Current social dilemmas related to the legalization of euthanasia in the countries of Western Europe, Australia and the USA

Current social dilemmas related to the legalization of euthanasia in Western Europe, Australia and the USA

Introduction

In the euthanasia and assisted suicide debate, it is rare to find an article that begins with an expression of neutral interest and then proceeds to examine individual arguments and data before drawing conclusions based on the results of scientific investigation. Although authors often give the impression of being unbiased in their introduction, they consistently seek to reach their previous conclusions. The positions of the authors tend to be clear before the conclusion - either one believes that the practice of euthanasia and assisted suicide is completely acceptable or completely unacceptable and unjust. The authors try to convince us that their choices are the only reasonable way to resolve the remaining euthanasia dilemmas. Although only a handful of countries have so far adopted the practice of euthanasia or assisted suicide (Belgium, Luxembourg, the Netherlands, the US states of Montana, Oregon, Vermont and Washington, and Switzerland), scholarly articles often support the legalization of euthanasia to the point of recommending the expansion of already existing practices. The current era is therefore characterized by the fact that more countries and states are debating the legalization of euthanasia or assisted suicide, while the nature of legislation and legal practice varies greatly from country to country, including as an ethical and empirical assessment of existing practice, which of course can be the subject of many discussions. (Mishara, David, Weisstub, 2013) It is indisputable that the question of accepting euthanasia will be open in Slovakia in the near future, while the current Slovak legislation understands euthanasia in the context of planned murder.

It is true that advances in medicine have greatly improved the methods used to treat seriously ill patients in the paradigm of prolonging their lives. However, it is increasingly recognized that prolonging life may not always be a suitable goal of medicine, and in this context the issue of euthanasia is the most discussed. (Chambaere, Cohe, 2017)

Before we move on to professional definitions of euthanasia, it is necessary to say that the measure of human dignity in society is primarily bioethics and law. Dignity is the real quality of everyone and we must respect it until death. Autonomy, as a basic principle of bioethics, establishes the ability of subjects to make decisions for themselves in all matters related to their life and health, while this decision-making must be based on will and reason. If we talk about the autonomy of a sick person, about his human dignity and his right to choose, accept or reject the pain and suffering caused by an incurable terminal illness that inevitably leads to death and his decision is in the context of voluntarily ending it, we are talking about euthanasia. (Camargo, 2016)

The very term "euthanasia" comes from Greek and means good dying or good death. This term was adopted by Greek and Roman philosophers and represented a death that comes quickly without much suffering and unnecessary prolongation. Nowadays, this phrase is used in interventions to alleviate the death of others. There are five practical levels related to euthanasia, it is primarily care aimed at alleviating psychological and physical suffering, spiritual help, ensuring that patients' lives are not deliberately prolonged, actively hastening death within the framework of ending the life of children and adults who are perceived as a burden on society, but also ending life in a persistent state of unconsciousness. (Birnbacher, 2015) According to Vlček and Hrubešová, the legal dictionary defines the term euthanasia as killing out of compassion or for the purpose of alleviating the pain of a dying person, while this killing is associated with a shortening of life expectancy. The common feature of the definitions related to euthanasia is thus primarily the aspect of intentional action that induces death. (2007)

Currently, we know several types of euthanasia, it is mainly an active form of euthanasia, when the lethal dose of medicine is either personally administered to the patient by the doctor, or it is only prepared by him and the patient administers it himself, the doctor only assists him; an unsolicited form of euthanasia, which is perceived as a variant of active euthanasia, when the patient is unable to request the acceleration of death; an involuntary form of euthanasia, which is not only unsolicited, but even unwanted, and a passive form of euthanasia, in which the doctor reduces the therapeutic activity, or does not perform certain procedures and thereby ensures the accelerated death of the patient, this is the equivalent of withdrawal or interruption of treatment, but not termination of care. (Vorlíček, Adam, 1998). The differentiation of euthanasia into active and passive forms is currently criticized as artificial, according to Holčapek, basically justifiably, because the difference is often given only by random circumstances. However, most authors recognize that this distinction is necessary for the needs of legal analysis. (In Kováč, 2005)

Recently, the issue of assisted suicide is mentioned more and more in the professional literature in connection with euthanasia, which involves assistance in ending life, but the person ends his own life by his own actions. Any person, including a doctor, can provide suicide assistance. There are certain differences between euthanasia and assisted suicide, but it cannot be ruled out that in some cases assisted suicide will be euthanasia at the same time. (Kováč, 2005)

