EUTANASIA - Lucrare Licenta Engleza

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

„ EUTHANASIA – AN ETHIC AND MEDICAL PROBLEM”

SCIENTIFICAL GUIDE PROF.DR. P. BOISTEANU

CANDIDATE BITSANI AIKATERINI

IASI – 2002

EUTHANASIA – AN ETHIC AND MEDICAL PROBLEM

CONTENT

1. 2. 3. 4. 5. .

Death from gnoseological point of view Death – the traditional aspects Historical points of view towards death Euthanasia – the deontological settlement Death from juridical point of view !he "roclamation of the European #ouncil a$out vegetative life and %therapeutic o$stinac&' (. !he medical case – $oo) records and responsi$ilit& in euthanasia *. "ersonal findings a$out euthanasia +. ,egal and $ioethic conclusions a$out euthanasia 1-. .i$liograph&

CHAPTER I
DEATH FROM GNOSEOLOGICAL POINT OF VIEW

/f the meta$olism0 the self – reproduction0 the self – renewal0 the homeostasic self – adjustment0 the reactivit& and the development characteri1e life0 death represents the stoppage of these vital functions. ,ife doesn2t represent a proteins2 wa& of life0 as the clasic literature was sa&ing0 $ut a nucleic acids2 wa& of life. 3irst of all0 in nature0 death is impressive as a necessar& phenomenon. !he disappearance of persons corresponds to an evolutive necessit&0 in the purpose to ma)e wa& for other genetic com$inations0 which are more favora$le for the species0 rise their adaptive potential and provide the varia$ilit& and the progress. !herefore0 it is said that death represents the species2 triumph over the person. 4ther wa& sa&ing0 the species2 discrimination and specialisation were done with the price of death and the one life2s reason in nature is represented $& its evolution. 5o0 the eternal life would $e anti – evolutive. Death had an essential and useful role for the partialit& of the species2 evolution. Death was impressive as a natural selection form and as an adaptive phenomenon in the living matter2s evolution. 3rom this point of view0 death represents a revenge of the species towards the person. Death represents the change of matter from a state in another0 the loss of the self – renewal capacit& of meta$olism and the loss of all the functions and essential characteristics of the meta$olism depends on it. Death represents the end of a sad e6istence for man& situations0 which fre7uentl& appear in medicine. Have we the right to )ill in the purpose to put an end to pain8 !his pro$lem represents a su$ject for high philosophical theories0 a6iolog&0 human right and legal medicine0 religious doctrine and morals and it is multi9facetted. !his pro$lem ma)es to appear %the necessit& of connection $etween sciences0 the prolific colla$oration of the intelligence through which free ourselves from the pre9specialised

narrow9mindedness and protect ourselves from the judgements that a too much influenced $& the professional spirit'0 as Diderot said. !he term of %euthanasia' has three main senses: ;<%.onne morte donce et sans souffrance' =,ittre ′<. 3r. .acon coined the term and gave this sense. 3r. .acon was a great English philosopher and one of the modern philosophical thought2s founders. He proposed that ever& art and science must contri$ute to an accepta$le death. .< !he interruption of an unavailing and $urdensome life =in this sense0 euthanasia o$tained a sad and terri$le reputation $ecause it was injourious and ar$itraril& connected with the term of eugen&0 which represents the intentional murder of the ph&sical or mental invalides<. #< !he interruption of a misera$le life =euthanasia is preferd to aneu$iosis< – represents the onl& one which is directl& concerning the therapist. !he practice of euthanasia is much older than the word. Euthanasia was found at old or primitive civili1ations. 4ld >ermans used to )ill the chronic ill patients. /n .irmania0 an incura$le person was o$liged to hang himself. ;fter ;mundsen0 the Es)imo were practicing suicide when pain $ecame irresisti$le? in some areas of /ndia0 the incura$le patient was accompanied $& his famil& on the $order of the river >anges and thrown in the river. ,ife and death0 even if the& are opposite phenomena0 the& loo) li)e two connected sides in the natural evolution of the living su$stance0 in the living organism0 death coe6isting with life. !he lethal phenomena which occur in the living organism =the red cells are living for 12- da&s0 the epidermis for 3- da&s0 the white cells for 13 da&s and the mitochondria for * da&s0 so that in eight &ears the hole organism is new again< made us consider that death is prepared $& life other wa& sa&ing0 living means d&ing. ;fter the stopping of the vital functions0 after death0 the white cells are still moving0 the perspirator& glands are still active0 the muscle have contractions0 the spermato1oon are still a$le of fecundation0 facts

which confirm the words of Eminescu0 who said that life is the nest of death and death the seed of life. /f the evolution of the individual is limited in time0 life is infinite and this characteristic depends on the capacit& of reproduction of the D@;9chains. /n this $ranch0 identical to the reproduction or $irth0 death is considered li)e a natural0 normal phenomenon and onl& death is violent immature and motivated0 ma& seem li)e unnatural and unusual. 5uch a conclusion opens the wa& to a conscious fight for life0 $& spreading its $orders =for e6ample $& resuscitation< and $& a rational use of life. !he conscience of limitation of individual e6istence in time0 $orn the conscience of death and this gave rise to a new significance of life. ;nother discover& was the fact that if e6istence is a chance of nature0 ma& $e a cosmic accident0 this means that we must give a sense to this chance0 $eing o$liged to adopt a cultural attitude towards death0 with the purpose of ma)ing life more productive. !his discover& is an impulse to the rational use of life $ecause it was said that nature invented death in the purpose of ma)ing life more interesting. Death gives to the conscious human $eing the power of $ecoming an authentic person0 the sense of life consisting of perennialit& =$& creation0 $& truth and $eaut&< in the conscience of the others and successors. "h&sical0 individual and ontological death can not $e defeated e6cept $& creation. !he pretended and unavoida$le fear of death0 the conscience of death gave $irth to the wish of survival after death $& creation0 the wish to contri$ute even after death at the progress of humanit& $& the individual creation. !o create means0 in fact0 to live twice0 also $ecause of the reason that death can not $e defeated $ut $& creation0 $& values0 this ma)e death a cultural phenomenon and an individual destin&.

CHAPTER II DEATH – THE TRADITIONAL ASPECTS ;cross the ages0 the representation of death were stoical in ancient times0 o$scure in the Aiddle ;ges and scientific toda&0 the scientific representation of death =thanatholog&< showing the fact that death can not $e defeated0 e6cept the creation which represent an access to universalit&. !hat is wh& the Bomanian peoples sa& %he perpetrated from life' in the purpose of communicating with %his far9awa&' and $ecame in this wa& the $etter consciousness of men =>. ,iiceanu<. /f to $e means to give a sense to life0 ever&one has the possi$ilit& to overta)e the limits of himself0 $& the humanism the Bomanian peasant was showing $efore death when he was as)ing himself if he didn2t irritate some$od& during his life. /n actual civili1ation0 there are different opinions concerning death. Aan& cultural changes determined changes in the e6perience of death. "eople living in cities0 contrar& to the areas0 associate whit an important aversion towards death and rituals =cr&ing0 funerals<. 4n the other side0 in villages the traditions0 the dimensions of the famil& and other factors determine a more fle6i$le attitude towards death $ecause &oung people from villages have a more tight contact with death. !he dail& contact with the manifestations connected with death =funerals< is more fre7uent in small towns and villages then in cities0 and in this wa&0 children and teenagers from towns have more fre7uent occasions to learn and accept the realit& of death. !he death of ver& close relatives =grandparents0 uncles0 and aunts< represents an immediate e6perience in villages. /n cities usuall& death occur in hospitals and most of the preparations for $urial happen outside the house =$ecause of the small dimensions of the flat0 for e6ample<.

Death $ecame a distant phenomenon from all the dail& activities of the human $eing and especiall& in cities0 the feelings of repulse and fear of death are ver& strong. #oncerning the importance of religion towards death0 man& people and especiall& ph&sicians who consider religion as a ver& important side of their life0 have the tendenc& to ma)e all the necessar& efforts to defend life.

CHAPTER III HISTORICAL POINTS OF VIEW TOWARDS DEATH !he point of view towards death of the ph&sicians has to $e much clearer and firmer compared to the rest of the population. !he ph&sician has an important social responsi$ilit& a$out all the acts he writes =of his actions and non9actions< from a moral and juridical point of view0 $ecause the medical profession represent an activit& of the social structures0 which has the purpose to conserve and preserve health and0 in the same time0 life. %!he privilege of the medical structures is to practice medicine in the $enefit of humanit&0 to conserve and preserve the ph&sical and ps&chical state of health without difference0 to diminish the suffering of an& patient. !he respect towards human life is untoucha$le and it is not possi$le to practice therapeutic attitudes against the laws of humanit&' =!he Declaration from !o)&o0 1+(5<. !hese phrases represent the $ase of the medical ethics. Euthanasia0 as a part of its0 needs a special attention in the actual moments of evolution of the societ&. Euthanasia represents a group of medical voluntar& or involuntar& actions with an ethical and juridical support0 which happen in the $enefit of the patient0 in the purpose of reducing his suffering if0 after the actual )nowledge of science0 his death is certain and fast. !he first rule0 which leaded our #hristian e6istence0 was %@ot to )illC' .etween theor& and practice0 the difference was alwa&s important. ;n&wa&0 several forms of civili1ation0 in different forms $orrowed this rule. /f we turn $ac) to the roots of the medical profession and at the ;nte9#hristian era0 we ma& find this rule in !he Hippocratic 4ath: %/ will prescri$e regimen for the good of m& patients according to m& a$ilit& and m& judgement and

never do harm to an&one. !o please no one will / prescri$e a deadl& drug nor give advice which ma& cause his death'. 5ince it was written0 man& centuries passed from the first version of the oath. /n time0 man& changes occurred concerning the pro$lem of the euthanasia. 5tarting from the concept that ever& human $eing has the right to a dignified death0 some philosophers and scientists agreed with the euthanasia ="laton0 ;ristotle0 !oma D2;7uino0 Diderot0 Doltaire0 3r. .acon0 .. Bussell< or as)ed for the euthanasia =3reud was injected with morphine when he as)ed for it and with the agreement of his wife<0 $ut most of the scientists showed the fact that science is human when it defends life. !his is the reason wh& the deonthologic codes and the laws punish euthanasia even if the crime is pretending to $e done $& pit&. /n the last &ears0 all over the world the points of view concerning euthanasia were changed ver& much. /n the ancient times the fear of the infectious diseases determined scientists to justif& euthanasia even if the crime concerned the severel& ill patients =those suffering of plague were $urn together with their homes? in the cases of ra$ies the patients were suffocated $etween the pallets0 $& asph&6ia with mud or water<. /n the last &ears euthanasia $rought much su$tle forms0 death $eing hurried $& h&droc&anic acid0 air or insulin injection in the cases of leu)emia or incura$le tumors. 5ome scientists pretend a sort of voluntar& death control =when the patient is as)ing for it< or involuntar& death control =for serious malformations or irreversi$le coma<. 5ome studies showed the fact that -E of the population agree with passive euthanasia =to let nature decide< and onl& 3-E agree with the active euthanasia. /n Holland0 euthanasia is legal if the patient is informed a$out the serious prognosis of the disease0 his decision is free0 conscious0 and without suggestions and the ph&sician together with the patient have no other solution in front of death. /n other countries0 there were a lot of discussions concerning the invention of some machiner& to ma)e death easier =the Fevor)ian2s machine<0 which don2t ta)e into account the fact that death is a period of life and pretend helping the patients to die

and that is wh& a lot of trials appeared. 5tarting from the thalidomide trial from .elgium to the 4+ victims of injection using insulin at a hospital in Dienna in 1+*+0 justice proved to $e ver& %human' in the rest of the cases. Euthanasia was applied in an a$usive wa& leading to genocide in the totalitarian governments0 especiall& Hitler2s. !he >erman national9socialist ideolog& esta$lished since 1+23 euthanasia li)e a method which allows the %cleaning' of the %;rian' state from the so9called %empt& coverings' li)e mentall& ill patients or incura$le diseases0 idea which Hitler created the first time in his $oo) %Aein Fampf'. ;fter he defeated $& violent methods the other political parties and $efore starting the war against civili1ation0 Hitler voted a law concerning the active euthanasia0 using the term of %li$eration through death of the persons who are considered incura$le after a complete medical e6amination or if the& are not in the limits of the human $ehaviour' =!he law of euthanasia from 1+3+0 5eptem$er 1<. .asing an this law0 in onl& two &ears (--0--persons were )illed0 just $ecause the& were ill. Ghile three teams of ph&sicians of the >erman Ainistr& of /nternal ;ffairs =!he "hilanthropic ;ssociation of #are0 !he #orporation of !ransport of the "atients and !he #ollective 5ervice of Gor)< were )illing thousands of people0 other teams were loo)ing for the diagnosis to write in the death certificates0 which had to $e given to the families. /n a short time0 the whole >erman& was suffering $ecause the war and the humiliations were replaced $& anger. !he priests in the churches were as)ing for the last signs of pit& and humanism of the >erman politicians. !he priest of Aunster0 Aonseniour Don >alen and the priest of Aunich0 #ardinal 3ualcha$er were arrested in concentration camps. !he surprise was general0 when the first anti9na1i dissident group appeared0 the %>erman Eagle' had to accept the li$eration of the priests0 and the program of euthanasia was stopped. /t seems that also after the war0 in man& countries were cases when %li$eration through death' was used especiall& of the

mentall& ill patients =or ma&$e of the dissidentsC< $ut until now we don2t have clear information. 3rom all these data0 it is o$vious that different political structures had different points of view concerning euthanasia and this was more or less accepted0 leading sometimes to its total interdiction ="linius suggested to use euthanasia for urinar& lithiasis or neuralgia<.

