& Physician Assisted

Suicide

Scope Definitions

Introduction

History

Why Euthanasia

Legal status

Status in India

Euthanasia and Psychiatry

Ethical issues

Conclusion

The term ‘euthanasia’ is derived from the Greek words- ‘eu’ meaning "good“ and ‘thanatos’ meaning "death".

Euthanasia - ‘the bringing about of a gentle and easy death for someone suffering from an incurable and painful disease or in an irreversible coma’ (Pearsall & Trumble, 1996).

Suicide - The act or an instance of taking one's own life voluntarily and intentionally

PAS - the practice of providing a competent patient with a prescription for the patient to use with the primary intention of ending his or her own life. The patient performs the act at a time of their own choosing

Definitions

Introduction

Euthanasia is a controversial subject, not only because there are many moral dilemmas associated with it, but also in what constitutes its definition.

Two of the strongest arguments revolve around patient autonomy and dignified dying.

It is a sensitive subject, with varying legal, ethical and philosophical views.

Furthermore, views and laws in regard to euthanasia differ among various countries, religions and regions.

WHY EUTHANASIA?

Until the 1940’s, medical care was often just comfort care, alleviating pain when possible.

During the last 50+ years, medicine has become increasingly capable of postponing death.

With advancing age, there is a perceived increase in suffering and disability.

Increasingly, we are forced to choose whether to allow ourselves to die.

Relieve suffering, maintain dignity, and shorten the course of dying when death is inevitable.

M.B

Hippocrates (ca. 460 BC - ca. 370 BC)- Euthanasia was practice, no need to preserve the life of a person who had no interest in living, or who thought

life as a burden.

1300s- English jurisdiction- considered as a criminal act. Mercy killing was also not supported by the ascendancy of Christianity (12th till 15th century).

1828- Anti-euthanasia was passed in New York.

1870- Samuel Williams suggested the use of morphine and analgesic medications for assisting quick and painless death.

1885- The American Medical Association strongly declined the use of analgesic for euthanasia.

Beginning of 20th century - mercy killing and assisted killing already entered the minds of the public.

History

1905- A bill for making it legal was circulated in Ohio, but it failed. A similar bill was introduced in the next year, which also failed.

1935- The first group for legalization of euthanasia, called Voluntary Euthanasia Legislation Society (VELS), was founded by a group of doctors in London.

1938- A similar organization, known as National Society for the Legalization of Euthanasia (NSLE) came into existence. Till date, many cases of physician-assisted suicide have been fought in the court.

1940- Non-voluntary euthanasia was practiced for the first time by German physicians, to eliminate the diseased and disabled Germans in closed gas chambers. The main purpose of the program was to get rid of handicapped children and people with psychiatric problems.

1945- It was estimated that 300,000 Germans had been killed.

20th century- Marked the formation of several organizations for addressing the concerns regarding euthanasia.

1986- Doctor Joseph Hassman was charged guilty for administering a lethal dose of Demerol to his mother-in-law. He was fined and sentenced to two years imprisonment for the act.

1999- Euthanasia became a public issue, with the imprisonment of Dr. Jack Kevorkian for conducting voluntary euthanasia on Thomas Youk (52), who was in the final stage of ALS (amyotrophic lateral sclerosis)

Classification and types

• On the basis of the nature of act being done, as:

Active and Passive

• On the basis of consent, as

Voluntary, Involuntary and Nonvoluntary

Active or Positive: It is a positive merciful act, to end useless suffering or a meaningless existence.

It is an act of commission, e.g. by giving large doses of drugs to hasten death.

Passive or Negative: It means not-using or discontinuing the use of extraordinary life-sustaining measures to prolong life.

This includes an act of omission, such as failure to resuscitate a terminally ill or hopelessly incapacitated patient or severely defectively newborn infant.

It involves non-use of the measures that would probably delay death and permit natural death to occur.

Active vs Passive

Voluntary - cases where the person himself requests the commission of euthanasia (active or passive).

Involuntary -  where the person on whom euthanasia is committed is mentally incompetent to make a choice and euthanasia is committed on the basis of the assessment made by others.

Non-voluntary - when a person is unable to give his/her consent, but gives another person the power to make that decision for them.

On the basis of consent

Physician assisted suicide-The physician provides the means, but the patient must act.

The patient maintains more autonomy, remains the actual agent of death, and may be less likely to be coerced.

-Physician-assisted suicide may involve providing

Information on ways of committing suicide

supplying a prescription for a lethal dose of medication or a means of inhaling a lethal amount of carbon monoxide,

providing a suicide device that the patient can operate.

-Jack Kevorkian

Devices

Deliverance Machine

The following three questions were displayed on the laptop screen; each required the patient to click a "Yes" button to proceed:

1. Are you aware that if you go ahead to the last screen and press the “Yes” button, you will be given a lethal dose of medications and die?

2. Are you certain you understand that if you proceed and press the “Yes” button on the next screen that you will die?

3. In 15 seconds you will be given a lethal injection ... press “Yes” to proceed

Dr. Philip Nitschke

The Hemlock Society

Founded by Derek Humphry in 1965

Final Exit, a how-to guide to suicide that was a best seller in 1991

supports physician-assisted suicide and active, voluntary euthanasia for the terminally ill, but it does not encourage suicide in the absence of terminal illness.

