UNIVERSITY OF MEDICINE AND PHARMACY„GR. T. POPA” IASI

FACULTY OF MEDICINEDEPARTMENT OF PSYCHIATRY

„ EUTHANASIA – AN ETHIC AND MEDICAL PROBLEM”

SCIENTIFICAL GUIDE CANDIDATE

PROF.DR. P. BOISTEANU BITSANI AIKATERINI

IASI – 2002

EUTHANASIA – AN ETHIC AND MEDICAL PROBLEM

CONTENT

1. Death from gnoseological point of view2. Death – the traditional aspects3. Historical points of view towards death4. Euthanasia – the deontological settlement5. Death from juridical point of view6. The Proclamation of the European Council about vegetative life and

“therapeutic obstinacy”7. The medical case – book records and responsibility in euthanasia8. Personal findings about euthanasia9. Legal and bioethic conclusions about euthanasia10. Bibliography

CHAPTER I

DEATH FROM GNOSEOLOGICAL POINT OF VIEW

If the metabolism, the self – reproduction, the self – renewal, the homeostasic self – adjustment, the reactivity and the development characterize life, death represents the stoppage of these vital functions. Life doesn’t represent a proteins’ way of life, as the clasic literature was saying, but a nucleic acids’ way of life. First of all, in nature, death is impressive as a necessary phenomenon. The disappearance of persons corresponds to an evolutive necessity, in the purpose to make way for other genetic combinations, which are more favorable for the species, rise their adaptive potential and provide the variability and the progress. Therefore, it is said that death represents the species’ triumph over the person. Other way saying, the species’ discrimination and specialisation were done with the price of death and the one life’s reason in nature is represented by its evolution. So, the eternal life would be anti – evolutive. Death had an essential and useful role for the partiality of the species’ evolution. Death was impressive as a natural selection form and as an adaptive phenomenon in the living matter’s evolution. From this point of view, death represents a revenge of the species towards the person.

Death represents the change of matter from a state in another, the loss of the self – renewal capacity of metabolism and the loss of all the functions and essential characteristics of the metabolism depends on it.

Death represents the end of a sad existence for many situations, which frequently appear in medicine. Have we the right to kill in the purpose to put an end to pain? This problem represents a subject for high philosophical theories, axiology, human right and legal medicine, religious doctrine and morals and it is multi-facetted. This problem makes to appear “the necessity of connection between sciences, the prolific collaboration of the intelligence through which free ourselves from the pre-specialised

narrow-mindedness and protect ourselves from the judgements that a too much influenced by the professional spirit”, as Diderot said.The term of “euthanasia” has three main senses:

A)“Bonne morte donce et sans souffrance” (Littre). Fr. Bacon coined the term and gave this sense. Fr. Bacon was a great English philosopher and one of the modern philosophical thought’s founders. He proposed that every art and science must contribute to an acceptable death.

B) The interruption of an unavailing and burdensome life (in this sense, euthanasia obtained a sad and terrible reputation because it was injourious and arbitrarily connected with the term of eugeny, which represents the intentional murder of the physical or mental invalides). C) The interruption of a miserable life (euthanasia is preferd to aneubiosis) – represents the only one which is directly concerning the therapist.

The practice of euthanasia is much older than the word. Euthanasia was found at old or primitive civilizations. Old Germans used to kill the chronic ill patients. In Birmania, an incurable person was obliged to hang himself. After Amundsen, the Eskimo were practicing suicide when pain became irresistible; in some areas of India, the incurable patient was accompanied by his family on the border of the river Ganges and thrown in the river.

Life and death, even if they are opposite phenomena, they look like two connected sides in the natural evolution of the living substance, in the living organism, death coexisting with life. The lethal phenomena which occur in the living organism (the red cells are living for 120 days, the epidermis for 30 days, the white cells for 13 days and the mitochondria for 8 days, so that in eight years the hole organism is new again) made us consider that death is prepared by life other way saying, living means dying. After the stopping of the vital functions, after death, the white cells are still moving, the perspiratory glands are still active, the muscle have contractions, the spermatozoon are still able of fecundation, facts

which confirm the words of Eminescu, who said that life is the nest of death and death the seed of life.

If the evolution of the individual is limited in time, life is infinite and this characteristic depends on the capacity of reproduction of the DNA-chains. In this branch, identical to the reproduction or birth, death is considered like a natural, normal phenomenon and only death is violent immature and motivated, may seem like unnatural and unusual. Such a conclusion opens the way to a conscious fight for life, by spreading its borders (for example by resuscitation) and by a rational use of life.

The conscience of limitation of individual existence in time, born the conscience of death and this gave rise to a new significance of life.

Another discovery was the fact that if existence is a chance of nature, may be a cosmic accident, this means that we must give a sense to this chance, being obliged to adopt a cultural attitude towards death, with the purpose of making life more productive. This discovery is an impulse to the rational use of life because it was said that nature invented death in the purpose of making life more interesting. Death gives to the conscious human being the power of becoming an authentic person, the sense of life consisting of perenniality (by creation, by truth and beauty) in the conscience of the others and successors. Physical, individual and ontological death can not be defeated except by creation. The pretended and unavoidable fear of death, the conscience of death gave birth to the wish of survival after death by creation, the wish to contribute even after death at the progress of humanity by the individual creation. To create means, in fact, to live twice, also because of the reason that death can not be defeated but by creation, by values, this make death a cultural phenomenon and an individual destiny.

CHAPTER II

DEATH – THE TRADITIONAL ASPECTS

Across the ages, the representation of death were stoical in ancient times, obscure in the Middle Ages and scientific today, the scientific representation of death (thanathology) showing the fact that death can not be defeated, except the creation which represent an access to universality. That is why the Romanian peoples say “he perpetrated from life” in the purpose of communicating with “his far-away” and became in this way the better consciousness of men (G. Liiceanu). If to be means to give a sense to life, everyone has the possibility to overtake the limits of himself, by the humanism the Romanian peasant was showing before death when he was asking himself if he didn’t irritate somebody during his life.

In actual civilization, there are different opinions concerning death. Many cultural changes determined changes in the experience of death. People living in cities, contrary to the areas, associate whit an important aversion towards death and rituals (crying, funerals). On the other side, in villages the traditions, the dimensions of the family and other factors determine a more flexible attitude towards death because young people from villages have a more tight contact with death.

The daily contact with the manifestations connected with death (funerals) is more frequent in small towns and villages then in cities, and in this way, children and teenagers from towns have more frequent occasions to learn and accept the reality of death. The death of very close relatives (grandparents, uncles, and aunts) represents an immediate experience in villages.

In cities usually death occur in hospitals and most of the preparations for burial happen outside the house (because of the small dimensions of the flat, for example).

Death became a distant phenomenon from all the daily activities of the human being and especially in cities, the feelings of repulse and fear of death are very strong.

Concerning the importance of religion towards death, many people and especially physicians who consider religion as a very important side of their life, have the tendency to make all the necessary efforts to defend life.

CHAPTER III

HISTORICAL POINTS OF VIEW TOWARDS DEATH

The point of view towards death of the physicians has to be much clearer and firmer compared to the rest of the population. The physician has an important social responsibility about all the acts he writes (of his actions and non-actions) from a moral and juridical point of view, because the medical profession represent an activity of the social structures, which has the purpose to conserve and preserve health and, in the same time, life.

“The privilege of the medical structures is to practice medicine in the benefit of humanity, to conserve and preserve the physical and psychical state of health without difference, to diminish the suffering of any patient. The respect towards human life is untouchable and it is not possible to practice therapeutic attitudes against the laws of humanity” (The Declaration from Tokyo, 1975). These phrases represent the base of the medical ethics. Euthanasia, as a part of its, needs a special attention in the actual moments of evolution of the society.

Euthanasia represents a group of medical voluntary or involuntary actions with an ethical and juridical support, which happen in the benefit of the patient, in the purpose of reducing his suffering if, after the actual knowledge of science, his death is certain and fast.

The first rule, which leaded our Christian existence, was “Not to kill!” Between theory and practice, the difference was always important. Anyway, several forms of civilization, in different forms borrowed this rule. If we turn back to the roots of the medical profession and at the Ante-Christian era, we may find this rule in The Hippocratic Oath: “I will prescribe regimen for the good of my patients according to my ability and my judgement and

never do harm to anyone. To please no one will I prescribe a deadly drug nor give advice which may cause his death”.

Since it was written, many centuries passed from the first version of the oath. In time, many changes occurred concerning the problem of the euthanasia. Starting from the concept that every human being has the right to a dignified death, some philosophers and scientists agreed with the euthanasia (Platon, Aristotle, Toma D’Aquino, Diderot, Voltaire, Fr. Bacon, B. Russell) or asked for the euthanasia (Freud was injected with morphine when he asked for it and with the agreement of his wife), but most of the scientists showed the fact that science is human when it defends life. This is the reason why the deonthologic codes and the laws punish euthanasia even if the crime is pretending to be done by pity.

In the last years, all over the world the points of view concerning euthanasia were changed very much. In the ancient times the fear of the infectious diseases determined scientists to justify euthanasia even if the crime concerned the severely ill patients (those suffering of plague were burn together with their homes; in the cases of rabies the patients were suffocated between the pallets, by asphyxia with mud or water). In the last years euthanasia brought much subtle forms, death being hurried by hydrocyanic acid, air or insulin injection in the cases of leukemia or incurable tumors. Some scientists pretend a sort of voluntary death control (when the patient is asking for it) or involuntary death control (for serious malformations or irreversible coma). Some studies showed the fact that 60% of the population agree with passive euthanasia (to let nature decide) and only 30% agree with the active euthanasia. In Holland, euthanasia is legal if the patient is informed about the serious prognosis of the disease, his decision is free, conscious, and without suggestions and the physician together with the patient have no other solution in front of death. In other countries, there were a lot of discussions concerning the invention of some machinery to make death easier (the Kevorkian’s machine), which don’t take into account the fact that death is a period of life and pretend helping the patients to die

and that is why a lot of trials appeared. Starting from the thalidomide trial from Belgium to the 49 victims of injection using insulin at a hospital in Vienna in 1989, justice proved to be very “human” in the rest of the cases.

Euthanasia was applied in an abusive way leading to genocide in the totalitarian governments, especially Hitler’s. The German national-socialist ideology established since 1923 euthanasia like a method which allows the “cleaning” of the “Arian” state from the so-called “empty coverings” like mentally ill patients or incurable diseases, idea which Hitler created the first time in his book “Mein Kampf”.

After he defeated by violent methods the other political parties and before starting the war against civilization, Hitler voted a law concerning the active euthanasia, using the term of “liberation through death of the persons who are considered incurable after a complete medical examination or if they are not in the limits of the human behaviour” (The law of euthanasia from 1939, September 1). Basing an this law, in only two years 700,000 persons were killed, just because they were ill. While three teams of physicians of the German Ministry of Internal Affairs (The Philanthropic Association of Care, The Corporation of Transport of the Patients and The Collective Service of Work) were killing thousands of people, other teams were looking for the diagnosis to write in the death certificates, which had to be given to the families. In a short time, the whole Germany was suffering because the war and the humiliations were replaced by anger. The priests in the churches were asking for the last signs of pity and humanism of the German politicians. The priest of Munster, Monseniour Von Galen and the priest of Munich, Cardinal Fualchaber were arrested in concentration camps.