CHAPTER IV
EUTHANASIA – THE DEONTHOLOGICAL SETTLEMENT

/n the purpose of classification of the forms of euthanasia we ma& divide it in voluntar& and non9voluntar&0 if we ta)e into account the consent of the patient and his capacit& of ps&chical integration in the social life. 3rom medical point of view0 euthanasia ma& $e active or passive. !he definition of euthanasia involves an important active compound from $oth sides the ph&sician and the patient. !he mentall& normal patient0 with the discernment unaffected $& the disease0 as)s the ph&sician to cut his suffering )nowing e6actl& that there is no therapeutic solution for his disease. !he ph&sician0 who )nows ver& well that the fight against death is useless0 agrees to determine a fast death0 without pain0 for the patient. !he passive euthanasia as)s for the consent of the patient0 while the ph&sician stops the specific therap&0 using onl& the simple medical care. /f the consent of the patient is missing0 the euthanasia is considered involuntar&. !here are cases =new$orn children with malformations or status of coma< when the famil&0 the ph&sician accepting the solution of the selective therap&0 gives the consent for passive euthanasia. !here are four t&pes of euthanasia: 1. Doluntar& active euthanasia – ma& $e similar with suicide. !he patient commits suicide0 which is considered euthanasia $ecause this solution is chosen $& the patient to stop his suffering. !he patient ma& $e assisted $& the ph&sician or other person0 who gives him the lethal drug0 the weapon0 etc. 2. Doluntar& passive euthanasia – ta)es place when a patient0 even if he receives a therap& that ma& save his life0 he refuses to

continue the therap&0 )nowing ver& well that his action ma& cause his death. 3./nvoluntar& active euthanasia – the patient doesn2t ta)e part to the decision concerning his death in the critical moment and nothing is done in an active wa& to hasten his death. He ma& $e or not conscious. ; certain person =the ph&sician0 a mem$er of the famil&0 a friend0 or some$od& else< decides the patient2s death to save him from a painful death. ;n overdose0 suffocation0 or an& other method ma& produce death. 4./nvoluntar& passive euthanasia – this case ma& appear when the ph&sician decides to stop the therap& of the patient0 )nowing that the treatment won2t prolong his life and in a certain moment would determine his death. 5o0 the ph&sician has the possi$ilit& to stop the life of an incura$le or terminal patient0 with or without his consent0 $& action or inaction. Ge ma& rise two important 7uestions: 9 /s death preferred to life0 over a certain point8 9 Gho decides where this point is8 /s there an&$od& who ma& sa& that $etween )illing someone or let some$od& die0 there is no difference8C Ge consider that the difference is ver& important $ecause action or inaction0 without ta)ing into account the result0 appears from different moral $asis. !he $ase of the difference is represented $& the fact that starting on the wa& of action0 the ph&sician has to have a ver& severe moral self9control0 of the wa& he chooses. !he ph&sician decides a$out the moment and method the patient would die. !he chosen drug would change the reason of death0 which would $e completel& different from death after a disease. Aore than this0 it is often discussed the possi$ilit& of which death is an accident of life and in this wa&0 euthanasia $ecomes a human action0 more or less legal. !he discussion concerning euthanasia started from the well9 )nown report of !he /nstitute of 5ocial ;ssistance from Botterdam0 which said that 5-E of the patients who die in Holland

in one &ear suffer medical assistance and 5E of them as)ed the ph&sician to help them to die0 while 4-- patients committed suicide $eing assisted $& the famil& or ph&sician. 5tarting from this stud&0 we concluded that active voluntar& euthanasia is not a legal e6perience in an& part of the world. !he Bemmelic) #ommission from Holland studied active euthanasia and found that interruption of life is as)ed in most of the cases $& the incura$le patients0 $ut most of the medical staff was confident to its sacred role – to help life until its natural limits. ;n& wa&0 a small num$er of ph&sicians have an active role in stopping the life of their patients. !he passive euthanasia and the selective non9therap& represent fre7uent medical actions accepted0 especiall& from financial reasons0 $& man& hospitals in the world. !he passive euthanasia and the selective non9therap& have the acceptance of the medical staff0 $ut not in all the cases. @ot to cure a minor disease of a &oung patient is not the same thing with the progressive diminution of the therap& of a new$orn child with important malformations0 or of an incura$le carcinoma that will die an&wa& in a ver& short time. Ge ma& discuss with this occasion a$out some aspects concerning the definition of the dail& therap& and of the special therap&. /t ma& $e accepted for the ph&sician not to use special therap& for prolonging life. !he reason of this idea is determined $& the economical e6penses of the medical care and especiall& of the distri$ution of the limited financial resources of a hospital. .ut all the financial pro$lems have to $e secondar& to the dignit& and the $enefit of the patient. Even if the medical sciences progressed a lot0 a medical therap& is %productive' depending on the patient and the disease. !his is the place of difference $etween a dail& therap& and a special one. /f the difference $etween the dail& and the special therap& is o$vious0 its application in the juridical practice is ver& difficult0 especiall& when we ta)e into account the right of the patient to a dignified death and to the informed consent0 $ut also when we don2t have his consent or state of consciousness. !he right of ever& patient to dispose of his life and his own $od&

represents a $asic factor0 even if we spea) a$out a$ortion0 of the consent to therap&0 or euthanasia0 as dail& or special therap&. !here are some cases when this $asic right ma& $e violated. /t is possi$le to continue a useless therap&0 even if the patient wishes to die. !he church ma& sa& that suicide is a for$idden act. Even the refuse of therap& is no more accepted in the medical world0 ta)ing into account the fact that a patient will never $e $etter informed than his ph&sician concerning the present therapeutic solution. Aore difficult is the evaluation of the incura$le state of the patient. !he prognosis of death depends first of all on the amount of medical care0 which the societ& is a$le to give to the patient. /n a sociological stud&0 +5E of the incura$le patients who were as)ed0 said that the& wish to $e resuscitated in the case the& reach the state of coma0 showing an important wish of life and a special possi$ilit& of adaptation. /f until now the pro$lem of euthanasia was studied compared with the capacit& of the patient to accept his death0 we also have to ta)e into account the case of the unconscious patient who is not a$le to e6press his wish? he is not a$le to spea) and he can not e6press his agreement concerning the therap&0 all the decisions $eing ta)en $& the others0 %in the patient2s interest'. !he onl& chance to evaluate the integration of these patients in the societ& is the evaluation of the level of $rain destruction and then the decision of selective therap& or non9therap& depending on the level of destruction found. Even discussed in the end0 the euthanasia of the new$orn children rises a lot of pro$lems. !he new$orn child with malformations is e6posed to passive euthanasia or non9treatment more than the adult. His consent concerning the therap& is a$sent and is e6posed to the ph&sician $& the wa& of the parents. /f the mother ma& decide a$out her $od& =as in case of a$ortion<0 from the moment the child was $orn0 $oth parents have to accept the interruption of the therap&. /f one of them $ecomes compulsor&0 no difference could $e found in this case $etween contraception and murder of the

new$orn child. 4f course0 it is true that the new$orn child is not a$le to e6press his personalit&0 $ut also the ph&sician can not )ill. Ge ma& accept that to let a child die ma& $e in his own interest in a certain moment. !he selective non9therap& of the children with severe malformations is not in disagreement with the o$ligation of the ph&sician to support life from conception to death. !o ta)e the patient2s life in an active wa& means to murder him and in this case0 age has no importance. #amp$ell and Dovnnie showed in their wor) called %Aodern "ediatric "ractice' that it is a great difference $etween not using an incu$ator to )eep alive a -- grams new$orn child or to ma)e a )illing injection0 even if the result is similar. Even from ethical and medical point of view0 we ma& accept that a human ph&sician0 who has the acceptance of $oth parents who are convinced a$out the $ad prognosis of their child0 ma& stop his active therap& determining the child2s death or he ma& use common drugs to the same result. !he 7uestion of the ph&sician consists in the definition of medicine0 which is a practice in the $enefit of life0 $ut to )eep alive a child who won2t $e a$le to find his place in the societ&0 $eing convicted to pain and suffering0 represents an e6ception from the purposes of medicine. !r&ing to a$stract the criteria for and against euthanasia0 we found some criteria positive to euthanasia: 9 !he fundamental right of a person to die without suffering as an e6pression of the a$solute respect concerning this right and the human $eing. Euthanasia offers to the patient a possi$ilit& of control towards his death. !his argument would represent the e6pression of the patient2s right to refuse life after he is no more independent0 the feeling of helpless and even fear of death. !he recent trials from #anada =the Ganc& and #o$eil cases< in which the ph&sicians refused to stop resuscitation even if the patients were conscious and as)ed for this decision =the decision of justice was to stop resuscitation<0 let the feeling that for the societ& life doesn2t represent onl& a lucid $rain0 $ut life needs a capa$le area0

that not onl& life is important $ut its 7ualit&. Hudges considered that the interruption of therap& doesn2t mean euthanasia. 9 !he fear of the communit& of some diseases =for e6ample the contagious diseases<0 especiall& in the past0 which determined man& d&ing men to $ecome victims of some $ar$arian euthanasia procedures0 li)e $urning in their houses0 asph&6ia0 etc. 9 !he need to control voluntar& death at ps&chiatric ill patients0 with no6ious $ehaviour0 when the patient is as)ing for it =voluntar& euthanasia< or have dictatorial laws =involuntar& euthanasia<. /n some dictatorial countries the old patients and the disa$led persons were considered under9humans and as a conse7uence0 victims of euthanasia. 9 ; sort of answer to the demand of some parents with children with serious diseases =li)e the 21 trisom&0 congenital malformations0 etc< who identif& their moral suffering with the ph&sical suffering of their children. ;rguments against euthanasia: 9 ,ife is a sacred creation and can not $e affected or destro&ed $& humans0 even if it is just at the $eginning. 9 !he legali1ation of euthanasia could open the gates to a$uses0 $eing well )nown the crimes with successional motivation or the genocide of ;dolph Hitler. 9 !he toda& considered incura$le diseases0 ma& $ecome cura$le $ecause of the progress of science. /t is well )nown the fact that "linius was recommending euthanasia for urinar& $ladder calculus or trigeminal neuralgia or in the Aiddle ;ge in ra$ies or plague and toda& such diseases ma& $e cured. 9 Euthanasia has involuntar& ris)s such the so9called cripthanasia =secret euthanasia<0 the encourage of the processes of euthanasia0 of the euthanasia $& delegation =offered to some profanes<0 of the discriminating euthanasia0 ta)ing into account other criteria than the incura$le disease. 9 .ut the most serious reason against euthanasia are those which violate the fundamental laws of medicine0 li)e the deviation of the medical assistance of d&ing patient0 the alteration of the

social role of healer of the ph&sician =from which comes the interdiction of the ph&sician to ta)e part to torture actions or punishment with death< and not in the end0 $& stri)ing the notion of the ph&sician $& the creation of a senseless conflict $etween the ph&sician2s right to cure and %the right to )ill'. /n this sense0 most of the medical professional associations consider that euthanasia ma& have a dangerous evolution towards the vulnera$le patients0 representing a danger for the moral integrit& of the medical profession. 9 !he ethical and juridical legali1ation of euthanasia would $e against the message of the medical profession0 whose purpose is to protect life0 indifferentl& of the forms in which the patient comes to the ph&sician. !he dut& of the ph&sician is to assist death and not to neglect or help death. 5uch $ehaviour has to start from the truth that the world is not our usufruct and an&one ma& decide when we have to come or leave the world. Death represents the onl& realit& which humans0 and ph&sicians0 can not vulgari1e0 a good death $eing a form of triumph of life. 9 Aedicine and justice are not perfect even if the progress was significant. !he error of diagnosis and of prognosis is real and it alters the 7ualit& of the medical act0 $ut which is human and has to $e ta)ing into account. /f this )ind of errors ma& $e accepted in universities where the e6perience of the ph&sicians is com$ined with the endowment0 what should we sa& a$out the diagnosis and prognosis in the villages or in isolated places0 where there is no technical endowment8C 5o0 we ma& conclude that justice ma& $e eluded $& the ph&sician and the he ma& dispose of the humans2 life0 who are waiting from him onl& hope and health0 $ased onl& on the principles of ethics0 which ma& $e cheater and without e6plaining to an&one8C 9 /f the patient in a transitor& state gives his consent for euthanasia =even if it is active or passive< and after some time0 $& a special chance and an efficient therap& ma& come $ac) to life0 what should happen8 Aa&$e the patient will regret his consent and

will consider the %profited' hours of life as the most $eautiful from all his life. /n conclusion0 we ma& sa& that the role of the ph&sician is to respect life0 even if it is fragile and to respect death li)e a warrant& of the respect for life. !he ph&sician has to cultivate the idea that over ever&thing humans have to survive to $e a$le to promote the 7ualit& of man. !he ph&sician has to help the patient to have a %human agon&'0 ma)ing him understand the fact that humans live onl& once and life has alwa&s a sense. !his human message of life0 which $rings hope $& itself0 has to $e correlated with the dignit& of man0 who has to $e alwa&s prepared to use his suffering0 to accept death in an& conditions0 with pride and dignit&. Ghen death can not $e defeated0 the ph&sician has to pacif& the soul to help a dignified death. !he medical morals is against the legali1ation of euthanasia0 justified $& the possi$le a$uses when euthanasia ma& turn from pit& to crime =!he #ourt from @urem$erg declared the na1i euthanasia as a crime of war<. 4n another side0 the legali1ation of euthanasia would affect the confidence towards the ph&sician who has the role to help the patient to %pass 7uic)l& over his death'. !he trials in this field tried to avoid the feeling of the pu$lic opinion0 that the ph&sician has the right to decide a$out life and death and to avoid the dissimulated murders motivated $& the eradication of suffering. !he active and passive euthanasia is against all the principles of medical ethics. Aore than this0 the legali1ation of euthanasia would determine a stagnation of the art to cure0 what can not $e cured toda& having the chance to $e cured tomorrow. 4n another hand0 the patient could lie0 $& dissimulation of severe suffering. /n this wa&0 it could appear the feeling that the ph&sician has complete rights concerning life and death0 which would $e against his human mission. ;ll these arguments ma)e from the euthanasia an unaccepta$le ethical and juridical act.

