Active Or Passive Euthanasia Morally Permissible?

Part One
INTRODUCTION

This study attempts to seek the core meaning of euthanasia (mercy killing), its application, how it can be beneficial to the society, its unconstructive effects, the stand of the church and its significance. Euthanasia has been largely affected by criticisms both from the field of medicine, religion, and law. In this study, the researchers shall identify those facts that govern the instances where in these fields interplay with each other to the various topics related to euthanasia and to its development.

Etymologically, in ancient times euthanasia meant an easy death without severe suffering. Today one no longer thinks of this original meaning of the word, but rather of some intervention of medicine whereby
the suffering of sickness or of the final agony are reduced, sometimes also with the danger of suppressing life prematurely. Ultimately, the word euthanasia is used in a more particular sense to mean "mercy killing," for the purpose of putting an end to extreme suffering, or saving abnormal babies, the mentally ill or the incurably sick from the prolongation, perhaps for many years, of a miserable life, which could impose too heavy a burden on their families or on society .

Euthanasia , also called mercy killing , is an act or practice of painlessly putting to death persons suffering from painful and incurable disease or incapacitating physical disorder or allowing them to die by withholding treatment or withdrawing artificial life-support measures. Because there is no specific provision for it in most legal systems, it is usually regarded as either suicide (if performed by the patient himself) or murder (if performed by another). A physician may, however, lawfully decide not to prolong life in cases of extreme suffering, and he may administer drugs to relieve pain even if this shortens the patient’s life .

It is the deliberate ending of life of a person suffering from an incurable disease. In recent years the concept has been broadened to include the practice of withholding extraordinary means or “heroic measures,” and thus allowing the patient to die. A distinction was traditionally made between positive or active euthanasia, in which there is the deliberate ending of life and an action is taken to cause death in a person, and negative or passive euthanasia, which is the withholding of life-preserving procedures and treatments that would prolong the life of one who is incurably and terminally ill and could not survive without them. However, now all euthanasia is generally understood to be active, and so the more accurate term forgoing life-sustaining treatment is replacing passive euthanasia .

By euthanasia is understood an action or an omission which of itself or by intention causes death, in order that all suffering may in this way be eliminated. Euthanasia 's terms of reference, therefore, are to be found in the intention of the will and in the methods used .

A study in euthanasia helps us understand not only its functions, the positive and negative effects but also to how we perceive the act itself. Euthanasia has many forms and an understanding of each form or type may help us be aware of its significance. Knowledge of the application contributes to how it can be developed to become useful to our society and give positive effects rather than negative effects.

In this analysis, we can give moral justification to what is euthanasia in an unbiased judgment given by facts and full understanding of such activity that goes between life and death.

