Pandemic palliative care protocol. Selecting people to die and abusing the purpose of palliative care.

Alex Schadenberg
Executive Director, Euthanasia Prevention Coalition

There are no easy answers in a healthcare crisis, especially when the demand for certain life-saving or sustaining treatments become greater than its availability. 

Justice and equality (non-maleficence) require us to provide healthcare for everyone who will benefit and yet if the availability of certain resources are limited then decisions are made which are often unjust and lack equality.

People with disabilities and the elderly are considered to be more likely to die from Covid-19 and therefore they may be denied life-saving or sustaining treatments to enable a person who is viewed as more likely to survive to receive treatment.

In a utilitarian sense, this approach seems rational, but when considering justice and equality these measures fail because they are based on selecting who will live and who will die based on personal beliefs that are often linked to negative or discriminatory attitudes or ideologies concerning people requiring different care.

A situation where a person chooses not to receive treatment because they have accepted that they are unlikely to survive or decided that the treatment outweighs the possible benefits is different because no one is imposing the withholding of treatment.

A situation where a person is truly dying and the treatment is futile, whether that person is 30 or 90 years of age is different. There is no societal obligation to provide treatment that lacks benefit or is medically futile. In this circumstance the person is not deemed futile but the treatment is futile.

Diane Coleman, Not Dead Yet.

People with disabilities genuinely fear that they will not be considered "worthy" for treatment, even when the benefit of the treatment is recovery. Further to that, some people with disabilities already require ventilator support to live. Should these people be denied ventilator support or have it withdrawn against their needs and wishes simply because another person requires a ventilator?

Pandemic palliative care: beyond ventilators and saving lives.

The CMAJ (March 31) published a protocol on the care of Covid-19 patients who are being withheld or withdrawn from treatment titled: Pandemic palliative care: beyond ventilators and saving lives. The authors of the protocol include Dr James Downar, the former chair of the Dying with Dignity Physician Advisory Committee and Dr Sandy Buchman, President of the Canadian Medical Association.

Read: Euthanasia doctor developed Ontario Covid-19 triage guidelines (Link).

The authors are asking for a response to the protocol. This is my assessment.

The protocol claims to be based on fairness and equality, but actually institutionalizes the inequality and injustice that lead to people with disabilities and other vulnerable groups being selected for death based on negative and discriminatory attitudes.

The protocol states:

Many people already have advance care plans that stipulate that comfort measures are to be used if they become seriously ill. Other patients who are intubated and receiving mechanical ventilation but are not improving clinically will be extubated. A third group of patients may be denied ventilation because of resource scarcity.

This statement tells us not to have blanket statements in our healthcare directive requiring comfort measures only. Certain medical conditions may lead to recovery with treatment, but with the above wording, no treatment will be provided.

This statement is also unethical. Withdrawing a ventilator is a treatment decision that requires consent from the patient or the power of attorney. Decisions to withdraw treatment are treatment decisions that in some jurisdictions require consent in the same manner as decisions to provide treatment. 

People with disabilities who require a ventilator fear that decisions will be made to extubate them because their health condition is not clinically improving. People with disabilities may not "clinically improve" not because they are treatment resistant but because of the nature of the disability. It is discrimination to deny treatment based on disability.

The protocol states that when a person is denied treatment that they must be provided palliative care. The authors state that they are not abandoning the patient when they provide palliative care and yet the triage system has already abandoned the patient.

The protocol leads to an abuse of the ethical use of palliative sedation.

Palliative sedation or terminal sedation is properly used for a patient who has symptoms that cannot be effectively alleviated in any other way. For instance, a person who is living with Neuropathic pain may only be effectively relieved of the pain through sedation. The authors of this protocol are proposing the use of sedation as a means of causing death, instead of (MAiD) euthanasia which is legal in Canada. The protocol states:

In our opinion, palliative sedation is preferable to medical assistance in dying (MAiD) for patients with severe respiratory failure caused by SARS-CoV-2, given the 10-day reflection period, number of witnesses and assessors required, and the current requirement for full capacity to determine eligibility for MAiD. 

When analyzing euthanasia data from the Netherlands and Belgium you will notice a significant number of "assisted deaths without explicit request." This protocol is endorsing the same procedures that are done in the Netherlands and Belgium to circumvent the euthanasia law. Downar is well aware that he is advocating for intentional acts to cause death. In 2014 Downar participated in the study:  Characteristics of Belgian "life ending acts without explicit request."

The protocol changes the ideology of palliative care. The concept of palliative care is to provide pain and symptom relief when a person is dying, to palliate the symptoms but never to hasten death. The protocol is suggesting that palliative care can replace active treatment, even when treatment may lead to recovery. So palliative care becomes a way of providing a comfortable death for people who have been medically abandoned.