3rom the point of view of the patients0 Dansell "attson made a stud& to see their points of view concerning the e6perience of death. He studied a group of 1-- old people0 35 women and 5 men0 with the overage of (2 &ears old. 3ift& percents of them had medium studies and the rest had superior studies. 3- were married0 35 were widower0 14 were never married and 21 were divorced. ;ll the su$jects were in pension. 3rom religious point of view0 5+ were "rotestants0 1* were #atholics0 and 2* had other religions or no religion. !he criteria used to choose them were that the& were coherent enough to $e a$le to answer to a set of 7uestions and0 of course0 the& accepted to answer the following 7uestions: 1.How do &ou feel toda&8 2.Ghat age would &ou li)e to have8 3./f &ou could do ever&thing &ou want0 where would &ou li)e to live8 4.Ghich are the most interesting and pleasant from all &our activities8 5.Do &ou wish to $e accompanied $& &our friends0 neigh$ours0 and relatives more than now or &ou wish to have more time for &ourselves8 .How does the future loo) for &ou8 (.Do &ou thin) at &ourself as $eing old8 /f &es0 when did &ou start to thin) this wa&8 *./f &ou would $e severel& ill0 desperate and &ou have a lot of e6penses for drugs0 would &ou agree that ph&sicians won2t ma)e an&thing to )eep &ou alive8 +./f &ou would $e severel& ill0 would &ou agree that ph&sicians would do something to shorten &our life8 1-./s religion important for &ou8 3or the 7uestions no. 20 30 40 and 5 the positive answers value one point. !he first 7uestion was used to o$serve the feelings of illness or health. !he answer no. 20 30 40 and 5 showed a %rating of contentment' evaluated from - to 1. !he 7uestion no. ( was used to show the wa& ever& old person feels his age and showed that some old persons feel li)e $eing half9 invalid. !he 7uestions no.*

and + had to $e written in a ver& simple manner to $e understood $& the su$jects0 for who words li)e %euthanasia'0 %favored life'0 or %favored death' are strange. !he last 7uestion was used to see the importance of the religion in his mind0 in connection with the acceptance of death0 when this doesn2t represent the wish of >od. 2I3 of the patients was feeling ver& well at the moment of the testing. Aore than 1I3 had ma6imal points for the %rating of contentment' =the& wish to have their present age0 the& wish to live where the& are living0 the& find all the life2s aspects as interesting0 the& meet enough friends and relatives<. 2I3 had low rates of contentment. 3or most of the old persons0 the& rejected the idea of $eing old. !he idea of severe disease and great e6penses for drugs showed the fact that over 5-E of the persons Jwished to live at an& priceJ. 25E of them said %let me die or help me to die'. Der& important seems to $e the fact those persons decided to live0 and all of them have strong religious feelings. /f the& were influenced $& religious rules against death with the e6ception of the >od2s wish0 the& were agree with the tempori1ing of death $& human action. /n the last time0 euthanasia was associated with another medical case called %assisted suicide'0 which are studied together now. Hac) Fevor)ian0 an active partisan of the %sweet death'0 invented the %suicide machine'0 until toda& 15 patients $eing %treated' with it. Even if in the 5tate of Aichigan a law was adopted0 which for$id assisted suicide0 Fevor)ian was not convicted until three &ears ago0 the assisted suicide considering that has no connection with murder. %!o assist a suicide doesn2t mean to )ill'0 Fevor)ian was sa&ing. He was selecting the patients using ten criteria0 such as discussions with the famil&0 video recordings0 discussions with the ph&sician2s famil&0 ps&chiatric e6amination to esta$lish if the patients is mentall& sane0 the lac) of famil& pro$lems confirmed $& the social institutions the a$sence of other interests0 the person2s consent0 etc.

Hanet ;d)ins0 suffering of ;l1heimer0 was the first person who suffered this procedure =perfusion with F#l and $ar$iturates<. ;t the $eginning0 the machine didn2t function well and that is wh& he was o$liged to find a more simple method0 using car$on mono6ide. Fevor)ian is convinced that *5E of the inha$itants of the state of Aichigan agree with him0 and the adopted law which convict assisted suicide with four &ears of prison is immoral0 $ecause the conscience of ever&one has to $e over the law and societ& is not allowed to decide in the person2s place0 when death is concerning just the person. ,aw is not allowed to control the medical practice and that is wh& such a law is h&pocrite0 as Fevor)ian said. !he opposition to assisted suicide represents in fact a conspirac& of the church and politics against humanit&. ;s usuall&0 in the practice of euthanasia0 the ph&sician2s help and his %therap&' is a rule0 man& authors spea) a$out medicathanasia which rise important pro$lems of conscience and ethical9professional attitude of the ph&sician. ; referendum made in Gashington0 in the purpose of advertisement of the assisted suicide $& the ph&sicians0 those who voted the referendum rejected this idea. !he law&ers0 alwa&s on $oth sides of the pro$lem0 used to $ring criteria of ethics to sustain their arguments. !hose who agree with the medical assisted suicide =A;5< consider that the right to self9determination is fundamental0 the decision to stop some$od&2s life if he wishes so0 has to $e respected $& the ph&sician0 who has to $e free to satisf& the patient2s wish0 even if the conse7uence is death. /n this case0 the ph&sician has to ma)e death as human as possi$le. !he law&ers consider in this case that the ph&sicians were alwa&s allowed to stop the therap& of the patients in terminal states =and this thing is generall& accepted< $ecause the patients have the right to refuse the therap& to preserve life. !he decision to stop the therap& of a terminal state patient to help the unavoida$le death is possi$le0 $eing rejected onl& $& someone who doesn2t se an important difference of intentions. 4n

the other side0 scientists consider that it is an important difference $etween the right to refuse an e6pensive and useless therap& in the case when the pathological process is unavoida$le and %the right to die' represents just a ti)e in the assistance of death. !he law&ers who are against this idea sa& that while it is accepta$le to cure a patient in a terminal state in a wa& in which death would result =to give to a patient with carcinoma enough morphine to produce a respirator& failure<0 the purpose to interrupt life is against the principles of medicine. 5ome$od& who cures persons doesn2t have to $e mi6ed up with some$od& who helps people to die. 4thers are afraid that once approved0 A;5 will have a fast evolution to an important num$er of cases and the societ& won2t $e a$le to convict it. "eople who agree with A;5 sa& that it has to $e limited to the conscious patients who as) voluntar& for death and who have an unendura$le suffering0 without possi$ilities of therap&. /n this case0 the opinion of a ph&sician is necessar& =especiall& an un)nown ph&sician< and the assistance of an un)nown0 independent witness. 4ne of the limits of the medical sciences is the classification of the diseases0 which still represent a proof of empiricism characteristics so that a prognosis is possi$le and a therap& ma& $e used. !he diagnosis and the prognosis are much more descriptive than prescriptive0 other wa& sa&ing. /t doesn2t matter how careful some predictions are made0 li)e the evolution of the disease0 the lac) of answer to therap&0 or the impossi$ilit& to improve the patient2s state0 ma& prove to $e wrong. /n some cases0 the result ma& $e worse than it was predicted0 $ut in other cases it ma& $e $etter. /nterrupting the evolution of the disease0 A;5 ma& improve the capacit& of prognosis in a frightening wa&0 helping the ph&sician to ma)e a ver& good prognosis of the result. %!he moment and the cause of death will $e )nown precisel&'. !his fact could prevent the ph&sicians to determine in

which cases the predictions were wrong. .ut this couldn2t prevent the cases when some patients would die =if A;5 would $e a common practice<0 $ut if the& were under medical care0 the& could recover. ;s long as medicine remains a science empiricall& practiced $& the human $eing0 some of the cases would $e for sure wrong interpreted0 not onl& $ecause of the certain level of the human )nowledge and which can not $e perfect0 $ut also $& a mista)e of reasoning or $& a simple human error of an& )ind. !his means0 in the case of A;5 that if the method would $e accepted0 some of the patients would $e assisted for death even if the& were not ade7uate for this0 while others would refuse this method of freedom. !here is an important reason to repulse A;5 $& the fact that the ph&sician ma& commit mista)es. /f this reason would $e generall& applied0 the ph&sicians couldn2t action $ecause the& could produce a harm. Ksing other procedures e6cept A;50 opposite results even the patient2s death could $e possi$le. .ecause the purpose in A;5 is completel& different from the other medical procedures0 an& error0 as small as possi$le0 is not accepta$le =$ecause a patient whose state of health couldn2t lead to death could $e )illed< the onl& possi$le solution is to for$id A;5. ;s for an& other medical procedure0 also for A;50 the $enefits of the procedure have to $e revealed compared with the harm it ma& produce. !he amplitude and irreversi$ilit& of such a decision also contri$ute to the difficult& of this procedure. Ge ma& identif& sources of error in the declarations of the patients prepared for A;5. 4n the other side0 the patient ma& $e wrong evaluated as $eing not a$le to decide A;50 ma& $e considered inaccurate $ecause he is not ill enough for A;50 or he ma& receive other therapies0 which don2t cure or improve the state of health. .& refusing A;50 the ph&sicians ma& ma)e a mista)e a$out the patient2s state of health and the patient is convicted to suffer for an un)nown period of time0 until the disease or other diseases ma& interrupt life0 or when the patient dies $ecause of other reasons.

4n the other side0 the patient ma& $e not correctl& evaluated0 as $eing justified to as) for A;5 as $eing wrong evaluated with an incura$le disease. !he errors of determination the patient2s need to $enefit from A;5 would $e harm not onl& for himself0 $& the decision of a fatal procedure0 which he could avoid0 $ut undermine the confidence of the societ& in the ph&sician2s capacit& to evaluate and appreciate the patient2s state. !he ph&sician who as)ed to assist a suicide has first of all to verif& the credi$ilit& of patient2s declarations concerning his suffering. !his ma& $e difficult to evaluate $ecause individuals are different concerning their resistance to pain and what ma& $e tolera$le for someone ma& $e intolera$le for someone else. 4f course0 the most important factor is not the patient2s suffering state $ut the ph&sician2s possi$ilit& to ma)e a correct evaluation. Knfortunatel&0 the ph&sicians have difficulties in the evaluation of the patient2s pain level0 even when the cause is of ph&sical nature. /t is o$vious that suffering0 $eing produced $& the $asic disease0 an& therap& won2t $e a$le to stop the pain0 $ecause the cause of the pain is the conse7uence of the evolution of disease and not of the secondar& complications0 which ma& $e cured. !his last idea has different aspects. Ghile a great num$er of secondar& complications ma& appear in the evolution of a terminal state0 a severe ps&chical depression ma& complicate a treata$le disease and ma& rise the wish to die. !his ps&chical depression ma& determine disorders of the appetite and sleep0 diminution of the energ&0 concentration disorders0 disorders in the dail& activities0 $ut also other ph&sical diseases ma& have the same s&mptoms. !he treatment of such depression ma& $e efficient and even in the cases that are resistant to therap&0 the patient ma& recover and the wish to die disappears. Ghat at the $eginning seems to $e a rational decision for A;50 after the recover& of the ps&chiatric disease0 it ma& appear li)e an illogical decision produced $& a mind affected $& depression. .ut not ever& patient who as)s for death has to $e considered ps&chicall& depressed. !he ph&sician

has to decide if the wish to die was $ased on the patient2s wish0 decision o$tained in a lucid wa& and not influenced $& momentar& states or other famil&2s interests0 of the others and even of the ph&sician. /n the end0 the ph&sician is the last who evaluates even if the nature of the pain is su$jective0 if the decision for A;5 has to $e ta)en. !he responsi$ilit& for the therapeutic decisions $elong to the ph&sician0 A;5 $eing considered in the sense of self9 determination of the ph&sician0 $eing implicated in the decision and not $ecoming a passive instrument who satisfies the patient2s wishes. !he incertitude of the correct clinical evaluation of the prognosis0 of the patient2s discernment0 associated with the ris) of confusion with the patient2s wishes and reasons0 of his famil& and of the ph&sician ma)es the decision concerning A;5 to $e difficult0 with a ver& high potential of error to justif& such a procedure toda& or in the ne6t future.

