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NEWS: Fabio Turone Anaesthetist helps Italian patient who wanted to die BMJ 2007; 334: 9 [Full text]

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Ceasing life perpetuating treatment vs administering life ending treatment

Peter W Sandbach   (7 January 2007)

A matter of life and death

Phil S Jones   (9 January 2007)

Withdrawal of consent and euthanasia are not the same

Ian D Rubin   (10 January 2007)

Court and medical profession in end of life decisions

Caterina Ferrari, Guido Miccinesi and Eugenio Paci   (12 January 2007)

Re: A matter of life and death

Fabio Turone   (21 January 2007)

Ceasing life perpetuating treatment vs administering life ending treatment 7 January 2007
Peter W Sandbach, Senior House Officer in Anaesthetics Broomfield Hospital, Chelmsford. CM1 7ET. Send response to journal: Re: Ceasing life perpetuating treatment vs administering life ending treatment	Editor, In response to some of the issues raised by your news article regarding Piergiorgio Welby (BMJ 334, 9) I felt that some ethical and legal distinctions needed to be made. I conducted a brief survey of dictionaries on the subject of euthanasia; my findings anecdotally indicate that most define euthanasia as the putting to death or "mercy killing" of someone prior to the "natural" end of their life. From your description of the process of Mr Welby's death which was instituted by Dr Mario Riccio, it could well be argued that rather than undergoing active euthanasia, life perpetuating treatment (in this case mechanical ventilation) was withdrawn because its continuation was deemed futile and unnatural (in view of a terminal illness with no hope of improvement in quality of life), according to the wishes of a patient who is competent to make this decision. The intravenous sedation used may well have been to alleviate distressing symptoms during the process rather than to cease ventilatory effort. This approach whereby life prolonging treatment is withdrawn if distressing, futile and against the patient's wishes is legal within the UK. Many religious scholars also draw this conclusion (MJA 2005; 183 (11/12): 616-621). It is also true that to actively treat a competent patient against his wishes could be construed as assault. If it occurred within these bounds, this event does not break any new ground in terms of UK practice or law. Neither does it add weight to the arguments proposed by the physician-assisted suicide lobby. Indeed, Dr Riccio's view that "In Italian hospitals therapies are suspended all the time, and this does not lead to any intervention from magistrates or to problems of conscience" is broadly consistent with consensus medical opinion, in stark contrast to most doctors' opposition to active euthanasia as represented by the British Medical Association (http://www.bma.org.uk/ap.nsf/Content/ARM2006bmanewsassisdying), the Royal College of General Practitioners, the Royal College of Anesthetists, The Association of Palliatve Medicine and The Royal College of Surgeons of Edinburgh to name but a few (Care Not Killing - http://www.carenotkilling.org.uk/?show=193). Yours sincerely, Competing interests: I am a committed Christian opposed to physician assisted suicide.
A matter of life and death 9 January 2007
Phil S Jones, Consultant in Intensive Care Medicine St Batholomew's Hospital, London EC1A 7BE Send response to journal: Re: A matter of life and death	Sir, With regard to the death in Italy of Piergiorgio Welby the BMJ published a news article [1] which sadly did little to illuminate an area where there is already far too much heat and not enough light. The first three paragraphs included the words "right to die", "unplugged" and "euthanasia", and were followed by a fourth paragraph describing a debate about "advance directives", "assisted suicide", and "euthanasia" (again). Readers ought to expect more from a medical journal than careless sensationalism. Has it escaped the BMJ's attention that, as the facts are reported, this case closely mirrors the 2002 case in this country of Miss B, on which the BMJ also reported at the time [2]? It appears that in both cases at the heart of the matter was the consistently and competently expressed wish of the patients not to receive further medical treatment even though they knew they would die as a result. Neither case had anything to do with an "advance" directive because the patients remained competent and were making their views known in the "present" (advance directives are only helpful in patients that are no longer competent). Nor was the "right to die" at issue; it was about "a patient's right to competently decline treatment". It was certainly not about euthanasia since it was the patients' refusal to be ventilated any longer that was critical - not the hand of the anaesthetist