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Re: Greek NICU medical and nursing staff attitudes regarding euthanasia

Dear Editor

We read with interest the Euronic study on euthanasia.[1]

We would like to add the views/attitudes of Greek medical and nursing staff working in NICUs regarding euthanasia. Any form of euthanasia is not supported by Greek law.

We conducted a study [2] which was published in 1998 in the official journal of the Greek Paediatric Society. The study involved the medical and nursing staff of 12 out of a total of 13 Greek NICUs. It as conducted through anonymous questionnaires. and the response rate was 75.1% (296completed out of 394 sent questionnaires).

On the question whether there had been direct or indirect experience of passive euthansia (withholding or withdrawing intensive care) 53% of the doctors and 37% of nurses answered that they had such an experience. Regarding (active) euthanasia however about 5% of doctors and nurses replied affirmatively. About 50% of doctors and nurses replied that they had experienced parents' pleas for either passive or active euthanasia regarding their baby. Three quarters of medical and nursing staff where for the legalisation of euthanasia without distinguishing whether they meant active or passive, despite the existence of a relevant question. There was no direct question on whether the Greek law should be changed.

Factors for euthansia with diminishing strength of association were: survival with handicap, pychological effect on the family, adverse prognosis regarding death, pity towards the neonate, parental plea, cost of intensive care. Factors against euthanasia were: sense of duty, religious beliefs and fear of criminal prosecution. There was no signiicant variation regarding these attitudes among the 12 NICUs. Doctors and nurses who completed the questionnaires were homogenous regarding ethnicity

References

1. Cuttini M, Casotto V, Kaminski M et al Should euthanasia be legal? An international survey of neonatal intensive care units staff Archives of Disease in Childhood Fetal and Neonatal Edition 2004;89:F19-24

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Re: European ethical issues surrounding Euthanasia: It is time to move towards a common goal

Dear Editor

In their paper M. Cuttini and colleagues point out the enormous variety of approaches to such a sensitive ethical and legal issue as euthanasia and the health givers’ attitude in taking care of a dying patient.[1]

The problems and different approaches become enormous when the dying patient is a neonate. Active euthanasia appears to be both acceptable and practiced in the Netherlands, France, Lithuania, and less acceptable in Sweden, Hungary, Italy, and Spain. More then half the doctors in the Netherlands and less in France feel that the law should be changed to allow for “greater active euthanasia than at present”. Most French doctors believe end-of-life issues should not be regulated by law.

In the United Kingdom, where active euthanasia is rejected, forgoing treatment for terminal patients is also practiced on quality-of-life grounds. In Italy a rigid “pro-life” position prevails. This position is so strong that in Italy we normally tend to resuscitate children in every kind of clinical situation. More specifically, we are often unable to interrupt the cure or decide whether palliative care is in the best interests of our patient.

This crucial issue was also emphasized in the recent case of a diabetic woman who refused to undergo surgery for the amputation of a foot and died a few days later from gangrene. This case raised a great deal of controversy regarding the individual’s right to decide on his/her own health, a right guaranteed by the 32nd article of the Italian Constitution. This case was immediately followed by similar one involving another woman in the same conditions and for whom the Court granted the doctors the right to amputate her foot against her will.

Moreover, only one month ago a 21-year old girl was sentenced by the Court for helping her mother suffering from amyotrophic lateral sclerosis to go to Switzerland to undergo assisted suicide. In this emotional and legal situation involving adults, to stop resuscitation of a neonate or fail to “try everything” is absolutely unthinkable. The fear of legal problems, health professionals’ prejudices and biases, as well as lack of knowledge, all represent obstacles in the quest for making a radical change. A more unconscious tendency to perform experimental therapy may be at the base of this attitude, and children affected by trisomy 13 and 18, congenital malformations considered incompatible with life, anencephaly, extremely severe asphyxia neonatorum, and extremely immature infants of less than 22 -23 weeks are resuscitated and kept alive despite the indications of Scientific Societies and the International Consensus Conference.[2] The intensive care of such babies of “uncertain viability”[3] for example, has in our opinion to be included in the “experimental studies” and reference must be made to the ethical Guidelines for such studies in children.[4] It is no longer acceptable for these babies to start and continue intensive care merely to “help future children”.

