The moral and ethical issues surrounding medical termination of life have been openly and extensively discussed over the past 20 years and have become one of the most legally complex and culturally sensitive issue to emerge in our time [1-2].
Text Box: Correspondence: Dr Tahir Ahmed Munir, Shifa College of Medicine, H-8/4 Islamabad Email; firstname.lastname@example.org Received: 07 Oct 2008; Accepted: 30 March 2009Euthanasia – a Greek word: “Eu” means “good” and “Thanatos” means “death”. One meaning given to the word is “the intentional termination of life by another at the explicit request of the person who dies”. The medical end-of-life decisions are normally divided into four categories: passive; refers to withholding or withdrawing life-prolonging measures, indirect; refers to the use of agents such as opioids or sedatives to alleviate symptoms of a terminally ill patient, assisted suicide; refers to prescribing and/or supplying a lethal drug in order to help someone to end his own life, and active euthanasia means a doctor actively ending a patient’s life. In passive and indirect euthanasia, the will of a competent patient, or the presumed will of an incompetent patient respectively, is crucial .
As advancement in medicine has increasingly enabled the chronically ill to live longer lives of dubious quality, euthanasia and assisted suicide has become a more actively debated issue.
Although euthanasia and assisted suicide are illegal in most countries, but are legal in Netherlands, State of Oregon in USA, and in the Switzerland. In Australia’s Northern territory, provincial legislation initially enabling euthanasia was almost immediately overridden by the country’s Federal Parliament. By contrast, in the Netherlands the practices have gained a degree of social and professional acceptance, and the medical community has developed standard medical and ethical criteria that must be met for euthanasia to be considered [1, 3-5].
Because of the legal and ethical dilemmas associated with the patient’s requests for assisted dying some healthcare providers may respond to such requests by instituting symptom management strategies designed to relieve suffering . Some palliative care providers assert that improved symptom management could virtually preclude patient request for assisted death [7, 8].
The Jews limit their autonomy by choosing, with advice of their rabbis, to follow God’s law as defined by the Bible and post-Biblical sources, shortening of life through suicide, assisted suicide, or euthanasia is categorically forbidden . Muslims strictly believe that only God should terminate their lives. An Islamic verdict [fatwa] stated that it is not a sin for a patient to refuse treatments of unpredictable efficacy . A Saudi study showed that 58% of Saudi doctors believed that patients in intensive care unit had the right to refuse treatment if it was futile .
The present study was carried out to determine the attitude of junior and senior physicians of a tertiary care hospital in Islamabad towards euthanasia and assisted suicide. In carrying out this survey, we were less concerned to promote a particular view for or against euthanasia than to contribute to the worldwide debate on this sensitive issue.
Text Box: Table-1: Characteristics of the Respondents. SEX Male 87 % Female 13 % Religion Muslim 100% Duties Junior Doctors 80% Specialist 20% Familiarity with Subject Familiar 59.6% Unfamiliar 05.8% Neutral 34.6% Participate in Practice Willing 09.7% Non willing 77.7% Neutral 12.6% Legalization of euthanasia Agreed 02% Non agreed 86.3% Neutral 11.7%This descriptive study was conducted during 2006 (January to November) at Shifa college of Medicine and Shifa International Hospital Islamabad Pakistan. Shifa International hospital is a 500 bed tertiary care hospital with 400 resident staff and 140 specialists. An anonymous enclosed questionnaire was distributed to randomly selected 160 doctors of internal medicine, oncology, psychiatry and surgery at Shifa International Hospital. The questionnaire consisted of respondent characteristics, their attitude towards euthanasia or assisted suicide, willingness to participate in these practices, reasons for oppositions, and safeguards if practice is legalized.
The respondents were requested to rate according to three-point scale showing degree of agreement (agree, neutral and disagree). For any uncertainty, the questionnaire clearly defined Euthanasia as “the deliberate administration of an overdose of medication to an ill patient at his / her request with a primary intent to end his / her life” and the Assisted Suicide as “prescribing a medication (e.g. narcotics) or counseling an ill patient to be able to use an overdose of medication to end his / her life” .
The data was entered and analyzed by SPSS Version 10.0. Descriptive statistics were used to calculate the frequencies.
The characteristics of the respondents are shown in Table 1.