The protocol claims that it will lead to greater equity. The protocol acknowledges that people who live with mental illness or other conditions face substantial challenges to receiving healthcare and they conclude that: "Palliative care thus becomes the compassionate option to counterbalance this inequality."

Palliative care is better than "sending them home to die" and to not palliate symptoms is to abandon the patient again. Nonetheless, this protocol institutionalizes the inequality and injustice. The protocol states that you must be kept comfortable as we abandon you. But it doesn't stop there, the protocol advocates for the abuse of the use of "palliative sedation" meaning, we will not only palliative your symptoms, but in certain circumstances we will end your life without your explicit consent.

Further information:

• US Department of Health and Human Services will uphold human rights in relation to health care resource allocation (link).
• Covid-19 reveals a deadly failure of priorities (link).

Belgian doctor charged with murder in the deaths of 9 patients.

Alex Schadenberg
Executive Director, Euthanasia Prevention Coalition

CHR van Hoei Hospital

On September 24 I reported that a Belgian doctor had been charged with murder in the deaths of four patients in the palliative care department of the CHR van Hoei Hospital.

HLN news has now reported that the doctor lost his contract with the hospital and has been charged with murder in the deaths of five more patients, making it nine total murder charges.

According to HLN news, the physician claims that the deaths were not murder but palliative sedation, more accurately referred to as terminal sedation.

The physician claims that he just wanted to stop the pain and these cases were not euthanasia.

Wim Distlemans

Dr Wim Distelmans, who is co-chair of the Belgian euthanasia control commission and operates a euthanasia clinic, told the Belgian news that palliative sedation is not regulated and occurs 4 times more often in Belgium than euthanasia. Distelmans stated (google translated)

“What happens too often is that doctors dramatically increase the doses of the drugs via the baxter to speed up the end of life. That's hypocritical, because they say to the family, "We just keep him asleep." In fact, such a doctor puts an end to life. You can't even call it euthanasia, because the patient didn't ask for it, "

The intentional overdosing of palliative patients is common and is ethically the same as euthanasia. These cases of terminal sedation represent an abuse of the proper use of sedation. Palliative sedation, when done correctly and ethically, should not cause the death of the patient and should not become confused with murder.

A 2015 Belgian study showed that more than 1000 people died an assisted death without request in 2013. Data, such as this, should create great concern, but in Belgium it has simply been a statistic. This case may begin to deal with the number of intentional deaths without consent occur in Belgium.

I will continue to follow this case. Currently the court is not publishing the facts of around these cases.

Québec - 1331 reported euthanasia deaths (April 1, 2018 - March 31, 2019) At least 13 deaths did not comply with the law.

Fourth report from Québec's Commission on end-of-life care

By Amy Hasbrouck and Taylor Hyatt 

Toujours Vivant - Not Dead Yet.

On October 2, Québec’s Commission on end-of-life care released its fourth report for the period April 1, 2018 to March 31, 2019. The Commission reported a substantial increase in the number of euthanasia over the previous years. They reported:

Link to the analysis by Amy Hasbrouck and Taylor Hyatt on the previous Third Québec report (Link).

• There were 1,331 euthanasia were reportedly performed this year April 1, 2018 - March 31, 2019). Added to the 1,630* for the 28 months from December 10, 2015 to March 31, 2018, bringing the total to 2,909 euthanasia in Québec since the program began. We’ll talk in a few minutes about why those numbers don’t add up.
• Continuous palliative sedation (CPS) was performed on 1,243 people during the reporting period. Added to the 1,704 CPS performed during the 28 months from December 10, 2015 to March 31, 2018, this brings the total to 2,947. 
• Euthanasia and CPS each accounted for 1.9% of deaths in Québec during the reporting period, for a total of nearly 4% of all deaths in the province. 
• *As explained in footnote 19 on page 27, 1,630 euthanasia deaths is a corrected total from the Commission’s summary report issued last spring. Apparently “two MAiD reported by an institution as having been administered were not administered.” 

The exact number of euthanasia deaths is hard to pin down from the report.

