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적극적 안락사의 확대 관련

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적극적 안락사의 확대 관련

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https://n.news.naver.com/mnews/ranking/article/001/0007769907

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스위스 안락사 지원병원 '디그니타스' 입구 (EPA=연합뉴스 자료사진)
(서울=연합뉴스) 고미혜 기자 = 간호사 출신의 건강한 영국 70대 여성이 "늙는 것이 끔찍하다"며 안락사를 택했다.

2일(현지시간) 텔레그래프, 인디펜던트 등 영국 일간지에 따르면 지병 없이 건강한 상태이던 런던 북부의 질 패러우(75)가 지난달 21일 스위스의 한 안락사 지원병원에서 생을 마감했다.

호스피스 완화의료 전문 간호사 출신으로, 노인 돌보는 법에 대한 2권의 책을 집필하기도 했던 패러우는 일터에서 수많은 노인들을 보면서 이 같은 말년을 계획한 것으로 알려졌다.

죽기 직전 선데이타임스와의 인터뷰에서 그녀는 "평생 나이든 사람들을 돌보면서 항상 '난 늙지 않겠다. 늙는 것은 재미없다'고 생각해왔다"며 "(늙는다는 것은) 암울하고 슬프다. 대체로 끔찍하다"고 말했다.

패러우는 "내가 이제 막 언덕 꼭대기에 올랐다는 것을 안다. 앞으로 더는 좋아지지 않을 것이다. 보행기로 길을 막는 늙은이로 기억되고 싶지는 않다"고 심경을 밝혔다.

그녀는 두 달 전 자신의 블로그에서도 죽음을 결심한 이유를 털어놓기도 했다.

그녀는 "70살이 될 때까지 난 매우 건강하다고 느꼈고 원하는 어떤 활동에도 참여할 수 있으며 여전히 바쁘고 쓸모 있다고 느꼈다"며 "그러나 대상포진을 심하게 앓고 난 후에 모든 게 바뀌었다. 비록 지금 건강하지만 내 삶이 다했고 죽을 준비가 됐다고 느낀다"고 말했다.

패러우는 스위스로 가기 전에 두 자녀에게 자신의 결심을 알렸으며, 스위스에는 남편과 동행해 라인강변에서 조용히 마지막 만찬을 함께 즐겼다. 장례식 준비도 스스로 모두 마쳤다.

마지막을 함께 한 남편 존은 "질은 몇 년 동안 이를 준비했다"며 "분위기를 너무 감정적이거나 무겁게 만들어서 마지막 순간을 망치고 싶지 않았다"고 전했다.

안락사가 금지된 영국에서는 최근 패러우처럼 안락사와 안락사 지원이 허용된 스위스로 가서 스스로 목숨을 끊는 사람이 늘고 있다.

텔레그래프에 따르면 지난 2008∼2012년 스위스에서 안락사한 611명 가운데 5분의 1은 영국인이었다.

지난 5월에는 죽음이 임박하지 않은 영국의 50대 암 환자가 스위스에서 안락사해 영국내 안락사 논쟁이 가열되기도 했다.

mihye@yna.co.kr
▶ [현장영상] 참수된 사자 '세실'...엠파이어스테이트빌딩에 부활? ▶ [오늘의 핫 화보] '불난' 황소의 질주본능...스페인 황소 축제
<저작권자(c) 연합뉴스, 무단 전재-재배포 금지>

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건강한 英70대, 스위스서 안락사..."늙는 건 끔찍해"

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스위스 안락사 지원병원 '디그니타스' 입구 (EPA=연합뉴스 자료사진) (서울=연합뉴스) 고미혜 기자 = 간호사 출신의 건강한 영국 70대 여성이 "늙는 것이 끔찍하다"며 안락사를 택했다. 2일(현지시간) 텔레그래프, 인디펜던트 등 영국 일간지에 따르면 지병 없이 건강한 상태이던 런던 북부의 질 패러우(75)가 지난달 21일 스위스의 한 안락사 지원병원에서 생을 마감했다.

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[공개사유]코로나19 시대의 정보공개, 무엇을 고민해야 하나?

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※ 정보공개센터가 민중의소리에 연재하고 있는 ‘공개사유’ 칼럼입니다. 무엇을 공개해야 하나 2015년 메르스 사태 당시 감염병 대응에 실패한 이유는 단연 ‘정보은폐’라고 꼽을 수 있다. 초기 메르스 감염이 의료기관을 중심으로 확산되었지만 발병 병원과 지역이 공개되지 않아 정부에 대한 불신과 시민들의 불안이 극으로 치달았다. 메르스 대응 실패라는 교훈을 통해 이번 코로나19 사태에서 투명하고 신속한 정보공개가 이루어졌으며, 전 세계적으로 주목받을 만한 방역 시스템이 구축되었다. 하지만 이러한 정보공개 이면에는 확진환자 개인의 사생활이…

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이 영상은 수요일에 내리도록 하겠습니다.
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1. 시선처리, 말의 속도와 정확성, 그리고 충분한 연습으로 컬리티 있는 토론이 될 수 있도록 해주세요.
2. 토론에 필요한 자료나 영상, 토론에 보여줄 자료는 토론 직전 패들렛에 올리도록 합니다.
3. 토론 시 필기도구를 준비하세요.

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인권침해 및 차별행위 조사

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NHRC, 국가인권위원회

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혐오와 차별을 넘어 누구나 존엄하게, 국가인권위원회

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교육·임금 등 격차 '유리천장지수' 최하위

(부다페스트=연합뉴스) 양태삼 특파원 = 여성의 사회 참여나 직장 내 승진을 가로막는 보이지 않는 장벽을 뜻하는 '유리천장'을 점수로 매긴 결과 한국이 경제협력개발기구(OECD) 회원국 가운데 꼴찌인 것으로 나타났다.

영국 주간지인 이코노미스트지가 8일 세계여성의 날을 앞두고 고등교육과 남녀 임금 격차, 기업 임원과 여성 국회의원 비율 등을 종합해 점수로 낸 '유리천장 지수'에서 한국은 100점 만점에 25.6점으로 조사 대상국 가운데 최하위인 28위를 기록했다.

이코노미스트지가 만들어 오는 8일 여성의 날에 앞서 내놓은 이 지수는 공인받지 않았으나 특정 국가 화폐의 실질 구매력을 나타내게 한 이 주간지의 '빅맥지수'처럼 활용될 것으로 보인다.

OECD 28개 회원국을 9개 항목으로 조사한 결과 핀란드는 100점 만점에 80점으로 1위를, 노르웨이와 스웨덴이 공동 2위(73.1점), 폴란드(73.1점)와 프랑스(72.1점)가 4-5위를 차지했다. 평균은 60점이다.

한국은 꼴찌에서 두 번째인 일본(27.6점)에 이어 대부분 이슬람 신자인 터키(29.6점)보다도 뒤처졌다.

한국이 최고점을 받은 평가 항목은 평균임금에서 차지하는 순보육비 부문이 유일하며 이는 무상 의무교육 등의 덕분이라고 이 주간지는 풀이했다.

평가 항목 중 남녀의 취업률 차이로 볼 수 있는 '노동 시장 참여율 격차'는 한국이 22%로 터키(42.6%)를 제외하고 최하위였고 1위인 핀란드(2.5%)는 물론 평균(12.7%)보다도 차이가 컸다.

기업 이사회에서 여성의 비율은 2.1%로 노르웨이(38.9%)와 평균(16.7%)보다 크게 낮았고, 일본(3.3%)보다도 떨어졌다. 남녀 임금격차도 36.6%로 평균(15.5%)의 배에 이르렀고, 노르웨이(7%)와 비교하면 다섯 배를 넘었다.

경영대학원(GMAT)의 여성 비율이나 출산휴가 기간, 고등교육 비율 등도 최하위권에 머물렀다.

tsyang@yna.co.kr

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한국 '유리천장' OECD 국가 중 가장 단단해 | 연합뉴스

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교육·임금 등 격차 '유리천장지수' 최하위 (부다페스트=연합뉴스) 양태삼 특파원 = 여성의 사회 참여나 직장 내 승진을 가로막는 보이지 않는 장벽을 뜻하는 '유리천장'을 점수로 매긴 결과 한국이 경제협력개발기구(OECD) 회원국 가운데 꼴찌인 것으로 나타났다. 영국 주간지인 이코노미스트지가 8일 세계여성의 날을 앞두고 고등교육과 남녀 임금 격차, 기업 임원과 여성 국회의원 비율 등을 종합해 점수로 낸 '유리천장 지수'에서 한국은 100점 만점에 25.6점으로 조사 대상국 가운데 최하위인 28위를 기록했다.

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갈수록 조직의 다양성은 증가하고 있다. 다양성을 갈등의 원인으로 보는 것이 아니라 적극적으로 관리해 기업 경쟁력의 원천으로 삼는 지혜가 필요하다.

세계적 인력 컨설팅 기업인 William Mercer는 장차 10년 내에 HR 분야에 큰 영향을 미칠 주요한 변화 중의 하나로 기업 구성원들의 다양성을 선정한 바 있다. 경쟁 환경의 변화에 따른 빈번한 M&A, 문화적 경계를 뛰어넘는 인력 이동의 가속화, 개인 가치관의 변화 등으로 미래의 기업은 지금보다 훨씬 복잡한 인력 구성을 가질 것이라는 예견이다.

다문화, 다민족으로 구성된 미국을 비롯한 많은 국가들에서는 이미 오래 전부터 조직 구성의 다양성에 대한 연구와 관심이 제기되어 왔지만 우리의 경우 이에 대한 관심이 별로 크지 않았던 것이 사실이다.

그러나 최근 우리 기업의 현황을 보면 다음의 네 가지 면에서 조직 내 다양성 증가의 이유를 찾을 수 있다.

첫째, 여성의 경제 활동 참가율이 증가하고 있다는 점이다. 1990년대 들어서면서부터 크게 증가하기 시작한 여성의 경제 활동 참가율은 지난 2000년 55.1%에서 2020년에는 59.8%까지 늘어날 것으로 전망되고 있다.

둘째, 일용 근로, 단기 계약직과 같은 비정규직 근로자의 증가가 두드러지고 있다. 기업이 인건비 절감을 위해 정규직보다는 비정규직을 선호하면서 한 기업 안에도 다양한 형태의 고용 계약이 이루어지고 있는 실정이다.

셋째, 경력직 채용 비율이 늘면서 다양한 이력을 가진 구성원들이 새롭게 조직에 참여하고 있다. 온라인 채용 정보업체인 파워잡의 분석 결과, 올해 취업 사이트에 등록된 채용 공고의 약 64%가 경력직 채용인 것으로 나타났다. 이러한 현상은 기업간 활발한 이직/전직이 일어나면서 구성원들의 경력이 다양해지고 있음을 보여주고 있다.

넷째, 새로운 세대의 등장과 더불어 개인 가치관의 변화도 다양성을 증가시키는 하나의 요인으로 작용하고 있다. 서울대학교 사회발전연구소에 따르면, 앞으로 10년 후에는 지금 신세대라 불리는 20, 30대가 기업 구성원의 2/3를 차지하게 될 것이라고 한다. 이들은 작년에 있었던 월드컵과 대통령 선거의 변화의 주역이었고, 권위주의를 거부하고 개방성을 삶의 중요한 가치로 받아들이는 등 기성세대와는 차별화된 가치관을 보이고 있다.

이와 같이 현재 우리 기업들이 겪고 있는 구성원의 변화는 앞으로 기업들이 조직의 다양성에 대해 새로운 시각을 가져야 함을 시사해 주고 있다. 이제까지 기업 내 다양성에 대한 접근은 주로 생물학적 성이나 인종, 신체의 장애 유무에 대한 차별을 배제하고 주로 채용과 승진에서의 기회 균등, 공정한 대우에 초점이 맞춰졌다.

최근에 와서는 노동력의 다양성을 기업의 효율성 증대와 연관지어 설명하면서 구성원간의 차이를 수용하고 이를 적극적으로 고무시키고자 하는 노력들이 증가하고 있다. 다양성을 기업 경쟁력 강화의 수단으로 받아들이는 것이다. '다양성 관리(Manag-ing Diversity)'라는 이 새로운 접근 방법은 구성원들의 다양한 시각을 회사의 주요 업무에 반영시키고 구성원들간의 차이를 내부화시켜 그로 인해 기업이 지속적으로 학습하고 성장할 수 있도록 하는 것이다.

조직에서 다양성은 칼의 양날과도 같다. 다양성을 잘 관리하느냐 아니면 그렇지 못하느냐에 따라 다양성은 조직에 득(得)이 될 수도 있고 실(失)이 될 수도 있기 때문이다.
● 관리하지 않는 다양성은 갈등을 초래한다
조직 내 가치관과 배경이 다른 구성원들이 가진 다양성을 제대로 관리하지 못하면 기업은 방향을 잃고 표류하고 만다. 사람들은 기본적으로 자신과 다른 것에 대해서는 저항하려는 경향이 있다고 한다. 비슷한 성격, 비슷한 배경을 가진 사람들끼리는 편안함을 느끼지만, 그렇지 않은 사람들 사이에는 긴장 상태가 조성되고 화합이 잘 이루어지지 않는다는 것이다.

이러한 현상은 상대 기업에 대한 충분한 이해없이 갑작스럽게 추진되는 M&A에서 그 전형적인 예를 찾아볼 수 있다. 독일의 Daimler Benz와 미국의 Chrysler의 합병의 경우를 보자. 합병 발표 당시 세계 자동차 업계에 엄청난 파장을 불러 일으켰던 두 회사는 각각의 다양하고 독특한 문화를 제대로 통합, 관리하지 못하여 주가 하락, 경영진 교체라는 더 큰 혼란을 초래하고 말았다.
● 다양성을 인정하고 관리하지 않는 조직은 인재를 유치하기 어렵다
개인의 다양성을 인정하지 않고 집단으로서의 조직 논리만을 강조하는 기업은 젊고 유능한 인재를 붙잡을 수 없다. 미국의 유명 소프트웨어 기업인 SAS의 연구원으로 20년 동안 근무한 Floyd Williams는 Fortune 지에 기고한 글에서 이렇게 말한 적이 있다. "나는 그동안 경쟁기업들로부터 수많은 스카우트 제의를 받았지만, 현재의 직장을 포기하지 않았다. 그 이유는 그들은 나 자신을 '개인'으로 인정해 주지 않았기 때문이다." 결국 자신의 다양성을 인정해 주지 않아서 다른 기업들이 제시하는 좋은 조건을 포기했다는 말이다. 바꿔 말하면 조직이 개인을 제대로 인정해 주지 않는다면 언제든지 유능한 인재들이 조직을 떠날 수 있다는 뜻이기도 하다. 이러한 인재의 이탈은 대체 인력의 채용, 교육 훈련에 드는 시간과 돈, 생산성의 하락과 같은 비용으로 연결되는데 이는 다양성을 인정하지 않는 조직이 치루어야 할 대가인 것이다.
● 다양성 관리는 조직의 창조성, 혁신성을 자극한다
조직 내에 속해 있는 개개인의 다양한 경험과 가치, 태도, 다양한 관점을 적절히 관리, 활용하는 것은 기업의 창의성과 혁신성에 기여한다.

다양성을 기업 가치로 활용한 대표적인 예로 Coca-Cola의 경우를 살펴 보자. Coca-Cola는 세계적인 다국적 기업답게 다양한 인종과 언어를 가진 사람들이 일하고 있다. 이들의 다양한 사고와 개성은 레몬 향을 첨가한 Diet Coke라는 새로운 제품의 개발을 가능하게 했다. 개개인의 입맛을 존중하고 이해하는 다양성을 추구하는 기업의 가치가 제품 개발 혁신으로 이어진 사례이다.
● 다양성 관리는 조직의 시너지를 창출한다
사람들 간의 정신적, 감정적, 심리적 차이점들을 소중히 여기고 이를 적극적으로 관리하고 통합할 때 시너지를 얻을 수 있다. Stephen Covey는 그의 저서 'Seven Habits of Highly Effective People'에서 시너지는 사람들이 내면에 갖고 있는 가장 큰 힘을 이끌어 내어 통합하는 역할을 한다고 하였다.

혁신적인 디자인으로 유명한 Sony는 소비자 연구를 위해 디자인 센터에 NTP (New Trend Product)라는 부서를 운영하고 있다. 이 부서는 기술자, 디자이너, 마케팅 담당자 등 다양한 경력을 가진 사람들로 구성되어 있는데, Sony는 이렇게 이질적인 배경을 가진 구성원들의 통합을 통해 창조적 혁신이라는 시너지 효과를 얻을 수 있었다고 한다. 상호존중을 통한 커뮤니케이션의 향상, 참여적 의사결정을 통해 힘을 공유하고 구성원의 적극성을 자극함으로써 이뤄낸 결과였던 것이다.

시너지는 개개인의 다양성을 잘 관리하면 전체의 합은 각 개별의 합보다 클 수 있다는 믿음에서 출발한다. 시너지를 제대로 창출하기 위해선 새로운 가능성, 새로운 대안에 늘 열려 있어야 하며 서로의 차이에 대해 인정과 존중을 하는 자세가 필요하다.

기업이 다양성 관리의 필요성을 인식했다 할지라도 그것을 실천하는 것은 또 다른 문제이다. 특히 국내의 경우, 오랫동안 단일성에 대한 가치와 기대가 지나치게 강조되어 왔기 때문에 다양성을 경영 현장에서 구체적으로 실천하기란 쉽지 않다. 다양성 관리는 기업 문화의 한 부분으로 경영진에서부터 종업원에 이르기까지 조직 구성원 전체의 올바른 인식과 의지가 중요하다.
● 다양성의 구심점을 확보하라 : 성과와 연계된 기업 비전 제시
조직의 다양성이 기업의 목적을 달성하는데 어떻게 도움이 되고, 다양성의 추구가 왜 수익성에 긍정적인 영향을 미치는지를 보여 줄 수 있어야 한다. 다양성의 표출이 조직의 공유 가치(Shared Value)에 역행하는 것이 아니라 기업의 장기적인 비전이라는 하나의 가치로 지향하도록 명확한 방향을 제시하는 것이 다양성 관리의 첫걸음이다.

미국의 여성 화장품 전문 회사인 Avon Products의 비전은 시장과 기업 현장 속에서 고객과 관련된 다양성 기회들을 관리함에 있어 세계 시장에서 선도적인 위치를 차지하는 것이다. Avon에서는 '다양성 관리'를 시장의 변화에 따라 신속, 유연하게 적응하여 종업원들이 갖고 있는 최대한의 역량을 발휘할 수 있도록 지원하는 것으로 파악하고 있다.

기업의 다양성이 조직의 성과를 달성하기 위해 추구해야 할 중요한 과제임을 분명히 드러내는 것은 구성원들에게 다양성 관리에 대한 자발적인 참여와 이해를 높이는 중요한 발판이 된다.
● 다양성을 이해하고 인정하라 : 훈련과 교육
경영자와 종업원들을 대상으로 조직 내 다양한 이슈에 대한 훈련, 교육을 통해 서로간의 '다름'에 대하여 이해와 인정을 하는 것이 중요하다.

Prudential의 모든 임원, 관리자, 그리고 종업원은 2일간의 다양성 인식 훈련 프로그램에 참가할 기회를 갖는다. 이 프로그램은 개인 및 조직의 다양성 문제와 그 영향에 대해 이해할 수 있는 기회를 제공해 준다. 첫째 날은 개인적 가치 및 커뮤니케이션 기대치, 그리고 스테레오 타입의 파악 등을 다룬다. 둘째 날은 커뮤니케이션 방식의 차이, 조직 문화, 그리고 역할 및 책임에 관한 사항을 강조한다. 이런 다양성에 대한 훈련과 교육 과정은 서로에 대한 이해를 도와주어 자신과 다른 것에 대한 거부감을 없애고 변화를 수용하는데 결정적인 기여를 하게 된다.
● 다양성을 숨쉬게 하라 : 구성원간의 커뮤니케이션 원활화
다양성 프로그램의 초점을 유지하고 제대로 실천하기 위해서는 조직 내 빈번하고 일관된 의사 소통이 중요하다.

Texas Commerce Bank는 1995년 초 소매 부문에 멘토링 프로그램을 도입, 잠재력이 큰 종업원들에게 시니어 경영진을 자신의 경험과 지식을 전달하는 멘토로 활용하고 있다. 이들은 2일간의 Training Session과 한 달에 한번 직접 대면, 이메일, 전화 등을 통해 수시로 접촉하여 서로에 대한 이해를 높이고 있다. 멘토링은 단순히 신입 사원들의 조직 적응을 도와 주는 차원을 넘어서 다양한 사고와 가치에 대한 열린 커뮤니케이션을 반영하고 더 나은 팀워크와 역동성을 가지게 하는 방편으로 활용될 수 있다.

문서를 통한 구성원간의 활발한 의사 소통 역시 조직의 다양성을 관리하는 중요한 수단이다. Hallmark는 다양성에 대한 회사의 진척 현황을 전달하고 구성원의 의견을 자유롭게 표현하는 수단으로 'Direct-ion', 'Noon News' 등과 같은 내부 간행물을 이용하고 있다.

조직 내 커뮤니케이션 프로그램은 회사의 전체적인 현황 및 다양성 문제에 대한 정보의 전달뿐 아니라 종업원 서로간에 자유로운 의견 교환을 도울 수 있다. 또한 다른 문화와 경험을 공유하는 장을 마련함으로써 조직에 대한 만족감을 더 높이는 계기가 된다.
● 다양성을 지원하라 : 경영진의 참여와 관심
CEO와 경영진들은 그들이 조직의 다양성에 대해 관심을 갖고 인정하고 있음을 보여주어야 한다. 이것은 단순히 문서나 말, 정책뿐만 아니라 경영진의 몰입을 반영하는 의사결정과 행동을 취함으로써 드러나야 한다. 20세기 최고의 경영학자로 인정받는 Peter Drucker는 진정한 기업의 리더는 '다양성을 유기적인 사고 방식 하에 통일시키는' 능력을 갖고 있다고 하였다. GM의 Alfred Sloan이나 GE의 Ralph Cordiner 같은 경영자가 바로 그러하다. 이들은 집단주의적 사고나 획일성의 위험을 인식하고 이를 경계하는 한편, 조직 내 다양한 의견을 표출하도록 유도하는데 힘을 썼다.

개인의 다양성이 지식의 활발한 창조와 공유로 이어지기 위해서는 자율과 조화에 가치를 두는 열린 리더십이 필요하다. 그러한 리더십은 다양성의 실현을 조직의 중요한 우선 과제로 삼고 필요한 자원을 할당하는 경영진의 구체적인 노력에서 비롯된다.

조직의 다양성 문제는 이제 불가피한 현실이 되고 있다. 이러한 변화는 도전이자 기회이며, 이 기회를 어떻게 활용하느냐에 따라 미래의 경쟁 판도는 크게 바뀌어질 수 있다. 다양성을, 조직의 성장을 방해하는 갈등 정도로 인식하는 수준에서 벗어나서 기업들은 다양성 관리에 적극적으로 나서야 한다. 그러나 여기에는 개인의 다양성을 조직의 지향 가치와 조화시키려는 노력이 선행되어야 한다. 기업의 비전과 잘 통합된 개개인의 다양성은 기업의 경영 능력을 한 단계 업그레이드하는 중요한 디딤돌이 될 것이기 때문이다.

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왜 다양성 관리가 필요한가

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갈수록 조직의 다양성은 증가하고 있다. 다양성을 갈등의 원인으로 보는 것이 아니라 적극적으로 관리해 기업 경쟁력의 원천으로 삼는 지혜가 필요하다. 세계적 인력 컨설팅 기업인 William Mercer는 장차 10년 내에 HR 분야에 큰 영향을 미칠 주요한 변화 중의 하나로 기업 구성원들의 다양성을 선정한 바 있다.

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https://www.ilyoseoul.co.kr/news/articleView.html?idxno=426906

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지난 8일 대학생 커뮤니티 앱 에브리타임에 게시된 글 [사진=에브리타임 캡처]

[일요서울ㅣ신수정 기자] 그간 사회 양극화 현상을 심화시키는 요인으로 취업 시장에서 인서울 대학교 출신 선호 현상이 지목된다. 사회로의 첫발을 내딛는 취업에서부터 격차를 발생시키기 때문이다. 이에 문재인 대통령은 혈연·학연·지연으로 얽힌 채용시장을 실력과 인성 중심의 채용구조에 나섰다. 이 일환으로 지난 2017년 말에 '블라인드 채용'과 '비수도권 지역인재 할당제' 도입을 선언했다. 이에 전국 총 10개 혁신도시 강원, 경남, 경북, 광주, 대구, 부산, 세종, 울산, 전북, 충북 지역에서 공공부문 채용에서 '지역인재 할당제'를 적용했다.
"역차별 후폭풍은 '실망 실업자' 양산할 것" 우려
공정함 검증된 '공무원 시험'에 전무후무한 과열 예상
최근 한국국제협력단(이하 코이카)의 채용에 '지역인재 할당제'로 인한 역차별이 드러나고 있다는 주장이 제기됐다. 해당 주장은 지난 8일 대학생 커뮤니티 어플 에브리타임에 올라간 게시글로부터 시작됐다.
코이카 '인국공 사태'급?
"채용 역차별" 주장
서울권 4년제 대학에 재학하며 취업을 준비하는 학생 A씨는 게시글을 통해 "일반 지원보다 지역 인재 지원 비율이 높은 경우는 처음 본다"며 사실상 해당 지역의 국립대학 전형이 아니냐고 지적했다.

게시글을 접한 또래 대학생들은 "지방에서 열심히 공부해서 서울대학 온 사람이 지방인재가 아니라니", "인서울 못하고 지거국(지방거점 국립대) 갔던 친구들이 메이저 공기업에 더 쉽게 들어간다. 그들도 노력한 결과겠지만 허탈한 건 사실"이라며 불만을 표했다.

A씨는 일요서울과 대화에서 "현행 지역인재제도상 35%까지 뽑아야 한다면 지역 균형 발전을 위해 양보하는 입장으로 이해할 수 있겠지만, 이렇게 절반이 되는 비율을 채용하는 상황은 명백한 역차별"이라고 말했다.

지역인재 할당제를 두고 역차별 문제를 제기한 것은 어제오늘 일이 아니다. 특히 해당 지역 출생이더라도 수도권 대학을 졸업했다면 지역인재로 인정받지 못한다. 결국, 지방 대학 졸업이 조건으로 적용되면서 좋은 대학에 들어가려고 열심히 노력한 지방인재는 '지역인재 전형'에서 타지방인재보다 차별받는 '역차별'이 성립한다는 주장이다.

A씨는 이런 역차별이 발생되는 이유로 "인위적으로 '결과적 공평함'을 추구하려는 정부 정책"을 말했다. 공평성은 과정과 결과 두 가지 요소에서 충족돼야 하는데, 결과의 공평함만 추구하다 보니 발생된 상황이라는 것이다.

또한 A씨는 "인국공 사태와 결은 다르지만, 공공기관 채용 역차별 사례란 점에서 인국공 사태급 채용 역차별이라 생각한다. 사기업들이 공채를 없애고 상시채용으로 전환한 상황에서 공기업마저 역차별 현상이 계속 발생한다면, 소위 '실망 실업자'들의 발생으로 공무원 시험에만 매달리는 취준생들이 양산될 것"이라고 설명했다.
지원별 모집 인원 보니...
코이카 공식 홈페이지에 게시된 '2020년 하반기 한국국제협력단 일반직·사회 형평적 채용공고'에 따르면 5급 일반직 신입 31명, 사회 형평적 채용 11명으로 총 42명의 신입직원을 채용한다. 공고는 지난달 29일에 개재돼 지난 8일부터 서류접수를 시작했다. 16일까지 서류접수 이후 필기시험과 실무·역량 면접을 거쳐 인원을 선발할 예정이다.

일반직은 직무별로 ▲일반 14명 ▲정보화운영 1명 ▲보건 1명 ▲비수도권 지역인재 15명을 채용한다. 이중 일반 전형과 비수도권 지역인재 전형만 '전공 무관'이고 정보화운영과 보건은 전공자로 지원 제한을 걸었다.

사회 형평적 채용은 직무별로 5급에서는 ▲보훈 2명 ▲장애인 3명 ▲시간선택제(개발협력연구) 2명을 6급에서는 ▲고졸자 정보보안 2명 ▲고졸자 사무행정 2명을 채용할 계획이다.

일반 채용공고와 다를 바 없어 보이는데 어떻게 '지역인재 할당제' 차별 주장이 제기된 것일까. 일요서울의 분석 결과, 보훈·장애인·경력단절여성·고졸자의 우대조건에 해당하지 않는다면 '정보화운영·보건' 같이 코이카가 우선하는 특정 전공 분야의 전공자이거나 '전공무관'의 일반 전형으로 지원해야 한다.

결과적으로 '전공무관'으로 5급 일반직 신입에 지원하는 경우 일반 전형과 비수도권 지역인재 전형 두 방법으로 지원하게 된다. 하지만 두 그룹별 채용 인원은 비수도권 지역인재가 1명 많은 상황이다.
코이카-취준생
입장 차 뚜렷
지역인재 할당제를 30% 이상 적용시키자 눈에 보일 정도의 역차별이 발생했다는 주장. 일요서울은 지난 14일 코이카 관계자와 접촉해 코이카의 입장을 들어봤다.

코이카 관계자는 일요서울과 통화에서 "전공제한도 일반직 채용에 포함되는 직무다. 비수도권 지역인재 채용인원은 15명이다. 전공제한을 포함해 나머지 일반직 채용은 16명으로 비수도권 지역인재를 과반하지 않는다"며 역차별 주장을 반박했다.

기자가 비수도권 지역인재는 30% 정도에 해당하는데 현재 일반직에서는 과반수에 가까워 역차별이 아니냐고 질문하자 관계자는 "일반직과 사회 형평적 채용 전체로 보면 35%에 해당해 문제될 것이 없다"고 답변했다.

코이카의 답변에 A씨는 "지역인재 35%를 일반직에만 적용시키면 사실상 절반은 지역인재로 채용하겠다는 얘기밖에 안 된다"며 "지역인재 할당을 정말 공평히 적용할 것이라면 전공 제한 직무와 사회 형평적 채용에도 지역인재 채용을 적용시켜야 한다"고 반박했다.

나아가 기재부 '공기업·공공기업 경영평가'에서 좋은 실적을 받아 정책 제안 및 예산 확보를 위한 채용 제도에 불과하다는 지적도 잇따른다. 총 42명의 채용인원 중 35%인 15명을 비수도권 지역인재로 채용하는 것을 두고 '비수도권 지역인재 채용' 정책을 따르고 있다고 형식적으로 보여주는 데에 치중한 채용이라는 비판이다.

문제를 주장한 대학생과 코이카의 입장이 뚜렷하게 갈리는 가운데, '지역인재 할당제'에 대한 역차별을 보완책은 규정되지 않고 있다.

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[단독] 지역인재 할당제 '35%'에 역차별 논란 가열

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일요서울ㅣ신수정 기자] 그간 사회 양극화 현상을 심화시키는 요인으로 취업 시장에서 인서울 대학교 출신 선호 현상이 지목된다. 사회로의 첫발을 내딛는 취업에서부터 격차를 발생시키기 때문이다. 이에 문재인 대통령은 혈연·학연·지연으로 얽힌 채용시장을 실력과 인성 중심의 채용구조에 나섰다. 이 일환으로 지난 2017년 말에 '블라인드 채용'과 '비수도권 지역인재 할당제' 도입을 선언했다.

