Euthanasia and abuse of such laws

[mr friendly guy]

One of the arguments against euthanasia is the slippery slope argument that the laws are vulnerable to abuse, despite the checks and balances inherent in proposals. IIRC the Dutch example required at least two doctors to sign off on it. The purpose of this thread is to discuss this particular aspect, especially in light that palliative care measures are suggested as a means to render euthanasia unnecessary.

To my mind people sprouting the slippery slope don't seem to have any idea how "easy" it is to utilise palliative care measures. Before I go on, I will just explain palliative care. Basically you keep people comfortable, and no curative or "heroic" measures are implemented. That is the patient is declared not for resuscitation, not for the intensive care unit, not for CPR etc, while various drugs are used to keep them comfortable. There are variations however I tend to use morphine + clonazepam via an infusion +/- hyoscine (which is really just for the relatives' benefit) *

To make someone for palliation there will have to be a not for resuscitation form (NFR) signed. The amount of paperwork requires varies between hospitals, however generally it varies from a doctor putting his signature on a form or asking a few more questions. Note a NFR doesn't necessarily mean we think said patient will die this admission, it just is a guideline for staff in case things do take a turn for the worse.

After the NFR form usually a short discussion with the relatives is made, and generally they agree and then prescribe. Now compare to various proposed euthanasia laws.

Both would require an NFR form, but euthanasia laws have proposed things like having two doctors (usually consultants) sign off, making sure that the patient is of sound mind etc. Contrast to how much less barriers are put up to palliative care, one doctor signing the form, no need to check if the patient is sound mind etc. While I appreciate their is an ethical difference between witholding treatment and letting "nature take its course" (albeit in comfort) and actively helping nature do the deed, the outcome is still the same. The patient passes away in comfort.

The same theoretical misuse of euthanasia laws, can occur with palliative care as well. What happens when a doctor chooses to palliate someone instead of actively treating for an ulterior motive. And if people start using Harold Shipman examples and the greed factor, I could point out so called "ash money". **
The point is, that these wild slippery slopes used to attack euthanasia, are even easier to apply to current treatment modalities because they have even less checks and balances than proposed euthanasia laws.

* since the gurgling noise from secretions patients make, of which hyoscine is designed to counter is thought to not cause them discomfort per se.

** ash money was the term used to describe being paid extra (and quite generous) too for filling out death certificates. In the UK (at least a few years ago) the money went straight to the Doctor filling out the certificate, while in Australia it goes to the hospital. I can similar concoct a story and point out that it gives doctors ulterior motive to palliate patients <insert wild conspiracy theory here>

[Shroom Man 777]

Then again the end of palliative care, the patient's eventual passing on, takes quite a bit of time to happen and allows the patient/family/doctors/whoever time to change minds or allows intervention if ever ulterior motives are found, unlike euthanasia, which happens much faster and isn't reversible.

Not really arguing, but there are differences between NFR (we call them DNRs, Do Not Resuscitate) and euthanasia that warrant the added precautions. The ethics are also kind of very different. "Make me comfortable but don't prolong my life, let it take its course" =/= "actually ending the patient's life"

[PainRack]

Palliative is reversible, euthanasia isn't.

Although to be honest, I'm quite..... surprised at the level of documentation Australia goes through.

There's none here whatsoever. You just need the doctor to have conducted a family conference and obtained verbal permission, then him inking up orders. Fuck. If there was some kind of permament record, it would save the on call doctors from scratching their heads regarding resuc status over the weekends.

[Sela]

@Shroom: FunFact: in medical education there's a push to get people to call it 'DNAR' (Do not attempt resucitation). Makes it sound more like it is, since majority of the time resucitation fails.

@OP:
So - maybe i missed the topic that sprung this topic, but I'm not following. What is it people might abuse about legal euthanasia?

[Stark]

'Misuse' is simply something people vaguely mention when opposed to euthanasia.

[Zaune]

There is of course another 'slippery slope' to consider, or at least an issue that requires a lot of deep thinking. If we allow people to choose to end their own lives in order to spare themselves physical pain from incurable illness, in what other circumstances should we respect someone's right to make that decision?

[Kojiro]

Just for reference here's the recently defeated bill from WA.