• On pages iii, 12, 27 (footnote 19), 37 and 38, the report says “1,279 people received MAiD between April 1, 2018 and March 31, 2019.” This figure, when added to the 1,630 from previous years, gives the reported total of 2,909.
• But on page 23, the report says “according to reports from institutions, 1,937 requests for MAiD were made between April 1, 2018 and March 31, 2019; of these, 1,271 were administered and 672 were not administered.” 
• The 1,271 figure, added to the 60 euthanasia performed by doctors outside of institutional settings and reported by the Collège des médecins du Québec (CMQ), gives a total of 1,331 euthanasia. 
• Maybe you’ve noticed that 1,937 minus 672 does not equal 1,271, but rather 1,265. The six missing people are accounted for in a note in figure 3.17 which does not show the outcome of the six euthanasia requests in region 10. The Commission explains: 
• “In order to respect the rules of confidentiality, and because of the risk of identification related to the disclosure of a small number of individuals, the exact distribution of the euthanasia administered and not administered could not be provided.” 
• As for the 1,279 figure used elsewhere in the report, we don’t know where it comes from, or if it includes the 60 euthanasia reported by the CMQ. And if you think we’re being nit-picky, just remember that euthanasia laws are supposed to impose “stringent limits” that are “scrupulously monitored and enforced.” 

This year, the Commission received 1,400 euthanasia reports, some of which document euthanasia performed before the reporting period. 

“The Commission notes that 86 forms were received more than six months after the administration of MAiD and some of them more than one year later.” 

A few things to note about the Commission’s process:

• The Commission can only evaluate compliance with the law; it has no influence over other aspects of the medical practice, even if they could affect euthanasia. So, for example, if the doctor makes a mistake in diagnosis or the cause of a decline in capacity, that would probably fall outside the Commission’s area of responsibility.
• Two-thirds of the commissioners must agree that a violation has occurred for a finding of non-compliance to be made. Such cases are referred to the institution’s Council of Physicians, Dentists and Pharmacists (CPDP) and the Collège des médecins du Québec. There is no remedy for the loved ones of ineligible people who are euthanized, or where safeguards are ignored. 
• This year the Commission introduced a new procedure for evaluating reports, in response to the growing number of euthanasia. Declarations are examined by a sub-group including at least three commissioners; if all group members agree that the eligibility criteria were met and the safeguards complied with, the case is recommended for approval by the whole commission. If there is disagreement in the small group, the case is referred to the full commission for further discussion. 

The commission took a first look at 1,384 reports, and needed more information or had questions on 31%, or 430 of them. The Commission found that 96% of the 1,354 cases it ruled on complied with the law, but it could not reach a decision in 41 cases (3%) because they didn’t get the information they requested from the doctor. The commission found that 13 euthanasia (1%) did not comply with the law.

• Four people were not eligible: 
• Three people did not have a serious and incurable illness (they all had broken hips); 
• One person’s medical insurance card had expired. 

• In nine cases, safeguards were violated. 
• The second doctor examined the person before the euthanasia request was signed in five cases. 
• The doctor did not conduct the interviews to ensure that the request was informed, that the person’s suffering persisted and they still wanted euthanasia. “In two cases, the physician who administered the MAiD met the person only on the day of the [euthanasia].” 
• One request form was witnessed by a non-qualified person. 
• “In one case, the second doctor consulted had a family connection with the doctor who asked for the opinion.” 

Of those who asked for MAiD, 65% received it.
The three most common reasons euthanasia was not administered were:

• The person was not eligible (246 people, or 37%)
• The person died before the evaluation process was completed or before MAiD could be administered (224 people, or 33%) 
• The person withdrew their request (127 people, or 19%). 

Forty percent of those approved were euthanized within ten days of making the request.

The Régie d’assurance maladie du Québec (RAMQ) reports that 682 doctors billed for services related to MAiD. According to the CMQ, of 23,478 doctors registered, 480 say they performed euthanasia in 2018.

If there’s a take-away message from this report, it would probably be that the number of euthanasia deaths is increasing rapidly, and procedures are still handled in a slip-shod manner. We still wouldn’t get on an airplane with a 1% chance of crashing, and a 3% uncertainty factor.

Summary Report on End-Of-Life Care (euthanasia) In Québec.

The following report was published by the disability rights group, Toujours Vivant - Not Dead Yet on April 12, 2019 and republished with permission.

By Amy Hasbrouck and Taylor Hyatt

Québec’s Commission on end-of-life care issued a summary report of the status of end-of-life care in Québec. The report deals with palliative care, continuous palliative sedation (CPS), euthanasia (administered or not), and the activities of the Commission itself. But the document only includes data up through March of 2018.

The report presents some obvious findings:

• The number of euthanasia and CPS are increasing. 
• Some doctors, hospitals, and regions provide more palliative care, CPS, and euthanasia than others. 
• Most of the people who die by euthanasia and CPS are over 60 years old and have cancer.
  

The report identifies some problems, such as that the Commission doesn’t have the data necessary to say how many people who need palliative care aren’t getting it. But we are aware of, or can predict other problems that are not addressed by the report, such as:

• People forced to live in institutions are requesting and receiving euthanasia; 
• We don’t know how doctors decide if a person is subject to “external pressure” to request euthanasia, and whether psychosocial, economic and discrimination-related factors are taken into account, besides coercion and abuse. 

