, “Foregoing life support in western European Intensive Care Units: the results of an ethical questionnaire”, Critical care Medicine, August; 27 (8): 1626-33. Ward and Tate 1994, “Attitudes among NHS doctors to requests for euthanasia”, BMJ, 308:1332-4, British Medical Journal. Surveys published in “Pulse” 1997, “Doctor” 1995, the Nursing Times 1997, and the BMA News Review 1996, an NOP Poll 1987, and surveys commissioned by the Dutch Social and Cultural Planning Bureau 1966-1991, |
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Steve Brennan, Consultant Physician. Northern General.Sheffield.S5 7AU
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Dear Sir, I was somewhat reassured by Emanuel's leading article on Euthanasia,but I do not share his opinion that we would be unlikely to legalise Euthanasia in the UK.While I very much hope we do not legalise it,and thankfully we have a very strong Hospice movement,I am afraid we in the medical profession in the UK do not have much in the way of ethical standards left.Years of working in a National Health Service and the ease with which we immediately worked with the 1967 Abortion Act lead me to feel that,if Parliament passed a Law allowing it,we would soon "fall in".We still see very little genuine training in Ethics in our Medical Schools, and like the rest of the population,we are largely apathetic about these things.I do hope I am wrong. Yours truly, Steve Brennan. | |||
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Jeremy Dearling, Staff Nurse The Stroke Unit, Queen Elizabeth Hospital King's Lynn
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Dear sirs, Mr Emanuel misses the point. Euthanasia already takes place and is widely supported. The question is not should we allow euthanasia but should we regulate existing practice using the Netherlands model. |
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Vaishali Mona Verma, Convenor Indian Medical Association, Australia Delhi, Medical practitioner
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Dear Ed, In the Hindu faith, it is laid down that the son/a near or dear one will light the funeral pyre..this lays down the duty of the family towards the loved one, to care for the aged and dying...so euthanasia is a faraway possibility..the focus is on family values and human values...there is always someone to care....alas my American friend in India told me how none of the siblings could make it for her mother's last rites in USA (she was cremated in a card-board box) by the State.The sheer non-existence of family support and family responsibility may promote the abuse of 'euthanasia" amongst my western friends. kind regards,
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Michael H K Irwin, Former United Nations Medical Director 9 Waverleigh Road, Cranleigh, Surrey Gu68Bz
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Editor - I believe it is quite mistaken for Ezekiel Emanuel to state that "if the objective is to improve the quality of care at the end of life then the battle over legalising euthanasia is an emotionally charged irrelevance". In my view, physician-assisted suicide and voluntary euthanasia are a matter of personal choice and human rights. Having these options is extremely important for many individuals (including, I suspect, many BMJ readers) and should not be lightly disregarded as a minority issue. In fact, I believe that legalising these two options would make the prospect of palliative care more acceptable to many terminally-ill patients. Also, it is essential, when considering physician-assisted suicide and voluntary euthanasia, to discuss the practice of "terminal sedation" or "slow euthanasia" which is knowingly performed in hospitals, nursing homes, hospices and private homes throughout the world. This is carried out under the doctrine loosely described as the "double effect", by which a physician may lawfully administer increasing doses of regular analgesic and sedative drugs that can hasten someone's death, as long as the declared intention is to ease pain and suffering. Of course, the key word here is "intention". Physicians may, without publicly declaring the true purpose of their action, respond to a terminally-ill patient's request and speed up the dying process in this way. From surveys in The Netherlands, in Australia and in Belgium, we know that "the alleviation of pain and symptoms with opioids in doses with a potential life-shortening effect" caused 19%, 31% and 19% of all deaths in these countries respectively (1). However, if we acknowledge the existance of voluntary slow euthanasia, it becomes clear that at least some of these deaths (perhaps at least a quarter, according to the Belgian figures) should rightly have been included with the relatively low figues for physician-assisted suicide and voluntary euthanasia quoted by Emanuel. (1) Deliens L, Mortier F, Bilsen J, et al. End-of-life decisions in medical practice in Flanders, Belgium: a nationwide survey. Lancet 2000;356:1806-1811 (25 November) (I am the Vice-Chairman of the Voluntary Euthanasia Society) |
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