The surprise was general, when the first anti-nazi dissident group appeared, the “German Eagle” had to accept the liberation of the priests, and the program of euthanasia was stopped.

It seems that also after the war, in many countries were cases when “liberation through death” was used especially of the

mentally ill patients (or maybe of the dissidents!) but until now we don’t have clear information.

From all these data, it is obvious that different political structures had different points of view concerning euthanasia and this was more or less accepted, leading sometimes to its total interdiction (Plinius suggested to use euthanasia for urinary lithiasis or neuralgia).

CHAPTER IV

EUTHANASIA – THE DEONTHOLOGICAL SETTLEMENT

In the purpose of classification of the forms of euthanasia we may divide it in voluntary and non-voluntary, if we take into account the consent of the patient and his capacity of psychical integration in the social life. From medical point of view, euthanasia may be active or passive.

The definition of euthanasia involves an important active compound from both sides the physician and the patient. The mentally normal patient, with the discernment unaffected by the disease, asks the physician to cut his suffering knowing exactly that there is no therapeutic solution for his disease. The physician, who knows very well that the fight against death is useless, agrees to determine a fast death, without pain, for the patient. The passive euthanasia asks for the consent of the patient, while the physician stops the specific therapy, using only the simple medical care.

If the consent of the patient is missing, the euthanasia is considered involuntary. There are cases (newborn children with malformations or status of coma) when the family, the physician accepting the solution of the selective therapy, gives the consent for passive euthanasia.

There are four types of euthanasia:1. Voluntary active euthanasia – may be similar with suicide.

The patient commits suicide, which is considered euthanasia because this solution is chosen by the patient to stop his suffering. The patient may be assisted by the physician or other person, who gives him the lethal drug, the weapon, etc.

2. Voluntary passive euthanasia – takes place when a patient, even if he receives a therapy that may save his life, he refuses to

continue the therapy, knowing very well that his action may cause his death.

3.Involuntary active euthanasia – the patient doesn’t take part to the decision concerning his death in the critical moment and nothing is done in an active way to hasten his death. He may be or not conscious.

A certain person (the physician, a member of the family, a friend, or somebody else) decides the patient’s death to save him from a painful death. An overdose, suffocation, or any other method may produce death.

4.Involuntary passive euthanasia – this case may appear when the physician decides to stop the therapy of the patient, knowing that the treatment won’t prolong his life and in a certain moment would determine his death.

So, the physician has the possibility to stop the life of an incurable or terminal patient, with or without his consent, by action or inaction.

We may rise two important questions: - Is death preferred to life, over a certain point? - Who decides where this point is?

Is there anybody who may say that between killing someone or let somebody die, there is no difference?! We consider that the difference is very important because action or inaction, without taking into account the result, appears from different moral basis. The base of the difference is represented by the fact that starting on the way of action, the physician has to have a very severe moral self-control, of the way he chooses. The physician decides about the moment and method the patient would die. The chosen drug would change the reason of death, which would be completely different from death after a disease. More than this, it is often discussed the possibility of which death is an accident of life and in this way, euthanasia becomes a human action, more or less legal.

The discussion concerning euthanasia started from the well-known report of The Institute of Social Assistance from Rotterdam, which said that 50% of the patients who die in Holland

in one year suffer medical assistance and 5% of them asked the physician to help them to die, while 400 patients committed suicide being assisted by the family or physician.

Starting from this study, we concluded that active voluntary euthanasia is not a legal experience in any part of the world.

The Remmelick Commission from Holland studied active euthanasia and found that interruption of life is asked in most of the cases by the incurable patients, but most of the medical staff was confident to its sacred role – to help life until its natural limits. Any way, a small number of physicians have an active role in stopping the life of their patients. The passive euthanasia and the selective non-therapy represent frequent medical actions accepted, especially from financial reasons, by many hospitals in the world.

The passive euthanasia and the selective non-therapy have the acceptance of the medical staff, but not in all the cases. Not to cure a minor disease of a young patient is not the same thing with the progressive diminution of the therapy of a newborn child with important malformations, or of an incurable carcinoma that will die anyway in a very short time.

We may discuss with this occasion about some aspects concerning the definition of the daily therapy and of the special therapy. It may be accepted for the physician not to use special therapy for prolonging life. The reason of this idea is determined by the economical expenses of the medical care and especially of the distribution of the limited financial resources of a hospital. But all the financial problems have to be secondary to the dignity and the benefit of the patient. Even if the medical sciences progressed a lot, a medical therapy is “productive” depending on the patient and the disease. This is the place of difference between a daily therapy and a special one. If the difference between the daily and the special therapy is obvious, its application in the juridical practice is very difficult, especially when we take into account the right of the patient to a dignified death and to the informed consent, but also when we don’t have his consent or state of consciousness. The right of every patient to dispose of his life and his own body

represents a basic factor, even if we speak about abortion, of the consent to therapy, or euthanasia, as daily or special therapy. There are some cases when this basic right may be violated. It is possible to continue a useless therapy, even if the patient wishes to die.

The church may say that suicide is a forbidden act. Even the refuse of therapy is no more accepted in the medical world, taking into account the fact that a patient will never be better informed than his physician concerning the present therapeutic solution. More difficult is the evaluation of the incurable state of the patient. The prognosis of death depends first of all on the amount of medical care, which the society is able to give to the patient.

In a sociological study, 95% of the incurable patients who were asked, said that they wish to be resuscitated in the case they reach the state of coma, showing an important wish of life and a special possibility of adaptation.

If until now the problem of euthanasia was studied compared with the capacity of the patient to accept his death, we also have to take into account the case of the unconscious patient who is not able to express his wish; he is not able to speak and he can not express his agreement concerning the therapy, all the decisions being taken by the others, “in the patient’s interest”. The only chance to evaluate the integration of these patients in the society is the evaluation of the level of brain destruction and then the decision of selective therapy or non-therapy depending on the level of destruction found.

Even discussed in the end, the euthanasia of the newborn children rises a lot of problems. The newborn child with malformations is exposed to passive euthanasia or non-treatment more than the adult. His consent concerning the therapy is absent and is exposed to the physician by the way of the parents. If the mother may decide about her body (as in case of abortion), from the moment the child was born, both parents have to accept the interruption of the therapy.

If one of them becomes compulsory, no difference could be found in this case between contraception and murder of the

newborn child. Of course, it is true that the newborn child is not able to express his personality, but also the physician can not kill. We may accept that to let a child die may be in his own interest in a certain moment. The selective non-therapy of the children with severe malformations is not in disagreement with the obligation of the physician to support life from conception to death.

To take the patient’s life in an active way means to murder him and in this case, age has no importance.

Campbell and Dovnnie showed in their work called “Modern Pediatric Practice” that it is a great difference between not using an incubator to keep alive a 600 grams newborn child or to make a killing injection, even if the result is similar.

Even from ethical and medical point of view, we may accept that a human physician, who has the acceptance of both parents who are convinced about the bad prognosis of their child, may stop his active therapy determining the child’s death or he may use common drugs to the same result.

The question of the physician consists in the definition of medicine, which is a practice in the benefit of life, but to keep alive a child who won’t be able to find his place in the society, being convicted to pain and suffering, represents an exception from the purposes of medicine.

Trying to abstract the criteria for and against euthanasia, we found some criteria positive to euthanasia:

- The fundamental right of a person to die without suffering as an expression of the absolute respect concerning this right and the human being. Euthanasia offers to the patient a possibility of control towards his death. This argument would represent the expression of the patient’s right to refuse life after he is no more independent, the feeling of helpless and even fear of death. The recent trials from Canada (the Wancy and Cobeil cases) in which the physicians refused to stop resuscitation even if the patients were conscious and asked for this decision (the decision of justice was to stop resuscitation), let the feeling that for the society life doesn’t represent only a lucid brain, but life needs a capable area,

that not only life is important but its quality. Judges considered that the interruption of therapy doesn’t mean euthanasia.

- The fear of the community of some diseases (for example the contagious diseases), especially in the past, which determined many dying men to become victims of some barbarian euthanasia procedures, like burning in their houses, asphyxia, etc. - The need to control voluntary death at psychiatric ill patients, with noxious behaviour, when the patient is asking for it (voluntary euthanasia) or have dictatorial laws (involuntary euthanasia). In some dictatorial countries the old patients and the disabled persons were considered under-humans and as a consequence, victims of euthanasia.

- A sort of answer to the demand of some parents with children with serious diseases (like the 21 trisomy, congenital malformations, etc) who identify their moral suffering with the physical suffering of their children.

Arguments against euthanasia: - Life is a sacred creation and can not be affected or

destroyed by humans, even if it is just at the beginning. - The legalization of euthanasia could open the gates to

abuses, being well known the crimes with successional motivation or the genocide of Adolph Hitler.

- The today considered incurable diseases, may become curable because of the progress of science. It is well known the fact that Plinius was recommending euthanasia for urinary bladder calculus or trigeminal neuralgia or in the Middle Age in rabies or plague and today such diseases may be cured.

- Euthanasia has involuntary risks such the so-called cripthanasia (secret euthanasia), the encourage of the processes of euthanasia, of the euthanasia by delegation (offered to some profanes), of the discriminating euthanasia, taking into account other criteria than the incurable disease.

- But the most serious reason against euthanasia are those which violate the fundamental laws of medicine, like the deviation of the medical assistance of dying patient, the alteration of the

social role of healer of the physician (from which comes the interdiction of the physician to take part to torture actions or punishment with death) and not in the end, by striking the notion of the physician by the creation of a senseless conflict between the physician’s right to cure and “the right to kill”. In this sense, most of the medical professional associations consider that euthanasia may have a dangerous evolution towards the vulnerable patients, representing a danger for the moral integrity of the medical profession.

- The ethical and juridical legalization of euthanasia would be against the message of the medical profession, whose purpose is to protect life, indifferently of the forms in which the patient comes to the physician. The duty of the physician is to assist death and not to neglect or help death. Such behaviour has to start from the truth that the world is not our usufruct and anyone may decide when we have to come or leave the world. Death represents the only reality which humans, and physicians, can not vulgarize, a good death being a form of triumph of life.

- Medicine and justice are not perfect even if the progress was significant. The error of diagnosis and of prognosis is real and it alters the quality of the medical act, but which is human and has to be taking into account. If this kind of errors may be accepted in universities where the experience of the physicians is combined with the endowment, what should we say about the diagnosis and prognosis in the villages or in isolated places, where there is no technical endowment?! So, we may conclude that justice may be eluded by the physician and the he may dispose of the humans’ life, who are waiting from him only hope and health, based only on the principles of ethics, which may be cheater and without explaining to anyone?!

