&

Physician Assisted
Suicide

Scope

Definitions

Introduction

History

Why Euthanasia

Legal status

Status in India

Euthanasia and Psychiatry

Ethical issues

Conclusion

Definitions
The term euthanasiais derived from the Greek wordseumeaning "good andthanatosmeaning "death".
Euthanasia - the bringing about of a gentle and easy death for
someone suffering from an incurable and painful disease or in an
irreversible coma (Pearsall & Trumble, 1996).
Suicide - The act or an instance of taking one's own life voluntarily
and intentionally
PAS - the practice of providing a competent patient with a
prescription for the patient to use with the primary intention of
ending his or her own life. The patient performs the act at a time of
their own choosing

Introduction

Euthanasia is a controversial subject, not only because

there are many moral dilemmas associated with it, but
also in what constitutes its definition.

Two of the strongest arguments revolve around patient

autonomy and dignified dying.

It is a sensitive subject, with varying legal, ethical and

philosophical views.

Furthermore, views and laws in regard to euthanasia

differ among various countries, religions and regions.

WHY EUTHANASIA?

Until the 1940s, medical care was often just comfort care,
alleviating pain when possible.

During the last 50+ years, medicine has become

increasingly capable of postponing death.

With advancing age, there is a perceived increase in

suffering and disability.

Increasingly, we are forced to choose whether to allow

ourselves to die.

Relieve suffering, maintain dignity, and shorten the course

of dying when death is inevitable.

M.B

History
Hippocrates(ca. 460 BC - ca. 370 BC)- Euthanasia was practice, no need to preserve
the life of a person who had no interest in living, or who thought
life as a burden.
1300s- English jurisdiction- considered as a criminal act. Mercy killing was also not
supported by the ascendancy of Christianity (12th till 15th century).
1828- Anti-euthanasia was passed in New York.
1870- Samuel Williams suggested the use of morphine and analgesic medications for
assisting quick and painless death.
1885- The American Medical Association strongly declined the use of analgesic for
euthanasia.
Beginning of 20th century - mercy killing and assisted killing already entered the
minds of the public.

1905- A bill for making it legal was circulated in Ohio, but it failed. A similar bill
was introduced in the next year, which also failed.
1935- The first group for legalization of euthanasia, called Voluntary Euthanasia
Legislation Society (VELS), was founded by a group of doctors in London.
1938- A similar organization, known as National Society for the Legalization of
Euthanasia (NSLE) came into existence.Till date, many cases of physician-assisted
suicide have been fought in the court.
1940- Non-voluntary euthanasia was practiced for the first time by German
physicians, to eliminate the diseased and disabled Germans in closed gas chambers.
The main purpose of the program was to get rid of handicapped children and people
with psychiatric problems.
1945- It was estimated that 300,000 Germans had been killed.
20th century- Marked the formation of several organizations for addressing the
concerns regarding euthanasia.

1986- Doctor Joseph Hassman was charged guilty for administering a

lethal dose of Demerol to his mother-in-law. He was fined and sentenced
to two years imprisonment for the act.
1999- Euthanasia became a public issue, with the imprisonment of Dr.
Jack Kevorkian for conducting voluntary euthanasia on Thomas Youk
(52), who was in the final stage of ALS (amyotrophic lateral sclerosis)

Classification and types

On the basis of the nature of act being done,
as:
Active and Passive
On the basis of consent, as
Voluntary, Involuntary and Nonvoluntary

Active vs Passive
Active or Positive: It is a positive merciful act, to end useless
suffering or a meaningless existence.
It is an act of commission, e.g. by giving large doses of drugs to
hasten death.
Passive or Negative: It means not-using or discontinuing the use of
extraordinary life-sustaining measures to prolong life.
This includes an act of omission, such as failure to resuscitate a
terminally ill or hopelessly incapacitated patient or severely
defectively newborn infant.
It involves non-use of the measures that would probably delay
death and permit natural death to occur.

