Legal approaches to end of life decision-making Penney Lewis - - PowerPoint PPT Presentation

Legal approaches to end of life decision-making

Penney Lewis Centre of Medical Law and Ethics King’s College London

Plan

• how the law regulates end of life decisions (ELDs)
• legal change
• empirical evidence of ELDs implemented by

doctors across broad spectrum of ELDs across broad range of jurisdictions

• varying legal systems, cultural and religious

backgrounds, health systems etc.

Regulating end of life decisions

End of life decisions (ELDs)

1. abstention: withdrawal or withholding of life-sustaining or life-saving treatment 2. symptom alleviation with possible or probable hastening of death 3. assisted suicide (AS) or physician-assisted suicide (PAS) 4. euthanasia ie termination of life on request 5. termination of life without request most jurisdictions permit 1 & 2 only small number also permit 3 or both 3 & 4 Netherlands permits 5 for neonates with parental requests

Decision-maker

patient (P) legal proxy for P

• appointed by P prior to incapacity
• through qualifying relationship with P
• appointed by court or other responsible body
• NB: existence of a ‘proxy’ does not always mean the proxy is

the decision-maker!

• eg France proxy is consultee not decision-maker

doctor court or tribunal

• 1. Most common ELD: abstention

P with capacity refuses life-sustaining treatment

• contemporaneously
• in advance (advance directive/decision, living will etc.)
• binding: UK; Ireland; Netherlands; Belgium; Switzerland; Canada; US

legal proxy for P lacking capacity refuses life-sustaining treatment

• differing legal standards
• substituted judgment (what the patient would have wanted)
• best interests (balancing benefits and burdens)

doctor makes abstention decision

• n basis of futility, best interests, substituted judgment, or other legal test
• differing concepts of futility
• eg clinically assisted nutrition & hydration (CANH) for P in vegetative state

(VS)

• resource allocation has background role
• eg decision whether to admit to intensive care or high dependency unit

• 2. Symptom alleviation?

legal acceptance of symptom alleviation with possible or probable hastening of death (BUT query whether these decisions are ELDs)

• doctrine of double effect (DDE) accepted: redefinition of intention to

exclude oblique intention (knowledge that side-effect will be virtually certain to occur)

• eg England & Wales; Switzerland; New Zealand
• medical indication/medical exception
• via specific statutory exception eg Denmark; South Australia
• by necessary implication from statutory obligation to inform patient,

proxy or family eg Netherlands; France

• application of defence of necessity
• eg Belgium?
• terminal and/or palliative sedation often subject of separate guidelines

with little formal legal involvement

3 & 4. Assisted suicide & Euthanasia range of terminology lack of consensus

• 3. Assisted suicide

specific criminal offence of assisted suicide

• most common law jurisdictions eg England & Wales; Ireland; Canada;

US

• many civil law jurisdictions eg Austria; Italy; Netherlands; Spain;

Portugal; Norway limited prohibition

• when motive is selfish eg Switzerland; Denmark (more serious offence

if committed for ‘reasons of personal interest’)

• perhaps England & Wales now falls here given post-Purdy

prosecutorial policy not to prosecute compassionate assistance by non- physicians resulting from legal challenge absence of prohibition

• eg Germany; Scotland; Sweden
• ther relevant offences may be used eg failing to assist person in

danger, involuntary homicide

• r disciplinary law may be used (eg Sweden)

• 4. Euthanasia

murder (or poisoning, administering noxious substance)

• most common law jurisdictions including UK
• some civil law jurisdictions eg France; Belgium; Luxembourg
• sentence may be mitigated by presence of request (eg England

& Wales) or aggravated by victim’s vulnerability (eg France) lesser offences

• consensual homicide
• some civil law jurisdictions eg Italy; Netherlands; Norway;

Denmark; Germany

• compassionate homicide
• eg Colombia; Germany
• compassionate consensual homicide
• eg Switzerland; Spain

• 5. Termination of life without request

murder (or poisoning, administering noxious substance)

• most common law jurisdictions including UK
• most civil law jurisdictions eg France; Belgium;

Luxembourg

• sentencing may reflect presence of compassionate motive

lesser offence of compassionate homicide

• eg Germany (prosecuted as manslaughter); Colombia

Defences to termination of life

statutory defences for doctors who perform euthanasia or assisted suicide in accordance with due care criteria

• eg Netherlands; Belgium; Luxembourg; Canada (also applies to nurse

practitioners) necessity

• available in Netherlands, Belgium where doctor faced conflicting

duties to preserve life and prevent suffering

• not applicable in common law jurisdictions, France

diminished responsibility

• ften used for family members, usually inapplicable to doctors
• may reduce severity of offence rather than exculpate
• eg compassionate consensual homicide (Switzerland)
• eg manslaughter (England & Wales)

Covert tools

decisions not to prosecute

• diversion to disciplinary process

selective charging decisions quashing indictment/refusal to indict accepting guilty pleas to lesser offences manipulation of intention or causation

