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II. RESTRICTIONS ON PAS

However, it is necessary to remember that Oregon is a sparsely populated State. Its population of around 4 million is less than half that of London. Oregon's death rate from legalized assisted suicide is the equivalent of some PAS deaths in England and Wales annually if there were to be a similar law here. Seen against the suicides Source: Office of National Statistics, Suicides in England and Wales by local authority —, 2 December recorded in England and Wales in , this represents a significant potential addition.

Advocates of PAS argue that legalization delays or replaces some non-assisted suicides and that deaths from PAS cannot simply be added to the total number of other suicides. This may be so, though it is difficult to substantiate or quantify. Another question which arises is the role that is appropriate for doctors in PAS.


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As noted above, the principal reasons given by those seeking PAS finding life less enjoyable, desiring autonomy, seeking dignity, wanting to avoid being a burden are personal or social rather than medical. So long as legalized assisted suicide is tied to specified medical states, doctors obviously have a role to play—to make a diagnosis, offer a prognosis and advise on possible treatments.

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It is questionable, however, whether they are best-placed to make judgements such as whether an applicant for assisted suicide has a settled wish to die or is free from pressure. This is a particularly important issue in view of the reluctance of the majority of doctors to participate in PAS and the consequent assessment of requests by referral doctors with little or no first-hand knowledge of the applicant. Doctors in Britain seem to recognize this difficulty. The current campaigning for legalization seeks to involve the Family Division of the High Court in the making of assisted suicide decisions.

It proposes that the Court should 'confirm' decisions made by doctors.

Euthanasia and Physician Assisted Suicide

There is something to be said for placing decision-making with the High Court if assistance with suicide were ever to be legalized in Britain. The Court already examines and rules on other cases involving life-or-death issues—for example, on discontinuation of life-sustaining treatment.

However, the hybrid arrangement proposed by those advocating a change in the law has been criticized by the Association for Palliative Medicine of Great Britain and Ireland APM as dividing responsibility for the same decision between doctors and the Court. Dispassionate consideration of complex issues — such as the settled nature of a request for assisted suicide, the weight of personal or domestic issues that may be influencing the request and the person's capacity to make such a serious and irreversible decision — is the proper province of the Court — and of the Court alone' Association for Palliative Medicine of Great Britain and Ireland, Letter to Members of the House of Lords, 9 January As observed above, there is no body charged with post-event qualitative analysis of how requests for PAS are being handled in practice—for example, whether there has been painstaking and rigorous investigation of such issues as decisional capacity and freedom from pressure; over what period the assessments are taking place; whether the doctors who conduct them are contenting themselves with consulting room interviews and accepting at face value what they are told or digging deeper into them; and what, if any, influences are being brought to bear on successful applicants to ingest the lethal drugs supplied to them.

But it exists and forms the basis of annual reports that are more than just statistical analyses. This proposed amendment, if it should succeed, would represent a significant extension of Oregon's PAS law. Nor is it clear who would judge that the person had lost capacity or what assurance there could be that a request from someone who had lost capacity was truly voluntary. The proposed amendment highlights a crucial issue with Oregon's law—that assessment of eligibility takes place only at the stage when a prescription for lethal drugs is sought. There is no requirement for re-assessment when those drugs come to be taken, which in some cases can be many months later and by which time the applicant's situation may have changed significantly.

The issue of whether assisted suicide should be legalized is a complex one. It covers many areas of expertise, including the law, clinical practice, mental health, society, ethics and disability. It is important to try and see the whole picture and how all the various elements interact with each other rather than to approach the subject from just one or another perspective. Legalization of assisted suicide can also be an emotive subject arousing strong feelings. There are respectable arguments to be made on both sides of the debate.

What is important is that discussion should focus on thoughtful and rational analysis of the evidence. It is also important, as in many other areas of public debate, to be clear about the question before jumping to conclusions about the answers. It is about whether it should be legalized.

That calls for an understanding of what the existing law says, why it says it and how it is applied.