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호스피스·완화의료 및 임종과정에 있는 환자의 연명의료결정에 관한 법률

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호스피스·완화의료 및 임종과정에 있는 환자의 연명의료결정에 관한 법률

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https://www.law.go.kr/LSW/lsInfoP.do?efYd=20220322&lsiSeq=238075#0000

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안락사 찬반 여론조사 기사

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안락사 찬반 여론조사 기사

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https://n.news.naver.com/mnews/article/081/0002981990

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입론 시 사용할 자료(흥미 유도)

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입론 시 사용할 자료(흥미 유도)

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https://youtu.be/OR6zIfdSlRI

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https://www.google.com/url?sa=t&source=web&rct=j&url=https://www.jjan.kr/articleAmp/20220920580284&ved=2ahUKEwiw9-qa-ur-AhXopVYBHXVCBUoQFnoECCoQAQ&usg=AOvVaw0QQC5ECiu6utL4Vlx3vSCK

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적극적 안락사와 관련한 법적 논쟁 (PDF)

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적극적 안락사와 관련한 법적 논쟁 (PDF)

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https://www.google.com/url?sa=t&source=web&rct=j&url=https://www.kicj.re.kr/boardDownload.es%3Fbid%3D0003%26list_no%3D9253%26seq%3D9&ved=2ahUKEwiw9-qa-ur-AhXopVYBHXVCBUoQFnoECCQQAQ&usg=AOvVaw0H_1EY3dKnFqtuN_c8XtHr

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안락사와 의사조력자살 의견2

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안락사와 의사조력자살 의견2

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https://euthanasia.procon.org/top-10-pro-con-arguments/

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Should euthanasia or physician-assisted suicide be legal?

"The right of a competent, terminally ill person to avoid excruciating pain and embrace a timely and dignified death bears the sanction of history and is implicit in the concept of ordered liberty. The exercise of this right is as central to personal autonomy and bodily integrity as rights safeguarded by this Court's decisions relating to marriage, family relationships, procreation, contraception, child rearing and the refusal or termination of life-saving medical treatment."

"Do we want doctors deciding who lives and who dies? No, we do not want that. This is a slope, a real slope where we are going to become God. We do not have that power. The Declaration of Independence says that we should have the right to pursue life, liberty, and the pursuit of happiness. Nothing in it says we have the right to pursue death, nothing."

Tom Coburn, MD
US Senator (R-OK)
Consideration of House Resolution 2260, Pain Relief Promotion Act of 1999, gpo.gov
Oct. 27, 1999

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Top 10 Pro & Con Arguments - Euthanasia - ProCon.org

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Should euthanasia or physician-assisted suicide be legal? Legalization Legalization: Medical Perspectives Legalization: Lawmakers' Views Vulnerable Groups Hippocratic Oath Legal Right Slippery Slope Palliative Care Physician Obligation Financial Motivations 1. Legalization "The right to die should be a matter of personal choice. We are able to choose all kinds of things in life from who we [...]Read More...

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안락사와 의사조력자살(PAS)에 관한 의견

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안락사와 의사조력자살(PAS)에 관한 의견

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https://hospicecare.com/policy-and-ethics/ethical-issues/essays-and-articles-on-ethics-in-palliative-care/euthanasia-and-physician-assisted-suicide-are-they-clinically-necessary-or-desirable/?gclid=CjwKCAjwge2iBhBBEiwAfXDBR1whlTFUe38gv0fEAKJywpaPG1NfwSPb156phO6nKhqDln8trXxsihoCu8UQAvD_BwE

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I. DEFINITIONS

EUTHANASIA

Euthanasia is 'a deliberate intervention undertaken with the express intention of ending a life so as to relieve intractable suffering' (House of Lords, 1994; Walton, 1995). If it is performed at the dying person's request, it is voluntary; otherwise, it is non-voluntary. The terms 'active' and 'passive' may be misleading (Walton, 1995).

PHYSICIAN-ASSISTED SUICIDE

Physician-assisted suicide (PAS) is defined as the provision of help by a doctor to a competent patient who has formed a desire to end his or her life (Walton, 1995). In PAS, the physician provides the necessary knowledge and means (equipment, drugs) but the act is completed by the patient. It is similarly a deliberate act with the express intention of ending life and is not ethically or morally distinguishable from euthanasia.

The performance of assisted suicide by persons other than physicians, as occurs in Switzerland, is ethically and morally equivalent to PAS.

TERMINATION OF LIFE WITHOUT EXPLICIT REQUEST

In Holland and Belgium, euthanasia is defined as being at the patient's request, so cases of 'ending of life without the patient's explicit request' have to be counted separately. It is ethically and morally no different to euthanasia.

INTENSIFIED TREATMENT OF PAIN AND SYMPTOMS

Intensified treatment of pain and symptoms may be entirely clinically appropriate, the possibility of life-shortening being acknowledged, but not intended.

In contrast, intensified treatment of pain and symptoms performed with the intention of hastening death or ending life, is no different to euthanasia-these are deaths caused by the active intervention of the physician.

WITHHOLDING/WITHDRAWING TREATMENT

Withholding or withdrawing therapy may be entirely clinically appropriate, the possibility of life-shortening being acknowledged, but not intended.

In contrast, withholding or withdrawing therapy performed with the intention of hastening death or ending life, is no different to euthanasia-these are deaths caused by the active intervention of the physician.

TERMINAL SEDATION

Continuous sedation until death (CSD) for the management of severe and refractory symptoms in the last days or week of life may be entirely clinically appropriate therapy, the possibility of life-shortening being acknowledged, but not intended.

In contrast, CSD performed with the intention of hastening death or ending life is no different to euthanasia-these are deaths caused by the active intervention of the physician.

THE SLIPPERY SLOPE

The 'slippery slope' is the gradual extension of assisted suicide to widening groups of patients after it is legally permitted for patients designated as terminally ill (Hendin, 1997a).
Manifestations include

Increased numbers of deaths per year

Increased proportion of requests granted

Widening the indications

Terminally ill to not terminally ill

Unbearable suffering to 'tired of life'

Adults to children

Inclusion of patients with dementia or psychiatric disease

Henk Jochemsen (Director, Lindeboom Institute for Medical Ethics, the Netherlands): 'The Dutch experience shows that once the termination of patients' lives is practised and that practice wins official toleration or approval, the practice develops a dynamic of its own that resists effective control.' (Jochemsen, 1994)

Herbert Hendin (Medical Director of Suicide Prevention Initiatives (SPI) and Professor of Psychiatry at New York Medical College): 'Virtually every guideline set up by the Dutch-a voluntary, well considered, persistent request; intolerable suffering that cannot be relieved; consultation; and reporting of cases-has failed to protect patients or has been modified or violated.' (Hendin, 2002)

José Pereira (Head of Palliative Care at the University of Ottawa): 'Abuse of guidelines has occurred in every jurisdiction around the world where assisted dying has been legalized.' (Pereira, 2011)

TERMINOLOGY

A range of euphemisms have been developed to avoid the terms euthanasia and PAS, particularly the stigma of the word 'suicide'. These include 'death with dignity', 'medical assistance in dying', and 'the peaceful alternative'. But these terms do not alter the nature of the act and, where possible, are avoided.

Daniel Callahan (co-founder and President Emeritus of The Hastings Center): 'The advocates for physician-assisted suicide make use of a favourite method from the spin-tool box, that of obfuscation, defined in dictionaries as an effort to render something unclear, evasive, or confusing.' (Callahan, 2008)

Robert Twycross (Reader, Oxford University): '[The pro lobby's] attempt to 'prettify' the language of death by not using terms such as assisted suicide, euthanasia, and killing...' (Twycross, 1990)

Wesley J. Smith (journalist and author of Forced Exit): 'According to Compassion & Choices, when a terminally ill patient swallows an intentionally prescribed lethal overdose of barbiturates, it isn't really suicide. Why? Because the word 'suicide' has negative connotations, and C&C wants people to feel positive about some self-killings.' (Smith, 2013)

II. WHAT'S HAPPENED

During the last 30 years, euthanasia and/or physician-assisted suicide (PAS) have been legalized in a number of countries. In chronological order, these are The Netherlands, the Northern Territory of Australia, Oregon (USA), Belgium, and Canada. Legal change was not required to allow assisted suicide in Switzerland.

A. THE NETHERLANDS

1. BACKGROUND

'The 1960s and 1970s were a watershed for Dutch society. From a conservative, tradition-bound country, the Netherlands transformed itself into a hotbed of social and cultural experimentation' (Weyers, 2012). Amongst these were the ideals of patient autonomy and assisted dying (Angell, 1996). There are a number of good accounts of the saga of Dutch euthanasia (Hendin, 1997b; Hendin, 2002; Ten Have and Welie, 2005; Griffiths et al, 2008; Youngner and Kimsma, 2012; Keown, 2018).

In about 1990, formalized guidelines for the practice of euthanasia and physician-assisted suicide were issued (Walton, 1995). These were:

In 2002, the practices became legally regulated with the passage of the Termination of Life on Request and Assisted Suicide (Review Procedures) Act by the Dutch Parliament (see Parliament of the Netherlands).
End of Life Clinic
In 2012, the Dutch Association for Voluntary Euthanasia (NVVE) founded the End-of-Life Clinic or Levenseindekliniek (see Levenseindekliniek).

2. GUIDELINES

The current (2015) Regional Euthanasia Review Committees Code of Practice (see Regional Euthanasia Review Committees Code of Practice) states the physician must:

In the accompanying notes, it explains:

The patient does not have to have a terminal illness - the patient's life-expectancy is not relevant;

The physician and the patient do not need to be in a treatment relationship;

There is no need for a written request;

The request must be well-considered, but it need not be persistent;

The request must be voluntary, without undue influence of others;

Palliative sedation is not a 'reasonable alternative' within the meaning of the Act; palliative sedation is defined as 'normal medical practice' and is not euthanasia;

It is not a requirement that the patient's family be informed - their consent is not required;

It applies to anyone aged 12 and over - parental consent is required for ages 12-15;

Only a physician can perform euthanasia;

The patient must be 'decisionally competent';

For patients with psychiatric disorders, there is no requirement for psychiatric review;

For patients who lack decisional competence and those with dementia, aphasia, reduced conscious state or in a coma, the physician can proceed with euthanasia provided there is a clear, written advance directive.

3. NUMBERS

The Dutch have reported their practices each 5 years since 1990 (Table 1) (van der Maas et al, 1991; van der Maas et al, 1996; Onwuteaka-Philipsen et al, 2003; van der Heide et al, 2007; Onwuteaka-Philipsen et al, 2012b; van der Heide et al, 2017). The figures are also available from The Royal Dutch Medical Association (KNMG) website (see KNMG). Reports for 2016 and 2017 are available (see Regional Euthanasia Review Committees. Annual Reports).
Table 1. Frequency of Physician Assistance in Dying in the Netherlands - expressed as a percentage of all deaths From van der Heide et al, 2017 Euthanasia

During the period 1990 to 2015, the incidence of euthanasia has risen from 1.7% to 4.5% of all deaths, or from about 2,190 to 6,000 cases per year (van der Heide et al, 2017).
Physician-assisted suicide

A smaller number of patients undergo physician-assisted suicide, which has remained fairly constant over the years (van der Heide et al, 2017).
Ending of life without the patient's explicit request

Intensified treatment of pain and symptoms

Intensified treatment for pain and symptoms was performed with the intention of ending life in 6% of cases in 1990 (van der Maas et al, 1991; Gunning, 1991; Keown 2002), and in 16% of cases in 1995 (van der Maas et al, 1996).

Weyers (quoting from a Dutch publication) indicates the intention rate (explicit plus subsidiary) declined from 21% in 1990 to 3% in 2010 (Weyers, 2014).

Withholding or withdrawing therapy Continuous deep sedation until death (CSD)

There is considerable variation as to what constitutes palliative sedation or terminal sedation (Krakauer and Quinn, 2010; Papavasiliou et al, 2014a; Taboda, 2015; Seymour et al, 2015; Henry, 2015; Sterckx et al, 2016).

Guidelines for palliative sedation have been proposed (Cherny et al, 2009; Legemaate et al, 2007; Verkerk et al, 2007).

Under Dutch law, palliative sedation is not euthanasia and is classified as 'normal medical practice' that 'must be clearly distinguished from the ending of life' (de Graeff and Dean, 2007; Verkerk et al, 2007).
Others question that distinction (Rady and Verheijde, 2010; Janssens et al, 2012; Boyle, 2015).

CSD has the advantage that it requires no second opinion, does not have to be reported to authorities, and carries no risk of prosecution. Doctors have admitted they are using it with the intention of hastening death or ending life, i.e. it is euthanasia 'in disguise' (Rietjens et al, 2004; Griffiths et al, 2008; Taboda, 2015; Sterckx et al, 2016).

Totals for 1990-2015
Estimating the magnitude of the Dutch experiment with euthanasia and PAS is an informative exercise.
Table 2. Estimate of total numbers of deaths 1990-2015

Physician-assisted suicide

5,400

Termination of life without explicit request

18,400

Intensified treatment of pain and symptoms

36,900

with the intention of hastening death

Withholding/withdrawing treatment with the intention of hastening death

285,000

Continuous sedation until death with the intention of hastening death

12,100

The figures in Table 2 are calculated from the Dutch data. They are an approximation, given the limitations of the published data, but they suggest of the order of 450,000 people may have been involved in the Dutch experiment.
4. DO THEY MEET THEIR OWN GUIDELINES?
Be satisfied that it is requested
In the Netherlands, euthanasia is by definition requested, but

Thousands of patients have had their lives terminated without request (see above).

It is stated that the decision to terminate life was not discussed with the patients because most of them were incompetent (van der Maas et al, 1991). But, 37% (1990) and 21% (1995) of them were reported to be competent (van der Maas et al, 1996; Jochemsen and Keown, 1999; Hendin, 2002).

Some regard these deaths as simply part of 'normal end-of-life medical practice' (Rietjens et al, 2007).

Others claim it is the doctor's duty to ensure that his patient dies a 'humane' or 'dignified' death (Griffiths et al, 2008; Keown, 2013).

'In 15% of cases where no discussion took place but could have, the doctor did not discuss the termination of life because the doctor thought that the termination of the patient's life was clearly in the patient's best interests.' (Jochemsen and Keown, 1999).

Keown provides some eye-opening quotes from Dutch doctors regarding these deaths without request: 'It is the patient who is now responsible in the Netherlands for avoiding termination of his life; if he does not wish to be killed by his doctor then he must state it clearly, orally and in writing, well in advance.' And 'Due consideration should be given to the question how termination of life without explicit request can be prevented. It should be the responsibility of the patients...' (Keown, 2013).

For some patients given intensified treatment of pain and symptoms, where the treatment was given with the intention of hastening death, it had not been discussed with them and was therefore not requested (Jochemsen and Keown, 1999).

Be satisfied that the patient's request is voluntary and free of coercion Be satisfied that the patient's request is well-considered

An American anthropologist who studied euthanasia in the Netherlands painted a glowing picture of the time taken and devotion shown by Dutch physicians when it comes to euthanasia: 'Euthanasia in the Netherlands involves discussions taking place over weeks, months, and sometimes years and does not largely focus on the final day itself.' (Norwood, 2018)

But a Dutch report stated: 'The period of time between the first discussion of the subject and the actual administration varied from less than a day to...' i.e. some people had euthanasia on the same day it was first spoken about (Muller et al, 1994).

Be satisfied that the patient is suffering unbearably Be satisfied that there were no reasonable (therapeutic) alternatives

Therapeutic alternatives were available in 17-35% of cases (van der Maas et al, 1991; van der Maas et al, 1996; Jochemsen and Keown, 1999; Hendin, 2002; Jansen-van der Weide et al, 2006; Buiting et al, 2009).

The Euthanasia Review Committees were interested in the presence or absence of therapeutic alternative in only 1% of cases (Buiting et al, 2009).

Of 450 patients referred to Hospice Rozenheuvel, 126 (28%) made an explicit request for euthanasia, but in the end only two patients were transferred to hospital to have euthanasia performed (Zylicz and Janssens, 1998).

The discussion of 'no realistic prospect of improvement' must depend greatly on the knowledge and expertise of the physician in question.

Have consulted an independent physician, who must see the patient and provide a written opinion

Consultation took place in only around half of all cases (Jochemsen and Keown, 1999; Hendin, 2002).

For euthanasia in nursing homes, 15% of physicians did not seek a second opinion (Muller et al, 1994).

Consultation occurred in 80% of reported cases, but in only 11% of unreported cases and 3% of cases involving termination of life without explicit request (Hendin, 2002).

Consulting physicians were not independent in 60% of cases (Buiting et al, 2009).

Consultation occurred in 85% of cases of euthanasia for patients with mental handicap, but it was often by another physician from the same nursing home (Muller et al, 1994).

In another study of end-of-life decisions for mentally handicapped patients, only 46% of physicians sought a second opinion (van Thiel et al, 1997).

Independence was compromised by repeated cross-referral between the same pairs of physicians, for convenience (Hendin, 1999; Onwuteaka-Philipsen et al, 1999).

In one study, consultants did not see the patient in 12% of cases (Hendin, 1999).

A special service-Support and Consultation on Euthanasia in the Netherlands (SCEN)-provides consultants who are independent in 85% of cases in which they are involved (Jansen-van der Weide et al, 2004 & 2007).

Provide a report to the appropriate authority.

Reporting of euthanasia and physician-assisted suicide has improved from 18% in 1990 to 81% in 2015 (van der Wal et al, 1996; Rurup et al, 2008; Onwuteaka-Philipsen, 2018).
But these reporting figures do not include the patients whose life was terminated without explicit request or those receiving intensified treatment of pain and symptoms, or withholding/withdrawal of therapy, or continuous deep sedation, performed with the specific intention of hastening death (Jochemsen and Keown, 1999; Hendin, 2002).

In cases where life was terminated without explicit request 2 out of 1000 cases were reported in 1990 and 3 out of 900 in 1995, i.e. 0.26% (Lewy, 2011).

Euthanasia is performed only by medical doctors
In summary, the Dutch themselves have documented that they have broken every one of their own guidelines.

5. ARE THE SYSTEMS OF REGULATION AND SAFEGUARDS EFFECTIVE?
Support and Consultation on Euthanasia in the Netherlands (SCEN) Euthanasia Review Committees
Henk ten Have (Professor of Medical Ethics at the University Medical Centre of Njmegen) and Jos Welie (Professor of Health Policy and Ethics, Creighton University, Omaha): 'The important lesson to be learned from the Dutch experiment is the virtual impossibility of regulating the practice of euthanasia and PAS through public debate, laws and policies.' (Ten Have and Welie, 2005)

Neil M Gorsuch (Associate Justice of the Supreme Court of the United States and author of The Future of Assisted Suicide): Does a regime dependent on self-reporting by physicians who have no interest in recording any case falling outside the guidelines adequately protect against lives taken erroneously, mistakenly, or as a result of abuse or coercion? How would we ever know? (Gorsuch, 2006)

6. IS THERE EVIDENCE OF A SLIPPERY SLOPE?

The 'slippery slope' is the gradual extension of assisted suicide to widening groups of patients after it is legally permitted for patients designated as terminally ill (Hendin et al, 1997a).

Paul van der Maas (Department of Public Health, Erasmus University, Rotterdam): '...whether the acceptance of euthanasia or assisted suicide when it is specifically requested by a greatly suffering, terminally ill, competent patient is the first step on a slippery slope that will lead to an unintended and undesirable increase in the number of cases of less careful end-of-life decision making and to the gradual social acceptance of euthanasia performed for morally unacceptable reasons.' (van der Maas et al, 1996).

The data for the period 1990 to 2015 show

Voluntary euthanasia for terminal disease has progressed to non-voluntary and involuntary euthanasia ('life termination without explicit request').

Euthanasia numbers (deaths per year) continue to increase.

The proportion of the requests for euthanasia that are being granted has increased from 26% in 1990 to 55% in 2015 (van der Maas et al, 1991; Onwuteaka-Philipsen, 2018).

Expansion of eligibility

When voluntary euthanasia for terminal illness was allowed, Dutch doctors performed euthanasia on patients with non-terminal illnesses including psychiatric disorders and mental handicap (Groenewoud et al, 1997; van Thiel et al, 1997).

It is now no longer necessary for the patient to have terminal or incurable illness. Euthanasia is available to anyone with suffering, no matter what their life expectancy may be.

Suffering includes psychosocial suffering, including 'being tired of life' and 'loss of dignity'.

Euthanasia for psychiatric disorders and dementia are now accepted.

Euthanasia is available for 12-year-olds.

Euthanasia is permitted on the basis of advance directives for patients who lack decisional capacity.

Now that it is legal for physicians to perform euthanasia, it is reported that nurses are doing it as well (Volker, 2015).

The assertion that vulnerable groups are not adversely affected by assisted dying (Battin et al, 2007) has been challenged (Finlay and George, 2011).

There are assertions that terminal sedation is being used instead of euthanasia because it does not require a second opinion, it does not have to be reported, and it carries no risk of prosecution (Rietjens et al, 2004; Griffiths et al, 2008; Sterckx et al, 2016).

The Dutch view
One of the better descriptions of the 'slippery slope', written in 2017, went as follows: 'The core of this argument is that as soon as euthanasia is allowed at all, even if only under certain conditions, it will necessarily follow that euthanasia will in future be performed under less stringent conditions and will eventually degenerate into an absolutely abject form of euthanasia, such as killing people involuntarily.'
The alternative view
It is not possible to list all the publications attesting to the existence of a slippery slope, but I include several good reviews that I have seen (Hendin, 1997a; Jochemsen and Keown, 1999; Hendin, 2002; Keown, 2002; Ten Have and Welie, 2005; Randall and Downie, 2009; Keown, 2012 & 2013; Sprung et al, 2018; Keown, 2018).

Henk Jochemsen (Director, Lindeboom Institute for Medical Ethics, the Netherlands): 'The Dutch experience shows that once the termination of patients' lives is practised and that practice wins official toleration or approval, the practice develops a dynamic of its own that resists effective control.' (Jochemsen, 1994)

Richard Fenigsen (Dutch cardiologist): 'Dutch doctors who practice euthanasia are not on the slippery slope. From the very beginning, they have been at the bottom.' (Fenigsen, 1997)

Karl Gunning (Director of the (anti-euthanasia) Dutch Physicians Union): 'Once you start looking at killing as a means to solve problems, you'll find more and more problems where killing may be the solution.' (Koch, 1996)

Tom Koch (University of British Columbia, Vancouver, Canada): 'Limited and closely regulated euthanasia for persons with a terminal illness [c. 1990] has been an expanding field that now [c.1995] includes patients with chronic conditions-for example ALS, Down's syndrome, clinical depression, and anorexia nervosa-and those in the earlier or chronic phase of illnesses that may eventually prove terminal: Alzheimer disease, Parkinson's disease, multiple sclerosis and AIDS.' (Koch, 1996)

José Pereira (Head of the Division of Palliative Care, University of Ottawa): 'In 30 years, the Netherlands has moved from euthanasia of people who are terminally ill, to euthanasia for those who are chronically Ill; from euthanasia for physical illness, to euthanasia for mental illness; from euthanasia for mental illness, to euthanasia for psychological distress or mental suffering-and now to euthanasia simply if a person is over the age of 70 and 'tired of living'.' (Pereira, 2011)

Margaret Somerville (Professor of Bioethics at University of Notre Dame in Australia) describes two types of slope: the "practical slippery slope"-which involves abuses of euthanasia once it is seen as legally acceptable, and the "logical slippery slope"-on which the people eligible for euthanasia and the circumstances in which it may be provided inevitably expand (Somerville, 2016).

Robert Twycross (Emeritus Reader, Oxford University): 'Once the barrier of legislation is passed, medically assisted dying takes on a dynamic of its own and extends beyond the original intent, despite earlier explicit assurances that this would not happen.' (Twycross, 2016)

7. DOES IT REDUCE THE (NON-ASSISTED) SUICIDE RATE?

8. OTHER ISSUES/CONCERNS

(i). 'Normalization' of euthanasia

(ii). End of life Clinic

(iii). Management of patients with psychiatric disorders or dementia

(iv). HIV

(v). Children

(vi). Amyotrophic lateral sclerosis (ALS)

(vii). Lack of physical disease

(viii). Euthanasia using opioids

(ix). Amount of life lost

(x). Contradiction of autonomy

(xi). Voluntary refusal of food and fluids

(xii). Arrogance

(xiii). Existential suffering for patients en route to assisted dying

(i). 'Normalization' of euthanasia

Insufficiently precise or strict were inevitably stretched, and there has been unrelenting progression towards euthanasia being 'normalized'-euthanasia has become just another option, perhaps even the default one, and has progressed from an exceptional act to a legal right (Keown, 2018).

'In the Netherlands, there has been a shift from PAD [physician-assisted dying] as a last resort to PAD as a default way to die...PAD is increasingly becoming a patient's right, a default way to die, and a default way to deal with life's difficulties.' (Boer, 2016)

(ii) End of Life Clinic (iii). Management of patients with psychiatric disorders or dementia Psychiatric examination of those requesting assisted dying Assisted dying for people with psychiatric disorders

In 1994, the Dutch Supreme Court ruled that euthanasia or assisted suicide were justifiable for a patient with severe psychic suffering due to a depressive illness and in the absence of a physical disorder or a terminal condition (Ogilvie and Potts, 1994).

64% Dutch psychiatrists were supportive of assisted dying for patients with a mental disorder in the absence of physical illness (Groenewoud et al, 1997).

Patients having euthanasia for psychiatric disorders were predominantly women, 55% were depressed; other conditions included eating disorders, prolonged grief, and autism (Kim et al, 2016).

The number of patients with chronic psychiatric conditions undergoing euthanasia increased sharply from 2009 to 2016 (Cook, 2017).

The End of Life Clinic, where there is no therapeutic relationship between doctor and patient, was responsible for 75% of the chronic psychiatric patients who underwent euthanasia in 2016 (Cook, 2017).

The Review Committees have now admitted that that incapacitated people are being surreptitiously killed (Chabot, 2017).

Others express a different view:

In a report on six patients with an intellectual disability and/or autism spectrum disorder, tests of decisional capacity did not seem stringent enough (Tuffrey-Wijne et al, 2018).

Dr Boudewijn Chabot (psychiatrist and father figure of Dutch euthanasia): 'The euthanasia practice is running amok because the legal requirements which doctors can reasonably apply in the context of physically ill people, are being declared equally applicable without limitation in the context of vulnerable patients with incurable brain diseases. In psychiatry, an essential limitation disappeared when the existence of a treatment relationship was no longer required. In the case of dementia, such a restriction disappeared by making the written advance request equivalent to an actual oral request. And lastly, it really went off the tracks when the review committee concealed that incapacitated people were surreptitiously killed.' (Cook, 2017)
Dementia

There are increasing numbers of patients with dementia who are requesting euthanasia, but management remains controversial (Rurup et al, 2005c; de Beaufort and van de Vathorst, 2016).

There has been a rapid increase in the numbers of patients with dementia undergoing euthanasia, from 12 in 2009 to 141 in 2016 (Cook, 2017).

Victor Lamme (Professor of Cognitive Neuroscience at the University of Amsterdam): Referring to the treatment of the demented Hannie Goudriaan by the End of Life Clinic -'the euthanasia doctor found in her pronunciation of the word 'huppakee' [hoppity] sufficient evidence for a clear and present desire to die.' (Lamme, 2016)

Dr Boudewijn Chabot (psychiatrist and father figure of Dutch euthanasia): 'In 2016, there were three reports of euthanasia of deep-demented persons who could not confirm their death wish. One of the three was identified as having been done without due care; her advance request could be interpreted in different ways. The execution was also done without due care; the doctor had first put a sedative in her coffee. When the patient was lying drowsily on her bed and was about to be given a high dose, she got up with fear in her eyes and had to be held down by family members. The doctor stated that she had continued the procedure very consciously.' (Chabot, 2017)
(iv). HIV (v). Children (vi). Amyotrophic lateral sclerosis (ALS) (vii). Lack of physical disease (viii). Euthanasia using opioids

Dutch euthanasia deaths caused by opioids are not being reported and the numbers are unknown (Rurup et al, 2008 & 2009; Onwuteaka-Philipsen, 2012a).

Some physicians believe deliberate ending of life with opioids falls within 'normal medical practice' and doesn't constitute euthanasia.

Others believe that opioids don't hasten death.
This is based on the reports that careful use of opioids in terminal care was not associated with shortening of life (Thorns and Sykes, 2000; Sykes and Thorns, 2003), but ignores the well-known fact that opioids used in higher doses are very effective at causing death.

The use of opioids in standard euthanasia fell from 39% in 1995 to 16% in 2005, although an opioid remained the drug of choice for ending life without explicit request (Rurup et al, 2009).

(ix). Amount of life lost

Many Dutch publications include earnest arguments about how little loss of life is associated with euthanasia and other life-ending procedures. This is meaningless nonsense as our ability to accurately predict the life expectancy of an individual patient, except in the last few days of life, is quite inexact (Glare et al, 2003; Randall and Downie, 2009).

Common sense suggests you would tend to underestimate the amount of life lost for the person whose life you had just terminated.

Two methods of estimating life lost with continuous sedation gave discordant results (Bruinsma et al, 2014).

In most Dutch reports, there is insufficient clinical information for one to judge the estimations of life lost. However, in the report of euthanasia for homosexual men with AIDS (Bindels et al, 1996), it is stated 'in the judgement of the physicians, most of these patients would have died naturally within one month...no person would have lived more than an additional three months.'
But five of the patients underwent euthanasia at the time of the initial AIDS-defining illness when, according to the current evidence at that time, the average life expectancy was two to three years (Marriott and McMurchie, 1996).

(x). Contradiction of autonomy

Advocates of assisted dying hold patient autonomy to be sacred.

But it is the doctor, not the patient, who decides whether or not the patient will have assisted dying.

It is the doctor, not the patient, who decides whether the patient will have PAS or euthanasia by injection.

'Patients' perception of total control over this type of death [euthanasia and physician-assisted suicide] is illusory.' (George et al, 2005)

(xi). Voluntary refusal of food and fluids (VRFF)

This topic is not discussed at length in the Dutch literature.

One published study showed it was well tolerated, even in the elderly; thirst was not a problem provided the mucus membranes of the mouth were lubricated (Chabot, 2012).

(xii). Arrogance (xiii). Existential suffering for patients en route to euthanasia

Little attention is paid to what may be considerable existential suffering of elderly patients between choosing to have euthanasia and having it done (van Wijngaarden et al, 2016).

9. SOME FINAL WORDS

Johannes van Delden (Professor of Medical Ethics, University Medical Center, Utrecht): It is difficult to relate the numbers and the increases over time with the statement 'The Dutch medical profession itself believes that euthanasia must always remain an exception. Euthanasia...must always be the last resort.' (van Delden et al, 2004)

Richard Fenigsen (Dutch cardiologist): '"Voluntary" euthanasia also brings an ominous change in society because of the message it sends to the elderly and sick, the weak and the dependent.' (Fenigsen, 1989)

Theo Boer (Professor of Health Care Ethics at Kampen Theological University in the Netherlands, who was previously pro-euthanasia and served on a Regional Euthanasia Review Committee from 2005 to 2014): 'I have become painfully aware [of] the possibility [that] euthanasia and assisted suicide increasingly contributes to a culture of death. I am deeply convinced that this leaning towards death increasingly influences severely impaired, deeply suffering, and elderly people to consider active killing as their only way out.' (Boer, 2014)

Els Borst (the doctor/Health Minister who guided the euthanasia legislation through the Dutch parliament). She admitted in 2009 that the government did not give enough attention to palliative care and support for the dying, that the legalization of euthanasia came 'far too early', and that there had been a decline in the quality of care for the terminally ill since then (Craine, 2009; Keown, 2012).

Gerrit Kimsma (Associate Professor of Medical Philosophy, Free University Center for Ethics and Philosophy, Amsterdam): 'Some physicians practice assisted dying without the emotional and moral sensitivity that we have argued is necessary to restrain the practice.' (Kisma and Clark, 2012a)

Margo Trappenburg (Associate Professor of Governance at Utrecht University, and someone who has been very involved in the development of Holland's euthanasia policies): 'Perhaps we should be allowed to be smug about our euthanasia policy, as something we managed to accomplish, something we really did right.' (Trappenburg, 2012)

Boudewijn Chabot (psychiatrist and father figure of Dutch euthanasia): 'I don't see how we can get the genie back in the bottle. It would already mean a lot if we'd acknowledge he's out.' (Cook, 2017)

B. THE NORTHERN TERRITORY (AUSTRALIA)

1. BACKGROUND

The Rights of the Terminally Ill (ROTI) Act was passed by the parliament of Australia's Northern Territory in May 1995. This was the first time, anywhere in the world, that euthanasia and physician-assisted suicide were made legal (Ryan and Kaye, 1996a).