CHAPTER V DEATH FROM JURIDICAL POINT OF VIEW #oncerning euthanasia we are situated $etween the moral convictions concerning the sanctit& of life and the impossi$ilit& of the human $eing to interfere in the >od2s wish and the development of the actual science0 which gives us the power to choose the moment of death. !he international laws sanction the right to live of ever& human $eing. !o refuse this right0 regardless of the state of ph&sical and ps&chical health and his age is e7uivalent with murder. !here are several proposals in different countries to accept %the murder from pit&'. !he general opinion is that the adult population ma& $enefit of medical care in the previous moments of death =(5E from the adult population as)ed in >reat .ritain and K5; gave a positive answer<. ;n&wa&0 there is the opinion that the help for death has to $e passive0 without ta)ing into account the imperative wish of the suffering patient. !he relation $etween ph&sician and patient doesn2t have to $e eclipsed $& the possi$ilit& that the ph&sician would change the white overall of the healer with the $utcher2s $lac) hood. /n Europe0 there are two opinion concerning euthanasia: in the @orth it tends to $e legali1ed and in the 5outh the great principles of life are still active. ;fter twent& &ears of discussion0 Holland gives an honora$le solution for the ph&sicians $& legali1ation of euthanasia in the cases of conscious and repeated re7uirement of the patient and the acceptance of a famil& doctor. ;n irreversi$le ph&sical or ps&chical suffering represents another condition. !he re7uirement has to come from a person who is conscious0 free of influence in

the conditions of the lac) of other methods of therap& or other t&pes of treatment and with the consent of ph&sician who has to e6ecute euthanasia0 other ph&sicians and priests. !a)ing into account the fact that such a decision can never $e o$jective and free $ecause of the terminal depressive state0 the discussions concerning the validit& of this law didn2t finish &et. Even in the places where euthanasia is not legali1ed and some ph&sicians refused to practice it0 some #ourts gave a positive verdict and o$liged the ph&sicians to e6ecute the verdict if the patient2s re7uirement accomplished the two essential conditions: incura$ilit& and conscious decision. !he usual method is to induce coma with the help of $ar$iturates followed $& a lethal injection. /n other countries0 the ph&sician who helped the patient to commit suicide is o$liged to give the documentation to a forensic pathologist =written report which includes 23 pro$lems<0 so that from 5+- cases in 1++10 the reported cases of euthanasia reached to 13-- in 1++2 =Holland<. /n a climate of mutual general tolerance the law succeed onl& to esta$lish the transparence concerning euthanasia. !he associations for the right to die in freedom =;DAD< plead also for the respect of the patient2s wish. /n >erman&0 the word %euthanasia' used $& the na1i had the sense of %help to die'0 especiall& in the cases of refuse of the victim =%therapeutic o$stinac&'<. Denmar) legali1ed the %passive euthanasia'. /n England0 after the #o6 and Hove affair0 the discussions concerning euthanasia had a new start and in the K5; the federal law called %5elf "atient Determination ;ct' respect the patient2s wish. /n the ,atin countries0 euthanasia is practiced even if it is not recogni1ed. /n .elgium it has e6tenuating circumstances and in /tal& it is for$idden $& the 4rder of the "h&sicians. /n 5pain it is e7uivalent with murder.

!he decision of Holland created an important $rea) in the European .ioethics. ;s a first result0 !he European #onvention of .ioethics was postponed. #lassicall&0 euthanasia0 li)e an as)ed murder0 motivated $& grave and incura$le suffering0 is not considered from a juridical point of view as committed in a state of necessit&. !he feeling that human li)e can not $e stopped in such circumstances was created and some delin7uents could prevail of this justification in such circumstances. Euthanasia is considered a murder with e6tenuating circumstances. /t is difficult to anticipate the evolution of the opinions of the European Hurisprudence. "erhaps0 in several decades this form of death will $e accepted in well9defined conditions0 this at last would e6clude an& form of a$use. Ge have to mention the fact that active euthanasia will $e depenali1ed from humanitarian and not economical reasons. Der& strong tendencies of opinion manifested in the K5; in the last &ears. #oncerning euthanasia we ma& distinguish two t&pes of patients: conscious patients who have a sufficient capacit& of understanding to reali1e what is there present state of health0 the nature and the effects of the proposed therap& and the ris)s0 which ma& follow the therap& or the interruption of it =5choendorff 5ociet& of @ew Lor) Hospital $elieves that %a conscious adult person0 generall&0 has the right to stop or continue his therap&'< and unconscious patients who ma& $e divided in patients who showed their wishes concerning death or maintaining life $efore the& $ecome unconscious and those patients who didn2t show their wishes. /n the case of conscious patients0 !he 5upreme #ourt of @ew Herse& decided: 1.!he person2s right to control his own $od& is a $asic social concept recogni1ed $& the #onstitution. 2.!he right to ta)e certain decisions concerning some$od&2s $od& is protected $& the #onstitution.

3.!he conscious patient2s right to stop the therap& of maintaining life is not a$solute. !here are four fields in which the state ma& limit the competent person2s right to refuse medical therap&: 1.!he preservation of life 9 there are a great num$er of mem$ers of %!he Hehovah Gitnesses' who refuse transfusions. ;lso in the cases of children0 unconscious patients and other persons who are not capa$le to ta)e a decision0 the state ma& o$lige the application of therap&. .ut this doesn2t mean that a conscious patient is not a$le to stop his therap&. 2.!he prevention of suicide – the interruption of the medical therap& doesn2t represent the same thing with the attempt to commit suicide. !he refusal of the medical therap& means that the disease will follow its natural course. Death will $e determined $& a disease and not $& the result of self9aggression. !he difference is that $etween self9destruction and self9determination. 3.!he protection of the innocent third person – man& of the cases of refuse the therap& involve persons who are parents of minor children with incura$le diseases and who depend of their decisions. 4.!he integrit& of medical ethics – some courts reali1ed that if the& give usual decisions of interruption of the therap& for the patients who ma& $e cured0 ma& lead to the demorali1ation of the medical profession. Ghen the patient is not in a terminal state and the therap& ma& $e hopeful for the saving his life0 some states ma& use their authorit& to repeal the patient2s decision. Ghen the therap& is long and death inevita$le0 the courts are more tolerant in accepting the refuse of therap&. ;n& wa&0 even in the cases in which the therap& ma& save the patient2s life0 the therap& ma& $e e6tremel& invasive =for e6ample li)e renal dial&sis<0 so that the court ma& not impose its authorit&. ; conscious patient has the right to refuse an& medical therap& including artificial feeding and cardiac9respirator& advisement. /n this case0 a clear e6ample is that of Fathleene 3arrell0 a 3( &ears old woman suffering of lateral amiotrophic

sclerosis =5,;< and connected to artificial respiration. Her hus$and as)ed !he #ourt of @ew Herse& to name a medical guardian for his wife mentioning that he gives the acceptance to disconnect the artificial respiration of his wife. !he #ourt was convinced that the patient was conscious and she wished to stop the therap& )nowing that0 an& wa&0 this will lead to death. !he words used $& the judge who gave the decision were identicall& with those meaning to stop the respirator& advisement of the patient. ;n& wa&0 it is interesting to anal&1e the words used $& the court: %with the advice of the therapist'. !his meant that if the therapist would change his opinion $efore stopping the advisement0 the guardian wouldn2t have an&more the protection of the court and the ph&sician wouldn2t have $een responsi$le of murder in the case of stopping the advisement. !he final anal&1e of this case leaded to the conclusion that %death which will follow is not a murder $ut0 in fact0 meaning the e6piration of the natural conditions of e6istence. /n the second time0 even if this act will $e considered a murder0 it will not $e illegal'. !he #ourt showed that %it is a clear and real distinction $etween ta)ing some$od&2s life in a illegal wa& and the stopping of the artificial material supports of sustaining life0 as a method of self9 determination'. !he #ourt clearl& decided that the application of this constitutional right is protected from the judgement for murder. 5o0 the patient2s right to refuse medical therap& even with the ris) to aggravate his disease or the ris) of death is protected $& the #onstitution and the federal law. /f the patient is mentall& normal and as)s for the interruption of the medical therap& of sustaining life0 this is a procedure that has to $e applied. !he first step is to evaluate the patient2s mental state. /f this is normal0 the ne6t step is to confirm of the patient is correctl& informed a$out the prognosis0 a$out other possi$le therapies and a$out the ris) of interruption of therap&. ;ll these conditions have to $e $ased in the same time on the o$servations of two ph&sicians =e6cept the therapist<0 who e6amine the patient. /f this procedure is respected0 the intervention of justice is not necessar&.

#oncerning the unconscious patients0 in the K5; is used a more ade7uate term0 that of %incompetent patient'0 which means that the patient lost the capacit& of understanding the received information of deciding a$out his options or to communicate a decision. ;n e6ample of such a patient is that of #laire #onra&0 *4 &ears old0 suffering of arterial h&pertension0 dia$etes mellitus0 vascular arteriosclerosis0 who was not a$le to spea)0 was not a$le to feed alone =she has a gastric catheter<0 she couldn2t control her e6cretion0 she was not a$le to move and she had a reduced intelligence. !he therapist appreciated that if #laire was confused0 %an& wa& she was conscious'0 she was not in a state of cere$ral death0 coma0 or a chronic vegetative state. #oncerning the perception of pain0 the& were not a$le to esta$lish a conclusion. ;t the clinical e6amination made $& another ph&sician0 who was not involved in this case0 the conclusion was that #laire was not moving from the semi9fetus position0 her intelligence didn2t improve and she didn2t answer to ver$al stimulation. Her nephew0 !homas Ghittemore0 who as)ed the permission of the court to stop her catheter0 made all the re7uests concerning #laire. .ecause he was living together with the patient since 5&ears0 he was sure that if she were conscious she wouldn2t admit the insertion of the catheter. .oth ph&sicians who e6amined the patient agreed that if the catheter had stopped0 the patient would have died in a wee)0 $ecause deh&dration. !he first ph&sician recommended to ta)e out the catheter $ecause #laire wouldn2t have lived more than several months in a deteriorate state in which it was possi$le for her to suffer ver& much. !he therapist decided that from a medical point of view it was not accepta$le the interruption of the catheter. !he #ourt of Hustice decided the interruption of the catheter $ecause the patient2s life was hard and she was a torture for the others.

#laire2s guardian claimed the #ourt $ut until the trial started #laire died with the catheter in place. !he #ourt considered that such a procedure =to ta)e of the catheter< represents a murder and not euthanasia. !he #ourt accepted the right to stop the life or the treatment to sustain life for the incura$le or in terminal states patients0 cere$ral death0 irreversi$le coma0 vegetative life0 or for those whose state of health wouldn2t improve with the help of the therap&. ,i)e in #laire2s case0 in the case of an& incompetent patient we have to act and decide in the same wa& the patient would have done if he was competent. !he #ourt showed that the sustaining therap& ma& $e continued or stopped to an incompetent patient0 when it is ver& clear that he doesn2t wish that therap& in other circumstances. /t has to $e o$vious from a medical point of view that the patient has to $e old0 incompetent with severe and permanent mental and ph&sical disorders and a hope of life of one &ear or less. !he person who ta)es the decision has to have medical )nowledge and to ma)e a good choice $etween accepting or ignoring the medical therap&0 li)e the patient would have done if he were competent. !his represents the su$jective test. /f the patient2s state is not clear0 justice ela$orated tests which allow to the persons who su$stitute the thin)ing of the incompetent patients =guardians< to ma)e a real evaluation of the $est interests of the patient. !he o$jective limited test is used in the cases when in a certain degree it is ver& clear that the patient would refuse the therap&0 $ut even this thing is not perfectl& sure. !o $e valid this test has to accomplish two conditions: we have to prove with the help of concrete proofs that the patient would refuse the therap&? and then the person who ta)es the decision has to $e convinced that the load of the life is more harmful than its $enefits for the patient. !he pain $ecomes in this wa& a criterion of evaluation. !he #ourt showed that in this $ranch have to $e included the