I didn't read it cover to cover but it seems very robust to me and difficult to abuse. Essentially in order to abuse it you'd have to have a small conspiracy of doctors and witnesses outside of the family.

[mr friendly guy]

@OP:
So - maybe i missed the topic that sprung this topic, but I'm not following. What is it people might abuse about legal euthanasia?

People actually do explain what they mean by misuse which is usually doctors killing patients for ulterior motive. I remember once on the Richard Dawkins board someone blatantly making allusions to Harold Shipman. Never mind that Shipman killed his victims in a country without euthanasia laws and was eventually picked up when Doctor's who were asked to co sign some forms became suspicious that he had a high number of patients dying. That and the fact he also forged a dead patient's will to leave the stuff to him.

Of course such people are usually ignorant on how easy it is to palliate. That being said while palliative care is reversible, you would have to uncover the fact that someone is attempting to off a patient for ulterior motive in a reasonable short span of time. While before euthanasia is even attempted, most bills require intensive discussion and paperwork, hence the time where it is "reversible". I am willing to bet that with these safeguards in place, the time to discover some god damn conspiracy to off someone is comparable, or can simply be legislated in, ie say the patient cannot have it done until x time has passed to 'think it over" and change their mind.

[Broomstick]

To make someone for palliation there will have to be a not for resuscitation form (NFR) signed. The amount of paperwork requires varies between hospitals, however generally it varies from a doctor putting his signature on a form or asking a few more questions. Note a NFR doesn't necessarily mean we think said patient will die this admission, it just is a guideline for staff in case things do take a turn for the worse.

My mother actually had a legal Do Not Resuscitate document drawn up that she carried with her, that would unequivocally state her wishes to any hospital she happened to be transported to. I think at some point the law was changed in Michigan so that paramedics and other first responders would be able to respect such a document- it used to be that if an ambulance was called the medics legally HAD to attempt resuscitation even if a DNR was in effect. Anyhow - as an illustration that one can have a DNR for some time - mom carried hers with her for fifteen years. During which time she carried on with her life, visited children and grandchildren, and so on. She was also hospitalized and treated for pneumonia during that time as well. Having a DNR doesn't mean you're cut off from medical treatment, it just means if you die they won't try to revive you. She had a bad heart, had already been through surgeries and such, and had decided the next time it stopped to let it stay stopped. People with a DNR aren't always invalids and aren't always visibly that ill or disabled.

While I appreciate their is an ethical difference between witholding treatment and letting "nature take its course" (albeit in comfort) and actively helping nature do the deed, the outcome is still the same. The patient passes away in comfort.

I think a difference in some peoples' minds is that people under palliative care can live a long time in some circumstances and nothing is being done to bring death sooner, whereas as euthanasia is seen as actively killing someone, that is, they regard it as murder. If the victim is helpless so much the worse in their mind, you're killing a helpless human being with no means of defense.

The same theoretical misuse of euthanasia laws, can occur with palliative care as well. What happens when a doctor chooses to palliate someone instead of actively treating for an ulterior motive.

That, and people have been euthanized under the guise of palliative care. Palliative care allows for administering pain medication in amount sufficient to reduce the breathing reflex, as an example, even if that slightly hastens death if that level of medication is required for pain control. In which case, you just administer a lot of morphine (or whatever) then say the patient was in uncontrollable pain.

Personally, I think it's a pretty rare circumstance where that happens. Insufficient pain control seems more an issue in medicine these days. Anyhow, it IS an issue in hospice care, particularly a concern of people unfamiliar with hospice which they or their relatives are entering for the first time.

Then, in the US, we have the issue of people thinking they're being "dumped" into hospice not because a cure is impossible but because insurance doesn't want to pay for it and they don't have the money themselves to pay for it.

But I think part of the fear of euthanasia abuse comes from a fear of someone else deciding their life isn't worth living. I hear people say things like they'd rather die than be in a wheelchair - but not everyone feels that way, you know. Among the disabled there is a real fear that, although the disabled person wants very much to live and finds enjoyment in life someone else will decide otherwise if they're temporarily incapacitated and have them euthanized with the best of intentions.

This is in addition to beliefs that doctors should do no harm, and killing for any reason is a harm.

