COMMITTEE: UTOPIA (Special Committee) ISSUE: Assisted Death

STUDENT OFFICER: Elif KURTAY

POSITION: Co-chair

I- Introduction

Assisted death has been a controversial debate topic for a very long time. However, a consensus hasn’t been reached for years. The end of life is a very crucial and critical topic to make a decision on. There are many conditions that affect whether a life can be taken away from a person with their request. The patients’ condition, the physician, whether the disease can be cured or not in the future, mental illness, religion, laws, etc. was a softer, maybe more rightful way to die than suicide. And recently assisted death (physician ) become a more justifiable way to end one’s own life than euthanasia. However, some people have neither accepted nor agreed any of the aforementioned forms of suicide due to some understandable and important reasons. By both sides, for and against, having their reasons that cannot get disregarded, a decision seems impossible to be made. Besides having different point of views, it is always possible to reach a joint resolution regarding any topic and in order to succeed this goal, all sides, discussions and factors of should be studied and well understood. Therefore, hoping that this report will help with the comprehension of the issue, it is expected that assisted death will be granted great concern and attention to conclude this ever ending debate. II- Overview 2.1) Definition of Key Terms Suicide: is the act of causing one's own death commonly because of a mental illness like depression, bipolar disorder, schizophrenia, personality disorders, alcoholism, or drug abuse. Physician: is who is educated, clinically experienced, and licensed to practice medicine but will not perform surgery; a medical doctor who is not a surgeon. Euthanasia: is the Greek term meaning “good death”, normally implies an intentional termination of life by another at the request of the person who wishes to die. It is generally implemented as the act of killing an incurably ill person out of concern and compassion for that person's suffering; also called as “mercy killing”. Assisted suicide: is suicide committed by someone with the help from another person; also known as physician-assisted suicide (PAS), physician aid-in-dying (PAD), assisted death or voluntary passive euthanasia. In this situation, a physician supplies information and/or the means of committing suicide, such as a prescription for lethal dose of sleeping pills, or a supply of carbon monoxide gas, to a person, so that the individual can successfully terminate his or her own life. 2.2) Background Information Physician-assisted suicide (PAS) received a worldwide public attention after Dr. Kevorkian, a retired pathologist from Michigan, participated in his first such procedure in 1990. Kevorkian set up a machine that allowed a 54-year-old woman suffering from Alzheimer's disease (a degenerative neurological condition) to press a button that delivered a lethal poison into her veins. Kevorkian went on to assist in the suicides of dozens of individuals suffering from terminal, debilitating, or chronic illnesses. In 1992, Michigan passed an “assisted-suicide bill” that was specifically designed to stop Kevorkian's activities, but technicalities and questions as to its constitutionality delayed its implementation, thus allowing Kevorkian to continue assisting suicides, often in direct opposition to court injunctions. Observers disagree about the humanity of Kevorkian's activities. Some see him as a hero who sought to give suffering people greater choice and . Others point to his lack of procedural precautions and fear that the widespread practice of assisted suicide will lead to the unnecessary death of people who could have been helped by other means, including treatment for depression. Many opponents of assisted suicide find the same faults in the practice that they see in other forms of euthanasia. They envision its’ leading to a devaluation of human life and even to a genocidal killing of vulnerable or so-called “undesirable individuals”. 2.3) Discussions on Related Issues Religious Ethics Religion is one of the main actors to consider for a patient, but particularly for ones that are terminally ill. So the patient might put his/her hopes in his/her religion believing that it will bring him/her happiness after death. The meaning and the beauty of life has always been questioned in many different religions. Every religion has their own practice when it comes to new life and the end of life. However, the most common belief is that life itself is sacred and it shouldn’t be taken away by another or oneself. Examples include Islam, Buddhism, Catholicism and Mormonism. About any form of suicide, Quran is very clear: "Do not kill yourselves as God has been to you very merciful". In Islam, it is believed that even though there is pain and suffering especially at the terminal end of an illness, there will be reward from God for those who patiently persevere in suffering. The sacredness of human life is appreciated in the Quran. "Do not take life which God has made sacred except in the course of Justice" (Quran 6:151). According to Buddhism, assisted suicide is an uncompassionate act as it causes grief to others and is believed to deprive them of spiritual development. Also, according to Buddhist belief, death will not relieve the killed person of suffering, but postpone the suffering to the next life. The Catholic Church opposes euthanasia and assisted suicide. In Pope John Paul II's words, medical killings such as those caused by assisted suicide are "crimes which no human law can claim to legitimize." Basing its arguments on passages from the Bible, Catholic theology has for many centuries opposed all forms of suicide. Catholicism argues that innocent human life cannot be destroyed for any reason. Furthermore, during the thirteenth century, the traditional Christian belief condemned any type of suicide, whether it was assisted or not, on the theory that it violated one’s natural desire and right to live. In Mormonism, anyone who takes part in 'assisted suicide' is regarded as having violated the commandments of God. However, the Church recognizes that when a person is in the final stages of terminal illness there may be difficult decisions to be taken. The Church states that 'When dying becomes inevitable, death should be looked upon as a blessing and a purposeful part of an eternal existence. Members should not feel obligated to extend mortal life by means that are unreasonable.’ Euthanasia vs. Assisted Death Physician-assisted suicide is often confused with euthanasia (sometimes called "mercy killing"). In cases of euthanasia the physician administers the means of death, usually a lethal drug. In physician-assisted suicide (PAS) the patient self-administers the means of death, the physician only assists to patient to get to the materials (drugs, machines) which will take their own life. Euthanasia is separated into two categories: passive euthanasia and active euthanasia. Passive euthanasia is the death of a person by altering some form of support and letting nature take its course. Examples include such things as turning off respirators, halting medications, discontinuing food and water so as to allowing a person to dehydrate or starve to death, or failure to resuscitate. In many jurisdictions, active euthanasia can be considered murder or manslaughter, whereas passive euthanasia is accepted by professional medical societies, and by the law under certain circumstances. Therefore, physician assisted death also goes by the name “voluntary passive euthanasia”.

