Euthanasia As Assisted Suicide

Euthanasia as assisted suicide

Euthanasia, according to WHO is defined as the medical action by which the patient’s death is caused. The word euthanasia derives directly from the Greek that means "good death" being eu (good) and Thanatos (death).

SAR defines it as "deliberate intervention to end the life of a patient without a cure perspective or as death without physical suffering".

In assisted suicide, the professional adopts a passive position, where he only provides the “drug cocktail” to the patient, who autonomously will be who self-administer the dose when he creates it convenient. In some countries it is only limited to the health field while in others it can also be carried out by any person.

DIRECT: There is a direct and deliberate intention to produce the patient’s death. It is divided into two subtypes.

•  Active: When done through lethal drugs.
•  Passive: When performed by omission, that is, life support mechanisms are stopped. Do not confuse with limitation of therapeutic effort, since in these they stop adding more to the previous ones the patient had without eliminating those prior to decision making.

Indirect: when there is no deliberate intention to shorten the patient’s life. It would occur, for example, if high doses of analgesics are administered to alleviate pain, which have a side effect that would be the shortening of life. In palliative care, several of these analgesics are combined to avoid this side effect, so they are not included in the euthanasia subtypes.

Voluntary: It occurs when the patient, being in full physical and mental faculties, makes the decision to require euthanasia.

Involuntary: They are divided into two:

•  When the patient, although he is no longer in full physical or mental faculties, did a testimony of anticipated wills in which he requested it.
•  When the patient at no time reflected his position before the technique, but still is performed.

Today according to data from the Collegiate Medical Organization in Spain there are approximately 2.000 people per year request euthanasia. What in global terms would represent, according to INE data, 1% of people who suffer the death process as such, understanding death as a staggered process that extends in a certain time and therefore, the number of people is excludedhealthy, who die suddenly without having suffered this death process previously (accidents, IAM severe without prior clinic, etc.) 

This fact, if compared, could be significant since, in Holland, before the legalization of euthanasia, there was a percentage very similar to the one in Spain, more specifically of 1´7% of the population than in2015 increased, meaning a total of 5.516 requests that were carried out, being Holland with 17 million people almost 3 times less than Spain.

This should not be confused with an increase in total deaths, but by an increase in the percentage of these total deaths that are through euthanasia.

This increase is also reflected in all countries, whether euthanasia and assisted suicide, so the data suggests that, if a portfolio of services in Spain was created, those 2 2.000 annual people would increase year after year, increasingly covering the percentage of induced deaths with assisted euthanasia or suicide applied to patients with terminal processes.

The profile of patients requesting euthanasia or suicide assisted in countries where any of these modalities is legal, are usually the terminal patients and within this wide group, we find that it is the oncological terminal patients who most request this practicecomprising 90% of total deaths and being only 10% that is distributed in various pathologies.

Recently, a large increase in patients with cognitive, movement, cardiac, sight and ear deterioration is being experienced due to various causes, which make up 15% and are in a stadium that is usually very advanced, as well asas of people with dysfunctionalities produced by problems of the central nervous system and mental illnesses that make up 7%. With 10%, patients with multiple problems would be located due to degenerative diseases of advanced evolution such as EM, ELA, etc.

On the other hand, although they are a small group of users, there would be those patients whose case reaches a high degree of dissemination, because their profile is usually a person who wants to end their life. These types of cases that propitiate an ethical revolution in the segment are and allow governments to know through statistics public opinion and thus be able to have an idea of where this type of techniques should be directed in each country, this type of patientIt would be understood around 1%.

In the temporal framework in which we are currently located, there are several studies that deal with the end of life, where most of them focus mainly towards palliative care, which are nursing procedures collected in the Official State Gazette in Spain (Law 5/2015, of June 26, on the rights and guarantees of the dignity of the terminal sick people).

In this study, the specific topic that is addressed is euthanasia and suicide assisprepared to perform an assisted euthanasia or suicide with the knowledge we currently have.

In Spain these two clinical practices are illegal (article 143 of the Criminal Code) and, therefore, we must guide ourselves through countries where one of them is at least carried out.

