Roger Woodruff, FRACP
Chairman, International Association for Hospice and Palliative Care (IAHPC)
Former Chairman, Palliative Care Group of the Clinical Oncological Society of Australia (COSA)
Medical Oncologist and Director of Palliative Care, Austin and Repatriation Medical Centre, Heidelberg, Victoria 3084, Australia
Compiled April 1999
Questions relating to the legalisation and provision of euthanasia and physician-assisted suicide have been keenly debated in the medical literature over the last few years. The following review is clinically orientated and is provided as a resource to those seeking more information on this subject.
Copyright 1999. Copies may be made with no modifications and only with acknowledgement:
Woodruff, R, Euthanasia and Physician-Assisted Suicide - Are They Clinically Necessary?, IAHPC, www.hospicecare.com.
2. Indications and reasons for requests
4. Side effects
5. Results of a more liberal policy on euthanasia The Netherlands
6. Results of a more liberal policy on euthanasia The Northern Territory of Australia
7. Results of a more liberal policy on euthanasia Oregon, USA
8. Surveys of professional attitudes and practices
9. Public opinion polls
Euthanasia. Euthanasia is defined as "a deliberate intervention undertaken with the express intention of ending a life so as to relieve intractable suffering" (House of Lords, 1994; Walton, 1995). If performed at the dying person's request or with that person's consent, it is voluntary; otherwise it is non-voluntary. The terms "active" and "passive" are misleading (Roy and Rapin, 1994; Somerville, 1995).
Physician-assisted suicide. In physician-assisted suicide, the physician provides the knowledge and means (equipment, drugs) necessary but the act is completed by the patient. It is similarly a deliberate act with the express intention of ending life and is not ethically or morally distinguishable from euthanasia.
1.2 Not Euthanasia
Other clinical practices are sometimes described as euthanasia but can be distinguished by examination of the ethical principles involved (Association for Palliative Medicine, 1993; House of Lords, 1994; Roy and Rapin, 1994; Walton, 1995; Randall and Downie, 1996). The goals of management are to produce benefit, to always act in the patients' interests (beneficence), to minimise or do no harm (non-maleficence), in accordance with their informed consent (autonomy).
2.1 Unrelieved pain and physical symptoms
Unrelieved pain and physical symptoms are cited less frequently than in the past. However, unrelieved pain, or fear of unrelieved pain at some time in the future, is an important reason why patients may seek assisted dying (Sullivan, 1997).
Reports from specialist palliative care services indicate that less than 5% of patients have pain that is difficult to control given drug therapy, anaesthetic procedures and psychosocial approaches that are available (Association for Palliative Medicine, 1993); and most of these can be helped considerably so that they are able to cope with any residual pain. The experience at St Christopher's Hospice in London is that less than 1% of terminally ill patients have unrelieved pain (Saunders, 1981).
That the results achieved in routine clinical practice are less satisfactory is a reflection of inadequate professional education and lack of universal access to specialist palliative care services (Cherney and Catane, 1995; Foley, 1995; Meier et al, 1997).
The management of other physical symptoms is continually improving, making them unlikely indications for euthanasia or physician-assisted suicide (Woodruff, 1999).
Pain and physical symptoms can be treated adequately in the vast majority of patients, given good professional education, a multidisciplinary approach to care and access to palliative care services.
Need for multidisciplinary and comprehensive palliative care. The optimal therapy for pain and physical symptoms (as well as anxiety, depression and existential distress) differs from standard medical treatment. It frequently requires the resources and expertise of an experienced multidisciplinary palliative care team, particularly if psychosocial problems are contributing to the patient's suffering. The co-ordinated efforts of different medical practitioners, nurses and allied health professionals, working with the patient and family as a unit, are needed to optimise management. It also requires the investment of considerable amounts of time, effort and commitment. This is not treatment that can be accomplished by a doctor working alone.
. Doctors who advocate euthanasia because their patients have unrelieved pain and 'unbearable suffering' should be questioned about their knowledge and expertise in palliative care, and asked how often they seek assistance from a multidisciplinary team experienced in the management of patients with advanced disease.
. Patients' attitudes to euthanasia change when a positive attitude and effective relief are introduced. Eleven of 870 patients (1.3%) referred to a specialist palliative care service in Sydney wanted their deaths accelerated. This number fell to five (0.6%) after institution of comprehensive palliative care (Glare, 1995).
Intractable distress. If optimal multidisciplinary palliative care is available, distress from unrelieved pain or physical symptoms is rare.
. Uncontrolled suffering in a dying patient is a medical emergency, not an indication for euthanasia (Wanzer et al, 1989).
. Sedation for intractable distress in dying patients will control symptoms in most cases. This does not constitute euthanasia (Chater, 1998; Lynn, 1998).
. A leading medical advocate for euthanasia has characterised palliative care as 'pharmacological oblivion' (Syme, 1996). This demonstrates a lack of understanding of both the medical and multidisciplinary aspects of palliative care.
2.2 Severe anxiety and depression
Requests for euthanasia may relate to severe anxiety or depression.
. A review of the literature concluded that 'psychiatric morbidity among patients requesting physician-hastened death is considerable' (Chochinov and Wilson, 1995).
. In a Canadian study of 200 terminally ill patients the incidence of depression was 58.8% amongst those with a serious or pervasive desire to die, compared to 7.7% among patients without such a desire. Four of six patients with a pervasive wish to die no longer desired death when interviewed two weeks later (Chochinov et al,1995).
. An American study found that cancer patients who seriously considered euthanasia were significantly more likely to be depressed (Emanuel et al, 1996).
. Analysis of patients undergoing euthanasia in Darwin showed depressive symptoms were common (Kissane et al, 1998).
. A survey of terminally ill hospice patients regarding the ending of life reported that few were fully competent and depression was common (Kelleher et al, 1998).
Diagnosis. The diagnosis of depression in the terminally ill can be very difficult (Chochinov et al, 1994).
. A number of studies document that doctors not trained in psychiatry miss up to half of cases of major depression in the medically ill (Ryan, 1996).
. Only 6% of Oregon psychiatrists were very confident that in a single evaluation they could adequately assess whether a psychiatric disorder was impairing the judgment of a patient requesting assisted suicide (Ganzini et al, 1996).
. By contrast, Marshall Perron, the politician responsible for the introduction of the euthanasia legislation in the Northern Territory of Australia, has stated "I understand severe depression to be fairly readily recognisable. You don't have to have a huge string of qualifications" (Perron, 1996).
Results of therapy. Patients' attitudes change when depression is treated (Ganzini and Lee, 1997; Massie et al, 1994).
. Severely depressed patients, particularly those with more hopelessness, showed a significant increase in desire for life-sustaining measures after treatment of depression (Ganzini et al, 1994).
. An Australian study also reported improved desire for life-sustaining treatments after successful treatment of depression (Hooper et al, 1996).
2.3 "Intolerable suffering," existential distress
Patients may request euthanasia for a variety of other reasons including loss of dignity, unworthy dying, dependency and tiredness of life-best grouped as existential distress (Association for Palliative Medicine, 1993; Cherny et al, 1994).