On the basis of consent

Voluntary- cases where the person himself requests the
commission of euthanasia (active or passive).
Involuntary - where the person on whom euthanasia is
committed is mentally incompetent to make a choice and
euthanasia is committed on the basis of the assessment made by
others.
Non-voluntary - when a person is unable to give his/her
consent, but gives another person the power to make that
decision for them.

Physician assisted suicide

-The physician provides the means, but the patient must act.
The patient maintains more autonomy, remains the actual agent of
death, and may be less likely to be coerced.
-Physician-assisted suicide may involve providing

Information on ways of committing suicide

supplying a prescription for a lethal dose of medication or a means

of inhaling a lethal amount of carbon monoxide,

providing a suicide device that the patient can operate.

-Jack Kevorkian

Devices

Deliverance Machine
Dr. Philip Nitschke

The following three questions were displayed on the laptop screen; each
required the patient to click a "Yes" button to proceed:

1.

Are you aware that if you go ahead to the last screen and press the Yes
button, you will be given a lethal dose of medications and die?

2.

Are you certain you understand that if you proceed and press the Yes
button on the next screen that you will die?

3.

In 15 seconds you will be given a lethal injection ... press Yes to proceed

The Hemlock Society

Founded by Derek Humphry in 1965

Final Exit, a how-to guide to suicide that was a best

seller in 1991

supports physician-assisted suicide and active, voluntary

euthanasia for the terminally ill, but it does not
encourage suicide in the absence of terminal illness.

The Hemlock Society's efforts influenced the 1994

passage of a ballot initiative to legalize physicianassisted suicide in Oregon and both public and medical
opinions toward more accepting attitudes of physicianassisted suicide.

Legal Status

Legal Status
More than 20,000 deaths registered in six countries: Belgium,
Denmark, Italy, the Netherlands, Sweden and Switzerland.

As of June 2015, euthanasia is only legal in the

Netherlands,Belgium, and Luxembourg.
Assisted suicide is legal inSwitzerland, Germany,
Albania, Colombia, Japan and in
The US states of Washington,Oregon, Vermont, New
Mexico and Montana.
February 13, 2014, Belgium became the first country to
allowvoluntarychild euthanasia without any age limit.[

NETHERLANDS

First nation to permit euthanasia

The law allows medical review board to suspend prosecution of doctors

who performed euthanasia when each of the following conditions is
fulfilled:

the patient's suffering is unbearable with no prospect of improvement

the patient's request for euthanasia must be voluntary and persist over time
the patient must be fully aware of his/her condition, prospects and options

there must be consultation with at least one other independent doctor who
needs to confirm the conditions mentioned above

the death must be carried out in a medically appropriate fashion by the

doctor or patient, in which case the doctor must be present

the patient is at least 12 years old

Groningen Protocol

For the Dutch public prosecutor, the termination of a

child's life (under age 12) is acceptable if 4
requirements were properly fulfilled:

The final decision about "active ending of life on infants"

isnotin the hands of the physicians but with the parents,
with physicians and social workers agreeing to it.

The presence of hopeless and unbearable suffering

The consent of the parents to termination of life

Medical consultation having taken place

Careful execution of the termination

The Status in India

Cases Of Significance

Maruti Dubal vs State of Maharashtra 1986 Article 21 includes right

to die.

Airedale Trust v.Bland 1993

P.Rathinam vs Union of India 1994

Suicide, as has already been noted, is a psychiatric problem and not a

manifestation of criminal instinct. We are in agreement with Dr (Mrs)
Dastoor that suicide is really a "call for help" to which we shall add that
there is no "call for punishment"
Gian Kaur vs State of Punjab 1996 Right to die is not part of article 21.
CA Thomas Master vs Union of India 80 year old man wanted to
voluntarily end life. Writ was dismissed , no distinction between
suicide and voulteering to die.

