Euthanasia and suicide are the same

Euthanasia versus Assisted Suicide: A Question of Conscience

Religions and societies discuss terminal care and assisted suicide. Four groups within the German Bundestag have now submitted bills - an overview.

In a nutshell, Franz Müntefering, former federal minister and parliamentary group leader of the SPD, is currently discussing help with suicide, he says. “All people need help in dying. We should not leave the word euthanasia to those who are in favor of assistance in killing. "

His view and the distinction between assisted suicide and assisted suicide is supported by the Vice President of the German Medical Association (BÄK) and President of the Lower Saxony Medical Association, Dr. med. Martina Wenker, shared. She too is of the opinion that it is a medical task to help patients in the last phase of life and to allow death in the process - but not to kill them. Palliative medicine specialists report that many colleagues are not at all clear about how wide the range of medical options is for medical end-of-life care in accordance with the principles of the German Medical Association. "Sometimes you have to have the courage to discuss whether you want to continue the curative treatment," says Wenker. To make this clear, she and colleagues initiated a series of palliative medical case reports in the Deutsches Ärzteblatt (http://d.aerzteblatt.de/RG72).

Dr. med. Martina Wenker, Vice President of the German Medical Association (BÄK) and Chamber President in Lower Saxony: “We doctors are aware of the great responsibility that we have in caring for the dying. We take people's fears seriously and want to enable them to lead a dignified life and also to die by the hand, but not by the hand of a doctor. ”Photo: BÄK

Four drafts are available

At the beginning of July, the German Bundestag will debate the new rules on assisted suicide in a first reading and decide on it at the beginning of November. There are currently four draft laws, ranging from a general ban on assisted suicide to almost complete impunity for assisting suicide.

The draft law by Patrick Sensburg and Thomas Dörflinger (both CDU) would like to regulate the assisted suicide in the most restrictive way. The application submitted in May calls for a general ban on assisted suicide. "With dying care, we have to encourage accompaniment to death and not promotion to death," said Sensburg. The German Medical Association considers such a tightening of criminal law to be counterproductive. Palliative care practitioners often walk a fine line. For example, palliative sedation carries the risk of shortening life. If such measures move into the realm of criminal law, fear of the prosecutor could deter many doctors from intensive pain therapy.

Dr. med. Harald Terpe (Greens), co-initiator of an intergroup draft: “How the Bundestag reacts to the new regulation of assisted suicide will send a decisive signal as to how we imagine the end of life in an aging society. The facilitation of assisted suicide would not promote individual self-determination, but a declaration of surrender. ”Photo: Bündnis90-Die Grünen_Bundestagsfraktion

Ten members of the Bundestag from all four parliamentary groups submitted a second draft law, which basically bans assisted suicide. In the future, however, they only want to criminalize “business-like”, that is, assisted suicide aimed at repetition. Specifically, Michael Brand (CDU), Kerstin Griese and Eva Högl (both SPD), Harald Terpe and Elisabeth Scharfenberg (both Greens), Michael Frieser (CSU), Halina Wawzyniak and Kathrin Vogler (both left) as well as Claudia Lücking-Michel and Ansgar beat Heveling (both CDU) proposed punishing the commercial promotion of assisted suicide with up to three years in prison. With this regulation, they want to meet associations such as “Euthanasia Germany”, the German branch of the Swiss association “Dignitas” or the Berlin urologist Uwe-Christian Arnold, who, according to his own statements, has already assisted in suicide hundreds of times.

The initiators emphasized that the draft does not aim to accompany the dying process, as doctors usually do. Relatives and close people who also do not act in a business-like manner are also excluded from the criminal liability. The group application should be a middle way and underline the need for legislative action to strengthen palliative medicine and hospices, explained Terpe. With the law, the MPs wanted to counteract a societal “habituation effect” to business-like forms of assisted suicide, emphasized Brand.

It is already foreseeable that the majority of Christian Democrats will support this draft, including Chancellor Angela Merkel, Federal Health Minister Hermann Gröhe, parliamentary group leader Volker Kauder and CSU leader Horst Seehofer. This draft law is going in the right direction, believes the President of the German Medical Association, Prof. Dr. med. Frank Ulrich Montgomery. “We have always warned that so-called euthanasia organizations can go about their business under changing legal status. That is why we have always called for a ban on organized assisted suicide. ”Otherwise, social acceptance of assisted suicide could all too easily arise, which could ultimately lead to enormous pressure on people in the last phase of life.