The multidisciplinary and holistic approach to care, central to the philosophy of palliative medicine, is particularly important in dealing with problems of existential distress. Therapeutic approaches have been developed to address problems related to dignity, integrity and remorse, and issues of hopelessness, futility and meaninglessness. Cognitive techniques can help patients modify the appraisal of their lives, diminish distress and enhance a sense of positiveness. Socialisation and interest in art and music or other hobbies will reduce boredom and loneliness and enhance the quality of life. Insight-directed therapy can help patients acknowledge that there are meaningful tasks to be done, joys to be shared, things to be said or completed, relationships to be savoured and differences to be settled (Association for Palliative Medicine, 1993; Cherny et al, 1994; Kelly et al, 1996). With comprehensive therapy, refractory existential distress is very rare.
. Attention to the psychosocial and spiritual aspects of care can influence patients not to act on their previous requests for euthanasia or physician-assisted suicide (Severson, 1997).
. At the Hospice Rozenheuvel in Holland (established in 1993), approximately 25% of patients asked for euthanasia at the time of admission. "When they hear what can be done for them, and how many possibilities of care and creative solutions to their problems are available, they hardly ever mention euthanasia further." (Zylicz, 1995)
. Larry McAfee, a Georgia man left quadriplegic and dependent on a ventilator after a motorcycle accident, appealed to the Second Circuit Court of Appeals for the right to discontinue treatment. However, "he did not exercise his court-authorized right to discontinue his ventilator, in part because wide publicity about his case brought forth support services that made his life more worthwhile to him" (Orentlicher, 1996).
It is reported that 50% of patients with AIDS consider physician-assisted suicide or euthanasia (Breitbart et al, 1996; Onwuteaka-Philipsen and van der Wal, 1998; Starace and Sherr, 1998).
. Requests for assisted death from patients with AIDS often relate to fears - fear of death, fear of pain, fear of dependence or fear of being a burden - and it requires careful and considerate communication to elicit the underlying cause (Cole, 1993; Voigt, 1995).
. In one study, the strongest predictors of interest in physician-assisted suicide were depression, hopelessness and experience with terminal illness in a family member or friend. Other strong predictors were infrequent or no attendance at religious services, and lack of social supports (Breitbart et al, 1996).
. Pre-morbid and co-morbid psychiatric syndromes, as distinct from the physical and psychological consequences of the disease itself, have been advanced as a possible explanation of the high rate of suicide in men with AIDS (Mishara, 1998).
Practices. There are two reports of patients with AIDS receiving euthanasia and physician-assisted suicide.
. In the Netherlands, one-third of patients dying with AIDS receive euthanasia or physician-assisted suicide (Onwuteaka-Philipsen and van der Wal, 1998). Given there is little professional education about palliative care, and because palliative care services are few in the Netherlands, it is unlikely these patients received palliative care.
. In the San Fransisco Bay area, a significant proportion of doctors looking after patients with HIV infection admit to performing physician-assisted suicide (Slome et al, 1997). Many of these doctors were primary care physicians and it is not stated what training or experience they had in palliative care.
Palliative Care. Provision of appropriate and multidisciplinary palliative care greatly reduces requests for assisted death.
. A report from the Mildmay Mission Hospice in London, a specialist palliative care service managing patients with AIDS, states that there were 1800 admissions over a three year period but only one request for euthanasia (McKeogh, 1997).
2.5 Carer fatigue
Requests for euthanasia, direct or implied, may result from family fatigue and exhaustion. This may occur if there is continuing inadequate relief of the patient's suffering, if there are inadequate resources and supports to carry out home care, or if the carers have unrealistic expectations of themselves (Cherny et al, 1994). These issues are all preventable or manageable given timely assessment and implementation of planned, co-ordinated, multidisciplinary care for the patient and the family together.
2.6 Iatrogenic - the "nothing more can be done" syndrome
The attitudes of the doctor and other professional carers can have a profound influence on the generation of hope or hopelessness in the patient and family (Byock, 1993).
. Doctors with little knowledge of palliative care, or lacking belief in its value, are likely to tell patients "nothing more can be done".
. A doctor feeling isolated and exasperated in the face of severe suffering will project his helplessness onto the patient and family.
. A doctor who views death as a medical and professional failure is likely to withdraw from the care of terminally ill patients and their families, who may feel abandoned (Hockley, 1993).
. If doctors exhibit helplessness and say "nothing more can be done", patients may quite reasonably consider euthanasia or physician-assisted suicide to be the only option to relieve or prevent suffering.
The iatrogenic causes of requests for euthanasia require professional education and some shift in attitude, as well as the availability of better palliative care services (Foley, 1997; Meier et al, 1997). Death from diseases such as cancer and AIDS should not be regarded as medical or professional failure. There should be professional pride in the skilful palliation of symptoms and in supporting patients and their families through a terminal illness.
. Some doctors seem unable to accept that some of the complex problems encountered in the management of the terminally ill require the involvement of other medical practitioners and allied health personnel with expertise in the treatment of physical, psychiatric and psychosocial suffering.
. Doctors who advocate euthanasia because their patients have 'unbearable suffering' should be questioned about their knowledge and expertise in palliative care and asked how often they seek assistance from a multidisciplinary team experienced in the management of terminal illness.
. "Nothing more can be done" should never be said as it is never true. It may not be possible to cure or reverse advanced disease, but it is never impossible to care.
2.7 Exercise of autonomy
The principles of individual autonomy and self determination lead some to believe that there is a fundamental right to request and receive euthanasia or physician-assisted suicide; others argue that such a right does not exist (Singer and Siegler, 1990; Saunders, 1992; Roy, 1993; House of Lords, 1994).
The concept of absolute individual autonomy is at odds with modern society. Innumerable laws and regulations exist, accepted by society as a whole, which limit individual autonomy for the purpose of protecting the rights of others.
. Total individual independence was termed by Shaw as "Middle class blasphemy. We are all dependent on one another, every soul of us on earth" (Shaw GB,Pygmalion).
. Comprehensive and multidisciplinary palliative care, focused on the needs and wishes of the patients and their families, can do more to enhance individuals' autonomy and self respect.
Euthanasia and physician-assisted suicide will shorten the period of pre-mortem suffering and eliminate fear about how and when death will occur. The patient will have a measure of control over the process of dying (Singer and Siegler, 1990).
The availability of euthanasia and physician-assisted suicide will not lessen the numbers of patients committing suicide. A review of 27,500 hospice patients in the UK showed only 5 suicides (Association for Palliative Medicine, 1993).
3.2 Economic Implications
Legalisation of euthanasia and physician-assisted suicide has the potential to save society considerable amounts of money, presently spent on the care of patients with terminal cancer, AIDS and other incurable diseases. This is of great concern given the financial restraints being exerted over the provision of health care and the advent of managed care.
. The amount that might be saved by reducing the use of aggressive life-sustaining interventions for dying patients in the USA was reported to be 'not substantial' at $30 billion. This study did not include the considerable costs paid by the patients and their families (Emanuel and Emanuel, 1994).