Countries’ Views on Physician-Assisted Suicide The debate surrounding physician-assisted suicide in the United States has been influenced by medical practices in other countries, particularly the Netherlands, which legalized both active euthanasia and physician-assisted suicide, in April 2001. Physician-assisted suicide in the Netherlands is conducted within strict guidelines that include the following requirements:  the patient's request for assisted suicide must be voluntary,  the patient must be experiencing intolerable suffering,  all other alternatives for treatment must have been explored,  the physician must consult another independent physician before proceeding. A study commissioned by the Dutch government indicated that, in 2001, about 3,500 deaths, or 2.5 percent of the 140,000 death cases that were reported in the Netherlands that year, occurred by active euthanasia. The study, known as the Remmelink Report, defined euthanasia as the termination of life at the patient's request. Figures also indicated that 300 deaths, or 0.2 percent, were caused by physician-assisted suicide. In the United States, the debate on legalizing assisted suicide began in earnest in the 1970s. On one side of the debate have been Patients' Rights groups who have lobbied for the , or the right to choose to die, of terminally ill patients. The strongest opposition to the legalization of physician-assisted suicide has come from physicians' groups such as the American Medical Association (AMA) and from religious groups that are morally opposed to the practice. The debate over physician-assisted suicide eventually reached the Supreme Court. Starting with 1994, an advocacy group known as Compassion in Dying filed two lawsuits challenging the constitutionality of state laws banning assisted dying in Washington and New York. Debates on PAS took a long time until June 26, 1997 when The Court ruled that state laws against assisting a suicide are not unconstitutional, but also stated that patients have a right to aggressive treatment of pain and other symptoms, even if the treatment hastens death. The Court wrote; "Throughout the Nation, Americans are engaged in an earnest and profound debate about the morality, legality and practicality of physician assisted suicide. Our holding permits this debate to continue, as it should in a democratic society." Ultimately then, the voters and representatives of the states and the legal system itself have to decide whether or not physician-assisted suicide will be legalized.

Derek Humphry and the "Slippery Slope" Argument One person who has done much for the case for physician-assisted suicide is Derek Humphry, a former journalist who founded the , in 1980, after seeing the pain and suffering his first wife experienced when she died from cancer. In 2003, the organization changed its name to End-of-Life Choices, which encompasses more clearly the issues supported by its members. With a new name and a new motto, "Dignity Compassion Control," the organization continues to advocate for the right of terminally ill people to choose . In Humphry's words, the "right to choose to die" is "the ultimate civil liberty." Humphry presents physician-assisted suicide as a merciful, dignified option for people whose illness has consumed their quality of life beyond the limits of tolerance and durability. He also points out that PAS occurs every day in medical facilities as physicians make decisions regarding the end of life. Others, including some medical ethicists, go so far as to claim that a decision to withhold antibiotics, oxygen, or nutrition from a terminally ill patient is no less "active" a form of euthanasia than is administering a fatal dose of morphine. On the contrast, proponents of physician-assisted suicide also claim that diseases kill people in far more cruel ways than would any means of death that a physician might provide for an irreversibly ill patient. As a result, Humphry see the action of assisting in suicide as entirely coherent with the physician's duty to the patient. However, Humphry has been an open critic of Kevorkian's work. He has described Kevorkian's theory and practice of assisted suicide as open-ended euthanasia. Noting Kevorkian's lack of precautionary measures such as the use of waiting periods and second opinions, Humphry sees any wider application of Kevorkian's methods as potentially leading to abuse and tragedy. "The thinking people in our movement are appalled by it," Humphry said. "If you have Kevorkian's type of euthanasia, it will be a slippery slope. Kevorkian's is a recipe for skiing down a glacier." Critics of physician-assisted suicide also use the familiar "slippery slope" argument, proposing that once physician-assisted suicide is legalized, other forms of euthanasia will more likely be practiced as well. They see assisted suicide as potentially leading to situations in which elderly, chronically ill, and handicapped people, along with others, are killed through active, non- voluntary euthanasia. Related to this idea is the view that widespread practice of physician- assisted suicide might claim the lives of those whose intolerable suffering is caused by treatable depression. 2.4) Related Organization and Actors Dr. Jacob "Jack" Kevorkian or as he was portrayed in the media "Dr. Death"; was an American pathologist, euthanasia activist, painter, author, composer, and instrumentalist. He is best known for defending a terminal patient's right to die via physician-assisted suicide (a.k.a. ‘assisted suicide’). However, many consider him a hero as he helped set the platform for reform. He famously said, "Dying is not a crime."

