Death Euthanasia Research Paper

Death Euthanasia Research Paper

The Netherlands and Belgium permit euthanasia performed by a doctor, and define it as the act, undertaken by a third party, which intentionally ends a person’s life at his or her request. Doctor‐assisted suicide is legal in The Netherlands, Belgium and Oregon. Assisted suicide, with or without the involvement of a doctor, is legal in Switzerland. In Australia, the Northern Territory approved euthanasia in 1995, but in 1997 this bill was overturned by parliament.Death Euthanasia Research Paper

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In the UK, the issue of euthanasia has been widely debated since the 1870s,1 and many argue that the question of the right to die has become one of the most important in contemporary ethics.2 A House of Lords select committee recently produced a report on Joel Joffe’s Assisted Dying for the Terminally Ill Bill, and recommended that, in future, assisted suicide and voluntary euthanasia be debated separately, allowing the possibility of a change in the law for one but not the other.3 Lord Joffe has since redrafted his bill, which had its formal first reading in November 2005.

 

The aim of human medicine is to save lives at all cost. Great suffering and excruciating physical pain are justified if they are necessary to save a life. Euthanasia is not permitted, even in the most extreme cases. Conversely, killing is very much a part of veterinary medicine. It is often recommended to avoid prolonged suffering and pain, even when animals are in no immediate danger of dying. This basic difference between the two medicines is profound. Each type of medicine necessitates its own, fundamentally different moral and philosophical approach. But this fundamental difference has not yet been comprehended. The methods and attitudes of human medicine color those of veterinary medicine. Veterinarians still put animals to death using injections, which are both painful and frightening to the animals, causing them to have an ugly, unpleasant death rather than a tranquil, peaceful one.Death Euthanasia Research Paper

Reasons for Euthanasia
Unbearable pain
Right to commit suicide
People should not be forced to stay alive

1. Unbearable pain as the reason for euthanasia
Probably the major argument in favor of euthanasia is that the person involved is in great pain. Today, advances are constantly being made in the treatment of pain and, as they advance, the case for euthanasia/assisted-suicide is proportionally weakened. Euthanasia advocates stress the cases of unbearable pain as reasons for euthanasia, but then they soon include a “drugged” state. I guess that is in case virtually no uncontrolled pain cases can be found – then they can say those people are drugged into a no-pain state but they need to be euthanasiaed from such a state because it is not dignified. See the opening for the slippery slope? How do you measure “dignity”? No – it will be euthanasia “on demand”. The pro-euthanasia folks have already started down the slope. They are even now not stoping with “unbearable pain” – they are alrady including this “drugged state” and other circumstances.Death Euthanasia Research Paper

Nearly all pain can be eliminated and – in those rare cases where it can’t be eliminated – it can still be reduced significantly if proper treatment is provided. It is a national and international scandal that so many people do not get adequate pain control. But killing is not the answer to that scandal. The solution is to mandate better education of health care professionals on these crucial issues, to expand access to health care, and to inform patients about their rights as consumers. Everyone – whether it be a person with a life-threatening illness or a chronic condition – has the right to pain relief. With modern advances in pain control, no patient should ever be in excruciating pain. However, most doctors have never had a course in pain management so they’re unaware of what to do. If a patient who is under a doctor’s care is in excruciating pain, there’s definitely a need to find a different doctor. But that doctor should be one who will control the pain, not one who will kill the patient. There are board certified specialists in pain management who will not only help alleviate physical pain but are skilled in providing necessary support to deal with emotional suffering and depression that often accompanies physical pain.

2. Demanding a “right to commit suicide” Probably the second most common point pro-euthanasia people bring up is this so-called “right.” But what we are talking about is not giving a right to the person who is killed, but to the person who does the killing. In other words, euthanasia is not about the right to die. It’s about the right to kill. Euthanasia is not about giving rights to the person who dies but, instead, is about changing the law and public policy so that doctors, relatives and others can directly and intentionally end another person’s life. People do have the power to commit suicide. Suicide and attempted suicide are not criminalized. Suicide is a tragic, individual act. Euthanasia is not about a private act. It’s about letting one person facilitate the death of another. That is a matter of very public concern since it can lead to tremendous abuse, exploitation and erosion of care for the most vulnerable people among us.Death Euthanasia Research Paper

3. Should people be forced to stay alive? No. And neither the law nor medical ethics requires that “everything be done” to keep a person alive. Insistence, against the patient’s wishes, that death be postponed by every means available is contrary to law and practice. It would also be cruel and inhumane. There comes a time when continued attempts to cure are not compassionate, wise, or medically sound. That’s where hospice, including in-home hospice care, can be of such help. That is the time when all efforts should be placed on making the patient’s remaining time comfortable. Then, all interventions should be directed to alleviating pain and other symptoms as well as to the provision of emotional and spiritual support for both the patient and the patient’s loved ones.

