Euthanasia is the act of intentionally ending a life to relieve suffering. Assisted suicide is intentionally helping another person to kill themselves.
There are four main types of euthanasia—1. active (the direct administration of a lethal substance to the patient by another party with merciful intent), 2. passive (withholding or withdrawing life-sustaining treatment, either at the request of the patient, or when prolonging life is considered futile; 3. indirect (the prescription of painkillers that may be fatal in an attempt to relieve suffering); and 4. physician-assisted suicide (a medical professional aiding a patient in terminating their life upon the patient’s request).
Euthanasia is legal in Colombia, the Netherlands, Belgium, Luxembourg, Canada, New Zealand, and Spain, as well as in some Australian states, namely, South Australia, Western Australia, New South Wales, Tasmania, Victoria, and Queensland.
In 1997, Colombia’s Constitutional Court ruled that “no person can be held criminally responsible for taking the life of a terminally ill patient who has given clear authorization to do so.” It defined “terminally ill” person as those suffering from cancer, AIDS, and kidney or liver failure “if they are terminal and the cause of extreme suffering”. On the other hand, euthanasia was refused for people with degenerative diseases like Alzheimer’s, Parkinson’s, or Lou Gehrig’s disease. In July 2021, Colombia extended the requirements to access euthanasia for non-terminal patients.
In 2001, the Netherlands legalized euthanasia, including physician-assisted suicide. In September 2004, the Groningen Protocol was developed, with specific criteria to be met for carrying out child euthanasia without the physician being prosecuted. On May 28, 2002, the Belgian parliament legalized euthanasia, and in December 2013, the law was extended to terminally ill children. Belgium is one of two countries, along with the Netherlands, that also grants the procedure for people with mental illness.
On February 20, 2008, Luxembourg became the third EU country to legalize euthanasia, the bill of which was passed on March 19, 2009.Terminally ill patients have the option of euthanasia after receiving the approval of two doctors and a panel of experts. In 2015/2016, Canada legalized voluntary active euthanasia (physician assisted dying) for all people over 18 who have a terminal illness that has reached the stage where natural death is “reasonably foreseeable.” At the same time, to prevent ‘suicide tourism’, only people eligible for Canadian health insurance are eligible.
In November 7, 2021, New Zealand legalized voluntary euthanasia; however, assisted suicide is illegal. In the same year, on June 25, Spain also legalized voluntary euthanasia. In the United States, while active euthanasia is illegal, assisted suicide is legal in some states, namely, California, New Jersey, the District of Columbia, Vermont, Maine, Washington, Colorado, Oregon, Hawaii, one county in New Mexico, and is de facto legal in Montana. Assisted suicide is also permitted in Switzerland.
In the United Kingdom, while active euthanasia is illegal, passive euthanasia is legal (patients have to give advance decision about refusing life saving treatment). Additionally, food and liquid can be withdrawn from a patient in a permanent vegetative state without the need for court approval. In India, also, while active euthanasia is illegal, passive euthanasia was legalized on March 7, 2018, by means of withdrawal of life support to patients in a permanent vegetative state.
In Japan, while there are no official laws on euthanasia, three conditions have to be met in the case of passive euthanasia: 1.the patient must be in the final stages of an incurable disease; 2. express consent of the patient to stop treatment must be obtained prior to death; and 3. passive euthanasia to be by way of stopping medical treatment, artificial respiration, blood transfusion, IV drip, chemotherapy, dialysis, etc. In the case of active euthanasia, four conditions have to be met: 1. the patient must be suffering from unbearable physical pain; 2.death must be near and inevitable; 3. Consent must be given by the patient, and 4. all other pain relief measures must have failed.
In the case of Nepal, the Nepal Medical Council Code of Ethics and Professional Conduct-2017 states that:
1. Euthanasia, the act of painless killing of a patient suffering from an incurable and painful disease, is not legalized in Nepal, and hence no medical practitioner should practice it. However, administration of narcotics and sedatives titrated to alleviate pain and distress in a dying patient is not euthanasia, but is palliative care which should be provided and clearly documented in the medical record.
2. If it becomes clear when caring for a terminally ill patient that the treatment isn’t working, and that any treatment that is not palliative in nature is futile, e.g., terminally ill patient admitted in ICU with ventilator support, medical practitioners should discuss the situation empathically with the patient’s family as soon as possible regarding discontinuation of life supportive measures keeping in mind the best interest of the patient.