The Act came into effect in July 1996 and was repealed in March 1997 by the federal Australian Government.

2. GUIDELINES

The ROTI Act was for patients who were terminally ill, required consultation with specialists in both psychiatry and palliative care, and involved a 2-week waiting period.

3. NUMBERS

During the 9 months of operation, seven patients sought euthanasia under the Act. Two died before it was enacted and one after it was repealed. Four patients died from euthanasia. They all had cancer. Pain was not a prominent symptom and fatigue, frailty, depression and social isolation contributed more to the suffering of the patients (Kissane et al, 1998).

4. OTHER ISSUES/CONCERNS

(i). Depression

(ii). Influence of the media

(i). Depression (ii). The influence of media

The ROTI legislation provoked much discussion in the Australian media.

Fran McInerney (Professor of Aged Care, Australian Catholic University, studied the representations of death, dying and medicine during the period 1995-1997): 'The media's predilection for reporting dramatic and unusual death coincided with the [requested death] movement's construction of contemporary dying as horrific, intractable, and intolerable...The framing of requested death activists as heroes, and of requested death itself as a redeeming and transforming act for those seeking it, were preeminent in press portrayals.' (McInerney, 2006)

C. OREGON (USA)

1. BACKGROUND

The Oregon Death with Dignity Act (DWDA), legalizing physician-assisted suicide (PAS), was passed by a voter referendum in November 1994.

A 1995 survey of Oregon physicians showed that 60% favored legalization of PAS, but less than half (46%) said they might possibly participate (Lee et al, 1996).

Over 50% of Oregon physicians were not confident they could predict a prognosis of 6 months or less (Lee et al, 1996).

There were concerns about the possible complications of the procedure.

A national survey reported 3% of physicians had participated in PAS (Meier et al, 1998).

A legal dissection of the Oregon and Washington State Acts concluded '[The Acts] are not about patient "choice" and "control." These laws instead enable people to pressure others to an early death or to even cause that death on an involuntary basis.' (Dore, 2010)

2. GUIDELINES

The DWDA (see Oregon Death With Dignity Act) provides for a person who

Is 18 years of age or older;

Is competent;
If there is concern that depression may be interfering with decisional competence, they must be referred to a mental health specialist;

Is a resident of Oregon;

Is suffering from a terminal disease with a life expectancy of 6 months or less;

Has voluntarily expressed his or her wish to die, and

Has made a written request, witnessed by two others.

The DWDA requires

One written request, witnessed by two others.

A minimum waiting period of 15 days from first request to procedure.

The lethal medication must be self-administered by the patient.

The certified cause of death is the underlying disease, and assistance in dying is not included on the Death Certificate.

3. NUMBERS

A summary of the data for 2017 and for the first 20 years are available at the Oregon Health Authority website (see Oregon Death with Dignity Act).

Progress reports have appeared in the medical literature (Chin et al, 1999; Sullivan et al, 2000 & 2001; Hedberg et al, 2002 & 2003; Blanke et al, 2017).

In 2017 1997-2017

1,967 patients have received lethal prescriptions.

1,275 have died from ingesting the medication.

The number of DWDA deaths has increased each year (1998: 16; 2017: 143) and the rate of change has increased significantly in the last five years (Table 3) (see Oregon Death with Dignity Act).

Only 4.9% were referred for psychological or psychiatric evaluation.

72% of patients were 65 years or older.

Underlying disease: cancer (78%), neurological disease including ALS (11%), respiratory disease (5%), and cardiovascular disease (4%).

Table 3. Number of PAS deaths in Oregon, 1998-2017 Drugs used
4. DO THEY MEET THEIR OWN GUIDELINES?
That it was requested

In contrast to Holland and Belgium, no attempt has been made to assess whether any patients had suffered 'life termination without request'. Officially, what is not reported to the Oregon Health Authority does not exist.
That the request was voluntary, without coercion That the patient requesting was competent That the patient had a terminal illness

The DWDA's definition of terminal illness can include chronic, treatable conditions like insulin-dependent diabetes, which if not treated may lead to the death of the patient (see Living and Dying Well).

It is noted that lethal prescriptions have been issued for reasons of caregiver burden and so as not to disappoint the family (Foley and Hendin, 2002; Keown, 2013).

That the patient had a prognosis of 6 months or less

Estimating prognoses of 6 months or less is difficult, more so in patients with non-malignant disease (Glare et al, 2003; Randall and Downie, 2009).

Lynn has pointed out the ambiguity of the 6-month rule-it could mean that a person is nearly certain to die within 6 months, is very likely to die, or that 51 percent of people with a similar condition will be dead within 6 months (Lynn, 2018).

That there was discussion of alternatives, including palliative care The consulting physician

There is no information regarding the independence of the second or consulting physician, or their attitude to assisted dying. Are they known advocates for assisted dying, recommended by Compassion and Choices, who provide pro forma/rubber stamp second opinions?
The self-administration of medication
5. ARE THE SYSTEMS OF REGULATION AND SAFEGUARDS EFFECTIVE?

The role of the Oregon Health Authority (OHA) is simply the passive recording of information, without any active surveillance or investigation (see Oregon Health Authority).

All reporting of cases is by the physician who prescribed the lethal medication, who has every incentive to report that all is well.

The monitoring process in Oregon has been described as a case of 'Don't Ask, Don't Tell', designed to cover up rather than reveal problems, and yielding only limited data which does not reveal what happened in any particular case (Foley and Hendin, 1999).

The OHA has only very limited data and what it has is largely kept secret, which has been referred to as a 'veil of confidentiality' and a 'culture of silence' (Foley and Hendin, 2002; Hamilton, 2002; Keown, 2013).

The prohibition of any reference to assisted dying on Death Certificates makes any meaningful review impossible.

There is no information to document that the patients met the guidelines as set out above, including having decisional competence and an illness that is terminal.

The OHA has no jurisdiction to investigate any reported case of PAS or any case of alleged abuse reported in the media. 'We are not given the resources to investigate [assisted suicide cases] and...we do not have any legal authority to insert ourselves.'
This includes cases in which it is alleged nurses performed assisted dying but were not prosecuted.

A review of the DWDA by a group representing people with disabilities commented on inadequate demographic profiling of DWD requesting patients, inadequate mental health evaluations, insufficient duration of physician-patient relationships, potential inaccuracy of the six-month prognosis, and inadequate exploration of alternative treatment. It concluded that the DWDA lacked sufficient safeguards (Drum et al, 2010).

In summary, one has to agree with the accusation that the Oregon law provides inadequate safeguards and lacks any enforcement of safeguards (Ganzini, 2016).

6. IS THERE EVIDENCE OF A SLIPPERY SLOPE?

7. DOES IT REDUCE THE (NON-ASSISTED) SUICIDE RATE?

8. OTHER ISSUES/CONCERNS

(i). Depression

(ii). Lack of physical suffering

(iii). ALS

(iv). Vulnerable groups

(v). Complications of the procedure

(vi). Relatives' mental health

(vii). Interface between PAS and palliative care

(viii). Duration of physician/patient relationship

(ix). Compassion and Choices disgraces

(x). Oregon Health Plan Bastardry

(xi).Voluntary refusal of food and fluids (VRFF)

(i). Depression
The DWDA does not exclude patients with depression, just those in whom depression is impairing their judgement around desire for death (Ganzini, 2014).
Incidence Diagnosis Relevance

Ganzini argues that there is no reason to stop patients with depression (except those with impaired competence) from accessing PAS (Ganzini, 2014), despite evidence from her own studies show that the treatment of depression may reduce the wish to die (Ganzini et al, 1994, 2000b & 2008).
Depression causing impaired competence

Ganzini regarded these attitudes as unacceptable as they were contrary to the patients' rights to autonomy. She attributed them to the ethical views and morals of the psychiatrists concerned, rather than their psychiatric skills (Ganzini et al, 2000a).
Summing up (ii). Lack of Physical Suffering
Daniel Sulmasy (Medical Ethicist, Kennedy Institute of Ethics and the Edmund D. Pellegrino Center for Clinical Bioethics, Georgetown University): 'Rather than having severe physical or mental suffering, patients who follow through on PAS in the USA appear to have a distinct personality type, characterized by a need for control and a dismissive attitude towards other persons. They represent only about 0.5% of the US population, and the question arises whether the risks to the other 99.5% of the population justify acceding to the wishes of this small minority.' (Sulmasy, 2017)
(iii). Amyotrophic Lateral Sclerosis (ALS) (iv). Vulnerable Groups (v). Complications of the Procedure

For the approximately 600 patients for whom information is available, the time to unconsciousness after taking the medication was 1-240 minutes, but the time to death varied from I minute to 104 hours (see Oregon Death With Dignity; Ganzini and Hedberg, 2018).

It should be noted that in 60% of the cases, where a health care provider was not present, there is no information about complications (see Patients Rights Council).

The cost of the medications has increased to around $4,000-5,000.

(vi). Relatives' Mental Health

A report on relatives of patients requesting PAS, 14 months after the suicide, reported 11% major depression, 2% prolonged grief reaction and 38% had required mental health care. It was claimed that PAS had no negative effect on the mental health of family members (Ganzini et al, 2009a).
(vii). Interface between PAS and Palliative Care (viii). Duration of the physician/patient relationship

There is concern about the prescribing physicians not knowing the patient well enough or for long enough (Ganzini et al, 2000b).
The prescribing physicians had known the patient for a median duration of 13 weeks (range 0-2138) before the patient's suicide (see Oregon Death With Dignity).

(ix). Compassion and Choices Duplicity

Kim Callinan, CEO of Compassion and Choices, presents the organization as supportive of research (Callinan and Silva, 2018).
But when approached by Ganzini to participate in a study of whether receiving a prescription resulted in reduction of anxiety and increased sense of peace (which I thought was a worthy question), Compassion and Choices refused (Ganzini, 2014).

(x). Oregon Health Plan Bastardry

The are multiple reports of patients with a terminal illness receiving letters from the Oregon Heath Plan, refusing cover for the costs of treatment of their underlying disease, but informing them they would be covered for doctor-prescribed suicide (Dore, 2010; Keown, 2012; see Patients Rights Council).
(xi). Voluntary refusal of food and fluids (VRFF)

A study of VRFF reported a very good median quality of death of 8 (on a scale of 0-9) (Ganzini et al, 2003b).

9. SOME FINAL WORDS

Dan Diaz (member of the Latino Leadership Council of Compassion and Choices) is quoted as saying that all PAD [physician-assisted dying] deaths are 'gentle, peaceful', whilst all non-PAD deaths are 'struggling and in pain' (Diaz, 2018).

Compassion & Choices Medical Aid in Dying Fact Sheet (December 2016):

'Medical aid in dying is a safe and trusted medical practice because the eligibility requirements ensure that only mentally capable, terminally ill adults with a prognosis of six months or less who want the choice of a peaceful death are able to request and obtain aid-in-dying medication...Almost two decades of rigorously observed and documented experience in Oregon shows us the law has worked as intended, with none of the problems opponents had predicted.' (see Compassion and Choices)

Daniel Callahan (co-founder and President Emeritus of The Hastings Center): He described the safeguards in Oregon as 'regulatory obfuscation. They look good, sound good, feel good, but have nothing behind them.' (Callahan, 2008)

John Keown (Professor in the Kennedy Institute of Ethics at Georgetown University): 'The next steps in Oregon...seem predictable. If autonomy and beneficence justify 'terminally ill ' patients obtaining prescriptions for lethal drugs then they justify non-terminally ill patients obtaining them, not least as they may have many years and not just a predicted six months of illness to endure. It is only a matter of time until the requirement of a ' terminal illness ' is removed by legislation or struck down by a court as unjustifiably discriminatory...Moreover, if autonomy and beneficence justify lethal prescriptions they also justify lethal injections, especially for those too disabled to lift or swallow a lethal cocktail. It is, again, only a matter of time before a right to a lethal injection is upheld, either by legislation or by a court holding that their prohibition discriminates against the disabled...' (Keown, 2018)

D. BELGIUM

1. BACKGROUND

Life End Information Foundation ( LEIF)

Following legalization, the Life End Information Foundation (LEIF) was formed to provide specifically trained physicians to act as consultants with euthanasia requests (Cohen et al, 2014).
Federal Control and Evaluation Commission on Euthanasia (FCECE)

All reported cases of euthanasia are reviewed by the Commission.

2. THE GUIDELINES

I was unable to find any governmental document listing the legal requirements in English. The following is largely taken from Griffiths (Griffiths et al, 2008).
If the patient expected to die in near future

The patient must be 18 years or older;

The patient must be legally competent and conscious at the time of request;

The request must be voluntary, well considered, repeated, and not the result of external pressure;

The patient must have persistent and unbearable physical or mental suffering that cannot be alleviated, resulting from a serious and incurable disorder caused by illness or accident;

The physician must discuss the condition and life expectancy, including the possibilities of other treatments and palliative care, and must have several conversations with the patient over a reasonable period of time;

The physician must obtain the opinion of another independent physician, who is qualified to give an opinion about the disorder in question, who must see the patient and provide a written report.
It should be noted that there is no legal requirement for the two doctors to agree (Nys, 2017).

If the patient is not expected to die in the near future
In addition to the requirements listed above-

The physician must obtain the opinion of a second, independent physician, who is a psychiatrist or a specialist in the disorder in question, who must see the patient and provide a written report;

Allow at least one month after receipt of the request.

The request

The request must be in writing
If the patient is not able, it must be written by a person designated by the patient, who must be 18 years or older and have no material interests in the death;

Advance Directives can be used in lieu of requests, provided:

Reporting

Physicians performing euthanasia must notify the Federal Control and Evaluation Commission on Euthanasia.

The 2014 law allowing euthanasia for children (Raus, 2016)

3. NUMBERS
Euthanasia Table 4. Frequency of reported cases of euthanasia - whole of Belgium From Dierickx et al, 2016 Table 5. Frequency of physician assistance in dying - Flanders From Bilsen et al, 2009 and Chambaere et al 2015 Physician-assisted suicide (PAS) Ending of life without the patient's explicit request

As in Holland, euthanasia is defined as being requested, so cases of life termination without explicit request have to be counted separately.

Life termination without explicit request comprised 1.7% of all deaths in Flanders in 2013, amounting to more than 1,000 deaths (Table 5) (Bilsen et al, 2009; Chambaere et al, 2015b).
This rate of life termination without explicit request in Flanders is more than double the rate in the Netherlands (Chambaere et al, 2015b).

There are currently calls to legalize life-ending without request (Jones, 2017).

Intensified treatment of pain and symptoms Withholding or withdrawing therapy

Withholding or withdrawing therapy may be entirely clinically appropriate, with the possibility of life-shortening being acknowledged, but not intended.

In contrast, withholding or withdrawing therapy performed with the intention of ending life, is no different to euthanasia-these are deaths caused by the active intervention of the physician.

In Flanders, withholding or withdrawing of therapy was involved in 14.6% of all deaths in 2001, 17.4% in 2007, and 17.2% in 2013 (Table 5) (Bilsen et al, 2009; Chambaere et al, 2015b).
A single study reports that withholding or withdrawing of treatment was performed with the explicit of hastening the end of the patient's life in 38% of cases (Bosshard et al, 2006).

Continuous sedation until death (CSD)

CSD for severe and refractory symptoms in the last days or week of life may be entirely clinically appropriate therapy, with the possibility of life-shortening being acknowledged, but not intended.

There are many inconsistencies between different studies as to exactly what constitutes CSD (Claessens et al, 2008; Taboda, 2015; Stierckx et al, 2016).

CSD performed with the intention of hastening death or ending life is no different to euthanasia-these are deaths caused by the active intervention of the physician.

In Flanders, CSD was involved in 8.2% of all deaths in 2001, 14.5% in 2007, and 12.0% in 2013 (Table 5) (Chambaere et al, 2015b; Robijn et al, 2016).

4. DO THEY MEET THEIR OWN GUIDELINES?
That the procedure is requested

As in Holland, the definition of euthanasia is that it is requested.

Life termination without explicit request accounted for 1.5-1.8% of all deaths in Flanders, equivalent to between 840 and 1050 deaths per year (Meeussen et al, 2010; Chambaere et al, 2010 & 2015b).
A 2007 study reported life termination without explicit request was not discussed with the patient in 78% of cases (Chambaere et al, 2010).

Intensified treatment of pain and symptoms is sometimes employeded with the specific intention of hastening death, and may not be discussed with the patient; no discussion implies no request (Bilsen et al, 2004a).

Withholding or withdrawing of therapy is sometimes performed with the specific intention of hastening death, and may not be discussed with the patient; no discussion implies no request (Bilsen et al, 2004a; Bosshard et al, 2006).

CSD was not discussed with some patients who were competent; no discussion implies no request (Anquinet et al, 2011).

That the request is in writing

Requests were not in writing for 50% of reported cases in 2007 and 31% of cases in 2013 (Chambaere et al, 2015b).

In the unreported cases, 88% lacked a written request (Smets et al, 2010).

That the person is competent and conscious

There is no requirement for psychiatric or psychological examination.

Few doctors, other than psychiatrists, are familiar with formal assessment of decision-making capacity (Fairman and Irwin, 2016).

That the patient has a serious and incurable disorder causing persistent and unbearable suffering

The euthanasia law requires 'persistent and unbearable physical or mental suffering that cannot be alleviated, resulting from a serious and incurable disorder caused by illness or accident.'

The underling causes of the unbearable suffering leading to euthanasia in 2014-2015, and accepted by the Commission (see Institut), were

cancer (68%)

'polypathology' (10%) - explained as 'the coexistence of several serious and incurable disorders linked to different dysfunctions that are sometimes associated with old age, and therefore not necessarily fatal'. Examples cited in the Commission's report include

disorders of gait and mobility due to osteoporosis;

limitation of movement resulting in a loss of autonomy;

eye disorders, resulting in inability to read a newspaper or watch TV, causing social isolation;

hearing impairment, preventing social contact;

cardiac disease reducing the patient's real living space, leading to loneliness;

the onset of dementia.

neurological disease (7%)

cardiovascular disease (5%)

mental and behavioral disorders (3%) - including dementia

The 2015 report admits the law is being interpreted in a liberal or flexible manner to include 'polypathologies' and behavioral disorders.

There is discussion of treatment possibilities, including palliative care

Few physicians have expertise in palliative care, severely limiting the palliative alternatives they might offer.
There is an independent second opinion Provide a report to the appropriate authority.

A 2007 national study reported 47% of cases of euthanasia were not reported (Smets et al, 2010).

A 2009 study reported that 27% of cases of euthanasia in Flanders and 42% in Wallonia were not reported (Cohen et al, 2012).

The euthanasia is performed only by medical doctors
In summary, the Belgians themselves have documented that they have broken every one of their own guidelines (Jones et al, 2017; Keown, 2018).

5. ARE THE SYSTEMS OF REGULATION AND SAFEGUARDS EFFECTIVE?

Life End Information Foundation ( LEIF)

LEIF consultants were employed in one-third of cases in which a second opinion was sought (Cohen et al, 2014).

LEIF consultants were more likely to be genuinely independent, but provided no other advantages (Cohen et al, 2014).

The Federal Control and Evaluation Commission on Euthanasia (FCECE)

All cases of euthanasia are to be reported to the Commission.

Regulation depends on self-reporting, and a significant proportion of cases are not reported (Montero, 2017; Keown, 2018).

Reporting of euthanasia in Belgium is anonymous and the lack of transparency has been acknowledged (Smets et al, 2009).

It is reported that the Commission has less than one hour to review all aspects of each case.

The Commission found fault with 24.7% of the reports submitted, but accepted the reports if they felt there was compliance with the essential requirements of the law; they have been accused of interpreting the law in a liberal or flexible way.

There has been only one referral to the public prosecutor during the period 2002-2015.

The Belgian system stands accused of being ineffective (Jones et al, 2017; Keown, 2018).

The Commission has been accused of illegitimately reinterpreting the law (Keown, 2018).

Pro-euthanasia neurologist, Dr Ludo Vanopdenbosch, resigned from the 16-member Federal Commission in September 2017, accusing the Commission of failing to refer a case to the public prosecutor concerning a man who had euthanasia at his family's request. He also asserted that any critical debate within the Commission was muzzled, and that many of the doctors on the Commission were leading euthanasia practitioners, who supported each other to defend euthanasia at all costs. Tlie accusations were strongly denied by the co-chair of the Commission, Dr Wim Distelmans.

Dr Distelmans, Google informs me, operates a euthanasia clinic in Belgium and is known for his involvement in controversial euthanasia deaths including: depressed women, twins who feared becoming blind, a woman with anorexia nervosa who was suffering psychologically after being sexually exploited, and Nathan Verhelst who died by euthanasia after a botched sex-change operation. He also conducts study tours to the Nazi death camp, Auschwitz, which he describes as 'inspiring'.

6. IS THERE EVIDENCE OF A SLIPPERY SLOPE?

There are increasing numbers of euthanasia cases over time.

There are increasing numbers of life terminations without request over time.

An increasing proportion of requests are being granted: 56% in 2007, 77% in 2013 (Chambaere et al, 2015b).

There is generous interpretation of the meaning of unbearable suffering to include 'polypathologies' and behavioral disorders.

There are increasing numbers of non-terminally ill and older patients (Dierickx et al, 2016).

There are increasing numbers of patients with a psychiatric disorder or dementia: 0.5% in 2002, 3.0% in 2013 (Dierickx et al, 2017).

There is now euthanasia for children.

The Belgians proudly declare there is no evidence of any slippery slope (Bernheim and Raus, 2017).

Etienne Montero (Faculty of Law, University of Namur, Belgium): 'The indications for euthanasia are constantly multiplying, despite the legislators' initial statements and intentions.' (Montero, 2017)

7. DOES IT REDUCE THE (NON-ASSISTED) SUICIDE RATE?

In Belgium, the number of suicides remained stable during the period 1998 to 2012 at 1.9%, i.e. there was no reduction in the suicide rate after passage of the Euthanasia Law (see Statbel).

8. OTHER ISSUES/CONCERNS

(i). The 'normalization' of euthanasia

(ii). Euthanasia for children

(iii). Euthanasia for psychiatric patients and those with dementia

(iv). Continuous sedation until death (CSD)

(v). Euthanasia and palliative care

(vi). Attempts to prohibit conscientious objection

(vii). Euthanasia and organ donation

(viii). Definition of euthanasia

(ix). ICU patients

(x). Arrogance

(i). The 'normalization' of euthanasia (ii). Euthanasia for children

In 2014, Belgium became the first country in the world to legislate euthanasia for children.

Euthanasia is permissible if the child has a 'reasonable understanding of the consequences' of their requesting a lethal injection, i.e. the child's capacity to understand disease, dying and death is supposedly a prerequisite to the implementation of the request.
Adults may choose euthanasia for reasons such as loss of autonomy, being dependent, or social isolation, but children and adolescents lack the experiential knowledge and sense of self to make those decisions.

The only description I found of this 'capacity to judge' (capacité de discernment) was vague (van Gool and de Lepeleire, 2017). I noted the criteria quoted for psychosocial development were dated 1968, and those for cognitive operations 1971.

Modern neuro-psychological and fMRI (functional Magnetic Resonance Imaging) studies of the relationship between the neuro-anatomical development of the brain in human beings and their emotional and experiential capacity demonstrates that both are not fully developed until the early 20s for girls and mid-20s for boys (Mendelson and Haywood).

I found the statement about children with serious illness sensing their own mortality and therefore having a clear understanding of death, quite sinister (van Gool and de Lepeleire, 2017). It's a bit like saying: 'This child is going to die, therefore he has good insight into dying and death.'

Euthanasia for children has been criticized. 'In the case of the new Belgian law, children seem to be asked to choose between unbearable suffering on the one hand and death on the other.' (Siegel et al, 2014).

Other reasons invoked against pediatric euthanasia besides capability of discernment, include pressure and abuse, and sufficiency of palliative care (Kaczor, 2016; Cohen-Almagor, 2018).

In a report of 165 childhood deaths (ages 1-17), 22% had CSD. In 23.5% of these cases, the physician's intention was to hasten death (Pousset et al, 2011).

(iii). Euthanasia for psychiatric patients and those with dementia (iv). Continuous sedation until death (CSD)

In Flanders, 5 to 10 years after the introduction of the Belgian model, CSD accounted for 12 to 14.5% of all deaths (Chambaere et al, 2015b).

In a study of 28 cases of CSD, 6 patients were competent, but the procedure was discussed with none of them (Anquinet et al, 2011).

CSD was commenced without the consent of patient or family in 5% of cases by GPs and in 28% of cases by specialists (Papavasiliou et al, 2014b; Sterckx and Raus, 2017).

9 of 28 patients treated with CSD were not suffering persistently or unbearably (Anquinet et al, 2011).

Another study reports that 'in nursing homes in Flanders, CSD is frequently used to hasten the patient's death. In some cases, CSD can even be considered a substitute for legal euthanasia.' (Rys et al, 2014a)

Of 249 cases of CSD in nursing homes in Flanders, 33% had dementia and 66% lacked competence (Rys et al, 2014b)

In one study, CSD was performed with the explicit intention of hastening the patient's death in 3-4% of cases (Papavasiliou et al, 2014b).

CSD is used for getting around personal, family or institutional reluctance regarding euthanasia (Sterckx and Raus, 2017)

(v). Euthanasia and palliative care (vi). Attempts to prohibit conscientious objection

There have been several legislative attempts to force doctors who refuse to perform euthanasia to refer the patient another physician favorable to this practice (Nys, 2017; Keown, 2018).

(vii). Euthanasia and Organ Donation.

(viii). Definition of euthanasia

19% of Belgian physicians did not label a death following the deliberate administration of neuromuscular relaxants as 'euthanasia'(Smets et al, 2012).
(ix). ICU patients

A statement of the Belgian Society of Intensive Care Medicine advocates the deliberate shortening of the dying process (what they call 'the process of terminal palliative care') in patients with no prospect of a meaningful recovery, by the administration of analgesic or sedative agents, even in the absence of discomfort. The recommendation applies to children as well as adults (Vincent et al, 2014).
(x). Arrogance

When there was a public outcry by some (adult) children who had not been informed prior to their parents' euthanasia, two euthanasia experts publicly declared them to have 'pathological mourning' and to be in need of psychiatric care (Beuselinck, 2017; Lemmens, 2017).

9. SOME FINAL WORDS

Wesley J. Smith (journalist and author of Forced Exit): 'Euthanasia in Belgium has gone completely out of control-including as just two examples-doctors killing the mentally ill and conjoining the death procedure with voluntary organ harvesting, as well as joint euthanasia deaths of elderly couples who ask to die for fear of future widowhood.' (Smith, 2018)

Willem Lemmens (Department of Philosophy, University of Antwerp): '[The] fundamentally problematic feature of the Belgian euthanasia social experiment...[is] a too exclusive and uncritical propagation of the ethical principle of respect for autonomy and self-determination.' (Lemmens, 2017)

Etienne Montero (Faculty of Law, University of Namur, Belgium): 'Since euthanasia was legalized in Belgium in 2002, experience demonstrates that it is an illusion to believe that euthanasia can be permitted as a narrowly circumscribed, well-defined exceptional practice to which 'strict conditions' apply and which is under rigorous control. Once euthanasia is allowed, the limiting conditions established under the law fall away, one after the other, and it appears practically impossible to maintain a strict interpretation of the statutory conditions and to prevent the extension of the law...Indications for euthanasia are constantly multiplying, despite the legislators' initial statements and intentions.' (Montero, 2017)

Raphael Cohen-Almagor (School of Law and Politics, University of Hull): 'The scope of tolerance toward the practice is enlarged so that yesterday's red light becomes obsolete today. As the restrictions are removed, practitioners and law-makers are already debating the next step and the additional groups to be included in the more liberal euthanasia policy as if the restrictive logic behind the Euthanasia Act were no longer valid. This is quite astonishing because human lives are at stake.' (Cohen-Almagor, 2017)

Willem Lemmens (Department of Philosophy, University of Antwerp): asks why 'none of the pro-euthanasia experts ever seems to consider the possibility that there might be something wrong with a law that creates such emotional and existential havoc.' (Lemmens, 2017)

Benoit Beuselinck (Oncologist, University Hospitals, Leuven, Belgium): '...the legalization of euthanasia has put a burden on doctors, families, palliative care services and has put in danger the patient's own life. Together with several colleagues, we believe that the law on euthanasia has created more problems and difficulties than solutions...It is the core business of doctors to offer genuine palliative care and alleviate the physical suffering of a patient while taking care for the mental, social and spiritual aspects of his or her suffering.' (Beuselinck, 2017)

E. CANADA

1. BACKGROUND

In February 2015, the Supreme Court of Canada's decision in the Carter v Canada case overturned the ban on doctor-assisted suicide (Chan and Somerville, 2016). The decision has been questioned on judicial grounds (Keown, 2018).

The unanimity in the title of the NEJM editorial-'Unanimity on Death with Dignity'-refers to the justices, not the population or the health care professionals (Attaran, 2015).
The editorial was written by an enthusing lawyer who believes strongly in the right to assisted dying and seems to believe that a dignified death can only be achieved with assisted dying.

In June 2016, federal legislation was enacted to allow assisted dying, referred to in Canada as medical assistance in dying (MAiD) (see Government of Canada).
Availability of palliative care

I was surprised to learn that 'If you die in Canada today [2016], it is much more likely than not that palliative care won't be available for you. Between 70 and 84% of all Canadians die without receiving, or having access to, palliative or end-of-life-care services.' (Dwyer, 2016)

The Canadian Health Minister has acknowledged that only 15% of Canadians have access to quality palliative care (see Patients Rights).

2. GUIDELINES
Eligibility
The law provides for a person who

Is eligible for Canadian government-funded health services;

Is 18 years of age or older and capable of making decisions with respect to their health;

Has a grievous and irremediable medical condition and meets all of the following criteria:

They have a serious illness, disease or disability;

They are in an advanced state of irreversible decline in capability;

They experience unbearable physical or mental suffering that cannot be relieved under conditions that they consider acceptable; and

Their natural death has become reasonably foreseeable [not further specified].

Has made a voluntary request for medical assistance in dying, free of any external pressure; and

Has given informed consent to receive medical assistance in dying after having been informed of the other means that are available to relieve their suffering, including palliative care.

The law excludes children, those with mental illness, and the use of advance directives.

Procedure
The physician or nurse practitioner must
Reporting
3. NUMBERS

In the first two years, the number of deaths by euthanasia and physician-assisted suicide appear to have increased rapidly (Table 6) (see Government of Canada).

It appears that almost 100% of these deaths were by euthanasia with very few (self-administered) assisted suicides.

Table 6. Number of cases of euthanasia and assisted suicide: Canada 2016-17 From Canadian Government Statistics (see Government of Canada)
4. DO THEY MEET THEIR OWN GUIDELINES?
That the patient has a grievous and irremediable medical condition That 'their natural death has become reasonably foreseeable'

This is medically meaningless, as it is reasonably foreseeable that we will all die.

5. ARE THE SYSTEMS OF REGULATION AND SAFEGUARDS EFFECTIVE?

Reporting requirements only came into effect in November, 2018.

Some claim the laws were intentionally drafted with 'purposeful flexibility'-using language you cannot define-to facilitate future widening of the regulations. This will make regulation more difficult.

6. IS THERE EVIDENCE OF A SLIPPERY SLOPE?

7. DOES IT REDUCE THE (NON-ASSISTED) SUICIDE RATE?

It is too early for any assessment.

8. OTHER ISSUES/CONCERNS
(i). Palliative care (ii). Moves to reduce safeguards

At the present time, immediately before the procedure, the person must be mentally competent and give express consent to the procedure. There are moves to have this rescinded for reasons to do with autonomy and human rights (Somerville, 2018).
(iii). Calls for inclusion expansion (iv). Prohibition of conscientious objection (v). Psychiatric issues
Difficulties with psychiatric disorders and assisted dying in Canada are emphasized by the work of Harvey Chochinov and his colleagues.
(vi). ALS

While 64% of ALS physicians supported the legalization of assisted dying, less than one-third of them were willing to actively participate. Most wanted a psychiatric review, a second opinion regarding eligibility, and referral to a third party for the actual assisted dying (Abrahao et al, 2016).
(vii). Organ Donation

The possibility of combining assisted dying with organ donation is being discussed, as a kind of homage to autonomy (Allard and Fortin, 2017).

