Physician_Assisted_Dying_lecture_INST_100155_2024_03_12_22_51_01.pdf

requests to die & physician assisted dying group 13  Our Objectives Requests to Die Physician Assisted Dying Cases: ELIZABETH BOUVIA Cases: DR. JACK KEVORKIAN P...

requests to die & physician assisted dying group 13  Our Objectives Requests to Die Physician Assisted Dying Cases: ELIZABETH BOUVIA Cases: DR. JACK KEVORKIAN Perspectives On Suicide Voluntary Euthanasia in the Netherlands Oregon’s Legalization Christianity and Voluntary Death Ethical Issues: The Concept of Assisted Suicide Killing versus Letting Die Ethical Issues: For and Against Assisted Suicide Relief of Suffering Rationality and Competence Patient Autonomy Autonomy The Roles of Physicians Mistakes and Abuses Current rules and regulations in India  Euthanasia Euthanasia comes from the Greek words: Eu (good )and thanatosis (death) and it means “Good Death”, Gentle and easy death. This word has come to be used for ‘mercy killing’. It is the act or practice of ending a life of a person either by a lethal injection or suspension of medical treatment. The word “euthanasia” was first used in a medical context by Francis Bacon in the 17th century , to refer to an easy, painless, happy death , during which it was a “ physician’s responsibility to alleviate the physical suffering of the body. Types of Euthanasia  Active Euthanasia It is when death is brought by an act for example taking a high dose of drugs To end a person’s life by the use of drugs, either by oneself or by the aid of a physician.  Passive Euthanasia When death is brought by an omission eg: when someone lets the person die , this can be done by withdrawing or withholding treatment. Withdrawing treatment : for example switching off a machine that keeps the person alive. Withholding treatment: for example not carrying a surgery that will extend life of the patient for a short time  Voluntary Euthanasia committed with the willing or autonomous cooperation of the subject. This means that the subject is free from direct or indirect pressure from others.  Non-Voluntary Euthanasia occurs when the patient is unconscious or unable to make a meaningful choice between living and dying , and an appropriate person takes that decision for him/her This is usually called murder , but it is possible to imagine cases where the killing would count as a favor for the patient.  Indirect Euthanasia This means providing treatments –mainly to reduce pain –that has a side effect of shortening the patient’s life Since the primary intent wasn’t to kill, it is morally accepted by some people.  Assisted Suicide This is usually refers to cases where the persons who are going to die need help to kill themselves and ask for it. It may be something as simple as getting drugs for the person, and putting those drugs within their reach  the case of elizabeth bouvia  History Elizabeth Bouvia was almost totally paralyzed and could only use her right hand and control her facial muscles. She had degenerative arthritis On her 18th birthday her father left her because of her disabilities. In 1982 she married an ex-convict, however, their relationship ended when she miscarried.  History She was let down by her husband and family, and she was depressed. Fed up with life, she was admitted as a voluntary patient at Riverside General Hospital, hoping to end her life, by starving to death.  The Legal Battle She came to Riverside Hospital for a hygienic place to starve to death. As her condition was not terminal, doctors refused to let her die. She was force fed Her right for privacy an dignity was violated, as a human being.  Legal Battle She filed a law suit on 1983 to let her die but the court allowed Ms. Bouvia to be forcefed. She applied law suit again in Mexico and Superior court which both let her to be forcefed. For the first time, a federal court said that a competent adult patient has tge right to refuse medical treatment  Legal Battle After her victory, Bouvia did not kill herself. When some caring people offered to help her die, she changed her mind. Most importantly, by giving her control over her life, they gave her a reason to live.  Legal Issues Autonomy Ms. Bouvia had her basic right of autonomy as a patient wherein she was to one to decide what was best for her. But the doctors and court did not heed to her wish and chose to act otherwise.  Legal Issues Non-maleficenece This basically says that if doctor couldn’t do any good, then they shouldn’t do any harm. Those doctors thought they were doing good but did harm, by stripping her of her basic human rights and violating her body by inserting nasogastric tube without her consent.  