. A review of the potential cost savings from legalising physician-assisted suicide concluded that the financial benefit would be small (Emanuel and Battin, 1998). The calculations were based on the proportion of Dutch patients classified as having euthanasia and physician-assisted suicide (rather than the larger numbers actually receiving it), as well as the Dutch estimates (likely to be underestimates) of by how much time life was shortened (see the Netherlands, below)
Other patients will have their autonomy compromised. The Dutch experience suggests that the vulnerable - the aged, the sick, the disabled and those who feel a burden - may experience pressure to request euthanasia. In the Netherlands, liberalisation of voluntary euthanasia has led to tolerance of euthanasia for patients not terminally ill and to non-voluntary euthanasia (see below).
Other patients will suffer more. Patients with advanced disease, who may elect to undergo euthanasia or physician-assisted suicide in the future, are unlikely to receive optimal symptom control, and they will not get the comprehensive and multidisciplinary assessment that is an integral part of palliative care planning for terminal care.
. A large number of Dutch patients treated with euthanasia were "suffering grievously" or had "unbearable suffering" (van der Maas et al, 1991; Pijnenborg et al,1993). The only plausible explanation is that they did not receive standard basic palliative care (Association for Palliative Medicine, 1993; Ernst, 1995).
Euthanasia will encourage poor medical practice. Patients who are likely to receive euthanasia in days or weeks are less likely to have their pain and suffering addressed in a comprehensive or caring way. The principles of palliative care will be lost and there will be no professional pride in the skilful palliation of symptoms and the support of patients and their families through a terminal illness (Singer and Siegler, 1990; Byock, 1993).
There will be loss of trust in the doctor-patient relationship. Patients may come to distrust their professional carers and may be fearful of the wishes of their relatives in a society where it is known non-voluntary euthanasia is practised (Randall, 1993).
. A study of oncology patients and the public reported that 19% and 27%, respectively, would change physicians if their physician admitted to involvement with euthanasia or physician-assisted suicide for other patients (Emanuel et al, 1996).
. A smaller study reported 8% of the public would not continue seeing a doctor if it was known he or she participated in euthanasia and physician-assisted suicide (Graber et al, 1996).
. Oncology patients with substantial pain and those whose disease had relapsed were significantly more likely to change oncologists (Emanuel et al, 1996).
These studies emphasise the voluntary nature of euthanasia and physician-assisted suicide and did not address the question of non-voluntary euthanasia as practised in the Netherlands (see below).
Euthanasia mentality. Experience indicates that the introduction of voluntary euthanasia for the terminally ill leads to tolerance of its use for patients not terminally ill, followed by non-voluntary euthanasia (Twycross, 1996, van der Maas et al, 1996). Following this, the elderly and the vulnerable may feel pressure to request euthanasia and doctors convicted of medical homicide receive no punishment (see the Netherlands, below).
Diminished autonomy. Legalisation of euthanasia implies the microethical concerns of one individual's autonomy (to request and receive euthanasia or physician-assisted suicide) take precedence over the macroethical concern for the autonomy of others in society (the elderly, the sick and those who feel a burden), a change which has implications far beyond medical practice.
Euthanasia will devalue human life. Regardless of any religion, it is justifiable to assert that life has value and meaning which will be reduced by the widespread practice of euthanasia or physician-assisted suicide (Singer and Siegler, 1990; Association for Palliative Medicine, 1993; Dickens 1994).
. The terminal stages of life may be a time of reconciliation and personal growth, particularly if pain and physical symptoms are controlled.
There is much information to be gained by a careful examination of the reports from the Netherlands, where a more liberal policy on euthanasia and physician-assisted suicide has been in place for some years.
5.1 The Guidelines
The guidelines for the practice of euthanasia and physician-assisted suicide in the Netherlands were set out by the Remmelink Committee Report in 1991 (Walton, 1995). These are:
(a) The request for euthanasia must come only from the patient and must be entirely free and voluntary.
(b) The patient's request must be well considered, durable and persistent.
(c) The patient must be experiencing intolerable suffering with no prospect of improvement.
(d) Other alternatives to alleviate the patient's suffering must have been considered and found wanting.
(e) Euthanasia must be performed by a doctor.
(f) The doctor must consult an independent colleague, before performing euthanasia.
(g) The doctor must submit a written report to the appropriate authority.
5.2 Euthanasia practices
There are two reports documenting the practice of euthanasia in the Netherlands (van der Maas et al, 1991, 1996) and several critiques of the data presented (Gunning, 1991; Fenigsen, 1997; Hendin et al, 1997).
Euthanasia had been performed by 62% of general practitioners, 44% of clinical specialists but only 12% of nursing home physicians (van der Maas et al, 1991).
Euthanasia. The number of patients receiving euthanasia increased from 2189 in 1990 to 3253 in 1995, accounting for 1.7% and 2.4% of all deaths, respectively (van der Maas et al, 1991, 1996.)
Physician-Assisted Suicide. The number of patients receiving physician-assisted suicide increased from 244 in 1990 to 271 in 1995 (van der Maas et al, 1991, 1996).
Life-Terminating Acts Without Explicit Request. The number of patients subjected to life-terminating acts without explicit request decreased slightly from 1030 in 1990 to 949 in 1995 (van der Maas et al, 1991, 1996).
Deaths Related to the Treatment of Pain and Symptoms. Deaths due to "alleviation of pain and symptoms with opioids in such dosage that the patients' life might have been shortened" were categorised separately.
. The 1990 report states that "in 6% of cases life-termination was the primary goal"; in 1995, such treatment was intended to hasten the patient's death in 15% of cases (van der Maas et al, 1991, 1996). These cases should be considered euthanasia.
Deaths Related to Withholding/Withdrawal of Treatment. Deaths relating to withholding or withdrawal of treatment were categorised separately.
. Such actions were undertaken with the explicit intention of "not prolonging the patient's life" in 50% of cases in 1990 and "with the intention of hastening death" in 66% of cases in 1995 (van der Maas et al, 1991, 1996). These should be considered cases of euthanasia.
Summary of Practices. The essential data from the two Dutch reports is set out below and, assuming the trends over time to be linear, allows an estimate of the total number of patients receiving euthanasia over a six year period 1990-95 (van der Maas et al, 1991, 1996). All categories of euthanasia, with the exception of life-terminating acts without explicit request, have increased. Overall, there was a 60% increase in all forms of euthanasia from 1990 to 1995.
Summary of Practices. The data from the 1990 and 1995 Dutch studies are set out in the Table (van der Maas et al, 1991, 1996). Assuming the trends over time to be linear, it is possible to estimate the total number of patients receiving euthanasia over the total six year period 1990-95 (Total 1990-95 in Table). All categories of euthanasia, with the exception of life-terminating acts without explicit request, increased. Overall, there was a 60% increase in all forms of euthanasia from 1990 to 1995.
Dutch Euthanasia Practices 1990-95
|1990 Study||1995 Study||Total||% Change|
|No. persons||No. persons||No. persons|
|Life-terminating acts without explicit request||1,030||948||5,934||-8.0|
|Deaths related to treatment of pain and symptoms given with the intention of hastening death||1,352||3,883||15,705||+187.0|
|Deaths related to withholding/withdrawal of treatment
done with the intention of hastening death
5.3 Non-voluntary euthanasia
. A number of patients were euthanased without explicit request, never mind consent (see table), (van der Maas et al, 1991, 1996).
. In 41% of 157 cases of euthanasia and physician-assisted suicide, it was not discussed with the patient. The justification for euthanasia was "the family asked for hastening of the end of the patient's life" (Pijnenborg et al, 1993).