There are probably other reasons people oppose euthanasia as well, though they don't come to mind at the moment.

[mr friendly guy]

I think a difference in some peoples' minds is that people under palliative care can live a long time in some circumstances and nothing is being done to bring death sooner, whereas as euthanasia is seen as actively killing someone, that is, they regard it as murder. If the victim is helpless so much the worse in their mind, you're killing a helpless human being with no means of defense.

The thing is, most euthanasia laws require the patient to give consent before hand. Some examples of euthanasia involves the patient actively drinking the toxic cocktail themselves (usually high dose barbituates) or injecting themselves (remember Jack Kervokian's euthanasia device, I certainly remember that even though I was only a kid at the time, like 6 or 7). Whereas in regards to current medical practice the doctor can choose to withold treatment, sometimes even without the relatives consent, as shown by numerous court cases where relatives try to stop doctors turning off life support machines.

The idea that the victim is helpless in cases of euthanasia but not helpless in regards to existing treatment modality just does not jive with reality.

That, and people have been euthanized under the guise of palliative care. Palliative care allows for administering pain medication in amount sufficient to reduce the breathing reflex, as an example, even if that slightly hastens death if that level of medication is required for pain control. In which case, you just administer a lot of morphine (or whatever) then say the patient was in uncontrollable pain.

Funny you should mention that. The health minister in a recent defeated bill (link above) was a GP before becoming a fully fledge politician. He opposes euthanasia and freely admits he gave palliative care even though he felt it was possible the morphine he gave would hasten death.

Personally, I think it's a pretty rare circumstance where that happens. Insufficient pain control seems more an issue in medicine these days. Anyhow, it IS an issue in hospice care, particularly a concern of people unfamiliar with hospice which they or their relatives are entering for the first time.

Is this the same mindset that gave us the death panels accusations I hear so much about.

But I think part of the fear of euthanasia abuse comes from a fear of someone else deciding their life isn't worth living. I hear people say things like they'd rather die than be in a wheelchair - but not everyone feels that way, you know. Among the disabled there is a real fear that, although the disabled person wants very much to live and finds enjoyment in life someone else will decide otherwise if they're temporarily incapacitated and have them euthanized with the best of intentions.

The thing is, this occurs with palliative care already. People in ICU in drug induced comas can have life support turned off. At least with euthanasia laws these people are still in charge of their faculties when they made the decision, hence they won't be euthanised. I know you are just pointing out other people's fears, but I wonder how much of a difference will it make to these people if they realise how much easier it is to just cease treatment without that person's consent. Most of the time which does not involve a court case.

This is in addition to beliefs that doctors should do no harm, and killing for any reason is a harm.

Those moral arguments are so simplistic. Especially in light that the patient usually makes the final choice, ie drinks the toxic concoction.
Certain doctors who support euthanasia have openly stated they have no moral compunction about doing it. Jack Kervokian backed it up with actions, despite this "not supposed to do harm business". In any event I have no moral compunction about injecting drugs as a form of capital punishment if I thought the accused was guilty, yet alone in euthanasia where the person being killed actively wants it.

[Broomstick]

I think a difference in some peoples' minds is that people under palliative care can live a long time in some circumstances and nothing is being done to bring death sooner, whereas as euthanasia is seen as actively killing someone, that is, they regard it as murder. If the victim is helpless so much the worse in their mind, you're killing a helpless human being with no means of defense.

The thing is, most euthanasia laws require the patient to give consent before hand.

And I think that comes directly out of that fear. Which is fine by me, I think there's enough people with such concerns it should be directly addressed.

On the other hand, other people state very plainly they want everything possible to be done up until he very last, no matter what. As long as that choice is equally valid, equally respected, and equally enforced I, personally, am OK with euthanasia in cases when the patient states in advance the conditions they wish it to occur.

Some examples of euthanasia involves the patient actively drinking the toxic cocktail themselves (usually high dose barbituates) or injecting themselves (remember Jack Kervokian's euthanasia device, I certainly remember that even though I was only a kid at the time, like 6 or 7).

