Friday, 13 July 2012

EUTHANASIA: The inherent dangers and obvious benefits


In 1973 while I was in my third year of studying criminology at the University of Toronto, I arrived late in one of my classes and all the topics in which we were to write a paper on were all chosen by my fellow students and the only one left was on the subject of euthanasia. I had no real idea as to just how difficult writing a paper on that subject would be. In any case, as I delved into the subject of euthanasia, I discovered just how difficult it is for everyone including terminally ill persons, their doctors and their family members to deal with euthanasia and accept it as one way to save terminally ill persons from further pain. I was at that time a member of the Corrections Committee of the Anglican Church and I was asked to write an opinion on that subject and submit it to the Church. In November of that year, an international medical journal called ‘Modern Medicine’ published my paper and I was later told that it was published in a number of countries around the world. That same year, it was published in a law journal and at that time, the Toronto General Hospital in Toronto invited me to give a lecture on that subject to a large number of the hospital’s doctors and nurses. Writing on that topic isn’t as difficult nowadays as it was then however the subject is still one that is widely discussed and to some people, a contentious issue.  In this piece, I am going to submit to my readers the second of three court cases which took place in Canada that dealt with euthanasia. But first, I will briefly explain what euthanasia is.  

 Legislation on euthanasia in Canada distinguishes between passive and active euthanasia, although the active procedure remains illegal. Passive euthanasia can include starvation or de-hydration, or withholding any life-preserving procedures. Sometimes the patient will sign a “Do Not Resuscitate’form and on occasion, family members have also signed such forms when their stricken loved one cannot do it.  Active euthanasia comes about when someone other than the patient brings about the death of the patient generally with the patient’s blessing.

 In recent years, several public cases of active euthanasia have re-opened the debate on what Canadian society considers to be socially and morally acceptable in terms of euthanasia. Incidentally, euthanasia is also called ‘mercy killing’.

 The ethics of physician-assisted suicide and euthanasia have been vigorously debated by individual citizens, politicians, lawyers, philosophers and ethicists since November 1973 when my paper on the subject was published in medical journals. In fact a questionnaire was included in the Modern Medicine journal in which a great many doctors submitted their replies of which the vast majority of them approved of the concept that terminally ill patients should be permitted to die without further treatment being administered if that is their patient’s wish. They also recommended that the legal aspect of euthanasia should be looked into. In recent years, several public cases of active euthanasia have re-opened the debate on what Canadian society considers to be socially and morally acceptable in terms of euthanasia.

 In my opinion, we all have a right to be concerned about people being euthanized against their will. This occurred by the thousands in Nazi Germany when Hitler and his cronies believed that society didn’t have to keep supporting Germany’s invalids and mental defectives. They were classed as “Life not worthy of life.”

In the spring and summer months of 1939, a number of Nazi planners which were led by Philipp Bouhler, the director of Hitler's private chancellery, and Karl Brandt, Hitler's attending physician, (latter hanged after the war) began to organize a secret killing operation targeting disabled children. On August 18, 1939, the Reich Ministry of the Interior circulated a decree compelling all physicians, nurses, and midwives to report newborn infants and children under the age of three who showed signs of severe mental or physical disability. Beginning in October 1939, public health authorities began to encourage parents of children with disabilities to admit their young children to one of a number of specially designated pediatric clinics throughout Germany and Austria. The parents didn’t know that their children would be murdered. The clinics were in reality children's killing wards where specially recruited medical staff murdered their young charges by lethal overdoses of medication or by starvation.
Euthanasia planners quickly envisioned extending the killing program to adult disabled patients living in institutional settings. In the autumn of 1939, Adolf Hitler signed a secret authorization in order to protect participating physicians, medical staff, and administrators from prosecution; this authorization was backdated to September 1, 1939, to suggest that the effort was related to wartime measures. Because the Führer Chancellery was insular, compact, and separate from state, government, or Nazi Party apparatuses, Hitler chose this in his private chancellery, to serve as the engine for the "euthanasia" campaign. Its functionaries called their secret enterprise "T4." The operation took its code-name from the street address of the program's coordinating office in Berlin: Tiergartenstrasse 4. According to Hitler's directive, Führer Chancellery director Phillip Bouhler and physician Karl Brandt undertook leadership of the killing operation. Under their auspices, T4 operatives established six gassing installations for adults as part of the "euthanasia" action: Brandenburg, on the Havel River near Berlin; Grafeneck in southwestern Germany; Bernburg and Sonnenstein, both in Saxony; Hartheim, near Linz on the Danube in Austria, and Hadamar in Hessen.

