Globally, various positive developments
have happened this year to obtain choices for a dignified death,
according to the World Federation of Right to Die Societies
(an international non-governmental organization with 38 member
societies in 23 countries, from Australia to Zimbabwe).
Around the world, living wills - allowing someone to state which
medical treatments one would or would not want if one no longer
had the mental capacity to make such decisions - are becoming
more and more acceptable, and, especially in North America,
Europe and Australia, are increasingly enforceable legally.
In several countries, such as Israel and Spain, centralized
computerised databases are developing to record individuals'
end-of-life choices. Health care proxies, having the legal power
to make decisions on behalf of someone who has become mentally
incompetent, are gaining public and political support - these
have varying titles such as "Enduring Guardians" in Tasmania
and "Welfare Attorneys" in Scotland. In Britain, a new pro-choice
living will allows everybody to choose the right treatment options
for themselves. Personal choice is surely the basis for all
laws ensuring a dignified death?
Throughout history, doctors (and families) have decided when
to withhold or withdraw medical treatment when patients are
near death. Once called "passive euthanasia", there is general
acceptance now in most countries that this is "good medical
practice". Recent efforts by the pro-life, anti-choice lobby,
especially in Australia and Britain, to have artificial tube
feeding and hydration regarded as basic nursing care, and not
as medical treatment, fortunately failed in 2003.
Earlier this year, an expert group of the European Association
for Palliative Care noted "In terminal sedation the intention
is to relieve intolerable suffering, the procedure is to use
a sedating drug for symptom control and the successful outcome
is the alleviation of distress. In euthanasia the intention
is to kill the patient, the procedure is to administer a lethal
drug and the successful outcome is immediate death". Terminal
sedation is increasingly regarded as "normal medical treatment".
But, surely it is really "slow euthanasia" over several days
(as life-sustaining interventions are withheld), and allows
physicians, who want to help terminally-ill patients, to easily
break the law? And, as an article in the European Journal of
Palliative Care recently noted "We need the option of (terminal)
sedation as the final barrier against euthanasia".
Public opinion polls in Australia, Europe and North America
continue to show extensive support for legalized physician-assisted
dying, with around 80% or more in favour. Even in countries
with strong religious traditions, such surveys can be interesting:
for example, in France, 75% of practising Catholics want to
decriminalize euthanasia.
Some individual societies of the World Federation have large
memberships: both those in The Netherlands and in Japan have
over 100,000 (in the latter country, 2600 members are in their
nineties and over 20 are more than 100 years old): Japan will
host the World Federation's biennial conference in 2004. And,
moving with the times, some societies are renaming themselves,
such as "End-of-Life Choices" for the former Hemlock Society,
in the United States, and "Right to Die - NL" in The Netherlands.
Regionally, the European societies are now, as "Right to Die
- Europe", working very closely together, becoming increasingly
pro-active. And, in the USA, closer cooperation between several
societies is also developing.
Medical end-of-life decisions (withholding or withdrawing treatment,
generously providing drugs to alleviate terminal symptoms and
perhaps hasten death, assisted suicide and euthanasia) frequently
precede dying. In June, a survey of six European countries (Belgium,
Denmark, Italy, The Netherlands, Sweden and Switzerland) revealed
that the proportion of deaths that were preceded by an end-of-life
decision ranged from 23% in Italy to 51% in Switzerland. Then,
in July, from New Zealand, it was reported that at the last
death attended by 1100 physicians, in that country, for 63%
of them there had been "a medical decision that could hasten
death".
Fortunately, many physicians and nurses see assisted suicide
and euthanasia as a caring response to intractable human suffering.
While national medical leadership (except in The Netherlands
and Switzerland) generally tends to resist supporting a change
in the law, other physicians are more understanding. For example,
a survey of 917 French doctors, reported in September, showed
that 43% of them believed "euthanasia should be legalized, as
in The Netherlands". Another survey, published in October in
Spain, revealed that 59% of 1057 physicians there were in favour
of legislation. Today, at least 85% of Dutch physicians support
the law on assisted dying which exists in that country. And,
a poll of 2700 British nurses, in November, showed that nearly
two-thirds wanted the law against euthanasia changed.
Around the world, various parliamentary assemblies have been
debating the issue of legalized assisted dying in the past year.
In Britain, the Guernsey States of Deliberation voted 38 to
17, and the Isle of Man House of Keys voted 15 to 7 to establish
committees to investigate the possibility of local laws (their
reports will appear in 2004); and the House of Lords held a
one-day debate in June, evenly divided, on a Patient (Assisted
Dying) Bill.
In the Luxembourg parliament, in March, a bill to decriminalize
voluntary euthanasia was defeated by one vote, 28 to 27, with
one abstention and four absentees: this issue will be raised
again during their general election next year.