The third draft law could also have a majority: With a civil law regulation, politicians of the grand coalition, including the CDU politician Peter Hintze and the SPD politicians Carola Reimann and Karl Lauterbach, want to ensure that doctors are allowed to regularly help terminally ill people with suicide. Together they presented a bill that prohibits assisted suicide altogether, but expressly allows it for doctors under certain conditions. "We want to protect the doctor-patient relationship and ensure that a terminally ill person who suffers severe agony and whom palliative medicine cannot help, receives medical help in the event of suicide," said Hintze. "We want to protect doctors from sanctions in this way," emphasized Reimann. They should be able to help their terminally ill patients in a hopeless situation to die within the framework of a responsible conscientious decision without being threatened by criminal prosecution and professional sanctions.

The religions follow a common path. Representatives of Islam, Christianity and Judaism reject killing on demand and medical assistance in suicide.

Specifically, the draft provides for a new Section 1921 a in the Civil Code. This provision is intended to allow people of legal age who are capable of giving consent and who suffer from an illness that is immediately fatal to ask their doctor for assisted suicide. Before doing this, however, they must be informed about alternative, in particular palliative medicine, options and have the diagnosis confirmed by another doctor. "Medical suicide assistance in the case of mental illness or in the case of dementia that precludes the ability to consent," explained Lauterbach. The principle of voluntariness also applies to the doctor. "But there are enough doctors who are willing to assist suicide," emphasized the doctor.

The fourth variant presented the most liberal draft by several MPs around Renate Künast (Greens) and Petra Sitte (Left). They only want to ban commercial assistance to suicide, otherwise assisted suicide should continue to be expressly unpunished. Only those who want to make a profit with assisted suicide should be punished. Suicide aid associations that only cover their costs are not covered by the bill. The self-determination of the individual must be respected, emphasized Künast. For doctors, the draft provides for documentation and advice on alternative, palliative options.

Prof. Dr. med. Karl Lauterbach (SPD), co-initiator of a draft of the coalition: “Our draft law is the only one that waives criminal law. While the other drafts worsen an already bad situation by tightening criminal law, we are relying on a purely civil law regulation. Criminal law should not rule at the bedside. ”Photo: SPD

Positions of the Religions

As different as the views in parliament about a new regulation of assisted suicide are, they are clear in relation to the religions: Most representatives of the Catholic Church resolutely reject medical assisted suicide and organized euthanasia. At a symposium of Caritas in North Rhine-Westphalia and the Caritas Academy Cologne-Hohenlind, for example, the Cologne Cardinal Rainer Maria Woelki warned against the "erroneous assumption" that only a life of youth, beauty, sportiness and a certain livelihood is worth living. He considers it inappropriate to speak of self-determination and a misunderstood quality of life in the context of dying. The cardinal emphasized that a state that regards human dignity as the highest good should do more to ensure that people are dignified on their last journey, instead of allowing them a quick and self-induced death at the end of their life. The chairman of the Evangelical Church in Germany, Heinrich Bedford-Strohm, recently argued in a similar manner. He demanded that the opportunities for dying with dignity should be improved without ending life prematurely. “Those who rely on new legal options for actively ending life weaken our social culture, which is shaped by the protection of life. The commitment of the Christian churches to hospice and palliative care in Germany impressively documents that there are better alternatives, ”he said.

And the two large Christian churches in Germany are not alone in this position. Although there are Jewish voices in favor of assisted suicide or even killing on demand, they have found no support in the current halachic discourse, said Munich Rabbi Dr. Tom Kucera at a conference in Bielefeld. In the halacha, the legal interpretations of the written canon of the Torah, the different opinions of rabbis, wise men and scholars are reflected. They aim at rules of conduct that affect the whole life of believers.

Dr. med. Stephan Probst, palliative medicine specialist at the Bielefeld Clinic: “The doctor of Jewish patients must be aware of the different interpretations of the Halacha, precisely assess and reflect the medical situation in order to carefully explore which individual path for the respective patient and his family correct one. ”Photo: Bielefel Clinic

From the halacha, however, it cannot be concluded that palliative medicine is forbidden because it allows death, adds the Bielefeld palliative medicine specialist Dr. med. Stephan Probst. There are Jewish families and patients who demand that everything must be done at all costs that could prolong life even a short time. However, the results of modern palliative medicine research would suggest that withdrawing active therapies is usually not life-shortening. “On the contrary, there are more and more studies showing that patients live longer if they are not treated at any cost with further aggressive end-of-life therapies.” Leaving out non-indicated fluids or oxygen insufflation does not shorten life either, but protects against unnecessary side effects and even more likely to prolong life. "The doctor of Jewish patients must be aware of the different interpretations of the Halacha, precisely assess and reproduce the medical situation in order to carefully explore which individual path is the right one for the respective patient and his family."