Ethical problems of euthanasia
Does an individual who has no hope of recovery have the right to decide how and when to end their life?

Why euthanasia should be allowed
Those in favour of euthanasia argue that a civilised society should allow people to die in dignity and without pain, and should allow others to help them do so if they cannot manage it on their own.

They say that our bodies are our own, and we should be allowed to do what we want with them. So it’s wrong to make anyone live longer than they want. In fact making people go on living when they don’t want to violates their personal freedom and human rights.It’s immoral, they say to force people to continue living in suffering and pain.

They add that as suicide is not a crime, euthanasia should not be a crime.Death Euthanasia Research Paper

Why euthanasia should be forbidden
Religious opponents of euthanasia believe that life is given by God, and only God should decide when to end it.

Other opponents fear that if euthanasia was made legal, the laws regulating it would be abused, and people would be killed who didn’t really want to die.

The legal position
Euthanasia is illegal in most countries, although doctors do sometimes carry out euthanasia even where it is illegal.

Euthanasia is illegal in Britain. To kill another person deliberately is murder or manslaughter, even if the other person asks you to kill them. Anyone doing so could potentially face 14 years in prison.

Under the 1961 Suicide Act, it is also a criminal offence in Britain, punishable by 14 years’ imprisonment, to assist, aid or counsel somebody in relation to taking their own life.

Nevertheless, the authorities may decide not to prosecute in cases of euthanasia after taking into account the circumstances of the death.

In September 2009 the Director of Public Prosecutions was forced by an appeal to the House of Lords to make public the criteria that influence whether a person is prosecuted. The factors put a large emphasis on the suspect knowing the person who died and on the death being a one-off occurrence in order to avoid a prosecution.Death Euthanasia Research Paper

(Legal position stated at September 2009)

Changing attitudes
The Times (24 January 2007) reported that, according to the 2007 British Social Attitudes survey, 80% of the public said they wanted the law changed to give terminally ill patients the right to die with a doctor’s help.

In the same survey, 45% supported giving patients with non-terminal illnesses the option of euthanasia. “A majority” was opposed to relatives being involved in a patient’s death.

What Happens During Euthanasia? by Paige Garnett
When a pet owner has made the very difficult decision to help his or her pet die, many questions arise regarding the actual process of euthanasia. What exactly occurs when a pet is euthanatized? Is the animal aware of what is happening? Is he in pain during the euthanasia process? What does the veterinarian use to help the pet die?

The term euthanasia is derived from the Greek terms “eu” meaning good and “thanatos” meaning death. A “good death” would be one that occurs without pain or distress. Euthanasia is the act of producing a humane death in an animal. In order to produce a humane death, the techniques employed should result in rapid unconsciousness followed by cardiac or respiratory arrest. Also, the technique should minimize any stress and anxiety experienced by the animal prior to unconsciousness.
If the animal appears anxious or distressed when presented for euthanasia, most veterinarians will administer a tranquilizer or sedative prior to the actual euthanasia injection. This ensures that the animal is restful and peaceful prior to the euthanasia. The tranquilizer may be given with a needle under the skin or in the muscle, or with pills which are taken orally. Generally it takes approximately 15 minutes for a tranquilizer to help the pet relax.

Most veterinarians use an injectable drug, most commonly pentobarbital, which is given in a vein. This barbiturate depresses the central nervous system beginning with the cerebral cortex, the part of the brain that determines awareness. The pet will lapse into unconsciousness, and then progress to anesthesia (the absence of pain). With an overdose of pentobarbital, deep anesthesia is followed by the stopping of breathing and then by cardiac arrest.Death Euthanasia Research Paper

The advantages of using a barbiturate are the speed of action and the very minimal discomfort to the animal (the only pain being associated with the needle puncture).
To inject the euthanasia solution, a vein is first prepared by painlessly clipping away the hair. A needle may be inserted directly into the vein and the euthanasia solution slowly injected, or a catheter (a small plastic tube) may be inserted in the vein and the injection given through it.

