Med Health Care and Philos (2010) 13:371381 DOI 10.

1007/s11019-010-9266-z

SCIENTIFIC CONTRIBUTION

Doctor-cared dying instead of physician-assisted suicide: a perspective from Germany

Fuat S. Oduncu Stephan Sahm

Published online: 23 July 2010 Springer Science+Business Media B.V. 2010

Abstract The current article deals with the ethics and practice of physician-assisted suicide (PAS) and dying. The debate about PAS must take the important legal and ethical context of medical acts at the end of life into consideration, and cannot be examined independently from physicians duties with respect to care for the terminally ill and dying. The discussion in Germany about active euthanasia, limiting medical intervention at the end of life, patient autonomy, advanced directives, and PAS is not fundamentally different in content and arguments from discussions led in other European countries and the United States. This must be emphasized, since it is occasionally claimed that in Germany a thorough discussion could not be held with the same openness as in other countries due to Germanys recent history. Still, it is worthwhile to portray the debate, which has been held intensively both among experts and the German public, from the German perspective. In general, it can be stated that in Germany debates about questions of medical ethics and bioethics are taking place with relatively large participation of an interested public, as shown, for instance, by the intense recent discussions about the legalisation of advanced directives on June 18 2009, the generation and use of
F. S. Oduncu (&) Medizinische Klinik, Campus Innenstadt, Klinikum der t Mu matologie und Onkologie, nchen, Ha Universita Ziemssenstrasse 1, 80336 Munich, Germany e-mail: Fuat.Oduncu@med.uni-muenchen.de S. Sahm Medizinische Klinik I, Ketteler-Krankenhaus, Lichtenplattenweg 85, 63071 Offenbach, Germany S. Sahm Institute for History and Ethics in Medicine, Goethe-University, Frankfurt, Germany

embryonic stem cells in research or the highly difcult challenges for the prioritizing and rationing of scarce resources within the German health care system. Hence, the current article provides some insights into central medical and legal documents and the controversial public debate on the regulation of end-of-life medical care. In conclusion, euthanasia and PAS as practices of direct medical killing or medically assisted killing of vulnerable persons as due care is to be strictly rejected. Instead, we propose a more holistically-oriented palliative concept of a compassionate and virtuous doctor-cared dying that is embedded in an ethics of care. Keywords Advanced directives Autonomy Doctor-cared dying End-of-life care Euthanasia German medical association Physician-assisted suicide PAS

Introduction Medical doctors in industrialized countries are, on the one hand, increasingly faced with ageing populations and, on the other hand, with rapid progress in medical technologies providing life-sustaining treatments. Doctors have to make tough decisions about end-of-life care. In this very intimate doctor-patient relationship, the notion of the ethical principle of autonomy is strongly stressed and sometimes overextended. As a consequence, patients and even patients without symptoms demand the premature termination of their lives in cases of incurable diseases. The following legalisation of euthanasia and PAS in the Netherlands (2002) as well as the legalisation of medical euthanasia in Belgium (2002) and Luxembourg (2008) have further stimulated controversial debates on the advanced

123

372

F. S. Oduncu, S. Sahm

termination of life in the terminally ill and dying (Oduncu 2002, 2003a, b, 2007a, b; Oduncu and Eisenmenger 2002). Dutch and Belgian doctors who take actions to hasten their patients deaths are exempted from criminal liability, if the so-called due care criteria of incurable and intolerable suffering and of voluntary request have been satised. Besides, the Swiss practice of legal PAS is increasingly requested also by patients from other countries. Today, the Swiss law has caused a booming suicide tourism, where each suicide organisation (DIGNITAS, EXIT and EX INTERNATIONAL) annually provides PAS for about 50 patients from foreign countries. Apart from the European euthanasia context, the Death with Dignity Act of the State of Oregon (USA) of 1997 permits the legal practice of PAS under certain conditions. In the past few years, several empirical surveys have been conducted to analyse the attitudes among medical professionals in different countries concerning medical ller-Busch action to hasten death (for a review see Mu et al. 2004). The written questionnaire studies showed between 10 and 50% of the medical doctors to be in favour of legally permitting euthanasia and PAS. To contribute to this debate, the Working Group on Ethics of the German Association for Palliative Medicine also conducted a survey among its physician and nursing members in order to analyse their attitudes towards different end-of-life medical practices, such as euthanasia, ller-Busch et al. 2003, PAS and terminal sedation (Mu 2004). The German Association for Palliative Medicine has explicitly rejected the practices of euthanasia and PAS as palliative options. Along the debate on end-of-life medicine, nally, the German Medical Association published its Principles Concerning Terminal Medical Care (hereinafter Princi rztekammer 1998), which had been ples) in 1998 (Bundesa rztekammer 2004) and 2008 re-published in 2004 (Bundesa rztekammer und Kassena rztliche Bundesvereini(Bundesa gung 2008). These Principles strictly reject medical euthanasia and PAS. The current article provides a German perspective on the highly sensitive issues of PAS in end-of-life medicine, but does not make a claim to completeness of all different positions of ongoing debates in Germany.

issues (Sahm 2009). This has also been the case with respect to discussion of end-of-life issues. Numerous times, German doctors have given their views on the ethics of limiting acts at the end of life, physicianassisted suicide, and how one could best maintain a patients right to self-determination at the end of life. These views have been published in different documents over the past few decades, and the evolution in terminology and concepts in these documents is very signicant and reects the ethical debate and arguments herein (Sahm 2006; Oduncu 2007b).

The introduction and development of the principles of the German Medical Association Concerning Terminal Medical Care in 1998, 2004, and 2008 Because of their proximity to the Netherlands, German doctors felt especially challenged in clarifying their positions on questions of euthanasia and PAS. Therefore, they initiated a public discourse in 1996 and 1997for the very rst timewhich was followed by the passing of a resolution on the principles of medical care for the terminally rztekammer 1997). In this way the medical ill (Bundesa profession provided the public with the opportunity to discuss and critique the physicians statement before its publication. This debate was reected by many reports in the mass media as well as in pertinent publications by the rztekammer 1999). medical profession itself (Bundesa Through these debates and discussions, one can justly say that the public contributed directly and truly participated in establishing the nal content of these standards for German physicians in end-of-life care. Finally, in 1998, the resolution, Principles of the German Medical Association Concerning Terminal Medical Care, was passed (Bundes rztekammer 1998). a With only a few modications to details, the German principles concerning terminal medical care were once again approved and published by the German Medical Association in 2004. And on January 7 2008, for the very rst time, the German Medical Association and the German Association of Statutory Health Insurance Physicians rztliche Bundesvereinigung) published a joint (Kassena document on Dying in Dignity: Principles and Recom rztekammer und mendations for Physicians (Bundesa rztliche Bundesvereinigung 2008). Kassena The Principles start with a denition of the doctors ethos concerning end-of-life care: The duty of the physician is to preserve life, protect and restore health, relieve suffering and to be there for the dying until death, while respecting the patients right of self-determination. Irrespective of the objective of medical treatment, a doctor is always obliged to provide so-called basic care

