2011
Marek Vácha
EUTHANASIA
Euthanasia
 eu = good, right; thanatos = death
 "Passive euthanasia" = withdrawing (=stopping)
medical treatment with the deliberate intention of
causing the patient's death
 „Active euthanasia“ = A deliberate act to end
another person's life on patient´s request
the difference between "active" and "passive" is that
in active euthanasia, something is done to end the
patient's life; in passive euthanasia, something is not
done that would have preserved the patient's life.
there is difference between „letting die“ and „killing“
Euthanasia
 Euthanasia means knowingly and
intentionally performing an act that is clearly
intended to end another person´s life and
that includes the following elements:
 the subject is a competent informed person with
an incurable illness who has voluntarily asked for
his or her life to be ended;
 the agent knows about the person´s condition and
desire to die and commits the act with the primary
intention of ending the life of that person
 the act is undertaken with compassion and without
personal gain
Assistence in Suicide
 Assistance in suicide means knowingly
and intentionally providing a person with
the knowledge or means or both required
to commit suicide, including counseling
about lethal doses of drugs, prescribing
such lethal doses or supplying the drugs
NAZI GERMANY 1939 - 1941
Karl Brandt
Philipp Bouhler
Nazi physician Karl Brandt, director of the
Euthanasia Program. August 27, 1942.
Program T4
 1000 : 10 : 5 : 1
Tiergartenstraße 4
This image originates from a film produced
by the Reich Propaganda Ministry. It is
captioned: "A moral and religious
conception of life demands the prevention
of hereditarily ill offspring." Nazi
propaganda aimed to create public support
for the compulsory sterilization effort.
Six places, where euthanasia were
performed
Brandenburg near Berlin (January 1940 - September 1940),
Grafeneck near Stuttgart (January 1940 - December 1940),
Hartheim near Linz in Austria (January 1940 - December
1944),
Sonnenstein/Pirna near Dresden (April 1940 - August 1943),
Bernburg near Magdeburg (September 1940 - April 1943),
Hadamar near Koblenz (January 1941 - August 1941).
Buses used to transport patients to
Hadamar euthanasia center. The windows
were painted to prevent people from
seeing those inside. Germany, between
May and September 1941.
1936
'This person suffering
from hereditary defects
costs the community
60,000 reichsmark
during his lifetime.
Fellow German, that is
your money too.'
Nazi poster bearing the phrase, translated
from German, "A strong and healthy nurse
is there only to give care to a dangerous
madman. Shouldn't we be ashamed?"
Clemens von Galen
Lebensunwertes Leben ?
“We must expect, therefore, that the poor defenceless patients are,
sooner or later, going to be killed. Why? . . . because in the judgement
of some official body, on the decision of some committee, they have
become “unworthy to live", because they are classed as “unproductive
members of the national community". The judgment is that they can no
longer produce any goods: they are like an old piece of machinery
which no longer works, like an old horse which has become incurably
lame, like a cow which no longer gives any milk. What happens to an
old piece of machinery? It is thrown on the scrap heap. What happens
to a lame horse, an unproductive cow? I will not pursue the
comparison to the end — so fearful is its appropriateness and its
illuminating power . . .
 If it is once admitted that men have the right to kill “unproductive"
fellowmen — even though it is at present applied only to poor and
defenceless mentally ill patients — then the way is open for the murder
of all unproductive men and women: the incurably ill, those disabled in
industry or war. The way is open, indeed, for the murder of all of us,
when we become old and infirm and therefore unproductive".

“For some months we have been heating reports that inmates of
establishments for the care of the mentally ill who have been ill for
a long period and perhaps appear incurable have been forcibly
removed from these establishments on orders from Berlin.
 Regularly the relatives receive soon afterwards an intimation that
the patient is dead, that the patient's body has been cremated and
that they can collect the ashes. There is a general suspicion,
verging on certainty, that these numerous unexpected deaths of
the mentally ill do not occur naturally but are intentionally brought
about in accordance with the doctrine that it is legitimate to destroy
a so-called “worthless life” — in other words to kill innocent men
and women, if it is thought that their lives are of no further value to
the people and the state. A terrible doctrine which seeks to justify
the murder of innocent people, which legitimises the violent killing
of disabled persons who are no longer capable of work, of cripples,
the incurably ill and the aged and infirm!”


