Canada

Important Position Paper on Criteria for Brain Death and Organ Donation: A Call to Action

nancyvalko assisted suicide, brain death, brain injury, Canada, conscience rights, culture, education, end-of-life, euthanasia, medical ethics, ventilators/life support

I am a signatory on this statement and it deserves to be read and shared. Although the statement touches on Catholic teaching, it is primarily is about science and ethics. Please read the statement and press release.

The statement, “Catholics United on Brain Death and Organ Donation: A Call to Action”, was published on February 27, 2024. It was prepared by Joseph Eble, a physician and President of the Tulsa Guild of the Catholic Medical Association; John Di Camillo, an ethicist of The National Catholic Bioethics Center; and Peter Colosi, a philosophy professor at Salve Regina University.

As a nurse, I have been writing about this topic for years, most recently in my May, 2021 blog “Rethinking Brain Death and Organ Donation” and my experience serving on an ethics committee at a hospital where a patient “failed” one of the hospital’s brain death tests and thus could not have her organs removed.

Although I already knew that the medical criteria used to determine brain death vary — often widely — from one hospital to another, one young doctor checked our area hospitals and came back elated after he found a hospital that did not include the test the elderly woman “failed”. He suggested that our hospital adopt the other hospital’s criteria to allow more organ donations.

When I pointed out that the public could lose trust in the ethics of organ donations if they knew we would change our rules just to get more organ transplants, I was told that I being hard-hearted to people who desperately needed such organs.

I was also alarmed when a 2011 Illinois almost passed a “presumed consent for organ donation” law in 2011 that would allow presumed consent unless a person ” opt(s) of the presumed donation by executing an anatomical gift as otherwise provided in the Act or by filing with the Secretary of State an organ donor opt out document. ” (Emphasis added) Thankfully, it was defeated especially with the help of the disability group Not Dead Yet.

FINDINGS OF THE POSITION PAPER

“At least half of donors declared brain-dead are actually alive when their organs are removed, according to the position paper endorsed by 151 Catholic health care professionals, theologians, philosophers, ethicists, lawyers, apologists, pro-life advocates, and others, including a brain death survivor and a professional organization.” (There is now a webpage of some of the people diagnosed as brain dead who “lived to tell the tale”.)

“Catholic United explains that the criteria for brain death establish only partial loss of brain function. This is now abundantly clear based on scientific studies, a recent effort to lower the legal standard for death, and updated brain death guidelines issued in October 2023.” (All emphasis added)

The statement calls for an effort “to unite against the utilization of the current brain death criteria” because they do not ensure that patients are dead. They recommend concrete action steps to protect vulnerable patients, enable informed decisions, identify better criteria for determining actual death, and protect the conscience rights of healthcare professionals and organizations”.

Also “Catholics United bridges a divide among faithful Catholics about whether the concept of brain death aligns with Church teaching. Some Catholics hold that brain death represents true death when there is complete and irreversible cessation of all brain activity, often called whole brain death. Others hold that brain death does not represent true death. Since the existing criteria establish only partial loss of brain function, all the endorsers—whether they accept or reject whole brain death as true death—agree that “the current brain death criteria in widespread use do not provide moral (prudential) certainty of death.” (Emphasis added)

RECOMMENDATIONS

The statement “calls on health care professionals and institutions to cease organ harvesting that relies on the inadequate criteria, noting that 70% of all donors are declared dead using brain death criteria. “ (Emphasis added)

Given the lack of moral certainty of death whenever the current brain death criteria are used, the statement affirms that “a clear majority of vital organ donors can be presumed alive at the time of organ harvesting.” Since the Catholic Church forbids removing vital organs when this would kill the patient, “it is therefore wrong to remove organs from patients declared dead using these inadequate criteria.”

Catholics United makes a number of other strong recommendations, including:

  • Declining to be an organ donor at the Department of Motor Vehicles.
  • Refusing to be an organ donor after death in advance directives.
  • Improving education on end-of-life care and organ donation at the pastoral level.
  • Identifying criteria that will establish certainty of death.
  • Advocating for conscience protection rights for health care professionals and institutions.

The statement also cites:

“Current president and co-founder of the pro-life advocacy group American Life League, Judie Brown, has decided to update its Loving Will Comfort and Care Directive in accord with the new recommendations. “I think that any organization that has a pro-life document addressing wishes at the end of life needs to be updated in view of this article,” said Ms. Brown.”

CONCLUSION

Unfortunately, now some countries’ healthcare ethics have even degenerated to the point where eight countries including Canada, the Netherlands, Spain, and Belgium allow organ donation after euthanasia by “combining medical assistance in dying (MAiD) with donations after circulatory determination of death (DCDD) is known as organ donation after euthanasia (ODE)”. (Emphasis added)

Personally, I am all for the ethical donation of tissues like bone, skin, corneas, etc. after natural death. And I am also a strong supporter of living donation. For example, I volunteered to donate one of my kidneys to a friend years ago and one of our grandsons was saved in 2013 by an adult stem cell transplant donated by a living person.

Hopefully, this statement can help all of us to better protect ourselves and vulnerable patients at the end of life- especially when it comes to organ donation-as well as promoting a dignified, humane and peaceful end of life.

A New Medically Assisted Suicide Organization Arises

nancyvalko assisted suicide, Canada, end-of-life, hospice, law, medical ethics, nursing, palliative care

In my June, 2016 blog “Tolerating Evil” at , I wrote:

“(A) few days after California’s new assisted suicide law took effect,  one doctor immediately opened up a dedicated assisted suicide clinic in San Francisco.

Dr. Lonnie Shavelson, 64 and a long-time supporter of physician-assisted suicide, was an emergency room doctor for 29 year and then spend 7 years at an Oakland clinic for immigrants and refugees before taking a 2 year break.

His new assisted suicide business could be quite lucrative. Although Medicare will not pay for assisted suicide costs, Shavelson says he will charge $200 for an initial patient evaluation. If the patient is deemed qualified under California law, Shavelson said he would charge another $1800 for more visits, evaluations and legal forms. (Emphasis added)

Shavelson defends his business by claiming that “..the demand (for assisted suicide) is so high, that the only compassionate thing to do would be to bring it above ground and regulate it.”

Now, a new medical group called American Clinicians Academy on Medical Aid in Dying  has been formed with a Board of Directors and Advisors and chaired by the same Dr. Lonnie Shavelson.

