Euthanasia & Terminal Care OLD News
Extracts from EEIN 1991-1994. Latest news is at the bottom. Provided by Eubios Ethics Institute , at
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Abbreviations for journals
On the issues of euthanasia and living wills see: BMJ 302: 870; NEJM 324: 882-8, 889-95, 1210-3; JAMA 265: 1868-71, 1874-5. The recent case of active euthanasia in Japan, where a doctor injecte KCl into an incompetent patient at the pleading of relatives, has been judged unethical. However, it has exposed the inadequacies of Japanese terminal care, where many patients who have pain remain in pain because pain killers are not completely covered by the national health insurance. This creates the desire to die, and when combined with the inadequate medical communication and trust between patient and doctor, there will remain relatively high public support for informed and consenting active euthanasia of competent patients, despite the illegality of it. 50% of the public asked by one TV station support active euthanasia if patient and family want it.

An article on the limits of treatment is N.S. Jecker, "Knowing when to stop: The limits of medicine", Hastings Center Report (May/June 1991), 5-8. There are also two related book reviews in the Hastings Center Report (May/June 1991), 34-5. There is a paper on the withdrawal of life sustaining treatment from severely brain-damaged persons in MJA 154: 559-61, see a related case in BMJ 303: 153.
Other papers include B. Pollard, "Medical aspects of euthanasia", MJA 154: 613-6, which argues against the adoption of the practice used in the Netherlands; K.S.M. Clark "Down the slippery slope", Bioethics Research Notes 3: 9-10, also 15-16; and a brief review by E.D. Pelligrino on the movement for voluntary euthanasia, JAMA 265: 3118-9. An editorial on the success of the Hemlock Society's book Final Exit in the USA is in Nature 352: 553. A debate on euthanasia in the European Parliament is discussed in BME (June 1991), 25-7. A letter on euthanasia is MJA 154: 491-2, & on PVS; BMJ 303: 121-2. A report of a survey of US judges about life-sustaining treatment is in NEJM 324: 1673-4.
At the end of the year, advance directives must be signed by many patients entering US hospitals. This is discussed in J. La Puma et al., "Advance directives on admission. Clinical implications and analysis of the patient self-determination Act of 1990", JAMA 266: 402-5, and an editorial on p. 411-2.

The results of a Dutch study on euthanasia are in P.J.van der Maas et al., "Euthanasia and other medical decisions concerning the end of life", Lancet 338: 669-74. In 17.5% of all medical decisions concerning the end of life, high levels of pain-relieving opiates were used, which may have shortened life; in another 17.5% non-treatment was a factor. Lethal drug delivery at request of patients was used in 1.8% of all deaths (of which 38% involved medical decisions, so the total number of patients deciding to use lethal drug injection as a medical decision was about 4-5%). Dutch doctors want to legalise euthanasia, rather than just having judge-ordered immunity from prosecution; NS (12 Oct 1991), 17. See also Lancet 338: 952-3; BMJ 303: 877.
In the USA, the Michigan Dr. Kevorhian, who was acquitted of murder charges, but told not to use his device again, has been letting patients use the euthanasia device again. This time two women were assisted with the aid of his machine. On machine involved an initial pull of the rope by the woman to release anaesthetic, and as her arm fell under the affects of anaesthetic a second switch was activated releasing sodium pentothal. The other used carbon monoxide; NY Times (25 Oct 1991), A10. There was much criticism as can be expected, and he may lose his medical license, and/or be criminally charged. On the situation of the law on assisted suicide in the USA and the U.K. see BMJ 303: 431-2. Letters on death and dignity are in NEJM 325: 658-60, see also a book review of the popular US book, The Final Exit, by Derek Humphrey, in NEJM 325: 894-5. Other book reviews are in NEJM 325: 367-8; JAMA 266: 1141-2. See letters on dying and euthanasia in CMAJ 145: 620; MJA 154: 710, 155: 58-9, 64, 133-4.
A report on how the Patient Self Determination Act will be applied in the USA is F. Rouse et al., "Practicing the PSDA", Special Supplement, HCR (Sept/Oct 1991), S1-16. On health care proxy and the living will; NEJM 325: 893-4; on doubts over the accuracy of proxy decisions; Annals of Internal Medicine 115: 92-8. On do not resucitate orders; JAMA 266: 794-5; CMAJ 145: 709-12. On the case of Mrs Helga Wanglie and medical futility see the HCR (Jul/Aug 1991), 23-35, (Sept/Oct 1991), 26-8; NEJM 325: 511-2, 512-5.
Comments on the varying definition of euthanasia by M. Sommerville are in Bioethics Research Notes 3: 17-8. The definition that people use affects the opinions concerning it. On the increasing use of euthanasia in China see J. Medicine & Philosophy 16: 131-8. Comments on the German reactions to the questions of euthanasia are in the HCR (Jul/Aug 1991), 2, see also p.4. A book review on euthanasia in the Nazi era is in Lancet 338: 372.
The European Parliament will be discussing the issue of euthanasia in November, or at least it should be, following the delays on votes on a clause supporting euthanasia from June.

