Euthanasia Last Update: October 2009 Contact: Christina Rose

DRZE/In Focus

Euthanasia Last update: October 2009 Contact: Christina Rose

I. Introduction and basic conceptual distinctions

On the one hand, the term Euthanasia (see module Euthanasia) may denote "assistance throughout the dying process", that is, support and accompaniment during the time leading up to death. In this sense, euthanasia entails the support of the dying person by giving care, pain-relieving treatment and personal comfort. As such, its urgent necessity in the dying process is undisputed. Yet on the other hand "euthanasia" can also denote "assistance in achieving death", then entailing the killing or "letting die" of a dying, seriously ill or suffering person in accordance with their own express or assumed wishes or interests. The issue of "assistance in achieving death" is discussed in the context of varying situations. The debate frequently distinguishes four types of euthanasia in the sense of "assistance in achieving death": 1 "Letting die"/"Passive euthanasia": renunciation of life-prolonging measures (while continuing to give "basic care" and pain-relief treatment 2 "Indirect euthanasia"/"Indirect active euthanasia": pain-relief treatment while tolerating a (non-intended) risk of shortening the patient's life span 3 "Assisted suicide"/"Support for voluntary death": assisted suicide e.g. by procuring and supplying the lethal drug 4 "Active euthanasia"/"Direct active euthanasia"/"Termination of life on request": Intentional and active acceleration or bringing about of death. Contrary to indirect euthanasia, death is not only tolerated but intended. Contrary to assisted suicide, the ultimate decisive impulse is not given by the patient but by a third party. The range of meaning of the term euthanasia is a wide one. It includes dying persons, seriously or incurably (physically or mentally) ill persons who are suffering inbearably or who see no purpose in continuing to live and thus express an urgent desire to be "released" through euthanasia. It also includes patients who are in a long-term coma or whose consciousness is already impaired in the terminal phase of a disease who can lo longer personally express any opinion regarding the implementation or termination of medically and technically viable, but therapeutically doubtful life-prolonging measures. It ranges to seriously damaged newborn babies incapable of expression, whose life expectancy is very short or who are expected to suffer greatly in life. However, not all forms of "letting die" are being summarized under the keywords "medically assisted suicide" or "euthanasia". Any therapeutic, palliative (meaning analgetic) or life-prolonging intervention requires the consent of the patient. If the patient refuses a certain measure and its omission leads to the patient's premature death, this situation is widely regarded as the manifestation of a patient's "right to a natural death". From a medical-ethical perspective, there is a general responsibility of the physician to preserve life, but not under all circumstances. Furthermore, life-prolonging measures cannot be responsible if they are ineffective, if their efficiency is questionable or if they involve disproportionately large suffering for the patient. The differentiation between the usage of " ordinary " and " exceptional " treatment methods (see module http://www.drze.de/in-focus/euthanasia (1) DRZE/In Focus

Ordinary and extraordinary treatment) are being discussed here, both from the medical perspective as well as from the moral perspective.

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II. Central discussion topics

In the discussion about the licitness of the various types of euthanasia, many different aspects play a role. The main topics of discussion are as follows:

Licitness of suicide A prerequisite for assuming the licitness of killing a person in accordance with his own wishes is that a person is permitted to end his own life intentionally in the first place. Whether or not this is the case - and if so under what circumstances - is the subject of debate. Basically, there are two approaches, both of which set different limits to an individual's right to self-determination concerning life and death: Proponents of the first approach (see module Unconditional illicitness of suicide) assume that human life is "inviolable" or "sacred". Human life is hence not only not at other people's disposal but also not at one's own disposal. This approach is rooted not least in Jewish-Christian traditions and is supported above all by the churches (see module Churches). The given reason is that life is God-given and that therefore God alone has the jurisdiction over life and death. If life is already coming to an end, there is no absolute obligation to prolong it by any means possible; however, its active shortening through suicide is objectively prohibited as a violation of God's sovereignty. Yet the subjective capacity for bearing responsibility may be diminished in such cases. Based on this approach, passive or indirect euthanasia in the case of a person whose dying process has already begun may be permissible under certain circumstances. However, under no circumstances shall it be permissible to assist suicide or carry out active euthanasia. From a legal-ethical perspective, it is principally being argued that in a liberal legal order a prohibition such as that of euthanasia can only be demanded if reasons (see module The burden of proof) can be given that are ideologically neutral and are thus, in general, comprehensible for everyone. In their argumentation as regards the content , which also opposes the argument of a general elusiveness of human life, supporters of the second approach (see module Conditional permissibility of euthanasia) refer to the capacity of humans to determine their own actions. The grounds of human dignity lie in this ability of self-determination. The obligation to protect this dignity is tied to this ability. Against this background, they argue, there is also an obligation to protect human life from life-threatening acts by third parties, as life is the prerequisite for human self-determination. However, a self-determined ending of one's own life, whether active or passive, cannot be unconditionally prohibited in the name of human dignity. This also applies to all types of voluntary euthanasia. However, the decision must have been carefully taken while in a clear state of mind and with an acute awareness of all circumstances; moreover, the way in which one's own life is ended may not imply any danger for third parties. Neither, therefore, is euthanasia overall nor are its various types and the desire for euthanasia to be prohibited per se. Rather, its permissibility should be assessed with regard to the extent to which the criteria mentioned are or can be fulfilled. Irrespective of the varying limits of self-determination, the respect for self-determination is a core aspect in the entire euthanasia debate. In order to protect one's right of self-determination one can make a living will (see module Living wills).

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Independently of the question of whether suicide is permissible, one must also considered whether killing by third parties, an aspect of active euthanasia, is permissible. There is debate as to whether the categorical prohibition of killing allows for any exceptions in this respect, what reasons there could be for these exceptions and whether the exceptions may create a "slippery slope" towards increasing their number. From a moral perspective, too, the question concerning the difference between active euthanasia and other forms of euthanasia arises. It depends on the possibility or impossibility of such a differentiation whether active euthanasia can be unconditionally prohibited if the other forms of euthanasia are, at least conditionally, being permitted. Opponents of the unconditional prohibition of active euthanasia argue that a moral distinction between killing someone and letting someone die is impossible to draw if either takes place for the same unselfish reasons. This is the case because in either case the result is the death of the patient. Further, it is argued that a "gradual", passive "letting die", to the extent that it involves unbearable, untreatable pain, may in certain cases be less humane than "quick" active euthanasia (e.g. by the administration of an intended overdose of pain-relieving medication). Advocates of the unconditional prohibition of active euthanasia above all point out that the "permission to kill" - more precisely, the permission to kill innocent people in situations not involving self-defence - is linked to a "weakening of the prohibition to kill". This could provoke misinterpretations and misuse, thereby destroying any trustful relationships between humans. This is the case even if the permit is only conditional. Besides, they assume that such a "weakening of the prohibition to kill" could lead to an increase in the readiness to kill. This, again, could entail a more widespread application of active euthanasia, possibly extending it to more groups of people than originally intended. Even if the permission to kill originally only refers to dying persons who, at the time in question, are capable of judgement and expression and who request their killing of their own free will, it could eventually still extend. Seriously ill but not yet dying patients as well as elderly or disabled people without an exhibition of their will could be affected by a further development of this permission. Thinkable is even an extension to (involuntary) euthanasia against the wishes of those concerned, out of "pity" or for "economic reasons". Advocates of the unconditional prohibition consider it impossible to eliminate these "slippery slope" risks, neither by means of fully comprehensive regulations governing exceptions nor by exempting active euthanasia conditionally from being a punishable offence while maintaining its unconditional illegality. This latter approach is pursued by proponents of partially allowing active euthanasia.

The physician as a "killer" When physicians are involved in the euthanasia process, the implied weakening of the categorical prohibition of killing has significant impacts on the patient-physician relationship (see module Euthanasia and the patient- physician relationship) . Traditionally, the physician's role vis-à-vis the patient is that of a "healer" and "helper". However, by practising active euthanasia the physician becomes an "active agent" in the achievement of death. This, it is argued, is in fundamental conflict with the basic principles of the profession and is accordingly viewed with scepticism or even rejected by the medical community. Instead, the German Medical Association and the German Medical Assembly agitate for a stronger palliative care (see module Palliative care).

The danger of a latent destruction of solidarity http://www.drze.de/in-focus/euthanasia (4) DRZE/In Focus

"Slippery slope" arguments are not only brought forward against allowing active euthanasia - they also play a role in the debate surrounding other types of euthanasia. The main concern is that too liberal a treatment of the euthanasia issue could lead to a destruction of society's solidarity with ill, suffering and dying people, and maybe even to pressure being put on ill and weak persons to seize the opportunity of euthanasia in order to "take their burden" off society. Such considerations do not necessarily oblige society to reject all forms of euthanasia unconditionally. However, they do call for prerequisites to be put into place in order to prevent the according developments.

Issues relating to the "authenticity" of the desire for euthanasia and the lack of alternatives to euthanasia If a person who wishes to die expresses his desire for euthanasia, it must be considered whether or not his desire is "authentic", i.e. whether he or she genuinely wants to die, and whether this wish could be fulfilled in some other way. Here, too, various points of view have been put forward: It is often pointed out that dying persons experience typical stages of dying (see module Stages of the dying process) which can be accompanied by major mood swings. If a dying person requests euthanasia in such a situation, - according to the respective opinion - that may not be the expression of a genuine wish to die but rather a "natural" and transient accompanying phenomenon of the dying process. It is also frequently maintained that the desire for euthanasia is rooted in great pain, feelings of abandonment and loneliness, but also in shame about one's helplessness and the resulting depression. These causes can be met by pain-relief treatment and/or personal comfort measures - an approach also pursued by the hospice movement (see module Hospice movement) in their support of dying patients. Opponents of these theories state that although personal comfort and pain-relief treatment and, in the case of mentally ill patients, psychotherapy, can often lead to a reversal of the wish to die, there are also patients whose severe physical and/or psychological suffering cannot be relieved by such measures. That, they argue, is the reason why - if only in exceptional cases - there may in fact be no alternative (see module Lack of alternatives) to euthanasia.