In August 1942, German medical professionals and healthcare workers resumed the killings, albeit in a more carefully concealed manner than before. More decentralized than the initial gassing phase, the renewed effort relied closely upon regional exigencies, with local authorities determining the pace of the killing.
Persons with mental and physical disabilities also fell victim to German violence in the German-occupied East. Although the Germans confined the "Euthanasia" Program, which began as a racial hygiene measure, to the Reich proper—that is, to Germany and to the annexed territories of Austria, Alsace-Lorraine, the Protectorate of Bohemia and Moravia, and the Warthegau in former Poland—the Nazi ideological conviction which designated these persons "life unworthy of life" made institutionalized patients targets of shooting actions in Poland and the Soviet Union. Here the killings of disabled patients were the work of SS and police forces, not of physicians, caretakers, and T4 administrators who implemented the "Euthanasia" Program itself. In areas of Pomerania, West Prussia, and occupied Poland, SS and police units murdered some 30,000 patients by the autumn of 1941 in order to accommodate ethnic German settlers transferred there from the Baltic countries and other areas.

Over 70,000 disabled persons were murdered by gassing in Europe under the Nazi Euthanasia Program between 1939 and 1941. Euthanasia means “easy death” but their deaths were anything but easy for them.
When the war ended, everyone believed that involuntary euthanasia would come to an end. Unfortunately, it didn`t. This is not to imply that people were dragged into killing institutions to be euthanized in the same manner that the Nazis did when they were in power. However, the spectre of involuntary euthanasia has raised its ugly head in modern times.

On May 19, 2010, Life Site News published an article that stated that in Belgium (which permits euthanasia) as many as 30 percent or more cases of euthanasia were carried out without the consent of the patients.
A team of Belgian and Dutch end-of-life researchers circulated a questionnaire to physicians who signed death certificates of patients who died in the Belgian region of Flanders between June and November 2007. The study showed that of the 208 reported Flemish deaths involving the use of “life-ending drugs,” 142 were killed with “an explicit patient request,” and 66 “were without an explicit request.”

The study, published in the Canadian Medical Association Journal showed that in the majority of cases of euthanasia without a patient’s consent, the euthanasia “option” was not discussed with them before they were killed, and that most were undergoing medical treatment with the hope of a cure for their illness.

The researchers noted that euthanasia and assisted suicide “mostly involved patients less than 80 years of age, those with cancer and those dying at home.” Euthanasia without a “specific request” from the patient was “mostly” carried out on patients over 80 years, “those with a disease other than cancer and those in a hospital. In most cases of patients killed without “an explicit request” (77.9%), “the decision was not even discussed with the patient.” Many cases in which patients were killed without requesting euthanasia, the researchers said, “involved patients whose diseases had unpredictable end-of-life trajectories,” with death not being an inevitable result.
The Belgian government’s statistics show that the number of euthanasia cases is rising dramatically, with 700 cases in 2009 compared to 500 in 2008. It is likely, moreover, that the actual numbers of people being euthanized with or without their consent is likely much higher than the official statistics.

In countries, such as the U.S., Canada and the UK, where the possibility of legalizing assisted suicide or euthanasia continues to be debated in their legislatures or parliaments, advocates of the practice routinely cite the ‘safeguards’ that are ostensibly built into the law to protect vulnerable patients.
In Belgium, while the law allows euthanasia for people without terminal illnesses and who are suffering from “constant and unbearable physical or psychological pain,” it also technically requires a patient’s written consent, the opinion of a third physician in cases where an illness is not terminal and a one-month waiting period for patients suffering from depression. So why then are patients being euthanized without first obtaining their consent and why were the Belgium ‘procedural requirements’ such as consultation of a second physician sometimes ignored?

Doctors who euthanized their patients without their patient’s consent were least reported by them as euthanasia when no second physician was consulted as per the ‘procedural requirement’.  
This means that physicians were killing patients on their own authority without regard to legal restraints. You could actually say that those doctors actually murdered their patients because they didn’t follow the necessary steps as per the protective guidelines before euthanizing their patients.

The next logical step in the euthanasia business is the linking of euthanasia and organ “harvesting.”
In  a letter to the editor of the medical journal Transplantation dated 2008, the authors of the letter wrote of a case of a legal euthanasia, and subsequent “harvesting” of organs, of a patient with “locked-in” syndrome, in which she was fully conscious but completely paralyzed, and who requested that she be euthanized. But before she died, she also decided to donate her organs.