The results of a survey in Canada about the preferences of people for making their own health care decisions are described in; D.W. Molloy et al., "Treatment preferences, attitudes toward advance directives and concerns about health care", Humane Medicine 7: 285-90. Of the sample of 909 public, more than 90% wanted some control over their own health care decisions and expressed a desire to put on record their preferences. Over 80% were concerned that they would receive treatment without being consulted. This survey supports the use of advance directives. A paper discussing how better decisions about life-sustaining technology may be made is W.A. Knaus et al., "Short-term mortality predictions for critically ill hospitalised adults: science and ethics", Science 254: 389-94. Concerns about the recently implemented Patient Self-determination Act in the USA are debated in NEJM 325: 1666-71.
Do not resusciate (DNR) orders are discussed in JAMA 266: 2407-12, 2433-4; and the limited success of resuscitation attempts outside hospitals in NEJM 325: 1393-8, 1437-9.
On aging and rationing of health care see BMJ 303: 1268-9. On the quality of life, and QALY see BMJ 303: 1136-7;Bioethics Research Notes 3: 25-6. The quality of life and metastatic breast cancer is discussed in NEJM 325: 1370-1.
The referendum held in Washington state, USA, on a proposition to legalise voluntary euthanasia was rejected by 55% of the voters, to a vote of 45% for euthanasia; BME (Nov 1991), 3; BMJ 303: 1223; Lancet 338: 1261; JAMA 266: 2895-900; Nature 354: 254. There had been signs that this proposal would have obtained majority support, but it has continued to raise the discussion of euthanasia in the USA. The main opponents were half of the medical profession and the Catholic church. This was further raised by the two cases of assisted suicide by Jack Kevorkan (EEIN 1: 82), at the end of October. He has been indicted for homicide again, so another court case will follow. See also NEJM 325: 1100-2, 1307-11. There has also been debate about euthanasia in the U.K. (Times 11, 16, 19, 28 Oct 1991); BMJ 303: 1422. On the book Final Exit, see Nature 353: 788; JAMA 266: 2150.
The European Parliament may debate euthanasia in January, BME (Nov 1991), 4-5. On terminating treatment, basically voluntary euthanasia, in Hungary see BME (Oct 1991), 13-20. On Dutch euthanasia see CMAJ : 1341-2; MJA 155: 422; Lancet 338: 1010-11, 1150, 1400.
A comparison of self-care among elderly Japanese and Americans is M.R. Haug et al., "Self care: Japan and the US compared", Social Science & Medicine 33: 1011-22. The Japanese reported less cases of physicians making mistakes, though this could also be due to a cultural difference, that Japanese may not speak out about this. However, the Japanese also reported far less disease symptoms, and less visits. A related issue is homecare; Lancet 338: 1303-4, 1275.

On living wills see J.A. Robertson, "Second thoughts on living wills", Hastings Center Report (Nov 1991), 6-9. A series of reviews on papers that look at advance directives is in BME (Dec 1991), 16-20, in addition to further reviews of some more general papers related to medical ethics on p. 20-23. Some letters on advance directives appear in JAMA 267: 51-2. A survey of patients in the USA is reported; A. Sehgal et al., "How strictly do dialysis patients want their advance directives followed?", JAMA 267: 59-63, 103-4. One third of patients wanted no leeway whereas another third chose complete leeway, for the family members making the decisions, while a third were intermediate. On the advance directive implementation in the USA; Nursing Management (Dec 1991), 29-32; and on reimbursement and advance directives see letters in JAMA 266 (1991), 3424-5; and a book review in Lancet 338: 1579.
A discussion of the protests by some groups in Europe to recent visits by Prof. Peter Singer, and on the freedom of academic speech regarding euthanasia see B. Schone-Seifert & K.-P. Rippe, "Silencing the Singer. Antibioethics in Germany", Hastings Center Report (Nov 1991), 20-7.
Comments on euthanasia cases from around the "world" (Japan, Netherlands, Canada, France, Australia, Germany, USA & Britain) are mentioned in BMJ 304: 7-10. A Japanese court has decided that a man who helped his terminally ill female partner die in response to her requests, in 1991, did so out of deep love, so he was only sentenced to 1 year with a 2 year stay of execution; Asahi Newspaper (1 Jan 1991), 31. Letters on euthanasia appear in MJA 155 (1991), 645-6. A discussion paper is G.I. Benrubi, "Euthanasia - the need for procedural safeguards", NEJM 326: 197-9.
On do not resusciate orders see; G.R. Scofield, "Is consent useful when resuscitation isn't?", Hastings Center Report (Nov 1991), 28-36. A survey on DNRs in an UK hospital is reported in E.J. Aaraons & N.J. Beeching, "Survey of "do not resuscitate" orders in a district general hospital", BMJ 303: 1504-6. See also BMJ 304: 121; C.B. Cohen & P.J. Cohen, "Do-not-resusciate orders in the operating room", NEJM 325 (1991), 1879-82.
On the court progress in the recent Dr Kevorkian trial in the USA (EEIN 2: 12) see Washington Post (15 Feb 1991), A4. Some guidelines for health staff on counseling dying patients of different religions are in Nursing Times; on Christianity (15 Jan 1991), 26-9, and on "Christian Science" (22 Jan 1991), 32-3.
Not on the topic of terminal care, but rather on the issue of elderly populations, see D. O'Neil, "Physicians, elderly drovers, and dementia", Lancet 339: 41-3.

