Dignifying Death

Germany Grapples with Assisted Suicide

euthanasia _Ralf Hirschberger_dpa
Euthanasia remains taboo in Germany.
  • Why it matters

    Why it matters

    Germany is facing a difficult debate about the ethics surrounding the right to take one’s own life.

  • Facts

    Facts

    • On November 6, the German parliament is to debate four motions submitted to amend the existing legislation relating to assisted suicide.
    • The government motion would allow for assisted suicide carried out by relatives but make it illegal for a business to profit from it.
    • Other amendments would be more or less liberal, including one motion allowing doctors to assist and another imposing jail sentences on anyone assisting.
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    Audio

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Carola Reimann’s father suffered from cancer. An inoperable tumor blocked his bile duct, requiring regular trips to the hospital last year. Soon, he was discussing crucial matters with other patients, men over 70 from a generation that rarely spoke of such personal things. They asked each other about the pain they were facing, how much they could endure and how they could die if they no longer wanted to suffer.

“Through my father, I have seen the insides of many hospital rooms,” Ms. Reimann said.

She’s not only a daughter who, along with other family members, personally experienced the agony of an ill loved one. She also is among the politicians seeking answers to such questions. As deputy parliamentary leader of the center-left Social Democratic Party, and was previously the chairwoman of the Bundestag’s health committee. What once was private anguish has become political. Ms. Reimann’s father didn’t want to suffer from agonizing pain, but didn’t want to confide his wishes to the doctors in the Catholic hospital or with the other patients.

Certainly, German history argues against the kind of complete liberalization some seek.

Euthanasia remains taboo in Germany. People can make decisions about other fundamental life issues: Men and women have the right to change sexes, abortion is an option, adults may love and marry whomever they choose. But the same laws apply today as they did in 1871 when it comes to taking your own life.

A self-determined and dignified departure from this life is a legal balancing act here.

Many Germans carry memories of the dark years when politicians, lawyers and doctors chose which lives were ‘valuable’ and which were ‘worthless.’ And there are moral arguments, too. Christian critics argue life is sacred and enduring pain is part of human dignity. Hermann Gröhe, Germany’s health minister and a member of the ruling center-right Christian Democratic Union, said, “I am of the conviction that the protection of life in our legal system demands a ban on businesslike, organized assisted suicide.” Still others view euthanasia as a repudiation of medical standards and fear ‘murder by prescription’ if critical care becomes too expensive.

It’s encouraging how openly parliament is discussing the subject. Four motions will be on the agenda on November 6, when the Bundestag votes on how assisted suicide will be handled in the future. Proposals range from drastic penalties for anyone who assists in a suicide to complete liberalization of euthanasia, even for those who are not sick.

It’s likely there will be parliament members who have little taste for any proposal, or who will at least seek to prevent certain changes. It’s quite possible nothing will change. Yet doing nothing would be wrong. Certainly, German history argues against the kind of complete liberalization some seek. However, the freedom to be able to decide about the end of one’s own life is part of human dignity.

euthanasia_Carola Reimann_Bernd von Jutrczenka_dpa
The deputy parliamentary leader of the center-left Social Democrats (SPD), Carola Reimann. Ms. Reimann began drafting legislation for euthanasia. Source: Bernd von Jutrczenka/DPA

 

The most important requirement would allow physicians to assist the critically ill unhindered. “I consider it to be irreconcilable with the imperative for human dignity, when the protection of life forces people to die an agonizing death,” said Peter Hintze, vice president of parliament and a member of the CDU.

Karl Einhäupl, chairman of the executive board of the Berlin Charité clinic group and one of the most respected medical authorities in Germany, added: “Undisputedly, as a society we need the norm that no one may actively kill, but is it justifiable when we condemn the terminally ill to endure torture when there is no prospect of a cure, when they understandably long for death, but can find no way to free themselves?”

A life of pain and dependency may be sacrosanct for religious people. In countries with liberalized euthanasia policies, the number of suicides can rise, but it tends to be related to what kind of support and efforts to alleviate pain are offered by society.

According to research in the U.S. state of Oregon, which introduced a euthanasia law in 1997, the majority of those choosing assisted suicide are usually not heavily dependent on others and therefore easily influenced. As in Belgium and the Netherlands, patients with an above average education who are financially secure are more likely to end their own lives when pain becomes unbearable.