Part Two-A
Physician-assisted deaths under the euthanasia law in Belgium: a population-based survey
Background: Legalization of euthanasia and physician assisted suicide has been heavily debated in many countries. To help inform this debate, we describe the practices of euthanasia and assisted suicide, and the use of life ending drugs without an explicit request from the patient, in Flanders, Belgium, where euthanasia is legal.
Methods: We mailed a questionnaire regarding the use of life-ending drugs with or without explicit patient request to physicians who certified a representative sample (n = 6927) of death certificates of patients who died in Flanders between June and November 2007.
Results: The response rate was 58.4%. Overall, 208 deaths involving the use of life-ending drugs were reported: 142 (weighted prevalence 2.0%) were with an explicit patient request (euthanasia or assisted suicide) and 66 (weighted prevalence 1.8%) were without an explicit request. Eutha - n Asia and assisted suicide mostly involved patients less than 80 years of age, those with cancer and those dying at home. Use of life-ending drugs without an explicit request mostly involved patients 80 years of older, those with a disease other than cancer and those in hospital. Of the deaths without an explicit request, the decision was not discussed with the patient in 77.9% of cases. Compared with assisted deaths with the patient 's explicit re quest, those without an explicit request were more likely to have a shorter length of treatment of the terminal illness, to have cure as a goal of treatment in the last week, to have a shorter estimated time by which life was shortened and to involve the administration of opioids.
Interpretation: Physician-assisted deaths with an explicit patient request (euthanasia and assisted suicide) and without an explicit request occurred in different patient groups and under different circumstances. Cases without an explicit request often involved patients whose diseases had unpredictable end-of-life trajectories. Although opioids were used in most of these cases, misconceptions seem to persist about their actual life-shortening effects.
Euthanasia and physician-assisted suicide are heavily debated issues in medical practice. In recent years, three European countries (Belgium and the Netherlands in 2002, and Luxemburg in 2009) and two US states (Oregon in 1997 and Washington State in 2009) decriminalized euthanasia and physician-assisted suicide under formal conditions.1-5 Canada is among a number of countries where the debate over legalization has flared up, with a proposed bill reaching Parliament and a pro-euthanasia proposal by the Quebec College of Physicians.6
Understandably, the issue of euthanasia triggers much emotion and can be fraught with speculative arguments. Opponents of euthanasia often argue that legalizing the procedure will lead to a rise in the use of life-ending drugs without a patient 's explicit request, especially in vulnerable patient groups.7-10 Thus far, however, no indications of this have been found in studies of physician-assisted deaths before and after legalization in Belgium and the Netherlands.9,11,12 In Belgium, the percentage of deaths in which life-ending drugs were used remained stable, and the proportion without an explicit request from the patient decreased.12 Other studies have shown that euthanasia, physician-assisted suicide and the use of life- ending drugs without explicit patient request are not confined to countries where physician-assisted death is legal.13-16
In addition to knowing the overall occurrence of physician- assisted death, it is equally important for an adequately informed, empirically based debate to know its performance in vulnerable patient groups and the care put into the decision and performance. In light of legalization and its alleged effects on the use of life-ending drugs without patient request, it is also important to map similarities and differences are - twee euthanasia and the use of life-ending drugs without explicit patient request. In this article, we report our investigation of demographic and clinical characteristics associated with physician-assisted deaths in Flanders, Belgium; the involvement of the patient, relatives and other caregivers in the decision-making process; reasons for the decisions; aspects of the treatment trajectory; and details of the performance in terms of drug use and the people administering the life-ending drugs.
Methods
Study design
In 2007 we conducted a large-scale study of death certificates in Flanders, the Dutch-speaking part of Belgium that has about six million inhabitants and 55 000 deaths per year. We obtained a stratified sample of all death certificates from June to November 2007 of Belgian residents aged one year or older from the Flemish Agency for Care and Health. We assigned the certificates to one of four strata according to cause of death and the corresponding estimated likelihood of an end-of-life decision. Sampling fractions for strata in - creased proportionally with this likelihood. The resulting sample comprised 6927 death certificates, which represented 25% of deaths during the study period and about 12% of all deaths in Flanders in 2007. Details of the methodology for this review have been described elsewhere.17
A five-page questionnaire and covering letter explaining the study were sent to the attending physician in each case. A response was regarded as implicit consent to participate. If the physician did not respond after three reminders, a one-page questionnaire was sent enquiring about the reasons for nonresponsive. Total anonymity for participating physicians and deceased patients was guaranteed through a rigorous mailing procedure involving a lawyer as intermediary be tween physicians and researchers. Information from the death certificates (patient sex, age, place of death and cause of death) was made available only after it had been coded, to preclude any identification of patient or physician. For the anonymity procedure, we received approval from the ethical review boards of the organizing universities, and recommendations from the Belgian Medical Disciplinary Board and the Belgian Federal Privacy Commission.
Questionnaire
We modelled the questionnaire after ones used and extensively validated in previous studies in Belgium and other European countries.11-13 For the present study, the questionnaire was validated through testing by a panel of physicians.
Physicians were asked about end-of-life decisions, defined as "medical decisions at the end of patients ' lives with a possible or certain life-shortening effect." We identified cases as physician-assisted deaths if the physician gave an affirmative answer to the following question: "Was the death the consequence of the use of drugs prescribed, supplied or administered by you or another physician with the explicit intention of hastening the end of life or of enabling the patient to end his or her own life?" Additional questions dealt with the lifeending drugs used and who administered the drugs. Other sections of the questionnaire asked about the involvement of the patient, family and other caregivers in the decision making process, the reasons for the decision, how long the patient had received treatment for the illness leading to death, the main goal of treatment in the last week before death and the estimated time by which the patient 's life was shortened.
For the deaths with an explicit request from the patient, we classified them as euthanasia if someone other than the patient had administered the drugs and as physician-assisted suicide when the patient had administered the drugs.
Statistical analysis
We weighted the reported percentages to correct for the disproportionate stratification of deaths and to correct for differences between the response sample and all deaths in Flanders in 2007 relating to sex, age, province of death, place of death and cause of death (differences were found relating only to place of death). We conducted statistical analyses with SPSS 17.0 software, using the complex samples procedure to account for the stratified sample design and associated standard errors. We used the Fisher exact test to compare differences in distributions between physician-assisted death with explicit patient request (euthanasia or assisted suicide) and the use of life-ending drugs without explicit patient request; statistical significance was set at a p value of less than 0.05.
Results
We received questionnaires for 3623 of the 6927 deaths. For 725 of the remaining 3304 deaths, a response was not possible because the physician no longer had access to the patient 's medical file because of a change of workplace, or the physician could not retrieve the identity of the patient. We removed these cases from the sample. The final response rate, therefore, was 58.4% (3623 of 6202 valid cases).
We identified 208 physician-assisted deaths: 142 (weighted prevalence 2.0%) with an explicit request from the patient (137 euthanasia, 5 assisted suicide) and 66 (weighted prevalence 1.8%) without an explicit request (Table 1). Euthanasia and assisted suicide predominantly involved patients less than 80 years old (79.6%), those with cancer (80.2%) and those dying at home (50.3%). Of the cases without an explicit request from the patient, most involved patients who were 80 years of age or older (52.7%), those without cancer (67.5%) and those who died in hospital (67.1%). The distribution of patient characteristics for life-ending acts without explicit request was similar to that for all other deaths in Flanders, except that it was performed more often in hospital and by clinical specialists.
The decision to end life was discussed with the patient in 22.1% of the cases without an explicit patient request (Table 2). In cases where the decision had not been discussed with the patient, the physician specified as reason(s) that the patient was comatose (70.1% of cases) or had dementia (21.1%); in 40.4% of cases, the physician indicated that the patient had previously expressed a wish for ending life (not equivalent to an explicit request for euthanasia). Physicians specified that the decision had not been discussed with the patient because the decision was in the patient 's best interest (17.0%) or because discussion would have been harmful (8.2%). Compared with euthanasia or assisted suicide, the use of life-ending drugs without an explicit patient request was discussed less often with other caregivers, but as often with the patient 's family. Pain and the patient 's wish for ending life were more often reasons for carrying out euthanasia or assisted suicide, whereas family burden and the consideration that life was not to be needlessly prolonged were more often reasons for using life-ending drugs without explicit patient request.
Assisted deaths with and without an explicit request from the patient differed significantly with regard to length of treatment of the terminal illness, the primary goal of treatment during the last week and the estimated time by which life was shortened (Table 3). In most cases in which euthanasia or physician-assisted suicide was performed, the patients had been treated for their terminal illness for more than 6 months (80.3%), the goal of treatment in the last week was patient comfort (94.3%), and life was shortened by 1 week or more (44.5%). In contrast, the cases without an explicit request were more likely to have a shorter length of treatment of the terminal illness (< 1 month in 46.1% of cases), to have cure as a goal of treatment in the last week (14.6% v. 1.2% of cases with an explicit request) and to have a shorter estimated time by which life was shortened (< 24 hours in 47.9% of cases) (Table 3).
Compared with drugs used in euthanasia and assisted suicide, opioids were used far more often in the ending of life without an explicit patient request, especially when used as the sole drug (Table 4). In these cases, the dosage was strongly increased in the last 24 hours in 45.8%, and the physician indicated it to be higher than needed to alleviate the patient 's symptoms in 46.8% (data not shown). Nurses were more often involved in the administration of the drugs when there was no explicit request from the patient than in cases of euthanasia or assisted suicide.
Interpretation
We found that, five years after the euthanasia law was enacted in Belgium, euthanasia and assisted suicide occurred in 2.0% of all deaths in Flanders during the study period. They predominantly involved patients less than 80 years old, patients with cancer and patients dying at home; the drugs used most often were barbiturates and muscle relaxants, alone or in combination; and the severity of pain or other symptoms, the lack of prospects of improvement and the patient 's wishes were the most common reasons for performing these acts.
The use of life-ending drugs without an explicit request from the patient occurred in 1.8% of the deaths in Flanders during the study period. Most of these cases involved patients 80 years or older and occurred in hospital. In the majority of cases, the patient was not involved in the decision, primarily because of coma or dementia; however, relatives and other caregivers were often consulted. Considerations involving the relatives and needless prolongation of life were reasons indicated by physicians for reaching the decision. Compared with euthanasia and assisted suicide, cases of assisted death without an explicit request from the patient had a shorter length of treatment of the terminal illness, were more likely to have cure as a goal of treatment in the last week, had a shorter estimated time by which life was shortened and more often involved the administration of opioids alone. Our finding that euthanasia and assisted suicide were typically performed in younger patients, patients with cancer and patients dying at home is consistent with findings from other studies.11,18-21 Our finding that the use of life-ending drugs without explicit patient request occurred predominantly in hospital and among patients 80 years or older who were mostly in a coma or had dementia fits the description of "vulnerable" patient groups at risk of life-ending without re - quest.7-10 Attention should therefore be paid to protecting these patient groups from such practices. However, when compared with all deaths in Flanders, elderly patients and patients dying of diseases of the nervous system (including dementia) were not proportionally at greater risk of this practice than other patient groups. In the Netherlands in 2005, use of life-ending drugs without explicit request was most often performed by clinical specialists (i.e., in hospital), but occurred relatively infrequently in older patients.11
The differences we observed in demographic and clinical characteristics between the cases of euthanasia or assisted suicide and those of life-ending drug use without an explicit patient request likely reflect differences in the illness trajectories of the patients concerned. Four out of five cases of euthanasia or assisted suicide involved patients with terminal cancer, which generally has a predictable illness trajectory. For these patients, much time can pass between diagnosis and death, which creates the opportunity for anticipatory decision making. In contrast, in the group without an explicit patient request, most of the patients had diseases other than cancer, which have less predictable end-of-life trajectories.22,23 In addition, with cure being the main goal of treatment in the last week for some of these patients, and with the length of treatment of the terminal illness often being less than one month, we believe that the use of life-ending drugs without explicit patient request often involved chronically ill patients whose general condition suddenly and drastically deteriorated to a point that left them permanently unable to communicate. In these situations, as is apparent from our findings, physicians need to decide on a course of action together with the patient 's family, which may result in a conflict of interest. This underscores the importance of advance care planning with family and caregivers, and of communication regarding the patient 's wishes should he or she become comatose or incompetent. Such measures will undoubtedly limit the number of cases of life-ending without explicit patient request.
Physicians in our study who indicated an intention to hasten the patient 's death without an explicit request from the patient most often used opioids, alone or with benzodiazepines. The use of opioids for ending life are discouraged because the patient may regain consciousness and because the procedure can take longer than expected.24-26 Furthermore, the life-shortening effect of opioids is subject to speculation. Recent studies have shown that the actual effect on the end of life is prone to overestimation.27-29 The estimated time by which life was shortened in many of the cases in our study was already very limited, especially compared with the estimated time in the cases of euthanasia and assisted suicide. We also found that, although physicians specified an intention to hasten death, opioids were often given in doses that were not higher than needed to relieve the patient 's pain. This suggests that the practice of using life-ending drugs without an explicit patient request in reality resembles more intensified pain alleviation with a "double effect," and death was in many cases not hastened. The problem may also exist in other countries; for example, in the study in the Netherlands, opioids were also frequently administered to end life without an explicit patient request.11,20,27 This points to the need for education of caregivers about misconceptions of opioid use.
We found that the use of life-ending drugs without a patient 's explicit request occurred more often in Flanders, Belgium, than in other countries, including the Netherlands, where euthanasia is also legal.11,13,16 Flemish physicians have been shown to be more open to this practice than physicians elsewhere,30 which suggests a larger degree of paternalistic attitudes. This being said, its occurrence has not risen since the legalization of euthanasia in Belgium. On the contrary, the rate dropped from 3.2% in 1998 to 1.8% in 2007.12 In the Netherlands, the rate dropped slightly after legalization, from 0.7% to 0.4%.11 Although legalization of euthanasia seems to have had an impact, more efforts are needed to further reduce the occurrence of life-ending drug use without an explicit request from the patient.
Limitations
Our study is limited because we could not exclude some degree of nonresponse bias. However, by obtaining an acceptable response rate from a large population sample and weighting for differences with all deaths, we believe the results to be representative of all deaths. Another limitation is that the study provides information only from the physicians ' perspective. Also, our study does not permit in-depth case analysis, which impedes interpretation of the contents of discussion and of reported motivations in the decision- making process.
Conclusion
Our study showed that physician-assisted death with an explicit request from the patient (euthanasia and assisted suicide) and use of life-ending drugs without an explicit request were distinct types of end-of-life decisions that occurred in different patient groups and under different circumstances. Unlike euthanasia and assisted suicide, the use of life-ending drugs without an explicit patient request often involved patients with diseases other than cancer, which have an unpredictable end-of-life trajectory. This finding underscores the need for advance care planning. Finally, misconceptions seem to persist about the life-shortening effects of opioid use. Future research should closely monitor both types of physician- assisted deaths in various countries with and without legal regulations for euthanasia.
This article has been peer reviewed.
Competing interests: None declared.
Contributors: All of the authors were involved in the design of the study, the collection, analysis and interpretation of data, and the writing or revising of the manuscript. The corresponding author had full access to all of the data in the study and had final responsibility for the decision to submit for publication. All of the authors approved the final version of the manuscript submitted for publication.
Acknowledgements: The authors primarily thank the Flemish Agency for Care and Health and lawyer Wim De Brock for their participation in the organization of the data collection. Geert Pousset deserves special praise for his part in conducting the data collection. They further thank the Belgian Medical Disciplinary Board for recommending the study. They are deeply indebted to all physicians who participated in this study.
Funding: This study was funded by the Institute for the Promotion of Innovation by Science and Technology - Flanders (IWT Vlaanderen - project IWT-SBO 050158).
Beliefs about euthanasia among university students: perspectives from Pakistan/Croyances

