Why Norway and Sweden Should Not Allow Physician-Assisted Suicide

(youtube video of his presentation)

Mark Komrad completed a 4-lecture tour of Norway and Sweden where he presented arguments to prevent the development of legislation and associated policies that would permit physician-assisted suicide (PAS) or euthanasia. He spoke to Members of Parliament, academics, physicians, other health care professionals, students, advocacy organizations, and members of the public. He also debated with proponents of these practices in Norway.
 
This article was translated and published in newspapers in conjunction with his appearances and is reprinted with permission.

Dr Mark Komrad

By Mark S. Komrad, MD 
Faculty of Psychiatry: Johns Hopkins, University of Maryland, Tulane University

The 2300-year-old history of medical ethics is grounded in the core ethical foundations established at the dawn of medicine — the Hippocratic values “professed” by physicians as a covenant-based community of values. This is the meaning of the word “profession.” The most distinguishing principle of the Hippocratic Oath has been the tenant rejecting the practice of euthanasia: “I will give nobody a poison, nor counsel any others to do so.” This is the root of the mighty tree from which the House of Medicine was built, this value persisting as societies and their demands have come and gone. To this day, the World Medical Association and many other major medical organizations continue this venerable and persistent ethical stance against physician-assisted suicide and euthanasia.

Several governments, in the last two decades, have invited and permitted physicians to transgress this prohibition against killing their patients. For example, Oregon, Canada, and Benelux have asked physicians to provide the means for certain patients who request the means to commit suicide or receive a lethal injection. These laws have empowered one class of human beings (ironically, physicians) to literally take the life of another class of human beings. Originally, the class who can be voluntarily killed or helped to suicide was limited to those at the very end of life. However, principles of justice have made it very difficult to limit such procedures to that category of people. The more experience a country has with such practices, the more the horizon of eligibility has expanded far beyond extreme end-stage cases.

In Oregon there is no way to distinguish between encouragement and coercion by those who “support” terminally-ill loved ones taking lethal drugs prescribed to cause death. There are no regulations to keep lethal prescriptions from being diverted. There is evidence of a contagious increase in ordinary suicide, subsequent to legalizing assisted suicide. New legislation is being pursued there to move to more active euthanasia and to make prognostic criteria for eligibility more vague. The law even allows patients whose conditions are not considered “terminal” to make themselves so, by choosing to refuse life-sustaining treatments — diabetics stopping their insulin, for example.

In Canada, the rate of euthanasia increased by 30% in the last half of 2017. One province has declared that it is neither ethical nor legal for a conscientiously objecting physician to refuse to refer a patient to a colleague who is more open to providing euthanasia. As is the nature of assisted suicide and euthanasia laws, suicide has been converted from a freedom to a right. Refusing to participate in the chain of duty to service that right can have adverse legal and professional consequences for some Canadian doctors. In Sweden, there are already adverse professional consequences, supported by law, for those qualified health care practitioners who refuse to provide abortion on demand, prior to 18 weeks. Such an established pathway mandating physician participation, even against conscientious objection, would be an existing, facilitated channel into which legalized assisted suicide in Sweden would easily flow.

In the Benelux, where these practices have evolved over 18 years, and 4% of all human deaths are by physicians’ injections, the slope has slipped to include eligibility for those with non-terminal illnesses, psychiatric conditions, young children, and uncomfortable lifestyles. Advanced directives and proxy consent for euthanasia of the incompetent are honored. There are strong advocacy efforts to de-medicalize the criteria for such procedures by allowing those who are “tired of living” or feeling that their life is “complete” to ask for euthanasia, with the hopes of developing a “suicide pill” that can be obtained without a medical evaluation or prescription — a high sanctification of autonomy. Organ donation by those seeking euthanasia is encouraged as a “virtue opportunity.” 

The profound changes to a civilized society produced by such laws are unnecessary and undesirable. The suffering and disabled should have even more access to the very latest, state-of-the art palliative care, without it being economically or morally short-circuited by institutional killing promoted as a seductive virtue — referring to it as “dying with dignity” or self-determination. The so-called “choice“ that is offered to the suffering to end their lives is a pseudo-choice, filtered through a physician’s own values, and commonly forced, by having very limited choices in other domains — economics, social support, healthcare, etc. It is unjust, and therefore impossible, in a democratic society, to limit these procedures to some — like the terminally ill — but refuse it to others — like those with chronic physical and psychiatric disabilities. Yet, it signals that chronic disability and its sufferings might constitute a “life not worth living.” It is an unfair and confusing public health message to designate one category of people who are helped to suicide, but another who are actively prevented from doing so with psychiatric care. It elevates autonomy as a value that overshadows, even crushes, other values that are necessary for the common good. 