. In 42% of deaths related to the treatment of pain and suffering, in 15% of which treatment was "intended to hasten the patient's death", there was no request for euthanasia (van der Maas et al, 1996).
. In 51% of deaths related to the withholding or withdrawal of treatment, in 66% of which it was done "with the intention of hastening death", there was no request for euthanasia (van der Maas et al, 1996).
. In 16 of 84 cases of unreported euthanasia, assistance was without the patients' explicit request (van der Wal et al, 1996)
5.4 Euthanasia for persons not terminally ill
. The proportion of patients considered to have had a prognosis of more than six months increased from 8% in 1990 to 20% in 1995 (van der Maas et al, 1991, van der Wal 1996). The initial study included a reported case of anorexia nervosa whose life expectancy may have been many years (Association for Palliative Medicine, 1993).
. These estimates of patients' prognoses were made by the doctors performing the euthanasia, and may constitute underestimates.
5.5 Secret euthanasia
The Dutch guidelines require that a written report be submitted for all cases of euthanasia, physician-assisted suicide and unnatural deaths.
. It has now been estimated that 82% of cases of euthanasia and physician-assisted suicide in 1990 were not reported (van der Maas and van der Wal, 1997).
. A confidential survey of general practitioners in the Netherlands showed that 40% of all cases of euthanasia were not reported. The data indicated the doctors reported only those cases about which they were sure they would not be prosecuted, when official guidelines had been strictly adhered to. In unreported cases, the reason for euthanasia was often 'unnecessary suffering' as judged by the doctor himself (van der Wal et al, 1992a; Twycross, 1996).
. A subsequent review noted "it is estimated that about a quarter of doctors will refrain from notifying the medical examiner" and that in "cases with shortcomings . about half of doctors do not report" (van der Wal et al, 1994).
. In 1995, five years after the implementation of explicit guidelines, 59% of cases of euthanasia and physician-assisted suicide were not reported (van der Wal et al,1996).
5.6 Abuse of guidelines.
The Dutch guidelines specifically require that the physician must consult with at least one other doctor.
. An anonymous survey reported that a second opinion had not been sought in 25% of cases of euthanasia (van der Wal et al, 1992a; Baile et al, 1993).
. Doctors performing euthanasia did not discuss the case with a colleague, never mind request a second opinion, in 30% of cases (Pijnenborg et al, 1993).
. In 17% of cases of euthanasia and physician-assisted suicide and in 41% of life-terminating acts without request, there was no consultation with a colleague (van der Maas et al, 1996).
5.7 Euthanasia for depression
. Less than 3% of Dutch patients requesting assisted death are referred for a psychiatric opinion (Ganzini and Lee, 1997; Groenewoud et al, 1997).
. Unrecognised and untreated depression has been documented in some Dutch patients subjected to euthanasia (Zylicz, 1995; Blijham, 1995).
. A Dutch psychiatrist who assisted the suicide of a physically healthy patient with a 'depressive disorder' received no punishment (Ogilvie and Potts, 1994; Spanjer, 1994).
. Dutch psychiatrists perform 3-5 physician-assisted suicides per year (Groenewoud et al, 1997).
. 64% of Dutch psychiatrists believe that physician-assisted suicide is acceptable for patients whose suffering is due to a mental disorder in the absence of physical illness (Groenewoud et al, 1997), although some maintain that the Dutch euthanasia guidelines, developed for use in somatic medicine, are not applicable in psychiatry (Schoevers et al, 1998).
5.8 Euthanasia for Mentally Handicapped People
. Euthanasia was performed on three mentally handicapped patients with serious physical illness and the deaths reported as natural (van Thiel et al, 1997; van der Maas, 1997).
5.9 Euthanasia for AIDS
. Approximately one-third of Dutch men with AIDS die by euthanasia or physician-assisted suicide (Onwuteaka-Philipsen et al, 1998).
. The question of whether palliative care was available to these Dutch patients is raised by the report from the AIDS hospice in London (McKeogh, 1997) in which 1800 admissions over a three year period resulted in one request for euthanasia.
. A study of male homosexuals with AIDS in Amsterdam reported 29 of 131 died as a result of euthanasia or physician-assisted suicide (Bindels et al, 1996). It is stated that the euthanasia "did little to shorten life" and the physicians performing the euthanasia estimated the maximum shortening of life was three months. However, five of the patients were euthanased at the time of the initial AIDS-defining illness when, according to reports from around the world, the average life expectancy should be two to three years (Marriott and McMurchie, 1996).
5.10 Pressure to submit to euthanasia
There is anecdotal evidence that Dutch doctors may not fairly discuss the option of palliative care, about which they have received little or no education.
. "A Dutch general practitioner had urged an unwilling patient to have euthanasia. To get away from such pressure, the woman engineered an inpatient admission whilst the GP was on holiday. On the GP's return, he visited the patient and urged her to return home so that she could have euthanasia" (Twycross, 1996).
There is anecdotal evidence of pressure to submit to euthanasia within Dutch society.
. "An elderly husband was dying of cancer and he and his wife agreed that euthanasia was not an option they wanted. Visiting friends and neighbours, however, put subtle pressure on the couple by expressing surprise that the husband had not yet opted for euthanasia" (Twycross, 1996).
. A Dutch wife who no longer wished to care for her sick husband "gave him a choice between euthanasia and admission to a home for the chronically ill. The man, afraid of being left to the mercy of strangers in an unfamiliar place, chose to be killed" (Hendin, 1997).
. Four Dutch nurses convicted of killing comatose patients with insulin and curare were given suspended sentences of two years each (Pollard, 1991).
. A Dutch nurse who gave a lethal injection to a friend with AIDS was found guilty but given a two-month suspended sentence (Spanjer, 1995).
. A Dutch woman with disseminated breast cancer told her doctor she would never choose euthanasia because of her beliefs. After some difficulties with her medications she woke up and said she was free of pain. When a second doctor came on duty, he asked her family to leave the room and ordered a 20-fold increase in the morphine dose following which the patient quickly died. When challenged, the second doctor replied "It could have taken another week before she died; I just needed this bed" (Twycross, 1996).
. A review of the final court decisions regarding physician-assisted death during the period 1991-1995 (van der Wal et al, 1996) reported:
- 11 physicians were acquitted or discharged from further prosecution
- 3 physicians were found guilty, but not punished
- 6 physicians were found guilty, but given suspended sentences of one week to six months
5.12 Euthanasia Procedures
. A 1992 study reported that euthanasia was performed by injection in only 75% of cases. The average time to death was 3.8 hours with a range of 1 minute to 72 hours. Complications or unintended effects were reported in 12% of cases (van der Wal et al, 1992b).
. The implementation of a standardised protocol reduced the time to death but 'the GPs stated that in 19% of cases death occurred too rapidly' (Onwuteaka-Philipsenet al, 1997).
5.13 Safe Ground or Slippery Slope?
. Decriminalisation of voluntary euthanasia and physician-assisted suicide has led to non-voluntary euthanasia, euthanasia for those not terminally ill, and euthanasia for patients without physical illness.
. The Dutch reports document a significant increase in all forms of euthanasia during the period 1990-95 (see Table).
