Ezekiel Emanuel: Euthanasia case not so compelling.

Alex Schadenberg
Executive Director - Euthanasia Prevention Coalition

Ezekiel Emanuel

Ezekiel Emanuel, chair of the Department of Medical Ethics and Health Policy at the University of Pennsylvania was published in the Medical Journal of Australia recently under the title - Euthanasia and Physician-Assisted Suicide: focus on the data.

Emanuel, who is an oncologist and bioethicist, examines the data from three points of view. First: euthanasia and PAS are rarely used when legal. Second: Pain is not the primary reason why people ask for euthanasia and assisted suicide. Third: euthanasia is not necessarily flawless, quick or painless.

First: Emanuel examines the data from the Netherlands, Belgium and the US States where assisted suicide is legal and concludes:

These data mean that the claim that legalising euthanasia and PAS will help solve the problem of poor end-of-life care is erroneous. Euthanasia and PAS do not solve the problem of inadequate symptom management or improving palliative care. These interventions are for the 1% not the 99% of dying patients. We still need to deal with the problem that confronts most dying patients: how to get optimal symptom relief, and how to avoid the hospital and stay at home in the final weeks. Legalising euthanasia and PAS is really a sideshow in end-of-life care — championed by the few for the few, extensively covered by the media, but not targeted to improve the care for most dying patients who still suffer.

Second: Emanuel examines the data from jurisdictions where it is legal and he states:

It is commonly thought that patients in excruciating and unremitting pain would want these interventions. Many healthy people believe that pain would be the reason why they may want them; however, evidence suggests otherwise.

Emanuel continues:

If not pain, then what motivates patients to request euthanasia and PAS? Depression, hopelessness, being tired of life, loss of control and loss of dignity. These reasons are psychological — they are clearly not physical pain — and are not relieved by increasing the dose of morphine, but by antidepressants and therapy. In the states of Oregon and Washington, the reasons for wanting PAS were: 90% of patients reported loss of autonomy, 90% were less able to engage in activities that make life enjoyable and 70% declared loss of dignity — depression and hopelessness are not listed and are not included in the reporting list. ...However, when researchers from the Netherlands — who were convinced that the main rationale was pain — interviewed patients who requested euthanasia, they found that few of the ones using euthanasia were experiencing pain, but most were depressed.

Emanuel concludes:

Indeed, in the states of Oregon and Washington, less than 4% of patients who had PAS had a psychiatric consultation. In Belgium, where an independent physician needs to be consulted for non-terminal cases, in 42–78% of cases that physician is a psychiatrist. Since psychological reasons dominate, one would think that requiring psychiatric evaluation would be a reasonable safeguard before providing euthanasia or PAS. Therefore, we need to think very differently about what drives people to want euthanasia. The picture most people have of patients who are writhing in uncontrolled pain despite morphine is simply wrong.

Emanuel then examines the concept that euthanasia is quick and easy. He states:

According to a study in the Netherlands from 2000, 5.5% of all cases of euthanasia and PAS had a technical problem and 3.7% had a complication. An additional 6.9% of cases had problems with completing euthanasia or PAS. Technical problems, including difficulty finding a vein and administering oral medications, occurred in 4.5% of euthanasia cases and in 9.8% of PAS cases. Moreover, 3.7% of euthanasia cases and 8.8% of PAS cases had complications, such as nausea, vomiting and muscle spasms. Overall, an additional 1.1% of patients who had euthanasia or PAS did not die but awoke from coma. The data suggest that the common view of euthanasia and PAS as quick, flawless, and painless ways to die is unrealistic.

Emanuel then concludes his article by stating:

When considering this evidence, the case for legalising euthanasia and PAS looks less compelling. They will not improve the care of many dying patients, they are not helping people in pain and enduring inadequately treated physical symptoms, and are far from quick and flawless. What is then the great impetus to legalise interventions to end lives for a small minority of patients who are depressed, worried about losing autonomy and being tired of life? 

We should end the focus on the media frenzy about euthanasia and PAS as if it were the panacea to improving end-of-life care. Instead, we need to focus on improving the care of most of the patients who are dying and need optimal symptom management at home.

Emanuel's research on euthanasia and assisted suicide is solid.