Legal Issues Utility Another issue raised in court was Utility. The greater good for the greatest number. If the doctors allow a disabled patient to let her commit suicide, then it might instigate the same in many other disabled patients and thereby for the betterment of other patients those doctors chose to force feed Ms. Bouvia Perceptions on Suicide Greece vs. Rome  Greece Ancient Greek aristocrats strove not simply to live, but to lead lives of nobility. The important thing is not to live but to live well. In short, the Greeks embraced death and thought of death as a path to wisdom  Rome Romans accepted death not as a path to wisdom but as a last resort. Emperor Marcus Aurelius said “If the room is smoky, if only moderately, I will stay; if there is too much smoke, I will go. Remember this, keep a firm hand on it, the door is always open.” greece rome  20th Century On the contrast to the ancient philosophers, Jean-Paul Sartre revived the argument for the open door. He emphasized on choice. “Not to choose is always a choice” religious views on euthanasia  Religious Views Those in favor of euthanasia argue that a civilized society should allow people to die in dignity and without pain They add that as suicide is not a crime, euthanasia should not be a crime  Religious Views MOST RELIGIONS DISSPROVE OF EUTHANASIA FOR A NUMBER OF REASONS : God has forbidden it Human life is sacred Human beings are made in Gods' image God gives people life , so only God has the right to take it away  The Christian view on Euthanasia Christians are mostly against euthanasia The arguments are usually based on the beliefs: Life is given by god Human beings are made in Gods’s own image Some churches also emphasize the importance of not interfering with the natural process of death. Life is a gift from God Christianity requires us to respect every human being.  Discuss let us know the views of different religions on euthanasia!! concept of assisted death and ethical issues  Concept of Assisted Suicide The term Assisted Suicide is a model that includes both what has been called physician-assisted "suicide" and euthanasia. Physician-assisted suicide : It occurs when a physician facilitates a patient’s death by providing the necessary means and/or information to enable the patient to perform the life-ending act. Euthanasia-Greek term for "Good death" : The physician taking an active role in performing or carrying out a patient's request for life termination.  Assisted Suicide One question raised by the case of Elizabeth Bouvia is what to call their intended action: suicide, rational suicide, assisted suicide, euthanasia, voluntary death, or self-deliverance? Let us Clarify some terms…  Terms First, euthanasia usually means the killing of one person by another for merciful reasons. The preceding cases do not involve euthanasia, because, in each case, death would be initiated by the person him- or herself. Second, a terminally ill patient who forgoes medical treatment doesn't really "commit suicide." We should distinguish between (1) cases where an underlying disease is incrementally leading to death and by choosing to not to do everything possible, the patient accepts death and (2) cases where a competent adult without a terminal illness causes his or her own death. The second kind of case is appropriately called "suicide."  Therefore.. The Bouvia case is best called cases of Assisted Suicide. Elizabeth Bouvia does not have a terminal disease, but also could not easily kill themselves, hence she needed help from others, hence the term assisted.  Ethical Issues For Assisted Suicide At the heart of the debate over end-of-life choices is the recognition that not all persons can be healed and not all suffering can be relieved. Health care professionals must recognize that sensitive and compassionate management of death is only one aspect of a longer dialogue about end-of-life choices. There can be no doubt that the desire for assisted suicide has increased with the sophistication of medical technology. As McLean (1999) suggests: ‘Medical advance and technology can result in prolonging life or slowing the dying process’. She cites Angell (1990) who states that ‘Some people now fear living more than dying, because they dread becoming prisoners of technology’. Assisted suicide is an issue where the interests of the individual cannot be separated from those of society as a whole. There may never be a simple solution to the debate. There are fears that decriminalizing assisted suicide could lead to abuse and the possibility of killing someone who did not want to die.  