Most animals die quickly, within ten seconds. Their eyes remain open and some animals urinate and defecate following death. Some animals gasp after they have died and may even twitch. These normal, mechanical responses can be very disconcerting to pet owners who stay with their pets during euthanasia if the owners are not prepared in advance.
The decision for euthanasia is a difficult one, but the actual process is painless and very quick, granting our beloved pets a peaceful ending to their lives. Pet owners should feel free to discuss all questions concerning the euthanasia process with their veterinarians, so that they may be as comfortable as possible with their decisions.

There are many different beliefs about the nature and meaning of death. But, regardless of belief, most people will agree that death should occur in as calm, relaxed, peaceful, and even exquisite a manner as possible. Unfortunately that is not the way death usually occurs when animals are killed with the customary method, lethal injection.Death Euthanasia Research Paper

The main problem with lethal injection does not seem to be the drugs, since they work very quickly and apparently painlessly. The problem is the pain and fright caused by the injection itself. In the standard procedure, the cat is brought into the room where it is to be euthanized. Then, because the injection is expected to hurt the animal and cause it to struggle or even break off the needle, an assistant holds it very tightly, while the vet gives it the injection. The strange room is already unsettling for any sensitive animal, especially the typical home-owned pet. But being forcibly held, as well as the sight of the needle, frightens it. The pain of the injection then makes a bad situation even worse and the drug works so quickly that the animal has no time to calm down and become tranquil. It dies in a state of fear and trepidation. Humans may take painful injections for granted, but they frighten animals out of their wits.

Our institute’s own experience provides insight into the dilemma. Since they have the most sensitive hearing of all tested animals, The Anstendig Institute has been keeping cats for research purposes. But we had the misfortune of having an outbreak of FIP (Feline Infectious Peritonitis) and four cats had to be put to sleep.Death Euthanasia Research Paper

The first, an exquisite blue-eyed, color-point Cornish Rex kitten, had been in intensive care before we were advised by the veterinary clinic at U.C. Davis that nothing more could be done for her. When it came time to put her to sleep, the catheters from the intravenous feedings were still attached and the fluid could be painlessly injected into the catheter. She did not have to be forcibly held still or pierced with a needle. I was able to hold her in tender communion and she had an exquisite, painless death experiencing all the love she had grown used to in her short life. In fact, it happened so gently, quietly, and quickly that the doctor had to tell me it was over. The only complaint was that the substance worked too quickly.

But the next victim, a rare Sphynx kitten had no such luck: he was not as wasted as the girl when he was diagnosed, but the vet recommended euthanasia because there is no known cure for the disease.1 At my request, the veterinarian gave the little boy a tranquilizing shot before the lethal injection. But, to my surprise, the final injection still caused the baby a great deal of fright and pain and I was just barely able to calm him down before he died in my arms. If I had not used certain yoga disciplines that allowed me to use my own breath to calm his, the poor little boy would have died in a panic of fear, agitation, and pain.Death Euthanasia Research Paper

In the late twentieth century superbly complicated miracles of medicine are taken for granted. Dentists and doctors can, after an initial application of analgesic, make painless even the most excruciating procedures. It is unacceptable that the final lethal injection caused that baby any pain whatsoever. His spirit should have been able to depart his body as peacefully and exquisitely as that of the other kitten. Veterinary medicine has not yet understood the need to work out an elegant, painless, peaceful method of killing and the important question is why?

We were saved many hours of pondering this question by an incident that happened at U.C. Davis: when the doctor informed us that the girl would have to be put to sleep, I acquiesced, but requested that I be present so that she could die in my arms. U.C. Davis is a veterinary school and the doctor’s students were in the examining room learning from his methods in handling real-life cases. When I said I wanted to be present when my kitten was put to sleep, the doctor launched into what obviously was meant to demonstrate the accepted method of handling such a request. He tried to discourage me, for my own sake, from being present, pointing out that many people find the experience different from, and much more unsettling than they expected. But I answered that we have a special, sensitive communication with our cats at our institute; that this kitten was used to a lot of love and that we wanted it to have that love when it departed this world.

That apparently simple statement had a surprising effect on those in the room. The doctor and his students stopped dead in their tracks. For a good minute there was absolute silence and stillness. Everyone was frozen in deep thought. No one moved. Finally the doctor relaxed and took a deep breath, at which time, one of the students blurted out “We never thought of it that way. We never thought of it from the cat’s point of view.” It then came out that, because veterinarians always have to deal with the owners, who are usually more difficult to deal with than the patients, they had come to view everything, even euthanasia, from the owner’s point of view and not from the point of view of what would be most humane and beautiful for the animal.Death Euthanasia Research Paper

This is, by no means, an indictment of veterinarians. Vets do have to deal with the owners, as well as the pets. And it often takes a great deal of effort to convince the owners to give the animals the treatment they deserve, with the resulting emphasis on dealing with the owners and not the pets. But that is not the only reason veterinary medicine has not yet established a humane, painless method of euthanizing pets.