9. SOME FINAL WORDS

The final words rest with seven Canadian physicians who provide troubling insights into what is really happening (Leiva et al, 2018).

The redefinition of euthanasia and assisted suicide as 'medical care', to which all citizens are entitled, leads to euthanasia and assisted suicide being seen as a tax-paid entitlement, and being described as a 'constitutionally protected civil and human right'. And doctors who do not co-operate are accused of violating human rights and even called bigots.

Within a year of the original legislation, 'the pressure for "Carter Plus" had become so great that the federal government legally committed itself to consider allowing euthanasia and assisted suicide for adolescents and children, for mental illness, and by advanced directive for those who lack capacity...'

'Canada's largest medical regulator demands that physicians who are unwilling to personally provide euthanasia or assisted suicide must collaborate in homicide and suicide by referring patients to colleagues who are willing to do so.' The non-negotiable need for an 'Effective Referral', and what such referral comprises are set out on the CPSO website (see CPSO).
A challenge to this policy by the Christian Medical and Dental Society of Canada was dismissed by the Ontario Divisional Court (Keown, 2018).

'[In Quebec], all public health care institutions (...including palliative care units) are required to provide or arrange for euthanasia...McGill University Health Centre complied with the law by arranging to transfer patients from the palliative care unit to be lethally injected elsewhere in the facility. [But] the Quebec Minister of Health forced euthanasia into the palliative care unit, citing 'patients' lawful right to receive end-of-life care'.

'Quebec law allows hospices to opt out of providing euthanasia, but when Quebec hospices opted out, the Minister for Health denounced them for "administrative fundamentalism," declaring their refusal "incomprehensible".' There are calls for the withdrawal of public subsidies for hospice and palliative care in Quebec and other provinces.

'...Public calls from influential voices have been heard for those medical students who are personally opposed to the euthanasia imperative, to either abandon, or refrain from applying for, medical training.' In the words of those influential voices: 'Medical schools should carefully...screen for conscientious objection.' (Savulescu and Schuklenk, 2017).

'We are disturbed and grieved by the story of a 25-year-old disabled woman in acute crisis in an Emergency ward, pressured to consider assisted suicide by an attending physician, who called her mother "selfish" for protecting her.'

'We are disturbed and angered to hear that hospital authorities denied a chronically ill, severely disabled patient the care he needed, suggesting euthanasia or assisted suicide instead.'

'We were astonished to hear that some emergency physicians in Quebec were...letting suicide victims die even though they could have saved their lives.'

And then there is the Orthodox Jewish nursing home that forbade euthanasia and assisted suicide on its premises out of respect for Jewish beliefs and concerns for its residents (who include Holocaust survivors). Dr Ellen Wiebe is alleged to have crept in at night and lethally injected a resident. When challenged, she regarded her actions as praiseworthy in that she had allowed him to die at home.

G. SWITZERLAND

1. BACKGROUND
The Right-to-Die Organizations
2. GUIDELINES
Under Swiss law

Euthanasia is not legal.

Termination of life without explicit request is not legal.

Assisted suicide from non-selfish motives is not illegal.
Assisted suicide from selfish motives (e.g. monetary gain) is illegal.

Physicians may participate in altruistic assisted suicide, but most leave it to the right-to-die organizations (Hurst and Auron, 2003).

Intensified treatment of pain and symptoms, withholding or withdrawal of therapy, and continuous sedation until death (CSD), with which it is acknowledged there may possibly be some shortening of life, are considered as normal medical therapy.

Guidelines of the right-to-die organizations

Exit and Dignitas have their own guidelines regarding patient eligibility.

3. NUMBERS

The frequency of assisted suicide in the German-speaking part of Switzerland in 2001 and 2013 are shown in Table 7 (van der Heide et al, 2003; Bosshard et al, 2016).
Table 7. Physician Decisions Regarding Dying in German-speaking Switzerland From van der Heide et al, 2003 and Bosshard et al, 2016
4. DO THEY MEET THEIR OWN GUIDELINES?

The majority of assisted suicides are reported-the number admitted to by physicians is about the same as the number of death certificates of non-natural deaths (Bosshard, 2008b).

5. ARE THE SYSTEMS OF REGULATION AND SAFEGUARDS EFFECTIVE?

In Switzerland, there is no requirement to report assisted suicides to a central registry.

6. IS THERE A SLIPPERY SLOPE?

Compared to 1990s, there are increasing numbers of older patients (mean age: 69.3, increasing to 76.9), females (52%, increasing to 65%), and people without a serious medical condition (22%, increasing to 34%) (Fischer et al, 2008).

Increasing numbers

Widening of eligibility criteria

21% of people receiving assistance by Dignitas and 65% of women attending Exit do not have a terminal or progressive illness (Fischer et al, 2008).

Social loss (or fear of) was reason for requesting suicide in 5/43 patients (Frei et al, 2001).

Increasing numbers of non-residents with non-terminal conditions. (Gauthier et al, 2015).

A precedent has been set regarding assisted suicide for the mentally ill (Appel, 2007).

7. OTHER ISSUES/CONCERNS
(i). Disregarding psychosocial matters (ii). IV & PEG infusions for assisted suicide

The arguments in favor of assisted suicide (c.f. euthanasia) are that it is in keeping with patient autonomy and also increases the patient's responsibility.

However, by 2000, 14% of assisted suicides in Switzerland were administered via IV infusion or PEG catheter (Bosshard et al, 2003). This was considered satisfactory provided it was the patient who was seen to switch the infusion on.

(iii). ALS

A study of patients with ALS showed the wish to hasten death was predicted by depression, anxiety, loneliness, perceiving to be a burden to others, and a low quality of life.

Some suggested that physicians should consider proactive discussion of assisted suicide with such patients (Stutzki et al, 2014).

(iv). Psychological morbidity for relatives

Increased posttraumatic stress disorder (PTSD), complicated grief, and depression were reported after assisted suicide (Wagner et al, 2012a & b).

Relatives reported feeling socially isolated and did not openly disclose assisted suicide as the cause of death for fear of social stigma (Gamondi et al, 2015).

(v). Palliative Care

Right-to-die organization personnel are now allowed into some teaching hospitals, which has caused major conflicts for staff on the palliative care services (Pereira et al, 2008).
(vi). Organ Donation

Consideration of organ donation after assisted suicide is recommended as a potential solution to the organ scarcity problem (Shaw, 2014).

(vii). Problems related to suicide tourism

III. WHAT NOW?

ARGUMENTS FOR AND AGAINST ASSISTED DYING

The arguments for and against euthanasia and physician-assisted suicide have been summarized (Biller-Andorno, 2013; Boudreau and Somerville, 2013; Byock, 2016; Keown, 2018; Sulmasy et al, 2018).

Many medical and nursing organizations have published position statements on euthanasia and physician-assisted suicide (see IAHPC). Recently, a number have adopted a position of neutrality, which is seen by proponents and the public and politicians as supportive of assisted dying (Sulmasy et al, 2018). 'If a medical association declares neutrality on this important issue, it squanders the precious role such associations have in providing guidance to the public and political sphere.' (Bridge et al, 2019)
Protagonists will tell you the main reasons why assisted dying must be legalized are-

Because we must respect the autonomy of the individual.

Because it is needed for patients with unbearable pain or suffering.

Because polls show a majority of the public are in favor.

Because more and more health care professionals support it.

Because legalization stops people committing suicide.

Because it would be better controlled 'out in the open'.

To which they may add-

There is no evidence of a 'slippery slope'.

Legalization poses no risk to 'vulnerable' patients.

There is no moral difference between allowing to die and euthanasia.

Doctors opposed to assisted dying do not have to participate.

Legalization is associated with improvement in palliative care.

But they don't mention-

That legalization leads to 'normalization' of assisted dying.

That palliative care reduces requests for euthanasia.

That the diagnosis of depression is often missed.

That the assessment of competence may be inadequate.

That assisted dying is contrary to ethos of medicine.

That it damages the doctor patient relationship.

That it may be harmful to doctors and nurses.

That it has a bad effect on palliative care.

That organ donation be part of assisted dying.

That economic interests are behind the push for assisted dying.

Protagonists will tell you the main reasons why assisted dying must be legalized are-
1. BECAUSE WE MUST RESPECT THE AUTONOMY OF THE INDIVIDUAL

Patients have a right to be involved in any decisions regarding their medical care.
True.

Patients have the right to refuse treatment, even if there is a risk to life.
True.

Patients have the right to make their own decisions about the time and manner of their death.
True.

The patient has a right to assistance to achieve that death, the so-called legal or human 'right to die'.
False.

Ronald Dworkin (Professor of Law and Philosophy, New York University): 'Making someone die in a way that others approve, but he believes a horrifying contradiction of his life, is a devastating, odious form of tyranny.' (Dworkin, 1993)

John Harris (Professor of Bioethics and Applied Philosophy, University of Manchester): 'Euthanasia should be permitted...simply because to deny a person control of what, on any analysis, must be one of the most important decisions of life, is a form of tyranny, which like all acts of tyranny is an ultimate denial of respect for persons.' (Harris, 1995)

Marcia Angell (former Editor, NEJM): 'The most important ethical principle in medicine is respect for the patient's autonomy and when this principle conflicts with others, it should almost always take precedence.' (Angell, 1997)

Richard Smith (former Editor, BMJ): '...the three themes that emerged...were control, autonomy, and independence.' (Smith, 2000)

Compassion and Choices: My Life. My Death. My choice.

In reply-
1.1 But...autonomy is not absolute.

In modern society, there are innumerable examples of limitations of personal autonomy, e.g. you cannot drive whilst drunk, or freely sell yourself into slavery.

Autonomy gives a right to refuse treatments, but it does not give a right to demand them, e.g. assisted death.

Advocates of euthanasia want recasting of the right to die as a right to have a physician facilitate one's death (O'Rouke, 2017).

Edmund Pellegrino (Director of the Kennedy Institute of Ethics at Georgetown University): 'In the last 25 years, patient autonomy has displaced physician beneficence as a dominant principle in medical ethics. This has enhanced the moral right of patients to refuse unwanted treatment and to participate in clinical decisions. But now, in some cases, patient autonomy is being absolutized. The right to refuse is becoming a right to demand treatment.' (Pellegrino, 1994)

Charles Foster (London barrister who teaches medical law and ethics at the University of Oxford): 'Autonomy is a vital principle in medical law and ethics, but there is a dangerous presumption that it should have the only vote, or at least the casting vote.' (Foster, 2009)

Michael Kekewich (Clinical Ethicist, Ottawa) 'The principle of respect for autonomy has for many patients evolved into a positive right to request treatments and expect accommodation'...which he describes as dysfunctional (Kekewich, 2014).
1.2 But...aren't 'autonomous decisions' subject to outside influences?
Robert Twycross (Emeritus Reader, Oxford University): 'Every person asking for assisted death brings with them the attitudes and feelings of their family, their socioeconomic problems, and whether or not they feel they are a burden.' (Twycross, 1996)

Shimon Glick (Jakobovits Center for Jewish Medical Ethics, Ben-Gurion University Faculty of Health Sciences, Beer-Sheva, Israel): 'Can a decision for suicide or euthanasia be truly autonomous? Can a vulnerable, sick, suffering person be truly capable of a truly autonomous decision in an environment where the media, the medical community, the bioethicists, the caregivers, and the family overtly and covertly convey the message that the time has come to die.' (Glick, 1997)
1.3 But...can't 'autonomous decisions' be influenced by psychological factors? Depression

Potentially treatable major depression is under-diagnosed and under-treated in patients with advanced disease (Breitbart et al, 2010a).

Major depression can be reliably diagnosed in 10-25% of patients with advanced cancer (Breitbart et al, 2000; Hotopf et al, 2002).
The argument that depressive symptoms in the terminally ill are 'normal sadness' or 'understandable depression', and that they are not amenable to treatment (Syme, 2008), is false.

There is a strong correlation between depression and the wish to hasten death in the terminally ill (Chochinov et al, 1995; Tieman et al, 2002; Kelly et al, 2004; van der Lee et al, 2005; Fairman and Irwin, 2016).

Ganzini reported that for patients given a prescription for lethal medication, those with depression were significantly more likely to use it (3/3 patients vs. 9/15) (Ganzini et al, 2008).

Major depression associated with terminal illness is potentially treatable and, if successful, there will be a significant reduction in the wish to hasten death (Ganzini et al, 1994; Kugaya et al, 1999; Breitbart et al, 2010b; Ng et al, 2014).

Other psychological matters
Brian Kelly and Francis Varghese (Professor of Psychiatry at the University of Newcastle, Australia and the University of Queensland, respectively): 'The reasons for a patient seeking suicide as a treatment are complex and go beyond questions of a patient's right to die. The request for euthanasia needs to be seen in the context of the patient's circumstances, including relationships with and attitudes of carers and health professionals, along with patterns of psychiatric disorder and psychiatric symptoms in the medically ill (Kelly and Varghese, 1996).
1.4 But...is autonomy used to justify progressive widening of the indications?
Etienne Montero (Faculty of Law, University of Namur, Belgium): ' In keeping with the philosophy of autonomy, it seems logical and even natural that, sooner or later, the 'strict' legal conditions weigh less than the firm and specific wishes of the patient.' (Montero, 2017)

Michael Cook (editor of BioEdge and founder of MercatorNet): In Holland, the law requires '(1) the request must be voluntary and deliberate; (2) there must be unbearable suffering with no hope of improvement; and (3) there must be no reasonable alternative to euthanasia...[But] patients define what is unbearable and they define what is a reasonable alternative...Autonomy has trumped medicine...' (Cook, 2017)
1.5 But...are there not apparent contradictions between autonomy and assisted dying?

That killing (assisted death) is the ultimate violation of another's autonomy; a dead person has no autonomy (Jeffrey, 2009).

That some decisions about euthanasia may reflect inadequate or non-existent palliative care.

That some decisions about euthanasia may be prompted by depression.

That some decisions about euthanasia may be due inadequate information.
Dianne Pretty wanted an assisted death because of her fear of choking to death; choking may occur with motor neuron disease but can be palliated and is not a cause of death (Foster, 2009).

For all the talk about patient autonomy, the actual decision makers are the physicians (Ten Have and Welie, 2005).

John Keown (Professor at the Kennedy Institute of Ethics at Georgetown University, Washington DC.): '[The argument for assisted dying] that it respects individual autonomy, is too often advanced as if it were an obvious conclusion rather than a controversial proposition. The counter-argument is that many requests for [assisted dying] are not truly autonomous but result from depression or inadequate palliative care.' (Keown, 2002 & 2018)

Kathryn Mannix (Palliative Care Physician, Newcastle, UK): '...to legalize assistance with dying arises from the argument that to deny assistance is to deny the autonomy, or right to choose, of an individual. Proponents describe this denial as dehumanizing, as though exercise of autonomy alone is the mark of human personhood. The humanizing aspect of choice is its potential for nobility: as humans, we can reflect on our being and on the consequences of our choices. The right to choose to die with medical assistance, when placed in this context, must be weighed against the nobility of relinquishing this right if its commission would damage other, possibly more vulnerable, members of our society.'(Mannix, 2005)

Charles Foster (London barrister who teaches medical law and ethics at the University of Oxford): 'Autonomy grew up as a street fighter, and was bloodied in some genuinely noble battles against medical paternalism. But like so many rulers with this sort of pedigree, it has quickly forgotten its democratic roots, and grown fat and brutal in power.' (Foster, 2009)

OJ Hartling (The Danish Council of Ethics, Copenhagen): 'The illusion of autonomy-the choice is meant to be free, but the patient is not free to make the choice; a choice that seeks to alleviate suffering and improve life by annihilating it is irrational; autonomy as to one's own death is hardly exercised freely. Even an otherwise competent person may not be competent in deciding on his own death on account of despair, hopelessness, fear or maybe a feeling of being weak, superfluous and unwanted.' (Hartling, 2006)

Robert George (Bioethicist, University College, London) et al: 'Therapeutic killing without explicit request, or of those lacking capacity, is the ultimate violation of autonomy.' (George et al, 2005)

Numerous others have made a case for the overriding importance of patient autonomy, including Margaret Battin (Professor of Philosophy, University of Utah) (Battin, 2005), Timothy Quill (palliative care physician) (Quill and Battin, 2004; Quill and Miller, 2014), Baroness Warnock (Philosopher) (Warnock and Macdonald, 2008), Guenter Lewy (Emeritus Professor of Political Science, University of Massachusetts) (Lewy, 2011), L. W. Sumner (Emeritus Professor of Philosophy, University of Toronto) (Sumner, 2011), and Rodney Syme (retired urologist, former president of Dying With Dignity Victoria) (Syme, 2008 & 2016).

2. BECAUSE IT IS NEEDED FOR PATIENTS WITH UNBEARABLE PAIN OR SUFFERING.

Assisted dying was sold to the public for the management of unbearable pain and symptoms in the terminally ill.

But it is being used for psychological ('to be in control') and social ('tired of life') reasons (Rurup et al, 2005a; Sulmasy, 2017; Keown, 2018).

Physical pain and other symptoms can almost always be alleviated (Sulmasy, 2016).

Proponents of assisted dying regard the relief of suffering as beneficence.
But such beneficence deprives them of their very existence.

Daniel Sulmasy (Medical Ethicist, Kennedy Institute of Ethics and the Edmund D. Pellegrino Center for Clinical Bioethics, Georgetown University): 'Rather than having severe physical or mental suffering, patients who follow through on PAS in the USA appear to have a distinct personality type, characterized by a need for control and a dismissive attitude towards other persons. They represent only about 0.5% of the US population, and the question arises whether the risks to the other 99.5% of the population justify acceding to the wishes of this small minority.' (Sulmasy, 2017)

3. BECAUSE POLLS SHOW A MAJORITY OF THE PUBLIC ARE IN FAVOUR.
The polls
Fran McInerney (Professor of Aged Care, Australian Catholic University): 'The framing of requested death activists as heroes, and of requested death itself as a redeeming and transforming act for those seeking it, were preeminent in press portrayals.' (McInerny, 2006)
The polls are asking about legalization
The Mackay Report (House of Lords): 'There was general agreement among our witnesses that the number of people who might be regarded as serious about ending their lives, who are not psychiatrically ill and who are unlikely to be deflected from their purpose is very small indeed and comprises to a large extent terminally ill people who have strong personalities and a history of being in control of their lives and whose suffering derives more from the fact of their terminal illness and from the loss of control which this involves than from the symptoms of their disease.' (House of Lords, 2005)

4. BECAUSE MORE AND MORE HEALTH CARE PROFESSIONALS SUPPORT IT

The polls

The assessment of the professional polls is fraught with difficulty. They depend on the interpretation of definitions, participant's responses and actions, and whether there are palliative care options included (Aranda and O'Connor, 1995; Waddell et al, 1996; Bachman et al, 1996; Emanuel et al, 1996; Slome et al, 1997; Meier et al, 1998; Emanuel et al, 1998a).

The early Australian studies were deliberately ambiguous, so that doctors who admitted they had given a patient opioids that might possibly have hastened death (but of which they had no intention) were classified as intentional euthanasia (Kuhse et al, 1997).

It depends on the population surveyed The responses are about legalization, not performance
5. BECAUSE LEGALIZATION STOPS PEOPLE COMMITTING SUICIDE

Proponents argue that the legalization of assisted dying provides an alternative for people with a terminal illness who might otherwise turn to 'impulsive, irrational and often violent' suicides. (Boer, 2016; Callinan and Silva, 2018; Tarzian, 2018)

But data is emerging that the number of 'ordinary' (non-assisted) suicides increases when assisted suicide is legalized (Callahan, 2018).

This is possibly suicide contagion, the increase in suicide that that accompanies publicity about suicide, which is a well-recognised phenomenon (Sulmasy, 2017).

In the State of Victoria, a big deal was made of the Coroner's deposition, detailing all the suicides in persons who had 'experienced an irreversible deterioration in physical health', which proponents said would be eliminated by assisted dying legislation (see Legal and Social Issues Committee).

5.1 The Netherlands 5.2 Oregon

The suicide rate in Oregon in 2012 was 42% higher than the national average (Shen and Millet, 2012).

During the period 1998-2012 (during which time the DWDA was operative), the non-assisted suicide rate increased from under 14 to 17.7 per 100,000 (Shen and Millet, 2012; Jones and Paton, 2015).

5.3 Belgium

The suicide rate in Belgium is the highest in Western Europe (see Statbel).

In Belgium, the number of suicides remained stable during the period 1998 to 2012 at 1.9%, i.e. there was no reduction in the (non-assisted) suicide rate after passage of the Euthanasia Law (see Statbel).

6. BECAUSE IT WOULD BE BETTER CONTROLLED 'OUT IN THE OPEN'
6.1 But...is it really being widely practiced?

There is no evidence that assisted dying is being practiced widely in the UK or USA (Meier et al, 1998 & 2003; Seale, 2006 & 2009).
6.2 But...would bringing it out in the open lead to more effective regulation?

The confidential surveys in the Netherlands and Flanders indicate euthanasia without request, non-reporting, and abuse of the guidelines continue unabated.

There is no information available to assess abuse in the Oregon system.

To which they may add-
7. THERE IS NO EVIDENCE OF A 'SLIPPERY SLOPE'

Robert Twycross (Emeritus Reader, Oxford University): 'Once the barrier of legislation is passed, medically assisted dying takes on a dynamic of its own and extends beyond the original intent, despite earlier explicit assurances that this would not happen.' (Twycross, 2016)

Peter Singer (Professor of Medicine and bioethicist, University of Toronto): 'Of all the arguments against voluntary euthanasia, the most influential is the slippery slope: once we allow doctors to kill patients, we will not be able to limit the killing to those who want to die.'

Wesley Smith (journalist and author of Forced Exit): 'It took the Dutch almost 30 years for their medical practices to fall to the point that Dutch doctors are able to engage in the kind of euthanasia activities that got some German doctors hanged after Nuremberg. For those who object to this assertion by claiming that German doctors killed disabled babies during World War II without consent of parents, so too do many Dutch doctors: Approximately 21% of the infant euthanasia deaths occurred without request or consent of parents.' (Smith 2004)

Daniel Sulmasy (Medical Ethicist, Kennedy Institute of Ethics and the Edmund D. Pellegrino Center for Clinical Bioethics, Georgetown University): There is a slippery slope, the final end being the legalizing of euthanasia for anyone for any reason or no reason (Sulmasy, 2014).

8. LEGALIZATION POSES NO RISK TO 'VULNERABLE' PATIENTS

The Walton Committee (House of Lords): 'We do not think it possible to set secure limits on voluntary euthanasia...We are also concerned that vulnerable people - the elderly, lonely, sick, or distressed - would feel pressure, whether real or imagined, to request early death.' (House of Lords, 1994)

The New York State Task Force on Life and the Law (Some members of this committee were supporters of euthanasia and assisted dying, but they ended up with a unanimous recommendation not to legalize assisted dying): '...legalizing assisted suicide and euthanasia would be profoundly dangerous for many individuals who are ill and vulnerable. The risks would be most severe for those who are elderly, socially disadvantaged, or without access to good medical care.' (New York Task Force, 1994)

Patricia Mann (Department of Philosophy, Hofstra University): 'There will be social expectations for individuals to choose PAS as soon as their capabilities decline to a point where they become dependent upon others in an expensive inconvenient way.'

(Mann, 1998)

Baroness Onora O'Neill (Professor Emeritus of Philosophy): 'Legalizing assisted dying places a huge burden on the vulnerable...[it] amounts to adopting a principle of indifference towards [the vulnerable], in order to allow a few independent folk to get others to kill them on demand...Laws are written for all of us in all situations.' (O'Neill, 2006)

John Keown (Professor of Ethics in the Kennedy Institute of Ethics at Georgetown University): 'The 'right to die' would surely in time become more of a 'duty to die', not least given the burgeoning costs of caring for a growing, elderly and demented population ...decriminalization [of assisted dying] could easily by itself signal to vulnerable groups, directly or indirectly, not only that they may seek an earlier death, but that they should.' (Keown, 2012)

Richard Fenigsen (Dutch cardiologist): 'The fundamental question about euthanasia: Whether it is a libertarian movement for human freedom and the right of choice, or an aggressive drive to exterminate the weak, the old, and the different, this question can now be answered. It is both.'

9. THERE IS NO MORAL DIFFERENCE BETWEEN ALLOWING TO DIE AND ASSISTED DYING
9.1 But...what about intention? 9.2 But...the cause of death is different.

Patients allowed to die are dying of their underlying condition.

With assisted dying, the cause of death is the lethal medication.

10. DOCTORS OPPOSED TO ASSISTED DYING DO NOT HAVE TO PARTICIPATE

An individual doctor's conscientious objection, for whatever reason, should be respected and this includes referral to another practitioner who performs euthanasia and physician-assisted suicide. Some doctors do not believe assisted dying is morally right, whether for religious or other reasons.

11. LEGALIZATION IS ASSOCIATED WITH IMPROVEMENT IN PALLIATIVE CARE

A 2007 study listed The Netherlands as one of the three countries with 'the most vital palliative care movements' (Centeno et al, 2007). This was based on measures including the number of congresses attended, and there was no attempt to measure the quality of care delivered.

Both the quality and quantity of palliative care in the Netherlands are clearly deficient (Zylicz, 2002).
The medical director of a Dutch hospice testified (c. 2004) that hospitals in general were 'totally devoid of input from palliative care specialists' (Keown, 2013).

The Belgians claim the inclusion of euthanasia strengthened and did not harm palliative care (Vanden Berghe et al, 2017).

In Canada, where 85% of the population do not have access to palliative care, there are accusations the promised increase in palliative care funding has not eventuated, and that palliative care funds are being diverted to assisted dying programs (Leiva et al, 2018).

Els Borst (the doctor/Health Minister who guided the euthanasia legislation through the Dutch parliament) admitted in 2009 that the government did not give enough attention to palliative care and support for the dying, that the legalization came 'far too early', and that a decline in the quality of care for the terminally ill had followed (Craine, 2009; Keown, 2012).
But they don't mention-
12. THAT LEGALIZATION LEADS TO 'NORMALIZATION' OF ASSISTED DYING

Victor Lamme (Professor of Cognitive Neuroscience, University of Amsterdam): 'The "normalisation" of euthanasia means that it is seen as an acceptable solution to the problem of the elderly who are felt to have outstayed their welcome, or who feel they are a burden to their families.' (Lamme, 2016)

13. THAT PALLIATIVE CARE REDUCES REQUESTS FOR EUTHANASIA

Quality palliative care will reduce the wish for hastened death.

Of 126 patients who made an explicit request for euthanasia at the time of admission to a Dutch palliative care unit, only 2 persisted with their request (Zylicz and Janssens, 1998).

For patients requesting PAS in Oregon, 46% of patients changed their mind after a substantive palliative intervention (Ganzini et al, 2000b).

14. THAT THE DIAGNOSIS OF DEPRESSION IS OFTEN MISSED

Marshall Perron (former Chief Minister of the Australian Northern Territory and the politician responsible for the introduction of the assisted dying legislation): 'I understand severe depression to be fairly readily recognizable. You don't have to have a huge string of qualifications.' (Perron, 1996)

15. THAT THE ASSESSMENT OF COMPETENCE MAY BE INADEQUATE

It is assumed that the examination of decision-making capacity is easy. It may be, but frequently is not.

Any physician is qualified to assess capacity, although in practice few doctors, other than psychiatrists, are familiar with formal assessment of decision-making capacity (Fairman and Irwin, 2016).
Assessment of decision-making capacity is not the same as obtaining informed consent for treatment.

There is agreement on the importance of mental capacity with regards to euthanasia and physician-assisted suicide, but there remains significant variation in views of what does or does not constitute mental capacity (Price et al, 2014).

The decision-making capacity of a significant number of patients with advanced disease will fall in the grey area, due to due to a range of causes including intercurrent illness, medications, and dementia.

'Only 6% of Oregon psychiatrists were confident that in a single evaluation they could adequately assess whether a psychiatric disorder was impairing the judgement of a patient requesting assisted suicide.' (Ganzini et al, 1996)

A survey of forensic psychiatrists (Ganzini et al, 2000a) reported that 78% recommended a stringent standard of competence, 73% indicated that 2 independent examinations were needed to determine competence, and 58% believed major depression should result in an automatic finding of incompetence.

16. THAT ASSISTED DYING IS CONTRARY TO THE ETHOS OF MEDICINE
Killing is inherently wrong; there is an inherent value in human life.

Religious views aside, most people regard killing as wrong.

Killing another person is the most extreme abuse of their autonomy. (Jeffrey, 2009)

Everybody is somebody. Euthanasia means it is morally acceptable to turn a somebody into a nobody.

Killing is contrary to the ethos of medicine
Robert Twycross (Emeritus Reader, University of Oxford): 'I am bound by the cardinal medical ethical principle that I must achieve my treatment goal with the least risk to the patient's life.' (Twycross, 1990)

Daniel Sulmasy (Medical Ethicist, Kennedy Institute of Ethics and the Edmund D. Pellegrino Center for Clinical Bioethics, Georgetown University): 'The traditional Hippocratic ban on physicians killing patients makes sense from the perspective of the psychodynamics of the patient-physician relationship. The preconditions of trust that constitute the safety of the interpersonal space in which the patient can expose his or her vulnerability to the physician in order to be healed would seem to include, at a minimum, that the physician pledge to the patient, 'I will not kill you.'' (Sulmasy, 2017)

Robert Twycross (Emeritus Reader, University of Oxford): 'A gap...between the philosophical sophisticates and those who are involved daily in the care of the dying. When viewed from the academic (or editorial) ivory tower the arguments in favour of legalized euthanasia may well seem logical and powerful. At the bedside, however, the arguments against are overwhelming.' (Twycross, 1995)

17. THAT IT DAMAGES THE DOCTOR-PATIENT RELATIONSHIP

The practice of assisted dying has adverse consequences for the patient-doctor relationship in terms of physician integrity and patient trust.

18. THAT IT MAY BE HARMFUL TO DOCTORS AND NURSES

Kenneth Stevens (Emeritus Professor of Radiation Oncology, Oregon Health and Science University, Portland): 'The physician is centrally involved in PAS and euthanasia, and the emotional and psychological effects on the participating physician can be substantial. The shift away from the fundamental values of medicine to heal and promote human wholeness can have significant effects on many participating physicians. Doctors describe being profoundly adversely affected, being shocked by the suddenness of the death, being caught up in the patient's drive for assisted suicide, having a sense of powerlessness, and feeling isolated. There is evidence of pressure on and intimidation of doctors by some patients to assist in suicide. The effect of countertransference in the doctor-patient relationship may influence physician involvement in PAS and euthanasia.' (Stevens, 2006)

19. THAT IT HAS A BAD EFFECT ON PALLIATIVE CARE
Palliative care services are being forced to perform euthanasia and physician-assisted dying

In Canada, state-funded institutions are being forced to perform MAID.

Also, in Canada, palliative care services are being forced to perform euthanasia in the palliative care unit and are not allowed to transfer euthanasia patients to a different part of the institution (Leiva et al, 2018).

Funding of palliative care services is threatened (Leiva et al, 2018)

In Canada, there are calls for the withdrawal of public subsidies for hospice and palliative care (Leiva et al, 2018).

'If PCUs [palliative care units] conscientiously object to MAID [medical assistance in dying] ...then they are neglecting to fulfil their responsibility to honor their own missions and values.' Not a big step to then try and have their funding revoked (Morrison, 2017c).

The Belgian model of palliative care is advocated Palliative care staff and services may be challenged by the introduction of assisted dying programs.
Considerable difficulties have been reported establishing assisted dying programs, including the relationship with the palliative care services in the same institutions (Loggers et al, 2013; Campbell and Black, 2014; Li et al, 2017; Pereira et al, 2008).
Offensive remarks are made
Rodney Syme (retired urologist, former president of Dying With Dignity Victoria):

'There is scant evidence to support the effectiveness of specialised palliative care for patients with terminal illness in terms of quality of life, patient or care giver satisfaction, or economic cost.' (Syme, 2016)

He describes the palliative care process as intrusive for the patient and family, and palliative care professionals with 'the mind-set' (i.e. not agreeing with his views) as hypocrites (Syme, 2008).