The Hemlock Society's efforts influenced the 1994 passage of a ballot initiative to legalize physician-assisted suicide in Oregon and both public and medical opinions toward more accepting attitudes of physician-assisted suicide.

Legal Status

Legal StatusMore than 20,000 deaths registered in six countries: Belgium, Denmark, Italy, the Netherlands, Sweden and Switzerland.

As of June 2015, euthanasia is only legal in the Netherlands, Belgium, and Luxembourg.

Assisted suicide is legal in Switzerland, Germany, Albania, Colombia, Japan and in

The US states of Washington, Oregon, Vermont, New Mexico and Montana.

February 13, 2014, Belgium became the first country to allow voluntary child euthanasia without any age limit.[

NETHERLANDS

First nation to permit euthanasia

The law allows medical review board to suspend prosecution of doctors who performed euthanasia when each of the following conditions is fulfilled:

the patient's suffering is unbearable with no prospect of improvement

the patient's request for euthanasia must be voluntary and persist over time the patient must be fully aware of his/her condition, prospects and options

there must be consultation with at least one other independent doctor who needs to confirm the conditions mentioned above

the death must be carried out in a medically appropriate fashion by the doctor or patient, in which case the doctor must be present

the patient is at least 12 years old

Groningen Protocol

For the Dutch public prosecutor, the termination of a child's life (under age 12) is acceptable if 4 requirements were properly fulfilled:

 The final decision about "active ending of life on infants" is not in the hands of the physicians but with the parents, with physicians and social workers agreeing to it. 

The presence of hopeless and unbearable suffering

The consent of the parents to termination of life

Medical consultation having taken place

Careful execution of the termination

The Status in India

Cases Of Significance Maruti Dubal vs State of Maharashtra 1986 – Article 21

includes right to die.

Airedale Trust v.Bland 1993

P.Rathinam vs Union of India 1994

“Suicide, as has already been noted, is a psychiatric problem and not a manifestation of criminal instinct. We are in agreement with Dr (Mrs) Dastoor that suicide is really a "call for help" to which we shall add that there is no "call for punishment"

Gian Kaur vs State of Punjab 1996 – Right to die is not part of article 21.

CA Thomas Master vs Union of India – 80 year old man wanted to voluntarily end life. – Writ was dismissed , no distinction between suicide and voulteering to die.

Aruna Shanbaug case

Aruna Shanbaug was a nurse working at the King Edward Memorial Hospital, Parel, Mumbai. On 27 November 1973 when she was strangled and sodomized by Sohanlal Walmiki, a sweeper.

She has been in a vegetative state since.

Pinki Virani, a social activist, filed a petition in the Supreme Court arguing that the "continued existence of Aruna is in violation of her right to live in dignity".

The Supreme Court's decision to reject the discontinuation of Aruna's life support was based on the fact that the hospital staff who treat and take care of her did not support euthanizing her.

She died from pneumonia on 18 May 2015, after being in a coma for 42 years.

Aruna Shanbaug case, Justice Katju

Passive euthanasia is legal in India.

On 7 March 2011 the Supreme Court of India legalised passive euthanasia by means of the withdrawal of life support to patients in a permanent vegetative state.

In India

December 23, 2014, Government of India endorsed and re-validated the Passive Euthanasia judgement-law in a Press Release.

Active euthanasia, including the administration of lethal compounds for the purpose of ending life, is still illegal in India

It is the High Court under Article 226 of the Constitution which can grant approval for withdrawal of life support to such an incompetent person.

Article 226(1) of the Constitution states: “Notwithstanding anything in article every High Court shall have power, throughout the territories in relation to which it exercises jurisdiction, to issue to any person or authority, including in appropriate cases, any Government, within those territories directions, orders or writs, including writs in the nature of habeas corpus, mandamus, prohibition, quo warranto and certiorari, or any of them, for the enforcement of any of the rights conferred by Part III and for any other purpose”.

In India

In India• A decision has to be taken to discontinue life support either by the

parents or the spouse or other close relatives, or in the absence of any of them, such a decision can be taken even by a person or a body of persons acting as a next friend. It can also be taken by the doctors attending the patient. However, the decision should be taken bona fide in the best interest of the patient.

• Even if a decision is taken by the near relatives or doctors or next friend to withdraw life support, such a decision requires approval from the High Court concerned.

• When such an application is filled the Chief Justice of the High Court should forthwith constitute a Bench of at least two Judges who should decide to grant approval or not. A committee of three reputed doctors to be nominated by the Bench, who will give report regarding the condition of the patient. Before giving the verdict a notice regarding the report should be given to the close relatives and the State. After hearing the parties, the High Court can give its verdict.

Supreme court guidelines

In India Cultural Aspects

Sallekhanā (also Santhara, Samadhi-marana, Sanyasana-marana),

• Jain practice of facing death voluntarily at the end of one's life.