Palliative care
 
The Commission admits it doesn’t have data to prove that the gaps in palliative care services observed in a report published in 2000 still exist, but they’re pretty sure that’s the case. The only data available count people who are receiving palliative care services, or who apply for euthanasia.

Service gaps exist in all areas where palliative care is delivered; home-hospice services, hospital-based palliative care units and free-standing hospices.

The report focuses on palliative care as an option only for people at the end of life. This despite the fact that effective pain relief is essential to many people with disabilities, and the authors propose expanding euthanasia to people who are not at the end of life.

The section on palliative care doesn’t address services to prevent institutionalization and requests for euthanasia, which are central to the Truchon/Gladu and Lamb cases.

Continuous Palliative Sedation
 
Of the people who died by Continuous palliative sedation:

• The report provides more detail about symptoms that justified CPS than about the kind of suffering that lead to requests for euthanasia: 
• Psychological / existential distress = 58%; 
• Physical pain = 28%; 
• Difficulty breathing = 25%; 
• Delirium and agitation = 20%.
  

• Ninety-four percent filled out and signed the consent form. In the other cases: 
• The form was not signed, but was in the medical file; 
• The form was missing from the file; 
• “oral” consent was given by the person or their family; 
• The form was not signed because the substitute decision-maker was absent.
  

• According to medical records, 83% of people received palliative care before asking for CPS and 6% never had palliative care. Information was not available in the remaining 11% of cases.

• Eighty-one percent died within three days of when CPS was started.

Euthanasia (administered)

• The number of requests was ten times more than anticipated before the program started. 
• “According to data gathered by the Commission, 1,632 people received MAiD in Québec between December 10, 2015 and March, 31, 2018.”  
• Footnote 33 states “the Commission is aware that the total of MAiD (1,632) … does not exactly correspond to the total declared in the reports from institutions and the Collège des Médecins du Québec shown in the latest report of the Commission’s activities,” published in December of 2018. That figure was 1,664, a difference of 32 euthanasia. The Commission does not explain this discrepancy. 
• It’s unclear whether the 1,632 figure comes from the total reported by institutions and the CMQ, or from doctors’ forms. In fact, nowhere in the 124-page summary report does the Commission explain why the number of euthanasia reported by institutions and the CMQ has been higher in the three annual reports, than the number declared by doctors. 
• Of the doctors’ declaration forms submitted to the Commission, 84 came in more than six months after euthanasia was provided. 
• By the Commission’s count, more than 60 euthanasia had not been reported by doctors as of March 31, 2018; 11 doctors’ reports were still missing when the summary report went to press. 
• As well, footnote 57 mentions “around 20” euthanasia that were not reported by the doctors or facilities, but which came to light following audits by institutions that found the information in their pharmacy records.
  

• The average time between signing the request and administration of euthanasia was 12 days. 
• The Commission describes the reasons for euthanasia request (suffering) in the broadest possible terms; Physical suffering, psychological suffering, or both. Not surprisingly, 89% reported both. The report did not specify how many people had what kind of discomfort (physical pain, breathing problems, nausea, existential suffering, feelings of loss of dignity, problems with self-esteem, grief, etc). 
• Of note, the Commission appears to have checked off “physical suffering” even where it wasn’t an issue. Footnote 43 states: “In light of the totality of information listed on the forms, physical suffering was determined to be present even if the form indicated that it was well managed or that there was only minor physical discomfort.” 
• The Commission says that 80% of people were receiving palliative care when they requested euthanasia, and 89% were getting it when MAiD was administered. However the Commission makes no assurances as to the quality or quantity of that service. This percentage of palliative care access is higher than that reported in a study from McGill University we reported on last December. 
• The authors note that the number of euthanasia performed at home in Quebec (20%) is half that of other parts of Canada (>40%) and Europe. Some people were admitted to hospital just to be euthanized. 
• The Commission estimates there could be up to 1,500 euthanasia performed in Québec during the fiscal year ending March 31, 2019. That’s almost as many as in the 28 previous months. 
• The data confirm the theory that there are a few “death doctors” who specialize in medical homicide, plus many other physicians who do one or two euthanasia per year.
  

Euthanasia not administered

• Of the 2,462 requests, 830, or just over 1/3, did not result in euthanasia. Such requests are not reported, so the commission had to look at the medical records of the people who made a request to determine the outcome, and to learn why euthanasia did not take place. The reasons fell into three broad categories: 
• the person was deemed ineligible, 
• the request was withdrawn; or 
• the person died before euthanasia can be carried out.
  