The medical, ethical and legal context of terminal medical care in Germany Before looking at the discussion of PAS in particular, it is useful to more closely examine the legal regulations, the jurisdiction, and the ethical debate about medical acts at the end of life. In general, there is a large participation of the German population in public debates on bioethical

123

Doctor-cared dying instead of physician-assisted suicide

373

(Basisversorgung) including inter alia: dignied accommodation, personal attention, personal hygiene, the alleviation of pain, of respiratory distress and of nausea, and the alleviation of hunger and thirst. The doctors duty is to help the dying in such a way that they are able to die with dignity. Moreover, a medical obligation to preserve life does not apply under all circumstances, since there are situations in which otherwise appropriate diagnostic and therapeutic measures are no longer indicated and limitation of treatment and intervention can be necessary or even compulsory. In these instances, palliative medical care will come to the fore. Active voluntary euthanasia, however, is rejected and punishable by German Criminal Code. Also, the Principles hold that participation of a doctor in suicide contradicts medical ethics and may be punishable by law as well. Both euthanasia and PAS are rejected by the Principles. Lifesustaining andprolonging measures may be withheld or withdrawn, if they would only delay the onset of death and if the progression of the illness can no longer be stopped. Even the alleviation of suffering can be prioritized in such a way that the probability of unavoidably shortening life may be accepted. All medical decisions must be in accordance with the patients will. In cases of unconsciousness, the patients presumed will is to be ascertained by his or her previous views and attitudes, philosophy of life, and religious conviction. The patients next of kin should be consulted to ascertain the presumed will of the patient. Here, the legal instrument of advanced directives (ADs) can guide the doctor in taking the appropriate action.

Active, passive, and indirect euthanasia While previous declarations used concepts such as passive and indirect euthanasia, in their Principles, the medical profession decided to refrain from these concepts, which had been long dismissed in the international debate as ambiguous and of little use or benet (for more information see Sahm 2000, 2006; Oduncu 2005a, 2007b). For the purpose of the discussion of PAS, it is not necessary to trace back this development in detail; its consequences are of more importance. The fact that the Principles do not distinguish between active and passive euthanasia implies a fundamental rejection of euthanasia in general. The Principles introduce a concept which describes the intention underlying an act rather than the mode of action (active vs. passive). The acts which were usually considered passive euthanasia, such as limitation or termination of specic interventions at the end of life, are now described as a change in the objective of treatment. In doing so, the Principles reconstitute the intention of the act in contrast to the traditional concept

(i.e. the concept of passive euthanasia). When an illness has advanced and the prognosis is considered terminal, the goal is no longer to maintain life or to cure, but instead to alleviate suffering. The goal of prolonging and preserving life is then replaced by palliative medical and nursing care. The advantages of this conceptual change are obvious. While the traditional concept blurs morally important distinctions, the focus on the motive underlying medical interventions or actions results in much greater clarity and ethical plausibility. The concept used in the Principles allows active euthanasia to be dismissed, while at the same time being aware of the limitations of a physicians duty to act in cases of advanced illnesses at the end of ones life. Whereas in Germany, the old concept was still used in jurisprudence until 2003, the application of the new concepts as found in the Principles became more and more widespread. In its recommendation of 2006, the National Ethics Council in Germany (predecessor of todays German Ethics Council) followed this conceptual framework and reported that it found the concept of passive euthanasia misleading (Nationaler Ethikrat 2006). The same was true for the related concept of indirect euthanasia.1 Internationally, the Ethics Task Force of the European Association for Palliative Care (EAPC) dismissed the concept of passive euthanasia as inadequate and misleading as well (Materstvedt et al. 2003). Public discussion of the permissibility of active euthanasia ared up repeatedly. Surveys showed conicting results in public opinion regarding this issue (Hibbeler 2005). As such, an accurate generalization cannot be made regarding the opinion of most Germans possibly a reection of the aforementioned blurring between the conventional concepts of active versus passive euthanasia. As always in social studies, it is often all about how the questions are phrased. More signicant, therefore, than the results of surveys is the fact that there had been no attempt thus far in Germany to legalise active euthanasia. There were no such bills that proposed to legalise active euthanasia submitted to parliament. German law does not make use of the traditional distinction between active and passive euthanasia. German law forbids homicide at the request of a victim, which refers to the case of active euthanasia. The law does not provide for the case of limiting treatment at the end of life. Hence, the criticism of the concept of passive euthanasia in medical ethics which nally led to the dismissal of the

The jurisdiction in Germany used to refer to the concept of indirect active euthanasia with respect to cases when palliative medical measures have had an unintended (side-) effect such as shortening the patients life. Treatment with pain killers in high doses had often been given as an example, yet, modern palliative medicine has exposed the concept of indirect active euthanasia as inapropriate and obsolete. For a circumstantial discussion see Materstvedt et al. 2003; Sahm 2006.

123

374

F. S. Oduncu, S. Sahm

concept itself does not make it necessary to change the law. The legal regulations concerning euthanasia in Germany are not different from laws in the majority of nations. Only the Netherlands, Belgium and to some extent Luxembourg have legalized active euthanasia so far. The same is true for the ethical position of the German doctors. The dismissal of active euthanasia in Germany is in keeping with the majority of medical associations of other nations and in keeping with the principles of the World Medical Association (1987).

Advocates of this law claim that the rights of patients to self-determination have been signicantly strengthened. Critics fear, however, that doctors would have to follow advance directives, although it may contradict the current interests of the patient. Arguments brought forth in this dispute have been the same in Germany as in other countries (Fagerlin and Schneider 2004; Tonelli 1996; Sahm 2005; Sahm et al. 2005a, b, c).

Physician-assisted suicide (PAS) in Germany: public debate and legal framework Only after having described the considerations shaping German laws on euthanasia and the emphasis placed on the right of self-determination in the new regulations on ADs, can the regulation on PAS be discussed in more detail. The public discussion on PAS has intensied over the past few years in Germany. A number of cases heated up the debate. For instance, the opening of branches of a Swiss euthanasia organisation in Germany, Dignitate Deutschland, ignited controversy. PAS was being discussed on television, in newspapers and on the radio. Dignitate Deutschland is a branch of the Swiss Organization Dignitas, whose goals are supposed to be research, development and realization of the self-determination as set forth in the constitution (Dignitate Deutschland 2009). Whereas the primary goal of the society is reportedly the promotion of the right to self-determination, representatives of that society speak more openly in televised discussions: they want to assist in suicide. One of the authors of this article had himself taken part in nationwide televised debates with representatives of this group (Sahm, cf Die Welt 2007). In 2008, public debate was again fuelled by the spectacular act of former Hamburg judiciary senator Roger Kusch, who helped persons commit suicide. When he did so, it was not a necessary prerequisite that the patients were in the last stage of a terminal illness. The only conditions were that the patients intention to kill themselves was clearly documented and that a psychiatrist documented their accountability. Towards this purpose, Roger Kusch founded a society, Dr. Roger Kusch Sterbehilfe e.V.. Since June 2008, Dr. Kusch has assisted suicide in ve cases. In this context, it is necessary to look at the legal position in Germany. Neither suicide nor attempted suicide is a punishable act. As such, it follows that assisting suicide cannot be a punishable act, either. Therefore, according to some authors, regulations in Germany have been considered exemplary for physician-assisted suicide (Battin 1992). However, this legal evaluation is not as simple as it may appear at rst glance. According to German law, the act