patients who suffer and will continue to suffer an irresisti$le pain for all the rest of their feature life. Gith this idea we get into the field of the pure o$jective test which is used when the patient2s wish are un)nown $ut the administration of the maintaining therap& is inhuman0 leading to irresisti$le pain. Ge have to ta)e into account also the possi$le suffering during a life under therap& and we have to deduce the duration and importance of the pain0 which the patient will feel if the therap& would $e interrupted. !his criterion is more important than the ph&sical pleasure0 emotional feelings and intellectual satisfactions0 which the patient would have if he would come $ac) to life. /f the load of pain in an artificial sustained life is clear to $e $igger0 than $& using the o$jective test0 the interruption of the patient2s life is allowed if he didn2t e6pressed his contrar& wish $efore $ecoming incompetent. !he conclusion is that if the used therap& just prolongs the suffering it doesn2t have to $e started or have to $e stopped. Hustice specified that when the proof is insufficient to satisf& the o$jective limited standard and the o$jective pure standard0 the therap& of maintaining life won2t $e interrupted until justice won2t conclude that it is positive for the $est interest of the patient. !he #ourt specified that there are not significant differences $etween the artificial feeding0 artificial respiration0 or other mechanical wa&s of sustaining life0 when the organism is no more capa$le to maintain a normal function $& itself. !here is a certain juridical procedure concerning the incompetent patients: 1./t has to $e a juridical determination of the fact that the patient is incompetent to ta)e a decision concerning the interruption of the therap& $& him. !his fact would $e esta$lished after medical e6amination performed $& two ph&sicians0 and the #ourt has to $e satisfied with clear and convinced argumentation. !he #ourt emphasi1ed the fact that the test of competence is used either for the decision concerning the medical therap& or for other t&pes of competence li)e that of guiding some$od& else0 to ta)e

care of some$od&2s $usiness. /n the case in which the patient is found incompetent0 a guardian will $e engaged. 2.!hese procedures will $e started $& an& person who thin)s that the interruption or diminution of the treatment of maintaining life would follow the wishes of the incompetent patient or for his interest. !his person has to announce the 4m$udsman 4ffice. ;n& person who thin)s the contrar& has also to report his opinion to 4m$udsman0 which is a status created $& the #ourt of @ew Herse&. 3.4m$udsman has to anal&1e an& reclamation li)e a possi$le a$use and is called to investigate the case and report it in twent& four hours to the #ommission for 5ervices for the Help of Humans or to an& governmental agenc&0 which is involved in such pro$lems. 4.!he patient2s state has to $e presented $& the therapist and nurses. 4m$udsman has to name other two ph&sicians0 from other hospitals than two therapists0 who have to confirm the irreversi$le patient2s state0 the possi$le therapies0 the possi$le ris)s and the wa& death would come if the therap& would $e interrupted. /f it is clear the fact that the patient would trust one of the mem$ers of his famil& or a close friend to ta)e a decision concerning his life together with the two medical confirmations0 4m$udsman ma& let the freedom to the person as)ed to decide. /f such a person was not named0 4m$udsman has to consult the persons who ta)e care of the state of health of the patient =hus$and0 parents0 children0 relatives0 etc.<0 who wish to ta)e such a decision. 4m$udsman will give to this person the right to decide. !he juridical reevaluation of this decision is not necessar&0 e6cept when a conflict appeared $etween those who decided famil&0 ph&sician0 and 4m$udsman. !he guardian is called for a patient who doesn2t have an& person to represent his interests. !he closest friends are not allowed to ta)e decisions in the name of the patient e6cepting the case when he speciall& named one of them in this purpose. 5.Gith the condition that the two independent ph&sicians named $& 4m$udsman to insure the medical assistance0 the guardian and the therapist ma& interrupt the therap& of maintaining

life0 if the guardian thin)s0 $ased on medical evidences and on the wishes of the patient0 that the conditions of the su$jective0 limited o$jective and pure o$jective tests were satisfied. ;n& wa&0 4m$udsman has to have a point of view concerning this decision. !he #ourt specified all the cases in which the discussion $ellow is not necessar& to appl&: new$orn children with severe malformations0 the adult who was never competent0 suffering from a painful and invalidating disease. ; special opinion was offered $& Hustice Handler who doesn2t agree that most of the opinions focali1ed on pain li)e the most important element0 the presence of the significant pain $ecoming the onl& criteria for the $est interests of the patient. !he e6clusive criteria of pain den& the categor& of people who0 at the end of their lives0 ma& strongl& disagree an artificial prolonged e6istence despite the a$sence of an& pain. His point of view is that the standard has to contain a multitude of medical factors esta$lished $& the persons who ta)e the decision in the place of the patient. 5uch a test has to $e applied onl& when the person is in a terminal state of a disease0 permanentl& unconscious0 and suffering from an irreversi$le disease of an organ or a vital s&stem. 5pecial pro$lems rise when the 7uestion concerning the interruption of h&dration and nutrition appears. /f the patient is competent all these are allowed. ;n e6ample is the case of a 55 &ears old woman0 suffering of ,;5 who0 when she was normal from a ps&chiatric point of view0 decided to use the right to die $& refusing an& nutrition $& gastric catheter or other artificial wa&s0 when she would loose the capacit& to swallow. !his decision was studied and approved $& the #ourt of @ew Herse&0 even if the police of the hospital and the opinions of the staff were against this decision. !he #ourt of @ew Herse& had to resolve also other cases of incompetent patients. !he case of "eter refers to a permanentl& unconscious person who lives in a sanatorium and who was not e6pected to die in one

&ear. !he #ourt o$served that the wish of life would $e the $est su$stitute for distinguishing the wishes of the patient0 who didn2t let an& sort wishes $efore $ecoming incompetent. /n this case0 a ver& important role had 4m$udsman. ;nother case was that of @ac& Ho$es0 who was in a permanentl& vegetative state. /f she would had $een - &ears old or over -0 4m$udsman would have $een an indispensa$le participant. !he 7uestion is if the artificial feeding li)e a form of medical therap& could $e interrupted. !he #ourt had to esta$lish the criteria concerning the self9determination0 to protect the incompetent patient. /n this case a mem$er of the famil& or a guardian were determined to su$stitute the thin)ing of the patient. !he incompetent patient0 who never showed his wishes0 continues to represent a pro$lem. /n the case of >eorge #lar)0 discussed on the (th of ;pril 1+* 0 a special attention was necessar& from the #ourt0 which had to $alance $etween the difficulties of a life with enterostom&0 compared with the hope of indefinite life of a patient with organic cere$ral lesions0 a ver& low cognitive level and a severe neurological and medical state0 $ut not in vegetative and coma state. .ecause the famil&0 the therapist0 and the committee of medical care from the hospital didn2t agree with the interruption of the therap&0 the #ourt decided that the therap& has to continue. /n the case of Eli1a$eth Dis$ecle0 the pro$lem of the #ourt was if a tu$e for feeding could $e surgicall& implanted in the stomach of a +- &ears old woman who suffered an invalidating trauma. Githout the feeding tu$e the patient would have died $& deh&dration and starvation. Gith the help of the tu$e0 the nutritional needs would $e covered0 even if she would permanentl& remain in a ver& $ad ph&sical and mental state. !he #ourt decided that the feeding tu$e will $e implanted and to sustain this decision the& gave the following arguments: 1.!his was the onl& efficient wa& to give the necessar& aliments to the patient.

2.!he surgical procedure is simple and ma& $e done $& local anesthesia. 3.!he patient was conscious and had an important capacit& of reaction. 4.Her sisters said that occasionall& the& heard the patient spea)ing words and phrases and her son said that several da&s $efore the patient gave coherent answers to some 7uestions. 5.!he patient didn2t feel pain and she was capa$le to feel and e6press pain. ./t was nothing o$vious concerning what she would have decided in the circumstances she was e6posed. (.!he prolonged use of the tu$e wouldn2t have $een em$arrassing for the patient. *.!hose who were ta)ing care of the patient2s health considered the use of the tu$e a $enefit and the guardian named $& the court agreed the decision. !he conclusion to implant the tu$e was adopted even if the medical e6amination revealed that the patient was suffering from congestive heart failure0 she had atrial fi$rillation despite the implantation of a peace9ma)er0 she had man& lesions of the right cere$ral hemisphere0 she was paral&1ed on the left side on the $od&0 she was not capa$le to move and to swallow. Aore than this0 the tu$e was implanted despite the fact that no one of these conditions wouldn2t ameliorate her state of health. !he medical e6amination clearl& esta$lished that she wouldn2t live more than several months0 even if all her necessities would $e covered. !he #ourt had the right to ree6amine the pro$lem if an& changes in the mental and ph&sical state of the patient would appear or if it will $e an important adverse reaction concerning the tu$e or the aliments introduced with its help. !he #ourt had the idea that %as long as Eli1a$eth was the patient of #hilton Aemorial Hospital or to another the idea to ta)e out the tu$e won2t $e accomplished without the accept of the "rognosis #ommittee of the hospital'. !hin)ing at the presented cases we reali1e that0 sometime0 will $e a moment when each of us has to die. !o dela& this

moment with the help of the medical therap& or other active mean has a sense as long as the 7ualit& of life is in a certain wa& satisfactor&. ;rtificial feeding and other forms of active therap& are useful as long as we are sure that the lost of the superior $rain functions is irreversi$le. /n this case0 decenc& shows as to $e prudent in the interference in the state of falling down of the organism. Ghen the patient is not a$le to decide0 medicine will decide. !he purpose is to ma)e the population sure that the patients won2t $e deprived of the indications of medical therap&. /n Aarch 1+* 0 the Huridical #ouncil of the ;merican Aedical ;ssociation =;A;< created an ethic law. /t was decided that it would $e ethical for the ph&sicians to interrupt all the medical wa&s of stopping life including artificial feeding and h&dration for the patients with irreversi$le coma even if death is not imminent and in the cases were the diagnosis of coma is confirmed. !he #ouncil of ;A; concluded that in an& moment the dignit& of the patient would $e preserved. !he dignit& is preserved when the patient2s wishes are e6pressed0 $ut can we agree with this definition when these wishes are not )nown8 /n conclusion0 the choice has to $e concordant with the law and with ethics. Ghen the choice is impossi$le to ta)e0 the medical decision will lead the course of the action with several wa&s of legal protection0 li)e the opinions of other ph&sicians0 consulting of the famil&0 of the friends and of the /nstitutional Ethics #ommittee. /n each case the interruption of the therap& is possi$le0 leading to inevita$le death. Gith comfort and without pain0 an eas& death is wished and ma& $e o$tained. !his is euthanasia. 5ome scientists consider that these patients are alread& in a phase that the& define as %death %0 so that the onl& possi$le thing to $e done is to finish this intermina$le death and not to end what remained from life. /n the Hospital of 5inai from @ew England0 the #ourt accepted that the medical staff has not to $e o$liged to stop artificial feeding if this is contrar& to their moral and ethical

principles and if these principles are recogni1ed and accepted $& most of the ph&sicians and the medical staff. Aan& ph&sicians consider that is $etter to accept not to start the necessar& therap& from the $eginning instead of stopping it at a certain moment. ; special group is represented $& the patients who0 as long as the& were conscious0 $efore or after the $eginning of the disease0 %told to the ph&sicians that the& accept to stop the special medical therapies in terminal states'. !hese declarations0 called %living will' =therap& for stopping life< are concrete documents0 which allow the interruption of the therap& of sustaining life and its procedure in the case of a terminal irreversi$le disease. !he declaration0 in an& form it would $e0 has to $e communicated to the ph&sician0 after it was ta)en in the presence of several witnesses and was written in the recordings. !he law sa&s that the persons who react according to the %living will' of the patients are not accused of murder or civil responsi$ilit&. !he interruption of the therap& of maintaining life0 according with the %living will' is not considered and doesn2t represent a suicide. !he #ongress of the K5; created a status0 which sa&s that all the hospitals have to inform the patients concerning the possi$ilities that the& could e6press their wish a$out their death. !he administration of the hospital has to decide a$out the procedure of the will and what forms of testimon& have to $e ta)en into account? from this decision the 7uestion rises a$out encouraging or not the patient to write his %living will' or not. /n the same time0 the administration has to instruct the ph&sicians and the medical staff a$out the repeal of the %living will'. !he %living will' ma& $e repealed in an& moment and in an& wa& without ta)ing into account the patient2s mental state. !he ph&sicians2 pro$lem is represented $& the wa& in which the& interpret the spo)en or not spo)en =moan< e6pressions li)e $eing repealing e6pressions. Does the words %/ don2t want to die' represent a wish of repeal8 How do &ou have to interpret a patient2s gesture8 Have the