• The reasons euthanasia was not administered: 
• The person was not eligible when the request was made (191) because:  
• They were not at the end of life – 97; 
• They were incapable of giving consent when the request was made – 58; 
• They did not have “intolerable suffering” when request was made – 48; 
• They did not have a “grievous and irremediable medical condition” – 37; 
• Their medical condition was not in an advanced state of irreversible decline – 35; 
• (Some people were ineligible for multiple reasons.)
  

• The person became ineligible during the evaluation process (164) because: 
• They lost capacity to give consent – 156; 
• Their suffering was relieved such that it was no longer intolerable – 3; 
• Other – 5.
  

• The person died before the evaluation was completed – 168; 
• The person withdrew their request or changed their mind – 167; 
• The person died before euthanasia could be administered – 67 
• Other / information not available – 73.
  

• The authors note that the variability between different locations comes from diverse interpretations of eligibility criteria, especially “end of life” and “constant and unbearable” suffering. 
• The Commission suggests that the fact that 51% of people who asked for euthanasia were not at the “end of life” and 30% were incapable of giving informed consent corresponds with the public’s desire to expand eligibility to these populations. Our view is that the fact that some people are excluded means the eligibility criteria are working, at least somewhat.
  

The application process

• Oral requests are often not documented on the request form until the evaluation process is nearly completed. 
• The authors say people are being discouraged from making a written request for euthanasia, and are being told, informally, that they wouldn’t be eligible. 
• The Commission downplayed problems with delays in receiving form, and numbers of errors and incomplete forms.
  

The activities of the Commission

• The report says nothing about what the Commission intends to do about the deaths of people who were deemed ineligible, or where the safeguards were not complied with
•  In 11 cases, the person was not eligible for euthanasia; 
• In 10 cases, the doctor didn’t talk with the person to ensure they were giving free and informed consent, and the persistence of their suffering; 
• In 9 cases, the consulting doctor examined the person before the euthanasia request was even signed; 
• In 5 cases the form was countersigned by someone who was not a health-care professional; 
• In 2 cases the doctor did not ensure that the safeguards were complied with.
  

• The Commission’s backlog of evaluations is glossed over. They’ve evaluated 1,498 of the 1,632 euthanasia declared (92%), leaving a backlog of 134 cases even a year later. This is especially pressing given the commission’s estimate for the number of euthanasia for the fiscal year just ended. 
• There are references to improvements promised by the electronic reporting system. But the report skips over problems mentioned in the annual reports related to:  
• How many forms are incomplete or have errors; 
• How many letters and phone calls are necessary to correct or complete the forms, or to track down missing forms; 
• Euthanasia reports that are not transmitted at all.
  

• Nor is there any discussion as to how these problems will be dealt with in the future. 
• The media coverage of the release of this summary report was a frenzy of pro-euthanasia propaganda, criticism of the number of people who are being denied their “right” to euthanasia, and calls to expand eligibility and speed up the evaluation process. We hope that our observations, our sober second thoughts, will not be completely lost in the hubbub.

Doctors Induce Twenty-Five Percent of Dutch Deaths

This article was published by National Review online on January 21, 2019

Wesley J Smith

By Wesley J Smith

An exposé on Dutch euthanasia published in The Guardian discloses that around twenty-five percent of Dutch deaths are induced/caused by doctors.

These are not all lethal-injection euthanasia deaths. As I have written here before, many more people are killed in the Netherlands by “terminal sedation”–a slow motion euthanasia wherein patients not in the active stage of dying are put into artificial comas and denied all sustenance until they dehydrate to death–than die by lethal jabs. (Terminal sedation should never be confused with the proper practice of “palliative sedation,” which eases a dying patient’s symptoms while not intentionally causing death.)

Back in 2012, I estimated that combined euthanasia, assisted suicide, and terminal sedation killings totaled about fourteen percent of all Dutch deaths. In the years since, these induced-death practices have apparently grown significantly, a phenomenon that did not escape the attention of The Guardian. From “Death on Demand: Has Euthanasia Gone Too Far?” (my emphasis):

As people got used to the new law, the number of Dutch people being euthanised began to rise sharply, from under 2,000 in 2007 to almost 6,600 in 2017. (Around the same number are estimated to have had their euthanasia request turned down for not conforming with the legal requirements.) 

Also in 2017, some 1,900 Dutch people killed themselves, while the number of people who died under palliative sedation – in theory, succumbing to their illness while cocooned from physical discomfort, but in practice often dying of dehydration while unconscious [that is, terminal sedation] – hit an astonishing 32,000. Altogether, well over a quarter of all deaths in 2017 in the Netherlands were induced.