The German law on advanced directives (ADs) comes into force on September 1 2009 The question of a patients self-determination at the end of life was, on the other hand, discussed with considerable public interest over the course of several years. The binding nature of ADs was at the centre of this discussion. However, the legal status of ADs was still unclear, since until recently, there was no law to regulate this eld. On March 17 2003, the German Federal Court of Justice decided in a precedentsetting case that ADs were to be considered binding, insofar as they relate to the particular treatment situation and there are no indications that the patient would no longer consent to their application (Bundesgerichtshof 2006). Life-prolonging procedures may be discontinued in compliance with the patients will, if the progression of the illness can no longer be stopped and they would only delay the onset of death. The patients will is the guiding principle for any action by the doctors. Although the decision of the Federal Court of Justice has strongly contributed to strengthen ADs, the decision contained signicant contradictions and other problems. In the following years, a number of proposals from different organisations and institutions as well as from different political parties emerged in order to get more clarity and to regulate the binding force of ADs and to ensure that patient autonomy is respected in end-of-life care (for an overview see Oduncu 2007b). Finally, on June 18 2009, the German Federal Parliament passed a law with a majority vote of 317233 votes legalising ADs. The law took effect on September 1 2009, ruling that a patients written directive is binding, insofar as it relates to the actual treatment situation and there are no indications that the patient would no longer consent to their application. The directive applies independent of the stage of the illness and any possible medical actions in question. There is no obligation on the part of patients to consult their physician before writing an advance directive. Doctors are, however, obliged to check whether the instructions laid down in a directive are applicable to the condition at stake (Deutscher Bundestag 2009).

123

Doctor-cared dying instead of physician-assisted suicide

375

must be distinctly differentiated from homicide at the request of a victim and aiding in a homicide. It depends on the circumstances whether the act of assisting a suicide is punishable. According to the German judiciary, the decisive question is: who is the deciding (i.e. true acting) agent, even if implicitly? The patient could have been under direct or indirect pressure. It is also a punishable act when a medical condition that facilitates suicide is not treated (Schreiber 1999). Yet, given the circumstances of a free, deliberate suicide, the legal position is very straightforward. Neither this act, nor the assistance thereof is punishable. Different criteria apply to the role which businesses and commercial entities may play in suicide. There is no German law prohibiting the involvement of businesses in suicide, per se. Triggered by Roger Kuschs provocative cases, proposals were made to legally prohibit professional or commercial aid in suicide. The debate has not yet been concluded: only a draft law has been discussed so far. The reasons against such a law are to a large extent strictly legal issues and not ethical ones, hence, they are beyond the scope of this paper. Yet it is easy to see that it is difcult to prohibit the organized and commercialized aid of an act which itself is not prohibited by law. The ethical and moral debate, however, proceeds nonetheless. In February 2009, the Hamburg Administrative Court prohibited Roger Kusch from assisting in further suicides. The verdict states that commercial aid of suicide is a socially reprehensible act which does not fall under the protection of professional freedom (Verwaltungsgericht Hamburg 2009). It is not clear yet whether a law will be passed in Germany that would prohibit professional or commercial aid in suicide. This depends i.a. on the on-going ethical debates. In 2006, the German Jurists Forum (Deutscher Juristentag) took a stand on physician-assisted suicide and other related issues. They moved to call upon physicians to abnegate their disapproval of assisting in suicide under certain circumstances. At the same time, they proposed prosecution of prot-seeking, commercial promotion of suicide. When evaluating the decisions of the German Jurists Forum, one should keep in mind that this group does not necessarily represent lawyers and practicing attorneys in Germany. Rather, the German Jurists Forum is a nonincorporated association open to all solicitors, barristers, attorneys, jurists of all subspecialties and even law students. All interested parties with a legal background may become members of the association. Proposals are voted on in forum sub-committees,which are not representative of the members, but are attended by those who are interested. Hence, decisions are made not by broadly representative councils of judges, attorneys and/or legal scholars, but by a small group of people who have some special interest in a particular debate. Despite these limitations, the

recommendations of this forum tend to attract attention among the German public.2 By contrast, the German Medical Assembly dismissed physician-assisted suicide several times as incommensurate with the nature of a doctors role in society. The Principles state: The participation of a doctor in suicide contradicts medical ethics and may be punishable by law (Bundes rztekammer 1998, 2004). The reference that it could be a considered a criminal act refers to the difculty in differentiating between homicide at the request of a victim and assisted suicide. This resolution was passed unanimously by the German Medical Assembly. In contrast to the German Jurists Forum, the German Medical Assembly is a true representative body of elected members.3 The decisions passed by this association therefore have more weight. In 2009, the German Medical Assembly once again conrmed its rejection of physician-assisted suicide. In addition, it dismissed organised and commercial assistance in suicide as unethical.

Arguments against the practice of PAS To assist in suicide is fundamentally different from active euthanasia. In its ideal form, the person who commits suicide has total control over all details of the undertaking at any time. Hence, ethical analysis has to take the particularities of suicide and provision of assistance into consideration (Oduncu 2005b, 2007b). There are two distinct sets of arguments made against PAS. Fundamental objections comprise the rst group and are directed against assisting in suicide on principle. These objections require an examination of whether the practice (here: assistance) per se is to be rejected as unethical. The second line of arguments is non-fundamental and concerns possible abuses of PAS. These are slippery-slope arguments, which are always secondary. One who makes a slippery-slope argument against PAS implicitly agrees with

The forum reports some 2,5003,000 attendees for each of the biennial meetings and a membership of approx. 7,000. The draft concerning assistance in suicide was voted on by only 110 attendees, who are not representatives of the forum, but are a group of interested members (Deutscher Juristentag 2006). 3 Germany is a federal state. Health care is an affair of the individual nder), of which there are 17. Physicians are federal states (Bundesla required to become members of the State Chamber of Physicians of their respective state. The State Chambers are public-law institutions and bodies of self-administration. Physicians elect delegates to the German Medical Assembly. The German Medical Association rztekammer) is a consortium of all the State Chambers of (Bundesa Physicians. The assemblies of the respective states elect members to represent their chamber in the nationwide German Medical Assembly of the German Medical Association.