- If the patient in a transitory state gives his consent for euthanasia (even if it is active or passive) and after some time, by a special chance and an efficient therapy may come back to life, what should happen? Maybe the patient will regret his consent and

will consider the “profited” hours of life as the most beautiful from all his life.

In conclusion, we may say that the role of the physician is to respect life, even if it is fragile and to respect death like a warranty of the respect for life.

The physician has to cultivate the idea that over everything humans have to survive to be able to promote the quality of man. The physician has to help the patient to have a “human agony”, making him understand the fact that humans live only once and life has always a sense. This human message of life, which brings hope by itself, has to be correlated with the dignity of man, who has to be always prepared to use his suffering, to accept death in any conditions, with pride and dignity. When death can not be defeated, the physician has to pacify the soul to help a dignified death. The medical morals is against the legalization of euthanasia, justified by the possible abuses when euthanasia may turn from pity to crime (The Court from Nuremberg declared the nazi euthanasia as a crime of war).

On another side, the legalization of euthanasia would affect the confidence towards the physician who has the role to help the patient to “pass quickly over his death”. The trials in this field tried to avoid the feeling of the public opinion, that the physician has the right to decide about life and death and to avoid the dissimulated murders motivated by the eradication of suffering. The active and passive euthanasia is against all the principles of medical ethics. More than this, the legalization of euthanasia would determine a stagnation of the art to cure, what can not be cured today having the chance to be cured tomorrow.

On another hand, the patient could lie, by dissimulation of severe suffering. In this way, it could appear the feeling that the physician has complete rights concerning life and death, which would be against his human mission.

All these arguments make from the euthanasia an unacceptable ethical and juridical act.

From the point of view of the patients, Vansell Pattson made a study to see their points of view concerning the experience of death. He studied a group of 100 old people, 35 women and 65 men, with the overage of 72 years old. Fifty percents of them had medium studies and the rest had superior studies. 30 were married, 35 were widower, 14 were never married and 21 were divorced. All the subjects were in pension. From religious point of view, 59 were Protestants, 18 were Catholics, and 28 had other religions or no religion. The criteria used to choose them were that they were coherent enough to be able to answer to a set of questions and, of course, they accepted to answer the following questions:

1.How do you feel today?2.What age would you like to have?

3.If you could do everything you want, where would you like to live?

4.Which are the most interesting and pleasant from all your activities?

5.Do you wish to be accompanied by your friends, neighbours, and relatives more than now or you wish to have more time for yourselves?

6.How does the future look for you? 7.Do you think at yourself as being old? If yes, when did you

start to think this way? 8.If you would be severely ill, desperate and you have a lot of

expenses for drugs, would you agree that physicians won’t make anything to keep you alive?

9.If you would be severely ill, would you agree that physicians would do something to shorten your life?

10.Is religion important for you?For the questions no. 2, 3, 4, and 5 the positive answers value

one point. The first question was used to observe the feelings of illness or health. The answer no. 2, 3, 4, and 5 showed a “rating of contentment” evaluated from 0 to 1. The question no. 7 was used to show the way every old person feels his age and showed that some old persons feel like being half- invalid. The questions no.8

and 9 had to be written in a very simple manner to be understood by the subjects, for who words like “euthanasia”, “favored life”, or “favored death” are strange. The last question was used to see the importance of the religion in his mind, in connection with the acceptance of death, when this doesn’t represent the wish of God.

2/3 of the patients was feeling very well at the moment of the testing. More than 1/3 had maximal points for the “rating of contentment” (they wish to have their present age, they wish to live where they are living, they find all the life’s aspects as interesting, they meet enough friends and relatives). 2/3 had low rates of contentment. For most of the old persons, they rejected the idea of being old.

The idea of severe disease and great expenses for drugs showed the fact that over 50% of the persons "wished to live at any price". 25% of them said “let me die or help me to die”. Very important seems to be the fact those persons decided to live, and all of them have strong religious feelings.

If they were influenced by religious rules against death with the exception of the God’s wish, they were agree with the temporizing of death by human action.

In the last time, euthanasia was associated with another medical case called “assisted suicide”, which are studied together now.

Jack Kevorkian, an active partisan of the “sweet death”, invented the “suicide machine”, until today 15 patients being “treated” with it. Even if in the State of Michigan a law was adopted, which forbid assisted suicide, Kevorkian was not convicted until three years ago, the assisted suicide considering that has no connection with murder. “To assist a suicide doesn’t mean to kill”, Kevorkian was saying. He was selecting the patients using ten criteria, such as discussions with the family, video recordings, discussions with the physician’s family, psychiatric examination to establish if the patients is mentally sane, the lack of family problems confirmed by the social institutions the absence of other interests, the person’s consent, etc.

Janet Adkins, suffering of Alzheimer, was the first person who suffered this procedure (perfusion with KCl and barbiturates). At the beginning, the machine didn’t function well and that is why he was obliged to find a more simple method, using carbon monoxide. Kevorkian is convinced that 85% of the inhabitants of the state of Michigan agree with him, and the adopted law which convict assisted suicide with four years of prison is immoral, because the conscience of everyone has to be over the law and society is not allowed to decide in the person’s place, when death is concerning just the person.

Law is not allowed to control the medical practice and that is why such a law is hypocrite, as Kevorkian said. The opposition to assisted suicide represents in fact a conspiracy of the church and politics against humanity.

As usually, in the practice of euthanasia, the physician’s help and his “therapy” is a rule, many authors speak about medicathanasia which rise important problems of conscience and ethical-professional attitude of the physician.

A referendum made in Washington, in the purpose of advertisement of the assisted suicide by the physicians, those who voted the referendum rejected this idea.

The lawyers, always on both sides of the problem, used to bring criteria of ethics to sustain their arguments. Those who agree with the medical assisted suicide (MAS) consider that the right to self-determination is fundamental, the decision to stop somebody’s life if he wishes so, has to be respected by the physician, who has to be free to satisfy the patient’s wish, even if the consequence is death. In this case, the physician has to make death as human as possible. The lawyers consider in this case that the physicians were always allowed to stop the therapy of the patients in terminal states (and this thing is generally accepted) because the patients have the right to refuse the therapy to preserve life.

The decision to stop the therapy of a terminal state patient to help the unavoidable death is possible, being rejected only by someone who doesn’t se an important difference of intentions. On

the other side, scientists consider that it is an important difference between the right to refuse an expensive and useless therapy in the case when the pathological process is unavoidable and “the right to die” represents just a tike in the assistance of death.

The lawyers who are against this idea say that while it is acceptable to cure a patient in a terminal state in a way in which death would result (to give to a patient with carcinoma enough morphine to produce a respiratory failure), the purpose to interrupt life is against the principles of medicine. Somebody who cures persons doesn’t have to be mixed up with somebody who helps people to die.

Others are afraid that once approved, MAS will have a fast evolution to an important number of cases and the society won’t be able to convict it.

People who agree with MAS say that it has to be limited to the conscious patients who ask voluntary for death and who have an unendurable suffering, without possibilities of therapy. In this case, the opinion of a physician is necessary (especially an unknown physician) and the assistance of an unknown, independent witness.

One of the limits of the medical sciences is the classification of the diseases, which still represent a proof of empiricism characteristics so that a prognosis is possible and a therapy may be used. The diagnosis and the prognosis are much more descriptive than prescriptive, other way saying.

It doesn’t matter how careful some predictions are made, like the evolution of the disease, the lack of answer to therapy, or the impossibility to improve the patient’s state, may prove to be wrong. In some cases, the result may be worse than it was predicted, but in other cases it may be better. Interrupting the evolution of the disease, MAS may improve the capacity of prognosis in a frightening way, helping the physician to make a very good prognosis of the result.

“The moment and the cause of death will be known precisely”. This fact could prevent the physicians to determine in

which cases the predictions were wrong. But this couldn’t prevent the cases when some patients would die (if MAS would be a common practice), but if they were under medical care, they could recover.

As long as medicine remains a science empirically practiced by the human being, some of the cases would be for sure wrong interpreted, not only because of the certain level of the human knowledge and which can not be perfect, but also by a mistake of reasoning or by a simple human error of any kind. This means, in the case of MAS that if the method would be accepted, some of the patients would be assisted for death even if they were not adequate for this, while others would refuse this method of freedom.

There is an important reason to repulse MAS by the fact that the physician may commit mistakes. If this reason would be generally applied, the physicians couldn’t action because they could produce a harm. Using other procedures except MAS, opposite results even the patient’s death could be possible. Because the purpose in MAS is completely different from the other medical procedures, any error, as small as possible, is not acceptable (because a patient whose state of health couldn’t lead to death could be killed) the only possible solution is to forbid MAS.

As for any other medical procedure, also for MAS, the benefits of the procedure have to be revealed compared with the harm it may produce. The amplitude and irreversibility of such a decision also contribute to the difficulty of this procedure.

We may identify sources of error in the declarations of the patients prepared for MAS.

On the other side, the patient may be wrong evaluated as being not able to decide MAS, may be considered inaccurate because he is not ill enough for MAS, or he may receive other therapies, which don’t cure or improve the state of health.

By refusing MAS, the physicians may make a mistake about the patient’s state of health and the patient is convicted to suffer for an unknown period of time, until the disease or other diseases may interrupt life, or when the patient dies because of other reasons.

On the other side, the patient may be not correctly evaluated, as being justified to ask for MAS as being wrong evaluated with an incurable disease. The errors of determination the patient’s need to benefit from MAS would be harm not only for himself, by the decision of a fatal procedure, which he could avoid, but undermine the confidence of the society in the physician’s capacity to evaluate and appreciate the patient’s state.

The physician who asked to assist a suicide has first of all to verify the credibility of patient’s declarations concerning his suffering. This may be difficult to evaluate because individuals are different concerning their resistance to pain and what may be tolerable for someone may be intolerable for someone else. Of course, the most important factor is not the patient’s suffering state but the physician’s possibility to make a correct evaluation. Unfortunately, the physicians have difficulties in the evaluation of the patient’s pain level, even when the cause is of physical nature. It is obvious that suffering, being produced by the basic disease, any therapy won’t be able to stop the pain, because the cause of the pain is the consequence of the evolution of disease and not of the secondary complications, which may be cured.

This last idea has different aspects. While a great number of secondary complications may appear in the evolution of a terminal state, a severe psychical depression may complicate a treatable disease and may rise the wish to die. This psychical depression may determine disorders of the appetite and sleep, diminution of the energy, concentration disorders, disorders in the daily activities, but also other physical diseases may have the same symptoms.

The treatment of such depression may be efficient and even in the cases that are resistant to therapy, the patient may recover and the wish to die disappears. What at the beginning seems to be a rational decision for MAS, after the recovery of the psychiatric disease, it may appear like an illogical decision produced by a mind affected by depression. But not every patient who asks for death has to be considered psychically depressed. The physician

has to decide if the wish to die was based on the patient’s wish, decision obtained in a lucid way and not influenced by momentary states or other family’s interests, of the others and even of the physician.