The dominance of human medicine in our thinking has made pain, especially the pain accompanying injections, an accepted part of our lives. Because we all have to undergo this pain rather often, we are oriented towards putting it out of our minds. Everyone develops his/her own “grin and bear it” and “be a man” form of coping with injections, as well as other painful forms of treatment. We tend to put out of our minds the fact that they do hurt.

Of course, a poor animal does not have this power to rationalize and resign itself to pain. It is simply scared by the syringe and the strange environment and shocked by the pain. It dies a fearful, agitated, unhappy death, no matter how swiftly and painlessly the solution does its work. Richard Wagner once remarked how he had no sympathy for the plight of man because man has, after all, the power of resignation. But he had great sympathy for animals because they do not have this power of resignation.

When traditional euthanasia by injection is recommended by a vet for a beloved pet, the owners are given the impression that it is a painless way of saving their animal much suffering and providing the animal with a quick beautiful death, attended by loving hospital personnel. But, even with the best-intentioned veterinarians, this is just not the case. Veterinary medicine has to rethink its approach to euthanasia. It must realize that, unlike human medicine, in which no pain and suffering is too great to inflict on the patient if it will save a life, animal medicine needs a different approach. A method must be found to put animals to sleep gently and peacefully in a loving and caring manner. And that method really should be standard procedure for all hospitals.Death Euthanasia Research Paper

If such a method of euthanasia should prove too expensive or impractical for hospitals like the SPCA that euthanize thousands of strays at their own cost, it should at least be available for pets, whose owners want to pay for it. We were ready to pay any necessary costs. But a suitable method had never been worked out. We had this experience with three doctors, all of whom had to improvise. Except for the girl with the catheters, we were unable to get any doctors to perform euthanasia in a truly painless manner in a suitably calm environment. Some of the surroundings were hectic and the injections into the artery invariably caused great pain.

Even if the substances used in lethal injection are the most painless and efficient method, a way must still be found to both gently tranquilize the animal and numb the area to receive the injection beforehand, so that the final injection does not cause any pain or upset whatsoever. After the initial tranquilization, time must be left for the animal to relax and calm down before giving it the final (painless) injection. The surroundings should be quiet and peaceful and the animal should be treated with love and affection. Such an approach may take more time, but a well organized animal hospital should be able to devise an elegantly rational arrangement that allows the necessary procedures with little extra demands on the doctor’s time.

One of us (JDB) was recently attending on a clinical service where a situation arose that prompted a discussion concerning assisted suicide. It revealed a surprising lack of consensus among physicians regarding the difference between assisted suicide and euthanasia, as well as an appalling level of confusion about basic facts. Such a situation is disconcerting, given that good ethical decision-making requires “getting the facts straight” as an essential first step. It may be understandable that personal perspectives will vary on matters such as physician-assisted suicide (PAS) and euthanasia, particularly in our pluralistic societies. However, it is unacceptable that conversations of a professional nature would proceed in the absence of agreement on relevant first principles and without a shared knowledge base. It would be akin to a cadre of interventional cardiologists, equipped with a shaky grasp of the vascular anatomy of the myocardium, debating the merits of an innovative approach to intracoronary stenting.Death Euthanasia Research Paper

This article addresses such lacunae in relation to euthanasia and PAS. (We will use the word euthanasia to include PAS except where we state otherwise or it is clear we are dealing with the issues separately). We define euthanasia and assisted suicide, reveal common misconceptions in this regard, and expose euphemisms that, regrettably, often serve to confuse and deceive. We review the main arguments advanced by proponents and opponents of legalizing euthanasia. The philosophical assumptions guiding our perspectives are laid out. We consider the effect of legalization on patients and their families, physicians (as individuals and a collectivity), hospitals, the law, and society at large. Our goal is to provide a vade mecum useful in end-of-life care and ethical decision-making in that context.

Definitions

Euthanasia

Euthanasia is an emotionally charged word, and definitional confusion has been fermented by characterizations such as passive versus active euthanasia. Some have suggested avoiding using the word altogether.1,2 We believe it would be a mistake to abandon the word, but we need to clarify it.