The main goal of regulating physician assistance in dying is to bring these procedures into the open and provide legal certainty to physicians. A key condition in all jurisdictions that have regulated assisted suicide or euthanasia is that physicians are permitted to perform these acts at the explicit and voluntary request of the patient. All systems that allow physicians to assist in dying also include the idea that physician assistance in dying is only accepted when it is the only way to deal with severe suffering from an incurable medical condition. Arguments against legal regulation of physician-assisted dying include arguments of principle, such as the wrongness of hastening death, and arguments that highlight the negative consequences of allowing physician-assisted dying, such as devaluing the lives of the elderly or those with chronic illness or disability. Public opinion polls show that some forms of acceptance and regulation of euthanasia and physician-assisted suicide are increasingly supported by the general population in most Western countries. Studies in countries where physician-assisted dying is regulated indicate that practices have remained relatively stable in most jurisdictions and that physicians follow the legal criteria in the vast majority of cases. (Van der Heide, 2013)

Questions related to the legalization of euthanasia

Physician-assisted suicide or euthanasia is currently understood by the professional public as an active and intentional termination of the patient's life at the express request of the patient. Although these practices remain highly controversial and illegal in most countries, the law is very liberal in Belgium, Switzerland, the Netherlands, and some US states such as Oregon. Cohen-Almagora (2015) speaks in connection with the adoption of legislation that allows euthanasia in the context that the primary task of doctors is to provide patients in the terminal period of life with the best possible conditions for preserving life as such. He claims that only the patient can subjectively evaluate his quality of life, and if it is low, there is a certain justification for ending his life. Matters of life and death are a serious matter and decisions should be taken with the utmost seriousness, and these decisions require sufficient controls against abuse, but also the application of control mechanisms that serve the patients' intentions.

One of the first countries to adopt legislation enabling euthanasia was the Netherlands, where the law on euthanasia came into force on April 1, 2002, and according to Kimsm, Dutch society became a social laboratory precisely because of its liberal policy, which created tendencies towards the so-called "adequate death". (2015) However, it should be noted that in the Netherlands, euthanasia is legally approved only if the doctor is convinced that the patient's request is voluntary, deliberate, permanent, while the doctor is well informed that the patient was fully competent at the time of writing the request and that he perceived his situation as hopeless. (Draper, Peisah, Snowdon, Brodaty, 2010) The most frequent characteristics of Dutch patients that were associated with a lower probability of the right to euthanasia were: fatigue with life, depression and the fact that the individual did not want to be a nuisance. Physical suffering in older patients was associated with a greater chance of meeting the requirements related to the emergence of the right to euthanasia, on the other hand, psychological suffering is assessed by doctors more in the context of the fact that the requirements for performing euthanasia are not met. (Brinkman-Stoppelenburg, Vergouwe, van der Heide, Onwuteaka-Philipsen, 2014).

Since 2002, Belgium has also had a national law legalizing euthanasia. The law prescribes several substantive care requirements and two procedural care requirements, i.e. consultation with an independent physician and euthanasia reporting to the Federal Review Board. Wide differences in reporting rates between the Dutch-language and French-speaking parts of Belgium have led to speculation about cultural differences influencing euthanasia practices in the two regions. Using Belgian data from a European evaluation study conducted in 2008 among a representative sample of the general public and data from a large mail questionnaire survey on euthanasia of 480 doctors in Flanders and 305 in Wallonia (conducted in 2009), it was shown that acceptance of euthanasia by the general population was slightly higher in Flanders than in Wallonia. Compared to their Flemish colleagues, Walloon doctors had a more negative attitude towards euthanasia and the obligation to report. Flemish doctors also received a larger share of euthanasia requests. In cases of euthanasia requests, Walloon doctors did not so often consult an independent doctor. The study thus points to some significant differences between Flanders and Wallonia in practice, knowledge and attitudes regarding euthanasia and its legal requirements, which probably explain the discrepancy between Wallonia and Flanders in the number of reported cases of euthanasia. Cultural factors appear to play an important role in the practice of euthanasia and the extent to which legal safeguards are respected. (Cohen, Van Wesemael, Smets, Bilsen, Deliens, 2012)

At the same time as the mentioned law on euthanasia, Belgium also adopted the legislative amendment of the law on palliative care, and the law on patients' rights was also included in the national legislation of Belgium. (Dan, Fonteyne, Clement de Cléty, 2014) We think that all three laws are related and their common implementation in practice was not accidental, because in the often complex relationship between patient and doctor, the principle of personal autonomy and free decision plays an increasingly important role.

However, although Belgium is a liberal country, the legalization of euthanasia and assisted suicide is still a controversial medical and social topic in Belgium. It is clear that although efforts to formulate differences between palliative care and euthanasia have prevailed in the countries of Western Europe in recent years, ethical disputes continue to persist. The prevailing opinion in scientific circles is that euthanasia and palliative care are morally different procedures. However, ambiguous moral and ethical experiences and variations from practice challenge this view. Have and Welvie e.g. in this regard, they argue that since all heterogeneous sedation practices within palliative care are focused on sedation, there is a risk that palliative care may be expanded to include procedures designed to bring about the death of the patient. This expansion of palliative care is supported by the conceptual intention to narrowly define palliative care to procedures that would amount to assisted suicide. (2014)