Ethical issues Against Assisted Suicide Opponents of physician-assisted dying view this act as causing harm to patients and essentially breaking the Hippocratic Oath. They also oppose it on the belief that taking a life actually devalues and disrespects that which should hold the highest value It is argued that sanctioning assisted suicide would violate the rights of others. Doctors and nurses might find themselves "pressured" to cooperate in a patient's suicide. In order to satisfy the desires of a patient wanting to die, it's unjust to demand that others go against their own deeply held convictions  Rationality and Competence In Elizabeth Bouvia’s case psychiatrist Nancy Mullen testified that because Elizabeth was suicidal she could not rationally make decisions about her life. Elizabeth Bouvia may have been depressed and psychological test might have shown this. but Mullen and Gill didn’t base their arguments on such tests. they were not Elizabeth’s therapists and were not treating her. Mullen and Gill reacted to content of Elizabeth decision rather than to psychological test. Indeed she was found to be competent by three psychiatric professional who actually tested her. In America patient is legally competent until proven otherwise and proven so in a legal hearing. AUTONOMY Is expressed as the right of competent adults to make informed decisions about their own medical care. physician assisted dying dr. jack kevorkian  Case: Dr. Jack Kevorkian Murad Jacob "Jack" Kevorkian (May 26, 1928 – June 3, 2011) was an American pathologist and euthanasia proponent. He publicly championed a terminal patient's right to die by physician-assisted suicide, embodied in his quote, "Dying is not a crime". Kevorkian said that he assisted at least 130 patients to that end.His passion, however, led to his death.  Dr. Death Main Goal Began working at the University of Michigan Hospital took pictures of terminal patients' eyes as they died results show that blood vessels in cornea contracts and become invisible as heart stops beating ( earned nickname ) 1958, published idea of using death row inmates for medical experimentation. ( ideas opposed and left job at the Michigan University hospital ) 1980s wrote articles for German journal Medicine and Law. ( expressed ideas on ethics of euthanasia ) 1987, advertised in Detroit newspaper as physician consultant for "death counseling"  Assisted Suicides 1990, first public suicide of Janet Adkins, 54 year-old woman diagnose with Alzheimer's disease Charges of murder were dropped, but State of Michigan took medical license away assisted in deaths of at least 130 individuals between 1990 and 1998 individuals took final action to end life ( attached to euthanasia device, constructed by Kevorkian, pushed button releasing drugs and chemicals to end their life ) deaths assisted by insertion of drugs intravenously using "Thanatron" or "Death Machine“ another device Kevorkian devised and constructed used gas mask which fed patient carbon monoxide "Mercitron" or "Mercy Machine" janet adkins Thanatron and Mercitron  Main Goal report revealed 60% of Kevorkian's patients were not terminally ill and at least 13 hadn't complained about pain.“ My aim in helping a patient was not to cause death. My aim was to end suffering." - Jack Kevorkian ending suffering first step to goal of establishing deadly human experimentation as a medical specialty use subjects (including infants, children, mentally incompetent) for experiments, and if they are still alive, they will be euthanized and organs harvested FUN FACT: he did most of his killing in his car, the Deathmobile Main Goal  Imprisonment and Death November 22, 1998 CBS News' 60 Minutes aired videotape made September 17, 1998 of voluntary euthanasia of Thomas Youlk, 52, in final stages of Lou Gehrig's Disease Kevorkian administered injection himself wanted persecution in hope to win in court and make euthanasia legal March 26, 1999 charged with second-degree murder and delivery of controlled substance without medical license granted parole after 8 years Died in 2011 as a result of liver cancer  What is there to Judge? Some find him a villain, while others find him a hero. There’s thee sides of the story: the good side, the bad side, and the side that actually happened. No matter how many people dislike Dr. Kevorkian, he is someone who won’t be forgotten because he fought for those who were on the border where there was nothing but suffering. the voluntary euthanasia in netherlands  Guidelines The Dutch Medical Association, in agreement with Dutch legal authorities, in 1973 began guidelines for physician-assisted death. They were that: (1) Only competent patients can request death (2) Requests must be repeated, unambivalent,unpressured, and documented (3) Physicians must consult another physician for a second opinion (4) Patients must be in unbearable pain or suffering, without likelihood of improvement.  Generalizations Several aspects of the Dutch experience caution against easy generalizations to North America. First, everyone in Holland has free medical care, including long-term nursing home care, and thus no patient, physician, or family needs to decide to die to ease the financial burden of care. Second, the typical Dutch patient has a physician who makes house calls, who has known him for years, whom he trusts, and who will be the one he asks to help him die. To an extent that American physicians would envy, the typical Dutch patient trusts his physician.  