123

376

F. S. Oduncu, S. Sahm

PAS under certain circumstances, but rejects PAS because real-world conditions surrounding it make abuse probable. Therefore, fundamental objections should always take precedence over slippery-slope arguments. The latter can, however, easily support the principle rejection of PAS and thus become especially powerful. Without general objections, slippery-slope arguments are very weak, since they would lose ground the moment abuse and propagation of a particular practice acceptable only in certain cases is prohibited. The argument presented here concerns the ethics of PAS. It is not about euthanasia. Nevertheless, some proponents of PAS try to argue along the same lines for both euthanasia and PAS.4 In the following section, an ethical analysis of the specics of PAS shall be provided.

On-principle arguments against PAS People who are suicidal due to a limitation in their freedom to act, for instance owing to a psychiatric illness, whether it be intrinsic or environmental, need treatment and help. It is very hard to give philosophical reasons for this ethical principle, but reasons do not have to be given here. Yet it is obvious that the abandonment of this ethical rule itself would mean the renunciation of the principle of benecence, which is a fundamental obligation for all physicians. Without this principle, medicine would lose its modus operandi and cease to have any clear direction or basis. It is therefore an essential prerequisite that assisted suicide may only receive justication and hence can only be discussed when the decision to kill oneself is made in absolute freedom. According to psychiatrists, cases of freely chosen suicides are an exception among all suicides (Fischer 2001). Fewer than 10% of all suicides fall under ller 1996). If at all, assisted suicide may this category (Mo only be justied in very few cases, when the will to kill oneself is clearly documented and adequately described as being sufciently independent of outside inuences or pressures. The ethical analysis of acts of suicide shows a peculiarity which affects the ethics of PAS. Suicide as a freely chosen act is an act beyond ethical evaluation. The reasons for this can be explained as follows.
4

All human life exists in a network of social relations. This network is fundamental to the right to respect and the right to freedom from bodily harm. It is fundamental that the network is based on the assumption that it is preferable that all its members exist instead of being annihilated.5 The social network is a prerequisite for all rights and claims. Yet whoever commits suicide steps outside of this network. He or she voluntarily renounces the right to respect and all associated rights and claims. The act of suicide, however, cannot claim moral respect for itself. Rather, the act of suicide is beyond moral and ethical evaluation, it escapes moral judgement. Ethically, suicide escapes judgement. When most nations refrain from punishing acts of suicide, it is due to this particular fact. Suicide is not approved or respected, rather, it is held to be beyond judgement. Hence, it is appropriate to refrain from a moral verdict in this case. However, this is true only for suicides committed out of complete and total free will. When the network of social relations inuences the act of suicide, the act of suicide can no longer be regarded as free, and its evaluation is not beyond moral judgement. It is this inuence that removes the element of freedom from the act. Absolute freedom which is an indispensable prerequisite to refrain from judgements regarding prosecution of suicide is the freedom from interference (which tends to promote suicide), not only the freedom of choice. And the more obvious the inuence is, the less voluntary the suicide can be. Therefore, e.g. cases of suicides cannot claim to be free acts even if they are committed as a sacrice to others, e.g. to spare relatives from the expenses of healthcare.6 When assisted suicide is counted among the portfolio of medical acts, it suggests social acceptance. Yet, as has been shown above, morally there is no acceptance, rather there is actually an attitude of abstention from moral judgement. Hence, if one offers assisted suicide as one professional solution among other treatment options, it limits a patients opportunity to act freely. This freedom, however, is a
5

For example, the assertion that in some cases doctors would be confronted with conditions that cause unbearable suffering not amenable to palliative treatment. In such a state of emergency termination of life or PAS would be justied, or even more, be obligatory. The assumption of a state of emergency is the very reason behind the Dutch ruling (which is frequently mistaken), as opposed to the reference to autonomy. In fact, the concept of a state of unbearable suffering restricts autonomy, because this diagnosis lies with the doctor. In addition, modern palliative care has disproven it long ago (for circumstantial discussion see Oduncu 2007b, Sahm 2006).

That is, of course, also an argument against physicians being involved in the execution of the death penalty, for example (or to be exact: it is an argument against death penalty per se). 6 In case studies, literature, movies and no doubt even in the realworld there are settings where persons commit sucide with the intention to save the life of others. Of course, here suicide may be ethically justied, or even regarded as a highly appreciated opus supererogativum. Yet the act is not free in the above-mentioned sense. Hence, the ethical judgement of these cases depends on the circumstances. If circumstances are brought forth to justify the suicide, then they are ethically reprehensible. The rst obligation is to change those circumstances. In highly developed countries, avoiding high costs of medical care can never justify suicide as an act of altruism. Altruism here is out of place (as opposed to e.g. Fenner 2007). To be clear, this is not meant to denounce those who commit suicide because of their particular motives; the point is that this cannot justify assisting patients with suicide.

123

Doctor-cared dying instead of physician-assisted suicide

377

necessary prerequisite for committing suicide out of free will. If this freedom is restricted, the assisted suicide is no longer ethically neutral. PAS is not immoral because suicide as a true free act is held to be immoral. Rather, offering medical options which include assisted suicide and, in so doing, suggesting social acceptance robs the patient of that freedom. That is what makes professional assistance in suicide immoral, an indecent proposal. One can think of cases in which assisted suicide may be justiable within an intimate personal relationship. Within such a relationship of true love, questions of social acceptance per se may be meaningless. However, this does not apply to the case of patient-physician relationship. Because, ethically, such an intimacy which has to be a relation of true love between doctor and patient is, in and of itself ethically reprehensible between doctor and patient. The doctor-patient relationship needs to be limited in intimacy. That is also why, for instance, sexual relations between psychiatrists and patients are regarded as unethical according to professional rules (Cullen 1999). Similarly, the relationship between doctor and patient should never take on a form in which it seems preferable to the attending physician that the patient ceases to exist.7 Outside of a closeness and intimacy that goes beyond doctor-patient relationship, however, the professional offer to assist in suicide would limit the patients freedom of choice. Hence, PAS needs to be rejected on principle. The professional offer to aid a person in killing herself/himself is an immoral offer. Proponents of PAS often proclaim that the act is a special expression of dignity in dying. Dan Callahan called this organised obfuscation, since it is not clear why ultimate control of death should guarantee dignity in death.