The board of this organization includes a Nursing Coordinator, Director of End-of-Life Doula Education, a Volunteer Systems Advisor, as well as Hospice and Palliative Care Advisors including chaplains, nurses and social workers. There is also an “Aid in Dying Ethics Consultation Service”, ethicist, lawyer and pharmacists. An Investigations and Data Collection group is also included as well as State Liaisons in various states.

Also included is Resident Training and Education, Patient Liaisons and Volunteers, Chaplains and End-of-Life  Spiritual Advisors, a legal advisor/ethicist, and a member of the San Francisco/Marin Medical Society with a Master’s in Public Health degree.

The American Clinicians Academy on Medical Aid along with the older Death with Dignity organization just had their second conference February 17-18 in Portland Oregon and provided “13 continuing education units for doctors and nurses” and 10 for social workers.

The conference included presentations like “ Some Myths about Aid in Dying”, “State Differences — Present and Future Legal Considerations”, “Hospices and Aid in Dying — A land of many journeys”, “Prognostic Dilemmas in Aid in Dying”, “Medical Aid in Dying for ALS: Navigating Complexities from Prognosis to Ingestion” and “Clinician Attendance on the Aid-in-Dying day — Doctors, nurses, volunteers, end-of-life doulas, hospice staff” and “Socially-Challenging Settings and Circumstances — homeless and impoverished; family conflicts; skilled nursing and long-term care facilities” and “Medically Challenging Cases: Complex gut function; Self-administration by oral, rectal, PEG and ostomy routes” presented by Dr. Shavelson himself. (All emphasis added)

The first National Clinicians Conference on Medical Aid in Dying occurred in 2020 at UC Berkley in California. It was sponsored   by groups like UC Davis Health,  Mission Hospice and Home Care, the San Francisco Marin Medical Society and the Center for Bioethics and Humanities at the University of Colorado that promotes “Research at the Intersection of Bioethics and Policy for Persons with Disability” (emphasis added) among other groups.

Apparently, Compassion and Choice  now has some competition in the relentless campaign to legalize and normalize medically assisted suicide in every US state.

COMPASSION AND CHOICES

Now, Compassion and Choices has a new “Federal Advocacy and Policy-Bringing the voice of the terminally ill to Capitol Hill“ that:

“advances federal legislation and regulatory change focused on:

  • Strengthening and expanding the full spectrum of end-of-life care such as advance care planning, hospice care, and palliative care, while protecting end-of-life options and patient autonomy from federal efforts to weaken or overturn federal and state laws.
  • Addressing disparities in end-of-life care for historically disadvantaged populations and advancing healthcare equity at life’s end.
  • Expanding professional end-of-life care education, training and development for all healthcare professionals.
  • Preventing healthcare entities from disregarding patient values and preferences by refusing care due to their ethical directives and policy-based restrictions. (All emphasis added)”

Compassion and Choices strongly opposes the “Assisted Suicide Funding Restrictions Act (ASFRA) (seeking repeal)” that:

“Prohibits the use of federal funds to provide or pay for any healthcare item or service or health benefit coverage for the purpose of causing, or assisting to cause, the death of any individual.” as well as “Seeking to permanently vacate the proposed rule, “Protecting Statutory Conscience Rights In Health Care (83 FR 3880),” from the U.S. Department of Health and Human Services, which attempted to allow medical providers expanded exemptions from critical healthcare services beyond what the law currently allows.”

Compassion also supports effort to “Establish Comprehensive Telehealth Reform” and also ominously, the Palliative Care and Hospice Education Act (PCHETA)

CONCLUSION

In 2018, I wrote the blog “Beware the New Palliative Care and Hospice Education and Training Act” (PCHETA)” about Senate Bill 693. 

A similar bill had already passed in the House and this Senate bill was also expected.

As I wrote then:

“As an RN with decades of nursing experience in hospice, oncology (cancer) and critical care, I have been involved with many end-of-life situations. I am an enthusiastic supporter of ethical palliative and hospice care which is indeed wonderful for patients of any age and their families.

Unfortunately, there is a growing trend towards calling unethical practices ‘palliative’ or ‘hospice’ care.”

And we certainly should not be allocating federal dollars for this.

But, despite the enormous push for the PCHETA, it never passed.

There was great opposition by American Association of Physicians and Surgeons, the National Association of Pro-life Nurses  , Sara Buscher, a retired attorney and CPA on the board of the Euthanasia Prevention Coalition – USA. who advocates for the elderly and disabled , the Healthcare Advocacy and Leadership Organization (HALO) and others.

Now, Compassion and Choices is working hard again to get PCHETA passed to “ increase the number of faculty at accredited healthcare programs” and “promote increased education and research in Palliative Care and Hospice care.” (All emphasis added)

If groups promoting medically assisted suicide throughout the US are successful in taking over the ethics education of our health care professionals, eliminating conscience rights for healthcare providers and institutions, continue to dismantle so-called legal safeguards called “obstacles” and allow the same poor oversight and documentation found in Oregon, the first state to legalize assisted suicide, we will see the inevitable and inexorable expansion of medically assisted suicide  that we are now seeing in Canada.

We need to demand the highest ethical standards in healthcare to protect ourselves, our healthcare institutions and the most vulnerable among us who need hope and help-not medically assisted suicide.

 

 

A DISTURBING BUT IMPORTANT LOOK INTO THE TRAINING OF DOCTORS FOR MEDICALLY ASSISTED SUICIDE

nancyvalko assisted suicide, Canada, Compassion & Choices, conscience rights, disability, end-of-life, law, medical ethics, mental health

Most people seem to assume that medically assisted suicide is a simple matter of getting a doctor to prescribe a lethal overdose, taking a pill or two and then go to sleep and die. Many seem unaware that a second consulting doctor (or other healthcare provider in some states) must agree.

This view, abetted by polls, well-funded groups like Compassion and Choices as well as a mostly sympathetic mainstream media, is disastrously wrong.

A stunning February 2022 article in Medscape for healthcare providers titled  “Medical Aid in Dying: Your Clinical Guide and Practice Points” exposes some very real problems with medically assisted suicide that are largely hidden from the general public.