• when medication used can be used to relieve pain as well as

to cause death, eg use of opioids

• when timing of death unclear
• eg Forzatti (brain death may have occurred before he disconnected

ventilator)

jury nullification light sentencing based on compassionate motive pardons

Legal change

legal change on assisted dying

• different legal routes towards legalisation:
• 1. constitutionally entrenched human rights
• eg Canada; Colombia
• 2. statutory interpretation

a) duty-based defence of necessity eg Netherlands b) medical exception: public policy + consent eg Montana

• 3. legislative approaches
• PAS for terminally ill only: eg Oregon; Washington; Vermont;

California; Colorado; Hawaii; Washington DC; New Jersey; Maine; Victoria (Australia)

• euthanasia for unbearable suffering: eg Belgium; Luxembourg
• esoteric: eg Northern Territory (Australia); Québec (Canada)

differing contours of regulation of assisted dying resulting from these mechanisms of legal change

• reveals interesting features
• highlights importance of choice of legal route in shaping

regulatory regimes

features

• request
• patient’s condition/experience of suffering
• terminal illness; unbearable & hopeless suffering
• type of assistance
• euthanasia; assisted suicide (sometimes prescription only)
• consultation and referral
• review/approval
• retrospective review; prospective approval
• assistor
• doctor; nurse practitioner; lay volunteer

OUP, , 2007 007

Empirical evidence

End of life decisions by doctors

• comparisons
• across jurisdictions, time periods and different kinds of medical

behaviour

• sources:
• anonymous prevalence surveys of doctors in different countries and

different years

• based on one originally designed by Dutch researchers
• caveats:
• 95% confidence intervals not shown
• as indicated, some comparisons from different years
• although similar, surveys not identical
• very small figures make comparisons difficult
• 95% confidence intervals overlap in some cases
• percentage of deaths in which ELD made varies across jurisdictions

10 20 30 40 50 60 70

Australia 1996 Belgium 1998 Belgium 2001-2 Belgium 2007 Belgium 2013 Denmark 2001-2 France 2009 Italy 2001-2 Netherlands 2001-2 Netherlands 2005 Netherlands 2010 Netherlands 2015 Sweden 2001-2 Switzerland 2001-2 UK 2004 UK 2007-8

Rates of absten tenti tion

• n (withdraw

thdrawal al or withh hhol

• ldin

ing g of life- prolonging nging treat atme ment) t) and symptom

• m alleviati

viation

• n

with h possible le life-shor

• rteni

tening ng effect (percentag rcentage of all deaths hs)

ABSTENTION SYMPTOM ALLEVIATION

1 2 3 4 5 6 7

Australia 1996 Belgium 1998 Belgium 2001-2 Belgium 2007 Belgium 2013 Denmark 2001-2 France 2009 Italy 2001-2 Netherlands 2001-2 Netherlands 2005 Netherlands 2010 Netherlands 2015 Sweden 2001-2 Switzerland 2001-2 Switzerland 2013 UK 2004 UK 2007-8

Rates s of euthana hanasi sia, physician-assiste ssisted d suicide de & termina nation tion

• f life without

t request est (perce centage tage of all d death ths) s)

EUT PAS TLWR

Sources

Bilsen et al. Medical End-of-Life Practices under the Euthanasia Law in Belgium. New Eng J Med 2009;361:1119-21, Table 1 Bosshard et al. Medical end-of-life practices in Switzerland: A comparison of 2001 and 2013. JAMA Internal Med 2016;176:555-556 Chambaere et al. Recent Trends in Euthanasia and Other End-of-Life Practices in Belgium. New Eng J Med 2015;372:1179-1181 Deliens et al. End-of-life decisions in medical practice in Flanders, Belgium: a nationwide survey. Lancet 2000;356.1806-11, Table 1

Kuhse et al. End-of-life decisions in Australian medical practice. Med J Aust 1997;166:191-6

Onwuteaka-Philipsen et al. Derde evaluatie Wet toetsing levensbeëindiging op verzoek en hulp bij zelfdoding. 2017 Onwuteaka-Philipsen et al. Trends in end-of-life practices before and after the enactment of the euthanasia law in the Netherlands from 1990 to 2010. Lancet 2012;380:908-15, Table 1 Pennec et al. End-of-life medical decisions in France: a death certificate follow-up survey 5 years after the 2005 act of parliament on patients’ rights and end of life. BMC Palliat Care 2012;11:25, Table 1

• Seale. End-of-life decisions in the UK involving medical practitioners. Palliat Med 2009;23:198-204, Table 1
• Seale. National survey of end-of-life decisions made by UK medical practitioners. Palliat Med 2006;20:3-10,

Tables 2&3 Van der Heide et al. End-of-life decision-making in six European countries: descriptive study. Lancet 2003;362:345-50, Table 2 Van der Heide et al. End-of-Life Practices in the Netherlands under the Euthanasia Act. New Eng J Med 2007;356:1957-65, Table 1 Van der Maas et al. Euthanasia and other medical decisions concerning the end of life. Lancet 1991;338:669- 74

Penney Lewis penney.lewis@kcl.ac.uk