Slippery-slope arguments against PAS Only against the backdrop of a general rejection of PAS do slippery-slope arguments gain some value (Oduncu 2005b, 2007b). Considering the demographical development in the Western world, the option of assisted suicide in an ageing society poses a dangerous inuence (Meier et al. 1998). When you consider PAS as part of the medical routine, it suggests social acceptance. It becomes inevitable that people with high care requirements, such as patients with chronic diseases or the elderly, feel pressured to not become a burden to others. This is not just a speculation and not just a baseless worst-case scenario. Rather,
7

empirical data from Oregon, where PAS is allowed, conrms it (Oregon Death with Dignity Annual Reports 2009). People are inclined to ask for assistance in suicide when they feel lonely or fear they are a burden to others (Breitbart et al. 1996; Breitbart and Rosendfeld 1999). The response which society gives to a request for aid in suicide reveals a great deal about its self-awareness. If then, as empirically shown, loneliness, loss of human dignity, and fear of being dependent on others become the main motive to ask for PAS, a sympathetic society should answer by offering more help and providing a better social network for that person (Akechi et al. 2002; Covinski et al. 1996; Emanuel et al. 2000; Lorenz 2003; Steinhauser et al. 2000; Suarez-Almazor et al. 2002; Wilson et al. 2000). A different response unmasks a society as inhumane. Further risks, to which others have referred for some time, have now been empirically conrmed. According to research by Linda Ganzini, every fourth patient who asks for aid in suicide displays signs of depressive disorders. These patients are not protected against inappropriate aid in dying. Although it is claimed that corresponding measures of psychiatric interventions will protect patients from suicide, the data show the opposite (Ganzini et al. 2008). Hence, the fear that permitting PAS would become a slippery-slope has been conrmed. This cannot be mitigated by the fact that the absolute number of patients who die through PAS has been relatively small to date. A morally reprehensible act cannot be justied by the fact that it rarely happens. Furthermore, the expansion of the practice to groups of patients that were supposedly excluded from PAS had already been taken place (see below). In this context, we should also remember what occurred after the introduction of active euthanasia in the Netherlands. Years ago, critics were appeased with the assurance that abuse of the system was to a large extent preventable. Yet, even in this case, empirical research has shown the opposite, as the large number of cases of involuntary active euthanasia shows (van der Maas et al. 1996; van der Wal et al. 1996; Onwuteaka-Philipsen et al. 2003; van der Heide et al. 2007). One who produces slippery-slope arguments is often appeased with misleading information. Once again, it is the phenomenon of obfuscation (Callan 2008). Empirical data conrm the fears of the critics.

The case of logical slippery slope In this ongoing debate about PAS are many more slipperyslope arguments. It is, however, important to look at one variation of this argument in particular, which is called logical slippery slope. The argument of the logical slippery

Others have pointed out that there is a disproportion between the prohibition of sexual relationships of doctors with their patients and the relaxation and individualisation which accompanies the promotion of PAS (Barilan 2003).

123

378

F. S. Oduncu, S. Sahm

slope was previously made in connection with the debate on active euthanasia and consequences of gene therapy (Holtug 1993; Boer 2003, Sahm 2000). The logical slippery slope refers to the expansion of a practice based on reasons that supporters give for justication, while limiting it to certain cases. Supporters of PAS refer to the right of selfdetermination in their justications. The right of selfdetermination includes, so they say, the right to control a persons own death. The contradiction of their arguments lies in their attempt to restrict PAS to cases of severe illnesses. This applies to the regulations in Oregon, the Netherlands, and Belgium, and also Washington State since 2008. Why should PAS be restricted to cases of severe illness, when the justication of PAS lies in a patients right to self-determination? This is illogical. The restriction of PAS to certain conditions (here cases of severe illness not amenable to treatments) refers to philosophical concepts of nature, such as the concept of disease a.s.f. If, however, PAS is to be justied due to an autonomous demand, the question of additional proper circumstances becomes superuous. In other words, the more additional criteria are necessary to justify PAS, the more the fundamental principle of the autonomous demand (autonomy, self-determination) will be compromised. This philosophical and moral paradox has previously been elaborated by the German philosopher Robert Spaemann (1997). This moral paradox created by the proponents of PAS and euthanasia has been further analysed and rejected by several opponents (Bobbert 2003; Oduncu 2007b, p. 145; Sahm 2000, 2006), arguing that according to the proponents argumentation, self-determination could only be implemented by simultaneously restricting it by additional rational criteria (e.g. severe illness). This limitation reveals a contradiction in the supporters arguments. If PAS is justied due to self-determination, then this justication has to apply to all cases, in which autonomous persons act without undue interference. Hence, the expansion of the practice to apply to more than only cases of severe illness is already imbedded in this argument. This is a classical case of logical slippery slope. Practice shows that the logical slippery slope is not only a theoretical objection. As previously mentioned, the judiciary senator from Hamburg, Roger Kusch, did not restrict his offer of assisted suicide to patients who were terminally ill. Referring to the autonomy argument, he also assisted people with suicide who were not terminally ill and even offered assistance to persons who were not ill at all (Verwaltungsgericht Hamburg 2009). As we have seen, apart from the fundamental objection, there are also a number of slippery slope arguments against PAS. These arguments support the rejection of PAS for more on-principle reasons outlined above.

Doctor-cared dying instead of physician-assisted suicide The ethical principles (autonomy, benecence, non-maleficence) can by nature only be understood interdependently, and should therefore be applied in a more hermeneutical manner better suited to the complexity of end-of-life care (Oduncu 2005b, 2007b). In this sense, a professional concept of doctor-cared dying does more justice to terminally ill and vulnerable patients than current legalised physicianassisted dying practices as performed in the Netherlands, Switzerland or the State of Oregon. The concept of doctor-cared dying (Oduncu 1999, 2001, 2005b, 2006a, b, 2007a, b) is to support every particular human being in all his/her personal and existential dimensions and relations, i.e. to treat this patient as a fellow human being (Sartre 1943; Schotsmans 1999). The German term for care is Sorge, which includes the active dimension of taking care of and the rather passive dimension of the caring for demeanour towards sick and needy fellow human beings (Reich 1978; Oduncu 2003b). This notion of Care Ethics demands total personal care of the sick and needy individual from caregivers within an intimate caring relationship, with the aim of promoting the physical and mental well-being of the patient. This can be achieved by competent, skilled and virtuous care of the patient. The underlying anthropology of Care Ethics is based on the ethics of solidarity and responsibility (Oduncu 2003b, 2007b). In practice, Care Ethics in end-of-life issues is best transformed through palliative care. In accordance with the former denition of the World Health Organisation (WHO 1990) and the European Association for Palliative Care (EAPC) (Materstvedt et al. 2003), good palliative care should be the active care of patients whose disease is not responsive to curative treatment. Instead, the multi- and interdisciplinary control of pain and of other physical symptoms as well as of psychological, social and spiritual distress is paramount to achieve the best quality of life for the patients and their families. Palliative care neither hastens nor postpones death, it provides relief from physical and psychological pain until the patients death occurs. This holistic concept of care is derived from Ciceley Saunders concept of total care as the appropriate response to her concept of total pain (Clark 1999). Palliative care provides far more than just an alternative to physician-assisted termination of life. To prove this, in 2003, the Ethics Workgroup of the German Association for Palliative Medicine (DGP) conducted the largest scientic survey so far among its physician and nursing members (n = 730), in order to evaluate their attitudes towards different end-of-life medical practices such as euthanasia, physician-assisted suicide (PAS), and terminal sedation. The results of the DGP members were compared to a control group (n = 843) of non-DGP physicians and nurses