I will give you an example of what is happening. One of the patients in
Marienthal was a man of 55, a farmer from a country parish in the Münster
region — I could give you his name — who has suffered for some years
from mental disturbance and was therefore admitted to Marienthal
hospital. He was not mentally ill in the full sense: he could receive visits
and was always happy, when his relatives came to see him. Only a
fortnight ago he was visited by his wife and one of his sons, a soldier on
home leave from the front. The son is much attached to his father, and the
parting was a sad one: no one can tell, whether the soldier will return and
see his father again, since he may fall in battle for his country. The son, the
soldier, will certainly never again see his father on earth, for he has since
then been put on the list of the “unproductive”. A relative, who wanted to
visit the father this week in Marienthal, was turned away with the
information that the patient had been transferred elsewhere on the
instructions of the Council of State for National Defence. No information
could be given about where he had been sent, but the relatives would be
informed within a few days. What information will they be given? The same
as in other cases of the kind? That the man has died, that his body has
been cremated, that the ashes will be handed over on payment of a fee?
Then the soldier, risking his life in the field for his fellow-countrymen, will
not see his father again on earth, because fellow-countrymen at home
have killed him.
Who could then have any confidence in
a doctor?
 Then no man will be safe:
some committee or other will
be able to put him on the list
of “unproductive” persons,
who in their judgment have
become “unworthy to live”.
And there will be no police to
protect him, no court to
avenge his murder and bring
his murderers to justice.
 Who could then have any
confidence in a doctor?
Tiergartenstraße 4 today
Slippery slope
Baby Knauer
dětská "eutanázie"
T4: "eutanázie" dospělých
Auschwitz
…after Auschwitz
 How can the progress of modern science
and medicine and industry promise to
liberate people from ignorance, disease,
and brutal, mind-numbing work, yet help
create a world where people willingly
swallow fascist ideology, knowingly
practice deliberate genocide, and
energetically develop lethal weapons of
mass destruction?
 Theodor Adorno
EUTHANASIA (ALL OVER THE WORLD)
1973 - 2010
Euthanasia
 we are able to cope with a concrete
illnesses...
 ...but we are unable to cope with aging
Euthanasia
 The Netherlands, 1994
 On April 10, 2001, the Dutch Parliament approved the
"Termination of Life on Request and Assisted Suicide (Review
Procedures) Act."(41) It amended sections of the criminal code,
specifically stating that the offenses of euthanasia and assisted
suicide are not punishable if they have been "committed by a
physician who has met the requirements of due care" that are
described in the act and if they have informed the municipal
"autopsist" in accordance with the Burial and Cremation Act.
 Australia: 1995 – 1997
 Oregon (AS) from 1998, Washington (AS)
from 2008
 Belgium from 2002
 Luxembourg from 2008
Oregon from 1998
 the patient must
 be a capable adult
 be an Oregon resident
 have a terminal illness, with less than six
month to live (!!)
 voluntarily request a prescription for lethal
drugs
 the request must be made both orally and in
writing
Countries where Euthanasia/AS are allowed
Euthanasia
„Dutch definition of euthanasia“
 =the intentional termination of the life of a
patient at his request by someone other
than the patient
Medische macht en medische ethiek
 Hippocratic oath
 the physician must preserve human life, save it
and prolong it, where and whenever possible
 today, with all the medical possibilities:
 the physician must preserve human life, save it
and prolong it, wherever it is sensible and
meaningful to do so.
 should the physician consider it no longer sensible
to proceed, then he should be permitted to end
patient´s life. This can be done in two ways:
 through ceasing all life-sustaining measures
 through actively terminating the life of the patient

Sohn, W., Zenz, M., (eds) (2001) Euthanasia in Europe. Schattauer. Stuttgart, New York. p.138
The Netherlands
 In 1973 Dr. Gertruida Postma, who gave
her dying mother a lethal injection,
received light sentence in the
Netherlands.
 The case and its resulting controversy
launched the euthanasia movement in that
country.
