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Active and passive euthanasia takes place in the UK
- John S Watts (4 May 2007)
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Euthanasia in neonates
- Joav Merrick, Isack Kandel (6 May 2007)
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Are we asking the right questions?
- Peter-Marc Fortune (8 May 2007)
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Folic Acid Fortification Prevents Need for Euthanasia
- Godfrey P. Oakley, J.r (9 May 2007)
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Legalising neonatal euthanasia; are we ready for this
- Sanjay K Agarwal, Sharan Rajiv, Specialist Neonatology (12 May 2007)
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Neonatal euthanasia: not a new idea
- Timothy S HINKS (14 May 2007)
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Dutch government should prosecute doctors
- Mark Houghton (16 May 2007)
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John S Watts, Specialist Registrar Child Psychiatry Canada House, Barnsole Road, Gillingham, Kent, UK. ME7 4JL
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EDITOR - Costeloe raises the issue of allowing active euthanasia as a therapeutic option in the UK in her editorial, and concludes that this would '...undermine progress and be a step backwards'.(1) Although she discusses the distinction between withdrawal of treatment and active killing, this is not further developed. Passive euthansia, whereby medical treatment is stopped and nature is allowed to take its course, is already available in this country, and this is supported by case law. The adult case of Anthony Bland, who had been rendered into a permanent vegetative state following the Hillsborough football stadium disaster, is perhaps one of the most widely known in this context.(2) The hospital had been treating him and keeping his body alive for some years by administering artificial nutrition and hydration, and they sought guidance from the courts as to whether this could be withdrawn legally. This form of passive euthanasia, was ruled lawful by the Law Lords as it was considered an omission, and not an act. One of the Law Lords said, 'If an act resulting in death is done without lawful excuse and with intent to kill it is murder. But an omission to act with the same result and with the same intent is in general no offence at all.'(2) With regards to children, similar rulings to the Bland case in the UK have been handed down. For example, in the case of Re C, the child had spinal muscular atrophy, and was kept alive by artificial ventilation. This treatment was felt to be merely prolonging her life rather than alleviating her suffering. The family court held that it was lawful to withdraw the artificial ventilation, and effectively allow her to die, despite the parents’ wishes to the contrary.(3) Despite the active euthanasia of children and neonates being illegal in the UK, there is some evidence that this practice is going on behind the scenes, and may not be as rare as Costeloe states.(4) The fact that passive euthanasia is available for the severely ill neonates that Costeloe discusses is, in my view, another very persuasive argument for not allowing the active euthanasia of newborns. It is also important to note that Dr Verhagen, the author of the Groningen Protocol mentioned in the editorial, has been the subject of extreme and vocal responses, some even comparing him to Nazi doctors involved in the Holocaust.(5) The debate around euthanasia for any age and for whatever reason continues to spark emotive responses, and whether active euthanasia remains illegal or not, its practice will continue in some circumstances in the UK. References 1. Costeloe K. Euthanasia in neonates. BMJ 2007;334:912-913. 2. Airedale NHS Trust v Bland House of Lords 4 February 1993 [1993] AC 789. 3. Re C (A Minor) (Medical Treatment), Family Division 18 November 1997 [1998] Fam. Law 135. 4. 'Dr Pieter Sauer, co-author of the Groningen Protocol … claims British paediatricians perform mercy killings... "English Neonatologists gave me the indication that this [euthanasia of newborns] is happening"' S-K. Templeton. Doctors: let us kill disabled babies. The Sunday Times November 05 2006. 5. G. Crouch. A Crusade Born of a Suffering Infant’s Cry. New York Times March 19, 2005. Competing interests: None declared |
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Joav Merrick, Medical director National Institute of Child Health and Human Development, Office Med Director,Jerusalem, Israel, Isack Kandel