123

Doctor-cared dying instead of physician-assisted suicide

379

with less or no palliative experience whatsoever. The percentage of respondents who were opposed to legalising different forms of premature termination of life were as follows: 91% of DGP doctors and 83% of DGP nurses opposed euthanasia, compared to 73% and 35% of nonDGP physicians and nurses; 75% of DGP physicians and 69% of DGP nurses opposed PAS in contrast to 59% and 22% of non-DGP doctors and nurses. In summary, only a minority of about 9% voted for legalising euthanasia and 25% for legalising PAS. Terminal sedation was accepted by more than 90% of all participants. The main criteria cited for the responses were personal ethical values, professional experience with palliative care, knowledge of alternative approaches, knowledge of ethical guidelines and of national legal framework conditions. The misuse of medical knowledge for inhumane killing in the Nazi period did not play a relevant role in the respondents negative attitude towards euthanasia and PAS. The study was able to prove with statistical signicance that respondents with palliative experience, professional competence and skills rejected euthanasia and PAS as medical options, whereas respondents with less or no palliative experience and knowledge in symptom control voted for a liberalisation of ller-Busch et al. 2003, 2004). Lack euthanasia and PAS (Mu of palliative knowledge may be an important factor that makes physicians/health care workers more likely to accept legalisation of euthanasia and PAS. Similar surveys conducted in other countries showed a much higher proportion of proponents for euthanasia and ller-Busch et al. 2004). We believe that palliative PAS (Mu care needs to become more established and to be promoted not only within the German health care system but all over the world, in order to improve the quality of end-of-life situations, which, in turn, is expected to decrease requests for physician-assisted killing. Patients fear of overtreatment in the case of an incurable progressive disease approaching death is one of the driving forces behing the request for aid in dying. The palliative concept of advanced care planning has been proven to reduce the risk of undue overtreatment of patients in advanced stages of their disease (Sahm 2006). However, the approach of palliative care might be endangered and unduly restricted by legalising practices such as euthanasia and PAS. As long as the practices of euthanasia or PAS are provided within medical care, the stimulus for improving palliative medicine will remain weak. Palliative care can only be taken seriously if the act of legalised physician-assisted killing is removed from the medical repertoire (Oduncu 2003b, 2007b). The German Principles Concerning Terminal Medical Care are based on the concept of palliative care and use the central German expression of Sterbebegleitung, which means being a companion to the dying, accompanying the

dying on their way and neither shortening nor prolonging it rztekammer 1998, 2004). The caring disposition (Bundesa inclines the responsible physician to respect the patient as an autonomous agent and to recognize the patients presumed value judgements, even if they are contrary to what the physician expects. Caring for is linked with delity to the Hippocratic Oath, which requires care directed towards the person of the patient, i.e. to the patient as person (Ramsey 1970). The Aramaic term RAHME precisely describes this concept, which reveals the basic idea of the German term Sorge, which includes the active dimension of taking care of as well as the rather passive dimension of a caring for demeanour towards sick and needy fellow humans. RAHME represents the spirit of integration between ancient intention-based medicine and contemporary evidence-based medicine, resulting in a more tting valuebased medicine, which should be the new goal of present and future health care (Oduncu 2003a, b, 2007b). It is this sort of doctor-cared dying which provides the appropriate attentiveness due to a Levinasian approach to the vulnerable and dependent human individual who does not loose his/her dignity despite all his/her inrmity and frailness (Oduncu 2003b).

Conclusion The rejection of PAS by the German Medical Assembly in its directives which was reafrmed in 2009 is, therefore, ethically justied and reasonable. This decision states that physician-assisted suicide contradicts established professional medical ethical standards. It further states that it must not be an option to recommend termination of life to patients in difcult and hopeless situations and to aid in this process. PAS is considered incommensurate with a doctors ethics and would destroy the bond of trust between patient and doctor. Also, organised assistance to suicide offered by professional or commercial organisations is considered unethical. Finally, it is necessary to take a closer look at a peculiarity of the end-of-life debate in Germany. It is often claimed that the debate cannot be held with the same openness as in other countries due to Germanys recent history of gruesome crimes during the Nazi regime. It is suggested that the German doctors and their rejection of PAS only represent a minority position (Hefty 2009). This, however, is not the case. The position of German doctors is in keeping with the majority of other organizations of doctors worldwide and with the World Medical Association (World Medical Association 1987). The allegation that the discussion in Germany would be restricted simply does not hold true. In fact, the arguments

123

380

F. S. Oduncu, S. Sahm Boer, T.A. 2003. After the slippery slope: Dutch experiences on regulating active euthanasia. Journal of the Society of Christian Ethics 23: 225242. Breitbart, W., and B.D. Rosendfeld. 1999. Physician-assisted suicide: The inuence of psychosocial issues. Cancer Control 6: 146161. Breitbart, W., B.D. Rosenfeld, and S.D. Passik. 1996. Interest in physician-assisted suicide among ambulatory HIV-infected patients. American Journal of Psychiatry 153: 238242. rztekammer. 1997. Entwurf der Richtlinie der Bundesa rzteBundesa rztlichen Sterbebegleitung und den Grenzen kammer zur a rzteblatt 94: A1342 zumutbarer Behandlung. Deutsches A A1344. rztekammer. 1998. Grundsa tze der Bundesa rztekammer zur Bundesa rztlichen sterbebegleitung. Deutsches A rzteblatt 95: A-2365 A A-2366. rz rztekammer. 1999. Symposium der Bundesa Bundesa rztekammer A rzte. ln: Deutscher A tliche sterbebegleitung. Ko rztekammer. 2004. Grundsa tze der Bundesa rztekammer zur Bundesa rzteblatt 101: A1298 rztlichen sterbebegleitung. Deutsches A a A1299. rz 2003, XII. Bundesgerichtshof. 2006. BGH- Beschlu vom 17. Ma Zivilsenat: XII ZB 2/03. Callan, D. 2008. Organized obfuscation: Advocacy for physicianassisted suicide. Hastings Center Report 38(5): 3032. Clark, D. 1999. Total pain. Disciplinary power, the body in the work of Ciceley Saunders, 19581967. Social Science and Medicine 49: 727736. Covinski, K.E., C.S. Landefeld, J. Teno, A.F. Connors, N. Dawson, S. Youngner, N. Desbiens, J. Lynn, W. Fulkerson, D. Reding, R. Oye, and R.S. Phillips. 1996. Is economic hardship on the families of the seriously ill associated with patient and surrogate care preference? Archives of Internal Medicine 156: 17371741. Cullen, R.M. 1999. Arguments for zero tolerance of sexual contact between doctors and patients. Journal of Medical Ethics 25(6): 482486. Die Welt 2007. Welt online: http://www.welt.de/fernsehen/article 756865/Sterben_mit_dem_Komplettpaket.html. Emanuel, E.J., D.L. Fairclough, and L. Emanuel. 2000. Attitudes and desires related to euthanasia and physician-assisted suicide among terminally ill patients and their caregivers. Journal of the American Medical Association 284: 24602468. Fagerlin, A., and C.E. Schneider. 2004. Enough. The failure of the living will. Hastings Center Report 34(2): 3042. Fenner, D. 2007. Ist die Institutionalisierung und Legalisierung der hrlich? Ethik in der Medizin 19: 200214. Suizidbeihilfe gefa Fischer, C. 2001. Gibt es den Suizid aus freier Entscheidung? In Vom Recht zu sterben, zur Picht zu sterben? ed. Schwank, A., and ndlin, R, 1928. Zu rich: Edition 8. Spo Ganzini, L., E.R. Goy, and S.K. Dobscha SK. 2008. Prevalence of depression and anxiety in patients requesting physicians aid in dying: Cross sectional survey. British Medical Journal 337: a1682. Hefty, G. 2009. Stichwort Patientenautonomie. Eine Tagung blickt ber die Grenzen Deutschlands und der passiven Sterbehilfe u hinaus. Frankfurter Allgemeine Zeitung 26th of June 2009. Hibbeler, B. 2005. Aktive sterbehilfe: Je nachdem, wie man fragt. rzteblatt 102(43): A-2897. Deutsches A Holtug, N. 1993. Human gene therapy: Down the slippery slope? Bioethics 7: 405419. Lorenz, K. 2003. Moral and practical challenges of physician-assisted suicide. Journal of the American Medical Association 289: 2282. Materstvedt, L.J., D. Clark, J. Ellershaw, R. Forde, A.M. Gravgaard, ller-Busch, J. Porta i Sales, and C.H. Rapin; EAPC H.C. Mu Ethics Task Force. 2003. Euthanasia and physician-assisted suicide: A view from an EAPC ethics task force. Palliative Medicine 17(2): 97101.