But while citing a Gallup poll showing that 74% of the American public support legalizing “medical aid in dying” (their preferred term for medically assisted suicide) as well as 58% of doctors, the article admits that:

“Study data, however, have revealed a discrepancy between attitudes about legalization and willingness to practice. Only 15% to 22% of physicians in favor of legal access to medical aid in dying would be willing or likely to provide such assistance” (Emphasis added)

And citing Oregon, the first state to legalize assisted suicide, the article claims that:

“Pain management and hospice use have improved in Oregon since passage of the Death with Dignity Act” but also that “Opponents of medical aid in dying express concern that in Oregon, more than 70% of patients who elect medical aid in dying are elderly and have cancer–both being commonly associated with depression–but fewer than 5% are referred for psychiatric evaluation”. (Emphasis added)

Tellingly, the article recognizes the toll assisted suicide can take on the medical professionals involved:

“A Mental Note for the Healthcare Provider: Discussion of end-of-life options represents a profound event for both the patient and the healthcare provider. Do not neglect your own self-care while guiding your patient through the emotionality that can be brought on by end-of-life decision-making.” (Emphasis added)

THE MEDICALLY ASSISTED SUICIDE PROTOCOL IS COMPLICATED

It is recommended that the patient does not eat or drink for 6 hours before ingesting the lethal dose called D-DMAPh.

Anti-nausea medication and a gastric motility medication is to be taken 1 hour before ingesting the life-ending medication.

A large dose of Digoxin to slow the heart is taken 30 minutes later and then a compound of anxiolytic, opioid and tricyclic medications are to be swallowed in less than 90 seconds.

Recommendations include:

– adding a favorite liquor may counter the bitterness of the mixture

– a small amount of sorbet can be ingested to avoid potential post-ingestion esophageal burning or distress

-Prepare for the possibility that the medication may not work if not quickly and fully ingested; it is crucial that the patient who self-administers not fall asleep before consuming the full dose-Patients should not take the medicine when alone or in a public place

-kept carefully out of the reach of children and vulnerable adults

-and must be disposed of properly. (Emphasis added)

For special circumstances:

“It is legal in all jurisdictions for physicians, other HCPs, or family members to assist in medical aid in dying but not to administer medical aid-in-dying medications.[1-9] The law requires that the patient self-administer the medication through ingestible means, which may include:

•         Drinking the medication mixture

•         Ingesting through a nasogastric tube

•         Ingesting the medication through a feeding tube, or

•         Insertion through a rectal catheter

Patients are permitted to receive help in preparing or mixing the medication for self-administration, but the patient must take a voluntary, affirmative act (i.e., swallowing or pushing a syringe) and administer the medication him- or herself. Medical aid-in-dying laws do not allow physicians, family members, or anyone else, including the dying person, to administer medical aid-in-dying medication by intravenous (IV) injection, parenteral injection, or infusion.” (Emphasis added)

The article states that decision-making capacity is the basis of informed consent and that:

“Guidance begins with assessment of the patient’s decision-making capacity and understanding of palliative measures as alternatives to or concurrent with medical aid in dying. No matter the practice specialty, HCPs (health care providers) are trained on the art of assessing a patient’s medical decision-making capacity and their ability to understand the situation, appreciate the consequences, reason rationally, and express a choice.” (Emphasis added)

If there is a concern, the patient:

 “must be referred for additional evaluation by a licensed psychiatrist, clinical psychologist, or clinical social worker. The request for aid-in-dying medication does not proceed unless the mental health professional affirms that the patient is free of mental illness, acute psychological distress, or demoralization.” (Emphasis added)

COMPLICATIONS

The article admits that complications such as regurgitation and seizures can occur but says they are infrequent.

Prolonged dying can also occur so the “families should make contingency plans for how to manage such circumstances” and “remain calm and engage with hospice or other support services as needed. Families should understand that to help avoid unnecessary deployment of police and emergency medical personnel, they should not call 911.” (Emphasis added)

The article also warns that:

“Those present at the death may witness the following changes, which frequently occur during the natural dying process: snoring; gurgling noises; changes in rate of breathing; and fluctuations in body temperature that may leave their skin cool, warm, moist, or pale. Physical movements or other external signs of distress are sometimes exhibited, but the internal peace of the person is not disturbed.” (Emphasis added)

Sadly, the article reports that 4% of patients in Oregon “chose not to inform their families of their decision” even though support groups “strongly recommend that at least 1 other person be present” but not the doctor.

LEGAL REQUIREMENTS DIFFER WIDELY BETWEEN STATES

The article illustrates how dramatic the differences are in state laws such as the eligible medical providers in New Mexico to include APRNs (advance practice registered nurses) and physician assistants and no consulting provider is required if the patient is in hospice.

and

“In Hawaii, a mental health evaluation is mandatory for all patients requesting medications under the law. In New Mexico, a mental health evaluation is also required if the patient has a recent history of a mental health condition or intellectual disability.” (Emphasis added)

Required waiting periods to make the second request varies from as little as none in Oregon and New Mexico if the patient is unlikely to survive the waiting period to at least 20 days in Hawaii.

The article also recommends that health care providers familiarize themselves with the assisted suicide group Compassion and Choice’s Doc2Doc helpline that “offers free, confidential telephone consultation with clinicians who are experienced in providing end-of-life medical care”.

Right now, 9 U.S, states (California, Colorado, Hawaii, Maine, New Jersey, New Mexico, Oregon, Vermont,  Washington)  and the District of Columbia have medically assisted suicide laws and 12 states (Massachusetts, Delaware, Minnesota, New York, Pennsylvania, North Carolina, Indiana, Kentucky, Rhode Island, Virginian, Arizona and Utah) have bills in their legislatures.

And there are more states seeking to expand their existing assisted suicide laws such as Vermont S 74  that threatens conscience rights by defining assisted suicide as a “healthcare service” and allows assisted suicide by telemedicine and Washington state HB 1141 that expands the prescriber to PAs (physician assistants), advanced registered nurse practitioners and allows the lethal dose to be sent by mail or courier.

CONCLUSION

Our neighbor Canada is a cautionary tale about the inability to limit medically assisted suicide.

In a June, 2021 article in the Psychiatric Times titled “First, Do No Harm: New Canadian Law Allows for Assisted Suicide for Patients with Psychiatric Disorders” , Dr. Mark Komrad chronicles the expansion of the 2016 MAID (medical aid in dying) law allowing medical euthanasia (the doctor directly administers a substance that causes death, such as an injection of a drug) and physician-assisted suicide for the terminally ill to expand to those “with nonterminal chronic illnesses and permitted euthanasia for those whose psychological or physical suffering is deemed intolerable and untreatable”.