We believe this situation is in contrast with the most elementary rights of children. Before addressing active euthanasia it is far more important, at least in Italy, to address the issue of aggressive therapy and palliative care. To be so stubbornly aggressive creates enormous problems first and foremost for the patient, secondly for his family who are always, however, hoping and trusting in the “power of medicine”, and thirdly, for the human society as a whole and not simply because of the enormous costs involved in intensive care. By curing everyone without any limits, the medical field is giving the wrong impression. We are not able to save everyone, we are not able to guarantee health, but our first duty is to “care” not to “cure” whatever the cost may be. Doctors must always keep the first Hippocratic rule in mind “non nocere”. The difference between “futile treatment” and “care” have to be far more thoroughly understood and taught in the undergraduate and in the postgraduate curricula of physicians. More involvement by Local Ethical Committees in practical cases could be of help in caring for these patients and in obtaining informed consent from their anguished families. A modification to the law together with greater education of health professionals is needed in Italy in order to overcome the prejudices and fears surrounding this ethical issue. In our opinion, it is not possible for the enormous variety of approaches to this extremely sensitive ethical issue throughout Europe to lead to a more uniform legal and clinical procedure in the short term, however it is still very important to bear in mind that all the European countries are becoming geographically closer. This means that significant differences in care can be overcome by choosing to be cared for in another country, as the different national laws on assisted reproduction have demonstrated. It is vital to hold a national and international consensus on these sensitive ethical issues, starting from a basic level such as discontinuation of futile treatment and use of palliative care, especially in neonatal patients.

References

1- Cuttini M, Casotto V, Kaminski M, de Beaufort I, Berbik I, Hansen G, Kollee L, Kucinskas A, Lenoir S, Levin A, Orzalesi M, Persson J, Rebagliato M, Redi M, Saracci R and other members of the EURONIC Study Group “Should euthanasia be legal? An international sur-vey of neonatal intensive care units staff. Arch Dis Child Fetal Neonatal Ed 2004;89:F19- F24

2- International guidelines for neonatal resuscitation: an excerpt from the guidelines 2000 for cardiopulmonary resuscitation and emergency cardiovascular care: International consensus on science Pediatrics 2000; 106(3):pe29

3- Kraybill EN Ethical issues in the care of extremely low birth weight infants. Semin in Perinatol 1998:22(3):207-215

4- Gill D. Ethical principles and operational guidelines for good clinical practice in paediatric research. Recommendations of the Ethics Working Group of the Confederation of European Specialists in Paediatrics (CESP) Eur J Pediatr 2004;163:53-57

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Re: Author's reply: on the meaning of words

Dear Editor

The message consistently emerging from studies carried out in different circumstances and countries, to which Greece is now added through the work of Dellagrammaticas et al,[1] identifies modern intensive care as too powerful a tool to be applied indiscriminately, implying that access to life-sustaining technology must be coupled with a responsibility for its appropriate use.

However, as Pignotti et al. point out,[2] the definition of what may represent appropriate use of medical technology is a matter of debate, which would be clarified by :

a) the abandonment of time-honoured, widely used but too general terms such as passive or active euthanasia, and the adoption of a terminology more closely reflecting the reality of clinical actions. For instance, in the EURONIC study witholding intensive care appeared to be both more acceptable and more widely practiced than withdrawing mechanical ventilation or other life-saving treatments once started [3] and, with the exception of France, the latter appeared much more acceptable than the administration of drugs to end life;

b) the detailed definition of the type of patient's illness. In every country physicians appear less willing to make end-of-life decisions on quality-of-life grounds,[3] that is for fear of survival with disability, than in the presence of a fatal or terminal illness (the so called "no chance" situation [4]), where the outcome is perceived as more dependent on the original disease than on the decision to limit treatment.

More accurate and internationally agreed upon descriptors of both illness and end-of-life interventions would contribute to clarify the terms of the theoretical debate and improve the quality and comparability of empirical research.

References

1. Dellagrammaticas HD and Iacovidou N. Greek NICU medical and nursing staff attitudes regarding euthanasia [electronic response to Cuttini et al. Should euthanasia be legal? An international survey of neonatal intensive care units staff] fetalneonatal.com 2004 http://fn.bmjjournals.com/cgi/eletters/89/1/F19#381

2. Pignotti MS and Donzelli G. European ethical issues surrounding euthanasia: it is time to move towards a common goal [electronic response to Cuttini et al. Should euthanasia be legal? An international survey of neonatal intensive care units staff] fetalneonatal.com 2004 http://fn.bmjjournals.com/cgi/eletters/89/1/F19#395

3. Cuttini M, Nadai M, Kaminski M et al., for the EURONIC Study Group. End-of-life decisions in neonatal intensive care: physicians' self -reported practices in seven European countries. Lancet 2000, 355: 2112- 2118.