Since euthanasia was first decriminalized in the Netherlands, the country’s doctors have traveled a very dark road. Induced deaths have expanded from the terminally ill who ask for it, to the chronically ill who ask for it, to people with disabilities and the elderly who ask for it, to people with dementia, psychiatric patients with mental illness (83 in 2017), and the infanticides of babies born with serious or terminal illnesses or disabilities, who don’t have the capacity to ask for it.

Dutch law permits organ harvesting to be conjoined with euthanasia. There have been joint geriatric killings of couples fearing widowhood. In 2015, Dutch statistics revealed that 431 patients were killed by doctors who never asked for euthanasia–known in the lexicon as “termination without request or consent”–with next to nothing done about it even though such unasked-for lethal acts are technically murder under the law.

Does this mean the Dutch are horrible, ghoulish people? Absolutely not. But they are logical. Once the population widely accepted the premise that killing is an acceptable answer to suffering, the country took that belief precisely where it leads.

Such horrors will happen here too if we allow ourselves to be similarly seduced by euthanasia consciousness. Those with eyes to see, let them see.

Child euthanasia has claimed the lives of three in Belgium

This article was published by Aleteia.org on August 27, 2018.

An ethicist in Antwerp expresses alarm that the practice of terminating the lives of seriously ill minors is going mainstream.

John Burger

By John Burger

A recent report in Belgium noted that legal euthanasia there has claimed the lives of three children in the past two years.

The response in Belgium? A big yawn.

“The report of the control commission has provoked not one article in the press, and no comments at all,” said Willem Lemmens, Professor of Modern Philosophy and Ethics at the University of Antwerp.

Lemmens was referring to a July 17 report from the commission that regulates euthanasia in Belgium, which noted that between January 1, 2016, and December 31, 2017, Belgian physicians gave lethal injections to three children under 18. In 2014, Belgium amended its already permissive euthanasia law to allow children of any age to request the procedure.

Euthanasia deaths in Belgium have risen from 2,021 in 2015 to 2,309 in 2017.

Richard Egan: Child euthanasia in the Netherlands and Belgium.

Charles Lane, writing for the Washington Post, reported that the three euthanasias of children included an 11-year-old who had cystic fibrosis (CF).

“This congenital respiratory disease is incurable and fatal, but modern treatments enable many patients to enjoy high quality of life well into their 30's or even beyond,” Lane wrote. “Median life expectancy for new CF cases in the United States is now 43 years, according to the Cystic Fibrosis Foundation.”

The others were a 17-year-old with Duchenne muscular dystrophy and a 9-year-old with a brain tumor.

“Doctors must verify that a child is ‘in a hopeless medical situation of constant and unbearable suffering that cannot be eased and which will cause death in the short term.’ After a child makes his or her wish for euthanasia known, in writing, child psychiatrists conduct examinations, including…intelligence tests, to determine that the youngster is capable and ‘not influenced by a third party’. Parents can, however, prevent the request from being carried out.”

But Lane was unconvinced. “What, exactly, convinced doctors that these children’s cases were hopeless, that their deaths were imminent—and that the kids fully understood not only euthanasia but also the treatment options that might have alleviated their condition?” he asked.

“These questions are no longer asked in the Belgian press,” Lemmens said.

In an interview on Friday, Lemmens said he sees a process of normalization going on in Belgium. “On the one hand, people take it more and more for granted for somatic diseases like cancer, or terminal diseases of neurological origin…And there’s discussion going on whether the law will be enlarged for people with dementia or for elderly who are not terminal but are just tired of living.”

Most of Belgium’s 4,337 euthanasias in 2016-2017 involved adults with cancer.

And yet, Lemmens reports, doctors overall are, “Very concerned and very eager to address needless suffering at the end of life, and some doctors really try to avoid euthanasia. They don’t like the procedures for it. If they apply palliative sedation they don’t need to go through all these procedures that the law requires.”

Palliative sedation is the use of narcotics to the point of suppressing the body’s respiratory system. The controversial practice relieves pain, but usually hastens death.

“There’s a discussion about the proper way to do palliative sedation,” he said. “The pro-euthanasia doctors will say that palliative sedation is always a means to hasten death in a way that is not so different from euthanasia. The only difference is that with palliative sedation the doctors avoid external control and act, according to pro-euthanasia doctors, in a paternalistic way. These discussions are going on between doctors, and I think the discussions prove there has been an increase in what I would call a gray zone in end of life practices.”

But Lemmens rejects the idea that the overall care for dying patients in Belgium is decreasing. “Overall, Belgium has quite a good health system,” he said.

He affirmed that there is pressure on Catholic hospitals to cooperate with euthanasia requests, partly due to the mergers between Catholic and secular institutions in recent years and the secularization of Belgian culture. The euthanasia law does allow an objecting physician to opt out, but it’s generally expected for such a physician to refer a patient to another doctor, even though the law does not require it.