• It is prescribed both for the householder and ascetics.

• • Sallekhana is made up from two

words sal (meaning 'properly') and lekhana, which means to thin out.

• Properly thinning out of the passions and the body is 'Sallekhanā'. Sallekhana is allowed only when a person is suffering from incurable disease or great disability

Prayopavesa (literally resolving to die through fasting)

Practice in Hinduism that denotes the suicide by fasting of a person, who has no desire or ambition left, and no responsibilities remaining in life.

It is also allowed in cases of terminal disease or great disability.

In IndiaCultural Aspects

Thalaikkooththal (Tamil: தலை�க்கூத்தல், lit. showering) is the traditional practice of senicide (killing of the elderly) or involuntary euthanasia, by their own family members, observed in some parts of southern districts of Tamil Nadu state of India.

The elderly person is given an extensive oil-bath early in the morning and subsequently made to drink glasses of tender coconut water which results in renal failure, high fever, fits, and death within a day or two.

Relevance to Psychiatry

Core symptoms of major depression in this population include pervasive anhedonia, the wish to die, compromised ability to think clearly, a sense of hopelessness about the future, a tendency to embellish pain and misery, and a view of the world that embraces pessimism and negativity.

Primary care physicians are ill equipped to diagnose depression in the elderly or other complex situations.

Even well-trained psychiatrists have difficulty with the diagnosis of depression in severely ill patients. Studies indicate that many patients with life-threatening illnesses substantially fortify their will to live after treatment of depression.

In PsychiatrySeveral critical issues for psychiatrists have been raised with the advent of ‘physician-assisted suicide’ (PAS), which is the deliberate prescription of medication to or counselling of ill patients so that such patients may use this medication orinformation to end their own life (Cohen et alet al, 1994).

• PSYCHIATRIC ASSESSMENT

• PHYSICIAN-ASSISTED SUICIDE FOR PSYCHIATRICILLNESS

PSYCHIATRIC ASSESSMENT

Psychiatric assessment is mandatory for patients who request PAS in somejurisdictions, but not in others.

In Oregon, a physician refers the patient to a psychiatrist or psychologist only if the physician believes a psychiatric disorder may be present.

A similar situation applies in The Netherlands, where psychiatric assessment is requested for only 3% of patients who request PAS.

Terminally ill patients with depression are more likely to change theirminds about PAS than patients without depression (Emanuel et al 2000)

Role of the psychiatrist

• Identify and treat psychiatric illness• Assess mental capacity and decision making ability

PSYCHIATRIC ASSESSMENT

Major themes that emerged among patients asking for euthanasia include

HopelessnessDependence on caregivingDemoralizationPain and Other SymptomsLack of social supportAbsence of Religious beleifs

Competence concerning treatment decisions signifies

• Ability to communicate his or her decision. • Factually understand the situation and its

consequences • Rationally assimilate the information.

Euthanasia in patients suffering primarily from mental disorder

Data exist only in the Netherlands.

3% of all requests for assisted death.

Only 2% are granted.

Motivations includeAbsence of hope of improvement

Unbearable mental suffering

Being a burden

Pain or other suffering

Loss of dignity

Euthanasia in patients suffering primarily from mental disorder

The psychiatrist has to make sure that there is no external pressure towards the ending of life, either perceived subjectively or actual.

The assessment of competence in a patient with a mental disorder and is not straight forward, the presence of a sliding standard of competence poses the risk of paternalism.

Assessment of the longing for death.

The suffering must be perceived by the patient as unbearable.

The suffering has to be beyond human aid.

• Dutch Supreme Court has ruled that PAS may be justifiable in certain cases in which there is unbearable mental suffering in the absence of physical illness.

• It is essentially impossible to describe any psychiatric illness as incurable, with the exception of advanced brain damage as occurs in progressive neurodegenerativedisorders such as Alzheimer’s disease and Huntington’s disease.

Euthanasia in patients suffering primarily from mental disorder

Arguments

Proponents

Quality of life and patient dignity are more important than the number of hours or days that a patient lives.

Respect for each patient's autonomy has become a guiding principle in medicine.

One of the ways that patients may exercise their right to self-determination is by asking for life-sustaining treatment to be withdrawn.

Some deaths—especially from cancer, AIDS, or progressive neurological lesions—may be slow and miserable. Pain cannot always be totally relieved with consciousness preserved.

Opponents

Euthanasia, even if the patient voluntarily requests it, is a form of killing, and outside of war, self-defense, and, perhaps, capital punishment, killing should never be sanctioned.

Never necessary, as most suffering can be relieved with skillful and compassionate care.

Many patients who request aid in dying may have unresolved psychosocial or spiritual issues or unrecognized or untreated depression, a difficult diagnosis to make in the context of chronic and painful medical illness.

“slippery slope”

Particular threat to the economically and socially vulnerable, and the poor, mentally ill, or disabled may be coerced to request it.

Euthanasia violates the time-honored mission of physicians to be unambiguously committed to preserving life.

Pitfalls

In 1991, the New England Journal of Medicine published the case of Diane, a woman with acute leukemia .