Euthanasia, ethical and social problem

Gonzalo Herranz, department of Bioethics, University of Navarra
Session at the Postgraduate Course for University Specialists in Bioethics.
Educational Promotion Service, University of Murcia, February 9, 1996.

Index

1. What has happened since last year?

2. On the skepticism with which the sociological data should be received.

3. The new legal status in Spain

4. An estimate of the consequences of euthanasia legislation for the internship of medicine.

5. The status in Holland or the demonstration that there is a slippery slope.

Value of life and the slippery slope

It seems that my destiny in Murcia is to talk again and again about euthanasia and suicide.

If three years ago and last year, in the courses organized at the time by Dr. Pastor, I spoke about euthanasia, it seems that this time it is my turn again with triple ration. I suspect that something in Dr. Pastor's computer or in his head must have started to reverberate.

One thing is clear: I cannot say the same thing. The organizer can repeat speaker and topic. But the attendees are entitled to hear new things, at least those who were present two years ago. It is not pleasant to be branded as a gramophonic record. And the truth is that there is no shortage of new subject , lots of news, much of it not very pleasant. I confess that some days I go home saddened by the things that are happening.

I will address four points in this first talk.

I will make a brief summary of the highlights of what has happened in the last year in the field of euthanasia.

2. I will say a few words about the skepticism with which one should regard the sociological data .

3. I will analyze the new Spanish legal rule on euthanasia, included in the new Penal Code. And finally,

4. I will try to calculate the consequences that legislation on euthanasia may have for the internship of Medicine.

1. What has happened since last year?

Among so many, which ones to talk about? I could talk about many and all of them very interesting. For example:

Pro-euthanasia activists everywhere continue to persevere in their efforts to achieve the decriminalization of voluntary euthanasia. It is regularly spoken and written about, insistently. Sometimes to the point of nausea. The HCR has dedicated the May-June issue of issue to assisted suicide, the July-August issue to re-examining the boundary that separates life from death, the November-December issue to studying how the life of the insane can end and whether they have the right to life-sustaining treatment. And so on, all of them.

It is obvious that the emphasis has tended to shift from euthanasia to medically assisted suicide. The financial aid to voluntary suicide is the slogan of the moment: it has, so to speak, an aura of libertarianism, of self-determination, of affirmation of man's absolute sovereignty over himself, so fashionable. The medical financial aid to suicide appears to be far removed from any accusation of abuse, of arrogance, more respectful of persons and rights. It is the just expression of the right to die with dignity.

That in the Netherlands, euthanasia and the medical financial aid to suicide continue to take root in society: there are indirect data - death certificates continue to be falsified despite the tolerant legislation in force there - indicating that euthanasia and so-called end-of-life medical acts are the most frequent cause of death. For a moment, there was the impression that the prosecutors and forensic experts were going to intervene more closely in the study of the reported cases, but not many of them were brought before the judges. And, then, the latter have not only been extremely benign with the physicians, but have very often congratulated them for their moral courage and for helping them to establish jurisprudence in favor of expanding the indications for euthanasia.

The unconstitutionality of the Oregon state law authorizing financial aid to commit suicide under certain conditions, which was approved by referendum in November 1994, remains undecided.

But in the meantime, legislation authorizing euthanasia has not been stopped. The modest Northern Territory of Australia has C a law called the rights of the terminally ill. On May 25, 1995, this first law legalizing voluntary euthanasia was passed. It should not be forgotten that the legal authorization of euthanasia in the Netherlands is part of a burial regulation (it is a simple modification of the requirements to be included in the certificate Death Certificate). The Darwin Parliament has determined the conditions under which doctors can end the life of terminally ill patients. The fundamental one is to call a psychiatrist to evaluate the mental and emotional state of the patient, to check if the request is sincere, free and informed and does not come from a depression that can be treated medically.