. 'Virtually every guideline set up by the Dutch - a voluntary, well-considered, persistent request; intolerable suffering that cannot be relieved; consultation; and reporting of cases - has failed to protect patients or has been modified or violated' (Hendin et al, 1997).
. The argument that the Dutch are not on a slippery slope and that 'Dutch physicians continue to practise physician-assisted dying only reluctantly and under compelling circumstances' (Angell, 1996) is not supported by facts.
5.14 Palliative Care
Palliative care is hardly known to Dutch doctors and medical students (Zylicz, 1991). Medical students are trained in how to practise euthanasia but not in the diagnosis and treatment of symptoms in terminal care (Zylics, 1995).
. An independent study of pain control at the Netherlands Cancer Institute showed only 29% of cancer patients received optimal treatment and that for 54% treatment was inadequate (Dorrepaal, 1989).
Dutch patients subjected to euthanasia are described as "suffering grievously" (van der Maas et al, 1991) and "suffering unbearably" with "palliative possibilities exhausted" (Pijnenborg et al, 1993). But these were the subjective opinions of the doctors performing the euthanasia, and there are no objective measures of the quality of the terminal care the patients received in either of these studies.
. These patients were dying in unbearable suffering because they did not receive standard palliative care (Association for Palliative Medicine, 1993).
. The latest study of Dutch euthanasia practices reports 100% of the patients had "unbearable" and "hopeless" suffering whilst admitting that therapeutic alternatives other than euthanasia were available for 26% of the patients (van der Wal et al, 1996). These estimates were made by the physicians performing the euthanasia and, as Dutch doctors are poorly educated in palliative care, the proportion of patients for whom other therapy was available was probably much higher.
Dr Zylicz, founder of one of the first palliative care hospices in the Netherlands says:
. "Training in palliative care for the GPs does not exist or is highly inadequate. Although much more frequently than ten years ago, the GPs still see only a few terminal patients at home. Some of these cases are very complicated and would need support from the multidisciplinary team. I am personally convinced that a lot, if not most, of euthanasia cases in Holland performed by the GPs at home are as a result of the GP feeling personally responsible, isolated and helpless in facing these kind of problems. Projection of this helplessness onto the patient and family is only one step from admitting the necessity of euthanasia" (Zylicz, 1995).
The Northern Territory of Australia
Legislation. The Rights of the Terminally Ill Act 1995 (ROTI) was passed by the Northern Territory Parliament in Australia in May 1995, making it the first place in the world to have legalised euthanasia. Due to legal challenges it did not come into effect until May 1996. The ROTI Act was repealed by the federal Australian Parliament in March 1997.
Regulations Involved. The ROTI Act stated that a terminally ill patient, experiencing pain, suffering, and distress to an extent deemed unacceptable, could request a medical practitioner for assistance to end his or her life. The doctor had to be satisfied that the illness was terminal and that there were no medical measures acceptable to the patient which could reasonably be undertaken to effect a cure, and that any further treatment was only palliative in nature. The doctor needed to certify that the patient was of sound mind and making the decision freely, voluntarily, and after due consideration.
A second medical practitioner was required to examine the patient to confirm the existence and terminal nature of the illness. A psychiatrist was required to examine the patient to confirm the absence of treatable clinical depression. The Act required a period of seven days to pass between the initial request and the signing of an informed-consent form, followed by a further period of two days before euthanasia would be provided.
Patients. Four patients died under the ROTI Act (Kissane et al, 1998). All had cancer. Accurate prognostication was a problem and there were differences in medical opinion about whether or not a patient's illness was terminal. Depressive symptoms were common and the difficulties experienced in the assessment of depression in the terminally ill was emphasised.
Legislation. The Oregon Death with Dignity Act came into effect in October 1997. The Act allows adult patients with a terminal illness who are 'capable' to receive prescriptions for self-administered lethal medications. The patients primary physician and a consultant are required to confirm the diagnosis of a terminal condition and the prognosis, and to determine that the patient is 'capable'. Assessment by a psychiatrist is not mandatory. The patient must make one written and two oral requests, the latter separated by at least fifteen days.
Patients. During the first year of operation, twenty-three persons received prescriptions for lethal medications; fifteen died after taking the medications, six died from their underlying disease, and two were alive at the time of reporting. Thirteen of the fifteen patients had cancer. Thirteen of the fifteen patients were widowed, divorced or never married. Concerns about suffering in the future and loss of control were common (Chin et al, 1999).
The infrequency with which the Act has been used suggests that the results of public polls reflect a fear of the unknown and a desire for autonomy. There is a huge difference between the majority of the physically healthy general population who are reported to be in favour of physician-assisted suicide, and the very small proportion of terminally ill patients (<10%) who actually request physician-assisted death (Chochinov, 1997).
A large number of surveys of professional attitudes and practices has been published in the recent medical literature, many purporting to show that a significant proportion of the profession are in favour of euthanasia or physician-assisted suicide (Fried et al, 1993; Solomon et al, 1993; Baume and O'Malley, 1994; Cohen et al, 1994; Shapiro et al, 1994; Ward and Tate, 1994; Doukas et al, 1995; Aranda and O'Connor, 1996, Bachman et al, 1996; Back et al, 1996; Di Mola et al, 1996; Emanuel et al, 1996; Ganzini et al, 1996; Lee et al, 1996; Verhoef and Kinsella, 1996; Waddell et al, 1996; Howard et al, 1997; Kuhse et al, 1997; Portenoy et al, 1997; Roberts et al, 1997; Slome et al, 1997; Suarez-Almazar et al, 1997; Emanuel et al, 1998; Meier et al, 1998; Shah et al, 1998).
Detailed analysis of these studies is beyond the scope of this review. The correct interpretation of these studies requires particular attention to a number of issues that may be confusing or misleading and are outlined here.
8.1 Definitions of euthanasia
The definition of euthanasia must exclude double effects and the withholding/withdrawing of therapy considered futile. It must also specify the intention to end the life of the patient.
. e.g. 'allowing the physician to take the final action that brings on a patient's death' (Bachman et al, 1996) is easily misinterpreted.
. e.g. 'the practice of injecting a patient with a lethal dose of medication with the primary intention of ending the patient's life' (Meier et al, 1998) would appear specific, but the authors note that responses indicated there was confusion between euthanasia and terminal sedation.
8.2 Definitions of physician-assisted suicide
The definition of physician-assisted suicide should acknowledge patients' intent as well as the physician's knowledge of that intent.
. e.g. 'a physician providing a sufficient dose of narcotics to enable a patient to kill himself' (Slome et al, 1997) is open to misinterpretation
. e.g. 'prescribed drugs to a patient knowing the patient intended to use them to end his or her life' (Emanuel et al, 1998) is more specific
8.3 Interpretation of participants' responses
Even in studies employing adequate definitions of euthanasia and physician-assisted suicide, there is evidence of misinterpretation by respondents.
. euthanasia may be confused with terminal sedation (Meier et al, 1998)
. euthanasia may be confused with proper pain control (Aranda and O'Connor, 1996)
. in a survey of physician practices, 21% of doctors misclassified their actions: of 56 doctors who said they had practised euthanasia or physician-assisted suicide, 7 described withholding treatment or increasing morphine for pain (without intent to end the life of the patient) and five reported patient suicide without physician involvement (Emanuel et al, 1998).