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EDITOR---This comment in response to a recent editorial on euthanasia in neonates (1) on the basis of an earlier review recently published (2). In response to advances in medical technology, physicians and lawmakers are slowly developing new professional and legal definitions of death. Additionally, experts are formulating rules to implement these definitions in clinical situations, as for example when procuring organs for transplantation. The majority of countries have accepted a definition of brain death, the point when there is a complete and irreversible cessation of brain activity, as the time when it is legal to turn off life -support system with permission from the family. Europe and especially the Netherlands seems to be the front runners, when in 2001 the Netherlands became the first country to legalize active euthanasia and assisted suicide and this way formalize a medical practice that the government had tolerated for many years. Under the Dutch law, euthanasia is justified, if the physician follows strict guidelines, which include: 1) the patient makes a voluntary, informed and stable request; 2) the patient is suffering unbearably with no prospect of improvement; 3) the physician consults with another physician, who in turn concurs with the decision to help the patient die and 4) the physician performing the euthanasia procedure carefully reviews the patient’s condition. Today it is estimated that about 2% of all deaths in he Netherlands each year occur as a result of euthanasia. In 2002 the parliament of Belgium also legalized active euthanasia, permitting physicians to perform euthanasia only for patients who are suffering unbearably with no hope of improvement. The patient must make a voluntary, well-considered and repeated request to die in writing. Other physicians must be consulted to confirm the condition of the patient and each act of euthanasia must be reported to a government commission for review. A discussion of euthanasia concerns questions from the medical, social and ethical fields and it is no wonder that the approach to the subject differs from society to society and from country to country. When the view of passive euthanasia was examined, most of the studies leaned towards consent and acceptance. However if we discuss the clear definition of active euthanasia, most countries absolutely prohibit it. The studies quoted also discussed the effect of religion on these views. The accelerated medical development in our generation enables us to prolong life artificially. This tendency will increase, and therefore the question presented in this paper will become more acute and require a clearer answer. The world around us is becoming more scientific and sophisticated and we, as human beings, must maintain the connection to our moral values and when we try to answer the question of euthanasia, we must discern the true motive of our acts. When are we directed by the needs of the suffering individual? Do we distinguish between the interests of the individual, the family, and society? Courageous answers to these questions, and to many others, are a necessary precondition when deciding on the weighty issue of euthanasia. A critical review of the euthanasia system in the Netherlands has been published by an Israeli researcher (3), who before visiting that country was a supporter of the way euthanasia was practised there, but came back with reservations about the practicality of its implimentation. It is worth listening to his proposed guidelines: · the physician should not suggest assisted suicide to his patient,
but instead the the patient should have the option to ask for such
assistance
Concerning neonatal euthanasia we agree with the essential criteria mentioned in the editorial in the BMJ (1), namely that the diagnosis must be accurate and prognosis hopeless, the quality of life poor with unbearable suffering, both parent must give informed consent, an independent physician must agree with the decision and euthanasia carried out according to accepted medical and cultural standards. AFFILIATION Joav Merrick, MD, MMedSci, DMSc, is professor of child health and human development affiliated with the Zusman Child Development Center, Division of Pediatrics, Soroka University Medical Center, Ben Gurion University, Beer-Sheva, Israel, the medical director of the Division for Mental Retardation, Ministry of Social Affairs, Jerusalem, the founder and director of the National Institute of Child Health and Human Development. Numerous publications in the field of child health and human development, rehabilitation, intellectual disability, disability, health, welfare, abuse, advocacy, quality of life and prevention. Received the Peter Sabroe Child Award for outstanding work on behalf of Danish Children in 1985 and the International LEGO-Prize (“The Children’s Nobel Prize”) for an extraordinary contribution towards improvement in child welfare and well- being in 1987. E-Mail: jmerrick@internet-zahav.net. Website: www.nichd- israel.com Home page: http://jmerrick50.googlepages.com/home Isack Kandel, MA, PhD, is senior lecturer/assistant professor at the Faculty of Social Sciences, Department of Behavioral Sciences, the Academic College of Judea and Samaria, Ariel. During the period 1985-93 he served as the director of the Division for Mental Retardation, Ministry of Social Affairs, Jerusalem, Israel. Several books and numerous other publications in the areas of rehabilitation, disability, health and intellectual disability. E-mail: kandelii@zahav.net.il REFERENCES 1. Costeloe K. Euthanasia in neonates. Should it be available? BMJ 334:912-3. 2. Kandel I, Merrick J. Euthanasia: A review. Int J Disabil Human Dev 2006;5(1):27-33. 3. Cohen-Almagor R. Euthanasia in the Netherlands. The policy and practice of mercy killing. Dordrecht: Kluwer, 2004. Competing interests: None declared |