ABSTRACT Opinions of university students about euthanasia were studied in 4 cities in Pakistan using convenience sampling. A total of 836 students (316 males and 520 females) completed a questionnaire in which euthanasia was defined as deliberate administration of an overdose of a drug by a doctor to relieve pain and suffering of a dying patient at his/her explicit request to end his/her life. Only 25.6% of students agreed that euthanasia should be legalized in Pakistan. The most common reason cited for legalization ofeuthanasia was to relieve patient 's suffering but only when a committee of physicians agreed to recommend it. Students who opposed legalization (74.4%) cited impediments to future medical research as the most common reason, followed by the risk of misuse by physicians or family members. Only 8.9% of students cited religious beliefs as a reason against legalization. There is a need in Pakistan for more debate about euthanasia.
Croyances concernant l 'euthanasie chez les étudiants des universités pakistanaises
RÉSUMÉ Les opinions des étudiants en université concernant l 'euthanasie ont été examinées dans quatre villes du Pakistan à l 'aide d 'un échantillonnage de commodité. Au total, 836 étudiants (316 hommes et 520 femmes) ont rempli un questionnaire dans lequel l 'euthanasie était définie comme l 'administration délibérée d 'une surdose de médicaments par un médecin pour soulager la douleur et la souffrance d 'un patient mourant, à la demande explicite de ce dernier, afin de mettre fin à sa vie. Seuls 25,6 % des étudiants consentaient à la légalisation de l 'euthanasie au Pakistan. La raison la plus fréquemment citée en faveur de la légalisation de l 'euthanasie était le soulagement de la souffrance des patients, à condition qu 'un comité de médecins soit d 'accord pour proposer cette décision. Les étudiants opposés à la légalisation (74,4 %) invoquaient principalement l 'entrave aux futures recherches médicales que représenterait cette pratique, puis le risque d 'utilisation abusive par les médecins et les membres de la famille du patient. Seuls 8,9 % des étudiants citaient les croyances religieuses comme motif d 'opposition à la légalisation. Il est nécessaire d 'approfondir le débat sur l 'euthanasie au Pakistan.
(ProQuest: ... denotes non-US-ASCII text omitted.)
Introduction
Physician-assisted suicide usually entails the use of drugs with the explicit purpose of causing death so as to ease suffering in a terminally sick patient. The United States National Cancer Institute defines euthanasia as "an easy or painless death, or the intentional ending of the life of a person suffering from an incurable or painful disease at his or her request" [1]. Although euthanasia has been legalized in some European countries [2,3] the practice is fraught with ethical, moral, social and economic controversy. Studies in other several countries have been done to evaluate the attitudes of health care personnel, as well as the general public, towards euthanasia [4-6]. Little is know about public attitudes in the Eastern Mediterranean region, however, and this is the first study in Pakistan to determine the opinions of university students about the legalization ofeuthanasia.
Methods
A cross-sectional survey from March to November 2007 was conducted among university students in the cities of Islamabad, Rawalpindi, Sahiwal and Multan. A convenience sampling method was used in which 5 graduate students approached students of both sexes on the campus of various universities in the 4 cities, and after obtaining verbal consent, distributed the questionnaires and collected the completed ones. Only those students enrolled in masters or higher degree programmes and aged ≤ 30 years were asked to complete the questionnaire.
The questionnaire was designed in a focus group with 6 students and revised after testing with 17 students. It defined euthanasia as deliberate administration of an overdose of a medication by a doctor at the request of a terminally ill patient suffering from unbearable pain to end his/her life. In total there were 8 questions, a mix of open and close-ended questions. There were 2 questions about euthanasia: "In your opinion, is euthanasiaethically justified?" (yes/no) and "Should euthanasia be legalized?" (yes/no). For the second question respondents chose from a list of reasons why it should be legalized/not legalized or could suggest "other" reasons in an open-ended format; respondents were allowed to give multiple answers.
Minitab, version 15 was used to analyse the data.
Results
A total of 836 students participated in this study: 316 (37.8%) males and 520 (62.2%) females. The mean age was 22.9 (SD 2.3) years for males and 21.9 (SD 1.8) years for females. Students were from the various departments of the arts and sciences faculties of the selected universities; no medical students were involved. Most students (84.6%) were enrolled in a Masters programme, while the rest were enrolled in MPhil or doctoral programmes.
A small proportion of students (17.2%) described themselves as very religious, 75.1% as moderately religious, while the rest described themselves as somewhat religious.
One-third of students (35.4%) had heard the term euthanasia before (33.2% of male and 31.0% of female students) and nearly half (47.5%) had reportedly seen a terminally ill patient in the past year (56.0% of males students compared with 42.3% of female students).
Overall 214 students (25.6%) agreed that euthanasia should be legalized in Pakistan (27.9% of male and 24.2% of female students). Table 1 depicts the students ' responses to reasons for and against legalization ofeuthanasia, by sex. The most common reason accepted for allowing euthanasia was to end a patient 's pain/suffering (10.2% of students), but only after a committee of physicians agreed to it (12.2%). Similar proportions of male and female students agreed on the reasons for legalization of euthanasia.
Three-quarters of students (74.4%) did not think that euthanasia should be legalized (72.2% of male and 75.8% of female students). The main reasons against legalization were that it could be misused by family members or physicians or that future medical research to find better care of dying patients would be jeopardized. A minority of students (8.9%) thought it was not acceptable for religious reasons (5.7% of male and 10.8% of female students).
A total of 88 students (10.5%) gave no reasons for or against legalization.
Discussion
Euthanasia raises complex ethical and moral issues. Arguments against euthanasia include the fear of this practice becoming a cost containment measure, that it devalues human life, that it goes against the core values of medicine/physicians, and that condoning voluntary euthanasia is a "slippery slope" towards allowing involuntary assisted killing [7-12]. Some of the arguments favouring the practice found in other studies included the need to relieve severe and incurable pain in the context of terminal illness or extremely poor quality of life, allowing patients to exercise freedom of choice and freeing up medical resources to help others [4-7,13,14].
Although 47.5% of students in our survey had seen a terminally ill patient in the past year, only 25.6% overall believed that euthanasia was should be legalized in Pakistan. Only 35.4% students were familiar with the term euthanasia prior to this survey, nevertheless every student in this survey expressed an opinion about the legalization of euthanasia and only 10.5% of students did not provide any specific reason either for or against legalization.
In our study, the most commonly accepted reason for allowing euthanasia was to end a patient 's suffering, but only when a committee of physicians agreed to recommend this course of action. Students who opposed legalization of euthanasia most commonly believed that it would be an impediment to future medical research in finding a better care of dying patients. Misuse of euthanasia by physicians or by family members were the next most commonly stated reasons for opposing legalization. Euthanasia has strong religious implications, but although 75.1% of students described themselves as either moderately or somewhat religious, only 8.9% specifically cited religion as a factor against legalization.
There is a need in Pakistan for the professional medical societies to encourage a wider debate abouteuthanasia, taking account of religious beliefs and the ethical questions surrounding the suffering of dying patients [7,15]. The need for population-based surveys to determine opinions about euthanasia would be pivotal to inform the debate in Pakistan.
Sidebar
Bioethics
The critical role of ethical practices in health care and research is not only well recognized to ensure equity in health care and research, but also is important to protect individuals and communities from unnecessary risks and harm.
Many countries in the Region have long been developing a core ethical framework for health care and research ethics. The overall direction of this development has been within the context of religious, social and cultural practices in the Region, while at the same time embracing the ethical values and principles of other nations that are not in conflict with the local value systems. Several countries in the Region have already developed capacities in health ethics, with properly instituted review and regulation processes in place. Egypt, Islamic Republic of Iran, Lebanon, Oman, Pakistan and Yemen have created national ethical review committees (ERCs), while Morocco, Saudi Arabia and Sudan, have institutional ERCs, which also double as national ERCs. Egypt and Islamic Republic of Iran have prepared their own national guidelines for ethics in health and Morocco, Saudi Arabia and Sudan are in the process of developing their own national guidelines. Formal long term (degree oriented) training programmes on ethics in health research ethics do not exist at present but informal short-term training is imparted at universities / organizations in Egypt, Islamic Republic of Iran, Lebanon, Pakistan, and Saudi Arabia.
Active and passive euthanasia: The case of Drs. Claudio Alberto de la Rocha and Nancy Morrison: CMAJ CMAJ