The Northern Territory's example looks set to be followed by other Australian states. At the very least, the typical strategies for creating social pressure in favor of euthanasia have begun to be put in place. Seven Melbourne doctors have published newspaper articles or written letters to the editors of medical journals to confess that they, honest and responsible professionals, openly confess to having committed the crime for which the new legal tolerance is being sought. Symbolically, the letter written to the most widely circulated newspaper was published on the same day as the Encyclical Evangelium vitae. In essence, the letter came to say that the medical financial aid to suicide and voluntary euthanasia and manager is a virtuous and dignifying way of providing necessary services to patients who wish to die with dignity and honor. This literature contains the main elements of the pro-euthanasia social message:

a. A declaration of righteousness. Physicians declare themselves to be sincere, of upright and sensitive conscience, humane, who after much and deep thought, decided to help their patients to die.

b. An offering to become victims. Physicians know that their self-accusation may be taken as test that they have committed a crime. But they, despite the risk they incur, take full responsibility for their actions and are willing to be victims of an unjust judicial system.

c. A protest against obsolete, unjust and coercive legislation. Their firm conviction that the law prohibiting financial aid to suicide is inhumane impels them to risk their degree program and to fight for the new civil rights tends to turn them into social heroes, practicing civil disobedience towards the unjust law.

d. A support for social progress. The aura of progressivism distinguishes them from hard-hearted, conservative people, entrenched in old-fashioned morality, who have lost the battle.

e. Denouncing the hypocrisy of the medical profession. The financial aid to suicide is, according to the complainants, a widespread internship , reiterated by many doctors, who clandestinely help many patients to die. Relieving patients of their pain and suffering through death is acting in the best traditions of medical ethics. To deny euthanasia or financial aid to suicide is, in many cases, an act of cruelty incompatible with the compassionate heart of the physician. What happened before with abortion is happening with this.

f. An action of the utmost respect for life. When physical or spiritual suffering is beyond the possibility of controlling it and the patient expresses a reasonable desire to financial aid, it is precisely out of respect for that life that the physician is impelled to help his patients with attendance to suicide or voluntary euthanasia.

This is a touching dialectic, one that strikes a deep chord in the hearts of the public, of the deputies eager to distinguish themselves in the parliamentary degree program . It is very easy for a country to succumb to a message so full of apparent compassion and humanity.

But it's not all "bad" news. At the 98th congress of the German Chamber of Physicians, held in Stuttgart, this resolution was taken:

"The Congress of German Doctors observes with deep concern the evolution of the practice and legal regulation of euthanasia in Holland. Though humane motives in the participating doctors may play a role in such an evolution, it is an unavoidable consequence of such a conduct that the killing of terminal patients is becoming an integral part of the medical function.

The foundation of the trust relationship between patient and doctor is from old the duty of the doctor of not harming human life, but caring for it and further its health. Such a trusting relationship is severely put in danger if the doctor, instead of his or her traditional role of curing and caring, plays also as a killer".

2. On the skepticism with which the sociological data should be received.

In the introductory sentences that Fins and Bacchetta, in their article published in the Journal of Clinical Ethics, put to an extensive annotated bibliography on recent and significant articles dealing with medically assisted suicide and euthanasia they say they hope that their effort to collect, select, and comment on the most important that has been published on both topics will serve to help readers try to see clearly in discussions on topic so vivid. Precisely because the attention is so vivid and so charged with conviction, it has become extremely difficult to understand the issues and values at stake, and even the words we use in this discussion.

If this is true in the academic and learned discussion of biomedical, legal, theological and philosophical journals, the confusion that reigns among ordinary people is much greater. The data sociological surveys are incredibly difficult to interpret, or lack validity.

It is repeated that people today are very open, very much in favor of euthanasia: that, for example, 68% of Spaniards believe that sweet death should be applied to patients who ask for it because they are suffering from a terminal and very painful illness, or because their life has a very poor quality leave. But these patients are very few.

But I do not believe that there has been anywhere a critical and serious survey , and a serene social reflection, not manipulated, on euthanasia. It is spoken with heat, but it is very difficult to achieve a serene discussion. I try to talk about this with the people who travel next to me on the bus, on the plane, with the cab driver. My impression is:

1. That many are in favor, but not a single one would dare to be the one to apply it. The same surveys say that there are practically no people, and even fewer physicians, who would be willing to practice euthanasia, even if it were decriminalized.

2. That there is a B terminological confusion induced by the media, especially by TV: the discussions always make reference letter more than euthanasia, therapeutic incarnation and the Sampedro case.