The word’s etymology is straightforward: eu means good and Thanatos means death. Originally, euthanasia meant the condition of a good, gentle, and easy death. Later, it took on aspects of performativity; that is, helping someone die gently. An 1826 Latin manuscript referred to medical euthanasia as the “skillful alleviation of suffering”, in which the physician was expected to provide conditions that would facilitate a gentle death but “least of all should he be permitted, prompted either by other people’s request or his own sense of mercy, to end the patient’s pitiful condition by purposefully and deliberately hastening death”.3 This understanding of euthanasia is closely mirrored in the philosophy and practice of contemporary palliative care. Its practitioners have strongly rejected euthanasia.4

Recently, the noun has morphed into the transitive verb “to euthanize”. The sense in which physicians encounter it today, as a request for the active and intentional hastening of a patient’s demise, is a modern phenomenon; the first sample sentence given by the Oxford English Dictionary to illustrate the use of the verb is dated 1975.5 The notion of inducing, causing, or delivering a (good) death, so thoroughly ensconced in our contemporary, so-called “progressive values” cultural ethos, is a new reality. That fact should raise the question: “Why now?” The causes go well beyond responding to the suffering person who seeks euthanasia, are broad and varied, and result from major institutional and societal changes.Death Euthanasia Research Paper

Physicians need a clear definition of euthanasia. We recommend the one used by the Canadian Senate in its 1995 report: “The deliberate act undertaken by one person with the intention of ending the life of another person in order to relieve that person’s suffering.”7

Terms such as active and passive euthanasia should be banished from our vocabulary. An action either is or is not euthanasia, and these qualifying adjectives only serve to confuse. When a patient has given informed consent to a lethal injection, the term “voluntary euthanasia” is often used; when they have not done so, it is characterized as “involuntary euthanasia”. As our discussion of “slippery slopes” later explains, jurisdictions that start by restricting legalized euthanasia to its voluntary form find that it expands into the involuntary procedure, whether through legalizing the latter or because of abuse of the permitted procedure.

In the Netherlands, Belgium, and Lichtenstein, physicians are legally authorized, subject to certain conditions, to administer euthanasia. For the sake of clarity, we note here that outside those jurisdictions, for a physician to administer euthanasia would be first-degree murder, whether or not the patient had consented to it.

Assisted suicide

Assisted suicide has the same goal as euthanasia: causing the death of a person. The distinction resides in how that end is achieved. In PAS, a physician, at the request of a competent patient, prescribes a lethal quantity of medication, intending that the patient will use the chemicals to commit suicide. In short, in assisted suicide, the person takes the death-inducing product; in euthanasia, another individual administers it. Both are self-willed deaths. The former is self-willed and self-inflicted; the latter is self-willed and other-inflicted. Although the means vary, the intention to cause death is present in both cases.Death Euthanasia Research Paper

Some will argue that agency is different in assisted suicide and euthanasia; in the former, the physician is somewhat removed from the actual act. To further this goal, two ethicists from Harvard Medical School in Boston, Massachusetts, USA, have proposed strategies for limiting physician involvement in an active death-causing role.8 It is, indeed, the case that patients provided with the necessary medication have ultimate control over if, when, and how to proceed to use it; they may change their mind and never resort to employing it. However, in prescribing the means to commit suicide, the physician’s complicity in causing death is still present. There are, however, some limits on that complicity, even in the jurisdictions where it has been legalized. For instance, even supporters of PAS in those jurisdictions agree it is unethical for physicians to raise the topic with individuals, as that might constitute subtle coercion or undue influence, whether or not intended.

PAS has been decriminalized in Oregon, Washington State, Montana, and Vermont, and absent a “selfish motive”, assisted suicide is not a crime in Switzerland.9 Even in these jurisdictions, however, one cannot legitimately speak of a “right” to suicide because no person has the obligation to assist in the suicide. Rather, assisting suicide has been decriminalized for physicians in the American states listed and for any person in Switzerland; that is, it is not a criminal offence for those who comply with the applicable laws and regulations.