In Belgium, in 2007, two large nationwide surveys were conducted, which made it possible to examine the differences in the frequency and characteristics of attitudes towards assisted suicide before and after the law was passed. Subsequent studies were evaluated using data from death certificates of the Flemish part of Belgium, which has approximately 6 million. inhabitants. In 2007, up to 1.9% of all deaths in Flanders were the result of euthanasia. The rate of more intensive pain relief in terminally ill patients increased from 18.4% in 1998 to 22.0% in 2001 and to 26.7% in 2007. In 14.5% of all deaths, physicians reported continuous or deep sedation until death, an aspect that was significantly higher than in 2001 (8.2%). As part of the research, it was found that the legalization of euthanasia in Belgium was accompanied by a rather significant increase in requests for euthanasia. (Bilsen, 2009) According to the Belgian law on euthanasia, consent to euthanasia is granted in about half of the requests. Factors related to the reason for the request, the treating physician's attitude toward the request, and the other physician's recommendation influence whether or not the request is granted. (Van Wesemael, Cohen, Bilsen, Smets, Onwuteaka-Philipsen, Deliens, 2011)

The death of another, whether through assisted suicide or euthanasia, is the subject of intense debate in Great Britain as well. Support for the legalization of euthanasia increased in Great Britain from approximately 76.95% in 1983 to 83.86% in 2012. This increase coincided with an increase in secularization, as the percentage of people with no religious affiliation increased from 31% to 45.4% over this time period. Multivariate analysis shows that religious affiliation and religiosity, as measured by the frequency of attendance at religious institutions the main aspects that create and shape attitudes towards euthanasia and that the main increase in support for euthanasia is in the group with the least religious affiliation. This study points to an increase in support for the legalization of euthanasia in Britain over the past 30 years at a time of increased secularisation. (Danyliv, O'Neill, 2015)

Reflections on euthanasia in countries where euthanasia is legal are mostly theoretical and often lack a first-hand perspective. Therefore, in 2012, Karlsson conducted qualitative research on a sample of sixty-six cancer patients in the palliative phase. Interviews were transcribed verbatim and analyzed using qualitative content analysis without predetermined categories. The participants expressed different attitudes towards euthanasia, starting with support or opposition, but it is important to note that the majority of respondents were undecided due to the complexity of the issue. The legalization of euthanasia was perceived either in the context of increasing the patient's autonomy in decision-making, i.e. it was about strengthening the patient's position, or in the context of the fear of reducing the patient's autonomy at the expense of increasing the autonomy of the medical staff, which was more than scary in the participants' imaginations. The research findings are described in terms of the fact that dying cancer patients claim that they cannot feel completely independent when euthanasia is approved, which affects the true autonomy of decision-making. Ultimately, patients fear the consequences of legalizing euthanasia. (Karlsson, Milberg, Strang, 2012)

As part of his research, Bülow investigated differences in opinions about euthanasia depending on religion. Structured questionnaires distributed in six Western European countries to 142 intensive care units. 304 doctors, 386 nurses, 248 patients and 330 family members participated in the research. Respondents who were religious and declared their religious beliefs were more supportive of treatment and were in favor of prolonging life. These respondents were less likely to be in favor of active euthanasia. In the conclusion, the author states that not only patients, but also health professionals and family members who have strong religious beliefs have different views on euthanasia than those individuals who do not declare their religious beliefs. (Bülow, 2012)

Similar results were reached by Verbakel, who attempted to find an explanation for the acceptance of euthanasia by assessing differences between individuals and countries using the four main arguments of opponents and supporters declared in the public debate about euthanasia. He performed a multilevel analysis of data from thirty-three countries, obtained from the European Values ​​Study 1999/2000 and the World Values ​​Survey 2000. The results supported the hypothesis based on the religious argument: religious people and people living in religious beliefs are more against euthanasia. Furthermore, Protestants and people living in Protestant countries have more favorable attitudes towards euthanasia than Catholics and people living in Catholic countries. In addition, the author found support for the hypothesis derived from the sloping surface argument: the fear that euthanasia will be misused, especially among people from vulnerable groups and people living in countries with a low adaptive health care system. As an autonomous hypothesis, the assumption appeared that highly educated people and people who rate personal autonomy highly, as well as people living in a country with a stronger than average inclination towards autonomy, show a much more favorable attitude towards euthanasia. The author concludes the study by saying that while the death with dignity argument assumes that people who witness unbearable suffering in their personal or national environment are more inclined to euthanasia. However, the results of his research show only weak support for the legitimization of euthanasia. Moreover, the cross-level interaction tests showed that the national context is able to some extent to reduce the differences between the groups in the society regarding their responses regarding the legalization of euthanasia. (Verbakel, Jasper, 2010)

David and Asch focused their research on euthanasia views on nurses in the US. According to the author, considerable attention is paid to euthanasia in the professional literature, in public discussions the problem of euthanasia is even included in the proposed state legislation, but almost all discussions in this area focus on the role of doctors. According to David, however, there are also nurses who can often best understand the patient's wishes in a difficult situation and act in the context of this understanding. 1,600 nurses participated in the research, and these nurses were asked to anonymously describe the requests of their patients, family members or other persons acting on behalf of the patient in the matter of assisted suicide. Of the total number of 1139 nurses who responded (71%), 852 reported working exclusively in adult intensive care units. Of these 852 nurses, 141 (17%) reported receiving requests from patients or family members to perform euthanasia or assisted suicide (1996).