3. That it is not easy to recover a valid language. Sánchez Dragó's answer after a TV program. Its informative and pedagogical function is of no interest whatsoever, but the action provoking confusion, demonstrating disagreement, and obscurantist, in the sense that it is impossible to discern the truth. It is not easy to educate: to establish clear, unequivocal definitions, so that the answers to the surveys and the positions taken would be clear, interpretable, independent, sincere, not vitiated by biases, not inducing preformed answers through the manipulative text of the question, the gesture of the pollster who invites and directs the answer in the permissive sense.

4. People should be asked very simple questions, one at a time, free of emotional charge. Often, the way the question is phrased predetermines a specific answer.

5. We do not reflect too often with seriousness on how civil society should pronounce itself on these serious questions that will modulate the tone of human relations: of children with parents, of doctors with patients, of the strong and healthy with the weak and sick.

6. Euthanasia is an extremely serious matter. The future of medicine depends to a large extent on the legislation that at any given time regulates the ability of physicians -and non-physicians- to kill certain human beings.

I believe, in conclusion, that sociological surveys are not up to the mark.

3. The new legal status in Spain

On November 23, 1995, the long legislative process of providing the Kingdom of Spain with a new Penal Code culminated. Organic Law 10/1995 was approved with the unanimous applause of the political forces. There is no doubt that the new Code has very positive and advanced aspects. However, I would like to express my concern about what has technically come to be described as B softening of the penalties imposed on those who practice euthanasia on another person and financial aid to die with dignity.

In the new Code, article 143 reads as follows:

1. Whoever induces another to suicide shall be punished with imprisonment for a term of four to eight years.

A term of imprisonment of two to five years shall be imposed on anyone who cooperates with acts necessary for the suicide of a person.

3. Shall be punished with imprisonment of six to ten years if the cooperation goes so far as to cause death.

4. Whoever causes or actively cooperates with necessary and direct acts to the death of another, by the express, serious and unequivocal request of the latter, in the event that the victim suffers a serious illness that would necessarily lead to his death, or that would produce serious permanent and difficult to bear suffering, shall be punished with the penalty lower by one or two Degrees than those indicated in numbers 2 and 3 of this article.

The text of this fourth paragraph, the one related to euthanasia or, better, to homicide due to serious illness, is enormously vague and produces uncertainty. I am sure that no physician has been called upon to collaborate in its essay. It seems obvious that voluntary euthanasia is included in it, and that any involuntary euthanasia is excluded. But will antecedent decisions, at least some living wills, be valid as a valid document of express, serious and unequivocal request? Would a living will be acceptable that would add, to the prohibition of therapeutic overkill, the antecedent, express, serious and unequivocal request for death, if the presumed victim were unable to decide, and certain circumstances were incurred in the course of a serious illness with an unfortunate prognosis, which the patient judges in advance to be difficult to bear? A document of this subject could authorize the internship of involuntary euthanasia in those who decide that, for example, senile dementia constitutes an intolerable way of life.

It seems obvious that article 143 creates a surprising asymmetry between the leniency with which the author of euthanasia is treated and the harshness with which the one who financial aid punishes the patient to commit suicide is punished. It is surprising that euthanasia is punished by one or two lesser penalties Degrees, when the dominant progressive legal tendency is not to distinguish between financial aid medical suicide and voluntary euthanasia, or even, as I said before, to treat more considerately the financial aid voluntary suicide because of its unalterable manifestation of autonomy and voluntariness in the victim, which makes it more authentic and sincere in the eyes of society and the law. It is incongruous that since suicide is decriminalized, financial aid is condemned in such a harsh way, comparatively speaking, to suicide.

Returning to the commentary on paragraph 4 of article, it is worth noting, as a very salient feature, the de-medicalization of the new crime. Just as in the current abortion law and in the latest draft Organic Law on the regulation of the voluntary termination of pregnancy, the legal text opens by stating that "the termination of pregnancy performed by or under the direction of a physician shall not constitute a crime", in the rule on euthanasia there is no mention of the physician at all in reference letter . There is no abortion without a physician. Euthanasia homicide does not require neither the presence nor the action of the physician, since it is defined by the convergence of two circumstances that do not require the immediate and direct participation of the physician: one, the request for death made by the victim, which, in addition to being express and serious, must be unequivocal; the other, the suffering of a serious illness, with an unfortunate prognosis, or one that causes severe permanent suffering that is difficult to bear.