Philip Nitschke (founder and director Exit International):

He told author Nikki Gemmell that her mother's physician-assisted suicide (which he helped arrange) amounted to 'empowerment', and that anyone opposing his views was either not mature or was suffering 'religious claptrap' (Gemmel, 2017; see Nitscke).

Andrew Denton (former TV personality and comedian):

'Palliative care doctors are poorly informed, unreflective and opposed to euthanasia for out-dated, ideological/religious reasons.' (Denton (2))

He accused Catholic palliative care doctors of delaying palliative symptom relief because they believed in the redemptive benefits of suffering. 'If a doctor has this core religious belief then there's a limit to how much and how quickly they're going to help you.' (Denton (1))

20. THAT ORGAN DONATION SHOULD BE PART OF ASSISTED DYING

21. THAT ECONOMIC INTERESTS ARE BEHIND THE PUSH FOR ASSISTED DYING

Reducing health care expenditure is a priority in most developed countries. Which brings up the inevitable question of how much money might be saved (by the insurance organizations, the state, and the families of the dying) by the introduction of assisted dying?

The State and the health insurance companies stand to make major savings.

Patients in Oregon are being told that the Oregon Health Plan will not pay for treatment of their underlying condition, although it will pay for assisted suicide. (see Patients Rights; Keown, 2012)

The Dutch End of Life Clinic is said to have approached the health insurance companies to fund a number of new teams

Derek Humphrey (co-founder of the Hemlock Society, the Final Exit Network, and Compassion and Choices): 'In the final analysis, economics, not the quest for broadened individual liberties or increased autonomy, will drive assisted suicide to the plateau of acceptable practice.' (Humphrey and Clement, 2000)

ON REFLECTION...
The way we manage the dying leaves much to be desired...
The doctor comfortably accompanying his patient, providing appropriate physical and emotional comfort...the patient informed, and content that they will be not abandoned.

There is much that needs to be done...
But is euthanasia and physician-assisted suicide the answer? Much change is needed, but not the introduction of medical assistance in dying.
SOME FINAL QUOTATIONS

Ira Byock (palliative care physician, author and Professor of Medicine at the Geisel School of Medicine, Dartmouth, New Hampshire):

'From its very inception, the profession of medicine has formally prohibited its members from using their special knowledge to cause death or harm to others. This was - and is - a necessary protection so that the power of medicine is not used against vulnerable people.'

'Physician-assisted suicide weakens the moral grounding and structural integrity of the medical profession in service to society. This damage is particularly acute for the specialty of hospice and palliative medicine in sowing confusion among the public and in diverting the discipline's research and policy foci away from alleviating persistent suffering.'

'In these adversarial arenas, the fight over physician-assisted suicide makes it appear as if a cultural chasm divides Americans. In fact, the chasm is a mirage, an artefact...Our differences are dwarfed by the common high ground of values, shared wishes for care...It is on this common ground that we can build better systems of medical care and social support and realize our full social potential. (Byock, 2012)

René Girard (French historian and social philosopher, 1923-2015): 'The experience of death is going to get more and more painful, contrary to what many people believe. The forthcoming euthanasia will make it more rather than less painful because it will put the emphasis on personal decision in a way which was blissfully alien to the whole problem of dying in former times. It will make death even more subjectively intolerable, for people will feel responsible for their own deaths and morally obligated to rid their relatives of their unwanted presence. Euthanasia will further intensify all the problems its advocates think it will solve.'

Barbara Karnes (American nurse, educator and author of A Time to Live): 'Dying a gradual death makes us the fortunate ones. We have been given the opportunity to say I love you, to amend the mistakes, to ride the rollercoaster, to say good-bye.'

Elisabeth Kübler-Ross (Swiss-born American psychiatrist, 1926-2004): 'Lots of my dying patients say they grow in bounds and leaps, and finish all the unfinished business. But assisting a suicide is cheating them of these lessons, like taking a student out of school before final exams. That's not love, it's projecting your own unfinished business.'

Michigan's Religious Leaders Forum (a group of Christian, Jewish and Muslim leaders): 'Those who promote this last, fatal escape as a "right" should remember that such a "right" may quickly become an expectation and, finally, even a "duty" to die.'

Dame Cicely Saunders (nurse, almoner, palliative care physician and founder of the modern hospice movement, 1918-2005):

You don't have to kill the patient to kill the pain. There is no such thing as intractable pain, only intractable doctors.

You matter because you are you, and you matter to the end of your life. We will do all we can not only to help you die peacefully, but also to live until you die.

I remain committed to helping people find meaning in the end of life and not to helping them to a hastened death. (Saunders, 2002)

IV. WHAT OTHERS SAY - SOME BOOK REVIEWS

Here are my reviews of books dealing with euthanasia and assisted-suicide.

Neuberger

DYING WELL. A Guide to Enabling a Good Death

Foley & Hendin

THE CASE AGAINST ASSISTED SUICIDE.

Keown

EUTHANASIA, ETHICS AND PUBLIC POLICY.

Neuberger

DYING WELL. A Guide to Enabling a Good Death 2e

Quill & Battin

PHYSICIAN-ASSISTED DYING.

Battin

ENDING LIFE: Ethics and the Way We Die

Blank & Merrick

END-OF-LIFE DECISION MAKING.

Ten Have & Welie

DEATH AND POWER.

Colby

UNPLUGGED. Reclaiming Our Right To Die in America

Gorsuch

THE FUTURE OF ASSISTED SUICIDE AND EUTHANASIA

Kelly

MEDICAL CARE AT THE END OF LIFE.

Shannon & Faso

LET THEM GO FREE. A Guide to Withdrawing Life Support

Wanzer & Glenmullen

TO DIE WELL. Your right to comfort, calm, and choice

Lewis

MEDICINE AND CARE OF THE DYING

Griffiths et al

EUTHANASIA AND LAW IN EUROPE

Hastings Center

CHOOSING DEATH.

Syme

A GOOD DEATH. An Argument for Voluntary Euthanasia

Warnock & Macdonald

EASEFUL DEATH. Is There A Case For Assisted Dying?

Foster

CHOOSING LIFE, CHOOSING DEATH.

Jeffrey

AGAINST PHYSICIAN ASSISTED SUICIDE.

Randall & Downie

END OF LIFE CHOICES. Consensus and Controversy

Goodman

THE CASE OF TERRI SCHIAVO.

Qualls & Kasl-Godley

END-OF-LIFE ISSUES, GRIEF, AND BEREAVEMENT.

Goldberg

DEATH WITH DIGNITY.

Orfali

DEATH WITH DIGNITY.

Lewy

ASSISTED DEATH IN EUROPE AND AMERICA.

Byock

THE BEST CARE POSSIBLE. A Physician's Quest to Transform

Jackson & Keown

DEBATING EUTHANASIA

Youngner & Kimsma

PHYSICIAN-ASSISTED DEATH IN PERSPECTIVE.

Berlinger et al

THE HASTINGS CENTER GUIDELINES FOR DECISIONS ON CARE NEAR THE END OF LIFE 2e

Hagger & Woods

A GOOD DEATH? Law and Ethics in Practice

Johnstone

ALZHEIMER'S DISEASE AND THE POLITICS OF EUTHANASIA

Keown

THE LAW AND ETHICS OF MEDICINE.

Gawande

BEING MORTAL. Medicine and What Matters in the End

Quill & Miller

PALLIATIVE CARE AND ETHICS

Sumner

ASSISTED DEATH. A Study in Ethics and Law

Renz

DYING. A Transition

Rehmann-Sutter et al

THE PATIENT'S WISH TO DIE.

Taboada

SEDATION AT THE END-OF-LIFE.

Dugdale

DYING IN THE TWENTY-FIRST CENTURY.

Dwyer

CONVERSATIONS ON DYING.

Stercks et al

CONTINUOUS SEDATION AT THE END OF LIFE.

Youngner & Arnold

THE OXFORD HANDBOOK OF ETHICS AT THE END OF LIFE

Roscoe & Schenck

COMMUNICATION AND BIOETHICS AT THE END OF LIFE.

Jones et al

EUTHANASIA AND ASSISTED SUICIDE. Lessons from Belgium

Mannix

WITH THE END IN MIND.

English et al

PHYSICIAN-ASSISTED DEATH: SCANNING THE LANDSCAPE.

Macauley

ETHICS IN PALLIATIVE CARE

Keown

EUTHANASIA, ETHICS AND PUBLIC POLICY 2e.

THE REVIEWS

1999
DYING WELL Guide to Enabling a Good Death Julia Neuberger
Radcliffe Medical Press, 1999

Brilliant! In 171 clearly-written pages, I found out about the origins of the attitudes to death and bereavement with which I grew up; I learned about the teachings and customs regarding death of the world's great religions and how palliative care professionals can best deal with them; I was treated to an erudite discussion on the meaning of a "good death", covering everything from common sense to euthanasia; and how we, whether we are health care professionals, family members, clergy, or friends, can help people achieve it; and finally, a description of our society's approach to grief and bereavement that does not shy away from pointing out what is wrong and why.

Anyone who works in hospice and palliative care should read this book. And, as it is written both for health care professionals and the general public, it should be available to be loaned out to people caring for loved ones through a terminal illness.

Rabbi Julia Neuberger has served as the Rabbi of a South London Liberal Synagogue for twelve years, is Chief Executive of the King's Fund, and is a Vice-President of the Royal College of Nursing and the National Carers Association.

Highly recommended.

Roger Woodruff (May 2004)

2002

This book cogently sets out the medical, ethical, philosophical and legal arguments against the legalization of physician-assisted suicide and, just as importantly, describes how palliative care needs to be developed so that we can uphold the right of the terminally ill not to suffer. The contributors are distinguished experts in medical ethics, palliative care, and law.

The book is divided into four sections. In the first - Autonomy, Compassion and Rational Suicide - Kass, Pellegrino, Callahan and Kamisar provide ethical, philosophical and legal arguments that neither of the major justifications for assisted suicide, autonomy and compassion, provides an adequate basis for legalizing the practice. And, in the words of the ethicist Sissela Bok, if you do legalize it "no country has yet worked out the hardest questions of how to help those patients who desire to die, without endangering others who do not".

The second section - Practice versus Theory - includes chapters on the practice of assisted suicide and euthanasia in the Netherlands, Oregon and the Australian Northern Territory. Hendin's extensive knowledge and insight is evident in his review of the Dutch practices and includes the remarkable statement by one of the authors of the 1995 Dutch report "that the person responsible for avoiding involuntary termination of life is the patient". Ben Zylicz describes working in palliative care in the Netherlands, where its development has been severely hampered by the easy availability of euthanasia; one feels a tug as he describes being prevented from seeing terminally ill patients with treatable symptoms, and patients for whom palliative care might offer so much being taken away to hospital for euthanasia. Foley and Hendin review the Oregon experiment and catalogue the lack of legal safeguards and the paucity of information that has been made available. The Northern Territory deaths are described and discussed by David Kissane.

The third section - Reason to be Concerned - discusses assisted suicide and palliative care in relation to patients who are disabled, vulnerable (minority groups, the elderly and the financially disadvantaged), or depressed. The chapter by Cohn and Lynn clearly and categorically refutes the claims seen almost constantly in the lay press and should be required reading for any journalist contemplating writing anything about assisted suicide.

The last section - A Better Way - includes chapters by Dame Cicely Saunders and Kathleen Foley, examining the state of palliative care and what needs to be done to improve it so that it provides better end-of-life care, for all those people who need it.

This book adequately accomplishes its goal of providing an open and tolerant discussion of both the case against assisted suicide and the case for palliative care. The book also provides some powerful insights into the shortcomings of the palliative care system and how it might be improved. The discussions are well written and are practical and clinically relevant. This excellent book will be a valuable resource for anybody interested in the delivery of better end-of-life care, whether they are clinicians, ethicists, or health care policymakers.

Roger Woodruff

As indicated by the subtitle, this book is unashamedly against the legalization of euthanasia and physician-assisted suicide, but it is written in a moderate and reasoned tone and in a manner easily understood whether you are a health care professional, lawyer, politician or just an interested member of the public.

Keown first explores the inexactitudes and ambiguities that abound in the euthanasia debate, and then dissects the arguments for and against. This includes a description of the doctrine of double effects, although more recently published information suggests that it may not need to be invoked; Sykes et al (Lancet Oncology 2003; 4:312) found no evidence that initiation of opioid or sedative therapy is associated with the precipitation of death.

The second part of the book is an in-depth assessment of the practices in The Netherlands, the Northern Territory of Australia, and the U.S. State of Oregon, and includes a clear illumination of the inadequacy of the much-vaunted legal safeguards against abuse. Despite all their talk, the most recent data published by the Dutch (Onwuteaka-Philipsen et al. Lancet 2003;362:395) shows no sign of any reduction in the incidence of non-voluntary euthanasia or euthanasia without request. It is to be hoped that Cambridge University Press will invite Keown to prepare an up-dated edition as more information and data becomes available from The Netherlands and Oregon. The third part of the book critically reviews the findings of various expert committees, associations and the courts.

By no means everyone will agree with the conclusions and opinions expressed in this book, but it should be required reading for anyone who intends to make a public statement in the euthanasia debate.

Roger Woodruff(May 2004)

2004

This is the second edition of Julia Neuberger's book that was first published in 1999. The order of the material has been shuffled a bit and the discussion has been expanded and brought up to date with the discussions that are occurring in both professional and lay societies.

As for the first edition (although the order has been altered), 'I found out about the origins of the attitudes to death and bereavement with which I grew up; I learned about the teachings and customs regarding death of the world's major religions and how palliative care professionals can best deal with them; I was treated to an erudite discussion on the meaning of a "good death", covering everything from common sense to euthanasia; and how we, whether we are health care professionals, family members, clergy, or friends, can help achieve it; and finally, a description of our society's approach to grief and bereavement that does not shy away from pointing out what is wrong and why.'

Reading this book will be both enjoyable and beneficial to anyone who works in hospice and palliative care.

Roger Woodruff(June 2005)

This book was compiled in response to the volume edited by Kathleen Foley and Herbert Hendin (The Case Against Assisted Suicide; For the Right to End-of-Life Care, Johns Hopkins University Press, 2002; see review) and to stress what the authors see as the positive aspects of Physician-Assisted Dying.

The tone is set in the introduction. Those in favor of Physician-Assisted Dying champion the causes of patient autonomy, mercy (the relief of pain and suffering), and patient non-abandonment (all very positive), whilst those who oppose it are worried about the wrongness of killing, diminished integrity of physicians, and the risk of abuse (all very negative).

The book is divided into four parts. The first examines the critical values of autonomy and mercy. The second explores the clinical, philosophical, and religious issues that underlie end-of-life practices. Part three examines practice in Oregon and the Netherlands. The last section deals with some of the legal and political turmoil that has surrounded the debate on Physician-Assisted Dying in the United States.

The opening chapter by Marcia Angell in an impassioned statement, based around the tragic circumstances of her father's suicide, that Physician-Assisted Dying should be legalized and that "many people would choose [it]". But in Chapter 11, where Linda Ganzini reviews the Oregon data, it is seen that only between one-third and one-half of one percent of patients dying of cancer in Oregon have availed themselves of the State's legalized Physician-Assisted Dying.

The chapter on patient autonomy deals with just that, and does not adequately address what effect legalizing Physician-Assisted Dying might have on the autonomy and rights of other people in society.

There are several chapters that discuss the Dutch practices, focusing particularly on the one thousand patients a year who are euthanased without specific request. [The fact that, according to the figures published by the Dutch, the incidence of non-voluntary euthanasia is a multiple of that number is not discussed]. But back to the one thousand. We are told that these patients had either expressed a wish for euthanasia at some time in the past (current wishes were not important) or they were incompetent. That's not what the published data says. We are also told "In a number of cases [in which patients were euthanased without explicit request] the decision had been discussed with the patient." That's a new twist.

Mention is made in several chapters that, as a result of the open and honest system they have, the incidence of non-voluntary euthanasia is lower in The Netherlands than in other less advanced countries, including Australia. These studies (e.g. Kuhse et al) are based on deliberately ambiguous questions that have been publicly discredited. I received a questionnaire last year, based on the Dutch format, for the International Collaborative Study on End-of-Life Decisions in Medical Practice. It asked the question regarding a patient in pain "Would you intensify the alleviation of symptoms by using drugs, taking into account the possibility or certainty that this could hasten the end of the patient's life?" So a good doctor, practicing good medicine, carefully titrating drugs to improve patient comfort, could or would be recorded as taking active steps to hasten death. So much for all those reports.

This is a worthwhile book and, given that any discussion has more than one side, I would recommend it to anybody with an interest in the debate about Euthanasia and Physician-Assisted Dying. But it did nothing to change my views, particularly about the Dutch practices. There are repeated references throughout the book that, if you just think about it properly, there is really no difference between hastening death and letting die. Death is a natural end to a life and will come to us all. Killing is something else. Or that's what I think.

Roger Woodruff (May 2005)

2005

A Dutchman came to see me last week. In his 80s, but mentally very on the ball. Towards the end of our meeting, he said, 'I want you to know that I am a very strong proponent of euthanasia.' This, it turned out, evolved from watching his father die slowly over a ten-year period in a nursing home, blind and deaf. It sounded awful to me but I avoided asking how many courses of antibiotics and other life-prolonging measures had been administered during that time. When I suggested that modern palliative care might go a long way to preventing the pain and psychosocial suffering associated with a terminal illness, he was unmoved. He was both a fervent autonomist and scared of dying the way his father had.

This book is about the way philosopher Professor Margaret Pabst Battin thinks we should now move on from the currently polarized debate about physician assisted-dying, and along the way she presents a lot of interesting information about the way people die. She starts with the present for-and-against debate, exploring some of the issues in depth. The middle section of the book describes the influences of historical, religious and cultural concerns, touching on a wide variety of topics from serpent-handling to suicide bombing. The final section is titled 'Dilemmas about Dying in a Global Future' and deals with issues related to increased life expectancy, genetic prognostication, and 'NuTech' methods for committing suicide, before coming to the predictable conclusion that physician-assisted dying will come to be accepted as our culture changes.

In her introduction, Battin urged me not to address the issues surrounding physician-assisted dying in 'all or nothing' terms. But I failed to reach the required standard. I felt that her description of the Dutch practices was somewhat selective. I was encouraged to pass over the 'notorious 1000' patients who are euthanased each year without current request or consent. The clinical facts, as published by the Dutch authorities, is that the true number is a multiple of this when you include deaths related to treatment of pain and symptoms given with the intention of hastening death and deaths related to withholding or withdrawal of treatment done with the intention of hastening death, many of whom were euthanased without request or consent. A more detailed appraisal of Dutch practices can be found in John Keown's Euthanasia, Ethics and Public Policy (Cambridge, 2002) and The Case Against Assisted Suicide edited by Foley and Hendin (Johns Hopkins, 2002), but I couldn't find reference to either volume. And just to set the record straight, the Australian data on physician-assisted dying published by Kuhse, which is quoted, was based on unethical and ambiguous questions and was discredited years ago.

On the other side is the possession of personal autonomy. I am somewhat bemused that this is such an important and central tenet in the physician-assisted dying debate when we all relinquish bits of personal autonomy all the time, every day, because we live in a society. And what about the data from Oregon, where it is legal to exert your personal autonomy and receive physician-assisted suicide? During the four-year period 1998-2001, there were about 20,000 deaths from cancer in Oregon. Now if 60% of Oregonians voted in favour of legalizing physician-assisted suicide that might lead to as many as 12,000 requests. But during that period there were only 70 deaths by physician-assisted suicide of patients with cancer - which is one-third of one percent. There are more complex issues at work.

And just a word about suicide bombing. Forgetting the historical context from centuries ago, should we really "see these actions as defensible cases of martyrdom" in the twenty-first century? This might be appropriate analytical thinking for philosophy departments, but I wonder whether a lot of people down here on earth would agree.

This book is well-written and certainly thought-provoking. I would not hesitate to recommend it to anyone with an interest in the debate about physician-assisted dying or the historical and cultural origins of the way people die. I learned a lot of interesting things along the way and was entertained by Battin's fictional essays. But would something as simple as improving pain control lead to fewer and fewer requests for physician-assisted dying? My Dutchman expects perfect pain control and euthanasia. And was I swayed towards legalizing physician-assisted dying? Not a bit.

Roger Woodruff, November 2005

This is a collection of expert reports on end-of-life issues from twelve disparate countries - Brazil, China, Germany, India, Israel, Japan, Kenya, the Netherlands, Taiwan, Turkey, the UK and the USA - representing East and West, developed and developing countries. The topics covered in each chapter include health care costs, where people die, the use of advance directives, the cut-off point for aggressive care, and policies regarding euthanasia and physician-assisted suicide, allowing the reader to make comparisons. Particularly interesting is the influence that history, culture and religion bring to care of the dying and, in more recent times, the HIV/AIDS epidemic.

Many interesting questions are raised. Have structural adjustments mandated by the World Bank and the International Monetary Fund, that place more emphasis on curative care than on public health programs, actually reduce the standard of health care in places like Kenya? As is to be expected, the quantity and quality of the data varied widely across the spectrum of countries.

Needless to say, I read the chapter on the Netherlands with keen interest. Overall, ten Have provides a balanced discussion but to argue that euthanasia is controversial and not an established practice does not sit well with all the data that has come out of Holland in the last 20 years. And for the Dutch government to insist that the law does not legalise active euthanasia, but merely provides a punishment exclusion ensuring that physicians will not be prosecuted. That doesn't really wash, either.

But I came away with a new word. Dysthanasia is a Brazilian term for the unnecessary prolongation of life, at all costs, when death is unavoidable.

Roger Woodruff, April 2007

Originally published in 1997, this edition has been up-dated to mid-2005 by American attorney and euthanasia expert, Wesley Smith. He describes the progress of the euthanasia juggernaut, which he describes as a death fundamentalism, and warns against the gradual decay of essential human values. The movement has changed from using the term euthanasia to 'Aid in dying', or 'Deliverance', or 'Gentle landing'. Individualism, Choice and Control are the buzzwords. He discusses the deeds of Jack Kevorkian and Australia's Philip Nitschke, the latter involving the infamous case of Nancy Crick. Said to be suffering from terminal cancer, hers was to be a widely publicized suicide, loudly applauded by the advocates of euthanasia, but at autopsy she didn't have cancer or any other serious physical illness.

In the next chapter, he goes on to argue that we are creating a caste of disposable people. Nancy Curzon and Terri Schiavo feature here. The question boils down to whether or not life should be preserved for life's sake, but I worry that after 10 or 15 years of persistent vegetative state, we might be guilty of prolonging suffering.

Smith then turns his sights on the Germans and describes how euthanasia was alive and well long before the Nazis came to power. He draws some worrying comparison with present trends. In his chapter on Dutch practices, which he describes as something much steeper than a slippery slope, he attempts to show how the rules (and now the legislation) were drawn up to legitimize behaviour.

Smith fervently believes that euthanasia betrays the morality inherent in medicine and says that euthanasia together with profit-driven Health Maintenance Organisations, with their emphasis on controlling costs by limiting services, make a deadly combination.

In the final chapter, Smith argues the pros and cons of creating a 'right to die' based on three questions.

Is there a deep and dividing need for this proposed revolutionary change that cannot be met through other means?

Are the expected benefits of the change worth the foreseeable risks of the change?

Would the change be progress?

This is a well-written, thoughtful and provocative book. Perhaps a touch over-dramatic in places but the 'no holds barred' approach appealed to me.

Roger Woodruff(April 2007)

This book escaped my notice when it was first published and was brought to my attention by the robots at Amazon.com. The authors, who spent twenty years observing and writing about the Dutch euthanasia movement, studied medicine and philosophy (HtH) and medicine, philosophy and law (JW). It provides a good history of the medical, social and political aspects of the debate, with more background information about what else was going on in Holland at the time than you would find in the medical literature. There are chapters providing a detailed analysis of Dutch euthanasia practices as reported, the response of the legal system, and an assessment of the ethical aspects of the debate. The final chapter is about what lessons can be learned from the Dutch experience, which should be read by more people involved in the debate in other countries. Their description of all the manoeuvrings on the part of the proponents of euthanasia, how medical acts were re-defined, re-classified and re-interpreted over the thirty years, makes fascinating reading.

And the title? It stems from their observation of the paradox that one of the origins of the euthanasia movement was to empower the patient rather than the doctor, but they have ended up with a system in which the doctor is all-powerful.

This book reinforces my views that euthanasia as practised in The Netherlands is neither controlled nor controllable. And remember, this book was published before the recent surge in deaths from terminal sedation reported from Holland. If you have an interest in the euthanasia debate and, like me, you missed this book when it was published, it's a must read.

Roger Woodruff (October 2014)
2006
William Colby was the lawyer who represented Nancy Cruzan in the first right-to-die case heard by the U.S. Supreme Court. Nancy died after being in a persistent vegetative state for 8 years, but 4 years after her family unanimously agreed that her feeding tube should be removed. Here, Colby dissects the implications of the case of Terri Schiavo, who suffered irreversible brain damage in February 1990 but wasn't allowed to die until Easter 2005. The first part of the book is about the bitter feud that broke out between Terri's husband and her family and the years of legal wrangling that ensued. It is very well written and I found it hard to put down. When the courts finally said Terri's feeding tube could be removed, Florida Governor Jeb Bush stepped in and over-ruled them with legislation that was dubbed 'Terri's law'. The law was immediately declared unconstitutional by the courts, but it took another eleven months of appeals before the Florida Supreme Court unanimously ruled it to be so. When that failed, legislation was hastily pushed through the Senate and House of Representatives, which brother George got up to sign at 1.00 in the morning.

But let's be fair to Colby. This book is about the ramifications of Terri Schiavo's case and it is well-researched and well written. How does a modern society grapple with cases like this? He provides a good description of the rapid advances made in medical technology over the last 50 years, followed by the advent of Living Wills and the like. He manages to provide a view of the problems from the point of view of ordinary people, health care professionals, spiritual leaders and legislators. The views of Pope Paul II and the infamous Dr. Kevorkian feature too, as does the Oregon physician-assisted suicide program. Hospice and palliative care are described as the jewel in the crown. To his credit, Colby never seems to take sides. He even has empathy with the demonstrator carrying a placard saying "Hospice Auschwitz". Fascinating reading.

Roger Woodruff (March 2007)

A Harvard law graduate with a doctorate in legal philosophy from Oxford University, Gorsuch examines in detail all the political, legal and philosophical goings-on surrounding the debate about legalizing physician-assisted suicide and euthanasia in the United States. It is very well researched and clearly written. His arguments are clear and substantiated. His description of practices in The Netherlands is unforgiving, which is exactly how this reviewer thinks it should be. The last part of the book deals with Gorsuch's moral and legal argument against legalization based on the idea that human life is intrinsically valuable and that intentional killing is always wrong, whilst leaving latitude for patient autonomy. While Gorsuch's views are clear, his dissections are balanced, and this book should be read by supporters, opponents and the undecided.

Roger Woodruff (June 2007)

David Kelly is professor emeritus of Theology and Health Care at Duquesne University in Pennsylvania. He brings a rich experience to this discussion of ethics in end-of-life care. I was particularly interested in the historical perspective - one is always a little surprised to be reminded how much things have changed during one's own professional lifetime. The case of Theresa Shiavo and the Papal allocution of 2004 feature prominently. However, Kelly does not dodge any hurdles and argues cogently for what he believes is ethically correct. He believes strongly that some life-sustaining treatment is ethically optional and may be withheld, and that there is a clear difference between actively killing dying people and allowing them to die. Who should make the decisions, and how they should be made, are discussed at length. This is an excellent guidebook for anyone interested in ethical decision-making in end-of-life care.

Roger Woodruff (June 2007)

This book is about how we can help our loved ones die in peace. The focus is on life and 'how its waning days could be peaceful and pain-free, and how caring for people at their most vulnerable can be an incredibly fulfilling experience'. It is not about physician-assisted death or grief and bereavement or cultural variations, it is about helping people get the most out of the last bit of their lives.

I was impressed. Written by a professional journalist, an enormous amount of research must have gone into writing this book. His investigative insights are sound and it is a good read.

With lots of stories about patients and their families, Kiernan paints a picture of what happens now and what might be, from the perspectives of the families, the patients, and the professionals. There are a range of suggestions for policy makers, the profession, and the public at large as to how things could be improved.

Enjoyable and insightful.

Roger Woodruff September 2011

2007

Donald Horne (1921-2005) was a well known Australian author and academic who came to prominence in 1964 with the publication of The Lucky Country, an evaluation of Australian society that questioned many attitudes.

Suffering terminal pulmonary fibrosis, Dying is his record of the experience of dying. It is a remarkable journal in which memories of his well-lived years sit alongside his unflinching view of their end. Ever the intellectual, he also recorded his last thoughts on such matters as faith and regret, the rewards of the engaged mind, the Iraq War, and the meaning of democracy, which are included as essays. There is also a poignant memoir of his last few weeks by his wife and long-time editor, Myfanwy.

Roger Woodruff (January 2008)

This little guide is written to help people facing decisions about taking a loved one off life support. Written by an emeritus professor of religion and social ethics from the UK (TS) and a Franciscan friar and Catholic priest from Chicago, Illinois (CF), it clearly sets out the steps that have to be taken. It is written simply and in a very warm and supportive manner. It also includes an ecumenical prayer service, with a variety of readings and prayers from Hebrew and Christian scripture, which could be used before life support is withdrawn.

Roger Woodruff(April 2007)

This book is written for the lay reader, presumably the patient with a terminal illness or a member of their immediate family. It covers two broad areas. The first is about appropriate life-prolonging therapy with patients with a terminal illness or conditions like irreversible dementia. Some of the examples given beggar belief. Wanzer's own totally demented, 92 year old mother, with a documented advance directive against invasive procedures, had a cardiac pacemaker inserted and was sentenced to live on for another five years. The totally demented man who had a hip replacement because he had a fractured neck of femur. Etc, etc. I have no problems with the arguments here.

The second issue relates to the need to legalise physician-assisted dying in the face of intolerable suffering and the presence of a terminal illness. Here I have problems. Wanzer correctly states that this is a situation that one might encounter once or only a few times in a professional lifetime, but I am concerned that a patient or family member reading this would assume that their risk of encountering intolerable suffering was high. And who judges 'intolerable'? Over the years, I have seen hundreds of patients (if not more), referred with intractable symptoms and unrelieved suffering. But with attention to detail and the help of the multidisciplinary team, their symptoms and suffering were brought under good control. So whilst you might entrust someone as experienced as Dr. Wanzer, to give the same powers to all doctors, many of whom have little experience in symptom control or end-of-life treatment, is a concern. He points out that the experience in Oregon shows no evidence of a slippery slope, but I would contend the Dutch have shown otherwise. He does not point out that the intractable suffering of the Oregon patients was largely psychosocial rather than physical/medical. And, of course, the results of public opinion polls are trotted out in support. As in most countries, these are basically 'Do you want your loved one to die in agony or legalise physician-assisted suicide?' No one should die in agony, but my experience is that with good palliative care and multidisciplinary support, the incidence of intolerable suffering is extraordinarily low.

I have no doubts about Dr. Wanzer's sincerity and he has done a lot to advance the discussion on end-of-life issues within the profession. His arguments about appropriate therapy? Long overdue. But physician-assisted dying? Neither necessary nor desirable.

Roger Woodruff (January 2008)

Has modern scientific medicine put curing the body before caring for the person? I guess most palliative care workers would think so. The opening chapters trace the historical and religious origins of this issue. Chapter 3 focuses on the treatment of cancer as an example to demonstrate the strengths and weaknesses of modern scientific medicine. The following chapters detail the development of palliative care and pain control. The last chapter is about the history and present status of the euthanasia movement. As has happened before, I did not entirely agree with everything I read in the chapter on euthanasia, but the historical descriptions of what happened in the late 19th and early 20th centuries were most interesting. This book will be of interest to anyone who works in palliative care and anyone interested in end-of-life issues.