Barbiturates, which slow down the activity of the brain and nervous system, are most commonly used to end life. Used medicinally in small doses, they can be a short-term treatment for insomnia, or seizures in emergencies. In different doses and administration techniques, they can also be used as anesthesia during surgery. A large dose will slow down the brain to a point where it stops telling the body to keep the respiratory system working, and breathing ceases. Both secobarbital capsules and pentobarbital (Nembutal) liquid have been used either alone or in combination for physician-assisted suicide. They are also injected for animal euthanasia. Their safety and efficacy in inducing a swift and uneventful death makes them the preferred drugs in countries where euthanasia is legal.
As per the Belgian professional association for pharmacists’ guideline, the recommended procedure is to administer a barbiturate overdose, optionally followed by a neuromuscular relaxant to induce respiratory arrest. Before administering the barbiturate, the physician can administer a benzodiazepine (midazolam) to induce sleep. The guideline issued by the Royal Dutch Medical Association states that a neuromuscular relaxant should always be administered. Other drugs like opioids and benzodiazepines (or combinations of both) without the use of a barbiturate and/or a neuromuscular relaxant are explicitly advised against because of the uncertain lethal effect and adverse side effects. Barbiturates are also the drugs of choice in Switzerland and some U.S. states where physician-assisted suicide is legal. In Canada, midazolam followed by propofol and a neuromuscular relaxant is the most common protocol for euthanasia.
ABC Net. Au, Oct 20, 2017, https://ab.co/3mc9VDc
Journal of Pain and Symptom Management, July 15, 2018, https://bit.ly/3teC68i
Dying is not a Crime: Dr. Death
An American pathologist, Murad Jacob “Jack” Kevorkian (May 26, 1928 – June 3, 2011), championed the right of terminally ill patients to die by physician assisted suicide. Famous for his quote, “Dying is not a crime”, he disclosed publicly that he had assisted the suicide of at least 130 patients.
A series of articles in the 1980s on his thoughts on euthanasia were published in the German journal Medicine and Law. In 1987, he began promoting himself in the US as a physician consultant for “death counseling”. His first public assisted suicide, involving a 54-year-old woman diagnosed with Alzheimer’s, was in 1990 in Michigan. Since the state had no laws on assisted suicide, he could not be charged with murder. However, the next year, his medical license was revoked. Between 1990 and 1998, he assisted in the deaths of 130 terminally ill patients. In 1997, he was tried for his role in a case of voluntary euthanasia of a patient with Lou Gehrig’s disease (ALS) and convicted of second degree murder, for which he served eight years of a 10-25 year prison sentence, before being paroled on June 1, 2007.
The infamous doctor’s modus operandi consisted of attaching the patient to a euthanasia device that he had devised, after which the patient then pushed a button, releasing fatal drugs or chemicals. In two cases, he used a device called “Thanatron” (“Death machine”, from thanatos, meaning death in Greek), which delivered the euthanizing drugs intravenously. Some other patients were assisted by a device named “Mercitron” (“Mercy machine’), in which carbon monoxide was fed through a gas mask.
A local press report disclosed that 60% of the patients he assisted in dying were not terminally ill, and some had not even complained of pain. Furthermore, at least 19 patients died within 24 hours after first meeting Kevorkian, and in at least 19 other cases, where five had depression, there was no psychiatric examination. Ironically, the doctor had himself written in 1992 that “a psychiatric consultation was always necessary when performing assisted suicides, because a person’s mental state was of paramount importance”. The report also revealed that he did not refer at least 17 patients who complained of chronic pain to a pain specialist, and that he did not obtain complete medical records for his patients, and at least three autopsies of his assisted suicides found that the individuals had no physical sign of disease.
After his parole, on March 12, 2008, he ran for the US Congress as an independent candidate, managing to garner 2.6% of the votes (8,987 votes). He authored several books: The Story of Dissection; Medical Research and the Death Penalty: A Dialogue; Beyond Any Kind of God; Slimmericks and the Demi-Diet; Prescription: Medicide, the Goodness of Planned Death; glimmerIQs; Amendment IX: Our Cornucopia of Rights; and When the People Bubble POPs.
The “Elon Musk of Assisted Suicide”
Philip Haig Nitschke (born August 8, 1947) is a former physician and founder of the pro-euthanasia group Exit International, who succeeded in having a legal euthanasia law passed in Australia’s Northern Territory in 1996, which was, however, later overturned by the Australian government. In that period, he assisted in the suicide of four patients, and became the first doctor to legally kill his patients. He created devices, including a product called the “exit bag” (a large plastic bag with a drawstring to be secured around the neck) and the “CoGen” (whereby carbon monoxide is inhaled through a face mask), to aid people who want euthanasia. In December 2008, he released details of a euthanasia machine that uses ordinary household products filled with nitrogen. In 2017, he invented a 3D-printed suicide capsule called “the Sarco”, which consists of a detachable coffin mounted on a stand containing a nitrogen canister. He is known as the “Elon Musk of assisted suicide”.