The problem of determining the assumed wishes of patients unable to make decisions Any kind of euthanasia can only be permissible if it is in line with the wishes of the person in question. The permissibility of euthanasia in cases involving patients who are no longer (or in the case of newborns, not yet) capable of judgement or expression is therefore only permissible if it is possible to previously determine the patient's assumed wishes. Basic issues here include first and foremost the "medical criteria" - diagnosis and prognosis. Moreover, various tools for determining the assumed wishes of a patient have been discussed as further steps. One possibility is a " living will " (or "patient's directives") (see module Living wills) drawn up by the patient himself in which he has expressed relevant wishes while still fully competent. Another option is consultation with a caretaker or legal guardian appointed beforehand by the patient or, if such was not appointed, one or more persons close to the patient. Whether or not these tools are really adequate is a matter of some controversy. Sceptics point out that the period of time between drawing up a living will and its application can often be very long, that a healthy person http://www.drze.de/in-focus/euthanasia (5) DRZE/In Focus cannot always adequately envisage their own dying process and that such a living will cannot account for every possible scenario and set forth instructions accordingly. In addition, the question is raised whether a patient's representative - a lawyer or a close relative - assesses or can assess the patient's wishes accurately, or whether such a representation may be open to possible abuse. For these reasons, none of these tools can be used in good faith; determining the patient's precise wishes is sometimes not even possible at all.

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III. Legal regulations

From a legal point of view (see module Legal aspects of euthanasia) the euthanasia issue touches primarily upon criminal law and, insofar as physicians are involved, medical professional law. As euthanasia is rarely explicitly regulated by the respective national legislation, court rulings reflecting the current legal assessment of this issue must be taken into account.

The view of the European Court of Human Rights On 29 April 2002 the European Court of Human Rights (ECHR) in Strasbourg announced its Judgement in the case Pretty vs. the United Kingdom (see module Judgement of the European Court of Human Rights in the case Pretty) . The decision ruled that legal prosecution of assisted suicide as laid down in the 1961 UK Suicide Act does not violate the basic human rights formulated in the European Convention for the Protection of Human Rights and Fundamental Freedoms. According to Section 2 § 1 of the 1961 UK Suicide Act "a person who aids, abets, counsels or procures the suicide of another, or an attempt by another to commit suicide, shall be liable on conviction on indictment to imprisonment for a term not exceeding fourteen years." On 21 December 2001 Diane Pretty, a 43-year-old British citizen suffering from motor neurone disease, had taken legal action against these provisions of the Suicide Act and the refusal of the national courts to grant her husband prior freedom from prosecution if he were to assist her in committing suicide. Mrs Pretty died of her disease on 11 May 2002 in a hospice.

The situation in the Federal Republic of Germany In Germany euthanasia is not governed by explicit legal regulations. In concrete cases it is assessed whether the criteria for the offences of "killing by a third party" ("Fremdtötung") as defined by § 211 (murder), §§ 212 and 213 (manslaughter) and § 216 (termination of life on request) of the German Criminal Code (Deutsches Strafgesetzbuch; StGB) (see module German Criminal Code (StGB)) are satisfied. According to German law, suicide does not constitute a criminal act, meaning that assisted suicide is also not punishable by law. What is looked at in court practice, however, is the question of whether other facts and circumstances constituting a criminal offence, such as manslaughter or omission (§ 323c StGB), apply. If assistance in committing suicide is given by a physician or close relative, the legal duty that such persons assume vis-à-vis the patient wishing to die is additionally of significance since omission can also be considered a criminal offence in such cases. The request to be allowed to decide by oneself about death is currently leading to approaches to commercially conducted euthanasia (see module Commercially conducted euthanasia) . In the German Medical Association's principles regarding the accompaniment of the dying process by physicians (" Grundsätze der Bundesärztekammer zur ärztlichen Sterbebegleitung ") (see module German Medical Association on the accompaniment of the dying process) of 2004, the "deliberate curtailment of life by measures which bring about death or accelerate the dying process" is rejected as "impermissible and subject to punishment". They also state that for dying patients "the relief of suffering can be of such importance that a possible resulting inevitable shortening of life may be tolerated". According to these principles, life- prolonging measures can only be terminated or omitted if "they only delay the moment of death and the illness cannot be prevented from worsening". In cases of patients who are unable to give their informed consent, the http://www.drze.de/in-focus/euthanasia (7) DRZE/In Focus physician must obtain a relevant declaration from the legal guardians who may have to be appointed by a guardianship court. (Vormundschaftsgericht). In its report on euthanasia of 23 April 2004, entitled " Sterbehilfe und Sterbebegleitung. Ethische, rechtliche und medizinische Bewertung des Spannungsverhältnisses zwischen ärztlicher Lebenserhaltungspflicht und Selbstbestimmung des Patienten " (see module Bioethics Committee of Rhineland Palatinate, Germany) ("Assisting and accompanying the dying process. Ethical, legal and medical assessment of the conflict between the physician's duty to sustain life and patient self-determination"), the Bioethics Commission of the State of Rhineland-Palatinate calls for sustained support for home care services and the wider provision of hospices and palliative medical services. Moreover, a majority of members on the Bioethics Commission argue that lawmakers should lay down clear rules on active, passive and indirect euthanasia. In particular, a law is needed to establish that "neither the omission or cessation of a life-sustaining measure at the express wish of a patient nor the shortening of life accepted as an indirect consequence of a necessary medication desired by the patient is unlawful". Diverging from the demands of the bioethics commission, a provision to this effect would apply whether or not "the patient's underlying illness is leading irreversibly towards death". The majority view of the Commission is that the courts should not have to prosecute a physician who terminates life at the request of a patient in cases where extreme suffering cannot, objectively, be alleviated. Moreover, medically assisted suicide should be deemed justifiable under certain circumstances, though only as an exception. In order to obtain more legal security for all persons involved in cases in which a written living will is at hand, the German Bundestag in June 2009 decided upon the law regulating living wills (see module Living wills). This law establishes clarity regarding the heretofore debated issue that the will of the patient has to be respected unconditionally - independently of the form and the stadium of his or her illness, meaning even if the illness does not irreversible lead to the patient's death. The written form (or a comparably reliable form of recording such as a video) is a prerequisite for the validity of a living will. In cases where a caretaker or an authorized representative have to make a particularly severe decision with regards to the assumed wish of the patient, according medical measures have to be authorized by a guardianship court. Living wills, which refer to the legally forbidden termination of life on request still remain void. In its opinion "Self-Determination and Care at the End of Life" published on 13 July 2006 the National Ethics Council (see module National Ethics Council) concentrates primarily on problems associated with the current terminology of euthanasia, which is assessed as "open to misunderstanding and misleading" as well as questions arising in the context of suicide. Two aspects, in particular, are being broached: firstly, the ethical evaluation of suicide in the face of incurable diseases, and secondly the tasks and duties of physicians with regard to suicide intervention, providing assistance for suicide and killing on request. In the framework of its opinion the National Ethics Council does not arrive at a unanimous position. Some members assert that providing assistance for suicide contradicts the physician's professional duty and that it is difficult to determine whether a patient's desire for suicide actually is based upon a freely accountable and seriously considered decision rather than a temporary mental crisis or depressive mood. A second group takes the opposing view that physicians are obliged to "use their medical skills in the best interest of their patients and to accept their self-determination". In a scenario of incurable disease this may also include providing assistance for suicide. What is more, assessing the decision-making ability of a patient forms part of a physician's everyday tasks. A http://www.drze.de/in-focus/euthanasia (8) DRZE/In Focus third position considers the physician's decision for or against assisting suicide to be a highly personal matter of conscience that should be condoned and not punished under a professional code of practice. The issue of the organised provision of assistance for committing suicide is also disputed among the members of the National Ethics Council. A majority of them have fundamental reservations in this regard, and even supporters consider it an undesirable alternative to professional suicide assistance provided by the attending physician. As to the question of killing on request, the National Ethics Council is unanimous that the corresponding prohibition under §216 of the German Criminal Code (StGB) should be preserved, although in specific cases provision should be made for an exemption from punishment.

The situation in Switzerland Similarly to Germany, Swiss legislation (see module Switzerland) does not explicitly regulate euthanasia. Active euthanasia - the deliberate killing of a person in order to terminate suffering - is however a punishable offence in accordance with §§ 111 (premeditated killing), 113 (manslaughter) or 114 (termination of life on request) of the Penal Code (Strafgesetzbuch). Article 115 of the Swiss Penal Code (see module Swiss Penal Code) states that "a person who, for selfish reasons, leads somebody to carry out suicide or assists that person in doing so, will be punished with a term of up to five years in a penitentiary or with imprisonment if the suicide attempt is successful." It follows that assisted suicide (see module Assisted suicide) is not a punishable offence if it is done for non-selfish reasons. The Swiss Academy of Medical Sciences (SAMS), as the competent professional body, published the two guidelines " Treatment and care of patients with chronic severe brain damage " (see module SAMW on the patients with chronic severe brain damage) ("Medizinisch-ethische Richtlinien für die ärztliche Betreuung sterbender und zerebral schwerst geschädigter Patienten" (27 November 2003)) and " Care of patients in the end of life " (see module SAMW on the care of patients in the terminal phase of life) (Betreuung von Patienten am Lebensende (5 February 2004)) , which supersede its 1995 "Medical ethical guidelines for the medical care of dying persons and severely brain-damaged patients" ("Medizinisch-ethische Richtlinien für die ärztliche Betreuung sterbender und zerebral schwerst geschädigter Patienten"). Under the old guidelines assisted suicide was not considered to be "part of the physician's activity". The acceptance of shortening life within the framework of palliative care of dying patients as well as the discontinuation of treatment or the omission of life-prolonging measures in futile cases in accordance with the patient's wishes were, however, recognised as permissible. Under the revised guidelines on "Care of patients in the end of life" ("Betreuung von Patienten am Lebensende"), the SAMS advocates a narrowly defined legal scope for the possibility of for physician-assisted suicide. Although the new guidelines reaffirm the SAMS view that "giving assistance to suicide is not part of the physician's mission", they deviate from the 1995 version by emphasising that the physician also has a duty to "take into account the patient's wishes", which can mean that "in certain special cases a doctor's personal decision to assist a dying patient to commit suicide is in accordance with his or her conscience and has to be respected". Against the backdrop of the setting up of assisted suicide organisations (see module Right-to-die organisations) and the associated so-called "suicide tourism", the Swiss National Advisory Commission on Biomedical Ethics (NEK) drew up an opinion (see module NEK (2005) Assisted suicide) on "Assisted Suicide" in April 2005 in which it sets out the current legal situation and interpretative practice. The http://www.drze.de/in-focus/euthanasia (9) DRZE/In Focus