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Before legislatures can responsibly contemplate such a major change to the criminal law as licensing doctors to supply lethal drugs to some of their patients, they need clear evidence that the existing law is unsuitable and, if that is the case, that what would be put in its place would be better. In Britain Parliament has not been persuaded that such evidence exists. Not all prescriptions for lethal drugs in Oregon result in PAS.

Around two recipients in three have used them to take their own lives since There are, however, some serious questions over the operation of the DWDA. In particular, are doctors the people who should be making judgements which involve personal or social values as well as clinical criteria and where, given the reluctance of most doctors to participate in PAS, the doctors making these judgements often have little or no prior first-hand knowledge of the patients concerned?

There is also the question of whether it is acceptable that a doctor's responsibility should cease when a prescription for lethal drugs has been issued. Releasing such drugs into the community is a serious matter. What assurance can there be that, if a patient takes lethal drugs home for storage and possible use at a later date, he or she does not lose decision-making capacity or come under pressure, whether from others or from within, to use them?

Both these questions are pertinent to a larger one: what arrangements are needed for ensuring that the all-important assessment and decision-making process is carried out with rigour and objectivity? It may be that the minority of doctors who assess such requests in Oregon are going about the task conscientiously and with care, but there is no way of knowing for sure that that is so. If they are assessing requests for PAS, who is assessing them?

Such pressures, which have often been discounted by advocates of legalized assisted suicide as scare-mongering, would seem to be emerging in Oregon. All things considered, Oregon's experience of the DWDA raises questions as to whether legalized physician-assisted suicide can be given a clean bill of health. Oxford University Press is a department of the University of Oxford. It furthers the University's objective of excellence in research, scholarship, and education by publishing worldwide.

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Conflict of interest statement. Physician-assisted suicide—a clean bill of health? Robert Preston. Oxford Academic. In the issue of assisted death was widely publicized by the international media after the first legal euthanasia case was held in Colombia. Also in this same year, assisted suicide was legalized in Canada and in the state of California in the United States.

From a systematic literature review, this work aims to establish the prevalence and the criteria adopted for the practice of euthanasia and assisted suicide in western countries and to discuss the position of similar countries where this practice is not recognized. A better understanding of the subject appears to be critical to the formation of opinions and the encouragement of further discussions. In the twentieth century, during the Third Reich, the word gained a negative connotation when it was improperly used in Nazi policies aimed at eliminating lives that were considered not worthy to exist 1.

Subsequently, after the word was demystified, discussions on the topic resurfaced, and, currently, the practice of euthanasia, in its classic sense, is allowed in some countries. In a more contemporary definition, euthanasia can be understood as employment or abstention of procedures that allow accelerating or inducing the death of incurably ill patients, in order to free them from the extreme suffering that torments them 1. The latter differs from assisted suicide as it is performed by a physician, while in assisted suicide the patient is the one who performs the final action.

Therefore, regarding the act, euthanasia is divided into active and passive, the first of which denotes the deliberate act of inducing death without the patient suffering using, for example, lethal injection , and the second refers to death by deliberate omission to start medical action that would guarantee the prolongation of survival. In July , the topic was widely reported by the media after the first legal case of euthanasia was performed in Colombia 4.

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Given the divergent views and the general interest of the community on the subject, having knowledge of the experience and the views of various countries regarding the issue is essential to form opinions 3. This is still a very controversial debate and - regardless of political, religious or moral aspects— it is fundamentally a human issue 2. Thus, the objective of this work is to establish the prevalence and the criteria adopted for the practice of euthanasia and assisted suicide in Western countries and to discuss the position of other countries where the practice is not recognized.

This work consists of a systematic review of the literature. The MeSH tool was used to help the search and categorization of articles. The research was based on 19 publications relevant to the topic investigated. A list with these publications is presented at the end in Appendix 1. The following previously established inclusion criteria were considered: original works or reviews, available in full, published between and The articles that did not fit the inclusion criteria were removed from the sample.

Regarding the exclusion criteria, we considered duplicated articles, publications prior to and those that, despite having the selected descriptors, did not directly address the proposed topic.