Above all, parliament must consider the thoughts and concerns of German citizens. In a survey by Infratest dimap, which provides electoral and political research in Germany, just 12 percent of respondents were against any form of euthanasia, while 38 percent would support assisted suicide and 43 percent demanded euthanasia be made available. A physician would administer a lethal injection at the request of the patient.

The current law reflects the moral concepts and medical practices of the 19th century. Suicide or attempted suicide is no longer illegal, but medical associations in many regions still forbid assisting the terminally ill in ending their lives.

“I think it is intolerable when someone is critically ill, but cannot speak openly with their doctor,” said Ms. Reimann, who has a doctorate in biotechnology. If doctors violate the laws of their profession, they cannot practice medicine. Ms. Reimann considers that a contradiction. “If I am on life support, I can say ‘stop,’” she said. “When I need medicine to die, I cannot ask the doctor for it.”

“According to a supreme judicial ruling, the doctor can give a critically ill patient medicine to relieve pain, even when this would induce death earlier,” Mr. Einhäupl of Charité said. “He is not allowed to administer it in the same dosage to assist a suicide. Legally, he must leave the room. A cynical thought.”

Critics of euthanasia fear a business of death. They predict euthanasia associations might drive the unstable to suicide.

Yet doctors are probably in a better position to alleviate fears and offer help than family members.

Although they may assist in a suicide, many family members face an emotional block or, in the worst-case scenario, a personal interest in the death.

That’s why Ms. Reimann last year began drafting legislation for euthanasia meant to absolve doctors from prosecution. Her efforts began the week her father had a relapse, prompting Ms. Reimann to telephone Mr. Hintze. The two politicians seem to have little in common, but they know and respect each other. Both agree modern pain relief can do a great deal, but cannot completely overcome suffering. They collaborated on a bill to liberalize euthanasia to eliminate the fear of doctors being dragged into court.

Critics of euthanasia fear a business of death. They predict euthanasia associations might drive the unstable to suicide. Others warn patients undergoing extremely costly treatments might find themselves compelled to take their lives. These concerns are justified in some cases, but more often it’s the idea of turning suicide into a business that drives those who oppose a dignified, self-determined end.

Medicine is making enormous strides in prolonging life, but Germany lacks a culture of dying, where death doesn’t occur only as a result of a medical malpractice. The terminally ill are treated in many ways, always without prospects for relief or prolonging life appreciably. Doctors have learned to treat, but not to let go. Medical practitioners want to legally protect themselves by doing everything possible, while economic demands at hospitals make it profitable to recommend chemotherapy or expensive operations for incurable patients.

This explains why Germans are not treated in the way they want at the end of their lives. Surveys found 66 percent want to die at home and 18 percent in a hospice or similar care facility. The reality is that 40 percent still die in hospitals, about 30 percent in care homes and only about 25 percent at home.

Little cost or effort is spared in preserving life. The Knappschaft health insurance company estimates about €30,000, or $33,057, is spent on the whole final year of life of a terminally ill patient. Expenditures for a policyholder of the same age, in comparison, are about €3,300. Yet statisticians say relative to all hospital spending, the costs of treating the dying consumes only 5.2 percent of the budget.

Those costs don’t always make life easier. They also prolong suffering. Healthcare management researchers, Heinz Naegler and Karl-Heinz Wehkamp, interviewed clinic doctors and nursing personnel about the consequences of cost cutting and payment based on fixed sums per case. They summarized their findings thus: “They talk about life-support patients bringing in the most money. And there has been widespread talk about how long they must lie in bed to optimize the lump payment per patient. Controlling sees to that.” One patient in chemotherapy can generate €100,000. Is an objective consideration of the hospital’s profits possible?

Yet medical professionals are also divided. Frank Ulrich Montgomery, president of the German Medical Association, said liberalization including doctors is “very clearly aimed at euthanasia.” If euthanasia were to become part of a doctor’s job, a good physician would have to “stay with the patient and do it right.” This could only be accomplished by listing the euthanasia in the schedule of fees, a sign of “how perverse the whole thing would be.” Doctors who treat pain usually are fundamentally opposed to euthanasia by injection.