Commission supports the liberal provisions of Article 115 StGB, which states that providing assistance for suicide is legal provided it is not driven by self-interest. Mentally ill patients, however, are to be considered an exception; they should not receive assistance with committing suicide if the suicide wish is an expression or symptom of mental disorder. The NEK also urges that assisted suicide organisations should be subject to government regulation in order to ensure "compliance with quality criteria for the clarification of assisted suicide decisions". In its statement " Duty-of-care criteria for the management of assisted suicide " (see module NEK Opinion no. 13/2006) of October 27th 2006 the NEK exposed which "minimum requirements need to be reviewed, fulfilled and documented", "for assisted suicide to be permissible from an ethical perspective". The suggested minimum requirements of the NEK state that there must be no question about the "mental capacity" of the person wishing to die. Farther, the wish to die has to occur from "severe, illness-related suffering". The wish to die must neither arisen "impulsively or from a crisis of a temporary nature" nor an out of a symptom of mental illness. Besides it is essential that the wish to die is achieved in the "absence of external pressure" and "all other options" were clarified with the person who wishes to die. To assess the situation properly, "repeated personal contacts and intensive discussions" as well as confirmation by an independent "second opinion [...], a person with the necessary expertise", are indispensable. To prevent abuse of assisted suicide, which is exempt from punishment, in assisted suicide organisations the NEK suggests a surveillance of assisted suicide organisations "by internal and external agents". A reference of the Federal Council from May 31st 2006 (see module Reference of the Swiss Federal Council) to the parliament not to enact any new legislation on the authorisation and surveillance of assisted suicide organisations preceded the NEK statement. The reference of the Swiss Federal Council predicated on a corresponding report of the Federal Department of Justice and Police (see module Swiss Federal Department of Justice and Police) . The statement arrived at the conclusion that malpractice with assisted suicide could be prevented at cantonal and municipal level by the consistent application and enforcement of applicable law as well as enacting regulations in terms of the sector of hospital, care and home management. The report rejected activities of the federal law with which assisted suicide organisations would be under peculiar government supervision. Such activities would be disproportional as well as being unqualified as they would lead to a too much red tape and unwanted institutionalisation as well as a federal certification of the assisted suicide organisation's work. Nonetheless, the public control of euthanasia-organizations in Switzerland remains an issue. The canton Zurich (see module Euthanasia in the canton Zurich) functions as a precursor regarding this discussion: On the one hand, one of the organizations operating in Switzerland has signed an according agreement with the canton; on the other hand, massive civilian protest has formed against the work of the euthanasia-organizations. Consequently, a referendum in the canton, the result of which is still being awaited, was brought about by means of collecting signatures due to an initiative by the citizens.

The situation in the Netherlands On 1 April 2002 the Dutch " Euthanasia and Assisted Suicide Act " (see module Legislation concerning Euthanasia in the Neatherlands) ("Wet toetsing levensbeëindiging op verzoek en hulp bij zelfdoding") came into force. The Act provides for amendments to the Criminal Code such that the facts and circumstances http://www.drze.de/in-focus/euthanasia (10) DRZE/In Focus constituted by Article 293 (termination of life on request) and Article 294 para. 2 (assistance in a suicide) shall not be considered punishable offences if they are performed by a physician who fulfils special duties of care. These include requirements that the physician should have a) become convinced that the patient had made a voluntary and deliberate request; b) become convinced that the patient had no prospect of improvement, and was experiencing unbearable suffering; c) informed the patient about his or her condition and prospects; d) come to the conclusion in consultation with the patient that there was no other reasonable solution given the patient's situation; e) consulted at least one other independent physician, who had seen the patient and provided a written opinion on the criteria of due care, as described in items a to d, and f) performed the euthanasia or assisted suicide with due medical diligence. In the case of patients who can no longer express their wishes but have previously put in writing their desire to end their life, the physician may comply with these wishes. If a patient aged between 16 and 18 expresses a wish to end his or her life, the physician may comply with this wish if the parents or guardian were involved in the decision. For patients aged between 12 and 16, the parents or guardian must give their consent. The physician must report the procedure followed in terminating the patient's life or assisting their suicide to the competent coroner and submit a report documenting his compliance with the requirements of due care. The report is audited by a review commission, the composition and competencies of which are set forth in the new law. If the review commission has any doubt as to the legality of the physician's procedure, it informs the public prosecutor's office. According to a press statement issued on 29 November 2005 (see module Dutch Ministry of Health, Welfare and Sport) by the Dutch Ministry of Health, Welfare and Sport (Ministerie van Volksgezondheid, Welzijn en Sport), a committee is to be set up in the Netherlands to advise the public prosecutor's office on cases of euthanasia involving newborns and partial birth abortions. It is envisaged that both scenarios should continue to constitute criminal offences; however, in future it should be left to the discretion of the competent public prosecutor's office - with the assistance of the new committee - to decide whether to pursue a criminal prosecution. The goal here is to ensure that decisions on partial birth abortions and termination of life are taken with the necessary due care. In addition, the Minister of Justice and State Secretary are thereby responding to the so-called " Groningen Protocol " (see module Groningen Protocol) , which was adopted by Groningen University Medical Centre as the basis for handling such cases. The committee is to consist of three physicians with different specialisations (composition to be decided on a case-by-case basis), an ethicist and a legal expert. By now, books (see module Guidebooks from the Netherlands) are being published in the Netherlands - both in English as well as in German translations -, which provide information about opportunities for committing suicide. Between 2007 and 2008, the cases of euthanasia in the Netherlands (see module More cases of euthanasia in the Netherlands) have risen by almost ten percent from 2120 to 2331. The trend that has become apparent since 2002 is thus continuing.

The situation in Belgium On 16 May 2002 the Belgian Chamber of Representatives passed the "Act on Euthanasia" by a majority of 86 to 51 votes with 10 abstentions. The Belgian Senate had already approved the bill on 25 October 2001. The http://www.drze.de/in-focus/euthanasia (11) DRZE/In Focus new Act permits a physician to carry out killing on request under certain conditions (see module Legislation concerning Euthanasia in Belgium) .

The situation in Luxembourg On 17th March 2009, a law concerning euthanasia became effective in the grand duchy of Luxembourg (" Loi du 16 mars 2009 sur l'euthanasie et l'assistance au suicide ") (see module Legislation concerning Euthanasia in Luxembourg) . According to this law, the assistance in suicide is permitted under certain circumstances, as is also the case in the Netherlands and Belgium. In the future, patients shall be given the opportunity to wilfully put an end to their lives under medical assistance. The exemption from punishment for this medical assistance is dependent on various conditions: The affected patient has to be of full age and to be caught in a situation that is hopeless from a medical perspective. The patient has to suffer from mental or physical pain without having any improvement of this situation in sight. The wish to decease has to be made voluntarily, well-considered, without any external pressure and it has to be formulated in writing. In the case of 16 to 18-year-olds, euthanasia is only allowed to be provided if the parents or legal representatives have previously given their consent. Regarding a patient who is unable to express his or her will, the will set out in the living will is decisive. According to the law, the doctor has to have several detailed conversations with the patient regarding the patient's decision; he has to inform the patient about his or her condition as well as all available medical opportunities. Furthermore, as a basic principle, a second doctor has to be consulted regarding his opinion on the severity and incurability of the disease. All cases of euthanasia have to be reported to a controlling commission, which is in charge of inspecting the adherence to the conditions set out in the law. The first reading to the law on euthanasia took place on 19th February 2008 and was accepted with 30 yes- votes, 26 no-votes and three abstentions from voting. Since there were, according to the privy council, judicial inconsistencies with the law on palliative care (" Loi du 16 mars 2009 relative aux soins palliatifs, à la directive anticipée et à l'accompagnement en fin de vie ") (see module Palliative Care in Luxembourg) , which had been proposed at the same time, the parlamentarians were not excused from the second reading. The revote regarding the law on euthanasia from 18th December 2008 yielded a result of 31 yes-votes, 26 no- votes and three abstentions from voting and thus confirmed the parlamentarians' positioning in the first vote. On 17th March 2009, the official register Memorial was released, in which the law was printed and thus came into effect. The law carries the date of 16th March 2009 and was signed by grand duke Henri. This delay in publication has to be attributed to a constitutional amendment concerning the rights of the grand duke. Prior to this constitutional amendment, the grand duke not only had to sign a law but to approve of it as well in order to have the law come into effect. It was made public in early December 2008 that grand duke Henri would not sign the law because he could not reconcile it with his personal conscience. The grand duke was then to be deprived of the right to veto by means of an amendment to Article 34 of the constitution: In the future, the grand duke shall now only pronounce laws but not approve of them anymore. The first reading concerning this amendment proposal was held on 11th December 2008 and was accepted. Since, in cases of a constitutional amendment, the Luxemburg Parliament can, however, not be excused from a second reading and this second reading is allowed to take place earliest 3 months after the first reading, a revote was carried out on 11th March 2009. The constitutional amendment was adopted unanimously and with the approval of grand duke Henri. http://www.drze.de/in-focus/euthanasia (12) DRZE/In Focus

The situation in France The " Loi n° 2005-370 relative aux droits des malades et à la fin de vie " (see module Legislation concerning Euthanasia in France) was adopted in France on 22 April 2002. It amends the Public Health Code (Code de la santé publique) in such a way that discontinuation of medical treatment at the request of a patient is not punishable in cases where the patient is in an advanced or terminal phase of a severe and incurable disease - even if this termination accelerates death. If the patient is no longer able to take a decision and there is no living will, the patient's family or a person of trust and an additional physician must be consulted. Living wills are taken into account, provided they were drawn up no more than three years prior to the date on which loss of consciousness occurred and have not been revoked. Active euthanasia, on the other hand, continues to be prohibited in France.