Roger Woodruff(July 2007)

2008

Written by three academic lawyers from the Netherlands and Belgium, this book describes recent trends in the practice of euthanasia and physician-assisted suicide, the evolution of the associated law, and systems of control for these practices. The prime focus is on the Netherlands, with a smaller section on Belgium, where legislation to legalise euthanasia was passed more recently. The third section details what is known about practices in other European countries. The book is detailed and well researched, if not light reading.

This is an excellent book that should be read by anybody with an interest in the debate about euthanasia and physician-assisted suicide, but the data presented does not ease my concerns about practices in the Netherlands. They report a recent reduction in the number of patients treated by euthanasia without request and in the number of euthanasia cases overall. But these seem to be balanced by a rise in deaths associated with 'palliative' sedation. (It was called 'terminal' sedation, but was changed to 'palliative' probably because it sounds nicer). When last surveyed, Dutch doctors said they used 'palliative' sedation for the purpose of hastening the patient's death in 50% of cases. But, in classifying the types of deaths, we are told the Dutch have now moved past worrying about the doctor's intention. To me, there is a huge difference between giving sedation to a terminally ill patient and carefully titrating it to control clinical symptoms, and using larger doses with the intention of hastening/precipitating the patient's death. The Dutch need to provide data on patients dying with 'palliative' sedation-what drugs were used, what doses were given, and what the intentions were. That would be interesting, very interesting. Could the fact that deaths occurring with 'palliative' sedation do not attract the same legal reporting requirements as deaths associated with euthanasia and physician-assisted suicide be relevant?

The other major theme in this book relates to the system of legal control. Griffiths, who is responsible for 'a substantial research programme on the regulation of socially problematic medical behaviour (RSPMB)', describes in some detail all the legal and legislative activity that has been designed to tighten the rules. As a physician, not literate in matters legal, I was left wondering whether they were really making headway or whether the Dutch had actually dug themselves a very deep hole. And legal rules need punitive teeth to be effective. When I last reviewed the results of Dutch trials regarding euthanasia/murder, I was amazed at the almost complete lack of punishment for those found guilty. Dr Van Oijen's case (described on pp 40-41), involved a hearing by the Medical Inspectorate following which he was tried for murder (in the District Court, the Court of Appeals, and finally the Supreme Court) and found guilty, for which he was given a conditional fine of 5,000 guilders (about €2,250).

Roger Woodruff (February 2010)
CHOOSING DEATH Should medicine's last 'last resort' be legal?
The Hastings Center Report Volume 38, No. 5, September-October 2008

see http://www.thehastingscenter.org/Publications/HCR/

The September-October 2008 issue of The Hastings Center Report has a collection of four essays exploring the issues in the debate on physician-assisted death. Timothy Quill and Margaret Battin give the appearance putting forward balanced arguments, seen from both sides, but this is really a veil and their stance is obvious. Timothy Quill admits physician-assisted death is imperfect, whilst arguing strongly about its necessity. Margaret Battin equates terminal sedation with 'pulling the sheet over our eyes'. I have not been convinced by their arguments in the past and remain unswayed, but their essays are worth reading for any student of this debate. Susan Wolf's essay is about her own father's terminal illness and death and the personal anguish she felt; but on later reflection is very content that physician-assisted death was not employed. The jewel in the collection is Daniel Callahan's essay on advocacy for physician-assisted suicide, which he describes as 'organised obfuscation'-an effort to render something unclear, evasive or confusing. This is a pleasure to read, as he clearly and concisely reduces the marketing of physician-assisted death to just that-organised obfuscation. He concludes '...the way single-minded advocates can foul the waters of public debate. Stirring up some verbal muck can work wonders for a bad cause.'

Roger Woodruff (July 2009)

Here is another book to be recommended to anybody involved with the debate about euthanasia and physician-assisted suicide, although many may not agree with what is said. Rodney Syme is a Melbourne urologist who has been at the forefront of the push to legalise physician-assisted death in Victoria and has served as the president of the Voluntary Euthanasia Society of Victoria, now sanitised to Dying With Dignity Victoria. The book recounts some of his clinical experiences over the years, from which he develops his arguments to challenge the legal and legislative fraternities and take a swipe at the palliative care community.

I was a bit put off by the style. The clinical histories are described in a melodramatic way and I didn't like the repeated use of exaggerated adjectives-anguished signature, progressive ravages, remorseless progression, etc. And the blind lady who bid him farewell as he vanished into the darkness?

I was a little more off-side when labelled a hypocrite because I didn't agree that 'the intention of a doctor [using terminal sedation] to relieve intolerable suffering is no different from that of a doctor who provides or administers medication that causes death quickly.' I beg to differ. He argues that patients treated by 'pharmacological oblivion' (his term for terminal sedation) should be subject to coronial enquiry. I was unconvinced by his argument that terminal sedation, not possibly, but always hastens the patient's death. In contrast, he says our more enlightened Dutch colleagues acknowledge that voluntary euthanasia will hasten death. Should do, if they do it right.

I was a little confused on the autonomy thing, which is a strong theme that runs through the book. He describes Philip Nitschke's computerised injection technique as 'allowing that person to control totally the delivery of the lethal medication.' Not after they click on 'Yes'. And 'the Dutch experience'-the 1000 patients a year euthanased without request? I don't think it was mentioned.

I was more confused by his attitude to palliative care. He states on several occasions how much he supports it, but describes the palliative care process as intrusive for the patient and family, and palliative care professionals with 'the mindset' (not agreeing with his views) as hypocrites. He describes as laughable Michael Ashby's statement that '... intentional ending of life is not part of palliative care practice and is different in kind from all other clinical intentions.'

Overall, the book is rather predictable. There are the usual references to polls, the surveys of professional behaviour (since discredited because of ambiguous questions), recounting of terrible end-of-life stories, and quotes from the usual suspects-Timothy Quill and Marcia Angell, for example.

On reflection, Syme gives some good examples of why physician-assisted death should not be legalised. Working alone, facing patients with severe suffering, he repeatedly admits feeling professionally inadequate. What did he do when he visited the family friend, not under Syme's care, dying of cardiac failure with severe breathlessness? Ordered the nurse to draw up the large dose of morphine (written up by the treating doctor), which he immediately administered by intravenous injection. What, I ask, will happen when doctors with less experience of end-of-life care than Syme are faced with similar suffering?

No sheep's clothing here.

Roger Woodruff July 2008

This book is to be recommended to anybody involved with the debate about euthanasia, although not all will agree with what is said. Written by a moral philosopher (Baroness Warnock) and a retired cancer specialist, this book sets out to provide a balanced discussion of what would be necessary for the legalization of physician-assisted suicide in the UK, to define what the issues really are. It certainly adds some intellectual tenor to the debate, although my reading was more than a little troubled.

I started off a little off-side when I read that I was one of those who were standing in the way of 'what society demands', trying to 'impose their convictions on the quiet majority'. The 2007 public opinion poll that is cited is not referenced, but when I last reviewed the public opinion polls from around the world, they mostly boiled down to 'Do you want to die in agony or legalize physician-assisted dying?' I have had a handful of serious requests for assisted-dying in 30 years of working as a medical oncologist and palliative care physician, which doesn't support what the newspaper polls tell us.

Then I stumbled at there being no morally relevant difference between killing someone and allowing them to die. I would contend that there is a great difference between accompanying a dying patient, allowing them to die and not artificially prolonging their life, and giving them a premeditated lethal injection. I was quite unconvinced by their philosophical arguments that killing patients was really no different to what I now do and wondered whether theoretical moral philosophy should be confined within ivory towers and kept out of the clinic.

I tripped at their dealing with 'the Dutch experience'-the 1000 patients who are euthanased without request each year. This was to be neither a concern nor a reason not to change the law in the UK, because the figures were not reliable as information was hard to obtain; but if we had information on the 40-50% of cases of euthanasia that are presently not reported, the figure isn't going to be less than 1000 patients per year and may possibly be much higher. It was also implied that many of these cases were handicapped babies; my copy of the New England Journal of Medicine indicates that more than 50% of the patients subjected to non-voluntary euthanasia were 65 years or older in the 1995 and the 2001 surveys.

I baulked at their reassurance that there is no evidence of increased assisted dying for vulnerable groups (the disabled, elderly and those with psychiatric illness) in the Netherlands; as we only have information on a little over half of the cases, such a conclusion is speculative. The reports from Darwin and Oregon reveal a preponderance of socially isolated individuals who could be described as a vulnerable group, but this is not discussed.

I was uncertain which way they wanted to go on the slippery slope business. Early in the book, they argue at length that slippery slopes don't exist but later conclude that future legislation will only succeed if it has guarantees against such slopes.

Does it present balanced arguments? I think not. In the end, I felt this book was a bit of a wolf in sheep's clothing and wondered whether there was a philosophical position on the honesty of wolves.

Roger Woodruff July 2008

2009

'Autonomy is a vital principle in medical law and ethics, but there is a dangerous presumption that it should have the only vote, or at least the casting vote. This book is an assault on that presumption, and an audit of autonomy's extraordinary status.'

Written by a London barrister who also teaches medical law and ethics at the University of Oxford, this is a book about medical law, not a treatise on medical ethics. Foster discusses a range of contentious issues from reproductive technology, to abortion, to confidentiality and consent, and, needless to say, euthanasia. In a style both entertaining and informative, Foster turns his gaze on the views of autonomists, pointing out where they are valid and where they have been carried way too far, particularly in relation to the debate about euthanasia and end-of-life decision making. I particularly liked his list of the 'many reasons why autonomy, if it were consistent, would oppose euthanasia/physician-assisted suicide'.

I had trouble putting this book down. If you have an interest in medical ethics or are involved in the debate about euthanasia/physician-assisted suicide, it comes strongly recommended.

Roger Woodruff (March 2010)

This is a clearly written review, concise but thorough, of the pros and cons of legalising physician-assisted suicide (PAS) in the UK viewed from the perspective of palliative care. Jeffrey does an excellent job of presenting both sides of the argument, but fudging, double-talk and euphemisms are given their due. I hadn't been aware of the significant recent increase in deaths associated with deep sedation in the Netherlands, possibly related to the fact that such deaths do not attract the same legal reporting requirements as deaths associated with euthanasia and PAS. Anybody who has an interest in the debate about PAS and euthanasia should read this book.

Roger Woodruff (February 2010)

This book was a pleasure to read. As in their previous volumes, Randall and Downie have the ability to write clearly and to develop arguments that are logical and transparent, all of which is a refreshing departure from a lot of the stuff published on euthanasia and physician-assisted suicide.

The first part of the book is about choices and argues that the best interests of patient are promoted by means of the traditional aims of medicine: to prolong life, to alleviate suffering, and to restore or maintain function, but they draw a clear distinction between patient choice and what might happen if patients are simply regarded as consumers with end-of-life services run on consumerist lines. In their no nonsense way, they state that to understand decision-making in end-of-life care requires us to distinguish between intended and foreseen consequences, between acts and omissions, and between killing and letting die. And the arguments of Mary Warnock and others are chopped up despatched.

Part two of the book is about issues in end-of-life care that are controversial. Is advanced care planning, as we know it today, the right way to go? Does it promote unrealistic patient expectations, does it cause avoidable emotional distress? They asked whether we should be asking a different question regarding the preferred place of care and death. The chapter on physician-assisted suicide and euthanasia debunks the arguments that some morally acceptable practices are equivalent to euthanasia and confronts the 'dignity' and 'right to die' arguments head-on. The 'human rights' issue casts a shadow, but one can argue that it has been taken too far in many fields besides end-of-life care.

A substantial appendix on ethical theories and terms is available on-line.

The material in this book is well-presented and articulate. If you are going to delve into these matters only once this year, this should be the book.

Roger Woodruff August 2011

2010

Much has been written about the terrible story of Terri Schiavo, who in 1990 suffered a cardiac arrest that led to a persistent vegetative state, but was not allowed to die until March 2005. In Goodman's words '...when politics intervened, the Terri Schiavo story turned from tragedy to farce ... a riot of kooky views and political vehemence.'

But this is a very serious book that sets out to dissect what we can learn about end-of-life care and decision making from this case. The ten essays in this volume are written by a range of experts including ethicists, medical specialists and attorneys and cover the moral, ethical, medical, religious and legal aspects. One can argue that there should not have been a political dimension. The role of the media 'to agitate and inflame public sentiment' is rightly criticised in the final chapter.

One little fact that I had not been aware of was that the Congress of the United States subpoenaed the permanently unconscious Ms. Schiavo to appear and testify. Hmmm.

Roger Woodruff (March 2010)

2011

This is an informative and practical guide to the issues involved in end-of-life care, be they the needs of the patient and family or matters that are of concern to professionals or institutions. It focuses on end-of-life care for our ageing population and is primarily directed at mental health professionals. But much of what is written is applicable to adults of any age and I think it should have a much wider audience than just mental health professionals. I think it would be of interest to palliative care professionals and to anyone involved with end-of-life care for older adults. There are good discussions on spirituality and meaning, advance care planning, grief and bereavement, professional self-care, and changing attitudes and behaviours (with regard to end-of-life care) in communities. I like the book because it was clinically practical, written by practicing clinicians, with due regard to the evidence base (such that it is), but without any long-winded discussion of theory.

I particularly liked Canetto's clear dissection of the 'model statute' that underpins Oregon's Assisted Suicide legislation, showing it to be 'far from being carefully crafted.'

Roger Woodruff (April 2011)
DEATH WITH DIGNITY Legalized Physician-Assisted Death in the United States 2011 Stuart C. Goldberg Esq.
No publisher cited

ISBN 978-1463 65084 1

Written by an attorney, this is a self-help manual for Oregonians and Washingtonians to help them understand and use their (wonderful, new) Death with Dignity Acts, and a guide for people and legislators in the other 48 states who want similar laws. I thought it was a bit macabre, certainly sad.

Viewed from afar, the absolutely miniscule number of people who have committed suicide under the Oregon Act, together with the fact that many were categorised as possibly being able to be helped by other compassionate interventions, brings into question the need for these laws.

In Australia, voting is compulsory. If you are 18 or over, you vote. So, if a referendum for physician-assisted suicide was passed here, I would have to sit back and acknowledge that that was what more than 50% of the population wanted. I have not seen the voter turn-out figures when these Acts were passed, but I suspect they were not high.

I was amused by some of the detail. Were I to give a patient a supply of lethal medication with which they subsequently took their life, the terms 'suicide' and 'assisted suicide' would certainly come into it. But to call it that is against the law in Oregon. Reminded me of Humpty Dumpty in Through the Looking Glass.

I suppose people working in palliative care need to know the book is out there.

Roger Woodruff (February 2012)

I didn't find anything new in this book. It is a tirade of facts, aligned to demonstrate that he is correct, and I thought the occasional derogatory comment to those who hold a contrary view were unnecessary. There is a lot of trumpeting of the results of public opinion polls; much has been written on how meaningless they may be. To give him his credit, he raises the possibility that the recent increase in palliative sedation in the Netherlands might be doctors practising euthanasia without all the bureaucratic hassles; given the reports that palliative sedation is used with the intention of hastening death, I would have though that to think otherwise would be naïve.

Roger Woodruff March 2011

This review is written by an octogenarian emeritus professor of political science who states 'I have arrived at a stage in my life when the issue of dignified and compassionate end-of-life care is of more than theoretical interest.' The focus is on how the systems are working rather than the pros and cons of euthanasia and physician-assisted suicide.

Lewy seems satisfied with everything in the Netherlands. He doesn't confront the issue of intent. When the Dutch were challenged about whether intent mattered, they stopped reporting it. He mentions euthanasia without request or consent, but seems to gloss over it. Reading the journals, it would seem that the recent reduction in euthanasia in the Netherlands has been balanced by an increase in 'terminal sedation', and in the majority of cases it was the doctors' intention to hasten death. The difference is that terminal sedation is not subject to the same stringent reporting criteria that apply to euthanasia. In short, it's pretty much all tulips in the Netherlands.

I was startled by the statement that 'among European physicians, Dutch doctors are now considered the best trained in [palliative care]'. I thought a few people from across the Channel might have something to say about that.

Lewy's view of euthanasia in Belgium is up-beat, with few criticisms. What happens in Switzerland is anybody's business, with Exit and Dignitas coming into conflict with government recommendations. The discussion of physician-assisted suicide in Oregon touches on some of the problems, but does not provide any arguments to counter the criticisms levelled by Kathleen Foley, Herbert Hendin, John Keown and others. I am afraid his last chapter, 'Assisted Death as a Last Resort' did not hold much water.

I don't doubt Lewy's scholarship or sincerity for one moment, but I found the conclusions he reached were curious. I am uncertain whether this relates to non-medical eyes or to the focus being on the regimes rather than the practices. I would recommend this book to anyone involved in the euthanasia debate as an example of how an intelligent but non-medical person can interpret the data that is out there.

Roger Woodruff August 2011

2012

'Americans are scared to death of dying.' That is the starting point for Ira Byock, one of the leading voices for palliative care in the USA, to take us through the problems in the health care system and in society that result in so many people dying badly or in suffering. These problems will increase as the older population begins to outnumber the young. Medical suffering aside, I was surprised by the statement that, even before the recent recession, 'well over a million American families annually filed for bankruptcy due to health care costs.' Byock, with the use of clinical vignettes and a lot of personal experience, explains how things might be done better, whilst admitting that it would be tantamount to a revolution in health care. His appeal is for better treatment of people with advanced disease and the dying, but he has no problem with the co-existence of medical excellence and tender human caring. Well-told, this book advocates strongly for the need for change in the way we look after people at the end-of-live. And although written about America, many of the matters discussed apply to other 'developed' countries. It was a pleasure to hear Byock speaking out about matters that concern many of us.

Roger Woodruff (May 2012)

Two heavyweights address the question of euthanasia, without knowing what the other has written. Emily Jackson is Professor of Law at the London School of Economics. Professor John Keown, who formerly taught law and the ethics of medicine in the Faculty of Law at Cambridge University, now holds the Rose F. Kennedy Chair in Christian Ethics in the Kennedy Institute of Ethics at Georgetown University.

The argument for change is made by Emily Jackson, who maintains that the case for status quo is indefensible, and I was left feeling she would know a number of ways in which I could be made a better person. She starts with a number of quotations from the emotional, highly-publicised cases, arguing that the law should be changed to accommodate the exceptional few; as a physician, I was led to believe that laws developed on exceptional cases were usually not good law. She argues against the various claims that change would be bad, but her recommended solutions are quite impractical. The need for a consistent request is self-evident, but the way she writes might lead you to think that doctor-patient interactions are black and white, clear-cut, and immune to all outside pressures on either party; the opposite is true. Her caveat that the patient is mentally competent is also self-evident, although how to establish this continues to worry the psychiatrists of Oregon and the UK. She advocates a social support 'filter' and a palliative care 'filter', but exactly how these would function is not defined. Given that no two patients present the same problems, it would be extraordinarily difficult and expensive to set up; from the clinical standpoint, it would verge on the impossible. I enjoyed reading her well-written and well-argued chapter, but nothing she said led me to think that a change in the law would be a good thing.

In return, John Keown (Euthanasia, Ethics and Public Policy, Cambridge University Press, 2002) quietly addresses the major reasons for changing the law - autonomy, legal hypocrisy, a right to suicide, compassion, and public opinion - and rebuts them all. Discussion of what is happening in the Netherlands and Oregon doesn't lessen his argument. In particular, he notes that the apparent recent decrease in euthanasia in the Netherlands has been accompanied by a parallel increase in the use of terminal sedation, a procedure that does not involve the same regulatory and red-tape requirements as euthanasia. He goes on to dissect two of Emily Jackson's recent papers and points out the fundamental flaws of the Joffe Bill.

A concise and excellent summary of the current state of play in the debate about assisted dying.

Roger Woodruff (January 2012)

This is an important book for anyone with an interest in euthanasia and physician-assisted death (PAD). It is a collection of essays written by 'the leading Dutch scholars and clinicians who shaped euthanasia policy and who have studied, evaluated, and helped regulate it'. So, this is the Dutch themselves telling us why they did it, how they did it, how they regulated it, and how good it is. Once I started reading it, I had trouble putting it down.

The cast of contributors is interesting. Youngner is a psychiatrist from Cleveland, USA. Kimsma describes himself as a 'practicing physician and philosopher'. Of the other 20, there are six doctors (two neonatologists, one epidemiologist, one ethicist, one psychiatrist and one public health specialist), plus three philosophers, three sociologists, two historians, two lawyers, two political scientists and two psychologists. Not your average crew from the medical coalface, I think they are what Cohen-Almagors (p.100) calls the 'euthanasia elite'-the people who drive the agenda. I felt none of them would hesitate to tell me how I could be made a better person. People and organisations opposed to euthanasia because of the effect it might have on medicine, law or society are generally regarded as stupid, blind or hung-up on religion-which was one of the downsides of this book for me.

The book is divided into six sections: Background and History, Regulation and Practice Deficiencies, Quality Assurance, Learning from the Practice, the Challenge of Unbearable Suffering, and a concluding Overview.

But for all their talking and all the words here, I remain totally unconvinced that they have done a good thing or that they have got it right.

The unreported cases? Well, they decided there was too much emphasis on the physician's intentions in the earlier studies and switched to the drugs used. They hide behind the observation that opioids, properly used, may not be life-threatening and so opioid-related deaths are not euthanasia, which brings the proportion of unreported cases down very nicely. My understanding is that the same opioid drugs, improperly used, are lethal.

The rise in palliative sedation? In 2005 it was reported that there had been a fall in the incidence of euthanasia and assisted suicide, but there was a compensatory rise in palliative sedation. Were the Dutch doctors trying to avoid all the legal strings attached to performing euthanasia? Well, 'the 2005 study... was not designed to examine this [question]', but suggests that it 'reflects positive choices in favour of palliative sedation.' Now, if I had two clinical options that resulted in the same outcome (the death of the patient, in this case) and one required hours of talking and paperwork and carried a remote risk of prosecution, and the other had none of the above...

Euthanasia without explicit request? 'Observational studies on the characteristics of practice cannot be used to prove that physicians [who euthanase patients without explicit request] were right or wrong.'

The definition of unbearable suffering? This pillar of the Dutch movement is beset with subjectivity, but it is all settled if '[the doctor] grasps the public norm concerning unbearableness.'

Much is made of the wonderful Dutch system of general practitioners whom, it says, the patients trust with their lives and their deaths. We are reassured that a request for euthanasia changes the physician-patient relation to an even higher level and that this 'connection' allows objectivity in proceeding to euthanasia. This implies Dutch doctors never get tired, never feel anxious or depressed, are immune to all extraneous aggravations and always make calm and perfect judgements in their patients' interests. Oh, but ...'it is certainly possible that some physicians practice PAD without the emotional sensitivity that we have agreed is necessary...'

Euthanasia is the best form of palliative care? That's a bit close to the bone! 'Excellent palliative care and physician-assisted death may go together, both in practice and principle.'

The author of the last chapter acknowledges that most of the heady ideals of the 1970s, when 'the Dutch saw their country as a shining example for all the world to follow', have collapsed or backfired. But she declares herself to feel smug about their euthanasia policy, 'something we did really right.'

Did they? But it's fascinating reading!

Roger Woodruff (February 2013)

2013

Reports and publications from the Hastings Center have been influential in shaping and defining our professional attitudes to ethics of clinical care, particularly in regard to euthanasia and physician-assisted suicide (PAS) and other matters related to end-of-life care. This second edition of their Guidelines is very welcome and provides a clear and reasoned approach to the different clinical scenarios.

The book is divided into three parts. The first is about the ethics of good end-of-life care, the education competencies required, the organisational systems that should be in place, as well as socio-economic and legal factors. The second part deals with guidelines on care planning and decision making, including the decision-making process and guidelines for pediatric patients, care transitions, and for institutional policies. The third part is about communication in the support of decision-making and care. In addition to the straightforward cases, it includes interesting sections on supporting the decision-maker when loved ones disagree, how to approach a dying patient who has an implanted defibrillator, and the institution or withdrawal of a range of treatments from cancer chemotherapy to dialysis; it also includes a good discussion on the relatively new topic of palliative sedation.

I didn't find anything dramatically new or controversial; in fact, I didn't find anything with which I disagreed. But it's nice to have it all in one place. It's a pleasure to read as the material is logically sequenced and each statement or recommendation is justified-you feel each bit has been thought through and care taken to write it clearly. If you have an interest in the ethical underpinnings of what we do, this book is for you. If you teach about ethics and clinical practice, or are responsible for it at your institution, this is required reading.

Roger Woodruff (July 2013)

This book grew out of a 2008 UK Clinical Ethics Network Conference entitled 'The Value of Life, the Value of Death.' The editors, an academic lawyer and a philosopher, present a collection of ten essays written by a multidisciplinary cast, exploring some of the legal, ethical, moral, and social aspects of end-of-life care. The medical and nursing perspectives are not well-represented (or are viewed from an ivory tower), but there is a lot in this book to make you sit up and think. The chapter by Lord Justice Munby on the legal rights of terminally ill patients was a pleasure to read. Daniele Bryden asks whether the diagnosis of death, equating death of the organism with death of the person, needs to be re-defined for end-of-life planning and particularly when organ donation and retrieval are considered. John Erik Troyer explores the implications for end-of-life care of the constitutional changes wanted by the fundamentalist Christian anti-abortion Personhood groups in the USA. Would every patient have to have everything done, until they were dead? Hagger and Rehmann-Sutter advocate the need for liberalising assisted suicide in the UK along the lines of the Swiss model (which 'reflects clear support for patient autonomy') and provide help for anyone, regardless of the state of their medical health. Viewed as a clinician who deals with real patients, no two of whom are the same, I think it would be totally unworkable. Vincent Kirkbride discusses the escalating costs of health care in the last year of life, whether or not we should expect a right of access to expensive treatments, and the turbulent history of the National Institute for Health and Clinical Excellence (NICE) restricting the use of expensive new anticancer drugs. Wood's chapter on palliate care and the 'good death' seemed more about philosophy than clinical care. There are another two chapters about end-of-life care for children and a mother's account of the death of her daughter from Tay-Sachs disease.

Reading these essays will have no effect on your clinical skills, but it is good to be reminded of these other legal, social and philosophical views on end-of-life care. There's plenty to think about here, although it is a little on the expensive side.

Roger Woodruff (November 2013)

'The ultimate aim-and hope-of this work is that it will infuse the euthanasia debate with a level of intellectual honesty, transparency and accountability that up until now has largely been missing.' Great objective, but a big task, I would have thought. But that is the goal for Professor Megan-Jane Johnstone, who is Chair of Nursing at Deakin University in Victoria, Australia and is also a nominated Consultant (in Ethics and Human Rights) to the International Council of Nurses in Geneva.

This book is not about the pros and cons of euthanasia and physician-assisted suicide (it lands on neither side), but about the contorted, manipulated, political debate that is going on using conditions like Alzheimer's Disease to stoke the fire.

Johnstone provides a description of the disease, including its variable course, and goes on to discuss media constructions and representations of it, described in the Foreword as 'the best discussion yet available on metaphors, analogy, and the stigmatization or even demonization of the deeply forgetful.' Johnstone discusses in detail what has contributed to the extraordinary success of the euthanasia activists-their political activity, using propaganda and fallacious reasoning, sophisticated marketing strategies, and much more. This is not to say the anti-euthanasia lobby has not been guilty of the occasional dirty-trick or lie, but what is laid at the feet of the pro-euthanasia people is staggering. Her catalogue of the use of the epidemic, military and predatory thief metaphors is illuminating. I particularly liked her classification of the kinds of narratives used to bolster the illusion that euthanasia is right-'reassurance', 'uncertainty', 'helplessness', 'choice', 'control', and 'dignity'. Her analysis of what has appeared in the media seems objective, and at the same time is very worrying.

But I guess I'm biased, having seen thousands of patients dying with cancer whose greatest wish was to live a little longer, a wish so sincere that it would silence the activists who believe in beneficent euthanasia for any one with dementia; that is, if they listened.

So who should read this book? Certainly anyone with an interest in the debate about euthanasia, and in particular anyone who wants to make public comment. Starting with the moral philosophers, sociologists, politicians and other self-styled experts (beautifully categorized in the Foreword as the 'hyper-cognitives') who can emphatically address difficult questions like the legalization of euthanasia with certainty and conviction. Unfortunately, knowing all the answers, they are less likely to read it.

I hope Johnstone gets her wish-that euthanasia can be discussed in a more honest and sensible manner. Although reading some of the material in this book makes me worry that the debate has already been dragged down to the level of farce.

Roger Woodruff (December 2013)

This book is about the ethical and legal principle of the inviolability of human life, and not some theological discussion. It is divided into three parts. The first is about the history, influence and misunderstanding of the ethical principle, the second discusses aspects of the beginning of life, and the last deals with a number of issues at the end of life.

I found the first section a bit heavy-going, as though it was written for academic lawyers, who in fact are the intended audience. I skimped on the second, but the third part (comprising fully a third of the book) was unputdownable. He provides in-depth but readable reviews of the debate about the decriminalization of euthanasia in the House of Lords, the report from the Council of Europe and there are commentaries on the Pretty, Purdy and Bland cases. In the chapter dealing with the Mackay Report (House of Lords), he describes the debunking of two popular myths-that the great majority of our communities are screaming for legalisation of physician-assisted death now, and that we doctors are doing it all the time in secret. Keown also comes up with numerous pieces of evidence (from material supplied with the Mackay Report) that might have significantly strengthened the case against euthanasia. The evidence obtained about practices in The Netherlands include some eye-opening quotes from Dutch doctors, such as:

'it is the patient who is now responsible in the Netherlands for avoiding termination of his life; if he does not wish to be killed by his doctor then he must state it clearly orally and in writing, well in advance.'

...and

'Due consideration should be given to the question how termination of life without explicit request can be prevented. It should be the responsibility of the patients...'

His chapter on palliative care is about not wasting time and energy on the euthanasia debate, but focusing on the legal and professional reforms 'needed to help the 90% or more of dying patients who will never even vaguely desire euthanasia,' and includes pertinent discussions of whether palliative care is an ethical duty and a human right.

John Keown is well known in euthanasia circles. His previous contributions include Euthanasia Examined-An Argument Against Legalisation (1995) and Euthanasia, Ethics and Public Policy-Ethical, Clinical and Legal Perspectives (2002), both from Cambridge University Press, and Debating Euthanasia (Hart Publishing, 2011), and are all to be recommended. His attention to detail and clarity of thought are admirable, but he writes in a moderate and reasoned tone and in a manner easily understood whether you are a health care professional, lawyer, politician or just an interested member of the public. The Law and Ethics of Medicine is no exception and is recommended to anyone involved in the discussions about physician-assisted death and perhaps to those thinking about better strategies for advancing palliative care.

Roger Woodruff (November 2013)

2014

I think this is a remarkable book for a number of reasons. It is medically accurate and believable (Gawande is a surgeon at Brigham and Women's Hospital in Boston as well as a professor at Harvard Medical School and the Harvard School of Public Health), it is well written (he is a staff writer for The New Yorker), the arguments about what should and should not be our goals in caring for the aged and terminally ill are thoughtful and well constructed, and, most of all, because he describes the human foibles that we see every day in the real world, which can undo even the best-intentioned and careful end-of-life care planning.

Gawande's thesis is that high-tech modern medicine often fails the elderly or those with terminal illness-people it is supposed to help. 'The waning days of our lives are given over to treatments that addle our brains and sap our bodies for a sliver's chance of benefit.' Using some poignant biographical sketches of family members and a retired geriatrician, he describes the medical and societal changes of the last 50 years or so that have changed our attitude to and experience of aging and dying. He tells the story of the poorhouse, the aged care facility, the nursing home-'designed to be safe but empty of anything they care about'-a trend perhaps interrupted by the advent of assisted living.

The last three chapters deal with terminal illness and include the tales of several memorable patients including Gawande's own father with his cervical cord astrocytoma. Gawande paints a true picture of how the patients, their families, and their doctors stumble through the minefield of decisions and choices-sometimes getting it right, sometimes getting it wrong. Palliative care and home-based hospice are well described and their value demonstrated, although the point is made that hospice is often involved only in the last few days. And 'Which funeral service do you want to use?' is not a question I ask at the first visit. There is thoughtful discussion about how we should be communicating with these patients and their families, without being paternalistic or expecting patients to make decisions they are not qualified to make, but with guidance-the so-called shared decision making. But done right, it's never easy.