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Peter-Marc Fortune, Consultant Paediatric Intensivist Royal Manchester Children's Hospital, Pendlebury, Manchester M27 4HA
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This article touches on a number of very important issues around end of life practice. However I am concerned it rapidly dismisses some of the key issues, around the methodology and definitions we use to describe our current practice and also draws focus from the dangers and limitations of the current approach. Firstly the distinction between 'active' and 'passive' euthanasia. Essentially, but not entirely, these concepts link to an approach that involves intervention in the active, or omission in the passive case. There is little doubt that these feel different and "experienced neonatologists and neonatal nurses feel comfortable with the distinction". But I question our current interpretation. How exactly is extubating a child with significant pulmonary disease (which may or may not improve) different from giving them a lethal injection? The former action is legal, accepted practice, the latter is not, does this make sense? In addition, cases like the above example are usually covered by a concurrent opiate infusion. This is administered under the so called 'Doctrine of double effect'. When a baby or child is taking terminal gasps or making similar movements the care team will often increase the infusion to reduce distress. Do they genuinely know the child is in distress or are they actually responding to the families and perhaps their own distress? If the latter is the case the action may well be entirely appropriate - but it is not reasonable to argue it is covered by the doctrine of double effect under which it is taken. The question is also raised as to the effect on the morale of staff that might be involved with a practice of legalised active euthanasia. Does anyone actually know it would be detrimental? I know from my own practice that the effects on staff who deliver ongoing futile care can be very destructive - so which is worse? I am troubled that the analysis we make of our practice is far from objective. Also the application of principles such as the doctrine of double effect, which makes us feel comfortable, but are not difficult to bring into question, might border on dangerous in the wrong hands. In particular, I worry that the narrow focus on the practice of active euthanasia draws us away from some of the key issues we face right now. Surely we need to consider the requirement for formal regulation of this whole area as it stands. Decisions expected to result in the death of a patient, through act or omission, active or passive, should be confidentially registered and available for scrutiny through both research and audit. Only then will we be able to understand current practice, ensure it is safe, and move on to properly consider even more challenging issues. Competing interests: None declared |
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Godfrey P. Oakley, J.r, Research Professor of Epidemiology, Rollins School of Public Health of Emory University Rollins School of Public Health, 1518 Clifton Rd, NE, Atlanta, GA 30322
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The experience from the Netherlands is that the vast majority of reported euthanasia for newborns is for severe spina bifida--a birth defect that mandatory folic acid fortification of flour prevents. The Dutch government has twice considered and rejected fortification. It is a strange public policy that supports euthanasia rather than prevention. The UK food authorities are currently considering requiring folic acid fortification of flour. I hope they improve the lives of children and adults by requiring fortification. Competing interests: co inventor on patent that would put folic acid into oral contraceptives and a paid consultant to Johnson and Johnson on this issue. |
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Sanjay K Agarwal, Specialist, Department of Psychiatry and Child guidance Clinic Tata Motors Hospital, Jamshedpur, India 831004, Sharan Rajiv, Specialist Neonatology
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Editor We respond to recent editorial on neonatal euthanasia,(1) which raises an important yet controversial issue. Neonatal euthanasia is not a purely medical issue. It has political, economical, ethical and religious aspect also and hence a highly emotive issue. Neonatal euthanasia although illegal, is not uncommon in India. Various socio-cultural factors unique to India are responsible for it. Indian Government spends only 0.9% of gross domestic product (GDP) on health care; among the lowest in the world. Only five countries, Burundi, Myanmar, Pakistan, Sudan, and Cambodia spend lesser. So majority of the people have to self finance their health care. Employers and health insurance pay for 9% and 5-10% respectively, of spending on private care, and whopping 82% is from personal funds.