In the end, the physician is the last who evaluates even if the nature of the pain is subjective, if the decision for MAS has to be taken. The responsibility for the therapeutic decisions belong to the physician, MAS being considered in the sense of self-determination of the physician, being implicated in the decision and not becoming a passive instrument who satisfies the patient’s wishes.

The incertitude of the correct clinical evaluation of the prognosis, of the patient’s discernment, associated with the risk of confusion with the patient’s wishes and reasons, of his family and of the physician makes the decision concerning MAS to be difficult, with a very high potential of error to justify such a procedure today or in the next future.

CHAPTER V

DEATH FROM JURIDICAL POINT OF VIEW

Concerning euthanasia we are situated between the moral convictions concerning the sanctity of life and the impossibility of the human being to interfere in the God’s wish and the development of the actual science, which gives us the power to choose the moment of death.

The international laws sanction the right to live of every human being. To refuse this right, regardless of the state of physical and psychical health and his age is equivalent with murder.

There are several proposals in different countries to accept “the murder from pity”. The general opinion is that the adult population may benefit of medical care in the previous moments of death (75% from the adult population asked in Great Britain and USA gave a positive answer). Anyway, there is the opinion that the help for death has to be passive, without taking into account the imperative wish of the suffering patient. The relation between physician and patient doesn’t have to be eclipsed by the possibility that the physician would change the white overall of the healer with the butcher’s black hood.

In Europe, there are two opinion concerning euthanasia: in the North it tends to be legalized and in the South the great principles of life are still active.

After twenty years of discussion, Holland gives an honorable solution for the physicians by legalization of euthanasia in the cases of conscious and repeated requirement of the patient and the acceptance of a family doctor. An irreversible physical or psychical suffering represents another condition. The requirement has to come from a person who is conscious, free of influence in

the conditions of the lack of other methods of therapy or other types of treatment and with the consent of physician who has to execute euthanasia, other physicians and priests.

Taking into account the fact that such a decision can never be objective and free because of the terminal depressive state, the discussions concerning the validity of this law didn’t finish yet. Even in the places where euthanasia is not legalized and some physicians refused to practice it, some Courts gave a positive verdict and obliged the physicians to execute the verdict if the patient’s requirement accomplished the two essential conditions: incurability and conscious decision.

The usual method is to induce coma with the help of barbiturates followed by a lethal injection.

In other countries, the physician who helped the patient to commit suicide is obliged to give the documentation to a forensic pathologist (written report which includes 23 problems), so that from 590 cases in 1991, the reported cases of euthanasia reached to 1300 in 1992 (Holland). In a climate of mutual general tolerance the law succeed only to establish the transparence concerning euthanasia. The associations for the right to die in freedom (ADMD) plead also for the respect of the patient’s wish.

In Germany, the word “euthanasia” used by the nazi had the sense of “help to die”, especially in the cases of refuse of the victim (“therapeutic obstinacy”).

Denmark legalized the “passive euthanasia”.In England, after the Cox and Hove affair, the discussions

concerning euthanasia had a new start and in the USA the federal law called “Self Patient Determination Act” respect the patient’s wish.

In the Latin countries, euthanasia is practiced even if it is not recognized. In Belgium it has extenuating circumstances and in Italy it is forbidden by the Order of the Physicians. In Spain it is equivalent with murder.

The decision of Holland created an important break in the European Bioethics. As a first result, The European Convention of Bioethics was postponed.

Classically, euthanasia, like an asked murder, motivated by grave and incurable suffering, is not considered from a juridical point of view as committed in a state of necessity. The feeling that human like can not be stopped in such circumstances was created and some delinquents could prevail of this justification in such circumstances. Euthanasia is considered a murder with extenuating circumstances.

It is difficult to anticipate the evolution of the opinions of the European Jurisprudence. Perhaps, in several decades this form of death will be accepted in well-defined conditions, this at last would exclude any form of abuse. We have to mention the fact that active euthanasia will be depenalized from humanitarian and not economical reasons.

Very strong tendencies of opinion manifested in the USA in the last years.

Concerning euthanasia we may distinguish two types of patients: conscious patients who have a sufficient capacity of understanding to realize what is there present state of health, the nature and the effects of the proposed therapy and the risks, which may follow the therapy or the interruption of it (Schoendorff Society of New York Hospital believes that “a conscious adult person, generally, has the right to stop or continue his therapy”) and unconscious patients who may be divided in patients who showed their wishes concerning death or maintaining life before they become unconscious and those patients who didn’t show their wishes.

In the case of conscious patients, The Supreme Court of New Jersey decided:

1.The person’s right to control his own body is a basic social concept recognized by the Constitution.

2.The right to take certain decisions concerning somebody’s body is protected by the Constitution.

3.The conscious patient’s right to stop the therapy of maintaining life is not absolute.

There are four fields in which the state may limit the competent person’s right to refuse medical therapy:

1.The preservation of life - there are a great number of members of “The Jehovah Witnesses” who refuse transfusions. Also in the cases of children, unconscious patients and other persons who are not capable to take a decision, the state may oblige the application of therapy. But this doesn’t mean that a conscious patient is not able to stop his therapy.

2.The prevention of suicide – the interruption of the medical therapy doesn’t represent the same thing with the attempt to commit suicide. The refusal of the medical therapy means that the disease will follow its natural course. Death will be determined by a disease and not by the result of self-aggression. The difference is that between self-destruction and self-determination.

3.The protection of the innocent third person – many of the cases of refuse the therapy involve persons who are parents of minor children with incurable diseases and who depend of their decisions.

4.The integrity of medical ethics – some courts realized that if they give usual decisions of interruption of the therapy for the patients who may be cured, may lead to the demoralization of the medical profession. When the patient is not in a terminal state and the therapy may be hopeful for the saving his life, some states may use their authority to repeal the patient’s decision. When the therapy is long and death inevitable, the courts are more tolerant in accepting the refuse of therapy. Any way, even in the cases in which the therapy may save the patient’s life, the therapy may be extremely invasive (for example like renal dialysis), so that the court may not impose its authority.

A conscious patient has the right to refuse any medical therapy including artificial feeding and cardiac-respiratory advisement. In this case, a clear example is that of Kathleene Farrell, a 37 years old woman suffering of lateral amiotrophic

sclerosis (SLA) and connected to artificial respiration. Her husband asked The Court of New Jersey to name a medical guardian for his wife mentioning that he gives the acceptance to disconnect the artificial respiration of his wife. The Court was convinced that the patient was conscious and she wished to stop the therapy knowing that, any way, this will lead to death. The words used by the judge who gave the decision were identically with those meaning to stop the respiratory advisement of the patient. Any way, it is interesting to analyze the words used by the court: “with the advice of the therapist”. This meant that if the therapist would change his opinion before stopping the advisement, the guardian wouldn’t have anymore the protection of the court and the physician wouldn’t have been responsible of murder in the case of stopping the advisement. The final analyze of this case leaded to the conclusion that “death which will follow is not a murder but, in fact, meaning the expiration of the natural conditions of existence. In the second time, even if this act will be considered a murder, it will not be illegal”. The Court showed that “it is a clear and real distinction between taking somebody’s life in a illegal way and the stopping of the artificial material supports of sustaining life, as a method of self- determination”. The Court clearly decided that the application of this constitutional right is protected from the judgement for murder. So, the patient’s right to refuse medical therapy even with the risk to aggravate his disease or the risk of death is protected by the Constitution and the federal law. If the patient is mentally normal and asks for the interruption of the medical therapy of sustaining life, this is a procedure that has to be applied.

The first step is to evaluate the patient’s mental state. If this is normal, the next step is to confirm of the patient is correctly informed about the prognosis, about other possible therapies and about the risk of interruption of therapy. All these conditions have to be based in the same time on the observations of two physicians (except the therapist), who examine the patient. If this procedure is respected, the intervention of justice is not necessary.

Concerning the unconscious patients, in the USA is used a more adequate term, that of “incompetent patient”, which means that the patient lost the capacity of understanding the received information of deciding about his options or to communicate a decision.

An example of such a patient is that of Claire Conray, 84 years old, suffering of arterial hypertension, diabetes mellitus, vascular arteriosclerosis, who was not able to speak, was not able to feed alone (she has a gastric catheter), she couldn’t control her excretion, she was not able to move and she had a reduced intelligence. The therapist appreciated that if Claire was confused, “any way she was conscious”, she was not in a state of cerebral death, coma, or a chronic vegetative state. Concerning the perception of pain, they were not able to establish a conclusion.

At the clinical examination made by another physician, who was not involved in this case, the conclusion was that Claire was not moving from the semi-fetus position, her intelligence didn’t improve and she didn’t answer to verbal stimulation.

Her nephew, Thomas Whittemore, who asked the permission of the court to stop her catheter, made all the requests concerning Claire. Because he was living together with the patient since 50 years, he was sure that if she were conscious she wouldn’t admit the insertion of the catheter. Both physicians who examined the patient agreed that if the catheter had stopped, the patient would have died in a week, because dehydration.

The first physician recommended to take out the catheter because Claire wouldn’t have lived more than several months in a deteriorate state in which it was possible for her to suffer very much.

The therapist decided that from a medical point of view it was not acceptable the interruption of the catheter.

The Court of Justice decided the interruption of the catheter because the patient’s life was hard and she was a torture for the others.

Claire’s guardian claimed the Court but until the trial started Claire died with the catheter in place. The Court considered that such a procedure (to take of the catheter) represents a murder and not euthanasia.

The Court accepted the right to stop the life or the treatment to sustain life for the incurable or in terminal states patients, cerebral death, irreversible coma, vegetative life, or for those whose state of health wouldn’t improve with the help of the therapy.

Like in Claire’s case, in the case of any incompetent patient we have to act and decide in the same way the patient would have done if he was competent. The Court showed that the sustaining therapy may be continued or stopped to an incompetent patient, when it is very clear that he doesn’t wish that therapy in other circumstances. It has to be obvious from a medical point of view that the patient has to be old, incompetent with severe and permanent mental and physical disorders and a hope of life of one year or less.

The person who takes the decision has to have medical knowledge and to make a good choice between accepting or ignoring the medical therapy, like the patient would have done if he were competent. This represents the subjective test.

If the patient’s state is not clear, justice elaborated tests which allow to the persons who substitute the thinking of the incompetent patients (guardians) to make a real evaluation of the best interests of the patient.

The objective limited test is used in the cases when in a certain degree it is very clear that the patient would refuse the therapy, but even this thing is not perfectly sure. To be valid this test has to accomplish two conditions: we have to prove with the help of concrete proofs that the patient would refuse the therapy; and then the person who takes the decision has to be convinced that the load of the life is more harmful than its benefits for the patient. The pain becomes in this way a criterion of evaluation. The Court showed that in this branch have to be included the

patients who suffer and will continue to suffer an irresistible pain for all the rest of their feature life. With this idea we get into the field of the pure objective test which is used when the patient’s wish are unknown but the administration of the maintaining therapy is inhuman, leading to irresistible pain.