The Japanese Medical Association has recommended that there be general legislation allowing doctors to withdraw life-sustaining treatment if patients wish to do so in cases of terminal illness. They want the law to recognise living wills, but opposed legalising euthanasia. The report by the life ethics committee also suggested that cancer patients be informed of their disease "in principle"; Asahi Evening News (19 March 1991), 1.
For a discussion on suffering and pain, see an article by L.Klug in Trends in Bioethics (March 1992), 1-7. A discussion of the book, Final Exit (EEIN 2:12) is in Hastings Center Report (Jan/Feb 1992), 30-3; AJLM XVII (1991), 475-7. On another book, The Ends of Human Life: Medical Ethics in a Liberal Polity, E.J. Emanuel, see a review in Lancet 339: 602. The difference between rational suicide and psychiatric disorders is discussed in NEJM 326: 889-91. A paper by H. Jonas, "The burden and blessing of mortality", Hastings Center Report (Jan/Feb 1992), 34-40; discusses death in the context of life. On the end of life, and difficult cases see NEJM 326: 933-5. The role of physicians in the death system is discussed in JAMA 267: 1265, 1269-70; see also p.949-53.
An opinion survey of Australian nurses has found that about half have been asked by patients to hasten their death, and 25% had been asked by doctors to aid the hastening of patient's deaths following requests of patient's; Australian Nurses J 21: 21-2. Also on euthanasia in Australia see Lancet 339: 800-1. The European Parliament has delayed voting on the motion on euthanasia, and several other news items on euthanasia are also in BME (March 1991), 4. In the Netherlands , a study has found that over two thirds of Dutch physicians have certified that a patient died of natural causes, when in fact they aided their death; BMJ 304: 462. The results of a Canadian survey of opinions on euthanasia to the same questions over the period 1962 to 1991, has shown how public support for euthanasia, including by lethal injection, has increased greatly; BMJ 304: 717.
Do not resuscitate orders are discussed in JAMA 267: 682-6, 1465-7. The introduction of advance directives in the USA should be studied by other countries, and should promote wide debate; BMJ 304: 398.

Revised euthanasia legislation is being proposed in the Netherlands, though there is still debate about whether laws should regulate this area of medicine; Lancet 339: 920.
The results of US public opinion on withdrawel of life support treatment is in R.J. Blendon et al., "Should physicians aid their patients in dying? The public perspective", JAMA 267: 2658-62. The level of support for legalising euthanasia has been about 60% since 1977, being about 63% in 1991, suggesting it has plateaued. See also Lancet 339: 1164. Letters on the US Patient Self-Determination Act are in NEJM 326: 1501-3; JAMA 267: 1920-1.
In one study of 1000 deaths, there appears to be little impact of the 1987 New York state do not resuscitate law on pratcice, though more formal dnr order are being written; J.C. Ahronheim et al., "Impact of do-not-resuscitate legislation on the use of cardiopulmonary resusciation in three teaching hospitals", NY State J. Medicine 92: 181-5; see also 129-30; G.P. Wolf-Klein et al., "The do-not-resuscitate order in a nursing home: Patient's choice or staff's decision", p. 131-4. A report of the AMA Council on Ethical and Judicial Affairs entitled "Decisions near the end of life" is in JAMA 267: 2229-33. It supports patient autonomy, but still cautions against euthanasia, saying that this issue needs more discussion.
The debate on nutrition and hydration in the catholic tradition is debated in In Keeping with the Trends (June 1992).
On growing old gracefully see Lancet 339: 1157-8; and on dying with dignity see World Health Forum 12: 375-81.