Postma Case
 Leeuwarden 1973
 Dr. Postma was sentenced to only one
week in prison
 this remarkably mild sentence was based on
the fact, that




the physician´s mother was incurably ill
she experienced her suffering as unbearable
she was already in dying phase
the ending of life was done on her own
expressed wish
The Netherlands
 1973 Voluntary Euthanasia societies formed in the




Netherlands
1982 A Rotterdam court states conditions under which
aiding suicide and administering Voluntary Euthanasia
will not lead to prosecution in the Netherlands
1984 The Supreme Court of the Netherlands declares
that V.E. is acceptable subject to ten clearly defined
conditions
1990 Notification procedure agreed between the Royal
Dutch Medical Association and the Ministry of Justice
1994 Amendments under the Burial Act incorporate the
notification procedure, giving the latter formal legal
status
Rotterdam criteria: 1982
 the patient makes a voluntary request
 the request must be well considered
 the wish for death is durable
 the patient is in unacceptable suffering
 the physician has consulted a colleague
who agrees the proposed course of action
The Netherlands
 The Penal Code of the Netherlands contains a variety of
provisions prohibiting the intentional taking of human life.
Two of these provisions specifically relate to physicianassisted suicide and active voluntary euthanasia:

Article 293 of the Penal Code prohibits taking a person's life at that
person's 'express and serious request'. This crime, sometimes
described as 'the offence of voluntary euthanasia'(133), is
punishable by imprisonment for a maximum of 12 years or by a
fine.
 Article 294 of the Penal Code prohibits assisting suicide. Where a
death by suicide has occurred, anyone who helped bring about that
death could be prosecuted under article 294 for intentionally inciting
another to commit suicide, assisting in the suicide of another, or
procuring the means for another to commit suicide. Where a death
has occurred, this crime is punishable by imprisonment for a
maximum of 3 years or a fine.
Netherland
 The most important reasons for the
request for euthanasia were
 futile suffering (29%),
 avoidance of humiliation (24%)
 unbearable suffering (18%).
 Although pain was among the reasons in
40% of cases, only in 5% of cases was
pain mentioned as the most important
reason.

Van der Wal G, van Eijk JThM, Leenen HJJ, Spreeuwenberg C. Euthanasia and assisted suicide. II. Do
Dutch family doctors act prudently? Family Practice 1992;9:135-40.
Remmelink Report
 Since 1984 the practice of euthanasia in Holland has been
very open, and many claims have been made as to its
frequency and its benefits or drawbacks. To establish the
facts on euthanasia, a government-sponsored study was
undertaken and the report released September 10,
1991. This report, Euthanasia and other Medical Decisions
Concerning the End of Life, commonly called the Remmelink
Report, has revealed disturbing findings. The population of
the Netherlands in 1990 was 15 million. The study findings
indicated the following annual figures:


2300 cases of active voluntary euthanasia.
400 cases of assisted suicide (the lethal means for death is
provided to the patient for self-administration)
 1040 cases of involuntary euthanasia (.8% of total deaths in
Holland). These cases --averaging almost 3 per day -- were those
in which the physician prescribed, provided or administered a
medicine with the deliberate aim to hasten the end of life, though
the patient had made no explicit request for euthanasia.
Remmelink Report
 14% of patients whose lives were ended
without their explicit request were fully
competent.
 62% of patients whose lives were terminated
without their explicit request had never given
any indication regarding termination of life.
 An additional 8100 patients died after pain
medication (morphine) was administered by
physicians who intended to shorten life. The
decision to administer the intentional
overdose was not discussed with 27% of fully
competent patients who died in this manner.
Remmelink report: 1991
The Netherlands
1995
2000
2,2% - 2,3%
2,2% - 2,6%
assisted
0,2% - 0,4%
suicidium
without explicite 0,7%
request
0,1% - 0,2%
Euthanasia
0,6% - 0,7%
…without specific request…
 there is a difference between questions
 what would the patient want in this circumstances?
 what do you want for the patient?
Netherland
 The most important reasons for the
request for euthanasia were
 futile suffering (29%),
 avoidance of humiliation (24%)
 unbearable suffering (18%).
 Although pain was among the reasons in
40% of cases, only in 5% of cases was
pain mentioned as the most important
reason.