This is very important for the medical profession. The extra-medicalization of the new crime could dispense us physicians from the task of paying more attention to topic, and say: it is not for us. But it is inevitable that, in any homicide by disease, there is a physician involved. It is to be expected that some doctor, a psychiatrist, for example, should be called in to evaluate the serious and unequivocal character of the request for death, that is, if the request is not vitiated by emotional or pathological situations that would invalidate it. The final status , agonizing or preagonic, and unbearably painful are data whose appreciation can be assumed to be within the reach of any judicious adult. Moreover, the very structure of the text and the absence of technicalities - there is no mention, for example, of terminal illness or prognostic factors - suggest a deliberate desire on the part of the legislator to exclude the physician from the center of the scene.

It is not necessary to be an expert in Criminal Law, to perceive that the status that the new legislation would create would be alarming due to its uncertainty and indeterminacy.

In the first place, because the penalty with which it is intended to dissuade the alleged perpetrator of homicide by disease is very light: the reduction, following the criteria set out in the new Code, on the one hand, the article 66 on the concurrence of extenuating circumstances, and on the other hand the article 70 on the calculation of the Degrees of the penalties, makes it possible to speak not only of sweetening, but also of internship decriminalization.

I will explain: the reduction by one or two Degrees with respect to that assigned to the cooperation to the acts necessary to the suicide of a person, that would be the medical financial aid to suicide, penalty set at two to five years, makes us reduce by half or a quarter the minimum figure indicated: that is to say, one year or six months. If to this we add the concurrence of a very qualified or more attenuating circumstances, inevitably present or easily demonstrable in the euthanasic action (motive of compassion, status of necessity), which authorize a further reduction to the application of a penalty lower by one or two Degrees to that indicated by the Law, reduce the penalty for euthanasia to a maximum of six months, that is the minimum duration of the prison sentence. It is usual that everything is reduced to weekend arrests, according to the judges' opinion. Since it is to be expected that, in euthanasia trials, the defendant's defense will be able to persuade the judges (and even more so the jurors, if they are called to give the verdict in crimes of this nature subject) of the altruism, mercy and compassion with which the defendant has acted, the rule is usually a final verdict of innocence. Presumably, in cases of homicide by disease, it will not be very difficult for lawyers to accumulate sufficient exonerating or extenuating circumstances of criminal liability, which will excuse the penalty or reduce it to its minimum level. entrance The entry into force of a article drafted in the aforementioned terms would be tantamount, in the short term deadline, to the de facto decriminalization of euthanasia.

That decriminalization is in a certain way in the will of the legislator is deduced from the inconcrete and nebulous character of the legal text. It does not indicate what precautions the author of the homicide by disease must take to ensure the express, serious and unequivocal nature of the victim's request. The tolerant regulation on euthanasia, in force since December 1993 in the Netherlands, is much stricter in this respect: it requires that euthanasia be performed by a physician; that the request be made by a competent patient, who must repeat it for at least one week and document it in writing, signed in the presence of witnesses; it requires the concurring opinion of another physician, called at enquiry and not involved in the patient's care, who, in addition to assessing the patient's psychological state, must confirm that the disease is in its terminal phase, that it causes an intolerable level of suffering, that it is resistant to current therapies, and that there are no effective treatments that can be offered as an alternative to compassionate death.

The new Spanish legal rule considers that an "express, serious and unequivocal request" is sufficient. But, as we all know: a firm, clear, poignant request for death can be made by a patient under the effects of chronic fatigue, tenacious insomnia, oppressive dyspnea, a nauseous state, or undiagnosed or poorly treated depression. An express and serious request for death may be the consequence of incompetent treatment of pain or other symptoms, or of affective withdrawal on the part of relatives and caregivers. It may even be made by the patient as a psychological and dramatic resource to focus the attention of others on him or her, or in retaliation for present neglect or past grievances.

The project leaves a great deal of latitude as to what is to be understood by "serious illness that would necessarily lead to death or produce serious permanent and difficult to bear suffering". First of all, it does not indicate to whom it corresponds to make that judgment. It seems, from the context, that it corresponds either to the one who executes the homicide or to the one who expresses the request. Leaving it to the weakened subjectivity of the patient could be irresponsible, even from a relativistic point of view. It is not even required that the disease has reached its terminal stage; we only speak of diseases with a necessarily fatal prognosis. But to what deadline? Medical prognosis is fallible, even for very experienced and competent professionals. Leaving it up to the patient to decide to ask for an end to his or her illness, even if it is serious, necessarily fatal and produces permanent and difficult to bear suffering, is like abandoning him or her. It is to grant him a responsibility that he is not in a position to assume. More and more, as psychological autopsies of suicides are performed with greater frequency, experience and care, it is concluded that rational and lucid suicide is a rare exception: that everyone who puts an end to his life does so as a victim of a psychic disorder that seriously diminishes his rational autonomy or annuls it, which must be treated with skill and thoroughly.