We have to take into account also the possible suffering during a life under therapy and we have to deduce the duration and importance of the pain, which the patient will feel if the therapy would be interrupted. This criterion is more important than the physical pleasure, emotional feelings and intellectual satisfactions, which the patient would have if he would come back to life. If the load of pain in an artificial sustained life is clear to be bigger, than by using the objective test, the interruption of the patient’s life is allowed if he didn’t expressed his contrary wish before becoming incompetent. The conclusion is that if the used therapy just prolongs the suffering it doesn’t have to be started or have to be stopped.

Justice specified that when the proof is insufficient to satisfy the objective limited standard and the objective pure standard, the therapy of maintaining life won’t be interrupted until justice won’t conclude that it is positive for the best interest of the patient. The Court specified that there are not significant differences between the artificial feeding, artificial respiration, or other mechanical ways of sustaining life, when the organism is no more capable to maintain a normal function by itself.

There is a certain juridical procedure concerning the incompetent patients:

1.It has to be a juridical determination of the fact that the patient is incompetent to take a decision concerning the interruption of the therapy by him. This fact would be established after medical examination performed by two physicians, and the Court has to be satisfied with clear and convinced argumentation. The Court emphasized the fact that the test of competence is used either for the decision concerning the medical therapy or for other types of competence like that of guiding somebody else, to take

care of somebody’s business. In the case in which the patient is found incompetent, a guardian will be engaged.

2.These procedures will be started by any person who thinks that the interruption or diminution of the treatment of maintaining life would follow the wishes of the incompetent patient or for his interest. This person has to announce the Ombudsman Office. Any person who thinks the contrary has also to report his opinion to Ombudsman, which is a status created by the Court of New Jersey.

3.Ombudsman has to analyze any reclamation like a possible abuse and is called to investigate the case and report it in twenty four hours to the Commission for Services for the Help of Humans or to any governmental agency, which is involved in such problems.

4.The patient’s state has to be presented by the therapist and nurses. Ombudsman has to name other two physicians, from other hospitals than two therapists, who have to confirm the irreversible patient’s state, the possible therapies, the possible risks and the way death would come if the therapy would be interrupted. If it is clear the fact that the patient would trust one of the members of his family or a close friend to take a decision concerning his life together with the two medical confirmations, Ombudsman may let the freedom to the person asked to decide. If such a person was not named, Ombudsman has to consult the persons who take care of the state of health of the patient (husband, parents, children, relatives, etc.), who wish to take such a decision. Ombudsman will give to this person the right to decide. The juridical reevaluation of this decision is not necessary, except when a conflict appeared between those who decided family, physician, and Ombudsman. The guardian is called for a patient who doesn’t have any person to represent his interests. The closest friends are not allowed to take decisions in the name of the patient excepting the case when he specially named one of them in this purpose.

5.With the condition that the two independent physicians named by Ombudsman to insure the medical assistance, the guardian and the therapist may interrupt the therapy of maintaining

life, if the guardian thinks, based on medical evidences and on the wishes of the patient, that the conditions of the subjective, limited objective and pure objective tests were satisfied. Any way, Ombudsman has to have a point of view concerning this decision. The Court specified all the cases in which the discussion bellow is not necessary to apply: newborn children with severe malformations, the adult who was never competent, suffering from a painful and invalidating disease.

A special opinion was offered by Justice Handler who doesn’t agree that most of the opinions focalized on pain like the most important element, the presence of the significant pain becoming the only criteria for the best interests of the patient.

The exclusive criteria of pain deny the category of people who, at the end of their lives, may strongly disagree an artificial prolonged existence despite the absence of any pain. His point of view is that the standard has to contain a multitude of medical factors established by the persons who take the decision in the place of the patient. Such a test has to be applied only when the person is in a terminal state of a disease, permanently unconscious, and suffering from an irreversible disease of an organ or a vital system.

Special problems rise when the question concerning the interruption of hydration and nutrition appears. If the patient is competent all these are allowed.

An example is the case of a 55 years old woman, suffering of LAS who, when she was normal from a psychiatric point of view, decided to use the right to die by refusing any nutrition by gastric catheter or other artificial ways, when she would loose the capacity to swallow. This decision was studied and approved by the Court of New Jersey, even if the police of the hospital and the opinions of the staff were against this decision.

The Court of New Jersey had to resolve also other cases of incompetent patients.

The case of Peter refers to a permanently unconscious person who lives in a sanatorium and who was not expected to die in one

year. The Court observed that the wish of life would be the best substitute for distinguishing the wishes of the patient, who didn’t let any sort wishes before becoming incompetent. In this case, a very important role had Ombudsman.

Another case was that of Nacy Jobes, who was in a permanently vegetative state. If she would had been 60 years old or over 60, Ombudsman would have been an indispensable participant. The question is if the artificial feeding like a form of medical therapy could be interrupted. The Court had to establish the criteria concerning the self-determination, to protect the incompetent patient. In this case a member of the family or a guardian were determined to substitute the thinking of the patient.

The incompetent patient, who never showed his wishes, continues to represent a problem. In the case of George Clark, discussed on the 7th of April 1986, a special attention was necessary from the Court, which had to balance between the difficulties of a life with enterostomy, compared with the hope of indefinite life of a patient with organic cerebral lesions, a very low cognitive level and a severe neurological and medical state, but not in vegetative and coma state. Because the family, the therapist, and the committee of medical care from the hospital didn’t agree with the interruption of the therapy, the Court decided that the therapy has to continue.

In the case of Elizabeth Visbecle, the problem of the Court was if a tube for feeding could be surgically implanted in the stomach of a 90 years old woman who suffered an invalidating trauma. Without the feeding tube the patient would have died by dehydration and starvation.

With the help of the tube, the nutritional needs would be covered, even if she would permanently remain in a very bad physical and mental state. The Court decided that the feeding tube will be implanted and to sustain this decision they gave the following arguments:

1.This was the only efficient way to give the necessary aliments to the patient.

2.The surgical procedure is simple and may be done by local anesthesia.

3.The patient was conscious and had an important capacity of reaction.

4.Her sisters said that occasionally they heard the patient speaking words and phrases and her son said that several days before the patient gave coherent answers to some questions.

5.The patient didn’t feel pain and she was capable to feel and express pain.

6.It was nothing obvious concerning what she would have decided in the circumstances she was exposed.

7.The prolonged use of the tube wouldn’t have been embarrassing for the patient.

8.Those who were taking care of the patient’s health considered the use of the tube a benefit and the guardian named by the court agreed the decision.

The conclusion to implant the tube was adopted even if the medical examination revealed that the patient was suffering from congestive heart failure, she had atrial fibrillation despite the implantation of a peace-maker, she had many lesions of the right cerebral hemisphere, she was paralyzed on the left side on the body, she was not capable to move and to swallow. More than this, the tube was implanted despite the fact that no one of these conditions wouldn’t ameliorate her state of health. The medical examination clearly established that she wouldn’t live more than several months, even if all her necessities would be covered. The Court had the right to reexamine the problem if any changes in the mental and physical state of the patient would appear or if it will be an important adverse reaction concerning the tube or the aliments introduced with its help. The Court had the idea that “as long as Elizabeth was the patient of Chilton Memorial Hospital or to another the idea to take out the tube won’t be accomplished without the accept of the Prognosis Committee of the hospital”.

Thinking at the presented cases we realize that, sometime, will be a moment when each of us has to die. To delay this

moment with the help of the medical therapy or other active mean has a sense as long as the quality of life is in a certain way satisfactory. Artificial feeding and other forms of active therapy are useful as long as we are sure that the lost of the superior brain functions is irreversible. In this case, decency shows as to be prudent in the interference in the state of falling down of the organism. When the patient is not able to decide, medicine will decide. The purpose is to make the population sure that the patients won’t be deprived of the indications of medical therapy.

In March 1986, the Juridical Council of the American Medical Association (AMA) created an ethic law. It was decided that it would be ethical for the physicians to interrupt all the medical ways of stopping life including artificial feeding and hydration for the patients with irreversible coma even if death is not imminent and in the cases were the diagnosis of coma is confirmed. The Council of AMA concluded that in any moment the dignity of the patient would be preserved.

The dignity is preserved when the patient’s wishes are expressed, but can we agree with this definition when these wishes are not known?

In conclusion, the choice has to be concordant with the law and with ethics. When the choice is impossible to take, the medical decision will lead the course of the action with several ways of legal protection, like the opinions of other physicians, consulting of the family, of the friends and of the Institutional Ethics Committee.

In each case the interruption of the therapy is possible, leading to inevitable death. With comfort and without pain, an easy death is wished and may be obtained. This is euthanasia. Some scientists consider that these patients are already in a phase that they define as “death “, so that the only possible thing to be done is to finish this interminable death and not to end what remained from life. In the Hospital of Sinai from New England, the Court accepted that the medical staff has not to be obliged to stop artificial feeding if this is contrary to their moral and ethical

principles and if these principles are recognized and accepted by most of the physicians and the medical staff. Many physicians consider that is better to accept not to start the necessary therapy from the beginning instead of stopping it at a certain moment.

A special group is represented by the patients who, as long as they were conscious, before or after the beginning of the disease, “told to the physicians that they accept to stop the special medical therapies in terminal states”. These declarations, called “living will” (therapy for stopping life) are concrete documents, which allow the interruption of the therapy of sustaining life and its procedure in the case of a terminal irreversible disease. The declaration, in any form it would be, has to be communicated to the physician, after it was taken in the presence of several witnesses and was written in the recordings.

The law says that the persons who react according to the “living will” of the patients are not accused of murder or civil responsibility. The interruption of the therapy of maintaining life, according with the “living will” is not considered and doesn’t represent a suicide.

The Congress of the USA created a status, which says that all the hospitals have to inform the patients concerning the possibilities that they could express their wish about their death. The administration of the hospital has to decide about the procedure of the will and what forms of testimony have to be taken into account; from this decision the question rises about encouraging or not the patient to write his “living will” or not.

In the same time, the administration has to instruct the physicians and the medical staff about the repeal of the “living will”. The “living will” may be repealed in any moment and in any way without taking into account the patient’s mental state. The physicians’ problem is represented by the way in which they interpret the spoken or not spoken (moan) expressions like being repealing expressions.

Does the words “I don’t want to die” represent a wish of repeal? How do you have to interpret a patient’s gesture? Have the

medical staff to ask the patient if he wishes the catheters to be taken out and then to wait for a gratification from the patient?

The repeal of the “living will” may be wrongly understood by the physician, and not to be honored, leading to an undesirable death of the patient.

Another problem is represented by the responsibility for the expenses of a long lasting disease. The patient is a vegetative state and the family’s members declare themselves not capable to continue to support the expenses of the therapy, doesn’t this represent – maybe in an unconscious way- an acceptance of the application of the wish to die written in the “living will”?

The “living will” considers that the interruption of the special medical therapy according to the patient’s declaration is not considered as euthanasia or suicide. The experts discussed about the illogical nature not to consider the refuse of the therapy like a form of passive euthanasia.