As can be seen in Table 1, the legalization even worldwide of these two practices is very recent, discarding countries like Holland where it was carried out since the 80’s under the precept of a series of legal gaps that existed in the law established inthose years and where it is also appreciable that the application in countries legally and under a jurisdiction today is also very small. This may be due to the fact that before in the health world in general, death was associated with a failure by the health team, giving rise to a very careless environment at the theoretical and practical level, where the eldest injured was the patient who inMany occasions died in precarious conditions.

Recently there is a boom in both political and sanitary sphere in the involvement of "good death" or "dignified death", where the implementation of health care through palliative care is carried out until the patient’s death, obtainingBetter control of both psychic and emotional pain and doing holistic care in all its spheres with the objective of the patient’s integral comfort.

In this new vision, situations have arisen continuously in which the objective of comfort has not been achieved for different reasons, ranging from a bad control of sedation and analgesia, as well as the desire on the part of terminals to want to endtheir lives. It is at this turning point where euthanasia and assisted suicide have emerged to solve this type of situations.

Evolution and progress

Another point to highlight is the evolution process that is being carried out in countries such as Belgium, which remind us a little of the evolution suffered by palliative care in Spain, since, in the beginning they were only used in the adult andAfter their normalization by society, they also began to apply in the child with a clear support from society, which on numerous occasions demanded it in cases with great media impact. This is a logical step to the improvement of the process and the accessibility of all types of patients, where cases of patients with advanced degenerations (especially at the neuronal level) or mental illnesses are still the subject of debate and study by the ethical committeeFrom most countries where some of the two techniques are carried out.

There is still a wide field to cover, since more studies must be carried out to ensure not to make mistakes and distinguish between a grounded request and with full faculties of an impulsive or with doubts about the patient’s decision capacity.

This arises a question that is still to be resolved in all countries that apply one of these two techniques, and is the fact that a person who is suffering an emotional anguish process that is not possible to solve, can be in favor of making arequest for any of the techniques and thus avoid the percentage of people who decide to end their lives through self-collitic methods or suicides. In these types of cases we find a strong emotional burden that complicates the process to discern the ethical committees of the countries about a decision -making.

To avoid this type of errors, each country has an action guide where in general, several checks are made by several professionals and debate about whether comply with the criteria for inclusion or not and that are guided by the current legislation itself. However, in 2017, 10 cases were demonstrated, [Footnoteref: 6] in which it was shown that this type process took badly by professionals and the possibility of making mistakes in these techniques is reflected, having to walk with feet oflead and extreme caution in decisions to be made for professionals. 

The treatment of both euthanasia and assisted suicide consists of a “cocktail” of drugs that are administered according to a sequence established by the guideline of each country that transmits it in the form of a strict protocol to follow in each case.

In Belgium, for example, it is done through an overdose of barbiturates, with the option of managing a benzodiazepine either prior or post administration of the barbiturate to induce respiratory arrest or to induce the dream previously. The Belgian guideline is widely similar to the Dutch guide issued by the Royal Dutch Medical Association (RDMA). However, in Holland, a relaxant must always be administered despite having clinical death indications.

Other drugs such as opioids and benzodiazepines or combinations of these medications without the use of a barbiturate and / or a neuromuscular relaxing is explicitly advisable in the Dutch guide due to uncertain lethal effect and adverse side effects. Both Switzerland, Luxembourg and the United States (only in the states of Oregon, Washington and Montana) use the same guide. In Canada, the most common protocol is Midazolam, followed by propofol and a neuromuscular relaxing that produces the patient’s death.

Many authors conceive it as a treatment since in some countries both assisted suicide and euthanasia constitutes, therefore, the last step of a continuum of options, which would begin with the elimination of pain, would continue with palliative care, the withdrawal oflife support therapies and palliative sedation until assisted suicide or euthanasia.

On the other hand, we find an area like the veterinarian, where euthanasia is perceived as a normalized and indexed service among the many offered by the veterinary professional and is conceived as an option to take into account at the end of the animal’s life. Similarly, the ATV (Veterinary Technical Assistant) is fully trained to perform these techniques which opens the doors to the infirmary to be able to participate in these situations if we compare the veterinarian with a doctor and the ATV with the nurse.

Obviously the differences between humans and animals at ethical levels are very distant, but today, more and more ethics are approaching in animals to ours, where many aspects of life and animal death have been discussed in termsproductive, but rarely about death, in this case euthanasia, in domestic animals that are increasingly humanized at the moral and sentimental level.