Alex Schadenberg: Belgium euthanized three children aged 9, 11 and 17.

Alex Schadenberg

For Alex Schadenberg, Executive Director of the London, Ontario-based Euthanasia Prevention Coalition, the mass media has been complicit in the advance of Belgium’s euthanasia laws. “The more cases that get promoted through the media, the worse it will become," he said. “Recently there was a case in the Netherlands of Aurelia Brouwers, a 29-year-old who died by euthanasia. She was physically healthy but was going through psychiatric issues. She intentionally went to the media; she became a media darling before she died in January this year. And the reason was: the more we hear about it, the more it is considered acceptable. What someone would never think of doing in the past, once we hear of others doing it, suddenly it becomes acceptable for somebody to do this.”

What troubles Schadenberg about Belgium’s euthanasia law is that even a 9-year-old’s “consent” to a doctor euthanizing him is accepted. “I don’t know how capable my 9-year-old was about consent, and now we’re talking about death,” he said. “In law we recognize there are limits to consent, for these very reasons, that there’s a certain level of ability, and yet we’re allowing death to be done in these cases.”

Schadenberg said child euthanasia is being talking about it in Canada right now. He said that in 2016 the government instituted committees to look at child euthanasia, euthanasia for people with dementia, and euthanasia for people with psychiatric conditions alone. “We’re expecting the reports in December,” he said. “I’m assuming that euthanasia for children will be considered very seriously.”

Dr Mark Komrad: Submission to New Zealand government committee

The submission by Dr Mark Komrad to the New Zealand Parliamentary Committee examining euthanasia and assisted suicide.

Dr Mark Komrad

Dr Mark Komrad I am submitting feedback to the New Zealand Parliament’s End of Life Bill. I am a psychiatrist and a medical ethicist in Baltimore, Maryland, USA on the faculty of Psychiatry at Johns Hopkins, University of Maryland, and the Sheppard Pratt Health Systems who has been engaged in the issue of assisted suicide and euthanasia, particularly in the case of psychiatric patients, in the U.S., Canada, and Europe.

• An important assumption underlying such assisted dying legislation is that physician-administered death is the only escape from unbearable suffering. This is not consistent with state-of-the-art palliative care, which includes a number of techniques, including but not limited to “terminal sedation,” in which consciousness is suppressed to the point where suffering is not experienced. Though there may be an increased risk of death from such a procedure, that is not the intention of the procedure. This and many other measures are quite effective at relieving suffering in a dignified and compassionate manner. If we kill patients as a means of relieving suffering, it undermines the entire enterprise of palliative care and will short circuit access, willingness, and even resources available for palliative care. This has happened in Belgium, where palliative care nurses are actually resigning, with the complaint that palliative care facilities are becoming “houses of euthanasia.” [https://tinyurl.com/y7kdh9ab , Caldwell, S. “Palliative care nurses quit ‘houses of euthanasia’” Catholic Herald, 18 Jan 2018] 

• The deep and millennia-old value that is “professed” by the profession of Medicine is to not kill in the name of healing. This was the unique feature of the very foundation of Medicine by Hippocrates, who made trainees swear an oath that they would “give no man a poison, nor counsel anyone else to do so.” This Hippocratic Oath is so core and fundamental to the ethos of medicine that it is still recited at medical school graduations to this day. Just as the teachings of Jesus were the foundational root out of which the mighty tree of Christianity grew, with all of its core value systems, this Hippocratic ethos was the root out of which the tree of Medicine has grown, and it is intimate to its fundamental substance as a profession. Although there is arguably a continuum between the role of “bringer of comfort” and “bringer of death,” society has a vested interest in maintaining the role of physicians as the “bringers of comfort.” Maintaining the “sterile field” in which physicians bring comfort, without deliberately killing, is crucial to the doctor - patient relationship. This is vital to how a physician thinks through possible options, the degree of devotion to helping the patient, and the willingness to sustain a field of support for a suffering patient. Compassion means “to suffer with.” Allowing doctors to kill patients can increase the unconscious temptation for doctors to avoid their venerable, age-old devotion to “suffering with.” 