In China, in March, 32 members of the National People's Congress
presented a motion for legalized euthanasia, with pilot schemes
to be introduced first in Beijing and Shanghai.
In July, in New Zealand, legislators voted 60 to 57, with one
abstention and two absentees, against a Death with Dignity Bill:
previously, in 1995, a similar bill was defeated 61 to 29, with
many abstentions.
In September, the Social, Health and Family Affairs Committee
of the Council of Europe's Assembly (where representatives of
the World Federation and Right to Die - Europe testified in
2002 and 2003) approved a report which called on European states
to collect and analyse empirical evidence about end-of-life
decisions, and to consider decriminalizing euthanasia - this
Committee's report is likely to be discussed in the Assembly
in January 2004. The Council of Europe's NGOs and Civil Society
Division has encouraged the World Federation to "establish working
relations with the appropriate services" of this intergovernmental
organization.
In October, in France, following the hastened death of quadriplegic
Vincent Humbert, the National Assembly established a Commission
to investigate issues relating to the "end of life".
Next year, in the United States, draft physician-assisted suicide
laws are due to be discussed in the Vermont legislature, and
again in Hawaii (where a proposal was defeated by only three
votes in 2002). In Australia, in New South Wales, Queensland,
South Australia and West Australia, state parliaments are expected
to be debating assisted dying bills within the next twelve months.
In Switzerland, a federal commission will continue to examine
the possibility of legalizing the existing practices in that
country (including the activities of Dignitas - a group which
uniquely provides assistance for foreigners). And, it is still
possible that the Colombian parliament might finally debate
the 1997 decision of its Constitutional Court in favour of voluntary
euthanasia.
Fortunately, physician-assisted dying continues to be openly
permitted in Belgium, The Netherlands, Oregon and Switzerland.
In these places, terminally-ill patients have "peace of mind"
knowing that they have an escape from possible intolerable suffering
with the help of physicians who do not need to act in secrecy.
These patients have greater control and choice of how and when
they die. And, legislation has generally established strict
and transparent procedures which is important for everyone.
Good palliative care exists in all these areas where physician-assisted
dying is presently possible. Ideally, such assistance should
be an option within the provision of all palliative care services
everywhere.
In Belgium, where their law on euthanasia came into force in
September 2002, present evidence indicates that generally everything
is going well, with increasing support from the medical profession.
The first official statistical and evaluation report, from the
Federal Commission of Control on Euthanasia, will be made in
2004.
In The Netherlands, where physician-assisted dying has been
possible since 1981, the latest official report (once, popularly
called the "Remmelink report" around the world) was issued in
May. Covering the year 2001, it estimated the number of cases
of euthanasia to be about 3500 (2.5% of all deaths) and of assisted
suicide as about 300. In particular, it was noted that "the
practice of medical decision-making relating to the end of life
in The Netherlands appears to be stabilized....there are no
signs indicating an increase in life-terminating treatment among
vulnerable patient groups". Thus, no evidence of any "slippery
slope", a favourite expression of the anti-choice lobby.
In a separate report, issued in July, it was interesting to
note that "the bereaved family and friends of cancer patients
who died by euthanasia coped better with respect to grief symptoms
and post-traumatic stress reactions than the bereaved of comparable
cancer patients who died a natural death" (77% of the cases
of euthanasia in 2001 in The Netherlands were for cancer).
Every year, an official report is issued in Oregon, where physician-assisted
suicide has been legal since 1998. In March, it was noted that,
in 2002, 33 physicians wrote prescriptions for lethal medications
for 58 terminally-ill patients who qualified for such assistance;
and 36 of these patients died this way. There is increasing
medical support in Oregon for its law: now, at least 400 physicians
have indicated their willingness to write prescriptions. As
in The Netherlands, there is no evidence of any "slippery slope",
or of one irresponsible physician being overgenerous with issuing
too many prescriptions. However, the Oregon law is not free
of its opponents: the federal Department of Justice continues
to take the state authorities to court, and it is possible that
this federal-state dispute may reach the US Supreme Court in
2004.
The Swiss Academy of Medical Science has stated that "Contrary
to its former position, (it) believes today that, in certain
cases, assisted suicide may be considered part of the doctor's
activities". Annually, about 150 assisted suicides occur in
Switzerland, mainly in the German-speaking, predominantly Protestant
areas.
A final comment - If physician-assisted dying is permitted in
Belgium, The Netherlands, Oregon and Switzerland, then why not
elsewhere? Around the world, everybody should be asking, "Are
we so different from the Belgians, the Dutch, the Swiss, or
those who live in Oregon?"