Van der Wal G, van Eijk JThM, Leenen HJJ, Spreeuwenberg C. Euthanasia and assisted suicide. II. Do
Dutch family doctors act prudently? Family Practice 1992;9:135-40.
The Netherlands
 On April 1st 2002, euthanasia became legal
in The Netherlands, rather than being
technically illegal but not punishable in
circumstances of ‘force majeure’ (necessity).
 Key points in the new law include the
following:
 incompetent patients can be killed if they have
written a statement in advance requesting
euthanasia.
 teenagers aged 16-18 may receive euthanasia,
not necessarily with the agreement of a parent or
guardian.
The Netherlands
 children 12-16 years old may receive
euthanasia with the agreement of a parent or
guardian.
 the doctor must hold the conviction that the
patient’s suffering is lasting and unbearable.
 all cases will be reviewed after the death of
the patient.
 the law does not prohibit doctors from
administering euthanasia to nonresidents.
The Netherlands 2002
 in order for the physician to assist with the
euthanasia, the following must occure
 the patirnt must request the assistance freely
and frequently, after careful consideration
 the physician may act on the request only if
the patient is terminally ill, with no hope of
improvement and in severe pain
 the physician must consult with another
physician and file a report with the coroner
The Netherlands 2002
 the standard process is
 to give a large dose of barbiturates to produce
com
 and then an injection of curare, which stops
respiration and heart rate
The Netherlands 2002
 types of patient availing themselves for
euthanasia option:
 women and men are equal in requesting
euthanasia
 the average age for men is sixty-three and for
women sixty-six
 requests are rare in people over age seventyfive and even rarer for those over age eightyfive
The Netherlands 2002
 The Dutch Patient´s Association:
 „We feel our lives are threatened. We realize
that we cost the community a lot. Many people
think we are useless, often we notice that we
are being talked into desiring death. We will
find it extremely dangerous and frightening if
the new medical legislation includes
euthanasia.“
Oregon from 1998
 the patient must
 be a capable adult
 be an Oregon resident
 have a terminal illness, with less than six
month to live (!!)
 voluntarily request a prescription for lethal
drugs
 the request must be made both orally and in
writing
Kevorkian case
 june 1990 – Janet
Adkins ended her
life with the
assistance of Dr.
Jack Kevorkian
 by the end of June
1998, Kevorkian had
participated in over
fifty similar events
using his suicide
machines
Kevorkian Sentenced to Prison
(1999)
In 1999, pathologist Dr.
Jack Kevorkian was
sentenced to a 10-25
year prison term for
giving a lethal injection
to Thomas Youk whose
death was shown on the
60 Minutes television
program.
 in 2006 he was released
Switzerland
 Suicide tourism
 In 2000 three foreigners committed suicide in
Zurich.
 In 2001, the number of death tourists to Zurich
rose to thirty-eight, plus twenty more in Bern.
Most of the deaths occurred in an apartment
rented by Dignitas, one of the four groups that
have taken advantage of Switzerland's 1942
law on euthanasia to help the terminally ill die.
Letting die
 = enabling nature to take its course
 but there is a difference between:
 withdrawing machines and medications from
the patient
 withholding or withdrawing artificial nutrition
and hydration
A Question
 What is the difference between
administering a large dose of morphine for
reducing physical pain
 and using that same dosage in response
to a person saying, „I want to end this“?
An Answer
 the physical pain occurs against the will of
the patient, and the morphine is therefore
a therapeutic response
 the statement „I want to end this“ is,
however, an expression of the individual´s
will
Pain
 organic
 emotional
 social
 spiritual
(Cicely Saunders)
Quality end of life care
according to „ „The Committee on Care at the End of Life of the US Institute of Medicine, NationalAcademy of
Sciences“
 overall quality of life
 physical well-being and functioning
 psychosocial well-being and functioning
 spiritual well-being
 patient perception of care
 family well-being and perception
„…tired of living“
 Jurisprudence from 1994 states that
 the extent of the suffering is determined by the
way in which it is experienced, and should be
abstracted from the cause.