on the syringe or on the ventilator plug. Lastly, neither case involved "assisted suicide"; at least, not unless one accepts the premise that the anaesthetist colluded with the Italian patient to deliberately inflict muscular dystrophy upon him some time earlier. Part of Dame Elizabeth Butler Sloss's judgement from the UK case bears repeating: she said a competent patient had "an absolute right to refuse to consent to medical treatment for any reason, rational or irrational, or for no reason at all, even when that decision may lead to his or her death." In contrast, in the UK euthanasia remains illegal, assisted suicide remains illegal, and patients have a right to die but they have to do it by themselves. If the courts can tell the difference between these concepts, why can't the BMJ? Differences in law between Italy and the UK do not excuse the use of incorrect, emotive copy. [1] Turone F. Anaesthetist helps Italian patient who wanted to die. BMJ 2007;334:9 [2] Dyer C. "Unlawfully treated" woman to move to new unit. BMJ 2002;324:753 Competing interests: None declared
Withdrawal of consent and euthanasia are not the same 10 January 2007
Ian D Rubin, Medical Director of Commercial Provider NG 1 5DW Send response to journal: Re: Withdrawal of consent and euthanasia are not the same	The news article entitled "Doctor helps Italian patient die" appears to completely miss the point. This case is nothing to do with euthanasia but is simply a matter of withdrawal of consent by a mentally competent adult. The GMC guidance on this matter leaves no room for doubt: “You should bear in mind that you are bound to respect an adult patient's competently made refusal of treatment even where complying with the decision will lead to the patient's death.1” The fact that the patient, Mr Welby, gave consent to being ventilated in 1997 has no relevance. He had an absolute right to change his mind at any time during the course of his treatment provided that he remained fully able to understand the consequences, which, it appears from the article, he quite clearly did. Thus the question should not have been of whether Dr Riccio should be open to prosecution for complying with Mr Welby’s decision to withdraw consent but whether all other healthcare professionals, who had continued Mr Welby’s treatment despite his withdrawal of consent, should be prosecuted for assault. An 82 year old acquaintance of mine was started on haemodialysis dialysis a few weeks ago. Whether she had been adequately informed of the nature and discomforts of the procedure I do not know. She decided, after a few days of treatment, to withdraw consent. Her response on being told she would die was “that is fine, death is natural at my age; you should use the resources for somebody else with a greater life expectancy”. The treatment, to her, amounted to torture. She subsequently died with dignity in the embrace of her family. Your article adds nothing to the debate about these difficult decisions faced by competent human beings at or towards the end of their lives. Whatever the patient’s age and whatever the treatment they are receiving, every competent patient has an absolute right to withdraw consent. When administering any treatment all healthcare professionals need to be aware that a rational person may decided that they do not wish to continue and however apparently well intentioned, it can be argued that to continue to administer treatment despite the withdrawal of consent constitutes an assault and arguably amounts to torture. People have the right to make decisions about their own lives and religious groups and healthcare professionals need to learn to respect them. Dr Ian Rubin 1. http://www.gmc- uk.org/guidance/current/library/witholding_lifeprolonging_guidance.asp#28 Accessed 7th January 2006. Competing interests: None declared
Court and medical profession in end of life decisions 12 January 2007
Caterina Ferrari, bioethicist Center for the Study and Prevention of Cancer, 50100 Florence, Guido Miccinesi and Eugenio Paci Send response to journal: Re: Court and medical profession in end of life decisions	The case of Piergiorgio Welby [1-2] lays itself to several interpretations. However it is our opinion that most of all this case has brought out how difficult it still is in Italy to recognize the centrality of the patient’s point of view and will in the context of the therapeutic relationship. In fact apart from the conceptual and lexical confusions whereby refusal of care, advance directives and euthanasia have all been put together, the narrative of the case is straigthforward: the physician who had Welby under his care refused, also because of his own ethical, religious and professional convictions, to accept the repeated and motivated requests of his competent patient to be put under sedation and therefore to