Another problem is represented by the patient’s suffering between the interruption of the therapy and death, and the wish to shorten pain by the administration of some drugs, action which is equivalent of the active euthanasia.

In the end, we don’t have to forget the persons who don’t have incurable diseases, who don’t have pain, whose therapy is expensive and harmful, whose quality of life can not be improved and those who have to pay for the therapy and don’t want to do it anymore. In all these cases, what they have in common is to take into account the quality of life, which is the origin of the following actions.

These are the points of view of the American lawyers and population concerning euthanasia. In Romania the origin of the four articles of the law concerning euthanasia and included in the Sanitary Law is of Holland inspiration. They are:

- The decision to voluntary interrupt the patient’s life by the therapist for his interest in the purpose of stopping his suffering, even if he clearly asks that his life would be interrupted (voluntary euthanasia), or his life is stopped in his own interest when he is not

able to express his wish (involuntary euthanasia) is possible to apply if such actions are not under the incidence of the penal law.

- The decision to interrupt the therapy of maintaining the vital functions for an unconscious patient who is not able to survive without circulatory and respiratory sustaining (patient in a terminal state) will be taken by at least two physicians specialized in intensive care, according to the criteria of evaluation of cerebral death, established by a national team of experts who analyzed the problem.

- Two physicians, one pediatrician acting sincerely and with the acceptance of both parents (if it possible) have to decide about the interruption of a newborn child’s therapy determined by a severe medical diagnosis, which shows that the future child’s life will be intolerable by pain, suffering, or cerebral incompetence, the therapy being abandoned.

- The physician and the rest of the medical staff have the right, based on individual conscience not to participate at this action.

Taking into account the reasons which we studied concerning euthanasia, it is impossible not to agree about the way in which it will be reflected in the future laws. It seems to be reasonable the practice of passive euthanasia and selective therapy in the clear cases, which are not susceptible of discussions. Maybe future laws, which would better express the charitable principles of euthanasia, would contain:

- Active euthanasia (the stopping by any methods the life of an incurable patient or in a terminal state not taking into account who is asking for it). It is forbidden the passive euthanasia (stopping life only by therapeutic methods not taking into account who is asking for it, when the patient is conscious).

- We may accept passive euthanasia of a patient in a state of deep coma when physicians’ team composed of intensive care specialists, neurologists, and forensic pathologists considering the unanimous criteria establish the irreversible death of the brain.

- A pediatrician together with another physician may decide to stop the newborn child’s therapy when he has congenital malformations, which are not compatible with life - based on a certain diagnosis – or cerebral incompetence.

The last paragraph of the proposals of law is incontestable.

CHAPTER VI

THE PROCLAMATION OF THE EUROPEAN COUNCIL ABOUT VEGETATIVE LIFE AND “THERAPEUTIC

OBSINACY”

As we discussed before, the American justice permitted the physicians to stop life or the therapy of maintaining life in the case of the incurable patients or in terminal states, cerebral death, irreversible coma, vegetative life, or whose life wouldn’t improve with the help of the therapy.

In England, after the case of Cox and Hove, were observed important tendencies of opinion concerning the “sweet death” connected especially with the vegetative states between the persons who accepted it and those who convicted it.

Doctor N. Cox was convicted for murder attempt because he practiced euthanasia to a 70 years old patient with rheumatoid arthritis using an injection with KCl, but the Order of the Physicians showed clemency. The court pleaded also for the innocence of other physicians (dr. Carr, dr. Lodwig), who used a cocktail of KCl and lidocaine, considering that the patients died because of the cancer and not of the cocktail of anesthetics.

A Voluntary Euthanasia Society also pleaded for the modification of the law concerning euthanasia. The consequence of these pressures was the liberalization of the physician’s right to stop artificial feeding in the case of permanent vegetative states. In accord with this law, Dr. Hove suppressed the alimentation catheter of a patient after he discussed with the lawyer concerning “the inefficiency to maintain in life a physical body” if the cerebral functions are missing. The House of the Lords confirmed this point of view. More than this, in the process of legalization in England of the social and legal implications of euthanasia, the discussions

continue (the actual law agrees to stop a therapy, but not the administration of a lethal injection to a person in a terminal state).

Against these arguments, Dr. Andreus said that with the help of the intensive care, KAT succeeded to bring back to life 34 comatose patients in a vegetative state, after 6 months of complex therapy directed especially on the visual and auditory functions, after one year for ten cases and three years for five cases, but for other experts, the economical reasons of these experiments (70,000 pounds per year for one case) are more important.

Economical euthanasia (the refuse of renal dialysis at patients over 70 years old) is in total contradiction with the medical ethics. So, we may ask which are the moral criteria concerning the hierarchy of medical care?

At the 27th Session of the Parliament of the European Council, the Supreme Court of the human rights, in the resolution no. 613/1976 some recommendations were made concerning the vegetative state. The meeting thinking that for the reasons exposed in the recommendation no. 779/ 1976 concerning the patients’ rights and analyzed in the Commission report concerning the social problems and health (document no. 3699), the real interests of the patients are not always best preserved by an excessive application of the modern technologies to maintain life, being convinced that what the dying people wish the most is to die in dignity and peace, as possible in comfort and with the help with the family and friends, thinking that the incertitude concerning the justice of the criteria to determine death could create an useless fear, insisting on the fact that to establish the moment of death is not more important than other patient’s interests, invite the medical experts of the member states to examine attentively the criteria on which are based today the decisions concerning the applications of the techniques of resuscitation and maintaining life. More than this, the meeting invited the Bureau for Europe of WHO to examine the criteria used in several European countries for the determination of death, using the actual medical knowledge and techniques, and to make proposals for unique point of view, which has to be applied

all over the world, not only in hospitals, but in the general medical practice.

In the Recommendation no. 779/ 1976 concerning the patients and dying persons’ rights, the Meeting of the Parliament of the Council of Europe considers that the fast and continuous progress of the medical sciences will generate problems and may be come even a threatening for the fundamental human rights and the integrity of the patients. Taking into account the tendency of the medical techniques to use more and more technique therapies (sometimes not so human), observing that for the patients sometimes it is difficult to defend their own interests especially when they are cured in big hospitals, considering that is unanimous accepted that the physicians have first of all to respect the patient’s wish, considering that the right for dignity and personal integrity the right to information and care for himself have to be well-defined and accessible to every person, convinced that the duty of the medical profession is to serve humanity, to protect health, to treat diseases and help suffering, with respect for the human life and convinced that maintaining life is not by itself the exclusive purpose of the medical practice but in the same time also suffering has to be calmed, considering that the physician has to make all the necessary efforts to calm the suffering and he has no right – even in the desperate cases – to shorten the natural course of life, emphasizing the fact that maintaining life by artificial methods depends by many factors like: quality and efficiency of the equipment, and the physicians who work in hospitals where the technique equipment helps an important maintaining of life, are in a delicate situation concerning especially the cases of maintaining therapy at a person with irreversible lesions of the cerebral functions, insisting that the physicians have to act according to science and approved medical experiences and that any physicians or member of the medical profession is not obliged against what his conscience tells him to do according to the patient’s right not to suffer, recommend that the Committee of Ministers invite the governments of the member states to:

1.a.To make all the necessary changes, especially connected with the activity of the medical staff and the organization of the medical services, to be sure that all the patients cured in hospitals or home to benefit of the alleviation of their sufferings in accord with the medical actual knowledge. b. To convince all the physicians that the patients have the right to a complete information concerning their disease and the possibilities of therapy and to take all the necessary measures that this information would be done at the moment of hospitalization in the same way the routine examinations are made. c. To be sure that all the incurable patients are psychologically protected to meet death and to have the necessary assistance, with the help of the medical staff (physicians and nurses) who have to be elementary prepared to be able to discuss the problems of death with the dying persons and also with the help of the psychiatrists, priests, social nurses attached to the hospital. II. To establish national commissions of investigation composed of experts from all the levels of the medical profession, lawyers, priests, psychologists, sociologists, to establish ethical rules of therapy of the dying persons and to determine the lines of application of the special measures of maintaining life and to examine all the cases the physicians have to face. For example: the penal or civil punishments, which appear when the physicians give up the artificial measures of maintaining life, in the case of terminal patients, whose lives couldn’t be saved with the help of the actual medical knowledge or when the physicians took all the necessary measures to alleviate pain and which could have secondary effects in the process of death, to examine the written declarations made by competent persons who accept the physicians not to take the necessary measures of maintaining life, especially in the cases of irreversible degradation of the cerebral functions. III. To establish if there are not already existing identical organizations or national commissions, which analyze the

complaints against the medical staff, made for errors or negligence in the medical practice. IV. To inform the Council of Europe about the results of the examinations, their conclusions and their proposals concerning the patients and dying persons’ rights and the legal and technical implications, this guarantee their application.

CHAPTER VII

THE MEDICAL CASE – BOOK RECORDS AND RESPONSIBILITY IN EUTHANASIA

Clammponiere said, “the problem of medical responsibility becomes day by day more grave and upsetting for all the physicians. If we want not to discourage honest intentions, which may cure the patient, we have to protect the honest physician who is conscious against the unjust actions”.

On the 30 of March 1989 the New England Journal of Medicine published an article concerning “the responsibility of the physicians towards the hopeless ill patients”, speaking about the patient’s rights and then analyzing the situation when the doctor who helps a hopeless patient to die commits a murder or not. The authors just recognize the fact that the problems complex. It remains the possibility that this alternative would be accepted in some of the cases.

In the USA all the states agree with the decisions showing that the therapy has to be discussed with the patient. The doctor has the legal duty not only to give to the patient clear information concerning his options and possibilities of therapy but also to include the possibility of interrupting the therapy. Especially when invading investigations or surgical operations will take place, it is very necessary to discuss the risks and benefits of the procedures, which will take place.

Another duty of the physician is not to apply a therapy without the patient’s consent or to oblige the patient to accept a form of therapy, which is not concordant to his wishes. The patient’s refuse will be written in the recordings.

In the branches of high risk of medical practice (emergencies, terminal states, reproduction technology, genetic advice) to avoid the mistakes and to distinguish them from the medical error needs to have a scientific experimental criteriology, which tends to prove the following facts:

- the physician did all the necessary things as therapist and as human for the patient’s interests;

- he respected the standards of professional behaviour in accord with his studies and his conditions of work;

- he used the recommended scientific methods and didn’t engage for the results he will obtain;

- he respected without exception, the patient and family’s consent;

- he satisfied the necessary patient’s examinations by other specialists if he was asked for it and he didn’t deprive the patient of his chances;

- he didn’t give to the others his responsibilities.The prevention of the juridical responsibility, of maximal

gravity may be done by respecting some deonthologic criteria, which will determine the contributions in an efficient way to the crisis of conscience of the medical responsibility. The physician’s competence becomes a patient’s right and a sine qua non condition of an efficient medical act. For the physician, competence becomes “the first form of honesty towards the patient”.