• No country that has experimented with medically assisted dying has been able to hold the practice to patients at the end of life. None. That is the intention with which it begins. The living laboratories of The Netherlands and Belgium, which have had over 15 years of experience with this since their law was struck, have seen an inexorable slope. It began with those who are terminally-ill, by the nature of their illness. It progressed to those who produced a terminal condition by refusing chronic life-sustaining treatment (i.e. insulin). Then it slipped to the chronically and non terminally ill; then to the removal of distinctions between mental and physical suffering (thus opening the door to psychiatric conditions and unbearable lifestyles); then to those who are merely “tired of living” or feel they have a “completed life;” then to proxy consent for euthanasia of the incompetent, children, people on life support, and people suffering from dementia — by family members; then to “mercy killing” of those without capacity, by doctors who are unable to find consenting family members. Now there is the push for over-the-counter suicide pills in the Netherlands. Each of these steps has been widely documented. 

• Shifting suicide from a freedom to a right is a profound shift for any society. When suicide is made a right, rather than a freedom, it implies that there is a duty to enable people to fulfill that right. That means setting up a class of human beings who now has a duty to help people fulfill the right to suicide. Whoever has that duty is now vested with the mantel of “compassion,” “virtue,” and “healing” in the act of killing, however well-intentioned. The now-regretful pioneer of euthanasia in The Netherlands, Doudewijn Chabot M.D., seeing society’s inability to constrain euthanasia to its originally legislated applications has noted, “a culture has emerged in which performing euthanasia is considered to be virtuous behavior.” This is not only true for doctors, but this sense of virtue is also bestowed on those who choose assisted suicide. They are cast as heroic and noble, while those who continue to suffer are seen as partially responsible for their own continued suffering, because they rejected the death solution. There are widespread anecdotes of this attitude towards the chronically suffering, developing in Belgium, which I discovered in my research. 

• There is much evidence for “suicide contagion” as a consequence of ordinary suicide. Several studies in the U.S. and in the Netherlands have shown that the introduction of physician assisted suicide has not only failed to curb the “natural” suicide rate, but has also been associated with an acceleration of that rate. Whether there is a cause and effect relationship is still unknown. Assisted suicide has certainly done nothing to curtail “natural” suicide. However, there is an extraordinary dissonance in a society that engages in public health measures and messages to prevent suicide, while simultaneously designating a “special privilige” to certain groups to not just permit suicide, but to help provide for and abet that goal—by the same professionals (physicians) who are otherwise engaged in thwarting suicide in others. 

• Suicidal thinking is a very reliable indicator of a treatable psychiatric condition. Many medical conditions, particularly degenerative ones, are known to be highly associated with clinical depression, as part of the diseases themselves—independent of the degree of impairment (i.e. not just a result of “demoralization”). Research from Oregon shows that clinical depression is commonly missed by physicians who write assisted suicide prescriptions [missed up to 26% of the time: Ganzini, et al, Prevalence of depression and anxiety in patients requesting physicians’ aid in dying: cross sectional survey British Medical Journal 2008; 337 :a1682]. This is congruent with extensive literature showing that clinical depression is missed in about 1/3 of patients by primary care physicians. There is also literature showing that psychiatric treatment aborts suicidal wishes in a large proportion of people with terminal illness [Liebenluft, et. al “The Suicidal, Terminally Ill Patient with Depression” Psychosomatics, 29 (4), 379]. As elsewhere in the world, the proposed New Zealand law makes psychiatric evaluation optional, as part of the evaluation for medical ending of life. The evaluating physician personally determines the need for psychiatric evaluation. If such a referral is made, it is largely limited to assessment of capacity, and it carries no mandated psychiatric treatment attempt to qualify for assisted dying. In addition, even if there is psychiatric evaluation, a patient can refuse to give access to collateral records or informants to enable a fully accurate assessment. 

• Reports from the Oregon Health Authority [https://tinyurl.com/ybyh9w63, “Oregon Death with Dignity Act: Data Summary, Oregon Health Authority, Public Health Division, 2016] demonstrate that the primary reason people request physician assisted suicide is psychiatric: fear, hopelessness, despair, anxiety, and inability to conceive of how they will cope as their illness progresses. These are much more commonly motivating factors (90% of the time) for assisted suicide than actual physical pain or current debilitation. It is fear of the future. Often these emotions are in the setting of complex family dynamics, abandonment, impoverishment, and a wide variety of other psychosocial stresses that affect coping ability. These are common, fundamental psychiatric issues, and addressing them lies within the skill set of mental health professionals—independent of any particular psychiatric diagnosis. It is vital to not bypass state-of-the-art means of addressing these concerns with mental health care, rather than providing a civilization-changing shortcut to medically provisioned suicide in the face of these existential distresses. Of all kinds of health care however, mental health care is often the least accessible, due to stigma as well as comparatively underfunded resources. So these factors facilitate a path of lesser-resistance, should the assisted suicide option be opened. This puts those who are more emotionally vulnerable and most in need of mental health care at risk of short-circuiting mental health treatment. 

Also, see my complete lecture on this issue at:  https://tinyurl.com/yboe394m