The July 1992 issue of Bioethics features several papers discussing aspects of the quality of life , plus several book reviews; Bioethics 6: 183-266. One paper, R.W. Perrett, "Valuing lives", pp. 185-200, asks looks at a controversial topic, of economic valuation of people's lives. Let us hope that the economic paradigm that has been adopted by most people as the determinant of the success of life, does not come to dominate ethics as it has come to dominate most other areas. The quality of life is difficult to define, perhaps it should be left to individuals as to how much quality they have in their life, and to others around them to attempt to enhance their quality of life. Letters on the quality of life are in JAMA 268: 471-2; JME 18: 48; BMJ 304: 1523-4; 305: 424; J. Coast, "Reprocessing data to form QALYs", BMJ 305: 87-90; H.R. Lentzner et al., "The quality of life in the year before death", AJPH 82: 1093-8; and on pain see Triangle 31: 9-19.
Comments on the need for spiritual care in health care is in St. Joseph's College Catholic Bioethics Centre newsletter, In Keeping with the Trends (August, 1992). As an observation on the Japanese situation, most Japanese hospitals do not have a priest or spiritual counselor, unlike Western hospitals.
Letters on safeguards for euthanasia are in NEJM 327: 201-2; Lancet 340: 56; MJA 156: 579-80; and on P. Singer's reception in Germany see JME 18: 103-4. Also on the ethics of euthanasia see NS (20 June 1992), 25-30. Research on the causes of suicide are described in Science 256: 1761; JAMA 267: 3027; NEJM 327: 490-1. On programmed cell death see TINS 15: 278-80; and on biological life span; BMJ 305: 431.
There are estimated to be between 5-39,000 PVS patients in the USA; HCR (May-June 1992), 2-3. The opinions of when intensive care and life support should be ended are still mixed, as shown in various opinion surveys - but should continued health care be given to PVS 'persons' at a time when funding is unavailable for many other patients with recovery chances. More comment on ICU policy is R.D. Troug, "Triage in the ICU", HCR (May-June 1992), 13-7; and on neonatal intensive care, N.M.P. King, "Transparency in neonatal intensive care", HCR (May/June 1992), 18-25. The sociology of providing food and fluids is discussed in SSM 34: 1271-6. A debate on futility is in NEJM 326: 1560-4; and on protecting patients from overtreatment; NEJM 327: 424-9.
A series of articles on the Patient Self-Determination Act are in Cambridge Quarterly of Healthcare Ethics 1: 97-126. A Canadian survey of physician attitudes to advance directives found that 86% favoured them; CMAJ 146: 1937-44. A UK advance directive bill is going to be introduced to the House of Lords later this year; BMJ 305: 139. Comments on the care of terminally ill patients are in Triangle 31: 1-7.

Some examples of cases in Australia where patients refused treatment, and resulted in law changes are discussed in MJA 157: 277-9. Recent Australian guidelines from the Ethics Committee of the Central Sydney Health Service on terminal care are J.M. Greenaway et al., "The management of terminally ill patients", MJA 157: 275-6.
In November, Californians will be voting on a referendum on whether to accept a "Death with Dignity" statute. The March-April issue of the Hastings Center Report (which I received after the Sept. issue) features many papers on the issue of euthanasia, HCR (March-April 1992), 6-55. See the feature article in the last issue of the EEIN 2: 58-9, which criticises the practise of euthanasia in the Netherlands. A letter on how to classify suicide is in BMJ 305: 472.
On the topic of assisted suicide see BMJ 305: 720; N.Y. State J. Medicine 92: 388-91. In Denmark people have a legal right to passive aid to help them die; Lancet 340: 901-2. In Kyoto from the 23-26 October there was an International Congress of the Right to Die societies, with 700 attendants from 15 countries. There is still no law related to living wills in Japan, though they are recognised by some doctors, and circulated to a limited extent.
In Britain a consultant specialist has been convicted of attempted murder for aiding euthanasia, and was sentenced to one year's suspended prison term; BME (Sept 1992), 3-4; Times (21, 22, 23 Sept 1992); BMJ 305: 728-9, 731; Lancet 340: 757-8, 782-3. The reaction to the decision has been mixed, but it has raised the euthanasia issue in the UK. The living will issue is also likely to be raised in the House of Lords later in 1992. The Sept. issue of the J. Medical Ethics includes a supplement with what is called the Appleton Consensus statement on guidelines for decisions to forego life-prolonging medical treatment. The discussion on voluntary euthanasia is reproduced in BME (Sept 1992), 6. A new living will form is being circulated in Britain, BMJ 305: 602-3.
The distinction between permanent and persistent vegetative states is made in BMJ 305: 486-7. The treatment options for persistently vegetative sate patients are discussed. The costs of persistent vegetative state are analysed in N.Y. State J. Medicine 92: 381-7. A "right to die" case is expected to go to the High Court at the end of 1992,BMJ 305: 732. A book review of a French book on permanent vegetative state is in HCR (July-Aug 1992), 22: 36-7. The book is the result of a two year project by a multidisciplinary team. The French view focuses on the relationship of the person in chronic vegetative state with their family, in contrast to the American view. The technology of magnetic resonance imaging may allow better judgements of brain function, see JAMA 268: 1387-8.
The case in Germany of a brain dead pregnant women who is being used as a fetal incubator is raising much debate. This experiment, to attempt to gestate a fetus from 13 weeks until birth in a brain dead mother was began against the will of her parents, who have since said they support it. They are exercising the mother's body and delivering hormones. No doubt should the pregnancy be successful they can do follow-up studies on the effect on the child - such kind of medical record breaking should be unethical. It is also contributing to discussion of abortion in Germany.