Matthias Thöns worries about something else. The palliative doctor continually works on the edge of legality. In the mornings, he works as an anesthesiologist in Witten in North Rhine-Westphalia while in the afternoons he hits the road with his eight-man palliative team, visiting people who are near death. Sometimes, two of his patients die on a single day. How does he bear it? “Death is not my enemy, but rather the pain, the suffering and the fear that comes before it,” he said. He attempts to alleviate it, but doesn’t always succeed as in the case of a man who just died of pancreatic cancer. Dr. Thöns met him shortly before his passing. A cancer doctor had told the sick man he could live four years instead of only three weeks if he began chemotherapy.

Dr. Thöns considers promises like that made to terminally ill patients to be dishonest. “They cling to every ray of hope and pointlessly suffer until death,” he said. In fact, in cases of difficult to treat tumors, chemotherapy prolongs survival only by a few weeks, on average.

Still, we are a long way from having a palliative station or a network for the incurable ill available at all hospitals and clinics. “The terminally ill must finally be better cared for and their pain alleviated,” Dr. Thöns said, but at the moment, the opposite is happening. “We are preventing people from dying in peace,” he said.

Matthias Mohrmann, a member of the executive board of the healthcare insurance company AOK Rhineland/Hamburg, noted: “It is essential for the care of the terminally ill to offer them the best palliative care possible to take away the pain and the fear.” More special departments in hospitals are needed while practicing doctors should build their knowledge of better outpatient palliative care, he said. There is, however, a limit for Mr. Mohrmann. “We will never sign a contract with a commercially operating euthanasia organization.”

 

euthanasia _old people_ Sebastian Kahnert_dpa
In Belgium, a card resembling a credit card refers to a patient’s will, which allows Belgians to specify they want active euthanasia. Source: Sebastian Kahnert/DPA

 

Euthanasia associations are active on a larger scale in neighboring countries like Switzerland, where many Germans looking to end their own lives travel. Swiss public prosecutors have argued many patients are already dead within 24 hours of entering the country. They say it is questionable whether it was comprehensively made clear beforehand why someone wants to take their own life.

Greater freedom also prevails in the Benelux countries. In Belgium, people carry a last will and testament in their wallets. A card resembling a credit card refers to a patient’s will, which allows Belgians to specify they want active euthanasia. The law stipulates euthanasia can be granted only in cases of “unbearable suffering” and when the patient is in complete possession of his mental faculties.

Since the law was introduced in 2002, growing numbers of Belgians are demanding euthanasia while more doctors are ready to provide it. The medical sociologist, Joachim Cohen, found that between 2007 and 2013, the percentage of deaths through euthanasia in the Belgian region of Flanders grew from 1.9 percent to 4.6 percent. In 2007, about half of the applications for euthanasia were approved. Now, around three quarters are approved.  One reason that so many doctors are now practicing euthanasia is because none of them has been prosecuted under law. When euthanasia was extended to minors in 2014, the uproar was louder outside Belgium than in it. In contrast to the Netherlands, Belgians can also choose to end their lives if they are suffering mental illness.

It’s a delicate issue. Who wants to judge whether a soul is incurable? Are those who campaign for assisted suicide stigmatizing certain afflictions and old age instead of offering aid?

In Oregon, where euthanasia has been the law since 1997, doctors of the terminally ill may prescribe something enabling them to take their lives. In many cases, however, it isn’t necessary since many doctors offer remedies for easing pain and there are enough hospices.

This model would be a good solution for Germany. On the other hand, one of the proposals in parliament, which would stiffen penalties for those assisting a suicide, would send the wrong signal.

Carola Reimann’s father died in September 2014. Doctors wanted to operate one more time; he said no. Everyone knew his living will. Ms. Reimann encounters similar wishes among her constituency in Braunschweig. “I met some people who say they have made their own decisions their whole lives long,” she said. “They don’t want to have Berlin forbidding them that in this final situation.”

 

This article first appeared in the business newsweekly WirtschaftsWoche.  Anke Henrich, Susanne Kutter and Silke Wettach are also writing for Wirtschaftswoche and contributed reporting. To contact the author: cordula.tutt@wiwo.de.

 

 

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