 However, jurisprudence from 2002 adds to
this that the cause must be medical:
 if a patient is suffering from the consequences
of old age and requests EAS because (s)he is
‘tired of living’, but does not suffer from a
severe disease, the physician is not allowed to
grant such a request
„…tired of living“
 One of the reasons for this, as given by
the Supreme Court, is that a physician is a
medical expert, and can therefore judge
the extent of unbearable and hopeless
suffering of a patient with a medically
defined disease, but is not an expert in
dealing with patients who are tired of living
Arguments For Euthanasia
 It provides a way to relieve extreme pain
 It provides a way of relief when a person's
quality of life is low
 Frees up medical funds to help other
people
 It is another case of freedom of choice
Arguments For Euthanasia
 There are two general arguments used in
favour of legalised euthanasia and
assisted suicide.
 One is the ending of unbearable physical
and/or psychological suffering in the case of
terminal illness, and the other is
 to enhance individual autonomy.
Arguments for euthanasia
 Refused by a court
in Dijon the right to
die under medical
supervision, she
was found dead at
home.
 According to
prosecutors, she
had taken a
"deadly dose" of
barbiturates.
Chantal Sebire
died March 19, 2008
Arguments Against Euthanasia:
 Euthanasia devalues human life
 Euthanasia can become a means of health
care cost containment
 Physicians and other medical care people
should not be involved in directly causing
death
 There is a "slippery slope" effect that has
occurred where euthanasia has been first
been legalized for only the terminally ill and
later laws are changed to allow it for other
people or to be done non-voluntarily.
Arguments Against Euthanasia:
 Increasingly, however, euthanasia activists have dropped
references to terminal illness, replacing them with such
phrases as:
"hopelessly ill"
"desperately ill"
"incurably ill"
"hopeless condition“
"meaningless life"
Arguments Against Euthanasia:
 Immanuel Kant
 Kant offered the "formula of the end in itself" as: "Act in
such a way that you treat humanity, whether in your own
person or in the person of another, always at the same
time as an end and never simply as a means."
 This places more emphasis on the unique value of human
life as deserving of our ultimate moral respect and thus
proposes a more personal view of morality. In application
to particular cases, of course, it yields the same results:
violating a perfect duty by making a false promise (or
killing myself) would be to treat another person (or myself)
merely as a means for getting money (or avoiding pain)
Arguments against euthanasia
 Emotional and psychological pressures could become
overpowering for depressed or dependent people.
 If the choice of euthanasia is considered as good as a
decision to receive care, many people will feel guilty for
not choosing death.
 Financial considerations, added to the concern about
"being a burden," could serve as powerful forces that
would lead a person to "choose" euthanasia or assisted
suicide.
Arguments against euthanasia
 permitting assisted suicide may at first look
like an affirmation of the patient´s liberty, but
it soon transforms into a duty to die
 protecting individuals´liberty is more
effectively achieved by making assisted
suicide a socially unacceptable option so
the individuals need not defend their desire
to continue living
Arguments Against Euthanasia:
 Immanuel Kant
 Kant offered the "formula of the end in itself" as: "Act in
such a way that you treat humanity, whether in your own
person or in the person of another, always at the same
time as an end and never simply as a means." This places
more emphasis on the unique value of human life as
deserving of our ultimate moral respect and thus proposes
a more personal view of morality. In application to
particular cases, of course, it yields the same results:
violating a perfect duty by making a false promise (or
killing myself) would be to treat another person (or myself)
merely as a means for getting money (or avoiding pain)
 we should not be asking whether one may
aid another in dying; we should rather
explore what prompts people to seek to die
in the first place
 and then we should remove those
motivations through proper pain medication
and through attentive care
 people asking for help in dying to overcome the
loneliness and the futility of their lives should not
be offered aid in dying but should rather be given
assistance in making the remainder of life
meaningful
Remember…
Competent patients have the right to refuse
treatment, even when the refusal will result
in disability or death.
Dysthanasia
 USA: about half of all patients spent their last
days in what the researches termed „an
undesirable state“, including
 a week or so in an intensive care unit
 having a physician who was unaware of wishes
not to be resuscitated
 being in serious, insufficiently treated pain
 the enthusiasm for physician-assisted suicide
is driven, in part, by the fear that we will
receive overly aggressive care at the end of
life and that our suffering may be prolonged
Euthanasia
 THE WORLD MEDICAL ASSOCIATION
RESOLUTION ON EUTHANASIA
 Adopted by the WMA General Assembly,
Washington 2002 May 2001 20.3/2001
Euthanasia
„Euthanasia, that is the act of deliberately
ending the life of a patient, even at the
patient's own request or at the request of
close relatives, is unethical. This does not
prevent the physician from respecting the
desire of a patient to allow the natural
process of death to follow its course in the
terminal phase of sickness."