Moreover, many patients can be manipulated by their relatives: homicide by disease can be requested by sick people persuaded or coerced by relatives who are emotionally or physically exhausted. How can a judge or jury decide, for example, that a husband who suffocates his wife with a plastic sack, who is suffering from widespread cancer and who has spent hours begging him to please end her life, has done so out of compassion, or because he is tired of hearing her chatter, or because he cannot manage to care for her? Or, how to determine whether the daughter who has given an overdose of insulin to her invalid mother has done so out of pity, to be relieved of a useless burden that prevents her from going regularly to her work at a decisive moment for her professional advancement, out of a desire to have the inheritance soon, or out of a combination of all these?

The new law may be an indirect way of granting people legal permission to get rid of the burden of certain difficult-to-bear illnesses. We will have to wait and see how judges apply it and how sensitive they are to mitigating arguments. Once the law is in force, how long will physicians be able to resist, at first, the requests - later on, the demands - for homicide addressed to them by patients and their relatives? The legal penalty is so light, and the indulgence of the courts so likely, that the physician who objects to euthanasia may be regarded as not very humane, as a hypocritical, uncompassionate hypocrite.

4. An estimate of the consequences of euthanasia legislation for the internship of medicine.

Many of us are convinced that decriminalizing or lenient legislation on euthanasia favors its generalization. Some say that nothing is wrong, that euthanasia is already among us, in the form of cryptanasia, in the same way that abortion was everywhere before it was decriminalized.

What happens is that nobody has published anything serious about cryptanasia, the clandestine death of patients by doctors and families in complicity. They talk about it, we have heard it from Australian doctors, but they have not measured it. Even they do not say how many times they have practiced it. It is a specious argument: the clandestine resists measurement.

What will happen? My thesis is clear: any legislation tolerant of euthanasia, no matter how restrictive it pretends to be on paper, causes an increasing deterioration, even brutalization, of medical care, because it degrades it ethically and impoverishes it scientifically.

The ethical decline is not difficult to calculate. In the dynamics of legal permissiveness, decriminalising euthanasia begins to mean that killing without pain is an exceptional way of treating certain illnesses, which is only authorised for extreme and very strictly regulated situations. But, without delay, inexorably, as a result of social habituation and pro-euthanasia activism, decriminalisation ends up meaning that killing for compassion is a de facto accepted therapeutic alternative. And so effective that doctors cannot morally refuse it. The reason is obvious: euthanasia - a clean, quick, one hundred percent efficient, painless, compassionate intervention, much more comfortable, aesthetic and economical than palliative treatment - becomes an invincible temptation for certain patients and their relatives. And for some doctors as well, because the sweet death of one or another of their patients saves them a lot of time and effort: the time they invest in following the case day by day, in palliating their symptoms, in visiting them, in accompanying them in the difficult final moment.

Once euthanasia is decriminalised, the serious thing for doctors is that their specific virtues - compassion, prevention of suffering, non-discrimination between their patients - are turned against them, so that they are driven by their own professional virtues to apply this supreme therapeutic with ever greater zeal: they cannot deny a patient the liberating death which, in similar circumstances, they have already given to others; nor can they delay until later what is now presented as the most effective remedy. The concept of terminal illness will become wider and wider; the indications for euthanasia will become more extensive and earlier and earlier.

