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Kill off patients to save money 21 Mar 98

BANGKOK A group of Thai doctors has proposed euthanasia as a way of malting money go further in economic hard-times. At a seminar entitled Dying with Dignity in Bangkok, the doctors said the country's economic crisis made it the perfect time for relatives and physicians to consider the issue, the Nation daily reported. The secretary-general of the Thai Medical Council, Supachai Khunarattanapruek, said doctors should think long and hard about "vegetable-condition" patients who were unlikely to recover. "Doctors need to consider that while terminally ill patients occupy beds for a long time, there are other patients who could be cured but who have to wait for the beds," he said. A physician from a prominent Bangkok hospital, Praidt Vatheesatokidj, said the number and cost of patients on life-support machines meant the issue needed serious attention. 'Consider the case of a patient who has occupied a bed in an intensive care unit for a year and whose relatives have had to spend a lot of money on the treatment to prolong his life," he said. "Is it worth it, or is it necessary?" AFP

Death with Dignity

The Dutch explore the limits of a patient's right to die Scientific American Mar 91

Americans who are suffering from an intractable illness and want to end their lives can be driven to desperate measures. Last year a woman with Alzheiiner's disease flew from Oregon to Michigan to meet a physician who had built a "suicide machine.' She pulled the switch on the machine, giving herself a lethal dose of drugs, inside the doctor's Volkswagen bus in a motel parking lot. Many others have no doubt followed the advice of the Hemlock Society, a leading advocacy group for humane euthanasia. It recommends taking an overdose of sleeping pills and then, just to be sure-placing a plastic bag over the head. "A dear plastic bag or an opaque one?" muses Derek Humphry, the Hemlock Society's founder, in a recent newsletter. 'Loving the world as I do, I'll opt for a clear one if I have to." Ideally, Humphry contends, physicians could help patients die painlessly and with dignity. But physicians in the U.S. are prohibited from administering or even (in most states) simply giving a lethal dose of drugs to a suicidal patient; withdrawal of treatment, which sometimes increases suffering, is the only legal option. In fact, although calls for "physician-assisted death" are increasing in the U.S. and Europe, only one country has begun allowing active euthanasia: the Netherlands. "It's a very pioneering effort," Humphry says. "People on both sides of the debate are closely watching it." One leading advocate for-and adniitted practitioner of-euthanasia is Pieter V. Admiraal, an oncologist and anesthesiologist at a Catholic hospital in Delft. He believes that, over time, the Dutch will demonstrate to the world that euthanasia can be "the last dignified act in the health care process.' He points out, however, that the debate over. who has a right to euthanasia and how it should be regulated is far from resolved in Holland. Terminating another person's life, even at the person's request, is still technicagy a crime, punishable by up to 12 years in prison.