remove the artificial ventilator to which he had been connected since 1997. The Court to which Welby had appealed confirmed that the Italian legal system recognizes the right to refuse therapies, also in the case life-saving therapies, but at the same time it acknowledged that, to date, such right is not “concretely protected”, since there are no rules that compel the physician always to respect the patients will. Consequently the Court invited the legislator to fill this gap [3]. On the other hand, the position expressed with large majority by the High Council of Health (Consiglio Superiore di Sanità-CSS that is the technical-scientific consultation body of the Ministry of Health) maintained that although “there is no doubt on the patient’s right to refuse care if he is capable of auto-determination, many questions arise concerning the interruption of life-sustaining treatments, the suspension of which determine ‘sic et simpliciter’ the biological termination of life”. Furthermore for the CSS it is necessary to reach a balance “between the respect of the individual will and a frame of widely accepted ethical principles which cannot and must not be absent in the decision related to the end of life” [4]. In other words for the CSS the right of the patient to refuse a treatment can be debated when dealing with the withdrawal of life-sustaining treatments. The confrontation between the two documents confirms that in Italy it is still undefined and vague how the doctors should behave when confronted with practical end of life decisions. Large part of the doctors still agree that it is the doctor that must decide if, when and how to suspend a treatment. This approach has also been described in the recent European study EURELD, which showed that, in case of end of life medical decisions, 44% of Italian doctors had not consulted any other doctor or nurse and in 52% of the cases the decision had not been discussed either with the competent patient or with his/her relatives. Furthermore the total of non-treatment decisions in this study appears to be much lower in Italy than in the other participating countries (4% of the total of deaths as opposed to 14% to 28% in other countries)[5]. [1]Turone F. Italy debates end of life decisions. BMJ 2006;333:719 [2]Turone F. Anaesthetist helps Italian patient who wanted to die. BMJ 2007;334:9 [3]http://www.aduc.it/dyn/eutanasia/tribunale_welby.pdf [4]http://www.ministerosalute.it/imgs/C_17_pubblicazioni_581_allegato.pdf [5]van der Heide A. et al. End of life decision-making in six European countries: descriptive studies. Lancet 2003; 362:345-50 Competing interests: None declared
Re: A matter of life and death 21 January 2007
Fabio Turone, Director, Agency Zoe of scientific and Medical information Milan, Italy Send response to journal: Re: Re: A matter of life and death	I quoted the words of Piergiorgio Welby in the news article, and I still don't think reporting them in a story about his death may "miss the point" or be considered "sensationalism". The request and the act were sensational, I'd say. I live in a country, Italy, in which most legislators are no less confused than the layman in mixing refusal of care with advance directives, assisted suicide and euthanasia (not to mention physicians). That's why the public debate is generally different from the one most bioethicists would consider correct. Unfortunately, hiding this fact wouldn't make things any more clear, I think. Anyway, I admit I may not be neutral in reporting such issues: my father Sergio Turone quietly committed suicide in 1995, after many years fighting a worsening illness, when he still could do so without needing help from anyone. He left a note with words of love to his family, in which among other things he wrote "Live life, live euthanasia!" (Viva la vita, viva l'eutanasia!"). He was a political journalist, and many years earlier he had written an article on the daily he worked for under the headline "Dear suicide, thank you!" in which he explained that what had given him strength in a particularly hard period after the first surgery was the decision he would say the last word if he decided life was not worth anymore. He certainly thought he had the right to die: he framed the article and hung it on the wall in his own apartment, so that all acquaintances would reflect on this. This possibility gave him some 13 more years of a very full and generous life (he was even elected in an important political function). Maybe he was confused in a bioethicist's perspective, but as a journalist and a lover of language he taught me one should never use exclamation marks - especially in a headline - unless one really wants to stress a point with exceptional means. My father's framed article is now hung in the newsroom, close to the coffee machine. Competing interests: None declared