For anyone who works in palliative care, this book provides a thoughtful discussion about the problems we encounter regularly that rings clinically true. And it's enjoyable to read.

'We've been wrong about what our job is in medicine. We think our job is to ensure health and survival. But really it is larger than that. It is to enable well-being. And well-being is about the reasons one wishes to be alive.'

Roger Woodruff (November 2014)

This Report, by an expert committee convened by the Institute of Medicine (IOM) of the National Academies is about the universal provision of comprehensive care, including hospice and palliative care, for people with advanced serious illness who are nearing the end of life.

The brief for the committee was daunting. To assess the delivery of medical care, social and other supports to the patient and the family; patient/family/provider communication of values, preferences and beliefs; advance care planning; health care costs, financing and reimbursement; and the education of health professionals, patients, families and the public at large. And to explore approaches to advance the field.

Not surprisingly, they concluded that the U.S. health care system is poorly designed to meet the needs of patients and their families at the end of life and that major changes are needed. However the report suggests that broad improvements in end-of-life care to make it compassionate, affordable, sustainable and high quality are within reach.

I was drawn to the more clinical issues, including advance care planning and how physician education might be changed to improve end-of-life care. For example, Recommendation 2: 'Professional societies and other organizations that establish quality standards should develop standards for clinician-patient communication and advance care planning that are measurable, actionable and evidence-based.' That would be a big step forward. In a New England Journal of Medicine Perspective, the co-chairs of the IOM committee note that 80 and 88% of American physicians surveyed in two studies indicated they would choose to forgo high-intensity end-of-life treatment (Pizzo PA and Walker DM: Should we practice what we profess? Care near the end of life. N Engl J Med 372: 595, 2015), and ask why we physicians are not helping more patients express their preferences so that they can make informed decisions about the care they want near the end of life. I liked the discussion of inadequacies in professional training, even going back to the 'death is seen as a medical failure' excuse.

Whilst this Report is written about and for the United States, many of the issues discussed are pertinent to other countries, both developed and developing. And there is a wealth of information and thought as the (long) list of problems and barriers is discussed.

The report can be purchased, or read free or downloaded as a free pdf file at www.nap.edu/openbook.php?record_id18748

Roger Woodruff (February 2015)

Hospice and palliative care is alive with ethical issues and this book, with a commendable list of contributors, sets out to discuss them. The opening chapters discuss hospice and palliative care in general, and ethical issues arising from modes of delivery in particular. Following this are a series of chapters about ethical issues related to pain relief, dyspnea, delirium, and psychosocial and psychiatric suffering.

The nitty-gritty of the book is in the last section-Difficult Decisions Near the Very End of Life. There are good chapters on withholding and withdrawing life-sustaining treatments, voluntarily stopping eating and drinking, and on medical futility. Andrew Billings' chapter on palliative sedation provides a good description of what we are talking about, where it fits in the ethical scheme of things, and underlines the responsibilities of the physician. The chapter on physician-assisted death by Quill and Miller left me dissatisfied and I did not agree that relieving a patient's symptoms with treatment that you knew might hasten their death, but in no way intended, was the same as popping them off. The chapter on physician-assisted suicide by Ganzini was interesting but did not add any important new information. I was most interested to read that her proposal for a study on whether receiving a prescription resulted in reduction of anxiety and increased sense of peace (an interesting and worthwhile question) was blocked by the pro-PAS organisation.

The final chapter is about physician-assisted death in Western Europe, The Netherlands in particular. I ran into a few bumps here. She starts with the Dutch data that ignores intention, and follows with the European studies. The Australian study, conducted I believe according to the same Dutch criteria, was deceptive in its ambiguity: if you said you had given a patient medication that you knew might possibly shorten their life, although you had no intention of so doing, you were counted as having intentionally shortened the patient's life. She tells us that 'termination of life without request is declining since 1990.' But the numbers stayed the same during the period 1990-2001, amounting to around one thousand patients a year, euthanased without request; the first significant fall was in the 2004 report. She tells us that palliative care services in The Netherlands are among the best in Europe, based on criteria such as attendances at palliative care conferences. She tells us that reporting levels for euthanasia have increased remarkably, but not that this is due to the fact that doctors no longer have to report opioid-related deaths because someone somewhere else in the world reported that opioids given appropriately were not associated with hastened death; that doesn't apply if you give a lethal dose, intentionally. I didn't see any mention of the recent rapid rise in the use of terminal sedation, which some have reported as being used in place of euthanasia (i.e. to intentionally hasten the death of the patient), because it doesn't have any of the legal connotations of euthanasia.

Overall, this is a good synopsis of the range of ethical issues encountered in palliative care, including the delivery of services, patient suffering and physician-assisted dying. It will be useful in the postgraduate classroom and should be of interest to anybody working in palliative care. Just don't believe everything you read about euthanasia in The Netherlands.

Roger Woodruff - February 2015

L. W. Sumner is Professor Emeritus of Philosophy at the University of Toronto. This is his admittedly partisan contribution, from an ethical and legal perspective, to the debate about assisted death. I note he describes it as an ethical, social, political and legal debate-medical doesn't seem to come into it.

The first section is about Ethics. He discusses refusal of life-sustaining treatment, followed by a long discussion about double effects, which he describes as 'relieving suffering and causing death'. This is the first hole he digs for himself, referring to the treatment of patients with increasing doses of opioids as having a probable or certain chance of hastening death; foreseeing a possibility of hastening death doesn't come into it. To his credit, he mentions that some maintain that appropriate doses of opioids do not shorten patients' lives, but I'm not sure he believes it. The Australian study (and similar studies from elsewhere) is trotted out to show that doctors frequently use doses of drugs in terminally ill patients that may hasten death. I was sent a copy of that Australian study, which I failed to complete. The questions were deliberately ambiguous, so that doctors who admitted they had given a patient opioids that might possibly have hastened death (but of which they had no intention) were classified as having intentionally given doses of medications they knew to be lethal. Which is just the result the investigators wanted. Utter rubbish, but the results turned up on the front page of the Sunday newspaper. I can't remember the headline, but it had to do with doctors and killing. Much is made by Sumner about how much a life might be shortened, perhaps to lessen the psychological impact if only a seemingly trivial amount of time is involved. The truth is that no one can know exactly how much a life is shortened by euthanasia, but the Dutch are notorious in this regard. I remember commenting in the mid-1990s on the euthanasia of a young man with AIDS whose life-expectancy using internationally accepted criteria, and using treatment available at that time, was in excess of two years. The Dutch said his life was shortened by less than a month, at the most.

The next chapter moves on to euthanasia and physician-assisted suicide that, from an ethical perspective, Sumner sees as no different from treatment with the possibility of hastening death. I do not agree. The physician's job is to relieve suffering, and killing people is not an option. Intention is a big thing.

The last chapter in this section is about deciding for others-the formerly competent and the never competent. Sumner argues that where there are no advance directives and the patient is not competent, the principle of 'acting in the patient's best interest' trumps all other considerations and is sufficient to make decisions about euthanasia. I definitely do not agree, and such an argument brings what happened in Nazi Germany back into the debate. Adopting such attitudes in a palliative care unit, or the geriatric or psychiatric wards, is to me unthinkable. As a doctor, I would consider doing a ward round thinking about who can or should be euthanased would constitute, to use the Dutch term, unbearable suffering.

Having argued to this point, I suppose Sumner has no reason to worry about euthanasia without request (one thousand patients a year in The Netherlands), euthanasia for treatable conditions like depression, or the recent marked rise in the use of terminal sedation in The Netherlands, which some report as being used as an alternative to euthanasia (i.e. for the intentional hastening of death) that does not carry any of the legal connotations of euthanasia.

Having satisfied himself that all forms of assisted death are morally permissible in given circumstances, the second half of the book is about legal matters, but I am not a lawyer and my interest had waned. I am sure Sumner will have come up with a means to make euthanasia legal, but not one to control it. Control was not a major issue in the ethics section.

The problem here is that the clear-cut theoretical case studies used are all very well for discussions held in ivory towers, but do not come close to covering the myriad variations (of patients, families, medical situations, and health care professionals, not to mention differing cultural values and beliefs) seen in the real-world ward or clinic. Sumner refers to people holding views opposite to his as having the Conventional View, although I was left wondering whether the capitalisation represented respect or the opposite. I also noted that in his discussions, the patient subject is always referred to as 'her'.

This book is well written and I would recommend it to anyone interested in the debate about assisted dying. It's just that I do not agree with some of the things it says.

Roger Woodruff (February 2015)

2015
DYING A Transition Monika Renz
Translated by Mark Kyburz and John Peck

Columbia University Press, 2015

164 pp

ISBN 978-0-231-17088-8

Monika Renz is a psychotherapist, music therapist, theologian and spiritual caregiver, with doctorates in both psychology and theology, who has been the head of psycho-oncology at the Kantonsspital St. Gallen in Switzerland since 1998.

Whilst most books dealing with palliative care cover a significant portion of the illness trajectory, Renz has taken a magnifying glass to the spiritual and psychological happenings in the last minutes or hours (days, at most), of patients' lives. She studied more than 600 patients dying of cancer, recording what happened (or did not happen) after each therapy intervention or encounter, including things both verbal and nonverbal. Analysis of this data is the underpinning of her hypothesis that the dying undergo transition into another state of consciousness, or another way of experiencing being, beyond anxiety, ego and pain. I am not going to attempt to summarize her description of the nature and meaning of these transition processes. But it results in her recommendations about how we might provide better end-of-life care.

I found this book pretty intense, but very interesting. I frequently had to reread a paragraph to understand the real meaning, but I have to say that what Renz (and her translators) say is perfectly clear; perhaps it is that I am not used to thinking in terms of Jungian psychology at the bedside. I was impressed by the similarities to some of the topics discussed by Patricia Pearson in Opening Heaven's Door, particularly regarding nearing death awareness and premortem serenity, although they are discussed here from a psychological, almost psycho-analytic, perspective. Many of the things she describes ring true, and perhaps this is a better way to describe and treat our dying patients. I would recommend this to anyone who works in palliative care and has an interest in the spiritual and psychological processes in dying patients, or anyone who simply wants to know more.

Roger Woodruff (November 2015)

This book is about terminally ill patients' wishes that do not just cover the circumstances of their death, but include the wish for death to come. There is an emphasis towards the psychosocial and ethical aspects of care.

The first part of the book explores the state of empirical psychosocial research on wishes to die. Included here is the 2004 paper by Nessa Coyle and Lois Sculco on expressed desire for hastened death; a new afterword by Nessa Coyle provides interesting insight into the changes that have occurred (and are continuing) in palliative care practice over the last ten years. The second part provides four different perspectives on the ethics of practically responding to wishes to die. In the third section, practical issues are discussed as they are encountered in palliative care for patients at the end of life who express wishes to die.

If you want to know more about the genesis of wishes to die, and some guidance as to how we might best deal with them, both as individual healthcare practitioners and as a society, then you will find this book of interest.

Roger Woodruff (November 2016)

The purpose of this book is to analyse several clinical, ethical, and legal questions related to the use of sedation at the end-of-life, also termed palliative sedation (PS). In her introduction, Taboada explains that it is focused on seven questions: is PS ethically different to euthanasia and physician-assisted suicide; is it necessary to invoke the principle of double effect to justify PS; is PS ethical in patients not imminently dying; are decisions about nutrition and hydration independent of decisions regarding PS; is PS appropriate for psycho-spiritual symptoms and existential suffering; is PS ethical for patients unable to give informed consent; and, are clinical guidelines for PS desirable.

I was impressed by the standard of the contributions to this book, which seemed thoughtful and well organised. The uniformity of presentation suggested good editing. Whilst considered answers are offered to some of the questions, an alternate view never seems far away. No one would argue about the minefield of different terms, concepts and definitions. Should there be indications for PS, or should it be based on the wider 'goals of care' that we use in palliative care? The question of PS for existential suffering raises further questions of how you define and assess that type of suffering. Much is said about the principle of double effects, which if used properly does differentiate PS from euthanasia; at the same time it is admitted that some uses of PS may in fact be intentional killing. When it comes to guidelines, one expert argues in favour, whilst another decries their use because they have a very negative effect on judicious medical decision-making.

I was particularly taken by the cogent arguments, by John Keown and others, regarding autonomy. "In spite of the undeniable importance of respect for 'autonomy', both for patients and also for health professionals, respect for autonomy should always be subordinated to the respect we owe to the 'basic human goods' of which the first and most important one is life itself." Hear, hear! And it's been known and believed for a long time-it's not something that has just been discovered. But the parliamentarians in my home State of Victoria are much wiser and have passed legislation to legalize euthanasia and physician-assisted suicide for the sole purpose of giving the power of autonomy to the individual.

If you work in palliative care and are interested in the ethics of end-of-life care and palliative sedation in particular, this book provides a lot of information and even more to think about.

Paulina Taboada is from the Center for Bioethics and Department of Internal Medicine at Pontificia Universeidad Católica de Chile in Santiago, Chile. The other contributors, experts in bioethics or palliative care, were from Canada (8), Chile (2), and the USA (2).

I must again complain that Springer will not supply review copies of their books, and that I feel that reviewing e-books on line is very difficult and probably does not do the authors credit.

Roger Woodruff (December 2017)

The Ars moriendi ('The art of dying') appeared in about 1460 after the Black Death (c.1340-1400) of bubonic plague had killed between one- and two-thirds of the population of Europe, and provided the layperson with guidance about the preparation for death according to the customs of the Church at that time. This book, with contributions from physicians, philosophers, theologians and bioethicists, asks what would be needed to create a contemporary Ars moriendi or 'art of dying well' in a society like the USA as it exists today.

Big questions are tackled. Recategorizing death from unmentionable to mentionable, even anticipated. Human finitude. What does and does not constitute a 'good death'. Do hospice and palliative care provide an answer? The second part of the book deals with the substance of dying well-rituals and practices, spiritual preparation, and the role of community. The final section is about children, the elderly and demented, and people with HIV/AIDS.

I enjoyed this book, which I found informative, thoughtful and stimulating, but it wasn't light reading. Bioethicists will lap it up, but it also asks questions that are relevant to the practice of palliative care on the ground today, such as what is meant by dying well, and how hospice and palliative care should be aiming to try and achieve that.

Roger Woodruff (November 2015)

2016

Cory Taylor is an Australian writer who has the great misfortune to have metastatic melanoma that is no longer responsive to therapy. This is her memoir, which I have to say is pretty clear-eyed and unsentimental.

Part of the book is a reflection on her personal and family life and her thoughts about the joys, the sorrows and the precariousness of life. The other is about what it means to be dying and her arguments for the right to choose the circumstances of her own death. Doctors and other health professionals get bad press for not talking about death and dying; religious beliefs (Christian, at least) are declared irrelevant; but her stash of (illegally imported) suicide medicine and the regular meetings of her local branch of Exit International, fare much better. The only thing stopping her, she says, is guilt about the selfishness of suicide and the collateral damage it may cause her family.

I was both provoked and disturbed reading this book. My objection to the legalisation of assisted dying has nothing to do with religious beliefs, but I find the attitude of the new sectarians, who apparently know everything there is to know about human suffering and insist that anything to do with any religious belief be banned from the discussion, to be both inappropriate and intolerant. The problem with legalised assisted dying is that it implies that every doctor will make the perfect decision, every time. But doctors are human.

Roger Woodruff (August 2016)

Well-known Canadian palliative care physician, Dr Larry Librach, died of pancreatic cancer in 2013, aged 67 years.

This is the story about his terminal illness, put together by author and journalist, Phil Dwyer. It includes some jewels about doctor-patient communication, the meaning of families, being at home, being a burden, hope, and a lot more. 'Larry had spent a lifetime teaching others that the best way to deal with this particular unwelcome guest [a terminal illness] is to acknowledge him, invite him into the circle, and address him openly. Share the doubts, the fears, the tears.'

There are also some pertinent comments about physician-assisted death. As a physician, he was against it; as a patient, he was against it. But when running CHPCA, he set up a working party to look at the issues, and I think came to the conclusion that the tiny number of patients who could never be satisfied by the best that palliative care could offer, would result in the legalisation of physician-assisted dying.

Larry's story is interspersed with Dwyer's recollections of his own brother's terminal illness-he died of throat cancer in the UK in 2010. Despite all that we hear about the wonderful Macmillan Nurses and the fantastic system of hospices and palliative care, the system of palliative care in Manchester described by Dwyer is woeful; neglect and disinterest are words that come to mind.

Another fact that raised my eyebrows. 'If you die in Canada today, it is much more likely than not that palliative care won't be available for you. Between 70 and 84% of all Canadians die without receiving, or having access to, palliative or end-of-life-care services.' So they are introducing medically assisted dying when only 16-30% of the population have access to palliative care?

I enjoyed this book, which has lots to think about.

Roger Woodruff (February 2017)

This book and I did not get off to a good start. It was advertised on amazon.co.uk as being newly published in December 2016. There was no mention that it had appeared as a hardback in 2013. But I didn't even get the paper edition; I was told to make do with the e-book, which I think makes the job of renewing doubly difficult. To cut a long story short, I wasted a lot of time dealing with stuff written for geeks, but was unable to download the book. When I tried a fourth time, the site snapped into action and told me I had used the maximum number of attempts allowed, and that I must report immediately to Cambridge University Press.

But this is meant to be about their book. In the introduction, on p 3, I read 'Suffice it is to say in 2004 Serge suffered a 'grand mal' (type of epilepsy) that was caused by a frontal brain lesion and by lung lesions that were treated by craniotomy.' I felt troubled. Lung lesions rarely cause epileptic seizures, and lung lesions are definitely not treated by craniotomy. It goes on to say, 'It is absolutely certain that, without the benefits of [continuous sedation], Serge would have died a horrible death.' I thought that statement was utter rubbish. I was losing patience.

Sterckx and Mortier are professors of ethics at Ghent University in Belgium; Raus is identified as a postdoctoral researcher at the same university.

The opening chapter, written by the three editors, is long-winded and repetitive to the point of being tedious. They were at pains to emphasise how controversial continuous sedation was, but it seemed like a lot of hot air to me. I realised that I had never considered how professors of ethics fill their working week. The chapter ends with a review of the content of the other 14 chapters. But instead of providing a short, sharp synopsis of each contribution, they attempt to summarise everything each author says, cross-referencing what was said by any of the other 13 on any particular point. I thought it was a useless mess that ground on for 11 pages.

The message that I got from skimming some of the other chapters was that there was absolutely no consensus about terminology and definitions, and that there were an almost unlimited number of clinical variations, which meant that no two people using the words 'continuous sedation' or 'palliative sedation' were talking about exactly the same thing, and that meaningful comparison of different reports was not possible. There were a number of good contributions about these variations and, viewed from a slightly different angle, they provide insight into the myriad considerations involved with terminal sedation. There were also a few contributions raging about the controversial nature of the subject (mainly from ethicists). The best chapter was by Dr Nigel Sykes from St Christopher's Hospice in London, who provides a clinically sensible description of the history of sedation in palliative care, what benefits it brings, cuts across the business of artificial hydration and nutrition (they are not relevant in appropriate patients), and really asks what all the hype and rage (by ethicists) is about.

The last chapter is by Margaret Battin, a professor of philosophy from Salt Lake City. A vocal advocate of physician-assisted dying, she seems to be expressing concern about terminal sedation that, 'once the process has begun, the patient no longer has a way of controlling the course of events on the way to death.' I felt a bit confused.

I remain concerned that the almost meteoric rise in the use of terminal sedation in The Netherlands represents euthanasia in disguise, and has the advantages of being free of the administrative hassles and legal risks associated with euthanasia. That sedation is being used to shorten life is addressed in several of the presentations in this book, but I could not find any quantitative estimates; however, in Griffiths et al Euthanasia and Law in Europe (Hart Publishing, 2008), there is a statement to the effect that Dutch doctors reported that in 50% of cases in which palliative sedation was employed, the intention was to shorten the patient's life.

Roger Woodruff (May 2017)

This book comes not that long after Palliative Care and Ethics (Oxford University Press, 2014). However, the earlier book was very focused on palliative care, and had the advantage that the majority of contributors were medically (or nursing) qualified, which I feel leads to much more meaningful and clinically applicable discussion. The present volume takes a much wider purview of end of life issues and includes contributions from bioethicists, lawyers, sociologists, and philosophers, with a much smaller proportion medically qualified. As I have got older, I have become less tolerant of the Professors of Philosophy who pontificate from their ivory towers about clinical matters of which they have zero practical experience; the noise they make is really just a pain.

The first section is about clinical and legal issues, and covers an interesting range of topics. I tripped up on the report from Holland about continuous sedation at the end of life, written by an ethicist and a philosopher. There are pages about double effects and other extraneous matters. I don't have a problem-a dying patient has intractable suffering, only way to relieve suffering is by sedation, use sedation. Yes, you can invoke the principle of double effect if you want. But what is not even mentioned in the article is the use of terminal sedation to hasten the patient's death, which has been reported by the Dutch themselves. In other words, it is euthanasia in disguise, and has the advantage that it doesn't have to be reported to authorities.

The second section is about theoretical, cultural and psychosocial issues. Eric Cassell on The Nature of Suffering and David Barnard's On Our Difficulties Speaking to and About the Dying were a pleasure.

Section III is about physician-assisted death. The chapter on The Netherlands is written by Gerrit Kimsma, Professor of Metamedicine at Vrije Universiteit; I had never heard of Metamedicine, but a Google search informed me that conventional medicine does not know the cause of 99% of illnesses, but Metamedicine had all the answers, and for a large fee would be of value to complementary practitioners, chiropractors and homeopaths. As previously (Younger and Kimsma, Physician-Assisted Death in Perspective, Cambridge University Press, 2012), he describes the long legal, professional and political struggles that have resulted in a wonderful societal emancipation. But he only tells the fraction of the truth that is convenient. What about the unreported cases? They can tell you how many cases of euthanasia are reported, but have no clue how many go unreported, especially now that euthanasia using opioids does not have to be reported. What about the meteoric rise in the use of palliative sedation? It's just 'normal medicine'; not if, as reported by the Dutch, it is being employed to hasten death ('euthanasia in disguise'). What about euthanasia without explicit request (a thousand patients a year)? Observational studies cannot be used to prove that physicians (who euthanased patients without request) were right or wrong. What about the common failure to obtain the independent second opinion required by law? Not discussed. I remain totally unconvinced that they did a good thing or that they have got it right.

Ira Byock's The Case Against Physician-Assisted Suicide and Euthanasia was a breath of fresh air.

The article by Margaret Battin (Distinguished Professor of Philosophy at the University of Utah) is entitled Goodbye, Thomas. After her previous diatribe (Battin, Ending Life, Oxford University Press, 2005), this is a mere six pages. It says her arguments for physician-assisted dying are indisputable, there are no valid arguments against, and that anyone who thinks that way is hung up on the thirteenth century thinking of Thomas Aquinas (1225-1274). The rejection of suicide by Aquinas way back then would not have included the sort of decisions involved in 21st century end of life care, and I thought the association somewhat farcical.

The last section is about the emergence of palliative care and includes a good

review by David Clark and Robert Arnold's Potential Perils to the Promise of Specialty Palliative Care.

Good book. Just don't believe everything you read about euthanasia in The Netherlands. And be wary of Professors of Philosophy.

Roger Woodruff (March 2017)

2017

Nikki Gemmell is a successful Australian writer with a string of novels and children's books to her credit.

This book is about the tsunami of emotional, psychological and physical problems after her mother 'euthanised' herself; Gemmell doesn't like 'suicide' because it implies the unhinged and irrational. Gemmell's mother had problems with intractable, unresponsive pain, which left her dependent and crippled.

Gemmell's relationship with her mother was tumultuous. 'If I had my life over I never would have had kids,' her mother said. Later in the book, the daughter admits that she wished her mother dead at times. Interestingly, Gemmell notes that un-maternal mothers do exist, but says they should not be judged. And despite the years of antagonism, she feels no relief after her mother's death; she describes her life as hell. The abandonment. We didn't listen enough. The words unsaid. Everything is upended. Catapulted into crisis. 'With her final act [mother] has altered my future. She has been attempting to do this since my teenage years...But finally, with this...she has crushed me.'

Philip Nitschke, long-time advocate of euthanasia and assisted dying tells Gemmell that her mother contacted his organisation Exit International and that she had (illegally) imported nembutal. He describes this as empowerment. And he adds that anyone opposing his views is either not mature or is suffering 'religious claptrap'.

Gemmell wrote about these issues in her weekly column in the national newspaper The Australian, and was inundated with responses. A selection of these is presented in the book, providing pithy insights into the problems with laws and with the medical system. Like the woman who said her husband's advanced cancer 'threw him into the willing arms of the medical fraternity who don't know when to stop.'

Gemmell goes on to provide what I thought was a reasonably balanced discussion about assisted dying. Coming from the autonomy/choice position, she comes to the conclusion that assisted dying should be legalized, stating that the embracing of individual choice is the mark of a mature nation. 'If the perpetrator's family cannot, by law, be involved in the wishes of the person wanting to die, you are condemning that person to a horrendously bleak and lonely death. And there will be many people left reeling in the wake of that death.'

I don't necessarily disagree with those sentiments, but I will never support the legalization of assisted dying because of what it brings with it. In every jurisdiction where assisted dying has been legalized, there has been disregard for the laws and safeguards that were put in place to prevent abuse and misuse of these practices. I have concerns that the majority of the medical profession are not adequately trained to formally assess decision-making capacity, and lack the psychiatrist's skills to make sure no patients with treatable conditions like depression go down the assisted dying path (and that includes me, on both counts). Many doctors cope poorly with severe pain or suffering and rapidly resort to the 'nothing more can be done' position, which is half way to assisted dying. How can you be sure the person is not being pressured by family or socioeconomic issues? How do you manage people who feel a burden or who are 'tired of life'? Where do you draw the line? 'Euthanasia creep' is inevitable-when legalization of assisted dying for a very limited group of people in very limited circumstances is expanded to include more people in more situations. In the words of Robert Twycross: 'Once the barrier of legislation is passed, medically assisted dying takes on a dynamic of its own and extends beyond the original intent, despite earlier explicit assurances that this would not happen.' Or Herbert Hendin: 'Virtually every guideline set up by the Dutch-a voluntary, well considered, persistent request; intolerable suffering that cannot be relieved; consultation; and reporting of cases-has failed to protect patients or has been modified or violated.' Remember the one thousand patients a year that were euthanased without request, never mind consent, in the Netherlands? Now the Dutch doctors say that in 50% of the cases where palliative or terminal sedation is used, the intention is to hasten the death of the patient, i.e. it is euthanasia. The Belgians have championed the cause that euthanasia is a normal part of palliative care, and there are now moves afoot in Canada to censure any palliative care service that declines to provide assisted dying.

Gemmell's book is excellent and I had trouble putting it down. It is a dreadful story and extremely personal. But she writes so well and the emotional aspects of the turmoil are vividly portrayed. I would happily recommend this book to anyone who works in palliative care. You will be drawn into her story and it provides a raft of issues on which to reflect-where the current system doesn't work, where it's doing harm. On the legalization issue, Gemmell and I start from different positions and with different data and, not surprisingly, come to different conclusions. Again, lots to think about.

Roger Woodruff (June 2017)

Rodney Syme is a urological surgeon in Melbourne, Australia. He has been an advocate of medically assisted dying for many years, working with the Voluntary Euthanasia Society of Victoria, now re-branded as Dying With Dignity Victoria.

Syme opens with the story of an unfortunate individual who died of laryngeal cancer. As it is described, his written advance directives were disregarded and he of course had unrelieved pain, suboptimal symptom control and suffered significant side effects of the medications he received. We are told repeatedly that this occurred under the care of a Catholic palliative care team in a Catholic hospice. In this and the other tales of woe, his language is dramatic, wringing every last emotional drop from his stories: suffering was always intolerable and unrelievable, no symptoms responded to therapy, etc, etc. But anyway, hard cases are said to make bad law.

He implies that vast numbers of people are now requesting medically assisted death ('the momentum'), which I dispute. In my practice as an oncologist and palliative care physician, I have dealt with at least ten times the number of patients with advanced disease that Syme has seen and I have never received one request for assisted dying; and, no, patients were always given plenty of opportunity to ask anything they wanted. I wonder whether the polls reported are based on asking people whether they want their loved ones or themselves to die in agony or vote for assisted dying; if that were the situation, I would probably vote for euthanasia.

In his discussion of palliative care, Syme states that it 'is one of the most important developments in modern medicine', but this is followed by 'there is scant evidence to support the effectiveness of specialised palliative care for patients with terminal illness in terms of quality of life, patient or care giver satisfaction, or economic cost.' Sounds a bit contradictory to me, but I think Syme feels assisted dying trumps palliative care every time. A more sinister thread comes to light in this chapter-that he believes it is the strong religious beliefs of some of the pioneers in the field of palliative care (Christianity, Catholicism in particular) that is preventing palliative care associations and the profession in general from embracing assisted dying; having worked with several of the individuals named, I found this quite disrespectful. He also says it is hypocrisy to oppose assisted dying whilst employing terminal sedation, which I think he regards as a slow and somewhat clumsy form of assisted dying.

Syme's discussions of dignity, vulnerability and burden are predictably slanted to his obsession for assisted dying. With regard to autonomy, Syme states that all doctors have a fundamental and overriding legal and ethical duty to respect patient choice-if they ask for assisted dying, there isn't any discussion; I do not go along with that. As noted recently in this column, there is a good paper written by two Australian psychiatrists, Brian Kelly and Francis Varghese, The Seduction of Autonomy: Countertransference and Physician Aid in Dying, which is a careful examination of the innumerable psychological issues and interactions involved with requests for assisted death and makes an absolute nonsense of yes/no attitude of our politicians (and Syme) towards patient autonomy and the right to assisted dying.

Interestingly, Syme finds euthanasia by lethal injection 'distasteful' and claims he would never do it. Making a date and time to give someone a lethal injection would be 'unconscionable'. But...well...if there was a question about ingesting or absorbing the medication, or paralysis,...then it would be OK.

Much of the last part of the book is about the legislation to be brought before the parliament of the State of Victoria to legalise medically assisted death. Syme thinks the proposed guidelines are excellent, although he would spread the net to include patients with 'advanced incurable illness'. In contrast, I think the guidelines are vague, clinically impractical and open to abuse. [www.parliament.vic.gov.au/file_ uploads/LSIC_pF3XBb2L.pdf].

The other issue with the guidelines, which is not discussed by Syme, is that doctors, like patients (and politicians, perhaps), are human. They vary. Some are good, some are less good. There are good ones who have bad days. There are some who cannot cope with a lot of pain and suffering and resort quickly to the 'nothing more can be done' position, which is half way to assisted dying.

Reading this book and the parliamentary report, I am flabbergasted that there is no mention of any problems with assisted dying in The Netherlands. Not whether some patients benefited, but the widespread abuse of the system. No one knows exactly how many cases of assisted dying are not reported, but it is believed to be significant. There is no mention that Dutch doctors often do not consult a colleague for a second opinion, even though it is required under the law. There is no mention that when voluntary euthanasia for terminal illness was condoned, Dutch doctors performed euthanasia on patients with psychiatric illnesses and mental handicap. There is no mention that throughout the 1990s, about one thousand patients a year were euthanased without request, never mind consent. Over the last few years, the number of patients undergoing euthanasia has continued to increase (5500 in 2015), in addition to which there has been a dramatic rise in the use of terminal sedation. Deaths involving palliative/terminal sedation jumped 150% in the five years to 2010. It has the advantage that it does not have to be reported to authorities and doctors have admitted they are using it to end patients' lives (i.e. 'euthanasia in disguise').

This is an important book, and I do not doubt Syme's sincerity for one moment. I agree with him that people in our society want and deserve better dying. I think that this involves things like health professionals talking more honestly about death and dying, getting people to think in advance about what they want ('having the conversation'-100% of them are going to die), and trying to limit futile therapy that simply prolongs suffering. I disagree with Syme that handing out lots of suicide sachets of Nembutal will fix the problem and worry that it may bring a whole lot of new problems.

Roger Woodruff (February 2017)

This is a collection of 16 real-life cases exploring the complex range of issues inherent in end-of-life medical care. The authors are at pains to emphasise how complicated things can get, although I doubt anyone reading this Newsletter needs any convincing.

