1. The Euthansasia Debate Dr M Feldman

2. Medical Ethics Six of the values that commonly apply to medical ethics discussions are: Beneficence - a practitioner should act in the best interest of the patient. (Salus aegroti suprema lex.)Beneficence Non-maleficence - "first, do no harm" (primum non nocere)Non-maleficence. Autonomy - the patient has the right to refuse or choose their treatment. (Voluntas aegroti suprema lex.)Autonomy

3. Medical Ethics Justice - concerns the distribution of scarce health resources, and the decision of who gets what treatment (fairness and equality).Justice Dignity - the patient (and the person treating the patient) have the right to dignity.Dignity Truthfulness and honesty - the concept of informed consent Truthfulnesshonestyinformed consent

4. Time for a change Public opinion for - 75 - 80% Only doctors against no evidence of slippery slope in Holland Recent cases Dianne pretty - mnd - wanted to avoid prosecution for husband English courts, appeal and European court refused

5. Time for a change Debbie Purdy- MS Again courts have refused to give blanket exemption Daniel James 23 yr old student English rugby player - no prosectuion Craig Ewert - MND - first televised euthanasia - Dignitas

6. Time for a change Why not here ? Patients could wait until needed The reality of palliative care - personal experince not for everyone - not for most

7. Results of Questionnaire on Dutch Model Do you believe in Euthanasia according to Dutch Model Y = 40% N = 35% Dont Know 25% Would you be prepared to take part Counsel only 50% Take part 30% Would not be involved 20%

8. Results of Questionnaire on Dutch Model Has the trip altered your views ? More in favour of euthanasia 75% Less in favour 5% My views are unchanged 20%

9. Tender loving care Euthanasia Palliative sedation < 1-2 weeks before expected death Death without intervention

10. 0,40,7without request 0,10,2assisted suicide 1,72,6euthanasia 2,23,5Ending of life 24,720,1Opioids with possible life- shortening effect 7,15,6Terminal sedation without administation of fluids 15,6%20,2%Stopping or withholding of life- prolonging treatment 20052001Type of decision

11. Palliative sedation - definitions Definition Health Council: “Bringing a patient in a condition of a deep sleep expecting to maintain it until the death of the patient.” Royal Dutch Medical Association KNMG: “Deliberately lowering a patient’s consciousness in the last phase of life”

12. Terminal / palliative sedation Refractory symptoms Life expectancy < 2 weeks Proportional loss of consciousness If necessary, until death No intention to shorten life Midazolam Questions o Withholding food and fluids? o Alternative for euthanasia? Source: Royal Dutch Medical Association, Palliative Sedation Guideline; 2002

13. Euthanasia: due care criteria Well-considered and durable request Unbearable suffering without prospect of improvement Proper information to patiënt No alternatives according to patient and physician Consultation of independent physician(SCEN) Medically appropriate realisation

14. American Views Oregon - assisted suicide legal since Oct 97 o Upheld by supreme court 2006 Washington - residents voted 58%to 42% for physician assisted suicide o Death within 6 months o Can get prescription for lethal drugs o Self administer Psychiatric patients excluded

15. American Views Rarely used - only 541 Rx with 341 taken 98 - 07 o Average age 69 o white middle class o Slightly more men o 86% in hospice programmes

16. A UK Poll on Euthanasia

18. Euthanasia objectors Go regularly to church ( whatever religion) Oppose abortion Oppose suicide Oppose capital punishment Worry about power of ' doctors' and dont trust them

20. Changing opinions Support for Euthanasia growing Liberal Democrat MP Dr Evan Harris backed Ms Purdy's wish for assisted suicide Scottish MP Margo Macdonald - attempt to legalise assisted suicide Now 38% of GP want ban lifted Similar number would be prepared to be involved RCGP and BMA - remain opposed