medical staff to as) the patient if he wishes the catheters to $e ta)en out and then to wait for a gratification from the patient8 !he repeal of the %living will' ma& $e wrongl& understood $& the ph&sician0 and not to $e honored0 leading to an undesira$le death of the patient. ;nother pro$lem is represented $& the responsi$ilit& for the e6penses of a long lasting disease. !he patient is a vegetative state and the famil&2s mem$ers declare themselves not capa$le to continue to support the e6penses of the therap&0 doesn2t this represent – ma&$e in an unconscious wa&9 an acceptance of the application of the wish to die written in the %living will'8 !he %living will' considers that the interruption of the special medical therap& according to the patient2s declaration is not considered as euthanasia or suicide. !he e6perts discussed a$out the illogical nature not to consider the refuse of the therap& li)e a form of passive euthanasia. ;nother pro$lem is represented $& the patient2s suffering $etween the interruption of the therap& and death0 and the wish to shorten pain $& the administration of some drugs0 action which is e7uivalent of the active euthanasia. /n the end0 we don2t have to forget the persons who don2t have incura$le diseases0 who don2t have pain0 whose therap& is e6pensive and harmful0 whose 7ualit& of life can not $e improved and those who have to pa& for the therap& and don2t want to do it an&more. /n all these cases0 what the& have in common is to ta)e into account the 7ualit& of life0 which is the origin of the following actions. !hese are the points of view of the ;merican law&ers and population concerning euthanasia. /n Bomania the origin of the four articles of the law concerning euthanasia and included in the 5anitar& ,aw is of Holland inspiration. !he& are: 9 !he decision to voluntar& interrupt the patient2s life $& the therapist for his interest in the purpose of stopping his suffering0 even if he clearl& as)s that his life would $e interrupted =voluntar& euthanasia<0 or his life is stopped in his own interest when he is not

a$le to e6press his wish =involuntar& euthanasia< is possi$le to appl& if such actions are not under the incidence of the penal law. 9 !he decision to interrupt the therap& of maintaining the vital functions for an unconscious patient who is not a$le to survive without circulator& and respirator& sustaining =patient in a terminal state< will $e ta)en $& at least two ph&sicians speciali1ed in intensive care0 according to the criteria of evaluation of cere$ral death0 esta$lished $& a national team of e6perts who anal&1ed the pro$lem. 9 !wo ph&sicians0 one pediatrician acting sincerel& and with the acceptance of $oth parents =if it possi$le< have to decide a$out the interruption of a new$orn child2s therap& determined $& a severe medical diagnosis0 which shows that the future child2s life will $e intolera$le $& pain0 suffering0 or cere$ral incompetence0 the therap& $eing a$andoned. 9 !he ph&sician and the rest of the medical staff have the right0 $ased on individual conscience not to participate at this action. !a)ing into account the reasons which we studied concerning euthanasia0 it is impossi$le not to agree a$out the wa& in which it will $e reflected in the future laws. /t seems to $e reasona$le the practice of passive euthanasia and selective therap& in the clear cases0 which are not suscepti$le of discussions. Aa&$e future laws0 which would $etter e6press the charita$le principles of euthanasia0 would contain: 9 ;ctive euthanasia =the stopping $& an& methods the life of an incura$le patient or in a terminal state not ta)ing into account who is as)ing for it<. /t is for$idden the passive euthanasia =stopping life onl& $& therapeutic methods not ta)ing into account who is as)ing for it0 when the patient is conscious<. 9 Ge ma& accept passive euthanasia of a patient in a state of deep coma when ph&sicians2 team composed of intensive care specialists0 neurologists0 and forensic pathologists considering the unanimous criteria esta$lish the irreversi$le death of the $rain.

9 ; pediatrician together with another ph&sician ma& decide to stop the new$orn child2s therap& when he has congenital malformations0 which are not compati$le with life 9 $ased on a certain diagnosis – or cere$ral incompetence. !he last paragraph of the proposals of law is incontesta$le.

CHAPTER VI THE PROCLAMATION OF THE EUROPEAN COUNCIL ABOUT VEGETATIVE LIFE AND “THERAPEUTIC OBSINACY” ;s we discussed $efore0 the ;merican justice permitted the ph&sicians to stop life or the therap& of maintaining life in the case of the incura$le patients or in terminal states0 cere$ral death0 irreversi$le coma0 vegetative life0 or whose life wouldn2t improve with the help of the therap&. /n England0 after the case of #o6 and Hove0 were o$served important tendencies of opinion concerning the %sweet death' connected especiall& with the vegetative states $etween the persons who accepted it and those who convicted it. Doctor @. #o6 was convicted for murder attempt $ecause he practiced euthanasia to a (- &ears old patient with rheumatoid arthritis using an injection with F#l0 $ut the 4rder of the "h&sicians showed clemenc&. !he court pleaded also for the innocence of other ph&sicians =dr. #arr0 dr. ,odwig<0 who used a coc)tail of F#l and lidocaine0 considering that the patients died $ecause of the cancer and not of the coc)tail of anesthetics. ; Doluntar& Euthanasia 5ociet& also pleaded for the modification of the law concerning euthanasia. !he conse7uence of these pressures was the li$erali1ation of the ph&sician2s right to stop artificial feeding in the case of permanent vegetative states. /n accord with this law0 Dr. Hove suppressed the alimentation catheter of a patient after he discussed with the law&er concerning %the inefficienc& to maintain in life a ph&sical $od&' if the cere$ral functions are missing. !he House of the ,ords confirmed this point of view. Aore than this0 in the process of legali1ation in England of the social and legal implications of euthanasia0 the discussions

continue =the actual law agrees to stop a therap&0 $ut not the administration of a lethal injection to a person in a terminal state<. ;gainst these arguments0 Dr. ;ndreus said that with the help of the intensive care0 F;! succeeded to $ring $ac) to life 34 comatose patients in a vegetative state0 after months of comple6 therap& directed especiall& on the visual and auditor& functions0 after one &ear for ten cases and three &ears for five cases0 $ut for other e6perts0 the economical reasons of these e6periments =(-0--pounds per &ear for one case< are more important. Economical euthanasia =the refuse of renal dial&sis at patients over (- &ears old< is in total contradiction with the medical ethics. 5o0 we ma& as) which are the moral criteria concerning the hierarch& of medical care8 ;t the 2(th 5ession of the "arliament of the European #ouncil0 the 5upreme #ourt of the human rights0 in the resolution no. 13I1+( some recommendations were made concerning the vegetative state. !he meeting thin)ing that for the reasons e6posed in the recommendation no. ((+I 1+( concerning the patients2 rights and anal&1ed in the #ommission report concerning the social pro$lems and health =document no. 3 ++<0 the real interests of the patients are not alwa&s $est preserved $& an e6cessive application of the modern technologies to maintain life0 $eing convinced that what the d&ing people wish the most is to die in dignit& and peace0 as possi$le in comfort and with the help with the famil& and friends0 thin)ing that the incertitude concerning the justice of the criteria to determine death could create an useless fear0 insisting on the fact that to esta$lish the moment of death is not more important than other patient2s interests0 invite the medical e6perts of the mem$er states to e6amine attentivel& the criteria on which are $ased toda& the decisions concerning the applications of the techni7ues of resuscitation and maintaining life. Aore than this0 the meeting invited the .ureau for Europe of GH4 to e6amine the criteria used in several European countries for the determination of death0 using the actual medical )nowledge and techni7ues0 and to ma)e proposals for uni7ue point of view0 which has to $e applied

all over the world0 not onl& in hospitals0 $ut in the general medical practice. /n the Becommendation no. ((+I 1+( concerning the patients and d&ing persons2 rights0 the Aeeting of the "arliament of the #ouncil of Europe considers that the fast and continuous progress of the medical sciences will generate pro$lems and ma& $e come even a threatening for the fundamental human rights and the integrit& of the patients. !a)ing into account the tendenc& of the medical techni7ues to use more and more techni7ue therapies =sometimes not so human<0 o$serving that for the patients sometimes it is difficult to defend their own interests especiall& when the& are cured in $ig hospitals0 considering that is unanimous accepted that the ph&sicians have first of all to respect the patient2s wish0 considering that the right for dignit& and personal integrit& the right to information and care for himself have to $e well9 defined and accessi$le to ever& person0 convinced that the dut& of the medical profession is to serve humanit&0 to protect health0 to treat diseases and help suffering0 with respect for the human life and convinced that maintaining life is not $& itself the e6clusive purpose of the medical practice $ut in the same time also suffering has to $e calmed0 considering that the ph&sician has to ma)e all the necessar& efforts to calm the suffering and he has no right – even in the desperate cases – to shorten the natural course of life0 emphasi1ing the fact that maintaining life $& artificial methods depends $& man& factors li)e: 7ualit& and efficienc& of the e7uipment0 and the ph&sicians who wor) in hospitals where the techni7ue e7uipment helps an important maintaining of life0 are in a delicate situation concerning especiall& the cases of maintaining therap& at a person with irreversi$le lesions of the cere$ral functions0 insisting that the ph&sicians have to act according to science and approved medical e6periences and that an& ph&sicians or mem$er of the medical profession is not o$liged against what his conscience tells him to do according to the patient2s right not to suffer0 recommend that the #ommittee of Ainisters invite the governments of the mem$er states to:

1.a.!o ma)e all the necessar& changes0 especiall& connected with the activit& of the medical staff and the organi1ation of the medical services0 to $e sure that all the patients cured in hospitals or home to $enefit of the alleviation of their sufferings in accord with the medical actual )nowledge. $. !o convince all the ph&sicians that the patients have the right to a complete information concerning their disease and the possi$ilities of therap& and to ta)e all the necessar& measures that this information would $e done at the moment of hospitali1ation in the same wa& the routine e6aminations are made. c. !o $e sure that all the incura$le patients are ps&chologicall& protected to meet death and to have the necessar& assistance0 with the help of the medical staff =ph&sicians and nurses< who have to $e elementar& prepared to $e a$le to discuss the pro$lems of death with the d&ing persons and also with the help of the ps&chiatrists0 priests0 social nurses attached to the hospital. //. !o esta$lish national commissions of investigation composed of e6perts from all the levels of the medical profession0 law&ers0 priests0 ps&chologists0 sociologists0 to esta$lish ethical rules of therap& of the d&ing persons and to determine the lines of application of the special measures of maintaining life and to e6amine all the cases the ph&sicians have to face. 3or e6ample: the penal or civil punishments0 which appear when the ph&sicians give up the artificial measures of maintaining life0 in the case of terminal patients0 whose lives couldn2t $e saved with the help of the actual medical )nowledge or when the ph&sicians too) all the necessar& measures to alleviate pain and which could have secondar& effects in the process of death0 to e6amine the written declarations made $& competent persons who accept the ph&sicians not to ta)e the necessar& measures of maintaining life0 especiall& in the cases of irreversi$le degradation of the cere$ral functions. ///. !o esta$lish if there are not alread& e6isting identical organi1ations or national commissions0 which anal&1e the

complaints against the medical staff0 made for errors or negligence in the medical practice. /D. !o inform the #ouncil of Europe a$out the results of the e6aminations0 their conclusions and their proposals concerning the patients and d&ing persons2 rights and the legal and technical implications0 this guarantee their application.

CHAPTER VII THE MEDICAL CASE – BOOK RECORDS AND RESPONSIBILITY IN EUTHANASIA #lammponiere said0 %the pro$lem of medical responsi$ilit& $ecomes da& $& da& more grave and upsetting for all the ph&sicians. /f we want not to discourage honest intentions0 which ma& cure the patient0 we have to protect the honest ph&sician who is conscious against the unjust actions'. 4n the 3- of Aarch 1+*+ the @ew England Hournal of Aedicine pu$lished an article concerning %the responsi$ilit& of the ph&sicians towards the hopeless ill patients'0 spea)ing a$out the patient2s rights and then anal&1ing the situation when the doctor who helps a hopeless patient to die commits a murder or not. !he authors just recogni1e the fact that the pro$lems comple6. /t remains the possi$ilit& that this alternative would $e accepted in some of the cases. /n the K5; all the states agree with the decisions showing that the therap& has to $e discussed with the patient. !he doctor has the legal dut& not onl& to give to the patient clear information concerning his options and possi$ilities of therap& $ut also to include the possi$ilit& of interrupting the therap&. Especiall& when invading investigations or surgical operations will ta)e place0 it is ver& necessar& to discuss the ris)s and $enefits of the procedures0 which will ta)e place. ;nother dut& of the ph&sician is not to appl& a therap& without the patient2s consent or to o$lige the patient to accept a form of therap&0 which is not concordant to his wishes. !he patient2s refuse will $e written in the recordings.