Passive euthanasia is defined as allowing a patient to die by withholding treatment, while active euthanasia is defined as taking measures that directly cause a patient 's death. The CMA supports the commonly held view that passive euthanasia is morally permissible in certain circumstances while active euthanasia is always wrong. In its policy summary on physician-assisted death, the CMA stated that both euthanasia and assisted suicide fall under this heading and said CMA members "should specifically exclude participation in" either practice. But the definition of physician-assisted death is qualified: "Physician-assisted death, as understood here, does not include the withholding or withdrawal of inappropriate, futile or unwanted medical treatment or the provision of compassionate palliative care, even when these practices shorten life." '
In "Active and passive euthanasia," a paper published more than 20 years ago, James Rachels challenges the doctrine that passive euthanasia can be morally permissible but active euthanasia cannot.4 He argues that killing someone is not, in itself, worse than letting someone die, and so active euthanasia is not worse than passive euthanasia.
In his view, we should decide whether euthanasia is permissible in a particular case, irrespective of the means by which death would be brought about. Then, if we think that euthanasia is indeed permissible, we should favour the means that is most humane. Consequently, in cases where a dying patient 's suffering cannot be adequately relieved by palliative care, active euthanasia should actually be favoured over passive euthanasia because it ends the suffering more
quickly.
If this conclusion is correct, why do many people think that killing is worse than letting die? The reason, Rachels argues, is that they "conflate the question of whether killing is, in itself, worse than letting die, with the very different question of whether most actual cases of killing are more reprehensible than most actual cases of letting die." Most cases of killing involve murderers with evil motives, whereas most cases of letting die involve physicians acting out of compassion. Consequently, we come to think of killing as worse than letting die even though our moral reactions to these cases are really based on the different motives for ending life. Rachels maintains that when the motives and other circumstances are the same, as in the Smith and Jones cases, it becomes clear that whether a person is killed or allowed to die is morally irrelevant. Therefore, he believes that the means of bringing about death should play no part in decisions about euthanasia.

