Grant Gillett MBChB (equivalent to U.S. MD); MSc (Psychology); D.Phil (Oxon); FRACS (equivalent to U.S. Board Certification in Neurosurgery); FRS NZ. Grant Gillett is a qualified neurosurgeon and practised until 2006. He also has a D.Phil (Oxon) and was a fellow in philosophy at Magdalen College, Oxford. He is now a Professor of Medical Ethics at the Bioethics Centre of the Otago University Medical School, and a fellow of the Royal Society. He is author of The Mind and its Discontents (2009), Subjectivity and Being Somebody: human identity and neuroethics. (2008), Bioethics in the clinic: Hippocratic reflections (2004) and over 350 articles in medical ethics, philosophy, bioethics, the philosophy of psychiatry and neuroscience. An abiding area of writing and research has been end-of-life care and euthanasia and he worked closely with the euthanasia report group of the BMA in 1988 and 1989. He continues to teach and write extensively on ethical issues and medical law in New Zealand and Australia, and the philosophical basis of contemporary clinical ethics. This report was prepared for the New Zealand Medical Association, 2017 A report on euthanasia for the NZMA I. Executive summary ........................................................................................................... 1 II. Preamble ........................................................................................................................... 5 III. Hippocratic traditions .................................................................................................... 5 3.1 The pause .................................................................................................................. 5 3.2 Narratives, lives, deaths and human sensibility ........................................................ 7 3.3 The sanctity of life ..................................................................................................... 8 3.4 Whose life is sacred? ................................................................................................. 9 3.5 The unique challenge of mortality .......................................................................... 10 3.6 Suicide and its relevance to euthanasia .................................................................. 12 IV. Care and intervention: our role as professionals and clinicians.................................. 14 V. International ethical-legal perspectives .......................................................................... 16 5.1 The Netherlands ...................................................................................................... 17 5.2 Belgium .................................................................................................................... 21 5.3 United Kingdom ....................................................................................................... 22 5.4 United States ........................................................................................................... 23 5.5 Canada ..................................................................................................................... 24 5.6 South Africa: an about turn against legal assistance in dying ................................. 24 5.7 The European Association of Palliative care ........................................................... 25 VI. Lecretia Seales and aid in dying in New Zealand ......................................................... 25 VII. Severely damaged human lives ................................................................................... 37 VIII. Futility .......................................................................................................................... 40 8.1 Varieties of futility ................................................................................................... 41 8.2 Decisions about futility and benefit ........................................................................ 42 IX. Other cultures and faith traditions: some tentative thoughts .................................... 43 X. Children: potentiality and human interests .................................................................... 45 10.1 The potentiality principle—further thoughts. ......................................................... 46 10.2 Severely impaired newborns and transplant decisions .......................................... 48 10.3 Children and clinical decisions ................................................................................. 49 XI. Ending the narrative in a fitting way ........................................................................... 52 11.1 The RUB: the worst possible end to the story ......................................................... 55 XII. Euthanasia broadly speaking: pulling the threads together ....................................... 58 12.1 Professional morality and legal reform ................................................................... 58 12.2 A sense of life in the midst of the clinic ................................................................... 59 12.3 Inspir(it)ed persons with a sense of life .................................................................. 61 XIII. Concluding remarks and convergences ....................................................................... 62 XIV. References (Alphabetical) ........................................................................................... 65 I. Executive summary A report on euthanasia for the NZMA This report is an update on the debate about euthanasia as it affects the medical profession in New Zealand. It examines ethical arguments and codes, personal and professional commitments, and the current state of the law. The report includes commentary from a variety of sources and tries to strike a balance in alignment with traditional ethics, New Zealand law, and international codes of medical ethics. It has been prepared by Professor Grant Gillett, MBCHB, D Phil (Oxon); FRACS; FRSNZ Bioethics Centre, University of Otago, and was commissioned by the New Zealand Medical Association’s Board. The Hippocratic tradition I will not give a fatal draught to anyone if I am asked, nor will I suggest such a thing. The Hippocratic tradition is committed to a version of the sanctity of life principle: that each human life is of unique value and ought to be protected and cherished on that basis alone. It is moderated by other considerations in clinical practice. Clinical intuitions, illness and end-of-life decisions Clinical decisions draw on our character as moral agents. End-of-life procedures, significantly differ from one another. Active voluntary euthanasia generally denotes intentionally ending a patient’s life at the patient’s explicit and competent request; physician-assisted suicide and physician aid in dying (where lethal drugs are prescribed to a patient for the purposes of self-administration) also involve an active intervention and differ from the limitation of life- prolonging treatment. Palliative care shares the widespread clinical intuitions of many doctors and leaves the profession holding to the traditional position and our duties to protect life. Human death has many and diverse meanings and requires caring attention and non- abandonment of a dying patient, in ways that often go beyond clear-cut policies or objective guides to action. The sanctity of life and its limits Medicine is not committed to a doctrine of the sanctity of life requiring that we prolong life whatever the condition of the patient concerned, but rather focuses on the supreme value of each human life. That allows voluntary euthanasia to be distinguished from the decision to forego “aggressive medical treatment” by applying certain helpful concepts: I. substantial benefit is an outcome that, now or in the future, the patient would consider worthwhile II. the risk of unacceptable badness or the RUB. A report on Euthanasia for the NZMA 1 These two concepts contribute to a patient-centred concept of medical futility in end-of-life care. The unique challenge of mortality: our role as professionals and clinicians Death is a certainty for all of us and, when confronting it, we meet as person-to-person such that medical technology per se has a limited, albeit vital, role. When any patient dies, the healthcare team feels the burden of that loss so that, if a patient is helped to die by a doctor at a given time and place, that doctor assumes a heavy moral burden. Those in hospice practice see such a solution to the problem of death and dying as a poor second best to careful attention to the needs of the patient and any despair or desperation induced by those needs. International ethico-legal perspectives Law or policy has specifically sanctioned active voluntary euthanasia in a number of settings (eg, Netherlands, Belgium, Luxembourg, Colombia, Canada) and in others active physician aid in dying is allowed (eg, Switzerland and the US states of Oregon, Washington, Montana, Vermont and California). Opponents of a law change have deep misgivings about acceding to a wish to actively end a patient’s life. It happens with patients who are deeply distressed and fearful and whom we, as healthcare professionals, tend to find troubling and distressing. That strains the Hippocratic ethos founded on trust and reverence for life, and the attitudes we have developed during our training and professional experience. Extant evidence as to professional and societal opinion are universally inconclusive, and published