An editorial in Bioethics 6(4), iii-vi discusses the relevance of the Dutch practice of legalised euthanasia for other countries that do not legally allow it. There remains considerable uncertainty in the numbers of cases in all countries, but more uncertainty in those countries where euthanasia is not regulated. Discussion of approaches to assisted death in the USA are in NEJM 327: 1381-8. In the November 3 referendum in California , the proposal for physician-aided death was rejected by a vote of 53% to 47%; Lancet 340: 1028-9; BMJ 305: 1175. The Chinese attitudes to euthanasia are discussed by Dr Zhang Ju in Bioethics Research Notes 26: 25-6. Letters on euthanasia are in BMJ 305: 951-2, 1224-5; Amer. College of Surgeons Bulletin 77: 7-17; Critical Care Medicine 20: 566-8.
A court case continues in Japan about a Tokai University doctor who carried out active euthanasia. The son of the dead patient has changed his testimony in the court to say that he cannot remember the patient asking for euthanasia; Yomiuri Shinbun (12 Nov 1992), 30. A call to end the death penalty in Japan has been made by 173 Diet members, calling on the government to ratify the UN convention from 1989. Since 1989 no one has been executed in Japan, but 56 people are on death row; Japan Times (28 Nov 1992). In the USA, Dr Jack Kevorkian has been active in assisting several more persons to die, while the Michigan law will be changed early in 1993 to make this practice a legal crime. Attitudes of medical students, housestaff and faculty physicians to euthanasia in the University of Miami Hospital show much uncertainty and stress the need for case-centred medical ethics training, Critical Care Medicine 20: 683-90. In the UK , Dr Nigel Cox, a rheumatologist who was convicted of attempted murder for active euthanasia using potassium chloride has been given an opportunity to return to practice the General Medical Council; BMJ 305: 1311; Lancet 340: 1345.
An interesting paper on the Indian Jainist practice of self-willed death is P. Bilimoria, "The Jaina ethic of voluntary death", Bioethics 6: 331-55. The legal and religious situation in India is discussed, along with the concept of the right to die. Description of some refusals of medical treatment which changed the laws in Victoria, Australia, are in MJA 157: 277-9.
On managing terminally ill patients see MJA 157: 275-6; NEJM 327: 1239-30. Quality of life measures are discussed in BMJ 305: 875-7, 1074-7, 1145-8, 1205-9, 1365-6; SSM 35: 1505-10. Advance directives are discussed in NEJM 327: 1165-9; Lancet 340: 1321-2; CMAJ 147: 1370. A related book review is in Lancet 340: 1084. A legal commentary is S.H. Kadish, "Letting patients die: Legal and moral reflections", California Law Review 80: 857-88.
Papers discussing whether we can ascribe mental states to the comatose are in Bioethics 6: 365-77. Letter on persistent vegetative state are in BMJ 305: 853-4, 886-7, 1159-60. The British High Court has ruled that doctors can stop feeding a vegetative patient, Tony Bland, BMJ 305: 1305-6, 1312; Lancet 340: 1343. The withdrawal of nutrition has been authorised by courts in Canada, new Zealand, South Africa, and the USA in the past. The process of forgoing life-sustaining treatment in the University of Minnesota hospital is reported in Critical Care Medicine 20: 570-7.
Prevention of suicide is discussed in letters in Lancet 340: 1233-4.
Guidelines on the ethical considerations for resuscitation are in JAMA 268: 2282-8. Related to euthanasia see Humane Medicine 8(4), 307-9, 317-20. A research paper on Drosophila (fruitfly) which did not find increasing mortality at older age suggests a new model of aging is needed; Science 258: 398-9, 461-3.