Kevorkian is claimed to have assisted the deaths of 130 terminally ill people in 1990s. In each of these cases, the individuals themselves voluntarily took the final action which resulted in their own deaths by pushing a button which released the drugs or chemicals. Kevorkian, as a physician, only attached the individual to a euthanasia device that he had devised and constructed. Two deaths were assisted by means of a device which delivered the euthanizing drugs intravenously. Kevorkian called the device a "Thanatron" ("Death machine"). Other people were assisted by a device which employed a gas mask fed by a canister of carbon monoxide, which Kevorkian called the "Mercitron" ("Mercy machine"). In 1999, Kevorkian was arrested and tried for his direct role in a case of voluntary euthanasia, even though what he believed he was doing was “physician-assisted suicide”. He was convicted of second-degree murder and served eight years in prison. He was released in 2007, on condition he would not offer advice nor participate nor be present in the act of any type of suicide involving euthanasia to any other person; as well as neither promote nor talk about the procedure of assisted suicide. Philip Haig Nitschke Nitschke is an Australian humanist, author and founder & director of the pro-euthanasia group . He campaigned successfully to have a legal euthanasia law passed in Australia's Northern Territory and assisted four people in ending their lives before the law was overturned by the Government of Australia. Nitschke was accepted as the first doctor in the world to administer a legal, voluntary, lethal injection. Nitschke states that he and his group are regularly subject to harassment by authorities. In 2015 Nitschke publicly burned his medical practising certificate as a response to what he saw as "onerous" conditions that violated his right of the freedom of speech, imposed on him by the Medical Board of Australia. Organizations Supporting Assisted Death There are many non-profit organization that supports and advocates assisted death because of the belief that people should have their own choice in their death and that they have ‘the right to die’. Some of the organization below provide advice and lethal drugs to the ones who want to commit any type of “suicide” under the conditions that the person either has a terminal illness, an unendurable incapacitating disability, unbearable and uncontrollable pain or mental illness (such as ‘Dignitas’). On the other hand, some organizations have a single aim of legalising assisted dying, within upfront safeguards. Examples of the organizations are:  Compassion & Choices  Death with Dignity National Centre  Dignitas (Switzerland)  Dignity in Dying  Disabled Activists for Dignity in Dying (DADID)  Exit  Exit International  Network  World Federation of Right to Die Societies Organizations Opposing Assisted Death The organization that are against assisted death mostly consists of medical groups, organizations for the people with disabilities and religious groups and their most common reason to oppose is that physicians-assisted suicide, like euthanasia, is unethical and must be condemned. The belief is that no one should be involved in death of someone else. Examples of the organizations are:  ADAPT  British Medical Association  Care Not Killing  Christian Medical Fellowship  The Euthanasia Prevention Coalition International  National Council on Disability  National Spinal Cord Injury Association   Patients' Rights Action Fund  Royal College of General Practitioners  Royal College of Physicians  TASH  The Russian Orthodox Church Canons  The United States Conference of Catholic Bishops  World Medical Association