Whoever has succumbed to the temptation of sweet death and performed euthanasia, either repents definitively, or will no longer be able to stop killing. Because if he is ethically congruent with himself, and believes that he is doing something good, he will do it in less and less dramatic cases and, in the name of ethics, by skirting legal barriers. For if the law, as seems likely in the first generation of euthanasia laws, only authorises euthanasia or financial aid to suicide for those who ask for it freely and voluntarily, what reasons can be given by those who have practised it according to the law to deny it to those who are incapable of asking for it, but whose life is more degraded or much more burdensome for others? He is certain that the insane person, the person sleeping in an irreversible coma, the victim in a chronic vegetative state, would undoubtedly ask for it if they had a moment of lucidity. Once euthanasia is authorised, the virtues of the doctor are turned against him. No matter how careful he is of his patients' autonomy, no matter how much he respects their capacity to choose, if he thinks that there are lives so lacking in quality that they do not deserve to be lived, he will conclude that sometimes there is only one thing left to choose: the death of the extremely weak. If a doctor or a nurse were to consider euthanasia as a superior remedy to palliative care, they could not help but become subjective mandators of terminally ill patients. Faced with a patient who is unable to express his or her will, they reason thus in their hearts: "It is horrible to live in such precarious biological or psychological conditions. I wouldn't want to live like that. That is not life. It is better to die. Therefore, I decide that the best thing for them is a sweet death". But the utilitarian judges that there are cases in which the desire of certain patients to go on living may be irrational and capricious, because they have an abhorrent prospect ahead of them. He reasons thus: the lives of certain patients capable of making decisions are so lacking in quality that they are not worth living. To insist on living them is an unjust desire, which entails an irrational consumption of resources, economic and human: that money and that work effort could be much better spent. It is very easy to expropriate the patient's freedom to choose to go on living.

With each passing day, I am convinced that palliative care contains an ethic of great density: it is in itself a dimension of medicine that cultivates and enriches the most intimate and basic ethical values. It is, moreover, the antidote that can protect us against the temptation of euthanasia, which is both frightening and attractive.

A highly effective antidote. Even the most upright doctor and nurse need to guard against the excesses of their virtues. To decriminalise euthanasia would be to plunge medicine into the self-aggressive disease of counterfeit compassion. The obligation to respect and care for all human life is a wonderful and inspiring moral force. With it, we must develop the theory and the internship of palliative, scientific and humane care, which will uproot from our hospitals the scandalous error of therapeutic overkill and which will highlight, by contrast, the cold inhumanity which, disguised as compassion, is hidden in euthanasia.

If physicians were to work in an environment in which they knew that they could not get away with treating or killing certain patients, they would become indifferent towards certain types of patients, and research would wither in vast areas of pathology. For if the senile patient or the patient suffering from Alzheimer's disease is given sweet death as the first option, who can feel motivated to study the causes and mechanisms of brain aging or the constellation of factors that determine dementia? If the patient with advanced cancer is offered cooperation with suicide as a valid therapy for his disease, who is going to be interested in the mechanisms of metastatic dissemination, in the metabolic disorders induced by the mediators of cachexia? All the mental and moral effort, the tension, sometimes exhausting, to fulfill the Hippocratic precept of seeking the good of the patient - "I will do what I know and can for the benefit of the sick person, and I will strive not to do him harm or injustice" - would suffer, in a society tolerant of euthanasia, an atrophy by disuse.

I must conclude. The scientific values of medicine suffer an impoverishment when part of them are absorbed in euthanasia. And so does the whole of humanity, which is expropriated from death. Because euthanasia, if generalized, would become the final solution to the unfathomable mystery of death. Death will no longer be a destiny staff, but a simple routine technical gesture, neatly executed.

Doctors who, in hospitals and homes, apply palliative care with humanity and science are doing much for the ethics of the health professions. The care they provide is saving medicine from the great danger of becoming an accomplice of the strong against the weak. Thank you very much.

5. The status in Holland or the demonstration that there is a slippery slope.

In the Netherlands, the legislative machinery has not stopped in the last two years. The approval of the Law at the end of 1993 was followed, within a year, by its extension to non-terminal cases and to patients with severe mental illness, as established by the Chabot court ruling and then enshrined in law by parliament.

In the last two years, reports have continued to be published on the internship of euthanasia in the Netherlands. The group of Public Health of the Erasmus University Rotterdam, together with the group of Bioethics of the University of Utrecht and the National Statistical Center have continued their programs of study on the incidence of euthanasia, financial aid suicide and end-of-life medical acts. In a major effort, they have published, apart from national reports in monographs in journals, in Dutch, a good issue of articles in Lancet, Br med J, Ann Inter Med, Fam Practice, to disseminate the information, giving it an objective and scientific picture. They have published programs of study on what happens in hospitals, in nursing homes, in the general internship , in the pediatric population, on actions without explicit patient request.

