BUGNON . O
DESC Réa LYON
Décembre 2006
ευθανασ'ια
“good death” or the facilitation
of a good death
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•
•
•
to cause death
intentionally
desire to promote the best interest
using the most gentle means
an “end of life without pain,
comforted, peaceful,
experiencing dignity and
respect as well as closeness
to family”
La dérive …
• Darwin “The Origin of Species” 1859
• Herbert Spencer “Social Darwinism”
• The eugenics movement
– (forced) sterilization, quarantine, abortion, and
even “euthanasia” of those thought to carry
undesirable genetic material
• Alfred Ploetz “racial hygiene” 1895
– the “Aryan” race
• lawyer Karl Binding / psychiatrist Alfred
Hoche
The National Socialist Physicians’ League 1929
6% of the entire German medical profession
La dérive …
“Law for the Prevention of Hereditarily Diseased
Progeny” 1933
“The Nuremberg Laws” 1935
La dérive …
By 1942, nearly one-half of all physicians in Germany
were Nazi party members
La dérive …
the T4 Program (“Tiergartenstrasse 4” in Berlin)
a “mercy death” to patients judged “incurably sick
by medical examination”
Hitler 1939
6000 children
200000 adults
La dérive …
The “euthanasia” program
sur le banc des accusés … ?
the “Physicians’ Trial” in Nuremberg (1946–1947)
20 Nazi physicians and biomedical scientists accused
7 acquitted
In Belgium
• Law on euthanasia : effect on 23 sept
2002
• « action on the part of a third person
intented to end the life of someone
who has requested it »
Euthanasia is no longer a criminal offense provided that …
Patient
• Older than 18, legally competent,
conscious at the time of the request
• Serious and incurable condition with
constant suffering and unbearable
physical or psychological pain which
cannot be alleviated with medical or
other treatment
Request
• Volontary, carefully considered,
repeated, without external pressure
• Written, dated, signed (possible help
by someone without material benefit
in the patiet’s death)
• Revocable at any time
Unbearable suffering ??
general weariness
no acceptable alternative
treatment
family or society coercion
Physician
• Fully informs patient about his health status, life
expectancy, possible therapeutic options including
palliatiative care
• Agrees with the patient that there is no other reasonable
option
• Checks for real unbearable suffering, and repeats
discussions to ensure that the request is not transient
• Consults another physician
• Discusses the request with care-team and family if wanted
by patient
• Is not obliged to perform a asked euthanasia provided the
medical chart is handed to another physician chosen by the
patient
Advance directives
• Any individual may write a declaration in
anticipation of a state in which euthanasia
may be an option, but in which he would no
longer be able or competent to make a
decision
• May designate impartial trusted individuals
to inform the phycisian about the presence
of an advance directive
• May be made at any time provided it
carries the signatures of two witnesses
• 5 years validity
Control process
• 1st document : details of the patient, physician,
consultations related to the request
• 2nd document : more details on the reasons for
and the nature of the request, and the method of
euthanasia used
• National Comission of Control and Evaluation
(8 physicians (50% Pr) , 4 Pr of law,
4 involved in care of the terminally ill)
• Doubts : 1st document opened and case referred
to the coroner
2 years later …
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500 cases euthanasia
0,2 % total death
83% flemish – 17% french
The most prominent reasons for the request :
“pointless suffering”
“deterioration or loss of dignity”
“weakness or tiredness”
1 advance directive and unconscious
64% > 60 years
83% cancer – 13% neuromuscular
48% specialist – 32.5% general practitioner –
19.5% specialist in palliative care
• 54% in hospital – 41% at home
• 81.5% barbiturates – 10% midazolam
In ICU …
• Patient often comatose, confused, too weak
to organize his toughts
no request from patient :
- is withdrawning or withelding of care in
patients with no hope of a meaningful survival
illegal ?
– Must we continue care ad infinitum even when
acknowledged as futile by all involved ?
In ICU …
• Advance directive and surrogate nominated …
– Is surrogate able to understand the complexities of
the situation, the options available and to take the
good decision at a time of heightened emotional
stress and anxiety ?
mechanical ventilation in pneumonia ??
Euthanasia = to achieve a good death
Dignified, Peaceful, Pain-free, in presence of family and
friends
• may be helped by withdrawning and withholding
care if adherence to bioethical principles
• Are intensivists illegal and do they need formal,
signed approval if
– effective communication and open discussion of all
options available
– increasing doses of sedatives and analgesic agents at the
right time
are performed ???
Should legislation recognize that ?
Merci pour votre attention
Références …
End-of-life practice in Belgium and the new euthanasia law
Intensice Care Med (2006) Jean-Louis Vincent
Euthanasia and physicianassisted suicide in The
Netherlands