Euthanasia
WMA , 1994:
„Physicians-assisted suicide, like euthanasia, is
unethical and must be condemned by the
medical profession. Where the assistance of the
physician is intentionally and deliberately
directed at enabling an individual to end his or
her own life, the physician acts unethically.
However the right to decline medical treatment
is a basic right of the patient and the physician
does not act unethically even if respecting such
a wish results in the death of the patient."
Euthanasia
BE IT RESOLVED that:
1. The World Medical Association
reaffirms its strong belief that euthanasia
is in conflict with basic ethical principles
of medical practice, and
Euthanasia
The World Medical Association strongly
encourages all National Medical
Associations and physicians to refrain
from participating in euthanasia, even
if national law allows it or
decriminalizes it under certain
conditions.
 Physicians should not abandon dying
patients but should continue to provide
compassionate care even when cure is no
longer possible
Hippocratic Oath
 I will not give a lethal drug to anyone if I
am asked, nor will I advise such a plan;
First world conference
on euthanasia: 2008
 The first International
Symposium on
Euthanasia and Assisted
Suicide held in Toronto
Nov. 30-Dec. 1 2008
 “I have experienced all the
symptoms which they
claim are symptoms for
euthanasia,” Davis said.
“If my country had had
laws allowing euthanasia
and assisted suicide when
I was at my lowest point, I
would be dead,”
RELIGION
PERSPECTIVES
A Jewish Approach
 Jewish sources view all forms of active
euthanasia and assisted suicide as
forbidden acts of murder
 that is true even if the patient explicitly asks to
be killed
Pragmatism
Judaism
 American school of
 Judaism requires us to
pragmatism, its media and
even its recent welfare
legislation reforms would think
of ourselves in utilitarian
terms, with our worth being a
function of what we can do for
ourselves and others
 American attitudes and laws
thus permit suicide, especially
when a person can no longer
do anything useful for either
herself or himself or for others
evaluate our lives in light of
the ultimate value inherent
in us because we were
created in God´s image
 Jewish ideology and law
therefore strongly oppose
commiting suicide or
assisting others in doing
so, for life is sacred
regardless of its quality or
usefulness
A Jewish Approach
 God created and therefore owns the entire
universe, including each person´s body
 and we therefore do not have the right
unnecessarily to destroy or dammage God´s
property , including even God´s vegetation
and inanimated property
 this obligation makes suicide an act of theft from
God, a violation of God´s prerogatives, and the
trespass of the proper boundaries between God
and human beings

(Dorff, E.N., (2003) Matters of Life and Death. A Jewish Approach to Modern Medical Ethics. The Jewish Publication
Society, Philadelphia, PA, p. 179)
A Jewish Approach
 Assisted Suicide
 the helper minimally inviolates Leviticus
19,14: „Do not put a stumbling block before
the blind“
A Jewish Approach
 Even though Jewish law goes quite far in
permitting terminally ill patients to die with
whatever palliative care they need and
without any other medical interference
 it does not permit suicide or assisted suicide
 the tradition maintains a firm line between
legitimately withholding and withdrawing
medical efforts on the one hand and
illegitimately helping a person actively to take
his or her life on the other
A Jewish Approach
 the value of life does not depend on the
level of one´s abilities
 it derives from the image of God embedded in
us
 the tradition thus strongly affirms the divine
quality of the life of disabled people
 the Jewish tradition requires that we recognize
the divine aspect of people in the last stages
of life, regardless of the quality of their lives
Christianity
The Role of Suffering:
 Down through the centuries and generations it
has been seen that in suffering there is
concealed a particular power that draws a
person interiorly close to Christ, a special grace.
Pope John Paul II: Salvifici Doloris, 1984
 We should relieve suffering when we can, and be with
those who suffer, helping them to bear their suffering,
when we can't. We should never deal with the problem of
suffering by eliminating those who suffer.
around 1470