The situation in Italy Contrary to the situation in Germany, in Italy euthanasia is not specifically regulated by law. However active euthanasia in principle belongs to the field of criminal law regarding premeditated killing ("omicidio volontario", Art. 575 codice penale). This regulation holds a minimum penalty of 21 years imprisonment. For a reduced sentence in the case of killing due to compassion, for individual cases there is a certain margin for judgement: Section 62 codice penale (see module Penal Code of Italy) acknowledges as mitigating circumstances when the offender acted out of certain moral or social motives defined by values ("motivi di particolare valore morale o sociale"). In the case of consent of the person wishing to die, the corpus delicti "killing with consent" ("omicidio del consenziente", Art. 579 codice penale) is applied with a range of sentences from 6 up to 15 years imprisonment. Different from the German legal situation, incitement to commit or assistance with suicide, acc. Section 580 codice penale ("istigazione o aiuto al suicido") is a punishable offence. Section 580 codice penale holds a range of sentences from 5 to 12 years. In the case of consent by the patient who wishes to die, passive euthanasia is covered by the right of self- determination (Section 32 § 2) concerning medical treatment guaranteed by the Italian constitution (see module Italian Constitution) . There it is said that apart from cases regulated by law, nobody may receive medical treatment by force. These exceptions on their part may in no case breach the imposed boundaries set by the 'respect for the human being' ("respetto della persona umana") (Section 32 § 2 Sentence 2). In case of the absence of consent, for the guarantor, this is the person (e.g. parents, spouse or physician) who is legally bound to vouch for the prevention of death, passive euthanasia is in principle the same as "killing by omission" and punishable under the law regarding active killing (Art. 575 i.V.m. Art. 40/2 codice penale). Only in cases of brain death, the termination or omission of life-sustaining measures is permitted provided that the brought in relatives of the brain dead, the concerning head physician, the attending physician as well as a forensic pathologist agree. If physicians and relatives disagree, a decision by the court is in need. An up-to-date case (see module Eluana Englaro) resulted in the discussion about euthanasia being resumed intensively in Italy; this debate has also been taken on by politics.

The situation in Great Britain As the case Pretty (see module Judgement of the European Court of Human Rights in the case Pretty) has shown emphatically, the " Suicide Act " (see module Suicide Act) expresses a general prohibition of http://www.drze.de/in-focus/euthanasia (13) DRZE/In Focus euthanasia. Euthanasia is punished with a prison sentence of up to 14 years. Concerning the actual sentence in an individual case, the legal situation in Great Britain allows for a wide scope of discretion. It is, indeed, possible for British citizens to travel to Switzerland in case they want to call upon euthanasia. However, if they are accompanied and assisted in this undertaking, the accompanying person acts illegally. In practice, prosecutions occur only rarely but as of yet, persons concerned could nonetheless not rely upon themselves not being charged. In July 2009, a single-case decision has fuelled the debate. Debbie Purdy (see module Guidelines concerning euthanasia in Great Britain) , a British citizen fallen ill with multiple sclerosis and willing to commit suicide, was successful in the House of Lords where she could move the highest judges to assure her husband immunity from prosecution in case that he should help her travel to Switzerland. In consequence to this case, the law lords commanded that the British prosecuting body (GPP) enact concrete guidelines, which give information about the conditions under which, in cases of assistance in committing suicide, there will indeed be prosecutions. As a result, the British prosecuting body in September proclaimed corresponding guidelines (see module Guidelines concerning euthanasia in Great Britain) . According to these guidelines, for example the differentiation between "aid" and "encouragement" to suicide as well as the question concerning whether the accompanying person benefits from the patient's death are decisive.

The situation in the USA As criminal legislation in the USA (see module USA: Nationwide regulations) is primarily drawn up by the individual states, there are no nationwide compulsory regulations regarding euthanasia and assisted suicide. The federal courts must clarify whether the individual states' legislation complies with the federal constitution. Active euthanasia is prohibited in all states, while the termination and refusal of treatment in accordance with the patient's wishes in futile cases (passive euthanasia) is generally accepted. The same applies to indirect euthanasia. Suicide and assisted suicide are also classed as an offence in some states. In some states there are initiatives aimed at legalising assisted suicide. On 27 October 1997 Oregon's Death With Dignity Act (see module US State of Oregon) came into force in accordance with which 'an adult who is capable [...] and has been determined by the attending physician and consulting physician to be suffering from a terminal disease' can make a written request "for the purpose of ending his or her life in a humane and dignified manner". Upon approval of the application, the patient receives a prescription for medication which will enable him to terminate his life himself. At the beginning of 2005 the case of Terri Schiavo (see module Terri Schiavo) in the United States provoked a fresh debate about the right to die and the handling of euthanasia. Terri Schiavo has suffered severe brain damage in 1990 when she collapsed and had been in a vegetative state since that time. While her husband and legally appointed guardian urged that her artificial feeding should be stopped and the patient allowed to die, supposedly in accordance with her (albeit only verbally expressed) wish, her parents wanted feeding to continue. In early 2005 President George W. Bush ordered that the legal dispute - which had been ongoing in the state of Florida for seven years and in the course of which artificial feeding has been stopped and resumed on several occasions - should be continued on the federal level. A legislative initiative was drafted specifically with the aim of ensuring that Terri Schiavo would be kept alive for as long as it took a federal court to reach a decision. In February the US Supreme Court ultimately decided the case in favour of Terri Schiavo's husband. http://www.drze.de/in-focus/euthanasia (14) DRZE/In Focus

The situation in Australia In Australia's Northern Territory (see module Australia) , the Rights of the Terminally Ill Act came into force in 1996. It permitted physician-assisted suicide for terminally ill patients whose suffering had reached unbearable limits. Four patients subsequently terminated their lives aided by a computer which released a lethal overdose of medication by injection when a button was pressed. The Act was overturned in 1997 by a law passed by the Australian parliament. Other Australian states also had legislative initiatives similar to that in the Northern Territory. Only recently a draft bill on the legalisation of euthanasia was presented to both houses of parliament of South Australia at the same time.

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Authors

Euthanasia • Introduction and basic conceptual distinctions Written by Ingo Hillebrand, substantially revised by Christina Rose and Katharina Campe (September 2009). • Central discussion topics Written by Ingo Hillebrand, substantially revised by Christina Rose and Katharina Campe (September 2009). • Legal regulations Written by Michael Weiffen, revised by Bert Heinrichs (August 2009), substantially revised by Christina Rose and Katharina Campe (September 2009).

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Modules Modules of Euthanasia

Assisted suicide

In 2000 a widespread public debate was triggered by the Zurich city council decision to reverse a prohibition, which had been in place since 1987, on carrying out and assisting suicide in facilities run by the health and environment department. The reversal has meant that since 1 January 2001, residents of homes for the elderly and the sick, who do not have any other home, may carry out suicide within these facilities and be assisted in doing so by relatives or members of euthanasia organisations. The staff of the homes are explicitly prohibited from assisting suicide in such cases. Objections to the new regulation have been repeatedly voiced. The city of Zurich has detailed its opinion on the objections in a press release and has documented these objections on its homepage: Press release of the city of Zurich

Australia

Rights of the Terminally Ill Act and other relevant documents

Bioethics Committee of Rhineland Palatinate, Germany

Report of the Bioethics Committee of the State of Rhineland Palatinate (Bericht der Bioethik- Kommission des Landes Rheinland-Pfalz)

The Bioethics Commission of the State of Rhineland-Palatinate has the task of advising the state government on developments in the life sciences and on ethical, social, legal and economic aspects of new technologies in this field and their potential consequences. It was established in 1986 by the state's justice minister as requested by Rhineland-Palatinate's Council of Ministers (Ministerrat). Bioethik-Kommission Rheinland-Pfalz (2004): Sterbehilfe und Sterbebegleitung, Ethische, rechtliche und medizinische Bewertung des Spannungsverhältnisses zwischen ärztlicher Lebenserhaltungspflicht und Selbstbestimmung des Patienten. (German only)

Churches

Since both the Protestant as well as the Catholic Church in Germany plead for the "inviolability" and "sacredness" of life, they disapprove of active euthanasia as "a targeted killing of a human being in his last http://www.drze.de/in-focus/euthanasia (17) DRZE/In Focus phase of life, which can ethically not be justified, even if the killing is carried out on the human being's explicit and desperate request". They advocate a "strengthening of alternatives [...] for a humane companionship of ill and dying persons [...] by showing commitment in Charity and deaconry, in the welfare centers, hospices and hospitals". Collection of ecclesiastic declarations Online version

Commercially conducted euthanasia

Due to the assistance to the suicide of a 79-year-old woman, the debate in Germany about commercial euthanasia is currently being enkindled again. This demands clear regulations from both the judiciary and the legislative branches. So far, federal attorney general Roswitha Müller-Piepenkötter (CDU) ( extern link ) as well as the Federal Council have so far expressed rejection of commercial euthanasia ( extern link ). A draft law regarding the prohibition of the businesslike mediation of opportunities for suicide ( extern link ) is currently being discussed in the Federal Council. German Criminal Code (Deutsches Strafgesetzbuch; StGB)

Conditional permissibility of euthanasia

For a critique of the "inviolability" and "sanctity" of life argument and of unconditional impermissibility of suicide, cf. the paradigmatic Siep, Ludwig / Quante, Michael (1999): Ist die aktive Herbeiführung des Todes im Bereich des medizinischen Handelns philosophisch zu rechtfertigen? (Can the active bringing about of death in the context of medical care be justified?), in: Adrian Holderegger (ed)., Das medizinisch assistierte Sterben. Zur Sterbehilfe aus medizinischer, ethischer, juristischer und theologischer Sicht. Universitätsverlag: Freiburg i. Ue./Herder: Freiburg i. Br., 37-55.