/n the $ranches of high ris) of medical practice =emergencies0 terminal states0 reproduction technolog&0 genetic advice< to avoid the mista)es and to distinguish them from the medical error needs to have a scientific e6perimental criteriolog&0 which tends to prove the following facts: 9 the ph&sician did all the necessar& things as therapist and as human for the patient2s interests? 9 he respected the standards of professional $ehaviour in accord with his studies and his conditions of wor)? 9 he used the recommended scientific methods and didn2t engage for the results he will o$tain? 9 he respected without e6ception0 the patient and famil&2s consent? 9 he satisfied the necessar& patient2s e6aminations $& other specialists if he was as)ed for it and he didn2t deprive the patient of his chances? 9 he didn2t give to the others his responsi$ilities. !he prevention of the juridical responsi$ilit&0 of ma6imal gravit& ma& $e done $& respecting some deonthologic criteria0 which will determine the contri$utions in an efficient wa& to the crisis of conscience of the medical responsi$ilit&. !he ph&sician2s competence $ecomes a patient2s right and a sine 7ua non condition of an efficient medical act. 3or the ph&sician0 competence $ecomes %the first form of honest& towards the patient'. /n Bomania0 onl& one case of active voluntar& euthanasia was judged in 1+(+0 when /./.0 an *4 &ears old man0 e6pressed in several moments his wish to die as)ing for an injection with a lethal su$stance. .eing alone at home he as)ed a hospital attendant to ma)e him an injection in the pericardial area with the intention to inject the heart0 with #ime6ane. ;fter the injection0 the victim felt $ad accusing agitation0 d&spnoea0 convulsions0 e6cretion0 and a state of coma and died at four hours after the injection. ;t the autops&0 in the pericardial area there were found pric)ed wounds with parchments all around0 an the internal e6amination hemorrhaged infiltration in the pericardial area and 1-- ml of

&ellow li7uid smelling of DD! in the left pleura0 and also the pericardium had hemorrhaged infiltration. !he complementar& e6aminations from the siring and the $ottles with insecticide and also from the organs showed a lethal 7uantit& of organic chlorine. /t was concluded that the death of /./. was violent0 and determined $& the injection in the pleural cavit& of H#;. .etween the into6ication and death it was a direct connection of causalit&. !r&ing to defend himself0 the hospital attendant said that the victim injected the su$stance $& herself0 thing that was impossi$le $ecause the victim suffered of an amputation of $oth arms. Hustice gave him e6tenuating circumstances0 convicting him for seven &ears of prison. /n the end0 if euthanasia is not totall& accepted0 an important element of the medical responsi$ilit& has to $e represented $& the assistance of death. /n front of the clums& cases of death =disthanasia<0 the ph&sician has no other deonthologic alternative then to give scientific0 ethic and human assistance to an& state of passage $etween life and death0 without ta)ing into account the clinical form which this would have. !his is more important toda&0 in the era of medical technolog&0 which created the ris) to survive in a vegetative state and which transformed death in %something o$scene'0 which determined B. A. Bil)e to write a$out the desperate shout addressed to the ph&sicians %not to steal death'. Death0 li)e a return in the cosmic world0 represent the need of immortalit&0 $ecause life if is not a$le to ma)e us e7ual0 onl& death ma& help to ma)e justice. !he lac) of this significance represents a ris) for life and death to $ecome a failed eternit&. !he acceptance of death would represent the last proof of generosit&0 altruism0 and even heroism in front of a %cosmic a$surdit&'0 concerning the start and the end of life in the Kniverse. /n this purpose medicine has to offer to the medical practice %the art to die'. 5uch an art is preceded $& a strong religious0 moral and cultural tradition after which:

9 Death doesn2t have to $e a tragic feeling0 $ut a simple and natural passing to another world0 the world of the spirit0 who survives in front of the perennialit& of the ph&sical e6istence. Aore than this0 as in other cases of life in the terminal states0 humans have to end their lives surrounded $& affection and not $& indifference0 the human act $eing completed onl& in a communion %$etween those who are coming and those who are going'. 9 ,i)e $irth0 death has to $e medicall& assisted0 to offer the necessar& silence which can not $e consumed then in intimac& =in the famil&< and after the patient2s li$eration from an& state of guilt? 9 !he first $asic element of the medical assistance of death is represented concerning the ph&sician2s )nowledge a$out the ps&cholog& of the terminal states0 in the purpose to help the patient to die with dignit& $ecause death ta)es onl& the $od& and not the creation =Fa1ant1a)is<0 and when the $od& represents just a method of transfer of the individual spirit into the universal one =@oica<. Death is a part of normal life. 5o0 it would $e normal to learn how we have to act when %we get in connection with' or %we interact' with death. Ge have to thin) what has to $e our $ehaviour during our professional and personal meeting with death0 in a calm manner and with dignit&. /n the second time0 the concept of moral help for a d&ing person is a normal answer determined $& the human connections0 and not a special action. Ever& one of us )eeps relative sta$ilit& of his life with the help of the connections with other humans in our social area. /n the third time0 to help doesn2t mean so much %to do' as %to $e'. /n the fourth time0 the help to die is contrar& to most of the t&pes of help. Ksuall&0 we help people to move $etween the pro$lems of life. .& helping some$od& to die we help humans to disconnect from the idea of living.

3or $eing a$le to assist other persons0 first of all we have to help ourselves $ecause death is a personal matter. !o $e a$le to answer fear and the other feelings of a d&ing person we have first to answer ourselves. Ge are face to face with the continuous tension0 which is coming from our interior: to $e connected with the significance of death and to $e capa$le to $e calm and o$jective. "ogo said: %/ saw and / found the enem& and with was us'. 5o0 for helping others to die we have first to fight with death of ourselves. 4nl& after death0 we ma& defeat the rejection full of fear of a d&ing person and to avoid the mechanism0 which reject fusion with death. Ge will act in a position of %detached compassion'. 4ur own opinions a$out death represent a com$ination of positive and negative. !he same for the d&ing person0 his famil&0 relatives and friends. /t is not normal to wait for positive attitudes in us or in others in an e6clusive wa&. 5ometimes we are angr& or frustrated $& death. !he cases of death can2t ma)e humans suddenl& )ind and gentle. !he d&ing persons represent a multitude of t&pes of human $eings0 some of them gentle and some not. Gith some people is eas& to communicate and with others not. ;fter some d&ing persons we are sorr& while others give us feelings of satisfaction. /t is our dut& to identif& and assimilate all these feelings0 to recogni1e that emotions represent a part of human e6perience0 to integrate the positive and negative feelings0 and in the end0 not to act against instinctual emotions0 not to filter feelings trough our own conscience0 and to react according to the responsi$le integrit& of the d&ing person and ourselves. ;nother form of help is to recogni1e the feeling of %saturation of death'. !his represent the fact that we ma& wor) with the d&ing persons for a ver& long time and with a ver& important personal implication0 so that0 we ma& pass the limits of saturation concerning the idea of death. Ge have to $e capa$le to identif& our personal limits concerning the saturation of death0 and

when we are close to them we have to come $ac)0 to )eep the distance and to recover. /t is not normal to as) us to $e capa$le to fight against death0 all the time with the same intensit& and to e6pect to survive from a ps&chical point of view. /f we don2t have our own plans to wor) and live with periods of recovering0 our defending ps&chical s&stems will wor) for us until we shall $e e6hausted. Ge have to )eep an ethical attitude towards the d&ing persons0 to tr& to ma)e a decent thing with ma6imal competence0 for which it is necessar&: 1. !o avoid the hostile reactions0 this ma& produce a harm to the d&ing person. 2.!o avoid our over appreciation0 this ma& lead to an operation or therap& to a patient who is not prepared for it. 3.!o avoid the deformed se6ual attitudes0 this ma& lead to possi$le reject or se6ual seductions of the patient. 4.!o avoid revealing all the confidences made $& the patient0 as a ha$it or to seem important for other persons. 5.!o avoid the e6cessive therapeutic am$itions0 this ma& lead to useless procedures. .!o avoid the useless stimulation of the an6iet& of the patient. ;fter we esta$lished our own attitude concerning the e6perience of death we have to esta$lish also some criteria concerning the help we have to give to the d&ing person: 9 !he integration of the idea of death in the stile of life of the person0 for $eing a$le to reach a simple death0 a stile of death adapted for ever& person0 special for ever& individual and different from the others. 9 !he person has to $e capa$le to fight with the initial crisis of an6iet& previous death. 9 Ever& person has to ma)e compromise $etween the realit& of his own life and the ideal image of life. 9 Ever&one has to preserve or to continue the important relations during life and little $& little to get used to the feeling of separation from the persons he loves0 when death is coming.

9 Ever&one has to ma)e a reasona$le e6periment of his instincts0 which ma& lead without interior conflicts to the acceptance of death. 9 ;nother principle is represented $& )eeping ade7uate answers to the phases of death: in the acute initial phase we are faced with an acute an6iet& and am$iguit&? in the second chronic phase $etween life and death the relations $etween humans diminish and the third phase is represented $& the $eginning of separation and falling down. 9 ; supplementar& principle is necessar& in terminal phase when we have to have a s&nchronicit& so that the social ps&chological and ph&siologic dimensions of death have the tendenc& to meet together in a common form. Ge have to tr& to )eep social and ps&chological attitudes0 which have to $e in accord with the state of the d&ing person. Ge have several o$jectives to fight against concerning what is happening in the mind of the d&ing person: 9 !he fear of un)nown – is e6pressed $& the initial acute crisis. /t is important to esta$lish a relation of confidence and trust0 in which the d&ing person ma& as) and receive answers0 which he ma& trust. /t is important to avoid0 when it is possi$le0 the specific answers. /t is useful to distinguish $etween the realities of life where we ma& answer e6actl& what we thin) and the philosophical0 religious0 speculative 7uestions for which we ma& give opinions $ut we can2t give answers. !his helps the d&ing person to distinguish $etween the well9)nown aspects of death a$out which he ma& some answers and the un)nown parts of death for which he ma& not get an& answers. 9 !he fear of loneliness – there are different pro$lems in an& phase of death. /n the initial phase of death the fear to $e e6cluded and a$andoned is more a fantas& then realit&. /n this phase it is useful to esta$lish ver& attentivel& who will $e the d&ing man and when. /n the second phase it2s recommended not to permit li)e the phenomenon of death to $e the onl& care of the d&ing man. 4ur dut& is to )eep the contacts of the d&ing man with his connections

and dail& o$ligations. /n the final phase it2s recommended to insure the patient a$out the permanent interests of the other persons concerning his state. /n this wa&0 d&ing man won2t feel the solitude of the final moments. 9 !he fear of regrets – here we have to avoid the creation of an atmosphere0 which will lead to the idea that sadness is permanent. Ge shall share with the patient his regrets0 and we shall e6press our sadness0 which is called %anticipate sadness'0 and which allows us to identif& the source of the regrets and to $e a$le to manipulate this emotion. /t is useful the help the d&ing man to identif& the specific sadness determined $& death0 and to ma)e a difference $etween it and other forms of regrets. 9 !he fear to lose the famil& and friends – the process of death amplifies the latent dimension of the human connections. 4ur role is to help the d&ing man and his famil&0 his friends to accept the variet& of feelings0 which e6ists $etween the two sides0 to clarif& the am$iguous and conflictual feelings and to accept some settlings of the emotional tensions. Ghen the resolution of the negative phenomenon appear =peace is coming<0 the d&ing man starts to separate from his relatives with a peaceful soul. 9 !he fear to lose the $od& – the first o$ligation is to clearl& inform the d&ing man a$out the phenomena that happen in his $od&. !he& need to )now what is $ad and wh& is $ad. !his o$ligation eliminates the m&ster& of the processes that happen in the $od&. !he patient has to )now that to lose the functions of his organism is not a shame. /t is important to distinguish $etween the functions of the organism that are health& and those that are ill =$etween the parts that are reall& health& and those that are affected $& the disease<. /t is useful to ignore the d&sfunction of the $od& and not to amplif& them. 9 !he fear to lose the self9control 9 we ma& consider the control from several points of view: the control of some$od&2s life0 the control of &our own life and of &our own $od&. !he diminution of the control concerning life ma& include the fear not to $e capa$le to determine life or death. !his attitude has to $e solved

from the $eginning of the phenomenon of death0 the d&ing man $eing a$le to ta)e decisions concerning his famil&2s life0 li)e propert& wills0 li)e famil& pro$lems0 funerals0 cremation0 and other pro$lems a$out the wa& the& have to live. ;ll these elements ma)e the d&ing man capa$le to determine as much as possi$le the direction of their lives. /n the same wa&0 the d&ing man ma& $e encouraged to control the emotions of the others. 9 !he fear of suffering and pain – suffering accompanies solitude and the fear of un)nown. Even the d&ing man0 who continues to $e visited $& friends and have connections with the surrounding world0 ma& live in pain0 which ma& $ecome intolera$le. !he source of pain0 its deepness and its duration have to $e e6plained as reasona$le as possi$le. /t is not the case to wish a stoic acceptance of pain. /t is useful to give analgesics $ut the common opinion that the pills would give a solution to the pro$lem of pain is not realistic. Ge ma& ameliorate pain onl& with the colla$oration of the d&ing man. "ain if ma& not $e eliminated0 ma& $e tolerated. 9 !he fear to lose the identit& – it is important to continue the specific identit& of the d&ing man. !his ma& $e reali1ed $& continuous contacts with the famil&0 friends0 who have to get in connection with the d&ing man and also with the persons full of life. /n the same time0 the patient has to $e allowed to )eep his clothes0 memories0 and intimac&0 which would contri$ute to the development of several hospital infections. 5o0 the patient has to involve as much as possi$le in the persons2 life0 which are parts of his identit& and to )eep as much as possi$le the consciousness of his self. /n conclusion0 the ph&sician has to help the patient to understand the idea that onl& $& the conscience of a dignif&ing death accepted and discharged of guiltiness ma& accomplish the intensit& of a successful life0 a medical esthetics of death having to ta)e into account this art of d&ing $& loving life and living it until the last moments0 to alleviate an& terminal state0 so that death won2t $e %monster'0 $ut a $eginning of immortalit&. !his esthetics

of death has to include also the ph&sician2s efforts to fight with the innocent death0 starting from the idea that %an& death $efore the necessar& age represents a mutilation of the Kniverse'. /n the end0 the esthetics of death has to include a respecta$le attitude concerning the $odies0 to avoid the repulsion towards the $odies0 li)e a possi$ilit& of humans to %give out an& $ad thought'. 5o0 it is necessar& to have a terminal assistance0 $& which: 9 li)e some$od& gives water to a d&ing man it is necessar& to give him the medical and pedagogical assistance? 9 /t is necessar& to diminish pain in the purpose of a supporta$le life? 9 !he ps&chological comfort is important to conserve the identit& and autonom& of the person until the last moment? 9 !o insure the material comfort0 to $e a$le to avoid an& isolation. ;nother aspect of medical responsi$ilit& in the cases of euthanasia is represented0 in the case of the patients in a state of coma0 the idea of interruption of the reanimation0 in the cases of overfulfilled coma with a flat EE> e6amination for $etween 2and - hours0 with the e6ception of children0 of pregnant women0 of poisonings0 of fro1en patient or when it is necessar& to donate organs. /n such conditions0 the ph&sician can not $e accused of forcing death. #oncerning the a$uses which ma& $e done in the $ac) of euthanasia0 it is not allowed to give the consent for prelevation of organs $& the donator since he was alive not to thic)en the trust of the patient in the efforts of the medical procedures and not to hurr& %the death of the donator $& a so called euthanasia' in the interest of the receiver. !he prelevation of organs from the death $odies ma& $e done onl& after the $iological death was confirmed $& the ph&sician and we have the famil&2s consent. !he criteria of the $iological death esta$lished $& the 4rder of the Ainistr& of Health0 refers to the need to esta$lish the death of the $rain $& a flat EE> recording of minimum 12 hours0 with the e6ception of the poisonings0 h&pothermia0 death during

pregnanc& and ma& $e done $& another team of ph&sicians0 e6cept that which ma)e the transplant.