The letter, from the physicians presiding over the case, said, “This case of two separate requests, first euthanasia and second, organ donation after death, demonstrates that organ harvesting after euthanasia may be considered and accepted from ethical, legal and practical viewpoints in countries where euthanasia is legally accepted. I agree.
They said, “The ethical and legal possibility of combination of the two separate processes, physician-assisted suicide and after-death organ donation was then considered and agreed by the institutional ethical committee president.”

Surely if this doesn’t set off alarm bells about how the sick and disabled are increasingly being looked upon not only as burdens (to themselves, families, and society), but potential objects for exploitation, what will?” For example, was the woman coerced into agreeing to donate her organs on the premise that if she didn’t agree to the doctor’s request, her wish to be euthanized would not be granted? Cases such as this one could be viewed as an organ source to be killed and then mined for the patient’s organs.                                                                                        
I am grateful to the authors of the piece titled ‘Voluntary Euthanasia’ that was first published on April 18, 1996, In reading it, it inspired me to write my own thoughts on this subject using their thoughts on the matter as a guide in what follows in this piece.

The motive of the person who commits an act of euthanasia should be to benefit the one whose death is brought about and should apply only for the following reasons where the patient—
(1)  is suffering from a terminal illness;

(2)  is unlikely to benefit from the discovery of a cure for that illness during what remains of her life expectancy;
(3)  is, as a direct result of the illness, either suffering intolerable pain, or only has available a life that is unacceptably burdensome (because the illness has to be treated in ways that lead to her being unacceptably dependent on others or on technological means of life support);

(4)  has an enduring, voluntary and competent wish to die (or has, prior to losing the competence to do so, expressed a wish to die in the event that conditions (a)-(c) are satisfied); and
(5)  is unable without assistance to commit suicide.

If any of these parameters are present, then there should be legal and medical provision to enable the patient to be allowed to die or be assisted by a doctor to die. It should be acknowledged however that these conditions are quite restrictive, indeed more restrictive than some would think appropriate. In particular, the conditions permitting access to voluntary euthanasia should only be for those who are terminally ill and in pain or are living their lives as vegetables.
While those parameters are not free of all ambiguity, for present purposes, surely it can be agreed that it does not include the bringing about of the euthanasia of victims of accidents who are rendered quadriplegic or victims suffering from early Alzheimer's disease or are suffering from depression. Those who consider that such cases show the first condition to be too restrictive may nonetheless accept that including them would, at least for the time being, make it far harder to obtain legal protection for helping those terminally ill persons who wish to die.

The fifth parameter would further reduce voluntary euthanasia by the patients themselves when physician-assisted suicide is a better course to follow and it is available to the patients.
The third parameter recognizes what many who oppose the legalization of voluntary euthanasia do not, recognize that it is the only release from pain available to patients who cannot be given sufficient relief from their pain or do not wish to remain as a vegetable at the expense of their family or society itself that leads them to want to be helped to die.

Some sufferers in terminal conditions may have their pain relieved but have to endure side effects that for them make life completely unbearable. Others may not have to cope with pain but instead be incapable, as with motor neurone disease, of living without forms of life support that simultaneously robs their lives of quality.
A final preliminary point is that the fourth condition requires that the choice to die not only be voluntary but that it be made in an enduring manner (not merely in a flippant manner) and be made when the patient is competent (in sound mind) to make that decision. The choice is one that will require discussion and time for reflection and so should not be settled in a moment. As in other decisions affecting matters of importance, normal adults are presumed to choose voluntarily euthanasia unless the presence of defeating considerations can be established. The burden of proof of establishing a lack of voluntariness or lack of competence is on those who refuse to accept the patient's choice. In realize that this burden can sometimes be met (e.g. by pointing to the person's being in a state of clinical depression) however the claim is only that the onus falls on those who assert that a normal adult's choice is not competent.

People for the most part choose to take responsibility for their own lives and recognize that dying is a part of their lives. Choosing choices about the manner of their dying and the timing of their death are, for many people, part of what is involved in taking responsibility for their lives. Many people are concerned about what the last phase of their lives will be like, not merely because of fears that their dying might involve them in great suffering, but also because of their desire to retain their dignity with as much control over their lives as possible during this phase in their lives. To deny the opportunity to people who cannot die with dignity the opportunity to be euthanized with the assistance of a medical doctor is a gross abuse of that person’s well-being and wishes.
The technological interventions of modern medicine have had the effect of stretching out the time it takes for many people to die. Sometimes the added life this brings is an occasion for rejoicing; sometimes it drags out the period of significant physical and intellectual decline that a person undergoes in burdensome ways so that life becomes, to them, no longer worth living.