In Romania, only one case of active voluntary euthanasia was judged in 1979, when I.I., an 84 years old man, expressed in several moments his wish to die asking for an injection with a lethal substance. Being alone at home he asked a hospital attendant to make him an injection in the pericardial area with the intention to inject the heart, with Cimexane. After the injection, the victim felt bad accusing agitation, dyspnoea, convulsions, excretion, and a state of coma and died at four hours after the injection. At the autopsy, in the pericardial area there were found pricked wounds with parchments all around, an the internal examination hemorrhaged infiltration in the pericardial area and 100 ml of

yellow liquid smelling of DDT in the left pleura, and also the pericardium had hemorrhaged infiltration.

The complementary examinations from the siring and the bottles with insecticide and also from the organs showed a lethal quantity of organic chlorine. It was concluded that the death of I.I. was violent, and determined by the injection in the pleural cavity of HCA. Between the intoxication and death it was a direct connection of causality. Trying to defend himself, the hospital attendant said that the victim injected the substance by herself, thing that was impossible because the victim suffered of an amputation of both arms. Justice gave him extenuating circumstances, convicting him for seven years of prison.

In the end, if euthanasia is not totally accepted, an important element of the medical responsibility has to be represented by the assistance of death. In front of the clumsy cases of death (disthanasia), the physician has no other deonthologic alternative then to give scientific, ethic and human assistance to any state of passage between life and death, without taking into account the clinical form which this would have. This is more important today, in the era of medical technology, which created the risk to survive in a vegetative state and which transformed death in “something obscene”, which determined R. M. Rilke to write about the desperate shout addressed to the physicians “not to steal death”.

Death, like a return in the cosmic world, represent the need of immortality, because life if is not able to make us equal, only death may help to make justice.

The lack of this significance represents a risk for life and death to become a failed eternity. The acceptance of death would represent the last proof of generosity, altruism, and even heroism in front of a “cosmic absurdity”, concerning the start and the end of life in the Universe. In this purpose medicine has to offer to the medical practice “the art to die”.

Such an art is preceded by a strong religious, moral and cultural tradition after which:

- Death doesn’t have to be a tragic feeling, but a simple and natural passing to another world, the world of the spirit, who survives in front of the perenniality of the physical existence. More than this, as in other cases of life in the terminal states, humans have to end their lives surrounded by affection and not by indifference, the human act being completed only in a communion “between those who are coming and those who are going”.

- Like birth, death has to be medically assisted, to offer the necessary silence which can not be consumed then in intimacy (in the family) and after the patient’s liberation from any state of guilt;

- The first basic element of the medical assistance of death is represented concerning the physician’s knowledge about the psychology of the terminal states, in the purpose to help the patient to die with dignity because death takes only the body and not the creation (Kazantzakis), and when the body represents just a method of transfer of the individual spirit into the universal one (Noica).

Death is a part of normal life. So, it would be normal to learn how we have to act when “we get in connection with” or “we interact” with death.

We have to think what has to be our behaviour during our professional and personal meeting with death, in a calm manner and with dignity.

In the second time, the concept of moral help for a dying person is a normal answer determined by the human connections, and not a special action. Every one of us keeps relative stability of his life with the help of the connections with other humans in our social area.

In the third time, to help doesn’t mean so much “to do” as “to be”.

In the fourth time, the help to die is contrary to most of the types of help. Usually, we help people to move between the problems of life. By helping somebody to die we help humans to disconnect from the idea of living.

For being able to assist other persons, first of all we have to help ourselves because death is a personal matter. To be able to answer fear and the other feelings of a dying person we have first to answer ourselves. We are face to face with the continuous tension, which is coming from our interior: to be connected with the significance of death and to be capable to be calm and objective. Pogo said: “I saw and I found the enemy and with was us”.

So, for helping others to die we have first to fight with death of ourselves. Only after death, we may defeat the rejection full of fear of a dying person and to avoid the mechanism, which reject fusion with death. We will act in a position of “detached compassion”.

Our own opinions about death represent a combination of positive and negative.

The same for the dying person, his family, relatives and friends. It is not normal to wait for positive attitudes in us or in others in an exclusive way. Sometimes we are angry or frustrated by death. The cases of death can’t make humans suddenly kind and gentle. The dying persons represent a multitude of types of human beings, some of them gentle and some not. With some people is easy to communicate and with others not. After some dying persons we are sorry while others give us feelings of satisfaction. It is our duty to identify and assimilate all these feelings, to recognize that emotions represent a part of human experience, to integrate the positive and negative feelings, and in the end, not to act against instinctual emotions, not to filter feelings trough our own conscience, and to react according to the responsible integrity of the dying person and ourselves.

Another form of help is to recognize the feeling of “saturation of death”. This represent the fact that we may work with the dying persons for a very long time and with a very important personal implication, so that, we may pass the limits of saturation concerning the idea of death. We have to be capable to identify our personal limits concerning the saturation of death, and

when we are close to them we have to come back, to keep the distance and to recover. It is not normal to ask us to be capable to fight against death, all the time with the same intensity and to expect to survive from a psychical point of view. If we don’t have our own plans to work and live with periods of recovering, our defending psychical systems will work for us until we shall be exhausted. We have to keep an ethical attitude towards the dying persons, to try to make a decent thing with maximal competence, for which it is necessary:

1. To avoid the hostile reactions, this may produce a harm to the dying person.

2.To avoid our over appreciation, this may lead to an operation or therapy to a patient who is not prepared for it.

3.To avoid the deformed sexual attitudes, this may lead to possible reject or sexual seductions of the patient.

4.To avoid revealing all the confidences made by the patient, as a habit or to seem important for other persons.

5.To avoid the excessive therapeutic ambitions, this may lead to useless procedures.

6.To avoid the useless stimulation of the anxiety of the patient.

After we established our own attitude concerning the experience of death we have to establish also some criteria concerning the help we have to give to the dying person:

- The integration of the idea of death in the stile of life of the person, for being able to reach a simple death, a stile of death adapted for every person, special for every individual and different from the others.

- The person has to be capable to fight with the initial crisis of anxiety previous death.

- Every person has to make compromise between the reality of his own life and the ideal image of life.

- Everyone has to preserve or to continue the important relations during life and little by little to get used to the feeling of separation from the persons he loves, when death is coming.

- Everyone has to make a reasonable experiment of his instincts, which may lead without interior conflicts to the acceptance of death.

- Another principle is represented by keeping adequate answers to the phases of death: in the acute initial phase we are faced with an acute anxiety and ambiguity; in the second chronic phase between life and death the relations between humans diminish and the third phase is represented by the beginning of separation and falling down.

- A supplementary principle is necessary in terminal phase when we have to have a synchronicity so that the social psychological and physiologic dimensions of death have the tendency to meet together in a common form. We have to try to keep social and psychological attitudes, which have to be in accord with the state of the dying person.

We have several objectives to fight against concerning what is happening in the mind of the dying person:

- The fear of unknown – is expressed by the initial acute crisis. It is important to establish a relation of confidence and trust, in which the dying person may ask and receive answers, which he may trust. It is important to avoid, when it is possible, the specific answers. It is useful to distinguish between the realities of life where we may answer exactly what we think and the philosophical, religious, speculative questions for which we may give opinions but we can’t give answers. This helps the dying person to distinguish between the well-known aspects of death about which he may some answers and the unknown parts of death for which he may not get any answers.

- The fear of loneliness – there are different problems in any phase of death. In the initial phase of death the fear to be excluded and abandoned is more a fantasy then reality. In this phase it is useful to establish very attentively who will be the dying man and when. In the second phase it’s recommended not to permit like the phenomenon of death to be the only care of the dying man. Our duty is to keep the contacts of the dying man with his connections

and daily obligations. In the final phase it’s recommended to insure the patient about the permanent interests of the other persons concerning his state. In this way, dying man won’t feel the solitude of the final moments.

- The fear of regrets – here we have to avoid the creation of an atmosphere, which will lead to the idea that sadness is permanent. We shall share with the patient his regrets, and we shall express our sadness, which is called “anticipate sadness”, and which allows us to identify the source of the regrets and to be able to manipulate this emotion. It is useful the help the dying man to identify the specific sadness determined by death, and to make a difference between it and other forms of regrets.

- The fear to lose the family and friends – the process of death amplifies the latent dimension of the human connections. Our role is to help the dying man and his family, his friends to accept the variety of feelings, which exists between the two sides, to clarify the ambiguous and conflictual feelings and to accept some settlings of the emotional tensions. When the resolution of the negative phenomenon appear (peace is coming), the dying man starts to separate from his relatives with a peaceful soul.

- The fear to lose the body – the first obligation is to clearly inform the dying man about the phenomena that happen in his body. They need to know what is bad and why is bad. This obligation eliminates the mystery of the processes that happen in the body. The patient has to know that to lose the functions of his organism is not a shame. It is important to distinguish between the functions of the organism that are healthy and those that are ill (between the parts that are really healthy and those that are affected by the disease). It is useful to ignore the dysfunction of the body and not to amplify them.

- The fear to lose the self-control - we may consider the control from several points of view: the control of somebody’s life, the control of your own life and of your own body. The diminution of the control concerning life may include the fear not to be capable to determine life or death. This attitude has to be solved

from the beginning of the phenomenon of death, the dying man being able to take decisions concerning his family’s life, like property wills, like family problems, funerals, cremation, and other problems about the way they have to live. All these elements make the dying man capable to determine as much as possible the direction of their lives. In the same way, the dying man may be encouraged to control the emotions of the others.

- The fear of suffering and pain – suffering accompanies solitude and the fear of unknown. Even the dying man, who continues to be visited by friends and have connections with the surrounding world, may live in pain, which may become intolerable. The source of pain, its deepness and its duration have to be explained as reasonable as possible. It is not the case to wish a stoic acceptance of pain. It is useful to give analgesics but the common opinion that the pills would give a solution to the problem of pain is not realistic. We may ameliorate pain only with the collaboration of the dying man. Pain if may not be eliminated, may be tolerated.

- The fear to lose the identity – it is important to continue the specific identity of the dying man. This may be realized by continuous contacts with the family, friends, who have to get in connection with the dying man and also with the persons full of life. In the same time, the patient has to be allowed to keep his clothes, memories, and intimacy, which would contribute to the development of several hospital infections. So, the patient has to involve as much as possible in the persons’ life, which are parts of his identity and to keep as much as possible the consciousness of his self.

In conclusion, the physician has to help the patient to understand the idea that only by the conscience of a dignifying death accepted and discharged of guiltiness may accomplish the intensity of a successful life, a medical esthetics of death having to take into account this art of dying by loving life and living it until the last moments, to alleviate any terminal state, so that death won’t be “monster”, but a beginning of immortality. This esthetics

of death has to include also the physician’s efforts to fight with the innocent death, starting from the idea that “any death before the necessary age represents a mutilation of the Universe”.

In the end, the esthetics of death has to include a respectable attitude concerning the bodies, to avoid the repulsion towards the bodies, like a possibility of humans to “give out any bad thought”.

