1. 1 PALLIATIVE CARE AND EUTHANASIA – ARE THEY MUTUALLY EXCLUSIVE? Aleksandrova-Yankulovska Silviya University of Medicine - Pleven Faculty of Public health Pleven, Bulgaria

2. 2 Euthanasia movement has started as: protest against the growing tendency in medicine to alienate individuals from their own death; in search for better death. Effective palliative care services render discussion about the introduction of euthanasia unnecessary

3. 3 In this paper I discuss the relationships between palliative care and euthanasia with respect to the question are they mutually exclusive.

4. 4 EUTHANASIA AND PALLIATIVE CARE ARE MUTUALLY EXCLUSIVE Historical point of view Cicely Saunders, St Christopher’s hospice, 1967 Through good palliative care requests for euthanasia can be prevented. Euthanasia is a poor solution when there is a shortage of palliative care.

5. 5 WHO Expert Committee, 1990 “… with the development of modern methods of palliative care, legalization of euthanasia is unnecessary. Now that a practical alternative to death in pain exists, there should be concentrated efforts to implement programmes of palliative care, rather than yielding to pressure for legal euthanasia” EUTHANASIA AND PALLIATIVE CARE ARE MUTUALLY EXCLUSIVE

6. 6 Dutch experience Janssens, Ten Have and Zylicz 1999. Hospice and euthanasia in the Nederlands. An ethical point of view. Journal of Medical ethics 25: 408-412 Rozenheuvel hospice 25% requested euthanasia at admittance 3 out of 769 (0,39%) persisted EUTHANASIA AND PALLIATIVE CARE ARE MUTUALLY EXCLUSIVE

7. 7 “double effect” ≠ euthanasia so long as the intention is to do good and not harm the patient, it is ethical to perform a medical intervention which carries with it the risk of hastening death Palliative care risks death. Euthanasia seeks death. EUTHANASIA AND PALLIATIVE CARE ARE MUTUALLY EXCLUSIVE

8. 8 Accepting euthanasia as an option may hinder the creative process of developing alternative palliative modalities. Evaluation of the quality of palliative care. Hospices poin to the inadequacy of palliative care in the formal health care system. EUTHANASIA AND PALLIATIVE CARE ARE MUTUALLY EXCLUSIVE

9. 9 Respect for autonomy Whoever suffers from intolerable pain and cannot foresee an end to the pain will quickly opt for euthanasia. Neither to hasten nor to postpone death. EUTHANASIA AND PALLIATIVE CARE ARE MUTUALLY EXCLUSIVE

10. 10 Multi-layered euthanasia requests German experts opinion: symptoms of terminal phase - pain, apnea, anorexia, constipation. internal motives - being satisfied with life, having no expectations, experiencing no sense, feeling oneself a burden to others. EUTHANASIA AND PALLIATIVE CARE ARE MUTUALLY EXCLUSIVE

11. 11 EUTHANASIA AND PALLIATIVE CARE ARE MUTUALLY EXCLUSIVE Multi-layered euthanasia requests Gallup poll, 1991 fear of cancer or other debilitating diseases; fear of becoming burden to one’s family; fear of surviving without really living; fear of severe, uncontrolled pain.

12. 12 Euthanasia goes against the basic ethical principles in medicine. Doctors have the responsibility to preserve life and relief suffering. Killing a patient is not beneficence, it is maleficence. Euthanasia oppose to the sanctity of life. EUTHANASIA AND PALLIATIVE CARE ARE MUTUALLY EXCLUSIVE

13. 13 Euthanasia contravenes three basic tenets of hospice’s mission and philosophy: Provision of a lethal medication would hasten death; Death would occur not as a result of a natural life process, but through medicalized control and scheduling; The family could be excluded. EUTHANASIA AND PALLIATIVE CARE ARE MUTUALLY EXCLUSIVE

14. 14 Euthanasia denies the person the final stage of growth. Different values and opinions about the human condition. The value of life is the basis for the realization of other values. Euthanasia degrades life. It makes the patient doubt his or her self-worth. EUTHANASIA AND PALLIATIVE CARE ARE MUTUALLY EXCLUSIVE

15. 15 Cicely Saunders: “You matter because you are you, and you matter until the last moment of your life. We will do all we can, not only to help you die peacefully but also to live until you die”. EUTHANASIA AND PALLIATIVE CARE ARE MUTUALLY EXCLUSIVE

16. 16 The effects on the personnel The loyalty to the patient and to the family could be at stake. EUTHANASIA AND PALLIATIVE CARE ARE MUTUALLY EXCLUSIVE

17. 17 EUTHANASIA AND PALLIATIVE CARE ARE NOT MUTUALLY EXCLUSIVE Euthanasia is a morally justifiable means of last resort. Euthanasia is a form of palliative care - the final act of palliation, so to speak. Euthanasia and palliative care share similar goals. After all, do they not both stress on the importance of patient autonomy, or aim to relieve pain and suffering or to provide “death with dignity”?

18. 18 Palliative care can never take away all euthanasia requests. According to the findings of a report that evaluated notification procedure with regard to euthanasia in the Netherlands, in 88% of all 3200 annual euthanasia cases the treatment at that time was palliative in character. EUTHANASIA AND PALLIATIVE CARE ARE NOT MUTUALLY EXCLUSIVE

19. 19 EUTHANASIA AND PALLIATIVE CARE ARE NOT MUTUALLY EXCLUSIVE Palliative care can never take away all euthanasia requests. Canadian Study among AIDS patients decision to plan an assisted death is not a result of rejection of palliative care or an inability to gain access to quality medical services but a result from desire to be in control of one’s death. overriding concern about loss of independence and the inability to make personal decisions.

20. 20 Euthanasia is already being practiced, though in different guise. “double effect” withholding or withdrawing treatment Consequentialistic point of view: consequence in all these cases is that the patient dies and pain and suffering are relieved EUTHANASIA AND PALLIATIVE CARE ARE NOT MUTUALLY EXCLUSIVE

21. 21 Respect for autonomy Campbell, C.S., J. Hare and P. Matthews. 1995. Conflicts of conscience. Hospice and assisted suicide. Hastings Centre Report, 25 (3): 36-43 Right of hospice patients to request euthanasia as an alternative because of "the right to control one's body… Hospice fails patients when it does not provide that choice". EUTHANASIA AND PALLIATIVE CARE ARE NOT MUTUALLY EXCLUSIVE

22. 22 CONCLUSION Arguments that palliative care and euthanasia are mutually exclusive are more and seem to be stronger. It is necessary to further develop palliative care. Need of more extensive research into pain and suffering experience, symptom control and palliative care services. The primary goal of palliative care is not to prevent euthanasia requests; the primary goal is to provide good care.