1. Euthanasia/ Sterbehilfe

2. Blue: active sterbehilfe allowed
Yellow: assisted suicide allowed (not medicalized in Germany: loved ones can assist)
Green: passive sterbehilfe allowed (stopping life support)
Red: none of these allowed
Black: unclear legislation

3. Definition Deliberate termination of life By a doctor
At a patient’s specific request
not the same as physician assisted suicide, because then the doctor doesn’t administer the lethal medication, but the patient him or herself: both are legal under the same law in the Netherlands, we’ll discuss both today

4. Memento Mori unknown photographer, 1845, Rijkmuseum
memento mori: do not forget we are all mortal
that is the only certainty in life: we will all die one day.
We just do not know how.

5. Strong will to live
Natural, most people

6. but there are circumstances under which individuals have no joy and prospect in living anymore. for example when you are suffering from an incurable fatal disease. circumstances under which you would rather die quickly and in a dignified manner than continue suffering.
the philosophical debate is about whether you should have the autonomy to decide about the way and the moment you will die.
that is philosophy, but the origins of our current euthanasia legislation are .....

7. Pragmatic

8. Contents ‘Conflict of obligations’ Euthanasia Act 2002
‘Slippery slope’?
Documentary
Discussion

9. Contents ‘Conflict of obligations’ Euthanasia Act 2002
‘Slippery slope’?
Documentary
Discussion

10. Imagine you’re a doctor
treating a cancer patient
poor prognosis, curation impossible
no treatment options left
bedridden
pain, pressure sores, short of breath

11. what if this patient asks you to help him die?
please doctor, give me something to let me no longer suffer
worldwide this happens every day
what would you do?

12. Conflict of obligations
Helping your patient
Protecting life
according to the hippocratic oath you should do both, but in this situation they are conflicting

13. Solution?

14. Solution?
with the excuse of pain relief or relief of suffocating: administering large doses of morphine, that will make you unconscious and then give a respiratory depression that leads to death
1. doesn’t always work
2. this must be kept secret! the intention is not pain relief, but ending the patients life.

15. Dutch approach Pragmatic This does happen
How to deal with it out in the open?

16. consensus Ending a person’s life is considered homicide,
Act 293 in Dutch Penal Code: Any person who terminates another person’s life at that person’s express and earnest request shall be punishable by imprisonment not exceeding twelve years or a fifth-category fine (up to € )
but...
Physician cannot be punished if he/ she acted according to ‘criteria of due care’
jurisprudence, from several cases that eventually led to the euthanasia act in 2002

17. Contents ‘Conflict of obligations’ Euthanasia Act 2002
‘Slippery slope’?
Documentary
Discussion
Not the official name

18. 2002 Termination of Life on Request and Assisted Suicide Act
Physician cannot be punished if acted according to criteria of due care

19. Criteria of due care voluntary and well-considered request
hopeless and unbearable suffering
the patient is fully informed on situation and prognosis
joint conclusion: no other reasonable and acceptable solutions are available
an independent second physician has written a report with the same conclusion
the procedure is carried out in a medically correct manner

20. Medically correct manner
Euthanasia:
intravenous sleeping medication - induces coma
intravenous muscle relaxant

21. Medically correct manner 2
Physician assisted suicide
oral method: patient drinks the medication
anti-emetics
barbiturate: induces respiratory depression followed by death
only possible with relatively strong patients: must be able to sit upright, must be able to swallow and must have a normal hydration status and bowel function

22. afterwards The municipal forensic doctor / coroner does autopsy
reports to public prosecutor for permission of burial/cremation
sends the results to regional review committee, that will assess whether the physician has complied with the criteria
there are five regional review committees, with at least one legal expert, one physician and one ethics expert

23. Question?
Is it a right to have euthanasia in the Netherlands?

24. Answer No, the physician may refuse minors:
12-15: possible with permission parents
16-18: possible with parents involved
it remains a request
as opposed to refusal of treatment which is a right

25. Numbers reported 2012 4188 3965 euthanasia
185 physician assisted suicide
38 combination
where were they performed?
at home: 3335 (GP)
(hospital, nursing home, hospice are much more rare)
only ten were not in accordance with the due criteria and were sent from the review committees to the public prosecutor and health inspector, in none of these cases prosecution followed though

26. Mortality the Netherlands 2010
total number deceased:
euthanasia 2,8%
ass. suicide 0,1 %
pain control and sedation 36%

27. Question?
Is palliative sedation euthanasia?

28. No
You only induce coma
There is no intention to terminate the life immediately, the intention is to make the patient as comfortable as possible, unaware of his/her suffering
For some patients it can be an alternative for euthanasia
It can take away the fear of dying in an undignified or horrendous manner
Only for patients with < two weeks life expectancy

29. Contents ‘Conflict of obligations’ Euthanasia Act 2002
‘Slippery slope’?
Documentary
Discussion

31. What to do with: Psychiatric patients? Dementia patients? Infants?
‘Tired of life’ category?
non-physicians who want to assist with suicide?

32. Ethical debate
Autonomy self determination

34. Discussion

35. The proper terminology?
euthanasia is a word that in Germany is a taboo, because it is the same term as was used by the nazis for their T4 programme: the extermination of ‘life not worthy of living’:
Only in veterinary medicine term used.
is the association correct? what is the important difference?