8.4 Population surveyed
The results of attitude studies vary with the population studied. In most studies, many of the respondents would have had little experience in the care of the terminally ill. In general, the perceived need for the legalisation of euthanasia or physician-assisted suicide is inversely proportional to clinical experience in the management of the terminally ill.
. In studies where the results were presented by specialty group, the lowest approval rates for euthanasia and physician-assisted suicide came from oncologists and palliative care doctors (Meier et al, 1998; Waddell et al, 1996).
. Psychiatrists, with little or no contact with the terminally ill, have the highest approval rates (Cohen et al, 1994; Shah et al, 1998).
8.5 Level of support for euthanasia and physician-assisted suicide
In addition to the problems caused by definitions which are vague and can be misinterpreted, different studies have asked questions in different ways that will result in different responses. There are four levels of support that can be summarised as follows.
'Do you think it is right, ethical?'
'Do you think it should be legalised?'
'If it were legal, would you perform it ?'
'Have you performed it?
. e.g. one study reported 60% of physicians in favour of legalisation of physician-assisted suicide, but only 46% of them would consider performing it if it were legalised, and only 7% admitted to having performed it in the past (Lee et al, 1996)
. e.g. in a study of oncologists' attitudes to euthanasia, 21% were in favour of legalisation, 8% would consider performing it, and 4% had performed it (Doukas et al, 1995).
8.6 Palliative care options
Many studies seek approval or disapproval of euthanasia or physician-assisted suicide in a clinical setting of severe suffering for which there is no palliative option.
. e.g. 'the patient is suffering unrelenting pain that he or she finds unacceptable' (Bachman et al, 1996)
Surveys of attitudes to euthanasia or physician-assisted suicide frequently use short case scenarios, but do not provide an option to offer palliative care (Bachman et al, 1996; Emanuel et al, 1996; Slome et al, 1997).
. in the one report in which palliative care was an option, 86% of respondents chose palliative care, 9% physician-assisted suicide, and 5% euthanasia (Waddell et al, 1996).
8.7 The non-responder factor
A number of surveys of professional attitudes compare demographic data of responders and non-responders and assume that the opinions of non-responders would not significantly affect the study results.
. in one study, non-responders were followed up by telephone and asked whether they 'agree that it is sometimes right for a doctor to take active steps to bring about a patient's death'. Of the 75% of surveyed doctors who responded to the survey, 59% agreed; of the 25% who did not respond but were subsequently contacted by telephone, only 18% agreed (Baum and O'Malley, 1994).
9.1 Public opinion
The rising tide of public opinion in favour of euthanasia or physician-assisted suicide is based on fear and a lack of medical knowledge. There is a widespread public perception, fostered by the voluntary euthanasia societies, that the treatment of pain and suffering is frequently ineffective and that euthanasia is the only means of ensuring adequate relief of suffering.
. unless very sophisticated and complete questions are asked, the results of opinion polls are questionable (Annas, 1994)
. the public needs to be educated about what comprehensive multidisciplinary palliative care offers
9.2 Public opinion polls
Questions asked may be biased in favour of a positive response.
. 'Please try to imagine doctors discovered that you have a terminal illness that is certain to involve a great deal of pain and suffering. If physician-assisted suicide were legally available, do you think you might request it?' (Bachman et al, 1996). A majority of sensible people, faced with that scenario, would answer yes.
The validity of the Australian opinion polls on euthanasia have been challenged (Jansz, 1996) and the polling organisation has admitted that the questions asked need to be restructured to avoid bias (Morgan, 1996).
. Jansz suggests "it would be more honest to rephrase the questions to:
If people are hopelessly ill, in great pain, with no chance of cure, would you
(a) get them as soon as possible to where their pain could be substantially reduced and where the hope of cure is replaced by the reality of care, or
(b) kill them as requested?"
10.1 There are no clinical situations necessitating the legalisation of euthanasia or physician-assisted suicide.
10.2 Comprehensive and multidisciplinary palliative care can effectively relieve much of the suffering of the terminally ill that is presently cited as justification for euthanasia or physician-assisted suicide.
10.3 With regard to palliative care:
. there is urgent need for professional education about the management of patients with advanced disease including acknowledgement of the vital role of the multidisciplinary aspects of palliative care
. palliative care should be an integral part of the management of patients with advanced disease and not geographically or ideologically separated from mainstream medicine
. the public need to be educated about what palliative care can offer
. there needs to be universal access to expert multidisciplinary palliative care
10.4 If laws relating to euthanasia or physician-assisted suicide are relaxed in order to uphold principles related to personal autonomy, a situation similar to that in the Netherlands will develop, characterised by:
. voluntary euthanasia leading to non-voluntary euthanasia
. euthanasia for the terminally ill leading to euthanasia for the non-terminally ill
. euthanasia for persons with potentially treatable conditions like depression
. the vulnerable - the aged, the sick, the disabled and those who feel a burden - experiencing pressure to request euthanasia
. guidelines being ignored or abused
. medical homicide becoming more acceptable, judged by the penalties imposed
10.5 Expert medical, legal and political opinion from around the world suggests that euthanasia cannot be controlled by anything less than complete prohibition.
Once legalised, euthanasia will be increasingly performed on those with increasingly less severe pain, distress or disability.