Dutch Ministry of Health, Welfare and Sport

Press release from the Dutch Ministry of Health, Welfare and Sport (Ministerie van Volksgezondheid, Welzijn en Sport)

Ministerie van Volksgezondheid, Welzijn en Sport (29.11.2005): Advisory Committee on termination of life of neonates. English online version

Eluana Englaro

The case Eluana Englaro

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After she had an accident in 1992, Eluana Englaro fell into a coma. For years, her father had been trying to enforce the termination of the total parenteral nutrition she was receiving. In November 2008, the highest Italian court of appeal approved in the last instance a directive of Milano's court of appeal, due to which the total parenteral nutrition of the patient could be discontinued. This, however, failed in the first place due to an intervention by the Ministry of Health. Nevertheless, Eluana Englaro was relocated to a nursing home during the first week of February; there, her total parenteral nutrition was terminated. The patient's relocation was accompanied by critics protesting against the court's ruling. The Vatican, too, criticised the ruling. The Italian government under Prime Minister Berlusconi tried to enforce the continuation of the total parenteral nutrition by means of an urgent decree. President Napolitano, however, prevented the coming into effect by refusing to sign the decree. Reacting to this, the government wanted to enact a law through an expedited proceeding, which would have required the continuation of the total parenteral nutrition. Nonetheless, Eluana Englaro passed away on 9 February 2009 before the expedited proceeding could be brought to a close. Due to first results derived from an autopsy, the patient died of dehydration, meaning she died of thirst. The physicians' proceedings would thus be consistent with the court's ruling. Critics, including Prime Minister Berlusconi, had previously made allegations und had speculated in public that Englaro might not have died a natural death. The short range of time between the termination of the total parenteral nutrition and the time of death particularly fuelled suspicions of such nature. These accusations did, however, not prove true after the autopsy. After the Italian Parliament, against the background of Englaro's death, had initiated another law concerning the regulation of euthanasia in Italy, the Italian Senate in late March 2009 passed a draft law according to which a termination of life-saving techniques, such as liquids and food, shall be prohibited in the future. The enactment of this law by the chamber of deputies is still being awaited. A report by the Times about the Vatican's criticism regarding the ruling in the case of Eluana Englaro Report by the Frankfurter Allgemeine Zeitung regarding the death of the coma patient Eluana Englaro (German only) Report by the New York Times regarding the death of the coma patient Eluana Englaro Report by the Süddeutsche Zeitung regarding the death of the coma patient Eluana Englaro (German only) Briefing by the New York Times regarding the cause of death in the case of Eluana Englaro

Euthanasia

British/American English, French and Italian use the terms "euthanasia", "euthanasie" and "eutanasia" respectively, a word derived from the Classical Greek "euthanasía" which means a "good" or "light" death in the sense of a pain-free, quick and also dignified death, as opposed to a slow, tortuous or undignified death. The term "Euthanasie" as a synonym for the German word "Sterbehilfe" (literally : assisted dying) has not succeeded in becoming common parlance in Germany due to its use throughout the national-socialist era to denote racist and eugenically motivated mass killings of then so-called "life unworthy of life" - ill and disabled people - as part of the Nazis' "Euthanasia Programme". Concerns that allowing euthanasia, especially in its http://www.drze.de/in-focus/euthanasia (19) DRZE/In Focus active form, could lead to such "forced euthanasia" play an important role in the German euthanasia debate (cf. section II of this text: Permissibility of active euthanasia). For an initial introduction to the euthanasia issue cf.: Lutterotti, Markus von / Eser, Albin (1989): Art. "Sterbehilfe", in: Albin Eser / Markus von Lutterotti / Paul Sporken (Hrsg.), Lexikon Medizin, Ethik, Recht. Herder: Freiburg, Basle, Vienna, 1086-1100. Schara, Joachim / Beck, Lutwin / Eser, Albin / Schuster, Josef (1998): Art. "Sterbehilfe", in: Wilhelm Korff / Lutwin Beck / Paul Mikat (Hrsg.), Lexikon der Bioethik. Bd. 3. Gütersloher Verlagshaus: Gütersloh, 445-454.

A comprehensive historic overview of the topic including the euthanasia debate in Germany is offered by: Benzenhöfer, Udo (1999): Der gute Tod? Euthanasie und Sterbehilfe in Geschichte und Gegenwart. Munich: Beck.

Euthanasia and the patient-physician relationship

Active euthanasia and the patient-physician relationship

The concern that allowing active euthanasia by a physician could undermine people's trust in each other, on the one hand, and the patient-physician relationship, on the other, is voiced not least by the churches and the medical community itself: John Paul II: Encyclical Letter Evangelium Vitae. Addressed by the Supreme Pontiff John Paul II to the bishops, priests and deacons, men and women religious, lay faithful and all people of good will on the value and inviolability of human life. esp. sections 64-67. Im Sterben: Umfangen vom Leben (While dying, surrounded by life). Gemeinsames Wort zur Woche für das Leben 1996: "Leben bis zuletzt - Sterben als Teil des Lebens". Kirchenamt der Evangelischen Kirche in Deutschland und vom Sekretariat der Deutschen Bischofskonferenz (eds.). Hannover / Bonn 1996 (Gemeinsame Texte; 6). Entschließung des 98. Deutschen Ärztetags 1995 zur Aktiven Sterbehilfe. In: Deutsches Ärzteblatt 92, Heft 23, 9. Juni 1995, 1687.

Euthanasia in the canton Zurich

Discussion in the canton Zurich concerning euthanasia

Due to the fact that an "advanced, more specifying regulation on the confederate level" (unofficial translation) is not in sight, Zurich's governing council with its decree of 14 March 2007 argued for the amicable arrangement of conduct rules with the euthanasia-organizations in the canton Zurich. The organizations shall make themselves subject to these regulations on a voluntary basis. The agreement is intended to be an intermediate step on the way to the introduction of a legal regulation. The two euthanasia-organizations Dignitas and EXIT both have their offices in the canton Zurich. While Dignitas still opposes federal control of its work, EXIT, at the request of the governing council, has come to an agreement with Zurich's office of the district attorney concerning an "agreement on organized euthanasia"; http://www.drze.de/in-focus/euthanasia (20) DRZE/In Focus for the purpose of quality management, this is being subordinated to specified framework conditions. The agreement pursues five goals: a Respect for the right to a dignified death b Guarantee of the right to self-determination c Assuming the care for persons at risk of committing suicide d Orderly handling of the prescription/application of medications e Orderly course of the examination concerning the causes of death. (unofficial translation) In this agreement, EXIT commits itself to • make transparent the organization and its financial means; this includes an annual inspection of the book keeping carried out by a statutory auditing division accredited by the state, • administer euthanasia only under specified conditions, meaning only in cases where a severe suffering due to illness is present, where alternatives have been clarified and contemplated, where the self-determined decision is deliberate as well as permanent, where no doubts exist concerning the suicidal person's power of judgment, and where there are no indications for a psychic indisposition, • adhere to a set frame for the course as well as the manner of euthanasia, which are being explained in a documentation file that is being given to the police officer and the public health officer arriving at the place of death after the suicide, • exclusively use the medical substance sodium-pentobarbital (NaP), and to • proceed cautiously as regards the selection of euthanasia-assistants and physicians of trust, to sufficiently educate these personnel as well as to allow each euthanasia-assistant as a general rule established in order to prevent a routine form arising to attend no more than twelve cases of euthanasia per year. In particular, the canton Zurich commits itself to pay the "costs for the procedure regarding the examination of the suicide as an exceptional event of death" (unofficial translation) out of the treasury's means. The text of the agreement (German only) In the meantime, protest is arising among the canton's citizens. This protest reflects in a double-initiative, which, first of all, argues to "Stop euthanasia" (and collected 8763 signatures for this goal) and which secondly demands a "No to euthanasia tourism in the canton Zurich" (which was supported by 9216 people). The requisite number of signatures for a referendum (6000 signatures) is hence exceeded in both cases. Consequently, the council of the canton now has to conduct an according popular vote. The petition "Stop euthanasia" for download as a pdf-document as well as information regarding the course of the proceedings (German only) Online version The petition "No to euthanasia tourism in the canton Zurich" as a pdf-document as well as information regarding the course of the proceedings (German only)

German Criminal Code (StGB)

German Criminal Code (Deutsches Strafgesetzbuch; StGB)

Deutsches Strafgesetzbuch (StGB) (German Penal Code; German only) http://www.drze.de/in-focus/euthanasia (21) DRZE/In Focus

German Medical Association on the accompaniment of the dying process

German Medical Association: Principles regarding the accompaniment of the dying process by physicians

As the institution with primary responsibility for the professional rules governing physicians in the Federal Republic of Germany, the German Medical Association (Bundesärztekammer) laid down its position on euthanasia in a set of principles on the physician's role in accompanying of the dying process ("Grundsätzen zur ärztlichen Sterbebegleitung") published in 1998. An updated version of these principles has been available since May 2004. Bundesärztekammer (2004): Grundsätze der Bundesärztekammer zur ärztlichen Sterbebegleitung, in: Deutsches Ärzteblatt (101), issue 19 (07.05.2004), p. A1298 - A1299. (German only) Bundesärztekammer/Kassenärztliche Bundesvereinigung (2008): Sterben in Würde, Grundsätze und Empfehlungen für Ärztinnen und Ärzte.

Groningen Protocol

The Groningen Protocol

The so-called "Groningen Protocol" of 2002 sets out five conditions which have to be fulfilled so that euthanasia on newborns is not a punishable offence: 1 the diagnosis and prognosis must be certain, 2 hopeless and unbearable suffering must be present, 3 the diagnosis, prognosis and unbearable suffering must be confirmed by at least one independent doctor, 4 both parents must give informed consent and 5 the procedure must be performed in accordance with the accepted medical standard. An article by two of the authors of the "Groningen Protocol", which includes a reproduction of the protocol itself, is contained in the New England Journal of Medicine. Verhagen, Eduard; Sauer, Pieter J.J.(2005): The Groningen Protocol - Euthanasia in Severly Ill Newborns. In: New England Journal of Medicine 352 (10), 959 ff.

Guidebooks from the Netherlands

Guidebooks in the Netherlands Concerning Euthanasia

In 2001, four Dutch physicians founded the Wetenschappelijk Onderzoek naar Zorgvuldige Zelfdooding (WOZZ), a foundation conducting scientific surveys concerning euthanasia. As a publishing venture, the foundation issues guidebooks regarding this topic and commercializes these out of range of the book-trade. The first book to have been published "Informatie over zorgvuldige levensbeëindiging" has been sold out by now. It is still available in German ("Wege zu einem humanen, selbstbestimmten Sterben"). To the website of the foundation WOZZ (in Dutch and German only) The book's German version Online version http://www.drze.de/in-focus/euthanasia (22) DRZE/In Focus

Furthermore, the following is available in Dutch, German and English: Boudewijn, Chabot (2009): Een waardig levenseinde in eigen hand / A hastened death by self-denial of food and drink / Ausweg. Das Leben beenden durch Verzicht auf Essen und Trinken. No place given.