Holland's Euthanasia Guidelines

But beginning in the 1970s, a series of physicians, including Admiraal, openly violated the ban on euthanasia, spurring Dutch courts to set forth conditions that can serve as excuses for the act. The first and most important condition is that the patient be rational and request death repeatedly. The patient may receive euthanasia even if family members object. If the patient so desires, the doctor may not even inform the family of the patient's decision, Adniiraal says. A committee of the Royal Dutch Medical Association, which has issued guidelines supplementing or evanding on those of the courts, suggested four years ago that minors be allowed to obtain euthanasia over the objections of their parents. 'Sometimes a 15-year-old chid can have a mature judgment," a report by the conuriittee stated, and "sometimes parents can have immature judgment' No such cases have come before the courts yet. Another condition established by court rulings is that at least two physicians must agree that the patient's request is reasonable. A doctor may refuse to perform euthanasia or to approve of the act, but the Royal Dutch Medical Association has stipulated that he or she is then obliged-albeit ethically, not legally-to put the patient in contact with another physician. In all cases, the patient must be suffering from "unbearable pain' with no hope of relief, according to the courts. But the patient's condition need not be terminal, and the pain can be mental as well as physical. In 1985 Admiraal gave a lethal injection to a woman who was in the advanced stages of multiple sderosis but was not in imminent danger of dying. He was charged with murder but acquitted. More recently, prosecutors declined to press charges against a doctor who performed euthanasia on a woman paralyzed from the neck down. Such cases-those in which patients are neither near death nor in -great physical pain-are exceptional, Admiraal notes. Because Holland provides good care to the severely disabled, he says, they rarely seek an end to their lives. He estimates that 80 percent of the patients who request euthanasia suffer from terminal cancer. A controversy has arisen recently over whether persons suffering primarily from mental rather than physical disorders have a right to euthanasia, according to Eugene P. R. Sutorius, an attomey who has defended Admiraal and other physicians prosecuted for euthanasia. Four years ago prosecutors decided not to try a psychiatrist who deliberately provided-but did not administer-an overdose of drugs to a man who had been institutionalized with severe depression and had repeatedly tried to kill himself. A similar case is now before the Supreme Court. These cases have led to much agonizing over whether the mentally ill can be considered competent and in possession of free will, Sutonus says. "We don't want to discriminate against the mentally disturbed," he explains, "but everyone knows this can be very slippery." Admiraal doubts whether assisting the suicides of mental patients will, or should, become accepted. "I think we will hesitate forever," he says, 'because there is always hope that we can cure these patients.' Only a physician may perform euthanasia. Admiraal recommends an injection of barbituates, which produces unconsciousness, followed by a shot of curare, which stops the heart and lungs. After death, the physician is required to inform the coroner, who in turn informs the local prosecutor. If the prosecutor suspects the death has occurred improperly, he may call for an autopsy and initiate a fuller investigation. Approximately 150 cases of euthanasia are reported annually, but Admiraal says that many more cases probably go unreported. Estimates vary widely, but one commonly cited figure is 3,000 a year, or about 2 percent of the deaths occurring annually among Holland's 15 millon people. If euthanasia occurred at that rate in the U.S., it would account for some 50,000 deaths a year. Pro-euthanasia organizations in Holland contend that the ambiguous legal status of euthanasia, which gives prosecutors great discretion in initiating an investigation or pressing charges, discourages physicians from reporting. Klazien Sybrandy, founder of the Information Center for Voluntary Euthanasia, argues that the government should formally legalize euthanasia, replacing the vague guidelines of the courts with specific statutes. Such a move, she asserts, would encourage openness and so reduce the potential for abuse. others think such a step may be unnecessary and perhaps even inadvisable. "It wouldn't change much,' Admiraal says. Sutorius worries that euthanasia might become "too mechanically done' if it is legalized. "You may take away some of the responsibility of individual doctors," he adds. Has Holland set a good example for the rest of the world? Absolutely not, insists Richard Fenigsen, a cardiologist in 's-Hertogenbosch. Fenigsen argues that the acceptance of "voluntary" euthanasia (he invariably puts the term in quotes) win inevitably lead to the murder of those who are judged to be mentally or physically inferior and a burden to society. Such Nazi-like practices are already secretly occurring in Holland, Fenigsen claims, and have so terrorized the elderly and infirm that many are avoiding doctors. Fenigsen has brought his message to the U.S. He has had articles published in the Hastings Center Report, an influential journal of bioethics, and the Wall Street journal. He recently traveled to Washington State to attack an initiative to legalize voluntary euthanasia for the terminally ill that is expected to go before voters next November. Yet Fenigsen's claims have been repudiated not only by Dutch authorities but even by some who share his distaste for euthanasia. "He's a wonderful Jewish Pole who went through hell" during World War II, says Teresa A. Takken, an ethicist at the Goleta Valley Hospital in Santa Barbara, Calif., and at the University of Utrecht, "but he exaggerates." Takken, a Catholic nun, thinks Holland's comprehensive health care and welfare system probably keeps requests for euthanasia to a minimum and makes the abuses envisioned by Fenigsen unlikely. But she contends that abuses could occur in countries that do not provide such care, notably the U.S. "We have no business even talking about euthanasia here until we have health care for all," she insists, "and even housing for all.' Corrine Bayley, an ethicist at St. Joseph Health System in Orange, Calif., agrees that economic considerations could corrupt decisions involving euthanasia in the U.S. She adds that American physicians generally have much shorter-term and less trusting relationships with their patients and so are less equipped to cope with requests for euthanasia. The litigiousness rampant in U.S. health care also poses a problem. Admiraal says he used to urge American physicians to test U.S. law by performing euthanasia according to the Dutch guidelines, "but they always tell me, 'No, no, no, we will be sued by some faraway relative or prosecutor.'" All these factors would certainly complicate euthanasia in the U.S., acknowledges Margaret P. Battin, a philosopher at the University of Utah who like Takken and Bayley has studied euthanasia in Holland. "But I don't think the answer is to prohibit euthanasia," she remarks. 'The answer is to change the U.S. health care system" so that abuses are less likely. Battin agrees with Humphry of the Hemlock Society that euthanasia should be a basic right. 'The central issue is one of control," she says. "Doesn't a person have the right to determine the manner of Ws or her own death and to avoid suffering and pain? -John Horgan