Aruna Shanbaug case

Aruna Shanbaug was a nurse working at the King Edward

Memorial Hospital, Parel, Mumbai. On 27 November 1973 when
she was strangled and sodomized by Sohanlal Walmiki, a
sweeper.

She has been in a vegetative state since.

Pinki Virani, a social activist, filed a petition in the Supreme

Court arguing that the "continued existence of Aruna is in
violation of her right to live in dignity".

The Supreme Court's decision to reject the discontinuation of

Aruna's life support was based on the fact that the hospital staff
who treat and take care of her did not support euthanizing her.

She died from pneumonia on 18 May 2015, after being in a coma

for 42 years.

Aruna Shanbaug case, Justice Katju

In India
Passive euthanasia is legal in India.
On 7 March 2011 the Supreme Court of India legalised passive euthanasia
by means of the withdrawal of life support to patients in a permanent
vegetative state.

December 23, 2014, Government of India endorsed and re-validated the

Passive Euthanasia judgement-law in a Press Release.
Active euthanasia, including the administration of lethal compounds for
the purpose of ending life, is still illegal in India

In India
It is the High Court under Article 226 of the Constitution which can grant
approval for withdrawal of life support to such an incompetent person.
Article 226(1) of the Constitution states: Notwithstanding anything in
article every High Court shall have power, throughout the territories in
relation to which it exercises jurisdiction, to issue to any person or
authority, including in appropriate cases, any Government, within those
territories directions, orders or writs, including writs in the nature of
habeas corpus, mandamus, prohibition, quo warranto and certiorari, or
any of them, for the enforcement of any of the rights conferred by Part III
and for any other purpose.

In India

Supreme court guidelines

A decision has to be taken to discontinue life support either by the

parents or the spouse or other close relatives, or in the absence of any of
them, such a decision can be taken even by a person or a body of persons
acting as a next friend. It can also be taken by the doctors attending the
patient. However, the decision should be taken bona fide in the best
interest of the patient.
Even if a decision is taken by the near relatives or doctors or next friend
to withdraw life support, such a decision requires approval from the High
Court concerned.
When such an application is filled the Chief Justice of the High Court
should forthwith constitute a Bench of at least two Judges who should
decide to grant approval or not. A committee of three reputed doctors to
be nominated by the Bench, who will give report regarding the condition
of the patient. Before giving the verdict a notice regarding the report
should be given to the close relatives and the State. After hearing the
parties, the High Court can give its verdict.

In India

Cultural Aspects

Sallekhan (also Santhara, Samadhimarana, Sanyasana-marana),

Prayopavesa (literally resolving to

die through fasting)

Jain practice of facing death

voluntarily at the end of one's life.

Practice in Hinduism that denotes

the suicide by fasting of a person,
who has no desire or ambition left,
and no responsibilities remaining in
life.

It is prescribed both for the

householder and ascetics.

Sallekhana is made up from two words

sal (meaning 'properly') and lekhana,
which means to thin out.

Properly thinning out of the passions

and the body is 'Sallekhan'. Sallekhana
is allowed only when a person is
suffering from incurable disease or
great disability

It is also allowed in cases of terminal

disease or great disability.

In India

Cultural Aspects

Thalaikkooththal (Tamil: ,
lit. showering) is the traditional practice
of senicide (killing of the elderly) or
involuntary euthanasia, by their own
family members, observed in some parts
of southern districts of Tamil Nadu state
of India.

The elderly person is given an extensive oil-bath early in the morning and
subsequently made to drink glasses of tender coconut water which results in
renal failure, high fever, fits, and death within a day or two.

Relevance to
Psychiatry

Core symptoms of major depression in this population include

pervasive anhedonia, the wish to die, compromised ability to
think clearly, a sense of hopelessness about the future, a
tendency to embellish pain and misery, and a view of the
world that embraces pessimism and negativity.
Primary care physicians are ill equipped to diagnose depression
in the elderly or other complex situations.
Even well-trained psychiatrists have difficulty with the
diagnosis of depression in severely ill patients.
Studies indicate that many patients with life-threatening
illnesses substantially fortify their will to live after treatment
of depression.