"An act becomes habit
which becomes a character
which becomes a destiny"
Angell M. Euthanasia in the Netherlands - Good news or bad? N Engl J Med 1996; 335: 1676-8
Annas GJ. Death by prescription. The Oregon initiative. N Engl J Med 1994; 331 : 1240-3
Aranda S and O'Connor M. Euthanasia, nursing and care of the dying : rethinking Kuhse and Singer. Aust Nursing J 1995; 3 : 18-21
Association for Palliative Medicine. Minutes of evidence taken before the Select Committee on Medical Ethics of the House of Lords. Session 1992-93. HL Paper 91-viii. London, HMSO, 1993
Bachman JG, Alcser KH, Doukas DJ et al. Attitudes of Michigan physicians and the public toward legalising physician-assisted suicide and voluntary euthanasia. N Engl J Med 1996; 334 : 303-9
Back AL, Wallace JI, Starks HE and Pearlman RA. Physician-assisted suicide and euthanasia in Washington State. JAMA 1996; 275: 919-25
Baile WF, Di Maggio JR, Schapira DV and Janofsky JS. The request for assistance in dying. The need for psychiatric consultation. Cancer 1993; 72 : 2786-91
Baume P and O'Malley E. Euthanasia : attitudes and practices of medical practitioners. Med J Aust 1994; 161 : 137-44
Bindels PJE, Krol A, van Ameijden E et al. Euthanasia and physician-assisted suicide in homosexual men with AIDS. Lancet 1996; 347: 499-504
Blijham GH. The person from Porlock. Ethical issues in terminal care, the Dutch perspective. Support Care Cancer 1995; 3 : 61-65
Breitbart W, Rosenfeld BD and Passik SD. Interest in physician-assisted suicide among ambulatory HIV-infected patients. Am J Psychiatry. 1996; 153: 238-42
Byock I. The euthanasia/assisted suicide debate matures. Am J Hosp Pall Care 1993; 10 : 8-11
Chater S, Viola R, Paterson J and Jarvis V. Sedation for intractable distress in the dying - a survey of experts. Palliat Med 1998; 12: 255-69
Cherny NI and Catane R. Professional negligence in the management of cancer pain. A case for urgent reforms. Cancer 1995; 76 : 2181-2185
Cherny NI, Coyle N and Foley KM. The treatment of suffering when patients request elective death. J Palliat Care 1994; 10 : 71-9
Chin AE, Hedberg K, Higginson GK and Fleming DW. Legalized physician-assisted suicide in Oregon - the first year's experience. N Engl J Med 1999; 340: 577-83
Chochinov HM. Assisted suicide for HIV patients. Am J Psychiatry 1997; 154: 294
Chochinov HM and Wilson KG. The euthanasia debate: attitudes, practices and psychiatric considerations. Can J Psych. 1995; 40: 593-602
Chochinov HM, Wilson KG, Enns M, Lander S. Prevalence of depression in the terminally ill: effects of diagnostic criteria and symptom threshold judgments. Am J Psychiatry 1994; 151 : 537-40
Chochinov HM, Wilson KG, Enns M et al. Desire for death in the terminally ill. Am J Psychiatry 1995; 152 : 1185-91
Cohen JS, Fihn SD, Boyko EJ et al. Attitudes toward assisted suicide and euthanasia among physicians in Washington State. N Engl J Med 1994; 331 : 89-94
Cole RM. Communicating with people who request euthanasia. Palliat Med 1993; 7 : 139-43
Dickens BM. When terminally ill patients request death : Assisted suicide before the Canadian Courts. J Palliat Care 1994; 10 : 52-56
Di Mola G, Borsellino P, Brunelli C et al. Attitudes toward euthanasia of physician members of the Italian Society for Palliative Care. Ann Oncol 1996; 7: 907-11
Dorrepaal KL, Aaronson NK and van Dam PSAM. Pain experience and pain management among hospitalised cancer patients. Cancer 1989; 63 : 593-598
Doukas DJ, Waterhouse D, Gorenflo DW and Seid J. Attitudes and behaviours on physician-assisted death: a study of Michigan oncologists. J Clin Oncol 1995; 13: 1055-61
Dunphy K. Sedation and the smoking gun: Double effect on trial. Prog Palliat Care 1998; 6: 209-12
Emanuel EJ and Battin MP. What are the potential cost savings from legalizing physician-assisted suicide? N Engl J Med 1998; 339: 167-72
Emanuel EJ, Daniels ER, Fairclough DL and Clarridge BR. The practice of euthanasia and physician-assisted suicide in the United States. JAMA 1998; 280: 507-13
Emanuel EJ and Emanuel LL. The economics of dying. N Engl J Med 1994; 340: 540-4
Emanuel EJ, Fairclough DL, Daniels ER and Clarridge BR. Euthanasia and physician-assisted suicide : attitudes and experiences of oncology patients, oncologists and the public. Lancet 1996; 347 : 1805-10
Ernst C. Against medical killing. Support Care Cancer 1995; 3 : 3-4
Fenigsen R. Dutch euthanasia revisited. Issues Law Med 1997; 13: 301-11
Fohr SA. The double effect of pain medication: separating myth from reality. J Palliat Med 1998; 1: 315-28
Foley KM. Misconceptions and controversies regarding the use of opioids in cancer pain. Anticancer Drugs, 1995; 6 Suppl. 3: 4-13
Foley KM. Competent care for the dying instead of physician assisted suicide. N Engl J Med 1997; 336: 54-8
Fried TR, Stein MD, O'Sullivan PS et al. Limits of patient autonomy. Arch Int Med 1993; 153: 722-8
Ganzini L, Fenn DS, Lee MA et al. Attitudes of Oregon psychiatrists toward physician-assisted suicide. Am J Psychiatry. 1996; 153: 1469-75
Ganzini L and Lee MA. Psychiatry and assisted suicide in the United States. N Engl J Med 1997: 336: 1824-6
Ganzini L, Lee MA, Heintz RT et al. The effect of depression treatment on elderly patients' preferences for life-sustaining medical therapy. Am J Psychiatry 1994; 151 : 1631-6
Glare PA. The euthanasia controversy. Decision-making in extreme cases. Med J Aust 1995; 163 : 558
Graber MA, Levy BI, Weir RF and Oppliger RA. Patients' views about physician participation in assisted suicide and euthanasia. J Gen Intern Med 1996; 11: 71-6
Groenewoud JH, van der Maas PJ, van der Wal G et al. Physician-assisted death in psychiatric practice in the Netherlands. N Engl J Med 1997; 336: 1795-801
Gunning KF. Euthanasia. Lancet 1991; 338: 1010
Hendin H. Seduced by Death New York, WW Norton, 1997
Hendin H, Rutenfrans C and Zylicz Z. Physician-assisted suicide and euthanasia in the Netherlands. Lessons from the Dutch. JAMA 1997; 277: 1720-2
Hockley J. The concept of hope and the will to live. Palliat Med 1993; 7 : 181-186
Hooper SC, Vaughan KJ, Tennant CC, Perz JM. Major depression and refusal of life-sustaining medical treatment in the elderly. Med J Aust 1996; 165 : 416-9
House of Lords. Report of the Select Committee on Medical Ethics. Session 1993-94, HL Paper 21-I. London, HMSO, 1994
Howard OM, Fairclough DL, Daniels ER and Emanuel EJ. Physician desire for euthanasia and assisted suicide: would physicians practice what they preach? J Clin Oncol1997; 15: 428-32
Jansz AW. Medicine and the community - the euthanasia debate. Med J Aust 1996; 165 : 118
Kelleher MJ, Payne A, Corcoran P and Chambers D. Euthanasia and the terminally ill : can the civil killing of others be eroded? Crisis 1998; 19: 116-8
Kelly BJ and Varghese FT. Assisted suicide and euthanasia: what about the clinical issues? Aust N Z J Psychiatry. 1996; 30: 3-8
Kissane DW, Street A and Nitschke P. Seven deaths in Darwin: Case studies under the Rights of the Terminally Ill Act, Northern Territory, Australia. Lancet 1998; 352: 1097-102