Unfortunately, I can not provide details in the particular case I am about to mention as medical privacy laws do not permit me to discuss them. I do, for a fact, know of one case where it was Kevorkian who performed the injection, not the "patient", who was too debilitated to move and, indeed, may have been too debilitated to give meaningful consent to the procedure. At that point I started to have very, very serious reservations about the man. Kevorkian went to jail for his actions, in the end.

The idea that the victim is helpless in cases of euthanasia but not helpless in regards to existing treatment modality just does not jive with reality.

Part of the problem, of course, is that at lot of people really don't want to think about death. It scares them, after all. So when these questions come up their reactions are all based on fear, gut-reaction, and little thought.

Funny you should mention that. The health minister in a recent defeated bill (link above) was a GP before becoming a fully fledge politician. He opposes euthanasia and freely admits he gave palliative care even though he felt it was possible the morphine he gave would hasten death.

As it happens, my sister is a hospice doctor now, and of course we went through these issues when my mom was in hospice. It's a bit of a grey area, and involves a pretty fine distinction. If adequate pain control requires so much medication that death is hastened it is still, nonetheless, ethical to give so much medication because the primary motivation is to relieve pain, and earlier death is an unfortunate side effect of adequate pain relief. On the other hand, giving medication with the prime motivation as euthanasia or death is NOT ethical.

Try explaining this to hysterical, distraught relatives. I dare you. Really, my sister does not receive adequate pay for some of the things she does.

Personally, I think it's a pretty rare circumstance where that happens. Insufficient pain control seems more an issue in medicine these days. Anyhow, it IS an issue in hospice care, particularly a concern of people unfamiliar with hospice which they or their relatives are entering for the first time.

Is this the same mindset that gave us the death panels accusations I hear so much about.

Yep! See "scared and uninformed people unwilling to think about death", as noted above.

This is in addition to beliefs that doctors should do no harm, and killing for any reason is a harm.

Those moral arguments are so simplistic. Especially in light that the patient usually makes the final choice, i.e. drinks the toxic concoction.

Certain doctors who support euthanasia have openly stated they have no moral compunction about doing it. Jack Kervokian backed it up with actions, despite this "not supposed to do harm business". In any event I have no moral compunction about injecting drugs as a form of capital punishment if I thought the accused was guilty, yet alone in euthanasia where the person being killed actively wants it.

Most laypeople have no clue about some of the very, very difficult ethical problems faced by doctors on a frequent basis. In fact, they don't want to know. (See "scared and uninformed"). And for most of those people, knowing a doctor would perform an execution (by the way, in the US doctors are not permitted to do this - participation in an execution will, at a minimum, have them lose their medical license permanently) or be involved with euthanasia would scare the living shit out of them. Americans idealize doctors and the "do no harm" thing. People want these decisions to be simple, even though they're not. Even though you and I both know that doctors sometimes aren't so sure about their course of action, that sometimes they do cause harm (usually unintentionally), and that medical ethics can become very dark and grey at times no matter how moral and ethical the participants in the matter.

[Sela]

I guess it just shows my ignorance in the issue that I *always* assumed euthanasia was done for and by the patient's wishes.

[PainRack]

Meh. For me the gray line of Palliative medicine will always be antibiotics and blood tranfusions.

Especially when giving blood may alleviate symptoms or antibiotics may improve quality of life. The difficulty between knowing whether an action is going to be life extension, life extension with no improvement in QOL or worsening QOL, or just improvement in QOL is disturbing.

[mr friendly guy]

I guess it just shows my ignorance in the issue that I *always* assumed euthanasia was done for and by the patient's wishes.

Oh it is. Its just that people have weird ideas about laws being abused because.. just because. Conjure images of Nazis to go with it.

Now deciding to institute palliative care or to with hold treatment can occur frequently without consent from the patient, because by that stage the patient is in no condition to make any decisions, so discussions usually occur after discussing with the relative. Theoretically if we think its hopeless we could make such a decision in defiance of the relatives' wishes, although I doubt many doctors are gung ho enough to test this.

Meh. For me the gray line of Palliative medicine will always be antibiotics and blood tranfusions.

When it gets to the stage where I start a morphine infusion no further antibiotics are given. Nor blood. I will give blood for symptomatic relief for those who have terminal illnesses eg cancer if they are not at the hospice stage yet.