Obviously there is no single, objectively correct answer as to when, if at all, life becomes a burden and unwanted to a patient who wants to die. But that is simply evidence of the importance of individuals being able to decide autonomously for themselves whether their own lives retain sufficient quality and dignity to make life worth living to them. Given that a critically ill person is typically in a severely compromised and debilitated state, it is, other things being equal, the patient's own judgment of whether continued life is a benefit that must carry the greatest weight, provided always that the patient is mentally competent to make such a decision.
If medical assistance is to be provided to help a person achieve his or her autonomously chosen goal of an easeful death (because she cannot end his or her own life), the autonomy of any professional who lends assistance also has to be respected. The value (or right) of self-determination does not entitle a patient to compel a medical professional to act contrary to his or her own moral or professional values. Hence, if voluntary euthanasia is to be legally permitted, it must be with respect for professional autonomy. Similarly, if a doctor's view of his or her moral or professional responsibilities is at odds with his or her patient's request for euthanasia, provision must be made for the transfer of the patient to the care of a doctor who faces no such conflict.

Objection 1
It is often said that it is not necessary nowadays for anyone to die while suffering from intolerable or overwhelming pain. We are getting better at providing effective palliative care, and hospice care is more widely available. Given these considerations, some have urged that voluntary euthanasia is unnecessary.

Unfortunately this isn’t always so. First, while both good palliative care and hospice care make important contributions to the care of the dying, neither is a panacea to the problem. Far more importantly, even high quality palliative care commonly can bring about a price in the form of side effects such as nausea, incontinence, loss of awareness because of semi-permanent drowsiness, and so on. A rosy picture is often painted as to how palliative care can transform the plight of the dying. Such a picture is misleading according to those who have closely observed the effect of extended courses of treatment with drugs such as morphine.
Second, though the sort of care provided through hospices is to be applauded, it is care that is available to only a small proportion of the terminally ill and then usually only in the very last stages of the illness (typically a matter of a few weeks).

Third, and of greatest significance, not everyone wishes to avail themselves of palliative or hospice care. For those who prefer to die on their own terms and in their own time and sometimes in their own homes, neither option may be attractive to them. For many dying patients, the major source of distress is having their autonomous wishes frustrated.
Fourth, the suffering that brings about a fervent wish to many to end their life, to them it is not always due to the pain brought about by illness. For some, what is intolerable is their dependence on others or on machinery because for them, the availability of effective pain control will be quite irrelevant.

Objection 2
A second objection to permitting the legalization of voluntary euthanasia is based on the premise that we can never be absolutely sure that a dying person's request to be helped to die is brought about by the patient’s mental competency with respect to his or her enduring and genuinely desire to die.

It is certainly true that a request to die may not reflect an enduring desire to die (just as some attempts to commit suicide may reflect temporary despair). That is why advocates of voluntary euthanasia have argued that normally a cooling off period should be required before euthanasia is permitted. I am in total agreement with that. For example, if a patient in never ending pain discusses the issue with others on different occasions, or reflects on the issue over an extended period, and does not waver in his or her conviction, then in my respectful opinion, that person’s wish to die should be considered as enduring.
But suppose a person is racked with pain, or mentally confused because of the measures taken to relieve his or her pain, and for this reason that person is not able to think clearly and rationally about euthanasia as an alternative? If this occurs, then it should be assumed that a person in those circumstances who wants to die should not be assumed to have a competent, enduring and genuinely voluntary desire to die. However, there are at least two important points to make about those people in such circumstances.

First, they do not account for all of the terminally ill, so even if it is acknowledged that such people are incapable of agreeing to voluntary euthanasia that is not inclusive proof that no one can ever rationally voluntarily request help to die.