In Psychiatry
Several critical issues for psychiatrists have been raised with the
advent of physician-assisted suicide (PAS), which is the
deliberate prescription of medication to or counselling of ill
patients so that such patients may use this medication or
information to end their own life (Cohen et alet al, 1994).

PSYCHIATRIC ASSESSMENT
PHYSICIAN-ASSISTED SUICIDE FOR PSYCHIATRIC
ILLNESS

PSYCHIATRIC ASSESSMENT
Psychiatric assessment is mandatory for patients who request PAS in some
jurisdictions, but not in others.
In Oregon, a physician refers the patient to a psychiatrist or psychologist only if the
physician believes a psychiatric disorder may be present.
A similar situation applies in The Netherlands, where psychiatric assessment is
requested for only 3% of patients who request PAS.
Terminally ill patients with depression are more likely to change their
minds about PAS than patients without depression (Emanuel et al 2000)

Role of the psychiatrist

Identify and treat psychiatric illness

Assess mental capacity and decision making ability

PSYCHIATRIC ASSESSMENT
Major themes that emerged among patients asking for
euthanasia include
Hopelessness
Dependence on caregiving
Demoralization
Pain and Other Symptoms
Lack of social support
Absence of Religious beleifs

Competence concerning treatment decisions signifies

Ability to communicate his or her decision.
Factually understand the situation and its consequences
Rationally assimilate the information.

Euthanasia in patients suffering

primarily from mental disorder

Data exist only in the Netherlands.

3% of all requests for assisted death.

Only 2% are granted.

Motivations include
Absence of hope of improvement
Unbearable mental suffering
Being a burden
Pain or other suffering
Loss of dignity

Euthanasia in patients suffering

primarily from mental disorder

The psychiatrist has to make sure that there is no external

pressure towards the ending of life, either perceived
subjectively or actual.

The assessment of competence in a patient with a mental

disorder and is not straight forward, the presence of a sliding
standard of competence poses the risk of paternalism.

Assessment of the longing for death.

The suffering must be perceived by the patient as

unbearable.

The suffering has to be beyond human aid.

Euthanasia in patients suffering

primarily from mental disorder
Dutch Supreme Court has ruled that PAS may be
justifiable in certain cases in which there is unbearable
mental suffering in the absence of physical illness.
It is essentially impossible to describe any psychiatric
illness as incurable, with the exception of advanced
brain damage as occurs in progressive
neurodegenerative
disorders such as Alzheimers disease and Huntingtons
disease.

Arguments

Proponents

Quality of life and patient dignity are more important

than the number of hours or days that a patient lives.

Respect for each patient's autonomy has become a

guiding principle in medicine.

One of the ways that patients may exercise their right

to self-determination is by asking for life-sustaining
treatment to be withdrawn.

Some deathsespecially from cancer, AIDS, or

progressive neurological lesionsmay be slow and
miserable. Pain cannot always be totally relieved with
consciousness preserved.

Opponents

Euthanasia, even if the patient voluntarily requests it, is a form of

killing, and outside of war, self-defense, and, perhaps, capital
punishment, killing should never be sanctioned.

Never necessary, as most suffering can be relieved with skillful and

compassionate care.

Many patients who request aid in dying may have unresolved

psychosocial or spiritual issues or unrecognized or untreated
depression, a difficult diagnosis to make in the context of chronic
and painful medical illness.

slippery slope

Particular threat to the economically and socially vulnerable, and

the poor, mentally ill, or disabled may be coerced to request it.

Euthanasia violates the time-honored mission of physicians to be

unambiguously committed to preserving life.

Pitfalls

In 1991, the New England Journal of Medicine published

the case of Diane, a woman with acute leukemia .