brought forward by the supporters and opponents of PAS are not very different in Germany than in other countries. They are being discussed in complete openness on television and in newspapers. Occasionally, though, supporters of PAS use references to Germanys peculiarity as a strategic argument against critics of PAS. They allege that the rejection of PAS by German doctors is guided by the social and psychological experience of recent history. This, however, means that the arguments made by the opponents should not be taken seriously, since it is implied that they cannot reason freely. This way, supporters of PAS create a fundamental asymmetry in the discussion, which nally puts an end to it. As a nation with many inhabitants, Germany exerts a great deal of inuence. Therefore, the rejection of active euthanasia and physician-assisted suicide in Germany is of great importance. However, by rejecting Germanys position with reference to its alleged unreasonable tradition though psychologically understandable some aim to inuence the debate on a European level. This political strategy, which tries to make use of Germanys past in this debate, is itself ethically questionable. In conclusion, the current article rejects the practice of legal PAS as due care and instead pleads for a doctorcared dying on the basis of modern palliative terminal care.
Acknowledgments The authors are indebted to Mrs. Bernadette Fisher who helped to prepare the manuscript, and to Mrs. Kathy Muller-Schertler for native language correction of the manuscript.

References
sse des 66. Deutschen JuristenDeutscher Juristentag. 2006. Beschlu tages. Available on http://www.djt.de/media/66_DJT_Besch luesse-1265647648.pdf. Accessed 7 July 2009. rztekammer und Kassena rztliche Bundesvereinigung. 2008. Bundesa rztinnen tze und Empfehlungen fu rde. Grundsa r A Sterben in Wu rzte. Available on www.aerzteblatt.de/plus0108. und A Deutscher Bundestag. 2009. Drucksache 16/8442. 16. Wahlperiode. Available on www.bundestag.de. Dignitate Deutschland. 2009. Available on http://www.dignitas. ch/index.php?option=com_content&task=view&id=110& Itemid=161. Accessed 6 July 2009. Oregon Death with Dignity Annual Reports. 2009. Available on: www.oregon.gov/DHS/ph/pas/ar-index.shtml. Akechi, T., T. Nakano, N. Akizuki, T. Nakanishi, E. Yoshikawa, H. Okamura, and Y. Uchitomi. 2002. Clinical factors associated with suicidality in cancer patients. Journal of Clinical Oncology 32: 506511. Barilan, Y.M. 2003. Of doctor-patient sex and assisted suicide. Israel Medical Association Journal 5(6): 460463. Battin, M.P. 1992. Assisted suicide: Can we learn from Germany? Hastings Center Report 22(2): 4551. tung auf Bobbert, M. 2003. Sterbehilfe als medizinisch assistierte To Verlangen: Argumente gegen eine rechtliche Zulassung. In well, and K. Steigleder, Bioethik. Eine einfu hrung, ed. M. Du 314322. Frankfurt a.M: Suhrkamp.