Second, it is possible for a person to indicate, in advance of losing the capacity to give competent, enduring and voluntary consent, how he or she would wish to be treated should he or she becomes terminally ill and suffers intolerable pain or loss of control over his or her life. ‘Living wills’ or ‘advance declarations are legally useful instruments for giving voice to people's wishes while they are capable of giving competent, enduring and voluntary consent, including to their wanting help to die. As long as they are easily revocable in the event of a change of mind (just as ordinary wills are), they should be respected as evidence of a well thought out decision on the part of the person who signed it. It should be noted however that any such living will for voluntary euthanasia or physician-assisted suicide is not at present legally accepted or enforceable in some places around the world. Incidentally, when I was practicing law, I prepared a number of such wills for clients who asked me to do so and I also prepared and signed my own living will.
Perhaps what is really at issue in this objection is whether anyone can ever form a competent, enduring and voluntary wish about being better off dead, rather than continuing to suffer from an illness, without having yet suffered from such illnesses. If this is what the basis of the objection is, it is too paternalistic on our part to be acceptable? Do we who do not suffer from such illnesses have sufficient evidence (e.g. based on our experience of the deaths of friends or family) to understand in our own minds that it is quite conceivable that the dying person has the same ability to understand the consequences of making such a choice? I think we do.

Objection 3
According to the doctrine of ‘double effect’,(also known as the ‘rule of double effect’) it is, for example in some countries to alleviate pain by administering drugs such as morphine, knowing that doing so it may shorten life and possibly end it but it is still illegal to give an overdose or injection with the direct intention of terminating a patient's life (whether at her request or not). In Switzerland, (and possibly elsewhere) some doctors would give a patient three morphine pills with a warning to the patient to not take them all at once as the result of ingesting all three at the same time will bring about death. They do this knowing in advance that the patient will take all three at the same time to bring about their own deaths. It is illegal of course but unless an autopsy was undertaken, who would know for sure as to how the patient died?

On one plausible reading, the doctrine of double effect can be relevant only where a person's death is brought about for wrong purposes or, to put it another way, recognized as an illegal harm. Sometimes the notion of ‘harm’ is understood simply as damage to a person's interest whether consented to or not. At other times, it is understood, more strictly, as a consequence that has been wrongfully brought about. Considering either reason, if the death of a person who wishes to die is not harmful (because from that person's standpoint it is, in fact, beneficial), the doctrine of double effect can have no relevance to the debate about voluntary euthanasia in collaboration with the patient’s absolute wish.
Objection 4

There is a widespread belief that passive (voluntary) euthanasia, in which life-sustaining or life-prolonging measures are withdrawn or withheld, is morally acceptable as a means of permitting the patient to die rather than keep suffering.
My concern about this method of bringing about death to the patient is that the consequences of withholding the functions of the breathing machine or permitting a patient to die of thirst is so gross, it begs denunciation.

Whether such decisions on the part of the doctor (and possibly at the request of the patient’s family) is described in terms of acts or omissions (a distinction which underpins the alleged difference between active and passive voluntary euthanasia), is generally considered a matter of being uncaring rather than anything of deeper importance.
Consider, for instance, the practice (still common in hospitals) of deliberately proceeding slowly in response to a request to provide assistance for a patient subject to a ‘not for resuscitation’ code. Or consider ‘pulling the plug’ on an oxygen machine keeping an otherwise dying patient alive in comparison with not replacing the tank when it runs out. Are these acts of omissions or are they cases of passive euthanasia or active euthanasia? I think such measures can be construed as being passive euthanasia although as I said earlier, if the patient is to die, it must be without pain or suffering of any kind as a direct result of the passive euthanasia they are subjected to.  

Further, the distinction between killing and simply letting a patient die is still unclear. Consider the case of a patient suffering from motor neurone disease who is completely respirator-dependent and for this reason finds his or her condition intolerable and for this reason he or she competently and persistently requests to be removed from the respirator so that he or she may die. Even the Catholic Church in recent times has been prepared to agree that it is permissible, in cases like this, to turn off the respirator.
Perhaps the difference is found in the health provider's intention. For example, at present, if someone's life is intentionally terminated, (such as a drug induced death) then that person has been killed, whereas if the person is no longer being aggressively treated, we can attribute that person’s death to the underlying disease. In many cases, the most logical interpretation of the physician's intention in withdrawing life-sustaining measures is to end the person's life. Consider the growing practice of withholding artificial nutrition and hydration when a decision has been made to cease aggressive treatment, and then see if we can agree in cases like those of motor neurone sufferers that we have let them die as a result of criminal negligence on the part of the doctor. In Canada, criminal negligence is applied to someone who has a duty to another to protect and save them from harm. Rhetorically, is there really a difference between a lifeguard who lets a swimmer drown and a doctor who lets a patient die when they both know that the persons they have a duty to protect from drowning and/or help those who are suffering from a terminal illness when both the lifeguards and the doctors are capable of saving and helping them?