Now, those Canadians “whose only medical condition is a mental illness, and who otherwise meet all eligibility criteria, will not be eligible for MAID until March 17, 2023″. (Emphasis added).

As a nurse with over 50 years of personal and professional experience in hospice, critical care, oncology, etc., I am willing to do anything for sick people– except kill them or help them kill themselves. These people deserve better!

Medically assisted suicide is a dangerous proposition that has proven to be impossible to strictly limit. It also corrupts the essential element of trust we must have in the health care system and makes suicide more attractive to vulnerable people as a way to solve life’s problems.

They are Lying to Us!

nancyvalko assisted suicide, Canada, culture, medical ethics

In my last blog “Legal Safeguards, Burdensome Obstacles and Conscience Rights”, I wrote about influential lawyer Thaddeus Pope’s article “Medical Aid in Dying: When Legal Safeguards Become Burdensome Obstacles” that listed  four ways to address such  “burdensome safeguards” in medically assisted suicide laws: “Expanding From Adults to Mature Minors”, “Expanding From Contemporaneous Capacity to Advance Directives” to pre-choose assisted suicide before becoming incompetent, “Expanding From Terminal Illness to ‘Reasonably Predictable’” and “Expanding From Self-Ingestion to Physician Administration”. (Emphasis added)

Other “burdensome obstacles” Mr. Pope has also cited include the waiting time between requests for assisted suicide and the administration of the lethal overdose for some patients and the physician requirement because of problems finding willing doctors.

While groups like Compassion and Choices and a mostly sympathetic mainstream media continue to tout allegedly strong “safeguards” in assisted suicide laws that allegedly prevent abuse, these “burdensome obstacles”- which already have been mostly eliminated in countries like Canada and Holland- are now beginning to fall here in the US and other new countries. Few of us are aware of this.

HAWAII

A case in point is Hawaii, whose legislature rejected assisted suicide just last year.

This year, a new bill, HB 2739, called the “Our Care, Our Choices Act” was recently fast-tracked in the legislature with testimony scheduled for February 27, 2018. It would allow advanced practiced registered nurses as well as doctors to be the “attending provider” for assisted suicide.

Despite the ubiquitous at least six problems with US assisted suicide laws that I have written about before, the Hawaii legislators claimed “robust safeguards” such as, “if appropriate”, the doctor (or nurse) can refer the terminally ill patient for  “counseling” to be performed by “a state-licensed psychiatrist or psychologist” but just for “determining that the patient is capable of making medical decisions and not suffering from a psychiatric or psychological disorder or depression causing impaired judgment”. This is not the same as the usual psychiatric/psychological evaluation required for other suicidal people. (Emphasis added)

(I submitted my testimony on this bill which is at the end of this blog.)

After “an emotional 5-hour hearing” February 27th, a joint House panel voted in favor of an amended version of HB 2739 that will now head to a vote of the full House in the near future.

The amended bill includes the welcome removal of advanced practice registered nurses as “attending providers” but added social workers to the psychiatrists or psychologists designated as the counselors to determining the patient’s “capability” and allows “counseling” by telehealth instead of in person. Finally, the new bill would also lengthen the time between oral requests for assisted suicide from 15 to 20 days.

Hopefully this terrible new assisted suicide bill will be defeated like last year’s.

But, as usual, Compassion and Choices continues to describe HB 2739 as just:

“Medical aid in dying is an end-of-life medical practice in which a terminally ill, mentally capable individual who has a prognosis of six months or less to live requests, obtains and—if his or her suffering becomes unbearable—self-ingests medication to die peacefully in their sleep.”

We all need to know that we are being lied to about assisted suicide and fight against such laws!

My Testimony on Hawaii’s HB 2739

February 26, 2018

Please Do Not Approve HB 2739, From a Mother and a Nurse

 As the mother of a physically healthy suicide victim who used an assisted suicide technique and as a registered nurse who has cared for suicidal people both personally and professionally for over 40 years, I implore you not to approve the dangerous HB 2739, the “Our Care, Our Choice Act”.

Despite the euphemism of “aid in dying” instead of medically (since advanced practice registered nurses can be “the attending physician”) assisted suicide and the demand for it as a fundamental right, this bill puts both desperate people and our health care system in danger. I want to address both issues.

My Daughter Marie Killed Herself Using an Assisted Suicide Technique

In 2009, I lost a beautiful, physically well 30-year-old daughter, Marie, to suicide after a 16-year battle with substance abuse and other issues. Her suicide was like an atom bomb dropped on our family, friends and even her therapists.

Despite all of our efforts to save her, my Marie told me that she learned how to kill herself from visiting suicide/assisted suicide websites and reading Derek Humphry’s book Final Exit. The medical examiner called Marie’s suicide technique “textbook final exit” but her death was neither dignified nor peaceful.

Marie was not mere collateral damage in the controversy over assisted suicide. She was a victim of the physician-assisted suicide movement, seduced by the rhetoric of a painless exit from what she believed was a hopeless life of suffering.

SUICIDE CONTAGION

Adding to our family’s pain, at least two people close to Marie became suicidal not long after her suicide. Luckily, these two young people received help and were saved, but suicide contagion, better known as “copycat suicide”, is a well-documented phenomenon.

After Oregon’s physician-assisted suicide law took effect in 1997, the rate of suicide increased. In 2015, the state’s health department said “The rate of suicide among Oregonians has been increasing since 2000” and as of 2012 was “42% higher than the national average”; suicide had become “the second leading cause of death among Oregonians aged 15 to 34 years.” These figures are in addition to deaths under the Oregon assisted suicide law, which legally are not counted as suicides.

My Marie was one of the almost 37,000 reported US suicides in 2009. According to the Centers for Disease Control and Prevention, suicide is the 10th leading cause of death among Americans with more than 44,000 people dying by suicide in 2015, more than 1.4 million people reported making a suicide attempt in the past year and almost 10 million adults reported thinking about suicide in the past year. Suicide costs society over $56.9 billion a year in combined medical and work loss costs.

Our urgent health care crisis is the staggering and increasing number of suicides, not the lack of enough medically assisted suicides.

The Effect of Medically Assisted Suicide on Our Health Care System

 MY STORY

Several years after Oregon’s law was passed, I was threatened with termination from my job as an intensive care unit nurse after I refused to participate in a deliberate overdose of morphine that neither the patient nor his family requested after an older patient experienced a crisis after a routine surgery.