CHAPTER VIII PERSONAL FINDINGS ABOUT EUTHANASIA /n a stud& made in Bomania we as)ed 5- persons aged $etween 2- and - &ears old0 with different occupations =law&ers0 engineers0 chemists0 economists0 students in technical universities< a$out euthanasia. !he 7uestions that helped me to find their point of view concerning euthanasia were the following: 3or the case of an old unconscious man with an incura$le disease and with insupporta$le pain: 1.Do &ou agree to continue to treat him without effect8 2.!o treat onl& his pain8 3.!o give a su$stance to help him die8 4.!o help him die faster $& passive euthanasia8 Ge repeated the same 7uestions also for the case of a conscious old man0 of a conscious &oung man0 of an unconscious &oung man0 all of them with incura$le diseases. /n the first case0 42E from those who were as)ed greed to continue the therap& without effects. 54E decided that is $etter to use onl& the analgesic therap& and a$out the administration of a lethal su$stance **E were against this measure and (4E were against the help to die. /n the case of a conscious old man (4E answered affirmativel& at the first 7uestion? 32E agreed with the therap& of the pain at the second 7uestion? * E were against euthanasia at the third 7uestion and *5E gave negative answers at the last. ; special pro$lem concerning the a$andoning of a lethal su$stance near the patient0 from the 43 persons who had a negative answer concerning the practice euthanasia0 1- of them said that if

the patient if conscious and as)s for it the& would give such su$stances. /n the case of the &oung incura$le patient although he was unconscious0 5-E agreed to continue the $asic therap&0 4-E considered the $est is to continue onl& the analgesic therap& and for a measure of suppressing the patient2s life *-E didn2t agree and for the last 7uestion ( E gave a negative answer. /n the last case of the &oung conscious patient0 for the first 7uestion (4E agreed with perseverance in therap&? at the second 7uestion 24E agreed onl& with the therap& against pain? concerning the application the euthanasia *4E refused the idea of the administration of a su$stance and *4E were even against helping the patient to die faster. !he same as for the old conscious man there is the possi$ilit& the patient $& himself to as) for the lethal su$stance. 3or the conscious &oung man onl& 1-E of the interviewed persons would follow the patient2s wish to give him the to6ic su$stance0 $ut not $efore he is as)ing for it. Ge ma& show the fact that from the investigated persons those $etween 4- and 5 &ears old0 who represented a$out 3-E from the studied group0 usuall& option to continue a therap& without effects and to give analgesics0 $ut don2t agree with the application of a certain from of euthanasia. !he &ounger group =2– 4- &ears old< is more permissive in this pro$lem. 3or a more specific e6amination of the degree of acceptance of euthanasia we made a stud& involving a group of 5- students in medicine who are more familiar with the idea of death or of incura$le disease than the general population. Ge as)ed them the following 7uestions: 1.Ghat is the difference $etween euthanasia and natural death8 2.Do &ou agree with active euthanasia =to hurr& the patient2s death $& the administration of a su$stance<8 3.Do &ou agree with passive euthanasia =to let the patient die $& stopping the therap& that )eeps him alive<8

4.Ghich would $e &our attitude in the case of a patient with cere$ral death =in a vegetative state< or in the case of a malformed new$orn child without an& possi$ilit& to recover8 Gould &ou agree with euthanasia8 5./f in a conscious wa& an incura$le patient would as) &ou0 would &ou practice euthanasia8 3rom the answers of the first 7uestion we concluded that the students in medicine have a ver& clear concept a$out the pro$lems of the test and the& are capa$le to ma)e a distinction $etween them: natural death representing the death after the e6haustion of the resource of the organism $& different reasons0 while euthanasia represents a death without pain $ut determined $& some$od&0 so that it involves a person who acts in the purpose of stopping the patient2s suffering. /f natural death has a pol&morph determination including various pathologies0 euthanasia represents a %shorten of the ph&sical evolution of natural death'. ;t the second 7uestion0 4(E of the persons agreed with the active euthanasia. #oncerning the passive euthanasia0 3 E e6pressed positive opinions. !he 7uestion four determined different opinions. 2-E of the students agreed with euthanasia in $oth cases0 2-E denied it in $oth cases and 1-E consider that euthanasia is necessar& in the case of the patient with cere$ral death0 $ut were against it in the case of the malformed new$orn child0 ta)ing into account religious reasons or considering that onl& nature is allowed to decide for it. ;t the 7uestion concerning the personal practice of euthanasia0 onl& 11.4E answered that the& would practice it %if the law will allow it'0 the rest of the persons considering that the ph&sician has to $e a therapist and not accepting this position. 5tud&ing the answers of m& colleagues0 / saw a certain pol&morphism of the arguments with which the& sustained or not the idea of euthanasia. !hose who agreed with euthanasia thought that to practice it at a patient in a vegetative state doesn2t represent to stop the life of the person0 $ut of a $iological heart – lung

e6periment considering it justified. 4thers thin) euthanasia would determine a removal of the ph&sician from their position of therapist $ecause0 even if a man has a primitive life0 identical with plants0 no$od& e6cept >od does have the right to decide a$out him letting to the patient the chance of the miracle. 5ome of the interviewed persons considered that euthanasia in a mas)ed form is alread& practiced =for e6ample the refuse of the surgeons to operate patients over a certain age<.

CHAPTER I LEGAL AND BIOETHIC CONCLUSIONS ABOUT EUTHANASIA Even if life and death represent two contrar& phenomena0 the& represent the two essential conditions of the evolution of the living matter in nature and in the living organisms0 death $eing interdependent with life. !he disappearance of humans represents the need of evolution in the purpose to give the place to other genetic com$inations more favora$le for the species and which grow their adaptive potential0 which is the $ase of varia$ilit& and progress. /n this wa&0 death is a revenge of the species against the individual. !oda&0 we ma& see different opinions a$out death0 depending on the cultural level0 religion0 profession0 and age. /n this sense0 the idea of euthanasia is ver& disputed. !his term includes a group of medical actions or inaction0 with an ethical and juridical support0 in the patient2 s interest0 leading to the shorten of a patient2s suffering who has in the actual moment of the medical science a predicta$le and fast death. During time0 the idea of euthanasia had different forms and was more or less accepted0 until its total negation. /n this sense were ela$orated positive arguments =the individual2s right to a dignif& death0 the communit&2s fear for some infectious diseases0 the need of control of voluntar& death at the ps&chiatric ill patients0 or involuntar& at the new$orn children with severe malformations< and against euthanasia =the respect of the sacred life0 the ris) of a$uses of euthanasia0 the chr&pthanasia0 the discriminating euthanasia0 and the contested place of the euthanasia $etween the medical norms and concepts<. Ge ma& conclude that the ph&sician

has to spread the idea that more than an&thing humans have to survive to promote the 7ualit& of human. Ghen it is not possi$le to defeat death the ph&sician will calm the soul to help the patient to have a respecta$le death. #onnected with the term of euthanasia is the pro$lem of the assisted suicide0 an e7uivalent of the voluntar& active euthanasia =together with the voluntar& passive euthanasia0 involuntar& active euthanasia and involuntar& passive euthanasia<0 which was promoted $& Hac) Fevor)ian with his suicide machine $ased first on h&drochloric acid and $ar$iturates0 an later on car$on mono6ide. !his idea was also ver& discussed0 considering that it has also favora$le arguments0 identical to those that sustain euthanasia as a whole0 and also negative reasons. 5tud&ing the positive and negative arguments concerning this procedure we ma& conclude that the incertitude of the correct clinical evaluation of the patient2s discernment0 together with the ris) of confusion $etween the wishes and the reasons of the patient0 his famil& and the ph&sician0 ma)e ver& difficult a decision for using the medical assisted suicide0 with a ver& high error potential0 so that0 this method ma& have the chance to $ecome ha$itual in the future. 3rom a legislative point of view man& attempts appeared in the world to legali1e or for$id euthanasia. /n Europe0 there are two tendencies concerning euthanasia. /n the @orth0 it tends to $e approved and in the 5outh the great principles of life are still sustained. ; special place is that of Holland0 where euthanasia was accepted and in Bomania the starting point for the four articles concerning euthanasia in the "roject of the 5anitar& ,aw has the origin in Holland. /n the K5;0 an important place to determine the application or not euthanasia is represented $& a form of e6pression of the patient2s wish – %the living will' – connected with the procedures that have to $e followed in the case in which he $ecomes unconscious. /n the same purpose to clearl& determine the application or not of euthanasia0 the #ouncil of Europe invite the Begional

.ureau for Europe of GH4 to e6amine the criteria for determining death0 which e6ist in several European countries0 in the light of actual medical )nowledge and technologies and to ma)e proposals in an unanimous sense0 which will $e universall& applied0 not onl& in hospitals0 $ut also in general medical practice. 5tud&ing the point of view of the population from our countr& we concluded that over *-E are against active euthanasia and over (4E don2t agree also with passive euthanasia0 considering that it is necessar& to continue the therap& even in a case of an incura$le disease0 and letting the nature decide. !he points of view of the students in medicine0 who we separatel& investigated0 showed that almost 5-E of them agree active euthanasia and the same percent was found for passive euthanasia. 5ome of the students agreed to practice euthanasia in the case of a patient in cere$ral death0 while others agreed to practice euthanasia onl& for severel& malformed new$orn children0 while others agreed for $oth cases. Even if euthanasia is not totall& accepted0 a ver& important pro$lem of the medical responsi$ilit& is represented $& the assistance of death. ,i)e $irth0 death has to $e medicall& assisted0 to confer to the patient the necessar& silence on the wa& to another world0 the world of the spirit0 who survives in front of the ephemeral nature of the ph&sical e6istence. /n this purpose0 the ph&sicians contri$ute $& their actions to the diminution of some feelings of the d&ing person: the fear of un)nown0 the fear of solitude0 the fear of regrets0 the fear to lose the famil& and friends0 the fear to lose the $od&0 the fear to lose the self9control0 the fear of suffering and pain0 the fear to lose the identit&0 other wa& sa&ing0 to insure the ps&chological comfort of the patient with the purpose to conserve his identit& and autonom& until the last moment of life. 3rom all the pro$lems discussed we ma& conclude that the respect of the ph&sician for life has to go until the medical ps&chological assistance of death. ;s long as an6iet& of the patient is $igger0 the need for a ph&sician would $e more acute. ,i)e an

adviser of these states0 the ph&sician will cultivate his aptitude to help the patient in a calm and decent wa& to the %other world'. /n this wa&0 the ph&sician accomplishes the human %model' of the respect in front of death. /nstead the ph&sician to sa& that nothing can $e done0 he will help death to $e calm and decent0 onl& in this wa& his human and professional mission $eing accomplished. ;s a conclusion0 the aging of the population0 the %human and patient2s rights'0 the diminished power of religion0 the refuse of suffering and of lac) of dignit&0 contri$ute in an important measure to the changing of opinion concerning euthanasia and the adaptation of the laws in this field. !he term of euthanasia is differentl& accepted depending on the culture0 nationalit&0 tradition0 religion0 ha$its0 and can not $e allowed or for$idden totall& with the help of the laws $ecause it represents a ver& delicate pro$lem and the conscience of ever& ph&sician has to discuss it for ever& separate case. !oda& or in the future it will $e impossi$le to create rigid laws to appl& or not appl& euthanasia $ecause finall& it represents a pure pro$lem of morals.

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