In 2012, Buiting published the results of research in which he asked respondents over the age of 64 whether they could imagine asking their doctor for euthanasia or whether they could imagine asking for a pill to end their life if they were tired of life and there was no serious illness. The author investigated the opinions of the respondents and their changes in attitudes over time, in 2001, 2005 and 2008. The research results indicate that the share of respondents with a positive attitude increased slightly over time, but significantly only in the age group of 64-74 years. In 2001, 58% of respondents were in favor of euthanasia, in 2005 it was 64% of respondents, and in 2008 it was 70% of respondents. In the end, the author states that these results ultimately mean an increased interest in making decisions about one's own life and that it is important that society takes the wishes of older individuals seriously. (Buiting, 2012)

Another study published by Rurup aimed to describe and compare the incidence of reported euthanasia and physician-assisted suicide in the first five years after the legislation was passed in the Netherlands and Belgium. In the period from September 2002 to December 2007, there were 10,319 deaths in the Netherlands, while there were only 1,917 cases in Belgium. The gender and age distribution was similar in both countries. The majority of patients suffered from cancer (83-87%), but patients also suffered more often from diseases of the nervous system, in Belgium it was 8.3% compared to 3.9% in the Netherlands. In the Netherlands, reported euthanasia was more often performed at home, compared to Belgium (81% vs. 42%), where it occurred more often in a hospital (52% vs. 9%). In the Netherlands, in all cases, euthanasia and assisted suicide were based on a verbal request from the patient concerned. In Belgium, 2.1% of reported cases were based on a written request. The author therefore came to the conclusion that the country that establishes the relevant legislation regarding the rules and procedures for euthanasia should agree on the way and circumstances of its implementation even before this legislation is put into practice, because it happens that the practice is different from the legislation itself. (Rurup, 2010).

A similar study was carried out by Smets, who looked at the reported medical practice regarding euthanasia in Belgium since the implementation of the law on euthanasia from September 22, 2002 to December 31, 2007. According to the author, euthanasia was most often performed with barbiturates, sometimes in combination with neuromuscular relaxants (92.4%) and only exceptionally with morphine (0.9%). Almost all patients reported unbearable physical (95.6%) or psychological suffering (68%). A small minority of patients (6.6%) suffered from neuromuscular diseases. In the conclusion of his study, the author states that the frequency of reported cases of euthanasia in Belgium has increased every year since the year of legalization. Euthanasia is more often chosen as a last resort at the end of life by younger patients, in cancer patients, and rarely in non-terminal patients. (Smets, 2010).

According to a French study, requests for euthanasia in palliative care units are not frequent. To understand the emergence of these requests for euthanasia, it is necessary and desirable to assess the dynamics of relationships between patients, relatives and caregivers. The aim of the pilot study, which was carried out by Bousquet, Guirimand, Aubry and Leboul, was to understand the subjective view of the caregivers on the request for euthanasia. For a period of 4 months at the Jeanne-Garnier hospice in Paris, semi-structured interviews were conducted with all nurses who provide palliative care and who also received requests for euthanasia from patients. Interviews were also conducted with patients, of course, if it was possible due to their health condition. These interviews were recorded, transcribed and qualitatively analyzed. Nine requests for euthanasia were reported by caregivers, with four patients able to be interviewed. Analysis of interviews with caregivers indicated that four of the nine cases involving termination of life through euthanasia were actual requests for euthanasia, an expressed wish for the patient to be interviewed by a physician in the paradigm of wanting to die and making a proper request for euthanasia. Although the nurses unanimously claimed that they could not afford to be influenced by these requests, they felt powerless, their competences and the usually idealized capacities of the institution in question declined. It is clear that the demands to perform euthanasia were difficult for the caregiver to accept and had a destabilizing effect on them. (Bousquet, Guirimand, Aubry, Leboul, 2016).