Out of 160 doctors, 105 (65.62%) responded back to the questionnaire. The male and female ratio was 7:1. The respondents were muslims, having moderate islamic teaching and familiarity with the subject, believed that the practice towards euthanasia and assisted suicide could not be ethically justified. Nine percent of the doctors showed their willingness to participate in this practice only in those terminally ill patients who were suffering from intractable pain. A small percentage of the doctors (2%) were in favor of legalization of euthanasia and assisted suicide but most of them (86%) were against this idea.
The respondents who were in favor and suggested restrictions and safeguards are shown in Table 2. The reasons given by respondents for their opposition to legalizing euthanasia and assisted suicide are shown in Table 3.
Our results reveal that majority of Pakistani physicians strongly disagree with the practice as well as legalization of euthanasia and assisted suicide in terminally ill patients; as they all strictly believe that only God should terminate their lives. Our results are in agreement with Ahmad et al  who reported that most of the Sudane doctors strongly opposed the practice of euthanasia and assisted suicide and those who were in favor recommend the practice only in special situation, subject to strict safeguards. The results are also in consistence with Parpa et al who showed that majority of the participant tended to disagree with euthanasia or physician assisted suicide in terminally ill patients .
Text Box: Table-2: Safeguard and restrictions suggested by the respondents. Restrictions and safe-guards Agree (%) Disagree (%) Neutral (%) Psychiatric consultation 70.9 20.3 8.9 Availability of alternative as hospital care 65.9 17.1 17.0 Two / More supporting doctors opinions 63.6 22.1 14.3 Consent of the family 48.8 32.4 18.8 Committee nominated by the Medical Council to review and agree to the decision 58.8 22.4 18.8 Table-3: Reasons cited by doctors for their opposition to legalizing euthanasia and assisted suicide. Reasons for Opposition to legalize Euthanasia / Assisted Suicide Agree (%) Disagree (%) Neutral (%) Religious Beliefs 83.5 4.1 12.4 Inconsistent with doctor’s role in life preservation 57.3 20.2 22.5 Fear of not adhering to prescribed requirements 28.0 36.0 36.0 Presence of subtle pressure on patients fearing dependency or humiliation 41.2 35.3 23.5 Loss of mental competence may impair a patient’s decision 80.3 10.5 9.2 Widespread misuse for handicapped and retarded patients 77.4 15.5 7.1 May impair scientific research to solve the problems of the dying 43.6 29.5 26.9Over 80% of the Pakistani doctors, who opposed these practices, cited religious grounds as compared to 56% in the Washington study as shown by Cohn et al . The Pakistani doctors like American doctors participated in this current international debate; however, major cultural differences are by different attitudes and the Hippocratic Oath has not facilitated the establishment of these practices in the medical profession. The Catholic and Lutheran Churches oppose all forms of euthanasia. Islam not only opposes euthanasia, but encourages believers to view pain and suffering as a potential blessing. Muslims strictly believe that only God should terminate their lives. However, an Islamic verdict (fatwa) five years ago stated that it is not a sin for a patient to refuse treatment of unpredictable efficacy . In a study carried out in Saudi Arabia (where there is a strict adherence to Islamic teachings), 58% of doctors believed that patients in intensive care units had the right to refuse treatment if it was futile . This is in keep with the earliest Islamic attitudes to seeking remedies since the time of the Prophet Muhammad (PBUH), whereby a patient has the right to refuse a remedy, especially if it is futile. Neither the fatwa nor the Saudi doctors’ view is indicative of any new trend; neither do they suggest the potential for attitude changes towards euthanasia.
Some opponents of euthanasia in our study argued that because effective palliative therapy was rarely available due to insufficient resources, then if euthanasia was legalized, it would become a substitute for securing efficient palliation. This was supported by the fact that in the Washington study, American oncologists and hematologists, who had the greatest exposure to terminally ill patients, were the strongest opponents of euthanasia and assisted suicide . In the Netherlands, two-thirds of requests for euthanasia or suicide are withdrawn, often as the result of palliative intervention .
Arguments that have been offered in favor of permitting physicians to aid suicide include the importance of patient autonomy, the claim that patients need this option to cope with symptoms at the end of the life, and the assertion that practices already accepted involve intentionally ending life. Arguments that have been offered against include the potential for abuse, the claim that forbidding intentional killing is essential to the ethics of medicine, and assertion that patients can be provided good and humane care at the end of life without assisting suicide. Addressing the demand for physician assisted suicide requires improvement in end of life. Care and continued discussion attentive to emerging empirical data .