Terminal sedation and palliative sedation

A lethal injection can be classified as “fast euthanasia”. Deeply sedating the patient and withholding food and fluids, with the primary intention of causing death, is “slow euthanasia”. The use of “deep sedation” at the end of life has become a more common practice in the last decade and has been the focus of controversy and conflict, especially because of its probable abuse.Death Euthanasia Research Paper

Certain terminology, such as “palliative terminal sedation”, creates confusion between sedation that is not euthanasia and sedation that is euthanasia. It was used, for example, by the Quebec Legislative Assembly in drafting a bill to legalize euthanasia.10 We note that creating such confusion might constitute an intentional strategy to promote the legalization of euthanasia. In the amended bill, the term “palliative terminal sedation” was replaced by “continuous palliative sedation”, which the patient must be told is irreversible, clearly indicating the legislature’s intention to authorize “slow euthanasia”, although many people might not understand that is what it means. The bill died on the order paper when a provincial election was called before it was passed. Immediately after the election the bill was reintroduced at third reading stage by unanimous consent of all parties and passed by a large majority. This new law allowing euthanasia in Quebec, the only jurisdiction in North America to do so, remains the focus of intense disagreement and is now being challenged as ultra vires the constitutional jurisdiction of Quebec.

“Palliative sedation”, which is relatively rarely indicated as an appropriate medical treatment for dying people, is used when it is the only reasonable way to control pain and suffering and is given with that intention. It is not euthanasia. “Terminal sedation” refers to a situation in which the patient’s death is not imminent and the patient is sedated with the primary intention of precipitating their death. This is euthanasia. The terms palliative terminal sedation and continuous palliative sedation confound these two ethically and legally different situations.Death Euthanasia Research Paper

Euthanasia advocates have been arguing that we cannot distinguish the intention with which these interventions are undertaken, and therefore, this distinction is unworkable. But the circumstances in which such an intervention is used and its precise nature allow us to do so. For instance, if a patient’s symptoms can be controlled without sedation, yet they are sedated, and especially if the patient is not otherwise dying and food and fluids are withheld with the intention of causing death, this is clearly euthanasia. Needing to discern the intention with which an act is carried out is not unusual. For instance, because intention is central to determining culpability in criminal law, judges must do so on a daily basis. We note, also, that intention is often central in determining the ethical and moral acceptability of conduct, in general.

Within the realm of decision-making in a medical context, withdrawal of artificial hydration and nutrition has continued to be a very contentious issue in situations in which persons are not competent to decide for themselves about continuing or withdrawing this treatment. The questions raised include: When does its withdrawal constitute allowing a person to die as the natural outcome of their disease (when it is not euthanasia)? And when does its withdrawal constitute starving and dehydrating a person to death (when it is euthanasia)

Angels of Death, which reports on Magnusson’s study of the euthanasia underground within the HIV/AIDS communities principally in Sydney, Melbourne, and San Francisco, is, in many respects, a unique work. It is written by a legal scholar but is quite deliberately non-legalistic; indeed, Magnusson makes clear his intention is not to create another manifesto but to inject new perspectives into the euthanasia debate. The book’s underlying methodology also sets it apart. It is based on the author’s own extensive empirical research, drawing on data gathered over three years in the course of indepth, face to face interviews with healthcare workers in Australia and the USA who have been involved in caring for people with AIDS. This kind of empirical research is not often undertaken by lawyers, and while a number of studies into attitudes and practices of healthcare professionals in relation to euthanasia have been carried out by researchers from other disciplines, very few have involved interview based research, relying instead predominantly on surveys.1 By any measure, Magnusson’s research has been undertaken with meticulous care. He is able to balance his gratitude and respect for his interviewees with the need to provide a dispassionate and evenhanded commentary on their accounts.Death Euthanasia Research Paper

The aim of Magnusson’s study is to investigate the attitudes and practices of Australian and American healthcare workers towards assisted suicide and euthanasia, especially within HIV/AIDS healthcare contexts. While this presents some atypical features from other healthcare contexts where assisted death is an issue (which may, in turn, have implications for the extent to which we can extrapolate from the book’s findings in relation to the “euthanasia underground”), it serves as a useful focal point for this study. The book presents and analyses first person accounts of involvement in assisted suicide and euthanasia and contextualises interviewees’ involvement in assisted death within the broader context of palliative care. The author’s intention in telling these stories of the “angels of death” “is to explore that secret part of the medical and nursing professions that few will ever talk about, and about which the public knows very little”.2 In turn, the book’s purpose is stated to be “to expose the social practices, relationships, and networks that constitute ‘underground’ euthanasia” with a view to demonstrating the complexity of the issue and capturing some of the “passion, pathos and bitter-sweetness of those bedside moments”.3 This is an ambitious objective but one which is richly fulfilled.