Guidelines concerning euthanasia in Great Britain

The case Debbie Purdy was decided upon by the highest British court on 30 July 2009. The lawsuit lasted for two years. Apart from the actual verdict, the law lords' decision includes first and foremost a command towards the prosecuting body which is of importance for the future: the law lords command the prosecuting body to enact binding guidelines, from which it can be seen if and when a prosecution has to be expected in cases of assisted suicide. In a first reaction to this decision, Keir Starmer, the head of the British prosecuting body, expresses his consent with the verdict. Among the provisional guidelines that are wished to be put in place as fast as possible, he further announced a comprehensive survey whose results shall be integrated into the development process of ultimate legal regulations announced by him for the year 2010. According to a representative survey conducted on behalf of the London Times (19 July 2009) in reaction to the suicide of a severely ill couple in the accommodations of the suicide organization Dignitas in Switzerland, the majority of the surveyed British argue in support of applying active euthanasia in Great Britain. Three- quarters of the surveyed persons pronounce themselves in favour of physicians' being allowed to provide active euthanasia in clinics. 85% of the participants did, however, express the opinion that legal euthanasia shall be tied to specific conditions such as the presence of an incurable disease. The original wording of the law lords' decision in the Purdy case To the first reaction of Keir Starmer To the content of the provisional guideline concerning prosecution To the documents and the proceedings of the survey concerning euthanasia conducted by the British prosecuting body Times' Article about its survey on the issue of euthanasia Results of the Times-survey regarding the wish for a legislative amendment

Hospice movement

The hospice movement

Detailed information on the approach, the objectives and the tasks of the hospice movement is offered by the Bundesarbeitsgemeinschaft Hospiz (German hospice foundation). Online version Children's hospice

Italian Constitution

The Italian Constitution http://www.drze.de/in-focus/euthanasia (23) DRZE/In Focus

The Senate of Italy Italian online version

Judgement of the European Court of Human Rights in the case Pretty

Judgement of the European Court of Human Rights in the case Pretty vs. the United Kingdom (29 April 2002)

Diane Pretty complained to the Court that the UK Suicide Act was in violation of Articles 2 (right to life), 3 (prohibition of torture), 8 (right to respect for private and family life), 9 (freedom of thought, conscience and religion) and 14 (prohibition of discrimination) of the European Convention for the Protection of Human Rights and Fundamental Freedoms. In its judgement of 29 April 2002 the European Court held that while the application was admissible, the prohibition of assisted suicide contained in the UK Suicide Act and the refusal to grant her husband immunity from prosecution if he assisted her in committing suicide were not in violation of the aforementioned Articles. Mrs Pretty had argued that Articles 2 (right to life) and 8 (right to respect for private life) of the Convention granted her the right to self-determination as to the prolongation or termination of her own life. In the case of the terminally ill, who are no longer able to commit suicide themselves and who wish to avoid a painful death, this would include the possibility of third party assistance in the act of suicide. The Court conceded that the prohibition of assisted suicide according to the UK Suicide Act "might be thought to touch directly on the private lives of those who sought to commit suicide." However, with regard to the "prevention of disorder or crime, for the protection of health or morals, or for the protection of the rights and freedoms of others" (Convention Section 8, §2) a relaxation of the legislation prohibiting assisted suicide would be disproportionate. According to the Court this applies especially to the UK legislation, which grants judges great flexibility in the determination of the sentence to be imposed in individual cases. Moreover, the Court stated that the refusal of the British courts to give an advance guarantee of immunity from prosecution for Mrs Pretty's husband was not disproportionate. Mrs Pretty died in a hospice on 11 May 2002. Judgement of the European Court of Human Rights in the case Pretty v. the United Kingdom (29 April 2002) (Press Release). Please follow the link and click on "Search the Case Law - HUDOC" and type in the following application number: 00002346/02 Convention for the Protection of Human Rights and Fundamental Freedoms

Lack of alternatives

Lack of alternatives of euthanasia

The controversy outlined above surrounding the basic issue of whether euthanasia would become "superfluous" if the possibilities of care, pain-relief treatment and personal comfort measures were fully exploited, receives significant attention in the euthanasia report written in March 1999 and commissioned by the Swiss Federal Department of Justice and Police, even though the vote of the working group was undecided. Euthanasia report of 1999. German only

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Legal aspects of euthanasia

Wolfslast and Conrads (2001) contains a good selection of legal documents on euthanasia. The volume contains legal texts, court opinions, directives and opinions from various countries; all documents are in German. Wolfslast, Gabriele / Conrads, Christoph (eds.) (2001): Textsammlung Sterbehilfe (Collection of texts on euthanasia). Berlin: Springer.

Legislation concerning Euthanasia in Belgium

Belgium: "Loi relatif à l'euthanasie"

The preconditions laid down for the performance of a killing on request are fulfilled if the patient is an adult or, if still a minor, he or she has a comparable legal status ("emancipated minor"). Moreover, the patient has to be of sound mind and has to express his or her well-considered request voluntarily and under no duress. The patient's medical situation has to be desperate and resulting in constant and unbearable physical or psychological suffering caused by an accident or a severe and incurable illness and which cannot be alleviated. The killing on request performed by a physician is legal only, if a certain procedure is adhered to: the physician has to inform the patient about his or her state of health, life expectancy and the available therapeutic and palliative options. The patient and the physician have to be convinced that there is no other "reasonable solution" for the patient. In a sequence of discussions with the patient over a suitable period of time the physician has to seek reaffirmation that the patient's physical and psychological suffering is truly permanent and the patient's death wish is persistent. Concerning the question whether the physical or psychological suffering is permanent, unbearable and beyond palliation a second, independent specialist has to be consulted. The wish to die has to be put in writing and signed by the patient's own hand. If the patient is incapable of doing so the request to die may be written down by a person of the patient's choice in the presence of the physician. This third person must not have any material interest in the death of the patient. If the natural death of the patient is not pending, i.e. will not occur within the foreseeable future, at least one month has to elapse between the written request to die and the performance of the killing on request. Adult patients or minors of a comparable legal status ("emancipated minors") may formulate a living will covering the case in which they may no longer be able to express their wish. This living will may call for a physician to "carry out euthanasia" if due to a severe and incurable impairment as a consequence of an accident or a disease, the patient is unconscious and this state is irreversible, according to current medical knowledge. The living will may contain a list of trusted third parties to be included in the decision on the assumed will of the patient. If the patient is permanently incapable of formulating such a request, he or she may appoint a third person who has no material interest in the death of the patient. A physician who performs a killing on request on the basis of a living will made by an incurable and irreversibly ill and unconscious patient acts legally, if he or she adheres to certain procedures. Among those are the obligation to consult a second physician in the assessment of the patient's medical situation and to include the third party laid down in the patient's living will in the process of establishing the patient's assumed wish. http://www.drze.de/in-focus/euthanasia (25) DRZE/In Focus

Any mercy killing has to be registered with and assessed by the "Federal Control and Evaluation Commission". The Commission has to judge whether the conditions and the procedures laid down for a legal killing on request are fulfilled. If two thirds of the 16-member commission (8 physicians, 4 members of the legal professions and 4 other professionals dealing with problems concerning the terminally ill) come to the conclusion that the preconditions are not fulfilled, the case has to be referred to the state attorney. "Projet de loi relatif à l'euthanasie" Online version The Belgian National Bioethics Committee initially published its opinion on euthanasia in 1997. In 1999 the committee published another opinion specifically on euthanasia with regard to persons unable to give their consent. Comité consultatif de Bioéthique de Belgique: Avis n° 1 du 12 mai 1997 concernant l'opportunité d'un règlement légal de l'euthanasie (in French only) Comité consultatif de Bioéthique de Belgique: Avis n° 9 du 22 février 1999 concernant l'arret actif de la vie des personnes incapables d'exprimer leur volonté (French only)

Legislation concerning Euthanasia in France

Loi n° 2005-370 relative aux droits des malades et à la fin de vie

Loi n° 2005-370 du 22 avril 2005 relative aux droits des malades et à la fin de vie (1) French online version

Legislation concerning Euthanasia in Luxembourg

Loi du 16 mars 2009 sur l'euthanasie et l'assistance au suicide

Legislation concerning Euthanasia in the Neatherlands

The Dutch "Euthanasia and Assisted Suicide Act"

See Gordijn 1997 for a good, concise overview of the development of the legal regulations governing euthanasia in the Netherlands and the accompanying public debate. Gordijn, Bert (1997): Euthanasie in den Niederlanden - eine kritische Betrachtung (Euthanasia in the Netherlands. A critical review). Berlin: Humanitas-Verlag. The Dutch text of the "Euthanasia and Assisted Suicide Act" (Wet toetsing levensbeëindiging op verzoek en hulp bij zelfdoding) which came into force on 1 April 2002 is available via the NVVE web pages. A German version of the "Euthanasia and Assisted Suicide Act" is available at the KNA web pages.