From March 1993 a new law in Michigan , USA, will come into effect making assisted suicide a criminal offence punishable by imprisonment. On Feb 15 (Dr) Jack Kevokian assisted another person, the 7th recorded, this time a 70 year old immobile man, commit suicide, using carbon monoxide inhalation. Discussion of Kevorkian is in Hospital Ethics (Sept/Oct 1992), 4-5; (Nov/Dec 1992), 9. A German equivalent has been arrested by a police operation, BMJ 306: 351-2.
A discussion of active euthanasia is C.S. Campbell, "Religious ethics and active euthanasia in a pluralistic society", Kennedy Institute of Ethics Journal 2 (1992), 253-78. Also on aid-in-dying see JME 18 (1992), 128-34. The defeat of the California referendum on assisted suicide is discussed in HCR 23(1), 32-3; and other articles are in Hospital Ethics (Jul/Aug 1992), 6-11. A critique of the issue concluding that there is not a right to die is L.R. Kass, "Is there a right to die?", HCR 23(1), 34-43. He reports that in the USA about 1.5 million deaths are year are preceded by decisions about when to end medical treatment. Another philosophical paper is J. McMahan, "Killing, letting die, and withdrawing aid", Ethics 103: 250-79.
The Netherlands has legalised mercy killings (active euthanasia) for patients who have given their informed request to die, by guaranteeing legal immunity from prosecution for physicians who follow guidelines. The Vatican has made negative comments, comparing it to Adolf Hitler's execution of the mentally and physically disabled, which has upset Dutch people. The government is also going to consider guidelines for patients unable to give consent. In the Remmelink Report, it was reported that in 1990 there were 2300 requested deaths and 1,000 nonconsenting acts of euthanasia. A paper saying that the euthanasia law does not enhance the autonomy of patients but enhances the autonomy of doctors is in J. Med. & Phil. 17 (1992), 419-37. Also see JME 18 (1992), 138-41.
A discussion of German views on euthanasia is in BME (Nov 1992), 19-23. A paper on clinical ethics is assisting euthanasia which looks at how to avoid malpractice in drug application is J. Med. & Phil. 17 (1992), 439-43. Many would consider it not as malpractice but assisted suicide or killing.
A discussion of the recent euthanasia decisions in the UK is in BME (Nov 1992), 3-5; Lancet 340 (1992), 1474-5. The British Medical Association strongly supports the use of advance directives (living wills). The World Medical Association adopted a condemnation of physician-assisted suicide in September 1992, which is in BME (Dec 1992), 6.
On the question of passive euthanasia, or letting die , there is wider acceptance of limits of treatment. The use of barbiturates in the care of the terminally ill is debated in NEJM 327 (1992), 1678-82. In the financial year 1991-2 the UK government contributed 17 million to regional health authorities in England to increase the support given to voluntary hospices, BME (Dec 1992), 7. In 1992-3 32 million was given. A legal review is A. Meisel, "The legal consensus about forgoing life-sustaining treatment: Its status and its prospects", Kennedy Institute of Ethics Journal 2 (1992), 309-346. Papers on the legal case of Tony Bland, in persistent vegetative state for nearly 4 years, include BMJ 305 (1992), 1506; 306: 11-2, 142-3; Lancet 340 (1992), 1534-5.
A review of the situation regarding surrogate-decision-making in New York state is in HCR 23(1), 5-11. A proposal for a law to govern such decision-making is in AJLM XVIII (1992), 203-32. Reviews of the Patient Self-Determination Act in the USA are in HCR 23(1), 12-24; there are some questions about how well it is working Hospital Ethics (Sept/Oct 1992), 14-5; (Nov/Dec 1992), 10-11.
A call for physicians to talk to patients about their death and when to stop treatment is made in JAMA 269: 321-2, following several studies of patient attitudes and outcomes. A study on the way American physicians tell the truth to dying patients is in SSM 36: 249-64. Papers on treating the terminally ill include MJA 157 (1992), 701-4, 714-5; JAMA 269: 50; J. Med. & Phil. 17 (1992), 445-54; JME 18 (1992), 115-6. On the quality of life, JRSM 86: 10-2; BMJ 306: 379-81. A sexist report in Japan, said that by the year 2025, one in two adult women would be looking after an Alzheimer's patient, compared to one in 25 now; Yomuiri Shinbun (19 Jan 1993), 2. Let us help that by 2025, men may also look after the elderly!
A review of the process of aging is in SA (Dec 1992), 87-95. In Japan in the mid-1900s, single men and women had 15-20 years lower life expectancy than married persons, and attempts to explain this are in SSM 36: 533-46. The choice of antidepressant medication may be associated with risk of suicide, so prescriptions need to be carefully made; JAMA 268 (1992), 3441-5. A UK High Court decision on whether prison authorities can let hunger-strikers die is discussed in BMJ 305 (1992), 1454.