Non-voluntary and involuntary euthanasia in the Netherlands: Dutch perspectives
Abstract: During the summer of 1999, twenty-eight interviews with some of the leading authorities on euthanasia policy were conducted in the Netherlands. They were asked about cases of non-voluntary (when patients are incompetent) and involuntary euthanasia (when patients are competent and made no request to die). This study reports the main findings, showing that most respondents are quite complacent with regard to breaches of the guideline that require the patient 's consent as a prerequisite to performance of euthanasia.
In November 1990, the Dutch Ministry of Justice and the Royal Dutch Medical Association set out Guidelines for the performance of euthanasia based on the criteria established in court decisions relating to the conditions under which a doctor can successfully invoke the defence of necessity. The substantive requirements are as follows:
1. The request for euthanasia or physician-assisted suicide must be made by the patient and must be free and voluntary.
2. The patient 's request must be well considered, durable and consistent.
The patient 's situation must entail unbearable suffering with no prospect of improvement and no alternative to end the suffering. ' The patient need not be terminally ill to satisfy this requirement and the suffering need not necessarily be physical.
3. Euthanasia must be a last resort.
The procedural requirements are as follows:
* No doctor is required to perform euthanasia, but those opposed on principle must make this position known to the patient early on and help the patient to get in touch with a colleague who has no such moral objections.
* Doctors taking part in euthanasia should preferably and whenever possible have patients administer the fatal drug themselves, rather than have a doctor apply an injection or intravenous drip.3?
* A doctor must perform the euthanasia.
* Before the doctor assists the patient, the doctor must consult a second independent doctor who has no professional or family relationship with either the patient or doctor. Since the 1991 Chabot case, 4 patients with a psychiatric disorder must be examined by at least two other doctors, one of whom must be a psychiatrist.
* The doctor must keep a full written record of the case.
* The death must be reported to the prosecutorial authorities as a case of euthanasia or physician-assisted suicide, and not as a case of death by natural causes.5
In 1990, the Dutch government appointed a commission to investigate the medical practice of euthanasia. The Commission, headed by Professor Jan Remmelink, Solicitor General to the Supreme Court, was asked to conduct a comprehensive nation-wide study of "medical decisions concerning the end of life (MDEL)." The following broad forms of MDEL were studied:
* Non-treatment decisions: withholding or withdrawing treatment in situations where treatment would probably have prolonged life;
* Alleviation of pain and symptoms: administering opioids in such dosages that the patient 's life could be shortened;
* Euthanasia and related MDEL: the prescription, supply or administration of drugs with the explicit intention of shortening life, including euthanasia at the patient 's request, assisted suicide, and life termination without explicit and persistent request.6
The study was repeated in 1995, making it possible to assess for the first time whether there were harmful effects over time that might have been caused by the availability of voluntary euthanasia in the Netherlands. It is still difficult to make valid comparisons with other countries because of legal and cultural differences, and also because similar comprehensive studies are quite rare.7
The two Dutch studies were said to give the best estimate of all forms of MDEL (i.e., all treatment decisions with the possibility of shortening life) in the Netherlands as approximately 39% of all deaths in 1990, and 43% in 1995. In the third category of MDEL, the studies gave the best estimate of voluntary euthanasia as 2300 persons each year (1.9% of all deaths) in 1990,8 and 3250 persons each year (2.4%) in 1995. The estimate for physician-assisted suicide was about 0.3% in 1990 and in 1995. There were 8900 explicit requests foreuthanasia or assisted suicide in the Netherlands in 1990, and 9700 in 1995. Less than 40% were actually undertaken. The most worrisome data is related to the hastening of death without the explicit request of patients. There were one thousand cases (0.8%) without explicit and persistent request in 1990, and nine hundred such cases (0.7%) in 1995.9
In 1990, 30% of the general practitioners (GPs) interviewed said that they had performed a life-terminating act at some time without explicit request (as compared with 25% of specialists and 10% of nursing home physicians).10 Life-terminating acts without explicit request were performed with older patients more, on the average, than were euthanasia or physician-assisted suicide.11 There were still treatment alternatives in 8% of cases in which a life-terminating act was performed without explicit request of the patient.
The physician did not use these alternatives when the patient indicated a desire to stop treatment because it "only would prolong suffering," or because the expected gain was not enough to make the treatment worthwhile.12 It should be noted that the level of consultation was significantly lower in life-termination acts without patient 's explicit request than in cases of euthanasia or physician-assisted suicide. A colleague was consulted in 48% of the cases (as compared with 84% in euthanasia and assisted suicide cases). Relatives were consulted in 72% of the cases (as compared with 94% in euthanasia and assisted suicide cases). In 68% of the cases, the physician felt no need for consultation because the situation was clear.13 Van der Maas and colleagues note that this should be considered in light of the very brief period by which life was shortened. 14 In 67% of the cases, life was shortened by fewer than twenty-four hours. In 21% of the cases, life was
shortened by up to one week.15
About a quarter of the one thousand patients had earlier expressed a wish for voluntary euthanasia.16 The patient was no longer competent in almost all of those cases, and death was hastened by a few hours or days. A small number of cases (approximately fifteen) involved babies who were suffering from a serious congenital disorder and were barely viable; hence the doctor 's decision, in consultation with the parents, to hasten the end of life.17
The Remmelink Commission regarded these cases of involuntary termination of life as "providing assistance to the dying." They were justified because the patients ' suffering was unbearable, standard medical practice failed to help and, in any event, death would have occurred within a week.18
The aim of this study is to explore how leading figures in the Dutch euthanasia policy and practice conceive this worrisome data. To that end, in the summer of 1999 I went to the Netherlands to visit the major centers of medical ethics as well as some research hospitals, and to speak with policymakers.
Methodology
Before arriving in the Netherlands, I wrote to some distinguished experts in their respective fields: medicine, psychiatry, philosophy, law, social sciences and ethics, asking to meet with them in order to discuss the Dutch policy and practice of euthanasia. Only one, Dr. Chabot, explicitly declined my request for an interview.19
The interviews took place during July-August 1999, in the Netherlands. They lasted between one to three hours each. Most interviews went on for more than two hours during which I asked more or less the same series of questions. During the interviews, I took extensive notes that together comprise some two hundred dense pages. Later the interviews were typed and analyzed.20
The interviews were conducted in English, usually in the interviewees ' offices. Four interviews were conducted at the interviewees ' private homes, and four interviews in "neutral" locations: coffee shops and restaurants. Two interviews were conducted at the office kindly made available to me at the Department of Medical Ethics, Free University of Amsterdam. To have a sample of different locations I traveled from Groningen in the north to Maastricht in the south, making extensive use of the Dutch efficient train system.
The interviews were semi-structured. I began with a list of fifteen questions but did not insist on all of them when I saw that the interviewee preferred to speak about subjects that were not included in the original questionnaire. With a few interviewees I spoke only about their direct involvement in the practice ofeuthanasia. Because I was interested in the problematic aspects of the euthanasia practice, after some general questions I addressed the troublesome aspects reiterated in the Remmelink report. This line of questions disturbed some of the interviewees, who wanted to know my own opinion on the subject matter before continuing to answer my questions. Others seemed eager to bring the interview to a close.
The Interviewees ' Responses
Hastening of Death without the Patients ' Explicit Request
The question that opened the critical line of the interviews was: "Some of the most worrisome data in the two Dutch studies are concerned with the hastening of death without the explicit request of patients. There were one thousand cases (0.8%) without explicit and persistent request in 1990, and nine hundred cases (0.7%) in 1995. What is your opinion?"
Most of the interviewees had similar interpretations of this finding. They said that this group includes cancer patients, PVS patients, newborns with severe health problems, and patients who are suffering that would die within a matter of days or even hours. By so doing, physicians strive to alleviate the pain of very sick patients at the end of their lives. In essence, what they are saying is that it is right to replace autonomy with beneficence in such severe circumstances. Some of the interviewees saw no problem in this, arguing that the balance favors termination of life in such instances. Many interviewees also emphasized that this practice was common long before euthanasia became available in the Netherlands and that it is not a specifically Dutch problem; there is a similar policy in hospitals all over the world.21
Consider the view of one of the foremost euthanasia activists, H.J.J. Leenen, on this matter. He argues that these are not cases of euthanasia. Nearly all of them involved cancer patients in the last phase of their lives, who were suffering greatly and who had had so much medication that they were no longer competent. Their physicians sometimes help these suffering, dying patients with the last push. Such cases do not indicate a slippery slope, and they occur in every country. Nevertheless, Leenen is worried that the physicians did not discuss the option of termination of treatment early on with these patients. Physicians know the consequences of increased doses of medication and should discuss the options at the beginning of the dying process. It is a physician 's responsibility to verify what patients want.
Bert Thijs, Director of the Medical Intensive Care Unit, VU ziekenhuis in Amsterdam, and Evert Van Leeuwen, Chairperson of the Department of Metamedicine, Free University of Amsterdam, recommend ethical and practical training as well as open discussions to overcome this problem. Physicians should discuss and debate this issue by holding regular consultation sessions. These discussions would make it possible for physicians to reflect on their decision-making process among themselves and with paramedics in their teams.
The two most productive researchers in the field of euthanasia, Gerrit van der Wal and Paul van der Maas, express remarkably similar opinions. Van der Wal of the Institute for Research in Extramural Medicine at the Free University, Amsterdam, explains that this category of patients, who did not make an explicit request foreuthanasia, includes comatose patients whose families asked whether it was necessary to keep the patients alive and who wanted to stop their suffering. In other countries, Van der Wal maintains, ending a patient 's life in such cases would be called double effect. In the Netherlands, "we are more explicit, more Calvinistic" (I asked what this meant, and he answered "more open, rigid, honest, straightforward"). He further argues that in most of these cases, the issue of euthanasia was not sufficiently discussed beforehand. Therefore, it is important to make the climate around euthanasia more open and to exchange views between physicians and patients. Van der Wal also notes that the doctors ' intentions regarding these patients were unclear. Most of the patients died from large doses of morphine ("double effect"), while the drugs used for euthanasia are muscle paralyzers. The doctors wanted to alleviate the pain and suffering of their patients, most of whom were in the advanced stages of cancer. They had only days or hours left to live and had been rendered incompetent from painkilling drugs. The doctors were then forced to act upon their own initiative without having an opportunity to consult the patients regarding euthanasia.22
Van der Maas, Professor of Public Health and Social Medicine at the Erasmus University of Rotterdam, reports that he is not worried about the data. In nearly all of the cases in question, the patients suddenly lost consciousness or their ability to communicate. Two-thirds were cancer patients in the advanced stage of the disease. They were suffering extremely, vomiting, unable to express themselves, and totally immersed in their agonizing condition. Most of them would have died within one to three days, and they actually died from opiates (double effect). Very few of these patients had living wills, but about half had indicated in the past that they would prefer to hasten death under such terrible conditions. Half of the patients had given no indication of what they wanted.23 Similarly, Heleen Dupuis calls the deaths of this group "double effect," rather thaneuthanasia, given that the opiate doses were increased.
Johannes van Delden provides the most interesting answer to the question regarding this worrisome data. He said that that these findings were in part artifact, the creation of the researchers in the construction of the categories, which included clear-cut expressed wishes, cases of no explicit request, and cases with some remarks. Of the one thousand, 56% expressed some view. However, the authors of the research "decided to have a clear-cut euthanasia group, and this group emerged from the way we chose to analyze." Van Delden explained that "you need autonomy and beneficence to perform euthanasia." There might be very extreme cases in which doctors decide to conduct euthanasia without the patient 's explicit request, but these cases are few in number. It is hardly conceivable to act in this way, "maybe in pediatrics." Van Delden did recognize that most of these cases were insufficiently justified and insisted that the autonomy requirement be maintained.24
Henri Wijsbek argues that most of these cases involve situations in which patients are unconscious, suffering greatly, and would have died within two hours.25 This practice occurs in many countries, and Wijsbek sees no problem with it. He adds his hope that under such circumstances, his doctors would do the same for him. When there is hopeless suffering, and doctors cannot alleviate the pain, the option of euthanasia should be available. Similarly, Van der Arend, who teaches at the Health Ethics and Philosophy Department of Maastricht University, explains that there are situations in which patients are suffering, unconscious or half-conscious, in the last stage of disease, and physicians then do not have any other choice but to end the patient 's life. He is not worried about the numbers, saying that he could not imagine that termination of life was the result of careless medical practice. Van der Arend added: "There will always be cases like these."
Rob Houtepen, who teaches in the same department in Maastricht, also sees no reason for alarm in regard to this data. He testifies that he is quite liberal about termination of life when people are suffering, even if they are incompetent. He believes that compassion is the primary consideration for euthanasia. Autonomy is a secondary consideration. It is unjust that people be denied the option to end their suffering, an option that is available to competent patients. In his mind, we should not make strict distinctions between competent and incompetent patients. Hence, Houtepen is "not shocked" by the figures, though he does recognize the need for stricter notification procedures so as to make more data available about the circumstances of each and every patient who did not make an explicit request.
Ron Berghmans, also from Maastricht, supports the need for more information about these cases and the circumstances involved in each case, particularly when the patient could have expressed an opinion about the issue. In addition, the issue of advance directives needs to be discussed further. The new law stipulates that ADs have the legal force of the patient 's voluntary explicit request. Berghmans reiterates the problem of how to evaluate suffering in cases of dementia and expresses doubt about whether we should honor the ADs of dementia patients.26
In his comments on the first draft of this study, Govert den Hartogh wrote that my implicit assumption is that the worrisome data is the result of the lax Dutch rules. He thinks that probably the opposite is true: in other countries, this figure would probably be much higher, precisely because euthanasia is forbidden and hence cannot safely be discussed with patients. Accordingly, the result of the Dutch rules, on this account, is that the figure is unusually low. This, however, does not mean that the data are not worrisome.
To substantiate his point, Den Hartogh referred to the recent research project in Flandres, which is a replica of the Van der Maas/Van der Wal studies. Belgian law forbade euthanasia and assisted suicide at the time of interview. According to this research, the overall percentage of deaths as a result of euthanasia or assisted suicide in Belgium is somewhat lower, but not very much lower, than it is in the Netherlands. However, the percentage of deaths from "euthanasia" without explicit request is five times as high (3.5%). Den Hartogh 's interpretation of these data is not that Belgian doctors, any more than Dutch doctors, "get rid of unwanted patients." Although they believe themselves to be acting in the best interests of the patient and fulfilling the wishes of the patient, they are simply reluctant to discuss the matter openly.27
Even if you do not consider it worrisome that when patients are suffering and on the verge of death the doctor provides morphine to ease the pain and the patient dies, yet in cases where the patients were competent and the doctor took their lives without asking them, this is worrisome. Some of the reasons given by the doctors for euthanizing these patients were invalid, as was the apparent unwillingness of some doctors to consult a colleague.28 Indeed, according to the 1990 report, among the considerations by the physician in performing a life-terminating act without explicit request of the patient were the patient 's low quality of life (31% of the cases), inability of the patient 's relatives to cope (32%), and economic considerations (1%).29
