This month’s Guest Writer is Professor Lukas Radbruch . . .
Throughout the year, IAHPC board members contribute a range of opinion pieces and other thought-provoking articles to the IAHPC Newsletter. Now it’s the turn of Professor Lukas Radbruch, now serving his second term as Chairman of the IAHPC. Lukas has a deep interest in ethics and has played a key role in developing position statements and publications on euthanasia and assisted suicide, for the IAHPC, the German Association for Palliative Medicine and the European Association for Palliative Care.
In the past four years I have been continuously involved in the discussion on euthanasia and assisted suicide. First, in the board of the German Association for Palliative Medicine as we struggled to find a clear position, then in an extensive consensus process for the European Association for Palliative Care (EAPC), which ended in the EAPC white paper on euthanasia and physician-assisted suicide (PAS), and now in the IAHPC position paper.
The underlying attitude in all groups is the same (and this has been confirmed in the EAPC consensus process for the European national associations): palliative care neither hastens nor postpones death, and thus practices related to euthanasia and assisted suicide should not be part of palliative care.
On the other hand, we all seem to agree that palliative care is not the antidote to euthanasia or PAS requests, as there are some (very few) patients who, even with optimal symptom control and good psychosocial care, prefer to have full control over how to end their lives, and who will ask for hastened death as they feel that this is the only way to exert that control.
We do not seem able to keep out of that discussion though. There are a few palliative care professionals, for example from the Flemish Association for Palliative Care in Belgium, that maintain that provision of euthanasia is just another option at the end of life that ought to be offered by palliative care teams; (our position papers all say no, it ought not to be offered). Critics have drawn parallels between some of the methods that we discuss in palliative care as last resorts, such as palliative sedation or voluntary stopping to eat and drink and providing euthanasia or assisted suicide (though we have made it clear that there are fundamental differences in the aims, means, and attitudes underlying these practices).
In Germany, a new legislation on assisted suicide was introduced in December 2015, following a year of intense public and political debate. The new section 217 in the German penal code makes it a punishable offence (with a fine or up to three years’ prison sentence) to promote or provide assisted suicide in a ‘business-like’ manner. Business-like means that the person is willing to assist more than once (so it could be punishable for the first case if it is clear that the offender plans to do this regularly), but it also means that this is dependent on whether there is a commercial interest. Persons with a close relationship to the patient, such as family members or friends, and where there is no business-like approach, are exempt from penalty. There is no specific mention of physicians in the law, but the understanding is that a general practitioner who has known the patient for some time and who has a personal relationship will not be punished, whereas the physician who provides assisted suicide routinely, and/or for patients who have been seeing him only recently, may be punished.
For the German Association for Palliative Medicine, we have actually supported this solution as it does leave an open door for desperate cases, while making it clear that organizations such as Sterbehilfe Deutschland or Dignitate, or individuals such as the physician Uwe Arnold, all of whom were promoting assistance with suicide, will no longer have a basis to work on.
However, the new legislation has already been challenged, and several constitutional complaints have been submitted. While it is not surprising that the organizations for assisted suicide are complaining, we have been astonished to see that some complaints have been filed by palliative care physicians, who claim that their professional work is jeopardized. They say that they are not able to listen and respond when patients make a wish for hastened death, as any information they might (inadvertently) provide, for example on voluntary stopping to eat and drink, might be construed as assistance with suicide. And they are afraid that opioid prescriptions (especially higher dosages or for longer periods) for patients that had mentioned a wish for hastened death might lead to prosecution.
Reading the explanatory statement of the new law carefully, and discussing this with our legal expert on the board, the German Association for Palliative Medicine made it clear that there is no need to be afraid. Listening to and respecting patients’ wishes for hastened death is part of the palliative care remit. This does not mean that we are promoting or providing assisted suicide. Similarly, discussing options such as palliative sedation and voluntary stopping to eat and drink is part of the palliative care toolbox. As for prescribing opioids: we do not prescribe them in order to promote suicide, but to relieve pain. Even if a patient has talked about a wish for hastened death, even if he has said that he might think about taking an overdose in the future, we still do not prescribe the opioids to facilitate suicide, and it would be inhumane to stop the relief of pain or dyspnea for fear of an overdose. The baseline is: we are providing palliative care not to promote suicide, but to relieve suffering. We have just published our guidance in the Journal of the German Medical Association.
In the IAHPC work, I am astonished about the differences between countries and regions in the discussions on euthanasia and PAS. In some countries, there is so much open support for liberal regulations. For example, in Canada the right not only for physician-assisted, but also nurse-assisted suicide, has been introduced recently and we have yet to see how this translates into practice. More shockingly, Colombia has introduced a right for euthanasia (or rather confirmed an older right in court), but the country has only some pioneer palliative care services, access to opioids is severely limited or non-existent, and I am afraid that patients who are suffering will ask for euthanasia because opioids are not available. Talking to colleagues in resource-poor settings, I also hear that there are very few requests for euthanasia or PAS and, if so, then these requests are caused by unrelieved suffering. The IAHPC focus of work is on developing countries, and in this setting there seems to be absolutely no need for euthanasia or PAS, as long as there are so many unmet palliative care needs.
So let us not get side-tracked by the discussion on euthanasia or assisted suicide, but let us stick firmly to our position that both have no place in palliative care!