123

Doctor-cared dying instead of physician-assisted suicide Meier, D.E., C.A. Emmons, S. Wallenstein, T. Quill, S. Morrison, and C.K. Cassel. 1998. A national survey of physician assistedsuicide and euthanasia in the United States. New England Journal of Medicine 338: 11931201. ller, H.-J. 1996. Psychiatrie. Hippokrates 367. Stuttgart. Mo ller-Busch, H.C., E. Klaschik, F.S. Oduncu, T. Schindler, and S. Mu glichem Leid? Eine Woskanjan. 2003. Euthanasie bei unertra r Palliativmedizin zum Studie der Deutschen Gesellschaft fu Thema Sterbehilfe im Jahre 2002. Zeitschrift fu r Palliativmedizin 4: 7584. ller-Busch, H.C., F.S. Oduncu, S. Woskanjan, and E. Klaschik. Mu 2004. Attitudes on euthanasia, physician-assisted suicide and terminal sedation - A survey of the members of the German Association for Palliative Medicine. Medicine, Health Care and Philosophy 7: 333339. Nationaler Ethikrat. 2006. Available on http://www.ethikrat.org/ stellungnahmen/pdf/Stellungnahme_Selbstbestimmung_und_ Fuersorge_am_Lebensende.pdf. Accessed 28 June 2009. Oduncu, F. 1999. Sterbebegleitung und Sterbehilfe. Stimmen der Zeit 217: 541554. ten! Stimmen der Zeit 219 (8): Oduncu, F.S. 2001. Begleiten statt to 520532. Oduncu, F.S. 2002. Belgien verabschiedet Euthanasie-Gesetz. Zeitschrift fu r medizinische Ethik 48: 310312. Oduncu, F.S. 2003a. Euthanasie bei unheilbarem Leid? Stimmen der Zeit 221(2): 121130. Oduncu, F.S. 2003b. Euthanasia: Killing as due care? Wiener Medizinische Wochenschrift 153: 387391. rztliche Sterbehilfe im Spannungsfeld von Oduncu, F.S. 2005a. A Medizin, Ethik und Recht. Teil 1: Medizinische und rechtliche Aspekte. Medizinrecht 23: 437445. rztliche Sterbehilfe im Spannungsfeld von Oduncu, F.S. 2005b. A Medizin, Ethik und Recht. Teil 2: Palliativmedizinische und medizinethische Aspekte. Medizinrecht 23: 516524. Oduncu, F.S. 2006a. Medizin am Ende des Lebens aus der Sicht des rde ist eine GemPalliativmediziners. Sterben in Wu einschaftsaufgabe. Mu nchener Medizinische Wochenschrift Fortschritte Medizin 20: 3538. Oduncu, F.S. 2006b. Freiheit zum Tod oder Unfreiheit zum Leben? Stimmen der Zeit 224: 597610. Oduncu, F.S. 2007a. Sterbebegleitung und sterbehilfe. Medizinethische aspekte. Gyna kologe 40: 947953. Oduncu, F.S. 2007b. Wu rde sterben. Medizinische, ethische und rechtliche Aspekte der Sterbehilfe, Sterbebegleitung und ttingen: Vandenhoeck and Ruprecht. Patientenverfu gung. Go Oduncu, F.S., and W. Eisenmenger. 2002. Euthanasie, sterbehilfe, sterbebegleitung. Eine kritische Bestandsaufnahme im internationalen Vergleich. Medizinrecht 20(7): 327337. Onwuteaka-Philipsen, B.D., A. Heide van der, D. Koper, I. KeijDeerenbert, J.A.C. Rietjens, M.L. Rurup, A.M. Vrakking, J.J. Georges, M.T. Muller, G. van der Wal, and P.J. van der Maas. 2003. Euthanasia and other end-of-life decisions in the Netherlands in 1990, 1995, and 2001. Lancet 362: 395399. Ramsey, P. 1970. The patient as person: Explorations in medical ethics. New Haven: Yale University Press. Reich, W.T. 1978. The encyclopedia of bioethics, ed. Reich, W.T., vol. I, 219. Washington: Macmillan Publishing Sahm, S.W. 2000. Palliative care versus euthanasia. The German position: the German General Medical Councils principles for medical care of the terminally ill. Journal of Medicine and Philosophy 25: 195219. Sahm, S.W. 2005. Imperfekte Autonomie und die Grenzen des gung. Zeitschrift fu Instrumentes Patientenverfu r medizinische Ethik 51: 265275. Sahm, S.W. 2006. Sterbebegleitung und Patientenverfu gung. Frankfurt: Campus.

381 Sahm, S.W. 2009. Biopolitik: Medizinische ethik und medien. In Diener vieler Herren? Ethische Herausforderungen an den Arzt. Festschrift fu r helmut siefert, ed. G. Bockenheimer-Lucius, and nster: Lit-Verlag. A, Bell, 161171. Mu Sahm, S.W., R. Will, and G. Hommel. 2005a. What are cancer patients preferences about treatment at the end of life? A comparison with healthy people and medical staff. Supportive Care in Cancer 13: 206214. Sahm, S.W., R. Will, and G. Hommel. 2005b. Attitudes towards and barriers to write advance directives amongst tumour patients, healthy controls and medical staff. Journal of Medical Ethics 31: 437440. Sahm, S.W., R. Will, and G. Hommel. 2005c. Would they follow what has been laid down? Cancer patients and healthy controls views on adherence to advance directives compared to medical staff. Medicine, Health Care and Philosophy 8: 297305. ant. Paris: Gallimard. Sartre, J.P. 1943. LEtre et le Ne Schotsmans, P. 1999. Personalism in medical ethics. Ethical Perspectives 6: 1019. rztekammer fu r einer Schreiber, H.L. 1999. Zum Entwurf der Bundesa rztliche Sterbebegleitung. SymRichtlinie zur Sterbehilfe. In A rztekammer, posium der Bundesa rztekammer, ed. Bundesa rzte. ln: Deutscher A 2037. Ko ten. In To Spaemann, R. 1997. Es gibt kein gutes To ten oder sterben lassen? Worum es in der Euthanasiedebatte geht, ed. R. Spaemann, and T. Fuchs, 1230. Freiburg i.Br: Herder. Steinhauser, K.E., N.A. Christakis, E.C. Clipp, M. McNeilly, L. McIntyre, and J.A. Tulsky. 2000. Factors considered important at the end of life by patients, family, physicians, and other care providers. Journal of the American Medical Association 284: 24762482. Suarez-Almazor, M.E., C. Newman, J. Hanson, and E. Bruera. 2002. Attitudes of terminally ill cancer patients about euthanasia and assisted suicide: predominance of psychosocial determinants and beliefs over symptom distress and subsequent survival. Journal of Clinical Oncology 20: 21342141. Tonelli, M.R. 1996. Pulling the plug on living wills. A critical analysis of advance directives. Chest 110: 816822. van der Heide, A., B.D. Onwuteaka-Philipsen, M.L. Rurup, H.M. Buiting, J.J. van Delden, J.E. Hanssen-de Wolf, A.G. Janssen, H.R. Pasman, J.A. Rietjens, C.J. Prins, I.M. Deerenberg, J.K. Gevers, P.J. van der Maas, and G. van der Wal. 2007. End-of-life practices in the Netherlands under the Euthanasia act. New England Journal of Medicine 356(19): 19571965. van der Maas, P.J., G. van der Wal, I. Haverkate, C.L.M. de Graaff, J.G. Kester, B.D. Onwuteaka-Philipsen, A. van der Heide, J.M. Bosma, and D.L. Willems. 1996. Euthanasia, physician assisted suicide, and other medical practices involving the end of life in the Netherlands, 19901995. New England Journal of Medicine 335: 16991705. van der Wal, G., P.J. van der Maas, J.M. Bosma, B.D. OnwuteakaPhilipsen, D.L. Willems, I. Havertake, and P.J. Kostense. 1996. Evaluation of the notication procedure for physician assisted death in the Netherlands. New England Journal of Medicine 335: 17061711. Verwaltungsgericht Hamburg (Administration Court). 2009. Untersagung kommerzieller Suizidbegleitung. Zeitschrift fu r Lebensrecht: 4857. Wilson, K.G., J.F. Scott, I.D. Graham, J.F. Kozak, S. Chater, R.A. Viola, B.J. de Faye, L.A. Weaver, and D. Curran. 2000. Attitudes of terminally ill patients toward euthanasia and physicianassisted suicide. Archives of Internal Medicine 160: 24542460. World Health Organisation. 1990. Cancer pain relief and palliative care. Geneva: World Health Organisation. World Medical Association. 1987. The World Medical Association resolution on Euthanasia. Available on http://www.wma.net/ e/policy/e13b.htm. Accessed 30 June 2009.

123