Further comments on the recent legal changes in the Netherlands regarding euthanasia (EEIN 3: 26), are in NS (20 Feb 1993), 3; BMJ 306: 415; Lancet 341: 426. A German scandal over death capsules for use in euthanasia is reported in Lancet 341: 551, 553. Denmark is using living will's following a law last September, BMJ 306: 414.
A series of papers on ethical issues in caring for dying, and on now to confront death is in Humane Medicine 9(1), 1-84. It includes several patient family's accounts, on the choice of dying at home, in hospices, and the working of advance directives. Do not resuscitate orders in the UK, and guidelines, are discussed in BME (March 1993), 3-5; Hospital Ethics (Jan/Feb 1993), 1-11; JAMA 269: 1025-9; NEJM 328: 506-9. A review of literature on living wills, advance directives, and passive euthanasia is in BME (March 1993), 16-20. A special issue of the J. Med. & Philosophy 17 (1992), 563-682, has essays in the aftermath of Cruzan. The views of doctors on patient's decisions to refuse life-sustaining treatment are surveyed in AJPH 83: 14-23.
A series of views and experiences on how medicine treats the elderly is in U.S. News & World Report (18 Jan 1993), 72-81. On treatment for the elderly see BMJ 306: 806-7, 821-4, 827-30; AJPH 83: 331-7, 338-41. On neonatal care ethics see Lancet 341: 794-5.
The subject of much euthanasia debate in the UK in recent months, Tony Bland, has died, after life-support was discontinued. This was after the Law Lords agreed, saying that at the moment in the UK High Court approval should be obtained for all such similar cases of PVS; BME (March 1993), 1-3, 5; Lancet 341: 410, 482-3; BMJ 306: 413-4. A summary of the legal judgements is in BME (Feb 1993), 31-4. On ethical problems with the concept of futility see Bioethics News 12(2), 33-40. On persistent vegetative state see Lancet 341: 428, 934. Also on euthanasia see Lancet 341: 763-4.
Another UK case, involving active euthanasia and Nigel Cox, is discussed in HCR 23(2), 2-3. Assisted suicide by Jack Kevorkian in Michigan has been legally outlawed from 1st April, for 15 months, while a commission examines it. Up until that time, he had assisted the suicides of 15 people. California has removed his name from the medical register, as had Michigan, so he is no longer able to practice medicine in the USA. Letters on physician assisted suicide are in NEJM 328: 964-6.
A report on the Hungarian attitudes to neonatal euthanasia are in K. Schultz, "Hungarian paediatricians' attitudes regarding the treatment and non-treatment of defective newborns. A comparative study", Bioethics 7: 41-56. It includes comparisons to attitudes in Australia, Poland, and Canada.
On the quality of life and different antihypertensive therapies see NEJM 328: 907-13, 914-21, 959-61. On the quality of life see Hospital Ethics (Jan/Feb 1993), 14-5. A comment on how to give sad news is in Lancet 341: 476-8.
Research on longevity genes is increasing, with much commercial investment; GEN (1 Mar), 1, 26-7. A review of the mechanisms of cell death is in PNAS 90: 786-9; and a book review on aging in Science 259: 1630-1. A review of aging in humans is in SA (April 1993), 18-24.

In New South Wales, Australia , guidelihnes removing the legal responsibility on physicians to prolong life-sustaining treatment have been issued, recognising a limited right to die ; Lancet 341: 1338; BMJ 306: 1363. General comments on euthanasia debate in the UK and in Europe are in HCR 23(3), 5; BME (May 1993), 25-32; and in Australia,Bioethics News 12 (3), 37-46. New UK guidelines on "Care in the Community for People who are terminally Ill" are summarised in BME (May 1993), 8-11. They are guidlines for dying at home. A description of the legal system regarding euthanasia in the Netherlands is in Bioethics Research Notes 4: 9-10. The Dutch doctors association also supports termination of people with dementia if a living will has been made; Lancet 341: 1196-9; BMJ 306: 1364.
Papers asking whether US laws against assisted suicide are unconstitutional is in HCR 23(3), 32-41; NEJM 328: 1573-6. It is specifically debating the Michigan temporary law designed to stop Kervokian from assisted further suicides. No other state has such a law, and the case is being debated now in the US. A UK legal case of doctors and manslaughter is in Lancet 341: 1404; BMJ 306: 1150, 1432-3, 1431-2. Guidelines on do not resuciate orders are in BMJ 306: 1593-6.
For many people it is important to increase their hope, and a paper on this is R. Jevne, "Enhancing hope in the chronically ill", Humane Medicine 9: 121-30. On care of the elderly see Science 260: 1160-1; JAMA 269: 2148, 2331-2, 2348-53, 2486-8; US News & World Report (26 April 1993), 65-72.
The legal dimensions of the Anthony Bland PVS case are discussed in Dispatches 3(3), 5-8. A New Zealand report on the subject, Persistent Vegetative State and the Withdrawal of Food and Fluids, prepared by the Otago University Bioethics Research Centre and approved by the NZ Medical Council is available from the NZ Medical Council, P.O. Box 11649, Wellington, N.Z. A summary is in the Otago University Bioethics Research Centre Newsletter 2(2), 6-7. The recovery of PVS patients after long periods is reviewed in BMJ 306: 1597-600; and a US report is in Annals of Neurology 33: 386-91.