Many physicians would say that their intention in withholding life-sustaining artificial nutrition is simply to respect their patient's wishes. This is acceptable in those instances where the patient is still able to competently ask that such treatment no longer be given or alternatively the patient's proxy makes the request. However, in the absence of such an oral or written request, the best explanation of the physician doing nothing to save his patient seems to be that the physician intends to deliberately cause the end of the life of his patient on his own volition or on the request of someone else.
Doctor’s permanently withdrawing nutrition from someone who is in a persistent vegetative state, does not seem merely to be a matter of letting death take its natural course, but, rather, one of intending to cause their patient’s death. What could be the point of the action, the goal aimed at, or the intended outcome, if not to end the patient's life? No sense can be made of the action as being intended to serve to relieve the suffering of the patient from his or her disease, or to keep the patient comfortable, or even, in the case of a person in a permanently vegetative state, of allowing the underlying disease to carry the person off. The loss of brain activity is not going to kill the person. What is going to kill the patient is the act of starving the patient to death or worse yet, permitting the patient to die of thirst or removing the ventilator so that the patient will suffocate to death. One could hardly say that in doing these acts, the doctors are being merciful and bringing the patient a merciful and easy death.

Similarly, giving massive doses of morphine far beyond what is needed to control pain, or removing a respirator from a sufferer from motor neurone disease would seem by parallel reasoning, to amount to the intentional bringing about of the death of the person being cared for. To be sure, there are circumstances in which doctors can truthfully say that the actions they perform, or omissions they make, lead to the deaths of their patients without them intending that those patients should die. If, for instance, a patient refuses life-prolonging medical treatment because he or she considers it useless, it might reasonably be said that the doctor's intention in complying is simply to respect the patient's wishes. The point is that there are many other circumstances in which it seems highly possible that the intention is anything other than the intention to bring about death  and hence, by an intention-based definition of killing, that the acts and omissions in question count as killing the patient. I don’t see any other way to conclude otherwise.
This in itself is a problem only if killing, in medical contexts, is always morally unjustified which is a premise that clearly supports much of the debate surrounding this fourth objection. But of course, this underlying assumption is open to challenge.  

For one thing, there may well be cases in which bringing about the death of the patient, where requested, is morally better than allowing a death where the latter would serve only to prolong the person's suffering. Further, despite the longstanding legal doctrine that no one can justifiably consent to be killed, (which I disagree) it surely is relevant to the justification of an act of killing that person by maintaining that the patient had autonomously decided that he or she would be better off dead.
Objection 5

It is often said that if society allows voluntary euthanasia to be legally permitted, then we will have set foot on a slippery slope that will lead us to support other forms of euthanasia, including non-voluntary euthanasia. Whereas it was once common knowledge that that was precisely what happened in Hitler's Germany, in recent decades the tendency has been to recognizing that happening in the Flanders’ area of Belgium and The Netherlands which naturally has confirmed the reality of the existence of the rhetorical slippery slope. Slippery slope arguments come in various versions. The common feature of the different forms of euthanasia is the contention that once the first step is taken on a slippery slope, the subsequent sliding follows inexorably, whether for logical reasons, psychological reasons, or to avoid arbitrariness in ‘drawing a line’ between a person's actions.
There is nothing logically inconsistent in supporting voluntary euthanasia while rejecting non-voluntary euthanasia as being morally inappropriate. Some advocates of voluntary euthanasia, will definitely wish also to lend their support to some acts of non-voluntary euthanasia (e.g. for those in persistent vegetative states who have never indicated their wishes about being helped to die, or for certain severely disabled infants for whom the outlook is hopeless). Others will think that what may be done with the consent of the patient sets a strict limit on the practice of euthanasia. The difference is not one of logical acumen; it has to be located in the respective values of the different supporters such as whether or not a person's self-determination or her best interests should prevail.

Why should it be supposed that those who value the autonomy of the individual and so support provision for voluntary euthanasia will, as a result, find it psychologically easier to kill patients who are not able competently to request assistance with dying? What reason is there to believe that they will, as a result of their support for voluntary euthanasia, be psychologically driven to practice non-voluntary euthanasia on their patients?
Finally, since there is nothing arbitrary about distinguishing voluntary euthanasia from non-voluntary euthanasia (because the line between them is based on clear principles), there can be no substance to the argument that only by arbitrarily drawing a line between them could non-voluntary euthanasia be avoided once voluntary euthanasia is legalized.