A human alternative

The Central Council of Muslims in Germany also sees terminal care and palliative medicine with palliative care as a good and humane alternative to direct active euthanasia. “A direct active euthanasia for the terminally seriously ill, both for the self-determined dying and at the request of the third party; Doctors or relatives ('killing on request') will be rejected. Suicide and medical aid to suicide are also rejected, ”reads a handout from the Central Council. On the other hand, from an Islamic point of view, no “objections to the use of sedation and painkillers, even in high doses, are seen if this is necessary for this seriously ill person”.

Prof. Dr. med. Bettina Schöne-Seifert, medical ethicist: “Palliative medicine cannot completely replace medically assisted suicide. We need reliable care offers for all sick people and those in need of care; but also tolerance towards the voluntarily responsible suicide of seriously ill patients and towards the doctors who can and want to help them. ”Photo: picture alliance

But what effects does it have on the work of doctors if assisted suicide and homicide on request are permitted under certain conditions, as in Belgium and the Netherlands? “In the very rural and Catholic east of Belgium, the law was initially put aside and ignored. And it was rejected in our palliative care unit and in the small hospitals, ”reported the anesthetist Dr. Ursula Wetzels from the St. Joseph palliative care ward in Moresnet, Belgium. But in the last few years the inquiries have become more and more frequent there too. During this time she herself “found a differentiated way of thinking” and wants to accompany every patient “in his uniqueness until the end of his life”.

According to Wetzels, euthanasia can only be carried out by a doctor in Belgium and the matter must first be examined by a commission. It is true that no doctor is obliged to perform euthanasia, but an institution such as a hospital must not refuse euthanasia in its rooms. According to Wetzels, medical assistance to suicide and killing on request is the "crossing of an ethical limit". However, she is convinced that euthanasia can be a final service to people and a sign of respect and humanity.

The Dutch family doctor and medical ethicist Dr. Gerrit K. Kimsma. "All the cases of euthanasia and assisted suicide that I have personally experienced and carried out have gone to my heart," he said at an event in Frankfurt / Main. Fortunately, there have only been a few cases so far. In the neighboring country, says Kimsma, the “concept of self-determination has triumphed, which means that a person should be fully informed about their medical situation, about the chances of therapy or about refusing medical interventions. In addition, the doctor and patient discuss together to what extent the suffering is to be regarded as hopeless and unbearable. ”This is one of the most important prerequisites for deciding whether to allow euthanasia or killing on demand.

Thomas Sitte, palliative medicine specialist and chairman of the board of the German Palliative Foundation: "Unfortunately, too many doctors do not know that they are already able to alleviate the suffering of their patients and allow them to die according to the guidelines of the German Medical Association for terminal care."

Risk of dam rupture

"It is not one of the medical duties to provide euthanasia," said the President of the German Medical Association in Cologne. In surveys, 70 percent of the population would have spoken out in favor of active euthanasia, but less than ten percent would use it for themselves. Since Hippocrates' oath, it has been an ancient self-image and the top priority of doctors to preserve life. By reaffirming this position, the German Medical Association has taken clear ethical leadership within the medical profession, said Montgomery.

Today almost all pain and even extreme shortness of breath can be brought under control, emphasized the President of the German Society for Palliative Medicine, Prof. Dr. med. Lukas Radbruch. At most, there are only a few individual cases left for which no change in the law is needed. But it is also important that the doctors know what options they have. "If a patient refuses ventilation, then a doctor can turn it off or he even has to turn it off if a patient so wishes," emphasizes the palliative care specialist.In a survey, however, half of the doctors would have taken the view that turning off artificial ventilation was a prohibited killing on request. Radbruch warned, however, that a dam would break if euthanasia was legalized. In Belgium and the Netherlands, where euthanasia is legally permitted and regulated, the number of cases has increased steadily. "It is now the norm for relatives to think about euthanasia in people at the end of life."

Gisela Klinkhammer,
Dr. med. Eva Richter-Kuhlmann