The British Medical Association has drawn up guidelines for the care of patients in persistent vegetative state, which are summarised in BME (June 1993), 8-10. Ethical issues in medical "futility", withdrawing treatment and persistent vegetative state are discussed in JME 19: 67-8, 71-6.
There have been a series of papers on euthanasia in Canada : CMAJ 148: 1190-1, 1293-7, 1363-8, 1463-6, 1699-1702, 1705-6, 1889-90, 1895-9, 1929-33, 2129-33. They include a survey of Alberta doctor attitudes in 1991, and a national survey is underway in 1993 by the CMA. The right to die in Canada, and Michigan , is discussed in Hospital Ethics (May 1993), 9-10, with further discussion of the Michigan situation in Hospital Ethics (Jul/Aug 1993), 11-2. Jack Kevorkian has been charged under the Michigan assisted suicide law after helping his 17th person commit suicide.
A Christian responses against active euthanasia is Humane Medicine 9: 207-15. Other comments on euthanasia are in SSM 37 (2), iii-v; Lancet 341Z: 1598-9, 342: 308; BMJ 307: 132; JAMA 270: 221-2, 797, 870-3, 874-6.
The debate on the ethics of rationing by age is in JME 19: 19-27. QALYs are discussed in SSM 37: 153-8, JRSM 86: 440-3, 449-50; NEJM 329: 505-7. There is some age rationing that already exists, Lancet 342: 1-2. The UN Principles for Older Persons are in IDHL 44: 360-2.
The use of the Patient Self Determination Act in Ohio, which also has a state law on advance directives , is surveyed in Hospital Ethics (May 1993), 10-2, and in general in (Jul/Aug 1993), 13-5. The views of medical staff in Canada on advance directives are surveyed in CMAJ 148: 133-8. There is a poor knowledge about them in outpatients, CMAJ 148: 1477-1502,; only 16% knew of living wills, 11% knew of durable powers of attorney and 4% about advance directives. In New Zealand see the above section. A survey of UK outpatients found that 75% said that if they had advanced senile dementia they would prefer not to have CPR, only 10% said that they would want it; JME 19: 104-7.
A survey by the Ministry of Health and Welfare in Japan conducted in March on people over 20 years of age (N=3000) found that 80% said that they don't want continued treatment if they are in vegetative state, and 75% said that they don't want treatment if in pain and close to death. The people over 70 years of age were about 10% more willing to have treatment continued.
A survey of the beliefs of patients with terminal cancer who used alternative medicine is in Sociol. Health & Illness 15: 199-216. The April issue of J. Medicine and Philosophy 18: 101-232 focuses on nonorthodox medical systems. Placebo response is another occasional cure with no sure scientific explanation, CMAJ 148: 2187-8.

On living wills see a commentary on the New Zealand situation in the University of Otago Bioethics Research Centre Newsletter 2(3), 2-3, by P. Skegg. In New Zealand an advance directive is the best way to ensure prolonged unwanted treatment is not given. Persistent Vegetative State is discussed in BMJ 307: 625. A survey of the reasoning used in withdrawal of support is N.A. Christakis, D.A. Asch, "Biases in how physicians choose to withdraw life support", Lancet 342: 642-5; see also p. 867-8.
Prehospital resuscitation and futility is discussed in JAMA 270: 1471-2, with a paper, M.J. Bonnin et al., "Distinct criteria for termination of resuscitation in the out-of-hospital setting", JAMA 270: 1457-62.
In Japan , The Ministry of Education has made a rare compulsory curriculum change for medical schools. All junior medical students must do a 4 day course on care for the elderly and bed-ridden patients, to learn practical matters and "communication" with such patients; Yomiuri Shimbun (31 Oct 1993), 1. The aged society of Japan is also discussed in World Health (May-June 1993), 9-11. On the issue of abuse of the elderly see Lancet 342: 691-2.
Also in Japan, a current best seller is the Complete Manual of Suicide (in Japanese). In France the suicide rate, 21 per 100,000, is now higher than the traffic accident fatality rate. On images of death, SSM 37: 573-4. Dying at home is discussed in BMJ 307: 915-8.
On dying with dignity see D. Callahan, "Pursuing a peaceful death", HCR 23(4), 33-8. The right to die without pain is debated in Lancet 342: 567-8. The Supreme Court in Canada has denied a case of physician assisted suicide, in a 5-4 decision, Lancet 342: 918-9. Book reviews on euthanasia are in NEJM 329: 816-7.
Two papers from the Netherlands on euthanasia are in Bioethics 7(4): 323-39. Australian opinion polls from may 22 found that 78% of people agreed with "If a hopelessly ill patient, in great pain, with absolutely no chance of recovering, asks for a lethal dose, so as not to wake again, should a doctor be allowed to give a lethal dose, or not?". The trends since 1962 has been steadily higher, Bioethics News 12(4), 4.
Allocation of medical funding ethically is discussed in American Scientist 81: 382-4.

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