To take one example: from the National Study of End-of-Life Decisions Among General Practitioners (Lancet 1994;309:1209-1212), the following conclusions are drawn:

a. In contrast to our own and many other countries, almost half of all deaths in the Netherlands take place not in the hospital, but in the patient's home. This places general practitioners in the position of having to make many end-of-life decisions in the privacy of their patients' homes.

b. In the Netherlands, general practitioners decide the end of life with life-shortening measures in more than half of their terminally ill patients.

c. The patient intervenes in the process of deciding the end of life in about half of the cases. In 40% this is not possible because of weakened consciousness or dementia, while in the remaining 10% the patient does not intervene for paternalistic reasons.

d. General practitioners who work alone, without being part of groups of internship, consult less with other physicians about their end-of-life decisions than those who work in partnership.

e. Medical decisions around end of life will become increasingly prevalent in the future. Physicians are required to become proficient in this subject.

What does all this mean?

Several things. Euthanasia has been trivialized in its various forms. The "I will give no man deadly poison even if he should ask me" of the Hippocratic Oath has been forgotten; the "utmost respect for human life" of the Declaration of Geneva is no longer practiced. Today, in the Netherlands, in the form of voluntary euthanasia authorized by law, of medical suicide financial aid , of involuntary euthanasia, of suspension or non-initiation of treatments, or of applying treatments with the intention of anticipating death, half of the people who do not die of fulminant or acute diseases, do so by medical intervention, more or less anticipating death.

Euthanasia has been trivialized to the point that it has been proposed on a congress of general practitioners that the euthanasic removal of some particularly demanding terminal care cases, which unduly burden the physician's daily diary , may be an effective, or at least worth considering, procedure stress reliever for general practitioners.

That, given the private, domestic nature of the setting in which so many people die, it is very easy for the rules established by law not to be followed. The term cryptanasia has been coined for this private internship termination of life. It cannot be forgotten that Dutch law requires the voluntariness of the patient, demonstrated and signified by documentation. General practitioners confess to omitting this legal requirement: either because patients are not in a position to apply for lucidly and repeatedly euthanasia or financial aid to suicide, or because, for paternalistic reasons, the physician knows best, the patient is not in a position to decide, because he does not understand or does not dare, it is the physician who expropriates the patient of his autonomy and decides for him.

The acquittal of Dr. Chabot for the death of a woman victim of severe depression has caused an intense commotion in public opinion and in professional circles. The case of Mrs. Hilly Bosscher.

It has been said that, following the enactment of the law in December 1993, prosecutors have begun working to prevent the law from being systematically disregarded. By April 1994, it had detected 12 cases of medical deaths of non-terminal patients. The Royal Dutch Society was so insistent that the professional requirements she had published six years earlier did not require a terminal status , but merely "unacceptable and hopeless suffering," that Parliament has amended the law to include "untreatable" moral or psychological suffering as a sufficient reason for euthanasia.

A article that impressed me a lot is the one published by Gerrit K. Kimsma graduate Clinical ethics in assisted euthanasia: avoiding bad internship in the application of drugs. Moved by some errors in the selection of euthanasia drugs and with the experience of the reactions to them expressed by relatives and bystanders, Dr. Kimsma writes a article to advise on the good internship of euthanasia. This requires determining the wishes of the patient or his relatives regarding the speed or slowness of the induced dying process, the avoidance of unpleasant symptoms of respiratory distress, convulsions.

The denouncement in the media of some cases in which physicians proved to be incompetent by using the wrong pharmacological substances, by abandoning the use of analgesics once the final treatment had been initiated, etc., prompted the Royal Dutch Society for the Advancement of Pharmacy to publish a monograph entitled Euthanasia manager, in which it states that the physician must be sufficiently familiar with the "handling" of the various groups of euthanasia drugs (curarinics, bartiturates, morphine and related substances, and insulin), as well as with insulin, and insulin), while stressing the need to formalize the clinical pharmacology of euthanasia drugs in search of the ideal euthanatic, a substance whose administration by different routes would regularly and consistently cause rapid, gentle and calm euthanasia. Such a substance, simple to apply, should guarantee its rapid, sufficient and reproducible efficacy, administered by different routes (oral, intravenous, intramuscular, subcutaneous or rectal). deadline The amount to be administered should be as small as possible; it should induce in a maximum of 30 minutes a deep and irreversible coma, leading to death within a couple of hours; its use should be reserved exclusively to physicians, or through medical prescription; it should lack unwanted physical or psychological side effects; its possible emetic action should be effectively prevented; and its lethal effect should be 100% guaranteed.