Egbert Schroten, who has served on many medical committees, says that the findings are worrisome but that the discussion about their seriousness is exaggerated. Such medical behavior always existed before the invocation of the euthanasia policy, and a good doctor needs to help patients who are in great pain. Suffering of body and spirit is the most important consideration, and here we speak of incompetent patients in the very last days of their lives, who suffer miserably
Ruud ter Meulen, Director of the Institute for Bioethics and Professor at the University of Maastricht, indicates that the issue worries him. He would like to have in place an explicit policy on termination of life, with no room for interpretation. The policy should insist on the explicit request of the patient and on strict medical criteria. There is also a need to define the concept of suffering. Ter Meulen expresses a critical view of the existing practice of passive euthanasia and the use of morphine to shorten life. He argues that it is not clear on which criteria decisions for passive euthanasia are based and what role the patient has in the decisionmaking process.
The three most critical voices in the present survey did not justify the existing situation. Both Chris Rutenfrans and Henk Jochemsen express concern about the lack of control mechanisms and the freedom that physicians have to decide the fate of their patients without consulting them. Jochemsen acknowledges that some were probably cases of double effect, but in others patients were competent and were still not apprised of the situation. This is not morally justifiable. The major consideration for physicians must be the suffering of the patient. Autonomy gives an additional justification, but does not constitute the major reason. While recognizing that the termination of life took place in the last stage of the disease, Jochemsen emphasizes that there was no preference expressed by patients in a significant number of cases.30
Most outspoken was Frank Koerselman, who is worried by the phenomenon and contends that junior doctors readily make Do Not Resuscitate (DNR) orders without much thought, especially when patients are old. Young doctors often evaluate a patient 's quality of life without even knowing the patient, and many of them do not find compelling reasons for working to save a ninety year old patient. Koerselman testifies that he has seen many cases in which DNR orders were taken by phone or given by a junior physician without consulting a senior colleague.31
Fears of Elderly Patients
The next inter-related question was: "Some Dutch studies appear to indicate that some elderly people fear their lives will be ended without their consent32 and that, in fact, families in the Netherlands requesteuthanasia more often than the patient.33 is this true?"
A study of thirty nursing homes showed that when medical indications for hospitalization of elderly patients arose, nursing home physicians decided not to transport the patient to the hospital in 12% of cases, particularly when there was a life-threatening emergency. In a considerable number of cases, the decisions were made without consulting the patients or their families.34 In a study done in Dutch hospitals, doctors and nurses reported that more requests for euthanasia came from families than from patients. The family, the doctors, and the nurses often pressured the patient to request euthanasia.35
Herbert Cohen, one of the country 's leading practitioners of euthanasia, said in an interview to John Keown that he would be put in a very difficult position if a patient told him that he really felt he was a nuisance to his relatives because they wanted to enjoy his estate. Asked whether he would rule out euthanasia in such a case, Cohen replied that in the end he wouldn 't because "that kind of influence-- these children wanting the money now-is the same kind of power from the past that... shaped us all." Cohen maintained that the same thing goes for religion, education, family of origin, "all kinds of influences from the past that we can 't put aside."36 It is unclear how this view could be seen as an acceptable interpretation of the Guidelines that speak of free and voluntary request of the patient as well as of unbearable suffering.
A minority of the interviewees dismissed the question as "ridiculous." Heleen Dupuis and A. van Dantzig expressed the most supportive voices for the existing policy and practice of euthanasia.31 Dupuis explains that when the patient is incompetent, the only available option for physicians is to cease treatment, not to perform euthanasia. Doctors will not euthanize a patient who cannot express his/ her will to die, even ifeuthanasia was requested in his/her living will. She maintains that most people are afraid of having no option at the end of life and that in any event, old and demented patients receive treatment. There is no room for fear, and it is ridiculous to be afraid. In turn, Van Dantzig dismissed the question as propaganda of the anti-euthanasia lobby. Cases that include bad relations in a family should not prevent euthanasia in the many other cases where the motivation is sincere. However, the patient needs to express a will to die. If the patient does not express such a will and does not suffer, then it is not an appropriate case for euthanasia. If the patient had a living will, then the living will should be respected.
Likewise, Van der Wal dismissed the question, saying that Segers was speculating, and that the articles I cited are "nonsense" and "scientifically unsound." In one of the articles he co-authored, Van der Wal wrote that Dutch studies do not provide any evidence for the elderly being in danger of becoming "victims" of euthanasiaor assisted suicide.38 Furthermore, Van der Wal did not know of any study on the role of families (according to Henk Leenen and Govert den Hartogh, no research has been done on the role of the family), and he and his research team were exploring the issue of conducting such research at the time of the interview. Van der Wal knows of only one opinion poll designed to investigate the issue, which, in his opinion, was conducted by a biased fundamentalist organization and was scientifically unsound. He further notes that euthanasia and assisted suicide among the elderly are rare. The age of most patients requesting euthanasia varies between fifty-five to seventy-five.39
Having said that, although Van der Wal dismissed the issue as "nonsense," he acknowledges that sometimes families find the suffering of their loved one unbearable and that there has been incidental anecdotal evidence of family pressure being brought to bear in the termination of a patient 's life. That is to say that family pressures do exist, but doctors testify that they are not affected by such pressures, and that most of the time they resist those pressures. Van der Wal emphasizes that, unlike other countries, there are no financial incentives for requesting euthanasia in the Netherlands because the costs of maintaining patients are not borne by their families.
H.J.J. Leenen says that he has never heard of patients who are afraid of euthanasia. On the contrary, one hears more about patients who fear that they will ask for euthanasia when their time comes, but their request will not be honored. J.K. Gevers and Govert den Hartogh do not think that families request euthanasia any more than patients do, or that physicians act on the wish of the family more than on the wish of the patient. In his comments on the first draft of this study, Den Hartogh wrote that in all of the cases reported, the doctor acted on the request of the patient, and that in almost all instances the family supported the request of the patient. There is hardly any evidence of undue influence of the wishes of the family on the decision of the doctor, either from the reported cases or from other sources.
On the other hand, some physicians and consultants are insufficiently aware of the possibility of subtle forms of psychological pressure exerted on patients by their families. They routinely allow the family to be present at all discussions with the patient. This is one of the ways in which the SCEN-project40 may lead to substantial improvement, as SCEN-doctors are trained to be alert to this possibility
Two interviewees" argued that even if such fears on the part of patients exist, they are unfounded. Opinion polls show that the public thinks it is unacceptable for the family to request euthanasia because they cannot cope with the patient 's condition. Families may request euthanasia for the patient because they might become exhausted by dealing with the patient 's suffering and illness, but such a request would not be granted because testimony of a relative does not constitute sufficient grounds for euthanasia. Schroten and Wijsbek have heard that elderly patients fear their lives might be terminated prematurely without their consent. They believe that these fears often arise from religious convictions and are totally unrealistic.
Parenthetically, let me refer to Bert Keizer 's exchange with a nephew of one of his patients, who assured him that "this is not at all what he [the patient] wanted, ending his days in a place like this." Keizer, who practices medicine in a nursing home in Amsterdam, writes: "it always annoys me, that tone of voice in which people say, Uncle would never have wanted this. What they mean is, he 's not as stupid as those other 56,000 Dutch people staying in nursing homes who have `let things go too far '."42
Van Delden, one of the authors of the 1990 comprehensive study, based his answer on this study The study shows that relatives made an explicit request to hasten the death of the patient in 14% of the cases, and others (physician, nurse or someone else who is not a relative) made the request in 1% of cases.43
Van der Arend tells of arguments he witnessed between relatives over financial affairs, even about an inheritance while the patient was still alive. Therefore, families should be engaged in the decision-making, but should not be given the last word. All parties should be involved in the euthanasia decision: the patient, the physicians and nurses, and the patient 's family If members of the family are not involved, they might end up going to court. Van der Arend added that patients usually trust physicians not to terminate their lives without their consent. When the patient is rendered incompetent and has not prepared a living will, the family assumes a larger role in the decision-making process, but still does not have the last word.
George Beusmans and Gerrit Kimsma, both physicians who practice euthanasia, testified that they always provide information to the patient as well as to the family. It is irrelevant if the family wants to take a certain course of action when the patient does not share the same preference. It is only the patient 's request that counts. When they practice euthanasia, it is done in the open with the consent of the patient, who must voice repeated requests and sign a written document. Kimsma asserts that his patients ' families have always been satisfied with the euthanasia procedure. He has never had a family member object to euthanasia, and he has sometimes organized family meetings to resolve differences of opinion. At the same time, Kimsma declares thateuthanasia is an individual matter of the patient and that he always resists family pressures for euthanasiawhen the patient does not want it.
Evert van Leeuwen argues that there are elderly people in nursing homes who fear that their lives will be ended without consent. However, euthanasia is rarely conducted in nursing homes. Indeed, studies show that Dutch nursing home physicians together receive an average of three hundred requests for euthanasia and assisted suicide annually, of which they comply with only twenty-five.44 In comparison to general hospitals, nursing homes have a less permissive policy on euthanasia.45 Bert Keizer writes that most of the patients in nursing homes belong to the generation that still associates "euthanasia" with "mass murder."46
Van Leeuwen maintains that there might be cases of inadequate care and, as a result, patients may die earlier than expected. Van Leeuwen further testifies that he once heard a physician describe how he and his colleagues could have improved a patient 's situation, but did not do so because the patient had no family to care for him were his condition to improve, thus leaving him alone in a difficult situation.47 In addition, when some families request that the elderly die peacefully, they are indirectly exerting their influence on the decision makers.
Rob Houtepen and Ron Berghmans argue that families do exert pressure for, but also against, euthanasia. Most physicians are aware of the pressure on them to perform euthanasia, and they resist it. The common procedure is to inform and to speak with family members.48 In turn, John Griffiths identified the issue of family pressure as one of the problems that needs to be addressed by effective regulation. Families that can no longer cope with the patient 's situation might exert pressure on doctors and influence them to opt foreuthanasia rather than to provide adequate pain relief. Griffiths maintained in a later communication that this problem is in no way limited to euthanasia. His impression is that it is far more important quantitatively in connection with abstention decisions.
Ruud ter Meulen, Henk Jochemsen and Frank Koerselman voiced the most critical voices on this matter. Ter Meulen is worried about the position of elderly people, given that there are waiting lists for nursing homes and for home care. The Netherlands is facing a shortage of resources, cuts in the nursing staff and a larger number of the elderly who wish to be in nursing homes. We can expect that the quality of care for the elderly will deteriorate. Euthanasia may be a promising alternative as a solution to a pressing problem, and Ter Meulen adds that this is especially true with respect to elderly patients who do not want to be a burden on their families. This consideration may play a role in their request for euthanasia. However, in his comments on the first draft of this paper, Ter Meulen added that there is no evidence of this issue playing a role in the practice ofeuthanasia at this point.
Henk Jochemsen, professor of Christian medical ethics, contends that it is often the case of the family, rather than the patient, asking for euthanasia when the patient has become a burden. Hence, Jochemsen thinks that some elderly patients indeed have good reason for this fear. He adds that patients sometimes also fear that treatment will continue beyond the necessary point. Jochemsen also objects to providing unnecessary treatment.
As usual, Koerselman expresses the most critical view, agreeing with the studies of Segers and Fenigsen, and testifying about his own experience. He argues that such fears on the part of the elderly do exist. In his view, families have informal influence on doctors, and it is impossible to ascertain that families who find it difficult to cope with the suffering of their loved ones do not influence the decisionmaking process. Koerselman told the story of an eighty-five-year-old patient with pneumonia and depression, both of which are treatable conditions. His family did not wish to treat him, and the GP agreed with the family that there was no point in treatment. Koerselman was invited to consult on the patient 's depression and said that if he had not taken an active role in this case, they would have taken the easy way out: "He would die, all would say that I acted humanely and would receive a nice bottle of wine from the family who physically wanted to prevent me from treating him." Koerselman asked the patient 's GP whether he had spoken with the patient alone. The response was negative. Koerselman had to order security guards to remove the family from the room so that he could speak privately with the patient. The patient said at first that there was no reason to continue treatment and that he did not want to become a burden on his family Koerselman explained to him that he suffered from pneumonia and depression, two perfectly treatable conditions, and that he might as well try to be a healthy eighty-five-year-old man. The patient then agreed to treatment and was eventually discharged from the hospital in very good condition, both mentally and physically
Conclusions
The aim of this essay was to provide an account of Dutch policy makers ' perceptions of some of the worrisome data revealed in the Remmelink Report. The present study reveals that most of the interviewed Dutch authorities in the field of medical ethics are quite complacent about involuntary and non-voluntary euthanasia, recruiting an array of justifications to show that there is no real cause for alarm even when patients ' lives are terminated without their consent.
In the United States, Oregon 's Measure 16 that allows assisted suicide is facing a challenge. In Australia, the Northern Territory Bill that allowed terminally ill patients to commit suicide with a doctor 's help was declared void. The legislatures of Canada and England resist attempts to legalize assisted suicide and euthanasia. The Netherlands represents a country in the liberal world that generally accepts the policy and practice of botheuthanasia and physician-assisted suicide, without seeing much difference between the two, and whose legislatures advance more bills that would legitimize euthanasia further, while broadening the scope of the practice.
I found it troublesome that scholars and decision-makers support a system that suffers from serious flaws while the stakes are very high; after all, we are dealing with life and death. There were variants of opinion regarding specific questions and issues, but only a minority questioned the system as such. Many of the experts depicted a society in which it is the role of doctors to help patients. They didn 't question the doctors ' motives, and saw no reason why doctors would perform euthanasia without compelling reasons. They argued that, of course, criminals exist in every society, in every sphere of life, but policy is not built around this small number of criminals. They believed there is a need to install control mechanisms against the possibility of abuse, but that the system 's rationale is good-to help people in their time of need. They emphasized that the two major reports of 1990 and 1995 indicate there is no slippery slope, yet ignored the fact that there is already too much abuse. Many of the interviewees failed to recognize that the system does not work because all the Guidelines, without exception, are broken time and time again. It is not always the patient who makes the request for euthanasia or physician assisted suicide. Often the doctor proposes euthanasia to his patient. Sometimes the family initiates the request. The voluntariness of the request is thus compromised. On occasion, the patient 's request is not well considered. There were cases in which no request was made and patients were put to death. Furthermore, the patient 's request is not always durable and persistent as required. The patient 's medical condition does not always entail unbearable suffering with no prospect of improvement. Sometimes nurses, instead of doctors, perform euthanasia. In quite a few cases, physicians fail to consult an independent colleague and/or euthanasia cases are reported as natural deaths.49