It is crucial that the development of law and policy on the important issue of euthanasia is based on an informed understanding of actual practice. This empirical work, through the collation and evaluation of indepth interviews, makes an important contribution to the euthanasia debate. This is particularly the case in the light of the limitations of earlier empirical work performed in Australia. The most substantial study to be carried out to date is that by Kuhse et al amongst Australian medical practitioners to assess their attitudes to and practices in relation to euthanasia,4 modelled on a major Dutch study.5 Significantly however, the researchers had not been able to undertake the interview component of the research. This was reported to be due to concerns about the potential legal liability of respondents and the need to maintain anonymity.6 (In the corresponding Dutch study, participating doctors had been granted immunity from liability.) Therefore, the study by Kuhse et al had relied exclusively on anonymous surveys. As Magnusson points out, “while survey-based studies can monitor trends in attitudes and actions, they do not facilitate a detailed exploration of the processes that operate at the bedside, and the social and emotional milieu within which assisted suicide and euthanasia are practised”.7 This limitation was overcome in Magnusson’s work where interviews were conducted on a pseudonymous basis in accordance with a written protocol which had been approved by the Human Research Ethics Committee of the University of Melbourne. No master list of interviewees was retained, thereby preserving the anonymity of respondents. Thus, although all accounts were self-incriminating and could potentially lead to serious criminal liability, the study was designed in a way to ensure that there can be no identification of individual respondents. Moreover, as Magnusson notes, this assurance of anonymity has facilitated unprecedented access to the world of illicit euthanasia.Death Euthanasia Research Paper

As one would expect, much of the book is devoted to presenting and exploring the accounts of the interviewees in this study. Chapter 1 entitled “Who would do such a thing?” examines who performs illegal euthanasia. It profiles five “euthanisers”, presenting some of the anecdotes, personalities, and personal philosophies that emerged from the interviews. It is short but confronting, highlighting the diversity of the individuals who take this path and their approach to euthanasia. The next few chapters seek to put these accounts into some context, examining the social and legal dimensions of the debate about assisted death. Chapter 2 surveys “doctors who kill”, setting out some of the reported accounts of doctor participation in euthanasia in Australia, the UK, and the USA. Chapter 3 focuses on the most prominent of the “voices” and issues in the euthanasia debate and looks also at the impact of AIDS on euthanasia advocacy. Chapter 4 explores some of the factors behind the demise of the “sanctity of life” idea and then reviews, under the heading “Experimenting with death”, some of the legislative models that have been implemented, including the now defunct Northern Territory Rights of the Terminally Ill Act 1995, Oregon’s Death with Dignity Act of 1994 which has legalised physician assisted suicide, and recent legislative developments in the Netherlands pursuant to which the longstanding defence of necessity for doctors who perform euthanasia in accordance with due care requirements has now been given an explicit statutory basis.Death Euthanasia Research Paper

Euthanasia and certain forms of assisted dying are currently legal or decriminalized in just a few countries. The Netherlands (2001), Belgium (2002), and Luxembourg (2009) have legalized euthanasia (Cohen, Van Landeghem, Carpentier, & Deliens, 2014 Cohen, J., Van Landeghem, P., Carpentier, N., & Deliens, L. (2014). Public acceptance of euthanasia in Europe: A survey study in 47 countries. International Journal of Public Health, 59(1), 143–156. doi:10.1007/s00038-013-0461-6
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), and Canada (2016) has introduced a federal law allowing medical aid in dying (Chochinov & Frazee, 2016 Chochinov, H. M., & Frazee, C. (2016). Finding a balance: Canada’s law on medical assistance in dying. The Lancet, 388(10044), 543–545. doi:10.1016/s0140-6736(16)31254-5
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; Upshur, 2016 Upshur, R. (2016). Unresolved issues in Canada’s law on physician-assisted dying. The Lancet, 388(10044), 545–547. doi:10.1016/S0140-6736(16)31255-7
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). In these four countries, euthanasia/assisted dying is legal provided those involved follow certain procedures involving an informed and competent request. By long standing arrangement, Switzerland does not prosecute those who assist a suicide death, provided they do not benefit from the outcome. A similar, more recent arrangement prevails in Colombia.