Medicalizing suicide out-sources to the medical establishment the moral responsibility for a taboo about taking one’s own life by suicide, reducing the moral deterrence to suicide and lowering the threshold of acceptability for all suicide. It takes the protected and vital ethos of health care professionals away from their millennia-old Hippocratic commitment to be providers of comfort, hope, and healing, to become providers of death, not just supporters of the dying.

Are Euthanasia Errors Acceptable?

By Fabian Stahle, a Swedish researcher.
Edited by: Alex Schadenberg, Euthanasia Prevention Coalition

When the advocacy for legalisation of euthanasia/assisted suicide approach a new jurisdiction it is always with the assurance that the proposed practise will only be used for extreme cases – persons in extreme pain and on their death bed. The advocates emphasize that strict safeguards will prevent anyone from being killed by mistake.

Dr Johan Andreen

These two speaking points in their sales pitch - only extreme cases and no mistakes – are constantly repeated in the first phase of introducing the idea of medical killing.

Currently the Swedish debate is in the introduction phase. A Swedish opponent of euthanasia, psychiatrist Johan Andreen, recently addressed the allegations about the proposed strict safeguards in an article in the Swedish Psychiatric Magazine, No 3, 2018. See page 54-56, (link) with translated title: "Taking Position In The Question About Euthanasia."

His article is a sharp and in-depth analysis of the weakness of the proponents claims and a passionate appeal for true compassion for the vulnerable.
The author asks the following question to those who propose euthanasia (and PAS) regime and to those who haven't yet made up their mind:

". . . Is it acceptable that any erroneous deaths at all take place in the context of something that should be a care measure?"

He then continues:

"If your answer is yes, the next question is: “why should we accept that when we do not accept it for other care measures?” Furthermore, how big a proportion is acceptable? Finally, how will we be able to establish and ensure safe control of that proportion of error with “assisted death"?

If the answer is no (which it reasonably ought to be), some of the follow-up questions would instead be: How can the law and its application ensure that mistakes and abuse of the law do not result in patients – who should have had care and support in a dignified life – having their lives shortened as well as a dishonourable ending to their life?

We had better watch out and navigate right in this paradoxical context. Because, although the existence and purpose of the act is to bring about death, and that this has been achieved, it will inevitably also have occurred in cases where care and treatment to live a meaningful and reasonably comfortable life should have been given. The assisted death will have the effect that some patients pass away as a result of the medical act, when this was incorrect and not the patient's actual desire and need. In the name of common sense and honesty, we should all be able to assume and agree that this will be unavoidable. In what world are there laws, doctors and healthcare systems that have no shortcomings and risks, or legal institutions that cannot be used for unintended and therefore illegal purposes?

The starting point must be, for empirical and logical reasons, that it will not be possible to introduce a "Swedish improved" version of the Oregon model that will not kill a number of people in error. . . . Let it be clear that this unintentional mortality would take place at a percentage or even permille level. It would also occur in a Swedish model.

Is any such mortality at all acceptable then? In our current situation, it is difficult to see, let alone find the opportunity to talk about this lethal side-effect or risk in the assisted death debate, since the act itself has the purpose of bringing about death!

So, here we need to see before us people who are depressed or just lonely and despondent. People who with pharmacological, psychotherapeutic and other treatment or just good care, compassion and counselling, together with their near and dear ones receive the support they need – but do not believe they can wish for – to be able to live out the time they have left. And no one can know the length of that time. 

There may be individuals who perhaps enter [into] their terminal condition due to the fact that in a state of depression – or sheer resignation – they stop taking or continuing treatment or investigation, or fail to ensure necessary intake of nutrition, fluid and basic activity and therefore become terminally ill. Is an outcome, involving an act that leads to death, acceptable in any or a few cases of these treatable and care-demanding non-terminal conditions? Should not our compassion, our strength and our resources instead be spent on scientifically developing – and with the use of care programs, focus and standardize – the help provided in cases of such suffering, the underlying disease and the social vulnerability?

In order to see with sharp clarity what we are talking about here – in a concrete corresponding care and treatment scenario – we need to begin to make comparisons with scientific pharmacological treatments.

When certain drugs appear to have clearly identified serious side-effects including fatality, severe illness or foetal damage, they are immediately withdrawn (the list could be long and will not here be encumbered with names). It does not matter that they have cost billions to develop and it does not matter that they may have a very good and important effect for the vast majority. It does not matter that these side effects are rare, if they cannot be safely prevented by any possible method. In those cases, we consider that to be enough. Our modern legislation guarantees that we should not have such drugs. The market for that drug will fall as soon as repeated reports of these outcomes occur. The company loses its credibility and status if, when the risk is clear, it does not immediately withdraw the drug before the drug authority in every country does.