Legality of Physician Assisted Dying In 2001, after 30 years of agreements and semi-legalization. Queen Beatrix signed a law making physician-assisted dying totally legal in Holland. After three decades of experimentation, 90 percent of Dutch citizens supported the law. The law lacked a controversial proposal allowing terminal 12- to 15-year olds the same right. The law did include the right of patients in the early stages of dementia, amyotrophic lateral sclerosis, or other progressive diseases to sign advanced directives allowing them to be killed at a later date. After 35 years, the Dutch embrace their famous experiment.  Statistics They resent Americans who claim they dispatch their grandparents to save money. The Dutch endure heavy taxes to pay for their national medical system and take pride in how their physicians respect personal autonomy and practice compassionately. In America, 55,000 children die each year, and in 2002 the prestigious Institute of Medicine concluded that most such children die badly. "Too often, children with fatal, conditions fail to receive competent, compassionate, and consistent care."8 Children often accept their dying before their parents, who notoriously"flog them to death" in painful experiments in hopes of miracles  Oregon’s Legalization The Act had draconian restrictions: Patients had to be: (1) clearly competent (2) have less than six months to live (3) to avoid impulsive decisions, wait 15 days before filling prescriptions. Physicians could not administer the fatal dosage, only prescribe to avoid impulsive decisions Oregonian physicians write prescriptions for about 50 percent more patients than those who use them. About a third die before the waiting period or die before self-administering the pills ethical issues  Killing vs Letting Die In their account of passive euthanasia, moral differences between killing and letting die. To kill is not the same as to let die. Similarly, there are significant differences between active and passive euthanasia. Our morals duties differ with regard to them. We are, in general, obliged to refrain from killing each and everyone. We do not have a similar obligation to try (or to continue to try) to prevent each and everyone from dying. In any case, to be morally obliged to persist in trying to prevent their deaths would be different from being morally obliged to refrain from killing all other people even if we had both obligations.  Relief of Suffering The relief of suffering is considered one of the primary aims of medicine. However, what suffering actually is and what physicians must do specifically to prevent or relieve it is poorly understood. Because of this, the most well-intentional and best trained physicians may cause suffering inadvertently in the course of treating disease and may fail to relieve suffering when that might otherwise be possible. Suffering must be distinguished from pain or other symptoms with which it may be associated.  Patient Autonomy Although physicians, patients, and the medical literature generally link pain and suffering, they are distinct phenomena. PATIENT AUTONOMY Autonomy means the ability to be self governing and self directed. Its opposite is to be treated paternalistically, like an incomplete child. Autonomy mattered to John Stuart Mill, who argued in his on liberty that over his body and mind, the individual is sovereign. Milli’s view implies that government should not impose its view of when and how people should die.  Patient’s View Physicians usually believe that they are best qualified to assess risk, and they are right as far as statistical risk is concerned. But acceptable risk is evaluative as well as statistical. Many patients want the right to make their own judgements about what is acceptable risk. When terminal patients make such evaluations, their concern is more than just fear of pain. Derek Humphrey of the hemlock society has written, it is not just a question of pain. It is a question of dignity, self-control, and distress, if you can not eat, sleep, or read and the quality of life is so bad, and there is a certainty that you are dying, it is matter of dignity to be able to end your life. role of physicians  Physician’s Roles, Cries for Help and Compassion To simplistically assert that "physicians should not kill" begs the key question at issue. A good physician makes sure his or her patient isn't depressed and doesn't choose death because of treatable symptoms. The short interviews by Dr. Kevorkian and his layperson sister, of his patients who arrived in town the day before they were killed, did not meet the highest standards of humanism in medicine  The Seven Roles of Physicians Some physicians argue that “physicians should not kill” and should always be healers. This statement incorrectly assumes that physicians can always heal, which is false. Everyone will eventually die. Mistakes and Abuses  Mistakes Physicians make mistakes. Surgeon Christiaan Barnard recalled a young woman with ovarian cancer who repeatedly begged him to kill her painlessly with morphine. Being aware that she was terminal—and hearing her screams at night—Barnard decided to help her. When he came into her room with a syringe loaded with morphine, she was quiet, and he thought that she was in too much pain even to scream. Then he realized that she was semiconscious, beyond pain, and changed his mind. The next morning, she felt better; soon she was in remission and lived another few months. In bioethics, many discussions begin with a phrase like “If a patient has a terminal illness....” Notice the word “if.” In presumably terminal illnesses, few claims are absolute until the patient’s last days.  