PART TWO-B
The stand of the group
The Evangelium Vitae, an encyclical book written by Pope John Paul II, states a viewpoint on the attitude towards death. “When the prevailing tendency is to value life only to the extent that it brings pleasure and well-being, suffering seems like an unbearable setback, something from which one must be freed at all costs. Death is considered ‘senseless’ if it suddenly interrupts a life still open to a future of new and interesting experiences.”
The decision to request that one 's life should be ended by means of an active intervention by another person rests on a misconception that a human life can be not worth living. People have made that judgment about themselves and about others for centuries, many choosing to take their own life.
Moreover the group believes that we cannot decide when our life will end, any more than we decided when it began. Much less does someone else - a relative, a doctor, or a legislator - decide when our life will end. None of us is the master of our life and death but God alone, the Supreme Being who has created us.
Euthanasia is performed mostly in cases of those who are sick, suffering and dying. It is ‘mercy killing’ – painless killing to eliminate the suffering of someone who has incurable sickness. But the question that intervenes is: Is life valuable only when healthy? Is the suffering useless?
Regardless of how sick a person may be, he still is entitled to the right to life. We do not have the right to take that life away from him, but rather help him preserve his life even more.
In addition to, the group believes that we do not have the right to die. We don’t have the claim to death, but rather, death has the claim on us. Likewise, euthanasia is a grave violation to the fifth commandment of God: “Thou shall not kill.”
PART TWO-C
As members of the church, it is essential to state decisively that nothing and no one can in any way consent the killing of an innocent human being or a person who is dying. Moreover, no one is permitted to pose for this act of killing, either for himself or herself or for another person commended to his or her care, nor can he or she consent to it, either unequivocally or unreservedly. Nor can any authority lawfully recommend or allow such an action. In view of the fact that it is an issue that contravene to the divine law, an transgression in opposition to the dignity of the human person, a sin against life, and an attack on humanity. It may happen that, by reason of prolonged and barely tolerable pain, for deeply personal or other reasons, people may be led to believe that they can legitimately ask for death or obtain it for others. Although in these cases the guilt of the individual may be reduced or completely absent, nevertheless the error of judgment into which the conscience falls, perhaps in good faith, does not change the nature of this act of killing, which will always be in itself something to be rejected. The pleas of gravely ill people who sometimes ask for death are not to be understood as implying a true desire for euthanasia; in fact, it is almost always a case of an anguished plea for help and love. What a sick person needs, besides medical care, is love, the human and supernatural warmth with which the sick person can and ought to be surrounded by all those close to him or her, parents and children, doctors and nurses .