In summary, the questions asked here are necessary and sufficient, and therefore crucial, to answer concerning euthanasia – regardless of model. Do we accept that the medical sector will be required to abolish and violate the thousands of years old parameters in our social contract – between individuals, people and the social system/state – that "you/we shall not kill"? Disregarding that a few countries have introduced euthanasia, do we not in the name of health care security and basic ethics have to talk about the fundamental risk to patients that this entails?

Do we accept that a societal change should be made that involves doctors and nurses participating in something that most of us agree is not, and can never be scientific treatment? Do we accept a state-imposed measure performed on the basis of patients' supposedly well-founded requests, following an arbitrary assessment by doctors – no science for this procedure exists – resulting in the death of a patient, a fellow human being, and that the possibilities for giving proper treatment and care are extinguished – forever? When this, apart from a series of risks and consequences for our society that have not been raised here, actually means that people who would have wanted and could have been helped to live will die of "assisted death"?"

As for Sweden we can already anticipate the second phase in the debate when it becomes clear for everyone, even for the proponents – although not admitted – that some collateral damage is inevitable. But the advocates play down the issue just like the Canadian doctor Ellen Wiebe, who in a debate in The Economist Magazine confessed (Link):

”I agree that one day I may make an error in my assessment and not realise that someone has been pressured into a decision to hasten their death. And the other independent assessor might make the same error. That might mean a person would die earlier than she or he may have preferred.”

Dr Wiebe continues with a rhetoric question that clearly demonstrates how the advocates in the implemantation phase shamelessly propagate for a miserable standard for protecting people from being killed.

"Should that error be the reason hundreds or thousands suffer needlessly against their will at the end of life? I am so glad to be Canadian in 2018 and to say, “No, that is not how it is here."

The confession that she "one day may make an error" may be an understatement in the view of her extensive experience of providing about 150 assisted deaths according to another article by her published in the The Economist Magazine (Link). 

Fabian Stahle is a Swedish researcher who, last year, uncovered hidden problems with the Oregon assisted suicide model.

Hidden problems with the Oregon assisted suicide law uncovered.

Alex Schadenberg

Executive Director - Euthanasia Prevention Coalition

Link to the article by Fabian Stahle: Oregon Health Authority Reveals Hidden Problems with the Oregon Assisted Suicide Model.

Euthanasia and assisted suicide are being promoted world-wide. Recently the Swedish National Council on Medical Ethics published the report, "Assisted death: A Knowledge Compilation."

Fabian Stahle, a Swede who opposes euthanasia, sent EPC an article revealing the hidden problems with the Oregon Assisted Suicide model. 

Stahle read the Swedish report and noticed a quote from Professor Linda Ganzini, from Oregon, who stated that the six-month expected survival time applies, 

“if no treatment is given to slow down the course of the disease”

Stahle responded to this statement by asking the Oregon Health Authority by email if Ganzini’s comment was correct. Stahle asked:

In the law, “terminal disease” is defined as an incurable and irreversible disease that has been medically confirmed and will, within reasonable medical judgment (in the opinion of the patient's attending physician and consulting physician), produce death within six months. 

Is this rule interpreted as ‘without administration of life-sustaining treatment’?”

Craig New analyst for the Oregon Health Authority responded

“. . . your interpretation is correct. The question is: Should the disease be allowed to take its course, absent further treatment, is the patient likely to die within six months?”

This means that the definition of terminal illness, in Oregon, includes people who will become terminally ill if they refuse effective medical treatment or care.

To clarify the response, Stahle followed up by asking the next two questions:

If the doctor suggests, to an eligible patient, a treatment that possibly could a) prolong life, or b) transform a terminal illness to a chronic illness, or c) even cure the disease—and if the patient doesn't give his/her consent to the proposed treatment is he/she still eligible to take use of the Act? 

If a patient with a chronic disease (for instance, diabetes) by some reason decides to opt out from the life-sustaining medication/treatment and by doing so is likely to die within 6 months, thereby transforming the chronic disease to a terminal disease—does he/she then become eligible to take use of the act?

New responded with the following answer:

“Interesting questions. While this is not addressed specifically in the law, the answer in both cases is yes – those patients would qualify.

Craig New confirms that the language in the Oregon assisted suicide law may have deceived people into thinking that the Oregon law is limited to people who are terminally ill.

Fabian Stahle included more detail in his article. Stahle concluded by stating: 

We need to consider the significantly expanded dimensions as to who qualifies for assisted suicide under the Oregon model. It is definitely not the scenario that is being presented in the polls or propaganda by advocates. Proponents want to sell the Oregon model with the assurance that the offer for medically assisted suicide only applies to dying patients where all hope is lost. But it is completely misleading. Sick people in Sweden and elsewhere deserve something better than laws with such inherent dangers beneath the surface.

Link to the article by Fabian Stahle: Oregon Health Authority Reveals Hidden Problems with the Oregon Assisted Suicide Model.