Comparing Hitler's Germany and the Flanders area of Belgium and The Netherlands of today, the former is easily dismissed as an indication of an inevitable descent from voluntary euthanasia to non-voluntary. There never was a policy in favor of, or a legal practice of, voluntary euthanasia in Germany in the 1920s to 1939 .There was, prior to Hitler coming to power, a clear practice of killing some disabled persons; but the justification was never suggested to be that their being killed was in their best interests; rather, it was said that society would be benefited.
That raises an interesting question. Does society in general really benefit from the practice of letting patients die? As much as I hate to admit it, society to some degree and in some instances does benefit.

In 1990, Terri Schiavo living in Florida suffered major brain damage when her heart failed which then cut oxygen to her brain. She entered the unfortunate condition of being in a persistent vegetative state. Her eyes were open and she went through periods of sleep and wakefulness. But that part of her brain that controlled most of her motor functions had been destroyed. She could breathe on her own, but she couldn’t eat on her own nor could she communicate in any manner but despite that, she was kept alive with a feeding tube. It is impossible to know whether or not her mind was destroyed but I am inclined to believe that it was.
The cost of keeping that unfortunate woman alive cost thousands of dollars each day for thirteen years. Now let’s presume that the cost was $2000 dollars a day. Multiply that with 365 days of the year times 13 years. The figure is staggering. It would cost the hospital and taxpayers nine and a half million dollars. If the court in Florida hadn’t finally put an end to it, the cost could have gone on for many more years.

I ask my readers this rhetorical question. Do you think keeping a person in a vegetative state for that long at that kind of expense is in the public’s best interests?
Admittedly, a man in a coma for thirty years finally came out of it. Based on the costs I previously mentioned, the cost of supporting him in his coma must have been astronomically staggering.

Some will say that all life, no matter in what stage it is in is worth all that money. But we have to be realistic. For example suppose you live in a small town that has a hospital and in that hospital there is a patient living in a vegetative state. The hospital is almost broke supporting that patient and the citizens of that town have been informed that the hospital may have to close down as a direct result of spending so much money to keep the vegetative patient alive.  If that happens, the nearest hospital is at least a two-hour drive away which could be fatal to anyone needing emergency treatment. Would you be prepared to say that despite the costs that are bankrupting the hospital, the patient should still be placed on life supporting machines in that hospital? I think not and that is because it would not be in the best interest of the community to keep someone who is in a vegetative state alive anymore at such an outrageous cost to the community. In the long run, it is the best interests of the community that has to take precedent over the interest of an individual. It has always been that way and no doubt will always be that way. 
Assisted suicide is often seen as fitting in some other countries where voluntary euthanasia is not legally tolerated. The deaths are brought about when doctors give their patients wishing to die large doses of morphine to relieve pain in the knowledge that this will also end their lives. It is true that in a very few cases, there was consultation only with other medical personnel, rather than with relatives; the researchers point out that this was due to the fact that families in The Netherlands strictly have no final authority to act as surrogate decision-makers for incompetent persons but they can act as surrogates for relatives wishing to die were of sound mind when they expressed such wishes.

That there have only been a handful of prosecutions of Dutch doctors for failing to follow agreed procedures however none of the doctors prosecuted really had a significant penalty imposed, and that the Dutch public have regularly reaffirmed their support for those agreed procedures which suggests that, contrary to the claims of some critics, the legalization of voluntary euthanasia has not increased the incidence of non-voluntary euthanasia. Indeed, such studies as have been published about what happens in other countries, like Australia where no legal protection is in place, suggest that the pattern in The Netherlands and elsewhere is quite similar.
I am not suggesting that there is no need to put in place safeguards against potential abuse of legally protected voluntary euthanasia. This is particularly important for those who have become incompetent by the time decisions need to be taken about whether to assist them to die.

Moreover, it is quite reasonable to think that the fundamental basis of the right to decide about life-sustaining treatment and the respect for a person's autonomy has direct relevance to doctor-assisted suicide. Extending the right of self-determination to doctor-assisted suicide being available to terminally ill patients or those approaching a vegetable state of existence seems to be the logical step in the future and it is in this current era.  
Indeed, the fact that suicide and attempted suicide are no longer criminal offences in many jurisdictions (although attempted suicide is in some countries) indicates that the central importance of individual self-determination by people who are suffering from a terminal disease or is heading towards a vegetative state, doctor-assisted suicide has been accepted. The fact that assisted suicide and even voluntary euthanasia have not yet been widely decriminalized is perhaps best explained along the lines that have frequently been offered for excluding consent of the victim as a justification for an act of killing, namely the difficulties thought to exist in establishing the genuineness of the consent.