On February 2, 2016, the French Parliament passed new legislation regarding the approval of newly created rights for terminally ill patients. At the same time, the text modifies and strengthens the rights of patients in the terminal stage of life, but also strengthens the position of substitute subjects with decision-making authority precisely in the context of the terminal period. According to new regulations and directives, it is necessary to always follow legally binding acts. There are two types of guidelines distinguishing the patient's condition according to whether or not the affected person suffers from a serious illness. The attending physician must follow the directives unless the directive is clearly disproportionate to the medical condition or incompatible with the patient's medical condition, and there is no time limit on the validity of the directives. The law primarily establishes a right to continuous deep sedation until death in three specific situations. It is a patient's request when there is a short-term prognosis of death and continuous deep sedation is the only alternative to alleviate the patient's suffering, secondly it is also a patient's request in the context of when the patient decides to withdraw from artificial life-sustaining treatment (if the patient is not able to express his/her wishes and there is a collective medical decision to withdraw aggressively unnecessary life-sustaining treatment) and finally there is continuous deep sedation mandatory if the patient shows signs of suffering or when the patient's suffering cannot be evaluated due to the poor cognitive state of the patient. The law provides for preliminary control of these procedures, which results in the development of a new type within the college just for medical decision-making. The satisfactory application of this new law will depend to a large extent on the implementation of a real policy in the development of palliative care itself. (Aubry, 2016)

The practice of euthanasia and assisted suicide (EAS) is always complex, but some cases show greater complexity. The aim of the next presented research was to identify and categorize the requirements for assisted suicide. The authors used in-depth interviews with 28 Dutch doctors, while the interviews focused on some of the complications associated with assisted suicide. At the same time, detailed interviews were conducted with 26 relatives of those patients who applied for EAS. Open coding and inductive analysis were used, through which the authors identified various complicated aspects of EAS that were described by the research participants. The complexity and complexity of EAS cases can be understood in the context of various misunderstandings, invisible suffering, but also the dynamics of the course of the disease and the emergence of various unexpected situations. At the same time, the interviews showed that the patient's relatives can influence the process towards EAS. In conclusion, the authors of the research state that this process can be disrupted, but also influenced not only by the patient and his attending physician, but also by the relatives themselves. (Snijdewind, van Tol, Onwuteaka-Philipsen, Willems, 2014)

Eliott and Olver, during discussions with 28 patients in Australia, registered an interest in euthanasia in 13 patients, the remaining patients expressed some mixed feelings and concerns. Approval of euthanasia was only hypothetical in relation to the future and was associated with acute or excruciating pain. Arguments supporting euthanasia framed the whole matter in the paradigm of free choice, preserving the dignity of death, as well as limiting excruciating pain and suffering. These arguments were presented by patients as a justification for euthanasia. (Olver, Elliott, 2008)

Pasman, Willems and Onwuteaka-Philipsen explored through in-depth interviews the perspectives of what happens after a request for euthanasia or assisted suicide (EAS) is denied. Interviews were conducted with nine patients who were denied and seven of these patients' physicians, as well as three relatives of patients who died after their application was denied and four of these patients' physicians. Interviews were conducted at least 6 months after denial, and the wish to die remained in all patients after denial, although sometimes diminished. However, in most cases, discussion between the patient and the doctor about this wish ceased, with the doctors being aware of the patients' continued wish to die. Open communication about the wish to die is important, even outside the context of euthanasia or assisted suicide, because if people do not feel able to talk about it, their quality of life can subsequently be further reduced. (Pasman, Willems, Onwuteaka-Philipsen 2013)

Twelve years after the legalization of the legislation regarding the legalization of euthanasia in Belgium and the Netherlands, various projects are currently emerging to extend this right, specifically these efforts concern patients with dementia. It seems important to avoid any trivialization of euthanasia, while the mass media could play the role of spreading various misinformation. When euthanasia is banned in patients with Alzheimer's disease or similar neurodegenerative diseases, we face ethical questions, because if we want to maintain the general status of a developed society, we must protect the most vulnerable individuals. (Higuet, 2014) Cases of elderly individuals suffering from a certain form of dementia create a special dilemma in euthanasia. Draper says there are two main reasons for the lack of these requests. This is primarily about the existing uncertainty as to whether patients with advanced dementia really experience the suffering they once feared or the lack of mutual understanding and reciprocity in advanced dementia between doctor and patient, which consequently makes euthanasia morally incomprehensible, even in the presence of the patient's written consent to euthanasia. (2010) Although the enactment of the Dutch Euthanasia Act theoretically provided a range of opportunities for euthanasia in incompetent patients with dementia, in practice it did not lead to obvious changes in the practice of euthanasia in these patients. The impossibility of communication between the patient and the doctor seems to be key in the reticent attitudes towards euthanasia in this group of patients. (De Boer, Dröes, Jonker, Eefsting, Hertogh, 2010) As there is no effective treatment for Alzheimer's disease or other types of dementia, there is evidence that persons with mild cognitive change and early dementia are at risk of suicidal behavior, often in the context of comorbid depression. The ensuing clinical, ethical, and legal dilemmas associated with physician-assisted suicide and euthanasia in the context of dementia are therefore the subject of intense debate. Indeed, there is a certain obvious potential, when early diagnosis, e.g. Alzheimer's disease can lead to an increased risk of suicide and an increase in requests for physician-assisted suicide. (Draper, Peisah, Snowdon, Brodaty, 2010)

