"Assistance to suicide must not become normal."

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The Bundestag has launched a bill on aiding and abetting suicide. Commercial offers of euthanasia are thus prohibited. But what does the new regulation mean for doctors and patients? A conversation with Prof. Lukas Radbruch, President of the German Society for Palliative Medicine.

Prof. Lukas Radbruch

Prof. Lukas Radbruch heads the center for palliative medicine at the Malteser Hospital in Bonn. He is President of the German Society for Palliative Medicine and holds the Chair of Palliative Medicine at the Medical Faculty of the Rheinische Friedrich-Wilhelms University in Bonn.

Prof. Radbruch, the German Bundestag today had to decide on four different bills on aiding and abetting suicide. He voted by a majority in favor of the proposal by MPs Brand and Griese, which prohibits commercial assisted suicide. Are you satisfied with the decision?

I think that's good. In my opinion, business-like suicide aid organizations have no business in Germany.

Doesn't the draft law have the sword of Damocles hanging over every medical professional that he has to answer in court if he aids in suicide as part of his profession?

That's right, that concern has been voiced. It is now important that the justification of the law is observed accordingly. It is already clear that this does not mean what palliative care practitioners and other doctors do who care for incurable or critically ill people. For example, the administration of medication to control symptoms or, if necessary, discontinuation of therapy - even if this has a life-shortening effect.

The model professional code for doctors says: “They are forbidden to kill patients at their request. You are not allowed to assist in suicide. ”Why not leave that to the conscience of the doctor who makes the decision in each individual case?

I think it is right not to leave this to the conscience of the individual doctor. As a doctor, how am I supposed to decide whether the patient really is free will or whether pressure has not been exerted after all, perhaps only very subtly? If so, then ethics committees would have to decide, not the individual doctor. In any case, I am glad that nothing will be changed in the code of conduct. That checklists for medically assisted suicide will not be drawn up anytime soon. Assisted suicide must not become normal.

What if palliative medicine does reach its limits, or if what it can do is not enough for the patient?

Sure, there are such cases. If, in an understandable extreme situation, a doctor decides to violate the professional code of conduct, the State Medical Association can initiate proceedings, but it does not have to. In fact, to the best of my knowledge, that last happened in 1976 - that was almost 40 years ago. However, it is very important not to make any arrangements for such individual cases. As doctors and as a society, we have to think carefully about the signals we are sending.

How do you react when a patient asks you for help with suicide?

Of course it has happened to me too. Then a patient asks: “Why can't you give me anything?” And maybe I don't always have an answer. But I keep finding that the seriously ill do not necessarily associate such a request with a mandate to act. If you ask more closely, they primarily want to be able to talk about how they are feeling. Most of them then want to be given alternatives. Most of the time, it's not about wanting to die, but about changing the situation, which is unbearable. And there we can do a lot.

For example?

We can refrain from any life-prolonging therapy, we can discuss with the patient that he can stop drinking and that he still does not have to be thirsty. We can also take away fears that have to be suffocated in agony. With morphine we can keep the patient without shortness of breath until the last minutes of life. And if nothing else works, we can also perform sedation and induce long-term sleep. There are plenty of options! For the vast majority of cases, they are sufficient.

But is it not understandable if someone prefers to die in a self-chosen, conscious moment instead of dawning towards death in a sedated manner?

I also believe that this is not the right path for everyone. We keep finding that for many people it is especially difficult to give up control. I have to hear and respect that as a doctor. But that doesn't mean that I have to comply with the request for help with suicide.

What reasons for wanting suicide have you heard most often?

The most common argument I hear from patients is "I don't want to be a burden to anyone". A patient even once told me that he wanted help with suicide so that his son could have a career. But is that an acceptable reason? From the patient's point of view, probably. But what does that say about us when we accept something like that?

How do you react when a patient confides in you that they have already taken precautions to take their own life if necessary?

Of course, a patient comes along and says: “Between us, in confidence: I've already put some of the painkillers aside. In a pinch, I'll take them all at once. ”I can understand that and I wouldn't take the medication away from him. But if I put it on the bedside table for him, I wouldn't! Instead, I would like to thank him for his trust and ask him to explain to me why he thinks this is necessary. Then it usually turns out that his fears are unfounded.

It will certainly reassure many people that there is so much that can be done palliatively. However, there are actually large gaps in palliative care in Germany. At the moment we have to assume that in many cases death is unnecessarily difficult because the patients are not adequately cared for.

It would be a very bad conclusion to say: We allow those who cannot access palliative care to die quickly!

In fact, even if all is not well, we have already achieved a great deal. When I started working in this profession over twenty years ago, things looked very different. It could happen that you came to the ward and heard people screaming in pain from the hallway. That won't happen to you again today. We have had palliative medicine as a compulsory subject in our studies for five years, so the young doctors have at least caught a few basic ideas.

The situation should soon improve even further: only yesterday the Bundestag passed the draft law to strengthen hospice and palliative care. How long do you think it will take before palliative care is possible across Germany?

Of course, we won't be closing the gaps from now on - we don't have enough trained specialists for that. I guess it will take three to five years for all of this to happen. But the concepts contained in the draft law - i.e. more networking in rural areas, the improvements in care facilities - these are good steps in the right direction.

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