Despite the wide debate over euthanasia and assisted suicide, there has been little discussion of the actual clinical outcome of these procedures . Complications arising from doctor-assisted suicide or euthanasia add to the existing suffering of the patient. Groenewoud et al  reported that complications were more likely with doctor-assisted suicide than with euthanasia. The study reported that the attending doctor had been required to intervene by administering a lethal drug in 21 of 111 cases in which the original intention was only to provide assistance with suicide. In another study, up to half the patients supplied with lethal drugs were unable to use them and required active intervention by a doctor .
Some doctors have reported regretting their decision to carry out euthanasia or assisted suicide . Ignorance of palliative options, difficulty in diagnosing and treating depression, and failure in evaluating external pressure on patients are not uncommon, and adversely effect the decision . Changing societal norms and pressures has resulted in at least one-third of patients with acquired immunodeficiency syndrome (AIDS) requesting euthanasia worldwide .
Pakistani doctors strictly opposed to euthanasia and assisted suicide. Treatment and social support should be provided to the terminally ill patients and their families through comprehensive programs run by multidisciplinary teams rather than euthanasia and assisted suicide.
|1. Groenewoud JH , van der Heide A, Onwuteaka-Philipsen BD, Willems DL, van der Maas PJ, van der Wal G. Clinical Problems with the Performance of Euthanasia and Physician-Assisted Suicide in the Netherlands. N Engl J Med 2000; 342: 551-6.
2. Porter T, Johson P, Warran N. Bioethical issues concerning death, dying, and end-of-life rights. Crit Care Nurs Q 2005; 1:85-92.
3. Bosshard G. Medical end-of-life decisions and assisted suicide. Ther Umsch 2008;65:413-6
4. Ganzini L, Nelson HD, Schmidt TA, Kraemer DF, Delorit MA, Lee MA. Physicians' Experiences with the Oregon Death with Dignity Act. N Engl J Med 2000; 342: 557-63.
5. Chao DV, Chan NY, Chan WY. Euthanasia revisited. Fam Pract 2002; 19: 128-34.
6. Volker DL. Assisted Dying and End-of-Life Symptom Management. Cancer Nurs 2003; 26: 392-9.
7. Foley K M. Competent Care for the Dying Instead of Physician-Assisted Suicide. N Engl J Med 1997; 336: 53-58.
8. Kazanowski K. A commitment to palliative care: could it impact assisted suicide? J Gerontol Nurs J 1997; 23: 36-42.
9. Kinzbrunner BM. Jewish medical ethics and end-of-life care. J Palliat Med. 2004; 4: 558-73.
10. Alnashy E. Death after refusing treatment. Al mujtamaa 1992; 23: 57-8
11. Mobeireek A. The do-not-resuscitate order: indications on the current practice in Riyadh. Annals of Saudi medicine 1995; 15: 6-9.
12. Cohen J S, Fihn S D, Boyko E J, Jonsen A R, Wood R W. Attitudes toward Assisted Suicide and Euthanasia among Physicians in Washington State. N Engl J Med 1994; 331: 89-94
13. Ahmad AM, Kheir MM, Rahman A, Ahmed NH, Abdalla ME. Attitudes towards euthanasia and assisted suicide among Sudanese doctors. East Mediterr Health J 2001; 7: 551-5
14. Parpa E, Mystakidou K, Tsilika E, Tsilika E, Sakkas P, Patiraki E, Pistevou-Gombaki K. Euthanasia and physician-assisted suicide in cases of terminal cancer: the opinions of physicians and nurses in Greece. Med Sci Law 2008; 48: 333-41.
15. Wolf SM. Physician-assisted suicide. Clin Geriatr Med 2005; 1: 179-92.
16. Finlay I. Physician-assisted suicide: issues facing doctors. Hospital medicine 1999; 60: 4-6.
17. Onwuteaka-Philipsen BD. Active voluntary euthanasia or physician-assisted suicide? J Am Ger Soc. 1997; 45:1208–13.
18. Emanuel EJ,Daniel ER, Fairclough DL, Clarridge BR. The practice of euthanasia and physician-assisted suicide in the United States: adherence to proposed safe-guards and effects on physicians. JAMA1998; 280: 507–13.
19. Grande GE, Barclay SI, Todd CJ. Difficulty of symptom control and general practitioners’ knowledge of patients’ symptoms. Palliative medicine.1997; 11: 399–406.
Onwuteaka-Philipsen BD, van der Wal G. Cases of euthanasia and physician-assisted suicide among AIDS patients reported to the Public Prosecutor in North Holland. Public health. 1998; 112:53–6.