However, the establishment of suitable procedures for giving consent to assisted suicide and voluntary euthanasia would seem to be no harder than that of establishing procedures for dying patients competently refusing burdensome or otherwise unwanted medical treatment. The latter has already been accomplished in many jurisdictions, so the former should be achievable as well.
I believe that doctors should have the choice as to whether or not they wish to participate in a doctor-assisted suicide but they should not be prohibited by law from lending their professional assistance to those competent, terminally ill persons for whom no cure is possible and who wish for an easy death. That day is coming. It is just a question of when.

What I think should come about is that all cases where patients who are suffering from incurable pain or are slowly becoming a vegetable and cannot speak for themselves, the courts should step in and after listening to everyone directly connected to the patient, either as a doctor or a relative, make the final decision.
The court should also have the authority to investigate thoroughly any case where the jurist suspects that there is an improper motive on the part of a relative to sanction the death of the patient. I would even go so far to say that if the relative or relatives are asking the court to order the termination of the life of a loved because until that person dies, his or her will cannot be processed, (depending on the amount of money or assets are listed in the will) the court should be very cautious about what decision is to be given in such a case. The jurist should first make the relatives requesting the termination to provide the original will to the court and if the persons swears that there is no will, then the jurist can proceed further. If there is a will, the relative swearing there wasn’t one risks imprisonment for perjury.

Whether or not there is a will, the jurist should consider what is in the best interest of the patient and not what is in the best interest of the relatives. .However, if the person is in a vegetative state, then the judge should consider what is in the best interest of the hospital and the taxpayers with respect to the huge amount of money that will be expended keeping such a person alive. 
What it all comes down to is to ease the suffering of a person who is in continuous and non-relenting agony and/or reduce the costs of continuing to support the life of such a person. If the person suffering is able to state that he or she wishes to stay alive, then no matter what the costs are, his or her wish should be the final word on it. On the other hand, if a person cannot communicate his or her wishes because that person is in a vegetative state, then a judge should make the decision.

Mercy killing in cases of people burning to death
There are times when people are trapped in buildings or cars and a fire is raging around them and they are slowly burning to death. If they cannot be rescued, surely this is a time to end their extreme agony by shooting them as soon as possible.

After I read my paper to my fellow students in my criminology class, I told them about an incident in which a man in the United States was trapped in the cab of his truck after a multi-vehicle accident and he was slowly burning to death. He screamed in agony and begged someone to shoot him. There were hunters on the scene but none of them wanted to risk going to prison for shooting the man. The man was alive for about ten minutes as he was slowly being roasted to death before death finally came to him and ended his agony. After I told this story to my fellow students, one of them who was a police officer told us that he was called onto the scene of an accident that week where a trapped man was burning to death. He said he wished someone would shoot the poor man to death to put an end to his agony.
There was a horrible multi-vehicle crash which occurred a number of years ago in Ontario. A 14-year-old girl was trapped in the back seat of her parent’s car. Her parents couldn’t get her out of the car and when the heat became too unbearable for them to remain; they crawled over the other cars to escape the flames. Then they had to listen to the dying screams of their daughter as the flames engulfed her. If one of her parents had a gun and shot the poor girl to death to end her agony, would a jury really convict her even if the judge said that they would have to? Consider what happened during the trial of a man in the United States in 1927.

A man watched and listened for months while his little daughter was slowly dying of tuberculosis and gangrene on her face. No doctors could find a way from stopping the pain. She was screaming all during her waking hours and begging her father to kill her. He finally told his daughter what he was going to do to end her suffering and she thanked him. He drowned his little daughter in the bathtub. He was later charged with murder. Justice Branson when addressing the jury; told them had the little girl been an animal and he let the animal suffer for as long as that little girl had suffered, he would be subjected to punishment. The jury found him not guilty. They knew that he was already suffering enough from the constant memory of his little girl making no effort to stop her father from drowning her.
To allow someone to slowly die from an incurable disease or by some other means and know that that person is suffering from continuous pain and there is no way in which the pain can be lessened, or that they can be saved, and do nothing to end their agony—is an extreme act of cruelty.

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