Kuhse H, Singer P, Baume P et al. End-of-life decisions in Australian medical practice. Med J Aust 1997; 166: 191-6
Lee MA, Nelson HD, Tilden VP et al. Legalizing assisted suicide - views of physicians in Oregon. N Engl J Med 1996; 334: 310-5
Lynn J. Terminal sedation. N Engl J Med 1998; 338: 1230
Marriott D and McMurchie M. HIV and advanced immune deficiency. Med J Aust 1996; 164 : 111-2
Massie MJ, Gagnon P and Holland JC. Depression and suicide in patients with cancer. J Pain Symptom Manage 1994; 9: 325-40
McKeogh M. Physician-assisted suicide and patients with HIV disease. N Engl J Med. 1997; 337: 56
Meier DE, Emons CA, Wallenstein S et al. A national survey of physician-assisted suicide and euthanasia in the United States. N Engl J Med 1998; 338: 1193-1201
Meier DE, Morrison RS and Cassel CK. Improving palliative care. Ann Intern Med 1997; 127: 225-30
Mishara BL. Suicide, euthanasia and AIDS. Crisis. 1998; 19: 87-96
Morgan GC. Medicine and the community - the euthanasia debate. Med J Aust 1996; 165 : 118
Ogilvie AD and Potts SG. Assisted suicide for depression : the slippery slope in action? BMJ 1994; 309 : 492-3
Onwuteaka-Philipsen BD, Mulle MT and van der Wal G. Euthanatics: implementation of a protocol to standardise euthanatics among pharmacists and GPs. Patient Education and Counselling 1997; 31: 131-7
Onwuteaka-Philipsen BD and van der Wal G. Cases of euthanasia and physician-assisted suicide among AIDS patients reported to the Public Prosecutor in North Holland. Public Health. 1998; 112: 53-6
Orentlicher D. The legalisation of physician-assisted suicide. N Engl J Med 1996; 335 : 663-7
Perron M. In Managing Mortality : Euthanasia on Trial. Ed Parsons I and Newell C. Villamanta, Geelong, 1996, p 124-5
Pijnenborg L, van der Maas PJ, van Delden JJM and Looman CWN. Life-terminating acts without explicit request of patient. Lancet 1993; 341 : 1196-9
Pollard BJ. Medical aspects of euthanasia. Med J Aust 1991; 154 : 613-6
Portenoy RK, Coyle N, Kash KM et al. Determinants of the willingness to endorse assisted suicide. Psychosomatics 1997; 38: 277-87
Randall F. Two lawyers and a technician. Palliat Med 1993; 7 : 193-198
Randall F and Downie RS. Palliative Care Ethics. Oxford University Press 1996
Roberts LW, Muskin PR, Warner TD et al. Attitudes of consultant liaison psychiatrists toward physician-assisted death practices. Psychosomatics 1997; 38: 459-71
Roy D. When the dying demand death. J Palliat Care 1993; 4 : 3-4
Roy DJ and Rapin C-H. Regarding euthanasia. Eur J Palliat Care 1994; 1 : 57-59
Ryan CJ. Depression, decisions and the desire to die. Med J Aust 1996; 165 : 411
Saunders CM. Current views of pain relief and terminal care. In : Swerdlow M (ed). The therapy of pain. MTP Press, Lancaster, 1981
Saunders C. Voluntary euthanasia. Palliat Med 1992; 6 : 1-5
Schoevers RA, Asmus FP and van Tilburg W. Physician-assisted suicide in psychiatry : developments in the Netherlands. Psychiatr Serv 1998; 49: 1475-80 Severson KT. Dying cancer patients: choices at the end of life. J Pain Symptom Manage 1997; 14: 94-8
Shah N, Warner J, Blizard B and King M. National survey of UK psychiatrists' attitudes to euthanasia. Lancet 1998; 352: 1360
Shapiro RS, Derse AR, Gottleib M et al. Willingness to perform euthanasia. Arch Int Med 1994; 154: 575-84
Singer PA and Siegler M. Euthanasia - a critique. N Engl J Med 1990; 322 : 1881-83
Slome LR, Mitchell TF, Charlebois E et al. Physician-assisted suicide in patients with human immunodeficiency virus disease. N Engl J Med 1997; 336: 417-21
Solomon MZ, O'Donnell L, Jennings B et al. Decisions near the end of life: professional views on life-sustaining treatments. Am J Public Health 1993; 83: 14-23
Somerville MA. Euthanasia. Lancet 1995; 345: 1241-2
Spanjer M. Mental suffering as justification for euthanasia in Netherlands. Lancet 1994; 343 : 1630
Spanjer M. Nurses cannot assist suicide in the Netherlands. Lancet 1995; 345: 849
Starace F and Sherr L. Suicidal behaviours, euthanasia and AIDS. AIDS 1998; 12: 339-47
Suarez-Almazor ME, Belzile M and Bruera E. Euthanasia and physician-assisted suicide: a comparative study of physicians, terminally ill cancer patients, and the general population. J Clin Oncol 1997; 15: 418-27
Sullivan M, Rapp S, Fitzgibbon D and Chapman CR. Pain and the choice to hasten death in patients with painful metastatic cancer. J Palliat Care 1997; 13: 18-26
Syme R. Three questions for euthanasia critics. The Age, 5 July 1996
Twycross RG. Euthanasia : going Dutch? J R Soc Med 1996; 89 : 61-63
van der Maas PJ. End of life decisions in mentally disabled people. BMJ 1997; 315: 73
van der Maas PJ, van Delden JJM, Pijnenborg L et al. Euthanasia and other decisions concerning the end of life. Lancet 1991; 338 : 669-74
van der Maas PJ and van der Wal G. Euthanasia and physician-assisted suicide in the Netherlands. N Engl J Med 1997; 336: 1386-7
van der Maas PJ, van der Wal G, Haverkate I et al. Euthanasia, physician-assisted suicide, and other medical practices involving the end of life in the Netherlands, 1990-1995. N Engl J Med 1996; 335 : 1699-705
van der Wal G and Dillmann RJM. Euthanasia in the Netherlands. BMJ 1994; 308 : 1346-9
van der Wal G, Leenan HJJ and Spreeuwengerg C. Bij justifie gemelde euthanasie en hulp bij zelfdoding. Med Contact 1992a; 47 : 1023-8
van der Wal G, van der Maas PJ, Bosma JM et al. Evaluation of the notification procedure for physician-assisted death in the Netherlands. N Engl J Med 1996; 335 : 1706-11
van der Wal G, van Eijk JT, Leenen HJ and Spreeuwenberg C. Het gebruik van middelen bij euthanasie en hulp bij zelfdoding in de huisartspraktijk. Nej Tijdschr Geneeskd 1992b; 136: 1299-1305
van Thiel GJMW, van Delden JJM, de Haan K and Huibers AK. Retrospective study of doctors' "end of life decisions" in caring for mentally handicapped people in institutions in the Netherlands. BMJ 1997; 315: 88-91
Verhoef MJ and Kinsella TD. Alberta euthanasia survey: 3-year follow-up. Can Med Assoc J 1996; 155: 885-90
Voigt RF. Euthanasia and HIV disease : how can physicians respond? J Palliat Care 1995; 11 : 38-41
Waddell C, Clarnette RM, Smith M et al. Treatment decision-making at the end of life : a survey of Australian doctors' attitudes towards patients' wishes and euthanasia.Med J Aust 1996; 165 : 540-4
Walton, Lord. Dilemmas of life and death. Parts 1 & 2. J R Soc Med 1995; 88 : 311-5 and 372-6
Wanzer SH, Federman DD, Adelstein SJ et al. The physician's responsibility towards hopelessly ill patients - a second look. N Engl J Med 1989; 120 : 844-849
Ward BJ and Tate PA. Attitudes among NHS doctors to requests for euthanasia. BMJ 1994; 308: 1332-4
Woodruff R. Palliative medicine. Symptomatic and supportive care for patients with advanced cancer and AIDS. 3rd edition. Oxford University Press, 1999
Zylicz Z. Euthanasia. Lancet 1991; 338: 1150
Zylicz Z. "Death on Request" and Dutch euthanasia policy. Progress in Palliat Care 1995; 3 : 43-4