In the United States, some individual states have legalized physician assisted suicide (PAS) (Varadarajan, Freeman, & Parmar, 2016 Varadarajan, R., Freeman, R. A., & Parmar, J. R. (2016). Aid-in-dying practice in the United States legal and ethical perspectives for pharmacy. Research in Social and Administrative Pharmacy, 12(4), e17. doi:10.1016/j.sapharm.2016.05.040
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). This process involves a doctor prescribing lethal drugs to a person who, following defined procedures, wishes to die by taking the drugs, and then does so. Oregon legalized PAS in 1997 and subsequently so did Washington State, Montana, Vermont and California (Gostin & Roberts, 2016 Gostin, L. O., & Roberts, A. E. (2016). Physician-assisted dying: A turning point? JAMA, 315(3), 249–250. doi:10.1001/jama.2015.16586
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).Death Euthanasia Research Paper

The case for assisted dying and/or euthanasia is being debated in many settings, especially those where no specific legislation yet exists and has led to a range of advocacy interventions. One way to influence policy is by generating formal statements on single issues. When associations, organizations and groups concerned about end-of-life issues promulgate their views on a specified matter, they can draw it to public attention and call for change.

We refer to advocacy interventions of this type as declarations. Although they may take different names (statement, resolution, manifesto, charter, commitment, or proclamation) such declarations group around a common purpose. They capture the goals of interest groups, make statements of intent, point to a more desirable state of affairs, and encourage greater awareness to achieve a stated goal. These declarations have no legal mandate but do have potential for influencing laws, policies, systems and processes on end-of-life issues. They have become a part of the landscape of end-of-life care, and the debates that swirl around it.

At the same time, they are poorly documented and largely ignored by researchers. Yet they are important markers in the evolution of end-of-life discourse. They give perspective on the changing discussion around specific issues and have some importance within the culture of many end-of-life care organizations. They merit research scrutiny, in particular, when declarations on the same topic take up opposing or differing perspectives.Death Euthanasia Research Paper

Building on an earlier study of declarations in support of palliative care development (Inbadas, Zaman, Whitelaw, & Clark, 2016 Inbadas, H., Zaman, S., Whitelaw, A., & Clark, D. (2016). Palliative care declarations: Mapping a new form of intervention. Journal of Pain and Symptom Management, 52(3), e7–e15. doi:10.1016/j.jpainsymman.2016.05.009
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), we focus here on such statements as they relate to euthanasia and assisted dying. Our aims were to (a) track over time the emergence of euthanasia/assisted dying declarations, in the global context, (b) describe their form, structure and characteristics, and (c) document their stated purposes. We set out to build a comprehensive collection of declarations that relate to euthanasia/assisted dying and are available in the public domain.

Euthanasia in the UK is illegal, but the application of the law is not always clear. For example, although doctors in the UK are not allowed to give treatment that causes death, doctors can withhold artificial nutrition and hydration (defined by the British Medical Association as “life‐prolonging treatments”) if they believe that this would be in the patient’s “best interests”. In the absence of consensus, any decision must be authorised by a court, but the meaning of “best interests” can be controversial. Giving food and drink to the sick has long been used to symbolise “compassionate care”,4 and some may regard the withdrawal of food and water, as in the Tony Bland case,i as a form of involuntary euthanasia or even murder.5,6 Thus, the law seems to be inconsistent.7 It forbids doctors to give a patient a lethal injection at his or her request, but permits a court to authorise death by starvation without such a request.Death Euthanasia Research Paper

The UK law on assisted suicide has also been described as “contradictory, confusing and opaque”.8 What counts as assistance in suicide in “mercy‐killing cases” seems to be rather arbitrary. In 1989, a couple were convicted because they sat and watched their daughter (who had motor neurone disease) commit suicide and die of an overdose, but in 2005 Graham Lawson was not prosecuted after he comforted his sister, who had multiple sclerosis, during a 26‐h suicide ordeal. She finally killed herself with a plastic bag. The Director of Public Prosecutions continues to consider cases individually. Under the Suicide Act 1961 section 2 (4), no prosecution for the offence of assisted suicide can take place without the consent of the Director of Public Prosecutions. He will exercise his discretion only after a suicide has taken place; therefore, no prospective guidance can be given to people.Death Euthanasia Research Paper

Previously, attitudes to euthanasia and assisted suicide were examined mainly from the perspectives of politicians, ethicists, health professionals and the general public.10,11,12 A few studies tried to capture the patients’ perspective indirectly—for example, Seale and Addington‐Hall13 found that a quarter of bereaved respondents would have preferred an earlier death, and examined the reasons, but they did not interview the people who were dying. Little is known about euthanasia or assisted suicide from the patients’ point of view.14 We explore these issues from the perspectives of people who knew they were terminally ill. Death Euthanasia Research Paper