Living wills

Living wills http://www.drze.de/in-focus/euthanasia (26) DRZE/In Focus

The term living will describes a person's declaration of intention, which the person expresses for the case that his or her health does not allow him or her to agree to or reject certain medical measures that concern him or her. These living wills are of high significance when it comes to the self-determination of a patient because varying moral concepts can cause the opinions of those involved in a situation of treatment to be opposed to one another. Especially in cases where patients by means of living wills reject for themselves life-prolonging measures or where they, for the case of their own inability to make decisions, which might set in at a later point in time, even demand to be let die or to receive active euthanasia, hence making necessary the involvement of a third party, situations arise in which a medically indicated measure does not comply with the will of the patient. In the debate concerning the legal status and the bindingness of living wills, several heterogenous opinions were expressed. Amongst others, the working group "Patients' autonomy at the end of life", which was established by the Federal Ministry of Justice on 10 June 2004, presented its final report in which it demands that the wishes expressed in living wills - if they apply to the concrete situation - shall be binding even "if the disease has not yet become fatal" (unofficial translation). To the contrary, the Inquiry Commission Ethics and Justice of modern medicine of the German Bundestag (15th legislative period) published an intermediate report on 13 September 2004. In this report, the Commission advocates that a renunciation or termination of a medically initiated or medically proposed life-sustaining measure shall be put into action only "if the underlying disease is irreversible and will, according to a medical evaluation, lead to death despite of medical treatment". (unofficial translation). Only recently has the legal status and the bindingness of living wills been legally regulated in the Parliament. On 18 June 2009, the German Bundestag decided on the law for changing the guardianship law, which had been proposed by, amongst others, the Members of the Bundestag Joachim Stünker (SPD) and Michael Kauch (FDP). It is the goal of this draft "to establish legal security for all persons concerned by means of legally regulating the living will" (unofficial translation) and to strengthen the respect for the maxim of self-determination. The living will, whose condition for validity is the written form or a comparable form such as a video-recording, is being fixed in the guardianship law. The will of the patient settled in the living will has to be observed independently from the nature and the stadium of the disease. Its neglect is considered a criminal assault. If, in a case of a particularly severe decision of a caretaker or an authorized representative, it is being suspected that he or she might not act according to the will of the patient, this decision needs to be approved by the guardianship court. The court also has to be contacted in cases where "physician and the caretaker have different opinions as to which decision is in accordance with the will of the patient" (unofficial translation) or in cases where "there is a justified risk that the person being taken care of dies as a result of the measure or suffers a severe and longer lasting damage to his or her health" (unofficial translation). Such a measure that has not been approved can be carried out only if a suspension is linked with a risk for the person being taken care of. Neither is it unconditionally essential to have a counselling interview with the physician before the living will is being written, nor does the living will have to be affirmed anew at regular intervals by means of signature and date. The decision to write or not to write a living will is up to every human being. Even if a living will would, from the view of nursing staff or relatives, disburden their subsequent action, no one shall be pressured http://www.drze.de/in-focus/euthanasia (27) DRZE/In Focus or forced to write a living will. Statements of will "which are aimed at the prohibited killing upon request remain invalid" (unofficial translation). As an alternative to the Stünker-draft, the Members of the Bundestag Hubert Hüppe, Beatrix Philipp, Prof. Dr. Norbert Lammert (all members of the Christian Democratic Union/Christian Social Union (CDU/CSU)) as well as further Members of the Bundestag submitted a petition in which they opposed the "legal overregulation of the living will" (unofficial translation). The wish to write a living will for the case of one's personal incapability to give consent is, the Members of the Bundestag state, understandable; future diseases and sufferings are, however, unpredictable. Although living wills are in practice given attention if the wishes expressed in the living will are in accordance with the respective situation, there will always be cases in which living wills cannot be applied and are hence not binding. According to this draft, the current legal situation is entirely sufficient, meaning that "legal regulations going beyond the current legal situation are neither necessarily nor convincingly possible" (unofficial translation). This draft could, however, not win through. The draft of a group surrounding the Member of the Bundestag Wolfgang Bosbach (Christian Democratic Union/Christian Social Union (CDU/CSU)) did not have majority appeal either. This draft envisioned that a statement of wishes in a living will shall be "preceded by a comprehensive medical and legal consultancy, be documented and authenticated with the living will by a solicitor and shall be no older than five years or confirmed by a new medical consultation" (unofficial translation). In cases of curable diseases, the physician is not obliged to attend to the wishes expressed in a living will that has been written without medical consultation. Contents not aimed at a termination of treatment are nonetheless, binding. Final report of the working group "Patients' autonomy at the end of life" (2004): Ethical, legal and medical aspects concerning the assessment of living wills (Abschlussbericht der Arbeitsgruppe "Patientenautonomie am Lebensende" (2004): Patientenautonomie am Lebensende. Ethische, rechtliche und medizinische Aspekte zur Bewertung von Patientenverfügungen) (German only). Inquiry Commission Ethics and Justice of modern medicine (2004) (Enquete-Kommission Ethik und Recht der modernen Medizin (2004)): Intermediate report of the Inquiry Commission Ethics and Justice of modern medicine. Living wills. (Zwischenbericht der Enquete-Kommission Ethik und Recht der modernen Medizin. Patientenverfügungen) (German only). Link to the Stünker-draft Link to the Hüppe-draft Link to the Bosbach-draft (German only) Further information regarding the content and course of the debate can be found here: Link to the debate in the German Bundestag (German only) Living at the end of life - establishing a better general framework for the critically ill and dying (Leben am Lebensende - Bessere Rahmenbedingungen für Schwerkranke und Sterbende schaffen) (German only) Link to the statement of the President of the German Medical Association (2008) (German only) Link to the statement of the Protestant Church (German only) Reacting to the law concerning the living will, Hamburg’s medical association has adapted its sample will to the new legal regulations: http://www.drze.de/in-focus/euthanasia (28) DRZE/In Focus

Sample of Hamburg's medical association . The sample is part of a brochure of the Department for social affairs, family, health and consumer protection (2009): Ich sorge vor (“I make provisions for the future”). Hamburg. Brochure "Ich sorge vor" The Reader "living wills" (2005) compiled by Dr. Katrin Grüber of the Institute Human being, ethics and science (Institut Mensch, Ethik und Wissenschaft) and Dr. Jeanne Nicklas-Faust on behalf of the federal parliamentary party Bündnis 90/Die Grünen (Green party) (German only) A comprehensive description of the single aspects concerning the living will as well as assistance in writing a living will can be found on the website of the humanistic association Berlin (humanistischer Verband Berlin) (German only): Humanistic association Berlin Draft wordings as well as text modules are provided, amongst others by: The German Federal Ministry of Justice (German only) The German Hospice Foundation (Deutsche Hospiz-Stiftung) (German only) The portal on medical ethics of the Ruhr-University Bochum provides an overview of text modules, which have been allocated by various sides in the course of the long-standing debate. Portal on medical ethics Information concerning the possibility for entrusting a person of trust with the enforcement of a living will is provided by the Federal Ministry of Justice in its brochure "law of legal care" (Betreuungsrecht) (unofficial translation). This brochure includes concrete information regarding the living will and the authorization for caretaking (German only). Brochure "Betreuungsrecht"

More cases of euthanasia in the Netherlands

Raising tendency of cases of euthanasia in the Netherlands

In the report of the five regional euthanasia-commissions in the Netherlands the number of cases of euthanasia in the year of 2008 is set at 2331. Comparing this number with the previous year (2120 cases), this means an increase by approximately 10 percent and is thus an increase comparable to the one between 2006 (1923 cases) and 2007. These numbers affirm a tendency which has become apparent as early as the year of 2003, the organizations say. More in-depth surveys show that this trend only concerns the cases of euthanasia for patients suffering from cancer. These constitute the "classical category" for which, always, by far the most cases are listed. Two main reasons are being assumed that motivate this increase, namely both reasons taken for themselves as well as in an interplay of the two of them: First of all, the difference between palliative care and euthanasia has become more apparent due to a respective guideline. It is thus being assumed that palliative measures are being chosen less frequently, euthanasia respectively more often than it was the case in the past. Secondly, the willingness to report assisted suicide was estimated at 80% in the most recent country- wide survey in the year of 2005. The remaining 20% mainly concerned euthanasia with the help of morphine. The presumption is that regular means for euthanasia are being made use of increasingly and that these cases http://www.drze.de/in-focus/euthanasia (29) DRZE/In Focus are also being reported, which leads to an increase in the reports. Whether the development can, indeed, be explained by this, is left open for further surveys, which are also to provide more clarity as regards the practice of medical decision-making concerning questions about the end of life. Link to the report of the commissions Dutch online version

National Ethics Council

Opinions of the National Ethics Council

The statement of the national ethics council (formerly: German ethics council) concerning self-determination and care at the end of life can be accessed via the following link: Nationaler Ethikrat (2006): Selbstbestimmung und Fürsorge am Lebensende. Stellungnahme. (German only)

NEK (2005) Assisted suicide

Swiss National Advisory Commission on Biomedical Ethics (NEK) (2005): "Assisted suicide"

Swiss National Advisory Commission on Biomedical Ethics (NEK) (2005): Assisted suicide.

NEK (2005): Assistance to suicide

National Ethics Council in the field of human medicine (NEK) (2005): Assistance to suicide

National Ethics Council in the field of human medicine (NEK) (2005): Assistance to suicide.

NEK Opinion no. 13/2006

Statement of the Swiss National Advisory Commission on Biomedical Ethics (NEK-CNE) Opinion no. 13/2006: "Duty-of-care criteria for the management of assisted suicide" (October 27th 2006)

Ordinary and extraordinary treatment

Ordinary measures are those that are based on medication or treatment which is directly available and can be applied without incurring severe pain, costs or other inconveniences, but which give the patient in question justified hope for a commensurate improvement in his health. Extraordinary measures are those that are based on medication or treatment which cannot be applied without incurring severe pain, costs or other inconveniences. Their application, however, would not give the patient any justified hope for a commensurate improvement in his health. If assessed from an ethical point of view, it is possible to distinguish between on the one hand life-prolonging measures the application of which is morally obligatory (ordinary measures) - http://www.drze.de/in-focus/euthanasia (30) DRZE/In Focus as they are likely to help the patient - and on the other hand those measures which can be applied optionally (extraordinary measures) as the benefit to the patient is not immediately obvious or subject to considerable debate. These limits were highlighted already in 1957 by Pope Pius XII, who pointed out that life, health and earthly actions are allocated, and thus subordinate, to spiritual purposes. Death is seen as an integral element of life, since according to Christian beliefs death is not the end, but the transition to new life. Speech by Pope Pius XII. "Legal and moral issues of reanimation" delivered on 24 November 1957 before a group of physicians who had come together upon request by the Georg-Mendel-Institut für Genetik. In: AAS 49 (1957), 1027-1033. (German in: A.-F. Utz / J.-F. Groner (eds.): Aufbau und Entfaltung des gesellschaftlichen Lebens. Soziale Summe Pius XII., Volume 3, Freiburg (Switzerland) 1961, 3266-3274.)