This is reflected through the owners of pets that in 95% of the time people believe euthanasia in a humanitarian way in cases where the animal has a terminal disease and is suffering.

In this section of comparison with the veterinarian there is also a very important ethical aspect and it is the ability to be given to the animal’s owner to decide on their care since this, logically, cannot be communicated. If we extrapolated it to humans, it could serve as a guide in the dispute that occurs in the decision -making of the family or tutors, in cases where the patient cannot communicate, leaving in the hands of theseThe possibility of choice, being on the other hand and not without lack of reason, the fact that the term "euthanasia", which means good death in Greek, is a contradiction in its terms when applied to a patient without the ability to express theirwill, given that good is an object of desire for a will (if a moral good is imposed, neither well or much less moral), and there is no such freedom to love.

That is why, in many of the countries in which some of the techniques are applied, each time, there are more cases in which the family manages to demonstrate (even if it is not with official documents) than the patient when he possessedFull decision -making capacities, expressed his desire to perform some of the techniques if he saw in the situation of specifying it, the ability of professionals to carry it is granted by the State, not yet being able to express it the patient at that precise momentfor disability. It would therefore be a case of involuntary euthanasia.

With respect to the economic field, a great reduction in its costs could be experienced in the Spanish health system, since it is estimated that about 70% of the sanitary expenditure that a person performs throughout his life,It would concentrate this percentage in the last 6 months of the person, where all kinds of expense would be included: of the personnel, infrastructure, diagnostic tests, drugs, etc., even leaving the expenses of health prevention and promotion included in that remaining 30%.

This fact is reflected in Canada where the application of any of the two techniques discussed in this issue reducing the annual costs of the Canadian health system between 34.7 and 138.8 million dollars, which widely exceed 1.5 and 14.8 million dollars that cost their implementation in the system. Even if both costs moved to their limits, leaving an average calculation as in the reflected data, that is, the total savings would be carried out and the total implementation costs would take to the maximum, there would continue to be savings, althoughless substantial, by the health system. This displacement could be produced by infrastructure projects of national dimensions or a dire management of resources by professionals for an extraordinary circumstance.

These economic data can never determine the implementation or not, of the use of this type of techniques, since the economy and health, although they are complemented, should not interfere with each other, due to the distancing with respect to the humanization that occursAnd how, interferes with the quality of care and the general quality of the health system.

That is why these data have a merely informative character, where an adequate use of them is indispensable. One of the multiple uses that could be made would be to reinvestig.

In Spain it is a topic of high complexity, where social and cultural values denote a clear differentiation between the ancient and new generations, where the conservative character of the first converges in a clear tendency towards the non -use of it, despitethat they are more likely to be users of these practices in a shorter period of time than the new generations which denote a more free character, where more than their own character they transmit it in general, referring that despite them they are not clearIf they were users, they would implement it in the system.

We are in a scenario very similar to that of Spain, except for the countries where at least one of the two techniques is applied where a high percentage of the population that is in favor of this.

However, the continuous debate since it is probably one of the most complex ethical sections of the 21st century, due to the conflict that these techniques produce between the rights and duties of the person, also including the deontological conflict that arises with the values that are instilledand approve in the disciplines of a sanitary nature, and must be modified the bases that have been intrinsic of them practically since their emergence.

In countries where these practices have been legalized, it has resulted in a modification of the Hippocratic oath where sections are modified as the principle of non -maleficence.

After all the aforementioned, all these above aspects converge in one last concept. The concept of performing and executing a quality euthanasia.

It is defined as quality euthanasia, the one that is carried out with a monitoring of the patient susceptible to it, by a multidisciplinary team subject to security and quality controls that are launched at the first moment of the period of taking of takingDecision to apply it, that is, it is not only about the administration of a lethal substance, but of a whole process of screening and detailed study of each case, where the patient receives holistic support on all his spheres to determine the veracityof your decision making and where until the last instance, you can reaffirm or withdraw your willingness to practice this technique.

Taking into account the above, we would find a clearly defined system in which quality reviews could be carried out to improve the procedure to be followed in each case and thus reduce the probability of error by precipitating the events. That is why the nursing plays a fundamental role where it would monitor the patient and triar.