Much has been published about euthanasia and slippery slope, both as an argument against its legal acceptance and its ethical soundness.

I will limit myself to transcribing a brief comment made by a Czech physician, Marta Munzarova, very recent and very simple.¹very recent and very simple. I think it has great value.

Value of life and the slippery slope

It is easy to fall into the trap of assuming that opposition to euthanasia comes only with the dogma of pro-life groups. But the following comment reminds us how crude is the utilitarianism underlying much modern liberal support for euthanasia.

In 1991 Gunning, referring to intentional killing of patients in the Netherlands, was afraid that in the future those people will be eliminated whose quality of life does not meet certain medical criteria. Next to birth control will be death control, and the new ethics of relative rather than absolute and equal values will ultimately prevail.

In 1995, Fletcher and Spencer's viewpoint article "Incompetent patient in the slippery slope" completes the recent discussions confronting different approaches with regard to elderly demented patients. Behind many of these debates are attitudes regarding life and death, which prepare the way for the practice of terminating "useless" lives.

In this context, it is useful to point out how the shift of mentality might have been prepared by some ideas dealing with the value of life and personhood: "What we need, then, is not a definition of death but an account of when it is right to say that personhood is lost.... Personhood... involves the capacity to want to exist and the sort of self-consciousness that makes the possession of such a want possible.... Once they are lost, the being has ceased to be a person and then, even if their body is still technically alive, it has lost its moral significance and can either be killed or allowed to die or preserved alive if we choose".

Or: "we cannot justify refusing to value the lives of severely retarded humans along with the lives of animals of similar capacities.... When we compare the lives of animals (and severely retarded humans) with those or normal humans, or persons, it does seem that there could be reasonable grounds for preferring the later, if the choice must be made.... For utilitarians too, the only things of value are conscious experiences; thus without consciousness, life would have no intrinsic value".

Ideas change the way of thinking about ourselves and about others. A similar way of thinking before the take-over of the Nazis in Germany proved to be very dangerous (as has the precise cause of "attacks" in the German-speaking world against its opponents since 1989). Then "the way to crimes against humanity was prepared by peculiar ways of thinking about humanity.... They then spoke of lebensunwertes Leben, life that is unworthy of life". The debates in which we are now embroiled deal with "when and 'what' becomes a 'who' and when, at the end of life, a 'who' becomes a 'what'.... It is by no means clear to many thoughtful people how we, in principle or in practice, distinguish lebensunwertes Leben from a 'quality of life index'".

"We tell ourselves that issues are raised by medical and technological advances and so we seek to reduce our sense of moral agency and responsibility". But the same questions in the case of elderly demented patients were discussed many hundreds of years ago by one of the greatest medical ethicists -Maimonides-. He too realised the great difficulties inherent in implementing commandments of honor and reverence to senile fathers or mothers. In some situations, his codification emphasizes that the child is exempt from staff service to the mentally disturbed parents but in no case from responsibility to ensure that others attend them. Many ideas raised during present discussions document that the slippery slope in thinking, "a peculiar way of thinking about humanity" is today's reality. Lives once thought to be undeniably human are now called into question. But if we accept the ideas that these lives become "worthless", we reduce the worth of all human lives to something relative, and we divide people into those who are worth more and those who are worth less.

Present society adores people who are successful, happy and young, and in doing so blurs the decisive difference between being valuable in the sense of dignity and being valuable in the sense of usefulness. Today it is therefore extremely urgent to be reminded of what Viktor Frankl said:

"If one is nor cognizant of this difference and holds that an individual's value stems only from his present usefulness, the, believe me, one owes it to staff inconsistency not to plead for euthanasia along the lines of Hitler's programme. That is to say, 'mercy' killing of all those who have lost their social usefulness, be it because of old age, incurable illness, mental deterioration, or whatever handicap that may suffer".

I think that it is necessary to awake!

(Note. Dr. Marta Munzarova works in the Department of Medical Ethics at Masaryk University in Brno, in the Czech Republic)