The patient had improved but did not wake up within 24 hours after sedatives used with a ventilator were stopped. It was assumed that severe brain damage had occurred and doctors recommended removing the ventilator and letting the patient die.

However when the ventilator was removed, the patient unexpectedly continued to breathe even without oxygen support. A morphine drip was started and rapidly increased but the patient continued to breathe.

When I refused to participate in this, I found no support in my hospitals “chain of command” and I could not pass off this patient to another nurse so I basically stopped the morphine drip myself, technically following the order to “titrate morphine for comfort, no limit.”

The patient eventually died after I left but ironically, a later autopsy requested by the family showed no lethal condition or brain injury as suspected.

The physician who authorized the morphine demanded that I be fired.

I’ve known other doctors, nurses and therapist who have similarly put their jobs on the line to protect their patients. Unfortunately, we are fast becoming pariahs in the face of medically assisted suicide legalization.

Society has long insisted that health care professionals adhere to the highest standards of ethics as a form of protection for society. The vulnerability of a sick person and the inability of society to monitor every health care decision or action are powerful motivators to enforce such standards. For thousands of years doctors (and nurses) have embraced the Hippocratic standard that “I will give no deadly medicine to any one, nor suggest any such counsel.” Should the bright line doctors and nurses themselves drew to separate killing from caring now be erased by legislation?

As a nurse, I am willing to do anything for my patients — except kill them. In my work with the terminally ill, I have been struck by how rarely these people say something like, “I want to end my life.” And the few who do express such thoughts are visibly relieved when their concerns and fears are addressed and dealt with instead of finding support for the suicide option. I have yet to see such a patient go on to commit suicide.

In 2015, the Canadian Supreme Court approved MAID (medical aid in dying aka medically assisted suicide) and lethal injection suicides began in Quebec, one of Canada’s largest provinces. Now, “only 5 of more than 2,000 Canadian patients who used medical aid in dying self- ingested the lethal medication.”

But a December, 2017 Canadian medical journal article “First Results from a Unique Study” done in Laval, Canada showed that although prior to the law, 48% of doctors said they would participate, 30% with conditions and only 28% said they would never participate, afterwards, 77% of the physicians getting MAID requests refused to actively participate, all of them using the conscientious objection clause, even though the study claimed the majority (72%) were in favor of MAID with only 13% of the doctors neutral or ambivalent. The most common reason given for refusal was “too much of an emotional burden to bear”.

Do assisted suicide supporters really expect us doctors and nurses to be able to assist the suicide of one patient, then go on to care for a similar patient who wants to live, without this having an effect on our ethics or our empathy? Do they realize that this can reduce the second patient’s will-to-live request to a mere personal whim – perhaps, ultimately, one that society will see as selfish and too costly? How does this serve optimal health care, let alone the integrity of doctors and nurses who have to face the fact that we helped other human beings kill themselves?

Conclusion

Medically assisted suicide is a dangerous proposition and HB 2739 goes beyond even Oregon’s law by approving advanced practice registered nurses as providers. Other countries have gone farther to include chronic psychiatric conditions, birth defects and even just old age.

We must not discriminate on the basis of health and choice when it comes to desperate people seeking suicide. We must treat all of our citizens with equal concern.

Legal Safeguards, Burdensome Obstacles and Conscience Rights

nancyvalko assisted suicide, Canada, conscience rights, law, medical ethics, nursing

After I wrote last week’s blog “The New Federal Conscience and Religious Freedom Division” , I was surprised by this criticism: “arguing conscience can make doctors (and others) look whiney, as opposed to heroic” and give assisted suicide supporters “an easy platform to describe them as selfish and out of touch ideologues who want to make their parents suffer.” But this comment did make me think.

Actually, I felt horror, intense sadness and fear when, as I wrote in the blog, I was “threatened with termination (after the fact) for refusing to participate in an unethical health care decision years ago.” I was trying to save my patient from being deliberately terminated with an overdose of morphine that neither he nor his family requested but I found no support in the “chain of command” at my hospital. I could not pass this patient to another nurse so I basically stopped the morphine drip myself, technically following the order “titrate morphine for comfort, no limit”.

Especially as the sole support of three children with no family support, I feared losing my job but I could not participate in good conscience for my patient’s sake. I did not feel either heroic or whiney.

Ironically, a later autopsy requested by the family showed no lethal condition or brain injury as suspected when the patient had a crisis after routine surgery.

I’ve known other doctors, nurses and therapists who have similarly put their jobs on the line for the real reason for conscience rights: protection of patients. We are a thinning white line in the face of expanding demands for deliberate death as a civil right while our US and other countries’ professional organizations are changing or considering changing their positions against medically assisted suicide and euthanasia.

If we who refuse to terminate our patients are harassed or eliminated from our professions and future potential students discouraged from choosing such a profession, patients will be denied the choice of such medical professionals and a final barrier will be broken in the lethal flood to follow.

WHEN “LEGAL SAFEGUARDS” BECOME “BURDENSOME OBSTACLES”

Already there are impatient calls to expand medically assisted suicide and euthanasia.

Thaddeus Pope, JD, PhD, the influential Director of the Health Law Institute and Professor of Law at the Mitchell Hamline School of Law in Saint Paul, Minnesota and writer of the Medical Futility Blog, wrote an article last December titled “Medical Aid in Dying: When Legal Safeguards Become Burdensome Obstacles” for the American Society of Clinical Oncology Post. (According to ASCO, it “has taken no official position on medical aid in dying”.)

Mr. Pope notes the “uniformity and similarity” of the six current medically assisted suicide statutes but brings up four so-called “safeguards” affecting the “next-generation issues: the justifiability of prevailing eligibility criteria and procedural requirements” that will allegedly need to be addressed. (Emphasis added)

The first is “Expanding From Adults to Mature Minors” which Mr. Pope characterizes as “unduly restrictive” in part because “Many states already allow terminally ill mature minors to withhold or withdraw life-sustaining treatment”. (Emphasis added)

Mr. Pope’s second issue is “Expanding From Contemporaneous Capacity to Advance Directives”, stating that “All six statutes require that the patient concurrently have both a terminal illness and decision-making capacity. But this dual mandate excludes many patients who have no other exit options” such as those with “advanced dementia”. (Emphasis added)

The third issue he cites is “Expanding From Terminal Illness to ‘Reasonably Predictable’” because:

“(T)his rigid time frame excludes patients with grievous and irremediable conditions that cause suffering intolerable to the individual. Some medical conditions may cause individuals to irreversibly decline and suffer for a long period before dying. Instead of demanding a strict temporal relationship between a medical condition and death, these statutes might be more flexible and instead require that death be ‘reasonably predictable’.” (Emphasis added)

Mr. Pope’s final issue is “Expanding From Self-Ingestion to Physician Administration”:

“First, it excludes patients who lose the ability to self-administer before they otherwise become eligible. Second, self-ingestion is associated with complications. For example, around 3% of these patients had difficulty ingesting or regurgitated the medication. Other patients regained consciousness after ingestion.” (Emphasis added)

And, as in most of the previous issues, Mr. Pope approvingly cites the rapidly expanding assisted suicide situation in Canada:

“Canadian patients avoid all these problems (with self-ingestion), because physicians usually administer the medication. As a result, only 5 of more than 2,000 Canadian patients who used medical aid in dying self-ingested the lethal medication.” (Emphasis added)

Ironically, there is one so-called “safeguard” that Mr. Pope would like to see tightened:

“that the prescribing or consulting physician refer the patient “for a mental health specialist assessment” if “there are -indications of a mental disorder.” Yet prescribing and consulting physicians have referred only 5% of medical aid in patients who are dying. Leading experts argue that this rate is probably too low relative to the expected rate of impaired judgment. Others are “surprised by how rarely the prescribing or consulting physicians refer patients for a psychiatric consultation.” (Emphasis added)

This discrimination in suicide assessment is not acceptable for any suicidal person-except now, of course, for a person requesting medically assisted suicide.

CONCLUSION

Without a strong resistance movement, these proposals are only just the next step in the death agenda. So far, much of the public, government officials and medical professionals have been shielded from the real truth by euphemisms and false reassurances from assisted suicide supporters, a mostly sympathetic mainstream media and often spineless professional and health care organizations. We all must educate ourselves to speak out before it is too late.

How Can Belgian Catholic Psychiatric Hospitals “Adjust” for Euthanasia?

nancyvalko assisted suicide, Canada, disability, euthanasia, law, medical ethics

I was in disbelief when I read Michael Cook’s article “Belgian Catholic psychiatric hospitals ‘adjust’ their view of euthanasia”.  I had to read the translated version on the Brothers of Charity order’s statement itself  myself to see if this was “fake news”.

Thankfully, Brother Rene Stockman, the superior general of the Brothers of Charity order, spoke out and said he was devastated by the news and then did three things:

“(F)irst we informed the whole congregation that as general superior we cannot accept this decision, because it is going totally against our charism of the charity. Secondly, we informed the Belgian Bishops conference about the situation and I am in contact with the president, Cardinal De Kesel. Also the Nuncio is informed. Thirdly, we informed the Vatican and all the information has been given to the Secretariat of State. In the meantime we continue to offer our clear arguments why we can never accept euthanasia.”

Brother Rene also warned that:

“In reality, only a few brothers are still involved in the government of the organization, so the majority are lay-people. Yes, there was a lot of pressure, but pressure doesn’t mean that we have to capitulate”

And

“Indeed, the presence of the brothers is not nearly sufficient, but also secularization is also poisoning the congregation in Belgium.”

Ironically, this comes less than 2 years after a pro-assisted suicide UK news service documentary titled “24 and Ready to Die” about Emily, a depressed young Belgian woman, was released but ended with the young woman changing her mind at the last moment.    Despite this, the documentary continued to support euthanasia even though one psychiatric “expert” who treated Emily was obviously wrong when she claimed that Emily’s suffering was so bad that it was “not compatible with life” and that her life did not have “sufficient quality”.

Emily is not the only one to change her mind. A 2014 Belgian study of 100 psychiatric patients  asking for euthanasia  showed that  “8 postponed or cancelled the procedure”. The study’s authors rationalized that these cancellations were “because simply having this option gave them enough peace of mind to continue living”! (Emphasis added)

Fortunately in 2016, the American Psychiatric Association passed a resolution opposing assisted suicide for the mentally ill.

Conclusion

As at least 3 European countries now allow assisted suicide for people with psychiatric problems and other countries like Canada are debating similar measures. Ethicists now write articles like ”Euthanasia for Reasons of Mental Health”  exploring the concept of including people with mental illness.

In the meantime, families like mine will continue to struggle with safety and treatment issues for our severely and chronically mentally ill relatives. We want real help for our loved ones, not assisted suicide or euthanasia. It is not compassionate, supportive or humane to have our loved ones “put down” like dogs.

Health Care Bullying Over Conscience Rights

nancyvalko assisted suicide, Canada, Compassion & Choices, conscience rights, law, medical ethics

Years ago, some of my fellow nurses were talking about assisted suicide and two of them supported physician-assisted suicide. I asked if they were comfortable with participating in an assisted suicide. Both were shocked and said no.

They believed the myth that doctors just write lethal prescriptions that patients then go home and take privately. It never occurred to them that they could be involved if the assisted suicide occurred in a healthcare institution, home health situation, etc. where they-unlike the doctor-could not just walk away.

These nurses were unaware that there were already nursing journal articles like “Assisted Suicide: What Role for Nurses?”  (2000) that quoted one Oregon hospice administrator:

“Initially, when the law was designed, the assumption was that physicians would be the first ones to explore PAS with patients…but in reality, nurses are usually the ones in the line of fire.”

While Compassion and Choices leaders now talk about “integrating” and “normalizing” assisted suicide in end of life care , this 17 year old article already stated that “Much of nurses’ roles lies behind the scenes long before the drama of PAS unfolds. Home care and hospice nurses actively help patients understand their rights, acting as advocates for those who are considering PAS.” (Emphasis added)

Now, two recent articles expose the lengths that assisted suicide activists will go to  legally bully health care professionals to participate in medically assisted suicide.

VERMONT

In an April 5, 2017 article titled “This State is Trying for Force Doctors and Health Care Workers to Give Patients Info on Assisted Suicide”, the Alliance Defending Freedom organization  filed a lawsuit against Vermont’s Act 39, arguing that

“Vermont’s Act 39 makes the State the first and only one to mandate that all licensed healthcare professionals counsel terminal patients about the availability and procedures for physician-assisted suicide, and refer them to willing prescribers to dispense the death-dealing drug. Act 39 coerces professionals to counsel patients about the ‘benefits’ of assisted suicide—benefits that Plaintiffs’ members do not believe exist—and in addition stands in opposition to a federal law protecting healthcare professionals who cannot participate in assisted suicide for conscientious reasons.” (Emphasis added)

CANADA

In a stunning March 28, 2017 Canadian Catholic Register article titled “Doctors being ’bullied’ over assisted suicide, legislators told at Bill 84 hearings” , doctors in Ontario, Canada spoke out about “being bullied, silenced and coerced in a pro-euthanasia environment which is forcing those who object to medically assisted suicide to provide an “effective referral” for patients who wish to die”. (Emphasis added)

Dr. Jane Dobson testified about the pressure she has faced: “If I don’t comply, I face fines and the possible suspension of my license.”