The phenomenon of child euthanasia is also interesting, which is still perceived contradictory in many countries, even in the Netherlands itself. The debate regarding the euthanasia of neurologically devastated newborns, whether due to severe prematurity or genetic malformations, has continued for more than 40 years. In the 1980s, there was a fight to ensure that children with disabilities were given all the rights of other children. Recently, some experts have spoken out in favor of withdrawing from treatment and leaning towards euthanasia. Who is right? What are the ethical principles to follow? What decisions are appropriate for parents who are afraid? Indeed, parents and doctors must use their individual expertise and values ​​to work together to determine the best interests of each child. (Koogler, 2013)

Out of the total number of 200,000 children born in the Netherlands, every year about 1,000 children die during the first year of life. For approximately 600 of these children, death is ordered by medical decision. The discussion about starting and continuing treatment in newborns with serious health problems is one of the most difficult aspects of pediatric practice. Although technological advances provide tools to address many of the consequences of birth defects and premature births, the decision to artificially end a newborn's life is particularly challenging. Even more difficult are the decisions regarding newborns who have severe disorders or deformities associated with suffering that cannot be alleviated and for which there is no hope of improvement. Suffering is a subjective feeling, it cannot be measured objectively in adults or children. However, we recognize that adults can determine when their suffering is unbearable. On the other hand, infants cannot express their feelings through speech, but they can do so through different types of crying, movements, and response to feeding. The newborn's responses, based on changes in vital signs (blood pressure, heart rate, and respirations) and observed behavior, can be used to determine the degree of discomfort and pain. Experienced caregivers and parents are able to assess the degree of distress in the newborn, as well as the degree of relief provided by medication or other measures. However, it remains questionable whether euthanasia is also acceptable for newborns and infants, despite the fact that these patients cannot express their own will. Or is it necessary to keep children with disorders associated with severe and lasting suffering alive when their suffering cannot be adequately reduced? Verhagen and Sauer state that in the Netherlands, as in all other countries, ending someone's life without their consent, except in extreme circumstances, is considered murder. The aforementioned authors claim that the child's life suffering, which cannot be alleviated in any way, could be considered one of these extreme conditions. Legal control over euthanasia in newborns is based on reports from doctors, with subsequent consideration by criminal prosecutors. In recent years, a protocol known as the Groningen protocol has been developed in the Netherlands for cases where a decision is made to end the life of a newborn. This approach suits the Dutch legal system and corresponds to the social culture, but it is not clear to what extent it would be transferable to other countries. (Verhagen, Sauer, 2005)

Conclusion

The issue of euthanasia is a broad topic and has many supporters and opponents. Supporters of euthanasia understand euthanasia as a humane way to end human life. However, there are serious assumptions that patients who have saturated biological, psychological, social, but also spiritual needs do not tend to think about euthanasia as one of the options for ending life. (Ulrichová, 2016)

Dobríková-Porubčanová (2005) claims that patients who request euthanasia are primarily those who feel a state of loneliness, abandonment, fear of the unknown, fear of the dying process, of death, fear of pain, fear of loss of human dignity, or have a sense of loss of the meaning of life, or feelings that they are a burden to others. Such a request should be considered as a certain signal evoking increased attention in the paradigm that the patient's needs are not being met to a sufficient extent. All these mentioned reasons lead the individual, as well as his family, to consider the question of the possibility of euthanasia, while euthanasia seems to be the only possible solution to a hopeless situation that has drained the individual's last psychological and spiritual strength. It is actually about finding a way out of life by ending it. (Bujdová, 2011)

In developed countries, there is an ongoing public debate regarding the approval of euthanasia as an autonomous choice to die in the face of unbearable suffering. However, there are considerable differences of opinion on how euthanasia is understood and in which social and moral context individuals who express themselves on the topic of euthanasia find themselves in one or another country. It is clear from the presented research that even in countries that have legitimized euthanasia, there are and continue to be various dilemmas associated with euthanasia, while some questions will only be answered by long-term practical experience. We are convinced that within a few years the countries of Central Europe, and thus Slovakia, will also face the challenge of legitimizing euthanasia, and we will have to deal with this issue professionally and humanely. In the countries that have approved euthanasia, there is still no e.g. the dilemma regarding the euthanasia of individuals with dementia resolved and the issue of child euthanasia still evokes negative connotations. In both cases, it is true that two different individuals are involved, but in parallel, these cases are connected with the fact that we cannot treacherously assess the depth of suffering, as we lack open communication, and the burden of responsibility is mainly in the case of newborns on the shoulders of doctors. In our opinion, the euthanasia of children is an ethical problem, because the dilemma of assuming responsibility is not resolved here.