So, it is necessary to have a terminal assistance, by which: - like somebody gives water to a dying man it is necessary to

give him the medical and pedagogical assistance; - It is necessary to diminish pain in the purpose of a

supportable life; - The psychological comfort is important to conserve the

identity and autonomy of the person until the last moment; - To insure the material comfort, to be able to avoid any

isolation.Another aspect of medical responsibility in the cases of

euthanasia is represented, in the case of the patients in a state of coma, the idea of interruption of the reanimation, in the cases of overfulfilled coma with a flat EEG examination for between 20 and 60 hours, with the exception of children, of pregnant women, of poisonings, of frozen patient or when it is necessary to donate organs. In such conditions, the physician can not be accused of forcing death.

Concerning the abuses which may be done in the back of euthanasia, it is not allowed to give the consent for prelevation of organs by the donator since he was alive not to thicken the trust of the patient in the efforts of the medical procedures and not to hurry “the death of the donator by a so called euthanasia” in the interest of the receiver. The prelevation of organs from the death bodies may be done only after the biological death was confirmed by the physician and we have the family’s consent.

The criteria of the biological death established by the Order of the Ministry of Health, refers to the need to establish the death of the brain by a flat EEG recording of minimum 12 hours, with the exception of the poisonings, hypothermia, death during

pregnancy and may be done by another team of physicians, except that which make the transplant.

CHAPTER VIII

PERSONAL FINDINGS ABOUT EUTHANASIA

In a study made in Romania we asked 50 persons aged between 20 and 60 years old, with different occupations (lawyers, engineers, chemists, economists, students in technical universities) about euthanasia. The questions that helped me to find their point of view concerning euthanasia were the following:

For the case of an old unconscious man with an incurable disease and with insupportable pain:

1.Do you agree to continue to treat him without effect? 2.To treat only his pain? 3.To give a substance to help him die? 4.To help him die faster by passive euthanasia?

We repeated the same questions also for the case of a conscious old man, of a conscious young man, of an unconscious young man, all of them with incurable diseases.

In the first case, 42% from those who were asked greed to continue the therapy without effects. 54% decided that is better to use only the analgesic therapy and about the administration of a lethal substance 88% were against this measure and 74% were against the help to die.

In the case of a conscious old man 74% answered affirmatively at the first question; 32% agreed with the therapy of the pain at the second question; 86% were against euthanasia at the third question and 85% gave negative answers at the last.

A special problem concerning the abandoning of a lethal substance near the patient, from the 43 persons who had a negative answer concerning the practice euthanasia, 10 of them said that if

the patient if conscious and asks for it they would give such substances.

In the case of the young incurable patient although he was unconscious, 50% agreed to continue the basic therapy, 40% considered the best is to continue only the analgesic therapy and for a measure of suppressing the patient’s life 80% didn’t agree and for the last question 76% gave a negative answer.

In the last case of the young conscious patient, for the first question 74% agreed with perseverance in therapy; at the second question 24% agreed only with the therapy against pain; concerning the application the euthanasia 84% refused the idea of the administration of a substance and 84% were even against helping the patient to die faster.

The same as for the old conscious man there is the possibility the patient by himself to ask for the lethal substance. For the conscious young man only 10% of the interviewed persons would follow the patient’s wish to give him the toxic substance, but not before he is asking for it.

We may show the fact that from the investigated persons those between 40 and 65 years old, who represented about 30% from the studied group, usually option to continue a therapy without effects and to give analgesics, but don’t agree with the application of a certain from of euthanasia. The younger group (20 – 40 years old) is more permissive in this problem. For a more specific examination of the degree of acceptance of euthanasia we made a study involving a group of 50 students in medicine who are more familiar with the idea of death or of incurable disease than the general population.

We asked them the following questions: 1.What is the difference between euthanasia and natural

death? 2.Do you agree with active euthanasia (to hurry the patient’s

death by the administration of a substance)? 3.Do you agree with passive euthanasia (to let the patient die

by stopping the therapy that keeps him alive)?

4.Which would be your attitude in the case of a patient with cerebral death (in a vegetative state) or in the case of a malformed newborn child without any possibility to recover? Would you agree with euthanasia?

5.If in a conscious way an incurable patient would ask you, would you practice euthanasia?

From the answers of the first question we concluded that the students in medicine have a very clear concept about the problems of the test and they are capable to make a distinction between them: natural death representing the death after the exhaustion of the resource of the organism by different reasons, while euthanasia represents a death without pain but determined by somebody, so that it involves a person who acts in the purpose of stopping the patient’s suffering.

If natural death has a polymorph determination including various pathologies, euthanasia represents a “shorten of the physical evolution of natural death”.

At the second question, 47% of the persons agreed with the active euthanasia. Concerning the passive euthanasia, 36% expressed positive opinions.

The question four determined different opinions. 20% of the students agreed with euthanasia in both cases, 20% denied it in both cases and 10% consider that euthanasia is necessary in the case of the patient with cerebral death, but were against it in the case of the malformed newborn child, taking into account religious reasons or considering that only nature is allowed to decide for it.

At the question concerning the personal practice of euthanasia, only 11.4% answered that they would practice it “if the law will allow it”, the rest of the persons considering that the physician has to be a therapist and not accepting this position.

Studying the answers of my colleagues, I saw a certain polymorphism of the arguments with which they sustained or not the idea of euthanasia. Those who agreed with euthanasia thought that to practice it at a patient in a vegetative state doesn’t represent to stop the life of the person, but of a biological heart – lung

experiment considering it justified. Others think euthanasia would determine a removal of the physician from their position of therapist because, even if a man has a primitive life, identical with plants, nobody except God does have the right to decide about him letting to the patient the chance of the miracle. Some of the interviewed persons considered that euthanasia in a masked form is already practiced (for example the refuse of the surgeons to operate patients over a certain age).

CHAPTER IX

LEGAL AND BIOETHIC CONCLUSIONS ABOUT EUTHANASIA

Even if life and death represent two contrary phenomena, they represent the two essential conditions of the evolution of the living matter in nature and in the living organisms, death being interdependent with life. The disappearance of humans represents the need of evolution in the purpose to give the place to other genetic combinations more favorable for the species and which grow their adaptive potential, which is the base of variability and progress. In this way, death is a revenge of the species against the individual.

Today, we may see different opinions about death, depending on the cultural level, religion, profession, and age. In this sense, the idea of euthanasia is very disputed. This term includes a group of medical actions or inaction, with an ethical and juridical support, in the patient’ s interest, leading to the shorten of a patient’s suffering who has in the actual moment of the medical science a predictable and fast death.

During time, the idea of euthanasia had different forms and was more or less accepted, until its total negation. In this sense were elaborated positive arguments (the individual’s right to a dignify death, the community’s fear for some infectious diseases, the need of control of voluntary death at the psychiatric ill patients, or involuntary at the newborn children with severe malformations) and against euthanasia (the respect of the sacred life, the risk of abuses of euthanasia, the chrypthanasia, the discriminating euthanasia, and the contested place of the euthanasia between the medical norms and concepts). We may conclude that the physician

has to spread the idea that more than anything humans have to survive to promote the quality of human.

When it is not possible to defeat death the physician will calm the soul to help the patient to have a respectable death.

Connected with the term of euthanasia is the problem of the assisted suicide, an equivalent of the voluntary active euthanasia (together with the voluntary passive euthanasia, involuntary active euthanasia and involuntary passive euthanasia), which was promoted by Jack Kevorkian with his suicide machine based first on hydrochloric acid and barbiturates, an later on carbon monoxide. This idea was also very discussed, considering that it has also favorable arguments, identical to those that sustain euthanasia as a whole, and also negative reasons. Studying the positive and negative arguments concerning this procedure we may conclude that the incertitude of the correct clinical evaluation of the patient’s discernment, together with the risk of confusion between the wishes and the reasons of the patient, his family and the physician, make very difficult a decision for using the medical assisted suicide, with a very high error potential, so that, this method may have the chance to become habitual in the future.

From a legislative point of view many attempts appeared in the world to legalize or forbid euthanasia. In Europe, there are two tendencies concerning euthanasia. In the North, it tends to be approved and in the South the great principles of life are still sustained. A special place is that of Holland, where euthanasia was accepted and in Romania the starting point for the four articles concerning euthanasia in the Project of the Sanitary Law has the origin in Holland.

In the USA, an important place to determine the application or not euthanasia is represented by a form of expression of the patient’s wish – “the living will” – connected with the procedures that have to be followed in the case in which he becomes unconscious.

In the same purpose to clearly determine the application or not of euthanasia, the Council of Europe invite the Regional

Bureau for Europe of WHO to examine the criteria for determining death, which exist in several European countries, in the light of actual medical knowledge and technologies and to make proposals in an unanimous sense, which will be universally applied, not only in hospitals, but also in general medical practice.

Studying the point of view of the population from our country we concluded that over 80% are against active euthanasia and over 74% don’t agree also with passive euthanasia, considering that it is necessary to continue the therapy even in a case of an incurable disease, and letting the nature decide.

The points of view of the students in medicine, who we separately investigated, showed that almost 50% of them agree active euthanasia and the same percent was found for passive euthanasia. Some of the students agreed to practice euthanasia in the case of a patient in cerebral death, while others agreed to practice euthanasia only for severely malformed newborn children, while others agreed for both cases.

Even if euthanasia is not totally accepted, a very important problem of the medical responsibility is represented by the assistance of death. Like birth, death has to be medically assisted, to confer to the patient the necessary silence on the way to another world, the world of the spirit, who survives in front of the ephemeral nature of the physical existence.

In this purpose, the physicians contribute by their actions to the diminution of some feelings of the dying person: the fear of unknown, the fear of solitude, the fear of regrets, the fear to lose the family and friends, the fear to lose the body, the fear to lose the self-control, the fear of suffering and pain, the fear to lose the identity, other way saying, to insure the psychological comfort of the patient with the purpose to conserve his identity and autonomy until the last moment of life.

From all the problems discussed we may conclude that the respect of the physician for life has to go until the medical psychological assistance of death. As long as anxiety of the patient is bigger, the need for a physician would be more acute. Like an

adviser of these states, the physician will cultivate his aptitude to help the patient in a calm and decent way to the “other world”. In this way, the physician accomplishes the human “model” of the respect in front of death. Instead the physician to say that nothing can be done, he will help death to be calm and decent, only in this way his human and professional mission being accomplished.

As a conclusion, the aging of the population, the “human and patient’s rights”, the diminished power of religion, the refuse of suffering and of lack of dignity, contribute in an important measure to the changing of opinion concerning euthanasia and the adaptation of the laws in this field.

The term of euthanasia is differently accepted depending on the culture, nationality, tradition, religion, habits, and can not be allowed or forbidden totally with the help of the laws because it represents a very delicate problem and the conscience of every physician has to discuss it for every separate case. Today or in the future it will be impossible to create rigid laws to apply or not apply euthanasia because finally it represents a pure problem of morals.

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