University of Toronto School of Medicine professor Dr. Maria Wolfs added that medical schools are facing pressure to “weed out students who might object to assisted suicide”. (Emphasis added)

Psychiatrist Dr. Janice Halpern testified that the policy is also “at odds with the subtleties of a psychiatric doctor-patient relationship and asked how long can a psychiatrist work with a patient “on finding their will to live again” before referring the patient for assisted suicide.

The Canadian Supreme Court legalized physician-assisted suicide in 2015 and as of the end of 2016, at least 744 people have died from physician assisted suicide with Ontario having the highest number.

One doctor who assisted the suicide of at least 40 patients in 2016 said that those numbers will increase “to the point of the Netherlands and Belgium because their laws are similar to ours, and that would mean about 5 % of all deaths.”

UNEXPECTED CONSEQUENCES

Ironically, there has been an unusual backlash in Canada.

According to a February 2017 article in Canada’s National Post newspaper , an increasing number of doctors performing assisted suicide are now saying “‘Take my name off the list, I can’t do any more”.  As the article states:

“In Ontario, one of the few provinces to track the information, 24 doctors have permanently been removed from a voluntary referral list of physicians willing to help people die. Another 30 have put their names on temporary hold.”

And

“The Canadian Medical Association says reports of doctors backing away from the act are not just anecdotal. “I can’t tell you how many, but I can tell you that it’s enough that it’s been noted at a systemic level,” said Dr. Jeff Blackmer, the CMA’s vice-president of medical professionalism.”

CONCLUSION

Groups like Compassion and Choices depend on assisted suicide being portrayed as a victimless and necessary medical intervention while, at the same time, they oppose conscience rights for ethical doctors and nurses trying to help and protect their patients and their professions.

However, it is hard to escape the reality that legally forced participation in medically assisted suicide damages the health care system, health care providers and even patients.

Conscientious Objection, Conscience Rights and Workplace Discrimination

nancyvalko assisted suicide, Canada, conscience rights, education, end-of-life, euthanasia, law, medical ethics

The tragic cases of Nancy Cruzan and Christine Busalacchi , young Missouri women who were claimed to be in a “persistent vegetative state” and starved and dehydrated to death, outraged those of us in Missouri Nurses for Life and we took action.

Besides educating people about severe brain damage, treatment, cases of recovery and the radical change in medical ethics that could lead to the legalization of euthanasia, we also fought for healthcare providers’ rights against workplace discrimination for refusing to participate in deliberate death decisions. We talked to nurses who were threatened with termination.

Although Missouri had some protections against forcing participating in abortion, there were no statutes we could find where health care providers were protected against being forced to participate in deliberate death decisions. We were also told by some legislators that our chance of success was almost nil

Nevertheless, we persisted and after years of work and enduring legislators watering down our original proposal to include lethal overdoses and strong penalties, Missouri Revised Statutes, Section 404.872.1 was signed into law in 1992. It states:

Refusal to honor health care decision, discrimination prohibited, when.

404.872. No physician, nurse, or other individual who is a health care provider or an employee of a health care facility shall be discharged or otherwise discriminated against in his employment or employment application for refusing to honor a health care decision withholding or withdrawing life-sustaining treatment if such refusal is based upon the individual’s religious beliefs, or sincerely held moral convictions.

(L. 1992 S.B. 573 & 634 § 7)

Fast Forward to Today

In 2016, we face groups like Compassion and Choices that have pushed assisted suicide legislation through in some states and hoping for an eventual sweeping Supreme Court decision making assisted suicide a constitutional right like abortion.

Some European countries like Belgium and Holland have virtual euthanasia on demand for even non-terminally ill people of any age. In Canada, their Supreme Court has forced assisted suicide on that country and now the province of Quebec has lethal injection kits available to any doctor.

Not surprisingly, conscience/workplace rights for health care providers are being vigorously fought both in those countries and here in the US.

For example, Compassion and Choices’ Barbara Coombs Lee, one of the architects of Oregon’s assisted suicide law, claims that strong conscience-right protections encourage “workers to exercise their idiosyncratic convictions at the expense of patient care” at the end of life.

Hope on the Horizon?

In May, a hospital in Poland stopped performing abortions after every single doctor signed a pledge refusing to do them.

Now, several hospitals in Santa Barbara  and Palm Springs as well as Providence medical centers are opting out of the new California assisted suicide law.

Personally, I believe that if people are given a choice when they are sick, they would naturally prefer a hospital that is committed to care rather than assisted suicide.

Thus, conscientious objection, workplace discrimination/conscience rights laws and the power of institutions dedicated to ethical health care can help turn the tide against assisted suicide laws or at least save some lives and mitigate some of the damage caused by assisted suicide laws. It may take a long time before killing sick or disabled people is again seen as abhorrent and unethical but the effort will be worth it.

As I have said before, “NO!” is a powerful and potentially lifesaving word.

Canada and Assisted Suicide for Psychiatric Patients

nancyvalko assisted suicide, Canada, disability, family, law, medical ethics, mental health, nursing

My first husband and the father of my children was a caring man and dedicated psychiatrist who himself eventually became disabled by mental illness. Early in our marriage, I helped him write his medical journal articles and we planned to eventually include me in his psychiatric practice to work with the families of his patients. As a nurse, I always believed that families were ideally the best support system for patients and our goal was to improve the care and outcomes of people with mental illness.

Tragically, my husband’s mental illness worsened despite intensive treatment. He ultimately abandoned our family and lived the next 26 years in and out of hospitals and assisted living places before he died of natural causes in 2014.

Thus I have a unique perspective on the legal, medical and personal aspects of mental illness.

At one point, a family member sympathetically suggested that it might be better for everyone if he committed suicide. I was horrified. You don’t give up on sick people and I told this person that I would do anything in my power to stop him if he tried to kill himself. Suicide would be the ultimate tragedy.