PART III
CONCLUSION
Every individual has the duty to lead his or her life in accordance with God 's plan.
No one can make an attempt on the life of an innocent person without opposing God 's love for that person, without violating a fundamental right or law and therefore without committing a crime of the utmost gravity.
Deliberately causing one 's own death, (euthanasia) is therefore equally as wrong as murder; such an action on the part of a person is to be thought as a rejection of God loving plan. Euthanasia, therefore, is a refusal of love for self, the denial of the natural instinct to live, a flight from the duties of justice and charity owed to one 's neighbor, to various communities or to the whole of society-although, as is generally recognized, at times there are psychological factors present that can diminish responsibility or even completely remove it.

Bibliography

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Seper, F. C. (1980, May 5). http://www.euthanasia.com/vatican.html. Retrieved 2013
Seper, F. C. (1980, May 5). Sacred Congregation for the Doctrine of the Faith. Retrieved from http://www.euthanasia.com/vatican.html
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RECOMMENDATION
As members of the church, it is essential to state decisively that nothing and no one can in any way consent the killing of an innocent human being or a person who is dying. Moreover, no one is permitted to pose for this act of killing, either for himself or herself or for another person commended to his or her care, nor can he or she consent to it, either unequivocally or unreservedly. Nor can any authority lawfully recommend or allow such an action. In view of the fact that it is an issue that contravene to the divine law, an transgression in opposition to the dignity of the human person, a sin against life, and an attack on humanity. It may happen that, by reason of prolonged and barely tolerable pain, for deeply personal or other reasons, people may be led to believe that they can legitimately ask for death or obtain it for others. Although in these cases the guilt of the individual may be reduced or completely absent, nevertheless the error of judgment into which the conscience falls, perhaps in good faith, does not change the nature of this act of killing, which will always be in itself something to be rejected. The pleas of gravely ill people who sometimes ask for death are not to be understood as implying a true desire for euthanasia; in fact, it is almost always a case of an anguished plea for help and love. What a sick person needs, besides medical care, is love, the human and supernatural warmth with which the sick person can and ought to be surrounded by all those close to him or her, parents and children, doctors and nurses .