Regarding the issue of euthanasia of individuals with severe dementia, it is necessary to say that severe dementia is characterized by memory disorders, fatigue, disorientation, but also by various degrees of speech disorders and emerging significant defects in decision-making. Such individuals experience pain more intensely, have a distorted perception of the world, and delusions also appear, while these symptoms in many cases lead to depression. We are once again faced with the dilemma of whether we will respect the patient's decision before the illness, that if his suffering becomes unbearable, he should be allowed euthanasia? But when will his suffering become unbearable? Will we be able to judge it? Is there suffering in individuals with severe dementia or is it just a lack of social understanding? Even today, there is no clear answer to these questions, and euthanasia in this age group is rare.

In conclusion, we would like to point out that in the countries of Western Europe, the perception of euthanasia in society is either in the context of increasing the patient's autonomy in decision-making itself or in the context of fear and concern about reducing the patient's autonomy at the expense of increasing this autonomy among the medical staff. Based on the experience of countries that have enshrined euthanasia in legislation, it is important to draw attention to the aspect that the circumstances of performing euthanasia are agreed upon before the legislation is put into practice, because it often happens that the practice is different from the legislation itself.

As far as Slovakia is concerned, if we rely on the results of published research that linked opinions on the legitimization of euthanasia with secularization, then Slovakia in this area remains traditionally highly Christian and the vast majority of the population subscribes to Catholicism. It is therefore questionable how secularization, which does not take place in Slovakia to the same extent as in the countries of Western Europe, will influence the public's opinion on the approval of euthanasia. Also debatable are the control mechanisms and reports, or other bodies and institutions that have the task of checking the correctness of the procedures in approving euthanasia. Who will oversee these bodies and what will be their authority?

In the paradigm of euthanasia, even palliative care becomes contradictory. Palliative care in connection with the euthanasia agenda causes a wave of misunderstandings and critical voices are heard. The problem is primarily in the understanding of strengthening the rights of patients in the terminal stage of life, but also in the legal strengthening of substitute subjects with decision-making power in the context of the terminal period. Will we continue to support the right to continuous sedation until death and ignore the patient's autonomous request to end suffering because the patient is in palliative care?

Author: Mgr. Katarína Kotradyová, PhD. List of references

AUBREY, R., 2016: End-of-life, euthanasia, and assisted suicide: An update on the situation in France. In: Revue Neurologique, 172 (12), p. 719-724.

BILSEN, J., 2009: Medical end-of-life practices under the euthanasia law in Belgium. In: New England Journal of Medicine, 361 (11), p. 1119-1121.

BIRNBACHER, D., 2015: International Encyclopedia of the Social & Behavioral Sciences (Second Edition), p. 280-284.

BOUSQUET, A., GUIRIMAND, F., AUBRY, R., LEBOUL, D., 2016: Soignants d’unités de soins palliatifs conconons à une demande d’euthanasie : étude qualitative pilote. In: Médecine Palliative : Soins de Support - Accompagnement – ​​Éthique, 15 (1), p. 4-14.

BRINKMAN-STOPPELENBURGT, A., VERGOUWE, Y., VAN DER HEIDE, A., ONWUTEAKA-PHILIPSEN, B, D., 2014: Obligatory consultation of an independent physician on euthanasia requests in the Netherlands: What influences the SCEN physicians' judgment of the legal requirements of due care? In: Health Policy, 115 (1), p. 75-81.

BUITING, H, M., 2012: Older people's attitudes towards euthanasia and an end-of-life pill in The Netherlands. In: Journal of medical ethics, 38 (5), p. 267-273.

BUJDOVÁ, N., 2011: Ethical aspects of hospice care. In: Cooperation of helping professions in palliative and hospice care. Bratislava : VŠZaSP St. Elizabeth, 2011. p. 48-53.

BULOW, H.H,. 2012: Are religion and religiosity important to end-of-life decisions and patient autonomy in the ICU? The Ethicatt study. In: Intensive care medicine, 38 (7), p. 126-1133.

CAMARGO, R.D., 2016: Euthanasia, derecho y voluntad, ¿acción correcta? Lo que debemos saber. In: Acta Colombiana de Cuidado Intensivo, 16 (2), p. 90-94.

COHEN-ALMGOR, R., 2015: An argument for physician-assisted suicide and against. In Ethics, Medicine and Public Health, 1 (4), p. 431-441.

COHEN, J., VAN WESEMAEL, Y., SMETS, T., BILSEN, J., DELIENS, L., 2012: Cultural differences affecting euthanasia practice in Belgium: One law but different attitudes and practices in Flanders and Wallonia. Social Science & Medicine, 75 (5), p. 845-853.

DANYLIV, A., O'NEILL, C., 2015: Attitudes towards legalizing physician provided euthanasia in Britain: The role of religion over time. In: Social Science & Medicine, 128, p. 52-56.

DAN, B., FONTEYNE, Ch., CLÉMENT DE CLÉTY, S., 2014: Self-requested euthanasia for children in Belgium. The Lancet, 383 (9918), p. 671-672.

DAVID, A., ASCH, M.D., 1996: The role of critical care nurses in euthanasia and assisted suicide. In: New England Journal of Medicine, 334 (21), p. 1374-1379.