(2) As a result, more than 40% of all patients admitted to hospital have to borrow money or sell assets, including inherited property and farmland, to cover expenses, and 25% of farmers are driven below the poverty line by the costs of their medical care.(3) In such a scenario parents of neonate with multiple congenital malformation or terminal, and incurable disease who are paying from their own pocket are forced to ask for euthanasia. This is practiced in the guise of “discharge against medical advice” and neonate is kept at home and disease is allowed to take its natural course. Hospitals cannot refuse discharge if parents ask for it. Not surprisingly, sometimes even neonate with treatable diseases (e.g. Persistant pulmonary hypertension,Respiratory distress syndrome) but requiring specialized and costly treatments meet the same fate for obvious reasons. Other factors like preference for male child, stigma of malformed child, poor social support system also influences the decision. Answer to the question of how often patients’ or relatives’ consent really reflects their best interests rather than representing obedience to the physician’s authority is unclear(4) particularly in a society where paternalistic model of doctor patients relationship is more common. The biggest robber of autonomy is sickness and poverty. So making active euthanasia legal when choice of passive euthanasia is already available will only open the door for possible misuse. Other side of the coin is should highly expensive treatments be allowed just to prolong the life of an individual when resources are scarce or should we sacrifice the interest of an individual for larger benefit of society. In India, where every year tuberculosis kills half a million people(5) and diarrhoeal diseases more than 600000 (both highly preventable and curable diseases) this is an uncomfortable question to answer. 1. Costeloe K.Euthanasia in neonates. Should it be available?BMJ 2007; 334:912-3. 2. Sengupta A, Nundy S. The private health sector in India. Is burgeoning, but at the cost of public health care. BMJ 2005;331: 1557-8. 3. Health, Nutrition, Population Sector Unit India South Asia Region. Raising the sights: better health systems for India’s poor. Washington: World Bank, 2001. 4. Cassell EJ. Consent or obedience? Power and authority in medicine. NEJM 2005;352:328-30. 5. Khatri GR, FriedenT. Controlling tuberculosis in India. NEJM 2002;347:1420-5. Sanjay K Agarwal sanjpsy@yahoo.co.in Competing interests: None declared |
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Timothy S HINKS, Academic Clinical Fellow, Respiratory Medicine Dorset County Hospital, DT1 2JY
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Professor Costeleo's suggestion is not new. In 1920 Karl Binding and Alfred Hoche published a book titled "The granting of permission for the destruction of worthless life. Its extent and form." arguing that in certain cases it was legally justified to kill those suffering from incurable and severely crippling handicaps and injuries. [1] By 1939 the killing of adult and paediatric patients began. The Nazi regime had received requests for ‘mercy killing’ from the relatives of severely handicapped children, and in that year an infant with limb abnormalities and congenital blindness (named Knauer) became the first to be put to death, with Hitler’s personal authorisation and parental consent [2] and fulfilling the 5 criteria of the Groeningen protocol [3] This ‘test-case’ paved the way for the registration of all children under three years of age with ‘serious hereditary diseases’. This information was then used by a panel of ‘experts’, including three medical professors, to authorise death by injection or starvation of some 6,000 children by the end of the war. [4] Perhaps 60 years later humanity is wiser and ready to repeat the experiment? [1] Hanauske-Abel HM. Not a slippery slope or sudden subversion: German Medicine and National Socialism in 1933. BMJ 1996; 131:1453-63 [2] Lifton RJ. The Nazi Doctors - a study in the psychology of evil. Papermac. 1986. pp50-51 [3] 3. Verhagen E, Sauer PJJ. The Groningen protocol—euthanasia in severely ill newborns. N Engl J Med 2005;352:959-62 [4] Ibid: 52-3 Competing interests: None declared |
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Mark Houghton, Freelance GP Sheffield S10 4EF, UK
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So the Dutch want to extend their disreputable involuntary killings to the children. Official figures show 1000 adults a year dying without consent there.[1] Its long overdue the Dutch government got in line with the rest of the world (except 2 or 3 tiny places) and prosecuted doctors who kill. All the Dutch I have spoken to are disgusted and a Prof of Palliative Care here has spoken of a wave of revulsion in Holland. Do we want that in UK? 1 House of Lords select committee report on the Assisted Dying Bill 2005. See also the Remmelink report from Holland. See also Van der Maas PJ et al (1991) Euthanasia and other medical decisions concerning the end of life. Lancet 338:669- 74 . Competing interests: None declared |
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