III- Specific Analysis on Relevant Conflicts and Problems There are two contradicting sides in the discussions regarding assisted death. The discussions has been continuing for a long time and it seem to continue for even more. The main conflict is the ethicalness of the PAS. The arguments of the in favour side of PAS, which consist of people who believe that it should be legal and it is ethically justifiable, are as follows: Respect for autonomy: Decisions about time and circumstances of death are only personal. People should have right to choose the timing and manner of their own death. Justice: Justice requires that terminally ill patients have the legal right to refuse treatment that will extend the duration of their deaths. For patients who are suffering but who are not dependent on life support machines, such as respirators or dialysis, refusing treatment will not be enough to hasten death. Therefore, to treat these patients equitably, we should allow assisted death as it is their only option to hasten death. Compassion: Suffering means more than pain; there are other physical, existential, social and psychological burdens such as the loss of independence, loss of sense of self, and functional capacities that some patients feel jeopardize their dignity. It is not always possible to ease suffering. Thus PAS may be a compassionate response to end suffering. Individual liberty: Though society or a religion has strong interest in preserving life, that interest lessens when a person is terminally ill and has strong desire to end their own life. A complete prohibition against PAS excessively limits personal liberty. Therefore PAS should be allowed in certain cases. Honesty & transparency: Some people acknowledge that assisted death already occurs, although in secret. The fact that PAS is illegal in most states prevents open discussion between patients and physicians. Legalization of PAS would promote open discussion and may promote better end-of-life care as patients and physicians could more directly address concerns and options. Ethics: The ethical argument is, of course, that a person has the right to choose whether they want to live or die as long as they do not affect the rights of others. Ethnic supporters also say that another should not or cannot interfere with the persons’ own free will to terminate their own life. The arguments of the opposing side of PAS, which consist of people who believe that it should not be legal and it is ethically impermissible, are as follows: Sanctity of life: Religious and cultural traditions upholding the sanctity of human life have historically prohibited suicide or assistance in dying. PAS is morally wrong because it is viewed as diminishing the sanctity of life. Passive vs. Active distinction: There is an important difference between passively "letting die" and actively "killing", similar to euthanasia. Treatment refusal or withholding treatment equates to letting die (passive) and is justifiable, whereas PAS equates to killing (active) and is not acceptable. Potential for abuse: Vulnerable people, lacking access to quality care and support, may be pushed into assisted death. Furthermore, assisted death may become a cost-containment strategy. Burdened family members and even health care providers might encourage such people to choose assisted death and the protections in legislation can never catch all instances of such exploitation. To protect against these abuses, PAS should remain illegal. Professional integrity: Historical ethical traditions in medicine is strongly contrary to taking life. For instance, the Hippocratic Oath states, "I will not administer poison to anyone where asked, and I will be of benefit, or at least do no harm." As a result, some major professional groups such as the American Medical Association and the American Geriatrics Society oppose assisted death. The overall concern is that linking PAS to the practice of medicine could harm both the integrity and the public's image of the profession. Fallibility of the profession: The concern here is that physicians will make mistakes. For instance there may be uncertainty in diagnosis and prognosis. There may be errors in diagnosis and treatment of depression, or inadequate treatment of pain. Thus the State has an obligation to protect lives from these inevitable mistakes and to improve the quality of pain and symptom management at the end of life.

IV- Recommendations Keeping in mind the statements, comments and discussions written in this report, if reaching a solid answer is hard and confusing, answering the following questions might help to clear the views on the issue. Suppose that you are suffering from a disease that is terminal, debilitating, and very painful. Should you have the right to die when you wish rather than live in continued agony? Should your doctor be legally free to help you take your own life, perhaps by prescribing some pills and telling you their fatal dosage? Or should the law forbid anyone—including doctors—to assist in the suicide of another human being? Can you decide your own death, even though you do not know if a cure can be found or not? Is it right to give up on your life while every religion forbids it? Although if you do not die, you will only suffer, is it better than death? These are just some of the questions that a patient, who asks for assisted death, thinks about. The issue of physician-assisted suicide, is very dependable, changeable, crucial and critical because a human life is the most important thing in the world. So how to care for its end, is an issue that should get great attention and given enormous thought. V- Useful links for further research http://www.livinganddyingwell.org.uk/ https://www.deathwithdignity.org/ https://www.compassionandchoices.org/who-we-are/ http://edition.cnn.com/2014/11/26/us/physician-assisted-suicide-fast-facts/ http://www.pbs.org/wgbh/frontline/article/the-shadow-side-of-assisted-suicide/ http://www.independent.co.uk/life-style/health-and-families/assisted-dying-hearing- arguments-for-and-against-a-bill-thats-divided-britain-10495745.html http://www.dignityindying.org.uk/blog/panel-favour-assisted-dying-win-debate-ucl/ http://content.time.com/time/nation/article/0,8599,1882684,00.html VI- Bibliography http://legal-dictionary.thefreedictionary.com https://en.wikipedia.org/wiki/Assisted_suicide https://en.wikipedia.org/wiki/Jack_Kevorkian https://depts.washington.edu/bioethx/topics/pad.html https://en.wikipedia.org/wiki/Philip_Nitschke http://metro.co.uk/2015/09/11/should-assisted-dying-be-legalised-arguments-for-and-against- as-mps-debate-bill-5386467/#ixzz46J1QVW9e http://www.ibtimes.co.uk/assisted-dying-bill-arguments-against-explained-1519278 http://www.dignityindying.org.uk/ http://www.islam-usa.com/index.php?option=com_content&view=article&id=381&Itemid=322 http://lawdigest.uslegal.com/family-laws/physician-assisted-suicide/7349/