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Growing international choices in dying

Thursday, August 20, 1970

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 favor. Even in countries with strong religious traditions, such surveys can be interesting: for example, in France, 75% of practising Catholics want to decriminalize euthanasia.


100 years old

Some member societies of the World Federation have large memberships; both those in the Netherlands have over 100,000 menbers (in the latter country, over 2,600 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”.

In reality, the difference between withdrawing treatment and giving a lethal injection is surely not an ethical one (in both situations, there is the decision that the patient can now die), but really an emotional one for the doctors involved?

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.


Doctor support

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. And, today, at least 85% of Dutch physicians support the law on assisted dying which exists in their country.

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.


Controversy in France

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 the 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 3,500 (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 have stabilized … there are no signs indicating an increase in lifeterminating treatment among vulnerable patient groups”. Thus, no evidence of any “slippery slope”, a favourite expression of the anti-choice lobby.


Coping with grief

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?”



Welcoming the delegates from all over the world was Kitty Jager, of NVVE.



At one of many fine meals provided at the Europe conference we can see, on the left Libby Drake (WF Secretary) and Claudia Wiedenmann, while on the right is Annelies Plaisant (USA, WF Director) and Kitty Jager (NVVE The Netherlands).



At the Europe conference, left to right: G. Hagberg (RTVD Sweden), Marthy Putz (Lux.) and H.P. Baars (NVVE The Netherlands).

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