Canada and Its New Assisted Suicide Law

In February 2015, the Canadian Supreme Court ruled unanimously in the Carter v. Canada case to legalize physician-assisted suicide for competent, consenting adults whose suffering is due to a “grievous and irremediable” medical condition and gave Parliament a year to develop a regulatory regime along these “parameters.”

The Parliamentary Special Joint Committee on Physician-Assisted “Dying” suggested that the “grievous and irremediable” criterion includes nonterminal medical conditions, including psychiatric disorders.

The federal government’s Bill C-14, on the other hand, defined “grievous and irremediable” as an “advanced state of irreversible decline in capabilities” in a person for whom “natural death has become reasonably foreseeable.”  The Senate ultimately passed the bill but the controversy about assisted suicide for psychiatric patients is still raging.

In a June 21, 2016 commentary in the Canadian Medical Association Journal “Should assisted dying for psychiatric disorders be legalized in Canada?”, authors Scott Y.H. Kim MD PhD and Trudo Lemmens LLM DCL warn against this.

As they note:

In Belgium and the Netherlands, medical assistance in dying has been provided to people with chronic schizophrenia, posttraumatic stress disorder, severe eating disorders, autism, personality disorders and even prolonged grief.

The authors conclude that:

Because of the necessarily broad criteria used to regulate assisted dying (in Canada), legalizing the practice for psychiatric conditions will likely place already vulnerable patients at risk of premature death.

However, others like Belgium psychiatrist Joris Vandenberghe, MD, PhD disagree:

“I think the current approach taken by the Canadian government is a bit too strict because it doesn’t fully recognize the enormous impact that psychiatric disorders can have on patients,” Dr Vandenberghe told Medscape Medical News. (Emphasis added)

However, even Dr. Vandenberghe recognizes the problems while still calling for more “safeguards”:

“I am generally not opposed to our euthanasia legislation and agree that patients suffering from psychiatric conditions should not be excluded from our legislation. However, extra precautions are urgently needed.

“I’m not happy with the way things work here [in Belgium]. Sometimes euthanasia is used with insufficient reluctance on the part of the healthcare professionals involved. We’re missing opportunities for treatment, and we need more safeguards,” said Dr. Vandenberghe.

So for me, the answer lies in a thorough evaluation of a patient prior to euthanasia. There really is no time pressure in psychiatric disorders, and if you have a multidisciplinary committee involved in the evaluation, you can take care of lot of the concerns we now have about euthanasia in the setting of psychiatric illness.”

The reality is that very few psychological or psychiatric referrals are even now made for anyone considering assisted suicide either in the US or in Europe. The answer is not more “safeguards” for assisted suicide practitioners to disregard while enjoying virtual legal immunity but rather an emphatic “No!” from the public as well the legal and medical systems. We also need an unbiased media to publicly expose the real facts about legalized medical killing.

 Conclusion

I have seen both the legal and medical systems often fail people with mental illness like my ex-husband who desperately need treatment and safety.

On the medical side, I begged for direction from my ex-husband’s doctors about what I could do to help him but I was told that there was nothing I could do or not do since the doctors were seeing him regularly. I was not allowed to even know his diagnosis without his permission.

On the legal side, I had problems getting supervised visitation even after a hostage situation.  Due to almost constant harassment, I had multiple orders of protection violated without adequate legal response. And despite being on mental illness disability, my ex-husband was allowed to file and lose several frivolous lawsuits-until he ran out of money.

It was a heartbreaking situation.

However, I always hoped that my ex-husband would improve so that he could at least have a better relationship with his children. Even though that did not happen, I am grateful that he did not die by suicide, assisted or otherwise.

Unfortunately, my family’s experience is not unique among families with a member who is mentally ill.

If our medical and legal systems are already often failing people with mental illness and their families, how can we allow them the power to “assist” our loved ones’ suicide?

That would be the ultimate betrayal of an already stigmatized and vulnerable group of people.

Tolerating Evil

nancyvalko abortion, assisted suicide, Canada, euthanasia, law, medical ethics

Years ago, one of my daughters was caught after she did something she knew was wrong. “But it looked so good!” she wailed. I told her that if evil looked like it really was, no one would choose it.

I thought of this incident when I read Kathleen Parker’s June 10, 2016 USA op-ed titled “Freedom to kill and permission for sick people to die”.

In the article, Ms. Parker reveals her struggle:

“Here, I should confess my own ambivalence. Basically, I’d like to have the means to end my own life on my own terms when my body has clearly called it quits. I’m just not sure I like the idea of the state and doctors lending a hand.”

Many people can find physician-assisted suicide alluring when they ponder their own potential demise. As a former hospice nurse myself, I recognized this in some of my patients even before assisted suicide was legalized. However, with care and treatment, we were able to help these patients live as well as possible before death. And I never saw a patient go on to die by suicide or assisted suicide.

It is a myth that a personal choice for assisted suicide will not affect others or have far-reaching consequences.

Ms. Parker’s conclusion recognizes this:

“As more than a dozen other states consider similar legislation, it isn’t irrational to wonder whether, in tampering with our medical culture of healing, we aren’t inviting unintended consequences that we’ll live — or die — to regret.”

The truth of her conclusion became starkly obvious when a few days after California’s new assisted suicide law took effect,  one doctor immediately opened up a dedicated assisted suicide clinic in San Francisco.

Dr. Lonnie Shavelson, 64 and a long-time supporter of assisted suicide, was an emergency room doctor for 29 year and then spend 7 years at an Oakland clinic for immigrants and refugees before taking a 2 year break.

His new assisted suicide business could be quite lucrative. Although Medicare will not pay for assisted suicide costs, Shavelson says he will charge $200 for an initial patient evaluation. If the patient is deemed qualified under California law, Shavelson said he would charge another $1800 for more visits, evaluations and legal forms..

Like the past so-called “back alley” abortionists, Shavelson defends his business by claiming that “..the demand (for assisted suicide) is so high, that the only compassionate thing to do would be to bring it above ground and regulate it.”

We cannot afford to be ambivalent or tolerant about evil, whether it is abortion, assisted suicide, terrorism, etc. Evil never limits itself because evil always seeks to expand unless it is stopped

We only have to look at Canada, the Netherlands, Belgium and other countries where assisted suicide has already expanded to direct euthanasia and, in some of those countries, even without consent and for virtually any psychological, emotional or physical condition.