Mistakes Before then, how “terminal” or how close to death the patient is, may depend on many factors that are not easy to assess:. These factors include; the patient’s attitude the family’s attitude the attitude of staff members the quality and level of care, and so on.  Abuses Some terminal patients were misdiagnosed and recovered. Physician-assisted dying allows a mistaken diagnosis to become a death sentence. Israeli physician Seymour Glick once revealed a dirty little secret of medicine: Every physician has some patients whom he dislikes. Some illnesses are messy, some families are intolerable, and some physicians make mistakes and harm patients. In such cases, physicians want the patients to “go away.”  current rules and regulations in india  PAS in India PAS is illegal in India However, It has a number of supporters In the form of non-profit organizations. An example is the Death with Dignity Foundation.  PAS vs Law In India, PAS would be the abetment of suicide under Section 306 of the Indian Penal Code, 1860. Anyone considering PAS or euthanasia should approach the Indian courts, however the court has never given a clear ruling permitting PAS to proceed. India is not alone as most countries have been attempting to obtain rulings on this subject. Majority of doctors opposed PAS legislation as a strong religious belief is independently relate to resistance to assisted dying.  Religious views on PAS Discussions about PAS will encounter a variety of problems, namely people’s moral standards, views on religion and culture, and the intensity of religiosity. More religious doctors, whether Christian or Muslim, believed that PAS is against their faith.  Legality In India passive euthanasia is legal. The Supreme Court of India legalized passive euthanasia by withdrawing life support from people in a permanent vegetative condition on March 7th 2018. Active euthanasia is still prohibited. PAS refers to active, voluntary, assisted euthanasia, in which the physician assists the patient by providing sufficient medication for the patient to kill themselves. Therefore PAS is illegal in India.  Laws IPC Section 309 states: whoever attempts to commit suicide and does any act towards the commission of such offence, shall be punished with simple imprisonment for a term which may extend to one year or with fine, or with both. India has the highest suicide rate in the south-east Asian region, according to the world health organization report released in 2019.  Laws Suicide was decriminalized in India in 2017, but section 309 of the Indian penal code still stays. Anyone who survives an attempted suicide can be booked under IPC section 309 which deals with “attempt to commit suicide”. The mental healthcare act (MHCA), 2017, which came into force in July 2018, has significantly reduced the scope for the use of IPC section 309 and made the attempt to commit suicide punishable only as an exception.  Laws Section 115(1) of the MHCA says: “not withstanding anything contained in section 309 of the Indian penal code any person who attempts to commit suicide shall be presumed, unless proved otherwise, to have severe stress and shall not be tried and punished under the said code.” According to penal code 1860, active euthanasia is an offence under section 302 (punishment for murder) or at least under section 304 (punishment for culpable homicide not amounting to murder).  Laws Arguments in favor of section 309: why it should be retained? There are occasions when people show up at government offices and threaten to kill themselves if their demands are not met. It is in these cases, where police suspect that the person does not intend to commit suicide but is using the threat as a way to unfairly pressure or blackmail the system. And during such instances this section need to be used  Quiz What was the reason the Doctor’s refusal to help Mrs Bouvia? A) Autonomy B) Non Maleficence C) Utility D) B & C  Quiz The term which means ‘the killing of one person by another for merciful reasons’? A) Physician Assisted Suicide B) Euthanasia C) Commit Suicide D) Terminally Ill  Quiz What is considered one of the primary aims of Medicine? A) Relief of Suffering B) Autonomy C) Letting Die D) None of the Above  Quiz Physician Assisted Suicide is legal in India according to the Act 2441 of the Constitutional Laws. A) True B) False  Links Dr. Kevorkian and his suicide assistance machine https://youtu.be/Rk3ri1ADIsI The truth about Physician Assisted Suicide https://youtu.be/WGzXGOsNNt8 Thank You