Palliative care

Palliative care is targeted on the comprehensive care of patients showing non-curable diseases. The aim is to provide these patients and their families with a best possible quality of life and satisfaction in life. Unlike active euthanasia death is not accelerated. The patient shall self-determinantly receive, until the time of death, the treatment most benefitial to him in both physical and psychological terms. Link to the German Medical Association Link to the decision memorandum of the 106th German Medical Assembly 2003 Online version Link to the editorial office for health / Federal Ministry of Health Link to the German hospice- and palliative association Online version Since July 2009, palliative care has been integrated as a compulsory subject in the course of medical studies into the approbation regulations for physicians. This was done by means of an according passage (which was suggested in a draft law ) in the “ law concerning the regulation of the need for adjunct care in hospitals ” (unofficial translation), which came into force on 10 July 2009. The law is to guarantee that “students of medicine can stand up to the expectations concerning the care for severely ill and dying patients in their later professional lives and that the comprehensive and competent care for these patients is guaranteed” (unofficial translation). Both in Germany and foreign countries, transregional organizations have committed to the cause of improving palliative care.

Palliative Care in Luxembourg

Loi du 16 mars 2009 relative aux soins palliatifs, à la directive anticipée et à l'accompagnement en fin de vie

Loi du 16 mars 2009 relative aux soins palliatifs, à la directive anticipée et à l'accompagnement en fin de vie French online version

http://www.drze.de/in-focus/euthanasia (31) DRZE/In Focus

Penal Code of Italy

The Penal Code of Italy codice penale Italian online version

Reference of the Swiss Federal Council

Reference of the Federal Council from May 31st 2006

Reference of the Federal Council from May 31st 2006 to the parliament demanding not to enact any new legislation on the authorisation and surveillance of assisted suicide organisations, compare the press release of the Federal Department of Justice and Police published the same day.

Right-to-die organisations

Since the provision of assistance for committing suicide without self-interested motivation is not a criminal offence in Switzerland, so-called "right-to-die" organisations have been set up in the country, including for example the charitable organisation "DIGNITAS - Menschenwürdig leben - Menschenwürdig sterben" ("DIGNITAS - Live with dignity - Die with dignity"). According to its charter, the purpose of the organisation is to "ensure that its members live with dignity and die with dignity and to enable others to benefit from these values". DIGNITAS "helps in concrete cases with the implementation of patient directives vis-à-vis doctors and clinics and is available to support preparation for death, accompaniment of the process of dying and to provide assistance with committing suicide." Since September 2005 the organisation has also had a branch in Germany (Hanover) under the name DIGNITATE. Those who join the organisation in Germany are given "direct advice in Switzerland [...] and can also receive accompaniment for the process of committing suicide". DIGNITATE's Internet website further states that the purpose of setting up the organisation in Germany was to ensure that " the modern Swiss form of assisted suicide [will] soon [be] possible in Germany". Further information on DIGNITAS The opening of the German branch in Hanover met with protests. For further documentation see: Die Zeit (27.10.2005, No.44)

SAMW on the care of patients in the terminal phase of life

Swiss Academy of Medical Sciences (2004): "Care of patients in the terminal phase of life". Medical- Ethical Guidelines of the SAMS

According to the guidelines "care of patients in the terminal phase of life", for assisted suicide to be licit, the physician must comply with three minimum requirements: 1. "The patient's disease justifies the assumption that he or she is approaching the end of life", 2. "Alternative possibilities for providing assistance have been discussed and, if desired, have been implemented", and 3. "The patient is capable of making the decision, the http://www.drze.de/in-focus/euthanasia (32) DRZE/In Focus wish to end his or her life has been well thought out and arrived at without external pressure, and the patient persists in this wish. These points must have been checked by a third person, not necessarily a doctor." In addition, "The death of a patient as a result of assisted suicide must be reported to the examining authorities as an unnatural death, for clarification." The scope of the new guidelines does not go beyond "patients in the terminal phase of life". These are patients whose doctor has arrived at the conclusion from clinical signs that a process has started which, experience indicates, will lead to death within a matter of days or a few weeks. Swiss Academy of Medical Sciences (2004): "Care of patients in the terminal phase of life". Medical-Ethical Guidelines of the SAMS (First publication to be submitted for approval; the German version is the original, binding version) The publication Ärztezeitung reported in December 2005 that effective January 2006 the university hospital in Lausanne has become the first hospital in Switzerland to allow active euthanasia in certain circumstances: Report of the Ärztezeitung

SAMW on the patients with chronic severe brain damage

Swiss Academy of Medical Sciences (2003): Treatment and care of patients with chronic severe brain damage. Medical-Ethical Guidelines.

In 2003 the SAMS stated that "the obligation to maintain life, however, carries some qualifications. The patient's wishes in this respect are the overriding criterion for decisions to reject or discontinue life-saving measures". If this is recorded in a patient's directives, the SAMS believes that they should be followed "as long as there are no concrete indications that they no longer represent his or her present wishes". If there are no patient directives, an attempt must be made to determine their presumed wishes. The responsibility for decisions that are reached for or against further treatment of a patient should, the opinion continues, be shared and everyone involved, as far as possible, should accept them. "However, the final decision rests with the doctor directly responsible for the patient". Swiss Academy of Medical Sciences (SAMS) (2003): "Treatment and care of patients with chronic severe brain damage". Medical-Ethical Guidelines. (Translated from the German version)

Stages of the dying process

On the phenomenology of the dying process and its stages, cf. as a basic text: Kübler-Ross, Elisabeth (2001): Interviews mit Sterbenden (Interviews with the dying). Kreuz-Verlag: Stuttgart.

Suicide Act

The "Suicide Act", which was enacted in 1961, first of all regulates that suicide is not longer punishable in Great Britain. Consequently, people whose suicide is unsuccessful can no longer be charged for the attempt http://www.drze.de/in-focus/euthanasia (33) DRZE/In Focus to commit suicide. The legal status of the assistance in committing suicide is regulated in paragraph 2. Article 2.1. arranges for a penalty of up to 14 years. Article 2.4 further regulates for single-case decisions to be made by the prosecuting body. To the exact wording of the law

Swiss Federal Department of Justice and Police

Report of the Federal Department of Justice and Police: "Euthanasia and Palliative Care - Does the Confederation Need to Act?" (April 24th 2006)

Report of the Federal Department of Justice and Police: "Euthanasia and Palliative Care - Does the Confederation Need to Act?" (April 24th 2006): According to the Federal Department of Justice and Police there is no English script, but a German and French version is available. German French

Swiss Penal Code

Schweizerisches Strafgesetzbuch, Zweites Buch: Besondere Bestimmungen

Switzerland

In 1994, councillor Victor Ruffy petitioned the Swiss Federal Council to set up an initiative for the legal regulation of euthanasia. In March 1997 the Federal Department of Justice and Police set up a working group and charged it with investigating the medical, ethical and legal issues surrounding this topic. The working group presented its report in April 1999 in which it recommends the explicit statutory regulation of indirect and passive euthanasia which in any case are legal in Switzerland. The majority of the working group further recommended to exempt active euthanasia from being a punishable offence in certain cases. The Federal Council acknowledged this report in January 2000 and submitted its own report in July 2000. The Council agreed with the working group's recommendation to regulate indirect and passive euthanasia legally, but rejected the working group's call for a "very restricted exemption" of direct active euthanasia from being a punishable offence. Medienmitteilungen der Schweizerischen Eidgenossenschaft Eidgenössisches Justiz- und Polizeidepartment (2000): Sterbehilfe. Bericht der Arbeitsgruppe an das Eidgenössische Justiz- und Polizeidepartment (German only) Bericht des Bundesrates zum Postulat Ruffy, Sterbehilfe. Ergänzung des Strafgesetzbuches (German only)

http://www.drze.de/in-focus/euthanasia (34) DRZE/In Focus

Terri Schiavo

The Terri Schiavo case

More detailed information and various court ruling on the Terri Schiavo case can be accessed under: Terri Schiavo Case: Legal Issues Involving Healthcare Directives, Death, and Dying

The burden of proof

The fundamental question concerning the legal-ethical permissibility of a penological prohibition within a democratic political system and the burden of proof that is linked with such an argumentation is being discussed by: Hoerster, Norbert (2009): Zur Legitimität der Sterbehilfe. In: Information Philosophie (2), 7-13.

Unconditional illicitness of suicide

The argument of the "inviolability" and "sanctity" of life which prohibits any curtailment of one's own life, is formulated in connection with the euthanasia issue by the churches in the following documents: Erklärung der Kongregation für die Glaubenslehre zur Euthanasie (Sacred Congregation for the Doctrine of the Faith - Declaration on euthanasia). 5 May 1980. Sekretariat der Deutschen Bischofkonferenz (ed.) (Verlautbarungen des Apostolischen Stuhls, 20). Bonn 1980. English version John Paul II: Encyclical Letter Evangelium Vitae. Addressed by the Supreme Pontiff John Paul II to the bishops, priests and deacons, men and women religious, lay faithful and all people of good will on the value and inviolability of human life. esp. sections 64-67. Im Sterben: Umfangen vom Leben (While dying, surrounded by life). Gemeinsames Wort zur Woche für das Leben 1996: "Leben bis zuletzt - Sterben als Teil des Lebens". Kirchenamt der Evangelischen Kirche in Deutschland und vom Sekretariat der Deutschen Bischofskonferenz (eds.). Hannover / Bonn 1996 (Gemeinsame Texte; 6). Online version

US State of Oregon

According to the study by Chin et al. 1999, in the first year after the Death with Dignity Act came into force 23 people applied for and received a lethal drug. Fifteen of them died after having taken the drug, six died of their diseases and two were still alive when the study commenced. Chin, Arthur E. / Hedberg, Katrina / Higginson, Grant K. / Fleming, David W. (1999): Legalized physician- assisted suicide in Oregon - The first year's experience. In: The New England Journal of Medicine 340 (7): 577-583. http://www.drze.de/in-focus/euthanasia (35) DRZE/In Focus

Fifth Annual Report on Oregon's Death with Dignity Act "The Oregon Death with Dignity Act"

USA: Nationwide regulations

Nationwide regulations governing euthanasia in the USA

The US Congress of the last term consulted on the draft Pain Relief Promotion Act of 2000. This Act would make assisted suicide and active euthanasia a criminal offence throughout the United States and overturn all contrary state legislation. Pain Relief Promotion Act of 2000

http://www.drze.de/in-focus/euthanasia (36)