De BOER, M.E., DRÖES, R.M., JONKER, C., EEFSTING, J.A., HERTOGH, C.M.P.M., 2010: Advance directives for euthanasia in dementia: Do law-based opportunities lead to more euthanasia? Health Policy, 98 (2–3), p. 256-262.

DOBRÍKOVÁ – PORUBČANOVÁ, P. et al., 2005: The incurably ill nowadays. The importance of palliative care. Trnava: Society of St. Vojtecha – Vojtech, spol. with r. o., 2005. 280 p.

DRAPER, B., PEISAH, C., SNOWDON, J., BRODATY, H., 2010: Early dementia diagnoses end risk of suicide and euthanasia. In: Alzheimer's & Dementia, 6 (1), p. 75-82. ELIOTT, J, A., OLVER, I., 2008: Dying cancer patients talk about euthanasia. In: Social science & medicine, 67 (4), p. 647-56.

HIGUET, S., 2014: Projet d'extension de la loi sur l'euthanasia en Belgique concernant les patients dements. Réflexions d'un gériatre spécialisé dans la prise en charge des pathologies neurodegeneratives. In: NPG Neurology - Psychiatry - Geriatrics, 14, p. 145-149.

CHAMBAERE, K., Cohe, J., 2017: Euthanasia and Public Health. In: International Encyclopedia of Public Health (Second Edition), p. 46-56.

KARLSSON, M., MILBERG, A., STRANG, P., 2012: Dying cancer patients' own opinions on euthanasia: an expression of autonomy? A qualitative study. In: Palliative medicine, 26 (1), p. 34-42.

KIMSMA, G. K,. 2015: Longevity reversed: Medicine, suicide and layicide after the Euthanasia Law of 2002. In: Ethics, Medicine and Public Health, 1 (2), p. 220-229.

KOOGLER, T. K., 2013: Chapter 18 - Ethical issues in the care of the neurologically devastated infant. In: Handbook of Clinical Neurology, 118, p. 215-224.

KOVÁČ, P., 2005: Euthanasia and active suicide from the point of view of criminal law. In: Via pract., 2 (4), p. 216–220.

MISHARA, B.L., WEISSTUB, D.N,. 2013: Premises and evidence in the rhetoric of assisted suicide and euthanasia. In: International Journal of Law and Psychiatry, 36 (5–6), p. 427-435.

PASMAN, H.R.W., WILLEMS, D.L., ONWUTEAKA-PHILIPSEN, B.D., 2013: What happens after a request for euthanasia is refused? Qualitative interviews with patients, relatives and physicians. In: Patient Education and Counseling, 92 (13), p. 313-318.

RURUP, M. L,. 2012: The first five years of euthanasia legislation in Belgium and the Netherlands: description and comparison of cases. In: Palliative medicine, 26 (1), no. with 43-49.

SMETS, T., 2010: Legal euthanasia in Belgium: characteristics of all reported euthanasia cases. In: Medical care, 48 (2), p. 187-192.

TEN HAVE, H., WELVIE, J.VM., 2014: Palliative sedation versus euthanasia: an ethical assessment. In: Journal of pain and symptom management, 47 (1), p. 123-136.

VERBAKEL, E., JASPERS, E., 2010: A comparative study on permissiveness towards. euthanasia religiosity, slippery slope, autonomy, and death with dignity. In: Public Opinion Quarterly, 74 (1), p. 109-139.

VERHAGEN, E., SAUERAUE, P.J.J., 2005: The Groningen protocol—euthanasia in severely ill newborns. In: New England Journal of Medicine, 352 (10), p. 959-962.

VLČEK, R., HRUBEŚOVÁ. Z., 2007: Health law. Bratislava: Epos. 254 p.

VORLÍČEK, J., ADAM, Z., 1998: Palliative medicine. Prague: Grada Publishing, a. with 480 p.

SNIJDEWIND, M. C., VAN TOL, D. G., ONWUTEAKA-PHILIPSEN, B. D., WILLEMS, D. L., 2014: Complexities in Euthanasia or Physician-Assisted Suicide as Perceived by Dutch Physicians and Patients' Relatives. In: Journal of Pain and Symptom Management, 48 (6), p. 1125-1134.

VAN DER HEIDE, A., 2013: Chapter 15 - Assisted suicide and euthanasia. Handbook of Clinical Neurology, 118, p. 181-189.

VAN WESEMAEL, Y., COHEN, J., BILSEN, J., SMETS, T., ONWUTEAKA-PHILIPSEN, B., DELIENS, L., 2011: Process and Outcomes of Euthanasia Requests Under the Belgian Act on Euthanasia: A Nationwide Survey. In: Journal of Pain and Symptom Management, 42 (5), p. 721-733.

ULRICHOVÁ, M., 2016: Euthanasia and the Needs of the Terminally III Merits and Risks of Voluntary Workers in Hospices. In: Procedia - Social and Behavioral Sciences, 217, p. 657-668.