It is divided into three sections. The first deals with complex issues related to pregnancy, newborns, and young children-the woman dying of tongue cancer who was pregnant, young parents facing difficult decisions regarding treatment for neonates with congenital abnormalities that may be further complicated by religious or cultural views, the 4-year-old with incurable cancer whose parents insisted on on-going intensive therapy, and a story involving post-mortem sperm retrieval. In each, there is the clinical history and a list of suggested discussion points, followed by two critiques-one focused on the ethical problems, the other on communication issues.

The second section concerns issues related to family involvement in decision-making-the woman who refused to believe that her young daughter was brain dead and that her life support could be discontinued, the mother of a young man with widespread colon cancer who forbade the involvement of the palliative care team, the 25-year-old woman dying of cardiomyopathy whose advance directive was successfully contested by her schizophrenic mother, and several more grievous tales.

The last section is about autonomy and balancing benefits and burdens-the Jehovah's Witness who refused permission for his fiancé to be transfused when surgery was unexpectedly complicated by haemorrhage, to treat or not to treat a man with advanced head and neck cancer, the alcohol- and drug-abusing man with life-threatening infection and the patient's right to treatment, and the man who had cared for his disabled wife for many years until he became depressed and unable to continue his caring due to self-neglect.

Based on the multiplicity and magnitude of difficulties, all the stories here score nine or ten on a scale of ten. What about the 19-year-old Hindu girl rendered quadriplegic and ventilator-dependent in an automobile accident, whose uncle told the medical staff that in their culture it is the family and not the patient who makes decisions, and that the life support should be stopped because her injuries were a result of bad karma from a previous life? In the end, I wished the authors had turned their blowtorch on the sort of problems we see everyday in palliative care: Mr or Mrs Ordinary with a single major issue.

In the introduction, it is noted that 20% of Americans live in a state where physician-assisted suicide is legal, but euthanasia and physician-assisted suicide do not get a mention after that, which I thought was an important omission. Dealing with the communication and ethical issues associated with physician-assisted dying will be one of the big challenges of the next ten years.

I found the text heavy going in places, but if you work in palliative care you will benefit from reading the stories and asking 'what went wrong?' and 'what could have been done better?' I thought the critiques provided good insight into how the experts think about these issues.

Lori Roscoe and David Schenck are from the University of Southern Florida in Tampa.

Roger Woodruff (March 2018)

This volume aims to provide an overview of Belgian euthanasia, including the legal, philosophical, bioethical, and clinical aspects.

As far as the system is concerned, we are told the law is reasonably strict, bit it cannot be regulated or policed. The system relies on self-reporting, but only about 50% of cases are reported. Then there is the second consultation, but there is no legal requirement for there to be unanimity of opinion. There are currently calls to legalise life-ending without request.

The Belgian data show there is a continuing rise in the number of patients having euthanasia each year, and the indications have been increased to include the psychiatrically ill and patients with non-terminal conditions. In the words of one commentator, 'The indications for euthanasia are constantly multiplying, despite the legislators' initial statements and intentions.' Sterckx and Raus report that continuous sedation until death (CSD) is used where there is personal, family or institutional reluctance regarding euthanasia. It is also noted that CSD was initiated without consent or request, either of the patient or of the family, in 28% of cases.

A more sinister aspect of Belgian euthanasia is that in just 12 years, it has gone from an exceptional act to the norm (the 'normalisation' of euthanasia); then it became a right- there is information in official documents and in the media regarding a 'right to euthanasia'. Following which, supply creates demand.

I crashed when I came to the chapter on palliative care. I knew the Belgians believed that euthanasia was an integral part of palliative care, but I was surprised when I was told the caring practice of 'euthanasia accompaniment' (euthanasiebegeleiding) is now part of the daily work of palliative care professionals. Then I think I was told (by someone sympathetic to euthanasia) that when euthanasia was introduced, palliative care professionals saw the limitations of palliative care (compared to euthanasia), 'which convinced palliative care professionals that euthanasia could be part of genuinely good care.' And that 'palliative care was not harmed but strengthened' by the introduction of euthanasia. I note the 2014 review of the integrated model (one co-author of which was Dr Distelmans) as giving Belgium a guiding role for the rest of the world.

I struggled with the chapter on euthanasia for children. The author went to lengths to tell me what a monumental amount of work and thought had gone into this. I noted the criteria quoted for psychosocial development were dated 1968, and those for cognitive operations 1971. The neuroimaging stuff is unconvincing and I think it will be a number of years before fMRI (or anything else) will be able to tell you if a particular child has a clear concept of dying and death. I found the statement about children with serious illness sensing their own mortality and therefore having a sense of death, quite sinister. It's a bit like saying: This child is going to die, therefore he has good insight into dying and death.

The chapter by oncologist Benoit Beuselinck was much better. He noted that requests for euthanasia were very uncommon with the cancer patients in his clinic and pointed out the problems for palliative care (patients in need of palliative care support are reluctant to be referred for fear of euthanasia), and concludes that 'the legalisation of euthanasia has put a burden on doctors, families, palliative care services and has put in danger the patient's own life.'

The discussions about managing patients with psychiatric disorders left me confused. On the one hand they talk about the difficulty differentiating 'between a death wish that is merely a symptom of depression, and one that can be canonised as an expression of free will' Euthanasia advocate Dr Distelmans believes such distinction can be performed in an objective manner. But I wondered if it mattered, as they said they adhere to the directive of the Dutch Association of Psychiatrists 'that stipulates that in cases of chronic depression, a wish to die can become durable and should be considered the expression of the well-considered rational choice of the patient.' Dr Distelmans is the co-chairman of the Federal Euthanasia Control Commission and is said to be convinced that euthanasia should be seen as a form of suicide prevention. I also learned from Google that he conducts study tours to the Nazi death camp, Auschwitz, which he describes as 'inspiring'.

There was an undertone of arrogance and insensitivity that I did not like. One commentator, Willem Lemmens, asked why 'none of the pro-euthanasia experts ever seems to consider the possibility that there might be something wrong with a law that creates such emotional and existential havoc.' When there was a public outcry by some (adult) children who had not been informed prior to their parents' euthanasia, two euthanasia experts publicly declared them to have 'pathological mourning' and to be in need of psychiatric care.

This book provides a thought-provoking look at what has gone on in Belgium, with an appropriate variety of perspectives and opinions. If you have an interest in the assisted dying debate, this is important reading.

The three editors work in the bioethics field in the UK.

And what do I think about the Belgian euthanasia experiment? Nothing good.
Roger Woodruff
(January 2019)

2018

Dr Kathryn Mannix is a Palliative Care consultant based at the Royal Victoria Hospital in Newcastle upon Tyne. It sounds as though her specialist career started in oncology, after which she moved into the new discipline of palliative medicine, a career path that seemed remarkably familiar to me. Having qualified as a Cognitive Behaviour Therapist in 1993, she started the UK's first CBT clinic exclusively for palliative care patients.

At the outset, Mannix bemoans the lack of talking about death and dying in the second half of the twentieth century. And then it's down to business: 'It's time to talk about dying. This [book] is my way of promoting the conversation...My weapon of choice for this campaign is stories...stories about normal humans, dying normal human deaths...'

The book is essentially made up of 30 clinical stories of people at or nearing the ends of their lives, 'and the intention is to allow the reader to experience what happens...how they cope; how they live; what matters most; how dying evolves; what a deathbed is like; how families react.' The stories are grouped under six headings and gradually progress from more objective things (physical changes, patterns of behaviour, and dealing with symptoms) to more abstract concepts like making sense of human impermanence, assessing what has truly been important to a given individual, and our legacy. Written primarily for the lay reader, there is a little explanatory introduction to each story and a short critique at the end of each section.

I thought the stories were well chosen and well told. I enjoyed reading them and learned a little bit about CBT along the way.

I wholly agree with what she is doing, but how do you get the masses to read this type of book, how do you get them to talk about death and dying? Many health care professionals go out of their way to avoid talking about death and dying, and the patients and their families see evidence of miraculous breakthroughs in medical science every night on the TV news.

Anyone who works in palliative care will find this book enjoyable to read and there are a large number of clinical issues to ponder. Whilst I could argue that we as a profession should be somehow advocating this book, it is difficult to know how to go about it.

When I did a little research into Dr Mannix's background, I came across some comments she made at the time of the euthanasia debate in the House of Lords (The Gaurdian 12 October, 2005). 'The bill to legalise assistance with dying arises from the argument that to deny assistance is to deny the autonomy, or right to choose, of an individual. Proponents describe this denial as dehumanising, as though exercise of autonomy alone is the mark of human personhood. The humanising aspect of choice is its potential for nobility: as humans, we can reflect on our being and on the consequences of our choices. The right to choose to die with medical assistance, when placed in this context, must be weighed against the nobility of relinquishing this right if its commission would damage other, possibly more vulnerable, members of our society.' I liked that, and it reflects the same clarity of mind evidenced in her book. But I was writing this during the week that the parliamentarians in my own State of Victoria legislated to approve physician-assisted death and euthanasia, although I suppose words like those of Dr Mannix would have gone straight over their heads. Now the leader of the federal Greens, a medical practitioner who dumped medicine to go into politics, is loudly championing the cause for the legalisation of euthanasia in all Australian States and Territories.

Roger Woodruff
PHYSICIAN-ASSISTED DEATH: SCANNING THE LANDSCAPE Proceedings of a Workshop English, Liverman, Cilio and Alper, Rapporteurs
National Academies Press, 2018

129 pp

ISBN 978-0-309-47695-9

Can be downloaded free at www.nap.edu/25131

Whilst this is certainly the most important palliative care book that crossed my desk in the last month, it is also the most disturbing.

After an introductory chapter, there is discussion of conceptual, legal, and ethical considerations in PAD. A number of important issues are discussed, including the difficulty in determining that a patient's life expectancy is less than six months, how best to assess capacity and competence (in distinct contrast to what happens now), the contradiction between the proponents who demand PAD in the interests of all the patients with unrelievable pain and physical symptoms and the Oregon patients who pursue it because of existential and not physical reasons, and the concern that no safeguards enacted or proposed to date will be able to stop some people's lives from ending without their consent through mistakes, coercion, or abuse.

Kim Callinan, CEO of the pro-euthanasia organisation, Compassion and Choices, waved the civil liberties/human rights card and I felt there was a little indignity that anyone might not agree with her; she chided those who sought to make the request process any more onerous. She provides no useful discussion about why opinion polls show the majority of people are in favour of legalisation of euthanasia, but (in Oregon) only a tiny, tiny fraction request PAD for themselves. She doesn't mention that only a fraction of the physicians who support legalisation say they might be willing to participate in doing it. Lastly, she trots out the prevention of suicide business, and ignores the evidence from Oregon and the Netherlands that the rates of non-assisted suicide have gone up since the legalisation of assisted suicide. I cheered when one participant questioned whether it was appropriate for an advocacy group to attend a scientific meeting.

The next chapter is mainly about PAD in Oregon. Linda Ganzini provides an overview of what has happened over the last 20 years, but I thought she dodged some important issues, depression in particular. There are concerns that significant numbers of patients with potentially treatable depression are getting PAD, but she maintains the incidence of depression is very low based on her study in which social workers (not physicians, never mind psychiatrists) were asked to give a gut-feeling score for depression on a scale of 1 to 5, without bothering to use any of the clinically validated instruments for the diagnosis of depression.

The scientific discussions were again suspended, this time for someone else from Compassion and Choices, to emotionally relate the unfortunate tale of his 29-year-old wife who was diagnosed with glioblastoma multiforme, which led to them moving to Oregon and her dying by assisted suicide. He decries the use of the term 'suicide', which he says is insulting. And I note he says all PAD deaths are 'gentle, peaceful', whilst all non-PAD deaths are 'struggling and in pain'. Perhaps he doesn't know that the Dutch reported that 18% of attempted assisted suicides had to be 'finished off' with euthanasia by injection. Perhaps he hadn't heard about what happened with the seven patients in Oregon who regained consciousness after taking a lethal dose of medication, never mind the poor fellow who woke up after three days and lived for another three months.

Chapter 4 is about PAD elsewhere in the world, mainly in the Netherlands. Bregje Onwuteaka-Philipsen spins the party line that the numbers are low and haven't changed much and it's all under perfect control. But between 1990 and 2015, deaths from euthanasia, PAS and termination of life without explicit request have increased from 2.7 to 4.9% of all deaths; between 2001 and 2015, the use of continuous sedation until death jumped from 5.6 to 18.3% of all deaths; and since 1990, there have been of the order of 18,000 cases of termination of life without request and they are still going strong with more than 400 cases each year. She avoids talking specifically about all the cases in which intensified treatment of pain and symptoms, withholding or withdrawal of therapy, or continuous sedation until death were performed with the explicit intention of hastening death.

A presentation by an anthropologist who studied euthanasia in the Netherlands paints a glowing picture of the time taken and devotion shown by Dutch physicians when it comes to euthanasia: 'Euthanasia in the Netherlands involves discussions taking place over weeks, months, and sometimes years and does not largely focus on the final day itself.' But a Dutch report I read stated: 'The period of time between the first discussion [of euthanasia] and the actual administration varied from less than a day to...' i.e. same-day service.

Chapter 5 discusses implementation and practice of PAD, and includes interesting discussions of the societal, institutional, professional and personal responses to PAD.

The one on which I choked was from 'a recognized expert in palliative care, bioethics and health care communication skills', who said that palliative care teams can be fully participatory in programs of PAD. This is the model promoted by the Belgians in which euthanasia is seen as an integral and necessary part of palliative care. I have great trouble comprehending this approach and believe what they are calling palliative care and what I call palliative care are different things. Over the years, I have repeatedly been impressed when one or other members of the palliative care team has made that extra effort, gone the extra mile, to deal with a patient's suffering. But that will never happen if it is likely (or possible) that the patient will have euthanasia in a week's time.

Chapter 6 discusses physician-assisted death in the context of other long-term support systems available to patients and the last chapter highlights some of the ideas and questions put forward.

This book has a lot of good material, in addition to the twaddle I have picked on. But what disturbed me most was that it seemed to be about 'how to do it' (access, voluntariness, competence, etc.) rather than 'should we do it?' What happened to intelligent debate about the limits of autonomy?

Get it and read it! It's free.

Roger Woodruff (September 201

Robert Macauley is the Cambia Health Foundation Professor of Pediatric Palliative Care at Oregon Health and Science University.

The book is divided into five sections. The first is a general overview and introduction that includes a description of the evolution of the field of clinical ethics. The second is Ethical Issues in Determining the Plan of Care, covering things like autonomy, advance care planning, surrogate decision-making, and code status. The next is about Death and Dying, which takes up one-quarter of the book and which attracted most of my attention. The fourth is about Pediatric Ethics and Palliative Care. The last is collection of other topics including palliative care for dementia and neurodegenerative disorders, organ donation, and the clinical practice of palliative care. Macauley refers to physician-assisted dying (PAD); I shall continue to call it what it is-physician-assisted suicide (PAS).

I got caught up in the section on Death and Dying. There were long (but accurate) discussions of most aspects of a range of issues, but I felt he avoided expressing his opinion. In the end, I felt he seemed to believe there were reasons for avoiding 'active' euthanasia, whilst appearing much more tolerant of PAS. As I have read elsewhere on numerous occasions, we are told that more than half the population of Oregon supported the Death With Dignity Act in November 1994. But according to the Oregon Secretary of State, only 1,254,265 people voted that day, indicating that the DWD Act was supported by only 34.9% of registered voters.

Although rich in theory, I couldn't find much discussion about the known practical difficulties. What about the Dutch patients given lethal medication without explicit request-a thousand patients a year throughout the 1990s, a significant proportion of whom were competent; I think the 2015 figure was down to 500-odd, or only ten per week. What about the Dutch patients subjected to continuous deep sedation until death (26,400 in 2015, or 18% of all deaths), in 5% of which cases (some say more) it is performed with the specific intention of hastening death?

And it's not just the Netherlands. Over 20 years, only 5% of candidates for PAS in Oregon have had a psychiatric assessment and there is evidence of patients with potentially treatable depression undergoing PAS. The lack of any oversight of the assessment process has been criticised, as in the cases where lethal prescriptions were issued for reasons of caregiver burden and so as not to disappoint the family. And the lack of any serious complications of the PAS procedure in Oregon (although I note one person took 104 hours or 4.3 days to die)? The Dutch say nearly one in five attempts at PAS ends up with doctor-administered euthanasia. Anyone know the truth?

In the discussions, I found it curious that the patient subject was always described as 'she', with her wishes and her rights. This is the same as in Sumner's Assisted Death (Oxford University Press, 2014), where I thought it might be a subconscious appeal to the innate sentiment to protect, or at least not harm, the fairer sex, whilst selling a horrid message.

Some comparison with Quill T and Miller F (eds.) Palliative Care and Ethics (Oxford University Press, 2014) is appropriate. I had trouble (and still do) with Quill's denial of the possibility of a double effect when treating pain and symptoms, and Weyer's discussion of euthanasia in Europe was so selective as to be a disgrace. The current volume has the considerable advantage of being single-authored.

Overall, I thought this book was a remarkable effort and I know it will be a useful reference for anybody who works in palliative care. Even in the sections that I have criticised, I have to

say that the discussions of the pros and cons of various issues (as far as they went) were set out in a calm and even manner.

Roger Woodruff (June 2018)
EUTHANASIA, ETHICS AND PUBLIC POLICY: AN ARGUMENT AGAINST LEGALISATION 2e John Keown
Cambridge University Press, 2018

ISBN 978-1107618336

This is the latest addition to John Keown's library of excellent books to do with euthanasia-Euthanasia Examined (Cambridge, 1995), Euthanasia, Ethics and Public Policy (Cambridge, 2002), Debating Euthanasia (Hart, 2012), and The Law and Ethics of Medicine (Oxford, 2012). Perhaps because a lot has happened in the 16 years since the first edition, I thought this latest was the best.

The book starts with a section on definitions, the clarity (or obfuscation) of which are very important in the debate. Part II outlines the three main arguments for permitting euthanasia and PAS, together with the counter-arguments. His descriptions of the moral issues are clear and the legal matters interesting. Following this there is a good chapter on slippery slopes, both 'empirical' and 'logical'. Part III explores the Dutch experience in detail, following which there are sections on Belgium, the (Australian) Northern Territory, Oregon, and Canada.

In the sections on the Netherlands and Belgium, Keown explains how laws that were insufficiently precise or strict were inevitably stretched, and there has been unrelenting progression towards euthanasia being 'normalised'-euthanasia has become just another option, perhaps even the default one, and has progressed from an exceptional act to a legal right. He quotes Belgian Professor Etienne Montero: 'Indications for euthanasia are constantly multiplying, despite the legislators' initial statements and intentions.' He carefully and logically dismantles John Griffiths' and Gerrit Kisma's defence of Dutch euthanasia, in particular regarding the effectiveness of the regulatory system. I was interested to read about Theo Boer (the Professor of Health Care Ethics who was previously pro-euthanasia and served on a Regional Euthanasia Review Committee from 2005 to 2014), who has now become a leading critic of the system. Boer has published figures showing the suicide rates in the Netherlands are the fastest growing when compared to surrounding European countries, most of which lack the option of euthanasia, and that the big increase from 2007 to 2015 occurred during the time when euthanasia had become more accessible.

The review of Oregon confirms there is no effective regulatory system in place and Keown believes it is only a matter of time before euthanasia by injection is condoned.

Canada, or at least the Canadian Supreme Court, does not get good press. Keown details a list of 'judicial errors' and claims 'the judgement of the Canadian Supreme Court was gravely flawed.' He asserts that 'disturbing and well-documented evidence, including that of Professor Montero showing the Belgians skiing past the Dutch down euthanasia's slippery slope, was waved aside'. He also criticises the use of what he calls fuzzy criteria (e.g. 'grievous and irremediable medical condition'); for the most meaningless criterion, I chose: 'their death has become reasonably foreseeable'. And the attempted prohibition of conscientious objection in Canada is ominous. Whilst I believe religious freedoms are preserved under Canada's Charter, the College of Physicians and Surgeons of Ontario has decreed that if a doctor is unwilling to perform euthanasia or physician-assisted dying, they must provide an 'Effective Referral' to a doctor who will, i.e. the College does not consider providing the patient with an 'effective referral' as 'assisting' in providing medical assistance in dying.

In a short Afterword, Keown details the legislation passed in my home State of Victoria. What he does not tell you is that the parliamentary committee that recommended assisted dying, after a nice tax-payer-funded junket to Holland, Switzerland, Canada and Oregon, cited no evidence of abuse or deficiency in the regulatory systems in any of the jurisdictions visited. And that a big deal (i.e. emotive appeal to the masses) was made of the Coroner's deposition, detailing all the suicides in persons who had 'experienced an irreversible deterioration in physical health', which proponents said would be eliminated by assisted dying legislation; the evidence from Oregon and the Netherlands is unequivocal that the suicide rate goes up after legalisation of assisted dying. And that we were repeatedly promised over a period of at least two years that self-administered oral medication was absolutely the only method being considered; then at the very last second, euthanasia by injection was added for any person who is 'physically incapable of the self-administration or ingestion' of the lethal substance; I have predicted that the breadth of interpretation of those words would be breath-taking. I could go on...

Reading the descriptions in this book, one is repeatedly reminded of the rising swell of public support for assisted dying, which Syme (Time to Die, MUP, 2016) refers to as 'The Momentum', which unequivocally demands legislation. Polls show 70% (or thereabouts) of ordinary people support legalisation. Polls of people who are terminally ill show that about 70% support legalisation, but less than 10% would request it for themselves if it were legal. And the Oregon experiment? There are about 7,500 deaths from cancer each year, or about 150,000 since the DWDA was enacted. Given that 35% of the adult population voted in favour of the DWDA, that should have resulted in 52,500 assisted deaths from cancer alone. Of the 1275 patients to 2017, 68% (867) had cancer. Which means only 1.6% of patients dying of cancer, who voted in favour of the DWDA, chose an assisted death. Seems to me the clinical 'need' and public 'demand' are much exaggerated.

This book is the best collection of information regarding euthanasia that I have seen and is strongly recommended if you have any interest in euthanasia and assisted dying debate.

John Keown holds the Rose F. Kennedy Chair in the Kennedy Institute of Ethics at Georgetown University, in Washington DC.
Roger Woodruff
(January, 2019)

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Euthanasia and Physician Assisted Suicide

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EUTHANASIA Euthanasia is 'a deliberate intervention undertaken with the express intention of ending a life so as to relieve intractable suffering' (House of Lords, 1994; Walton, 1995). If it is performed at the dying person's request, it is voluntary; otherwise, it is non-voluntary. The terms 'active' and 'passive' may be misleading (Walton, 1995).

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미래의 사회는 사람과 사람의 연결, 국가와 국가 간의 연결을 넘어서 모든 사물들이 데이터를 주고받으며 세상 대부분의 것들이 함께 연결되는 초연결사회를 향해 나아가고 있습니다. 그렇다면 이 초연결사회에는 어떤 일들이 일어날까요?

빛

초연결사회에서 우리의 생활은 침대에서 일어나 다시 잠드는 순간. 심지어 잠을 자는 시간 동안에도 '연결'되어 있다. 잠을 자는 동안에는 침대와 베개에 탑재된 센서가 나의 건강상태와 수면 패턴을 측정해주고, 수많은 CCTV가 우리 집과 우리 동네를 24시간 1초도 놓치지 않고 감시하여 범죄와 사고를 예방해준다. 아침 하루 일과를 준비할 때는 나의 특성을 파악해 오늘 해야 할 중요한 일들과 나의 관심사를 스마트 거울, 휴대용 스마트 디바이스 등을 통해 알려주고, 사무실로 출근하지 않아도 컴퓨터나 화상회의, 가상 업무 공간 등을 이용해 업무가 가능하다. 게다가 일을 하는 동안에도 책상과 의자, 피트니스 밴드 등이 나의 자세를 파악해 교정해주고 운동이 부족할 때는 적절한 운동방법까지 제안을 해준다. 또 식사를 할 때에는 나의 유전자와 건강상태 데이터를 토대로 내 몸에 좋은 식습관을 제안하고 내가 하루에 섭취한 칼로리와 소모량을 자동으로 계산해준다.
IoT 웨어러블 팔찌 Nymi: https://www.youtube.com/watch?v=G8VfyLnRPus
그림자

뉴스를 켜니 또다시 해커에 의한 범죄 소식이 전해진다. 초연결사회에 반대를 하는 극단적 집단이 병원을 해킹한 것이다. 그들은 병원 응급실의 수많은 기기들 작동을 멈춰 20명의 환자가 사망했고, 약품 조제 로봇을 조작해 치명적인 양의 약을 처방해 수 십 명의 환자가 부작용을 겪고 있다. 더욱 심각한 사태는 그들이 환자 5000명의 의료정보를 유출해 갔기 때문에 앞으로 2차, 3차 피해가 우려된다는 점이다. 또한 나의 여성 친구는 최근 집안의 홈 CCTV가 스토커에 의해 해킹이 되어 전 세계로 자신의 샤워장면이 실시간으로 중계가 되어 우울증을 겪고 있으며, 게임을 좋아하는 내 조카는 엄마, 아빠가 집을 비울 때도 홈 CCTV와 웹캠 등을 통해 게임을 하고 있는지 아닌지 감시를 하기 때문에 게임을 하고 싶어도 할 수가 없다. 또 어린 시절 철없이 인터넷에 독일 나치를 찬양하는 글을 올렸던 내 중학교 동창은 아직까지 그 기록이 남아있어 회사에 채용되는 데에 어려움을 겪고 있다. 인터넷에 무심코 적어놓은 모든 글을 누구든 쉽게 찾아볼 수 있기 때문이다. 또 동성애자임을 숨기고 있던 내 친구는 게이클럽 이벤트 광고가 스마트폰으로 전송된 것을 어머니에게 들켜 원치 않는 커밍아웃을 해야 했다.

이 모든 시나리오가 앞으로 10년 안에 충분히 벌어질 수 있는 일이며, 그중 몇몇은 이미 벌어지고 있는 일이기도 합니다. 이렇듯 초연결사회는 우리에게 장밋빛 미래만을 약속해주지는 않을 겁니다. 모든 기술의 발달과 세상의 변화가 그러하듯, 우리의 생활을 편리하게 만들어주는 한 편 그로 인한 다양한 문제들을 양산해 낼 것입니다.

특히나 초연결사회에서 가장 문제가 되는 부분은 보안과 사생활 침해에 대한 부분인데, 그런 문제가 예상됨에도 불구하고 초연결사회로 향하는 거대한 흐름을 막을 수는 없을 것입니다. 기술의 진보는 우리가 거부할 수 없는 거대한 파도와 같은 압도적인 힘을 가지고 있기 때문입니다. 그렇다면 앞으로 초연결사회를 맞아할 우리들이 할 일은 예상되는 문제점들은 최대한 대비를 하여 막고, 우리가 누릴 수 있는 이점들을 최대한 이용하는 것이라고 할 수 있습니다.

우리가 초연결사회를 지향하고 스마트시티를 구축해야 할 이유는 다양하지만 그중에서도 우리에게 주는 큰 혜택 중 하나는 범죄예방 효과 겠죠. 현대사회의 뉴스를 보게 되면 하루에도 몇 번씩 살인과 폭력, 강간 등에 관한 소식을 보게 됩니다. 특히나 묻지마 살인이나 여성혐오 범죄와 같은 소식들은 피해자뿐만 아니라 나도 이유 없이 당할 수 있다는 사회 전체적인 불안감을 증폭시키기 마련입니다.

특히나 상대적으로 힘이 약한 여성의 경우에는 범죄에 노출되기가 쉽죠. 그렇다 보니 남성은 밤늦게까지 돌아다녀도 불안함을 느끼는 경우가 드물지만 여성은 내가 살고 있는 동네를 늦은 시간 마음 편하게 돌아다니기 쉽지 않습니다. 이를 해결하기 위해 경찰이 순찰을 돌거나 편의점에 몸을 숨겨 신고를 할 수 있는 시스템 등이 도입이 되고 있지만 이 역시 불안감을 해소해주기에는 역부족이라 할 수 있습니다. 그렇다면 만약 초연결시대에 맞게 도시가 미리 범죄를 예방할 수 있는 시스템을 갖춘다면 어떨까요?

판옵티콘이란 '모두'를 뜻하는 'pan'과 '본다'를 뜻하는 'opticon'의 합성어로 영국의 공리주의 철학자 제레미 벤담이 만든 원형 감옥 시스템입니다. 그 감옥은 중앙 감시탑을 중심으로 빙 둘러진 감방으로 구성이 되어 있는데, 감시탑은 조명을 어둡게 해놓고 감방은 불을 밝게 켜놓기 때문에 감시탑에서는 감방 안의 수감자들의 행동을 잘 파악할 수 있지만 반대로 수감자들은 감시자가 나를 보고 있는지 아닌지를 알 수가 없죠. 그렇다 보니 수감자들은 감시자가 나를 보고 있을지도 모른다는 불안에 허튼 행동을 할 수가 없게 됩니다.

그렇다면 초연결사회는 어떤 모습일까요? 초연결사회에서는 수많은 CCTV가 도시를 사각지대 없이 감시하며 경비 로봇과 드론이 24시간 도시를 순찰하게 됩니다. 덕분에 범죄를 저지르고 싶어도 언제 어디서든 나를 지켜보고 있다는 생각에 범죄를 저지르기 힘들어지겠죠.

물론 정신이상자나 작정하고 범죄를 저지르는 사람은 어떻게든 범죄를 저지르겠죠. 하지만 그 범죄의 빈도수가 줄어들 것이라는 가능성은 상당히 높을 것이라고 기대할 수 있습니다. 그리고 만약 이렇게 누군가 24시간 사각지대 없이 나를 보호해주고 있다고 느낀다면 상대적으로 힘이 약한 여성, 어린이, 노약자들은 안심하고 사회활동을 즐길 수 있을지도 모르죠.

하지만 이는 반대로 모든 사람들이 판옵티콘이란 감옥 안에 갇혀 감시를 받고 있는 듯한 느낌을 줄 수도 있을 겁니다. 그에 따라 사생활 침해에 대한 논쟁과 여러 파생 문제점들 또한 발생 가능성이 매우 높습니다. 결국 초연결사회로 가는 과정에 있어 마찰을 피할 수는 없겠죠. 우리 사회가 '안전한 사회'인지 '안전한 감옥'인지에 대한 논쟁이겠죠.

범죄가 판치는 도시엔 행복도 없다

우리들은 초연결사회에서 어떻게 안전하면서도 자유로운 사회를 만들어갈 수 있을까요? 그를 위해서는 개인, 국가, 기업의 노력이 함께 진행되어야 할 겁니다.

먼저 개인은 사생활에 대한 개념 변화에 적응 해야 할 것입니다. 사실 이미 세상이 초연결사회로 변모해 감에 따라 사생활에 대한 인식도 달라지고 있습니다. 현대의 젊은이들은 페이스북, 인스타그램 등 SNS 서비스를 통해 자신의 사생활을 자발적으로 노출하고 그를 즐기고 있는 세대입니다. 정보의 공유가 자연스러워진 환경에서 살고 있는 젊은이들에게는 SNS를 통한 자신의 생활모습 공유 역시 자연스러운 문화인 것이죠.

한국의 연예계만 생각을 해보더라도 과거에는 서태지와 아이들이나 H.O.T.처럼 90대 가장 인기 있던 가수들은 자신들의 사생활을 철저히 숨기는 신비주의 전략을 고수했지만, 2000년대의 가수들은 SNS를 통해 자신의 생활을 팬들과 공유하며 팬들과의 소통을 더욱 중요시하고 있는 점을 발견할 수 있습니다. 현대를 살고 있는 젊은이들에게는 사생활을 공개하지 않는 사람보다 자신의 멋진 사생활을 공유하는 사람이 더욱 매력적으로 느껴지는 겁니다.

게다가 사생활이란 개념 자체가 인류 역사상 그렇게 오래되지 않은 개념인데, 미래학자 제러미 리프킨은 그의 저서 '한계비용 제로사회'에서 근대 이전 사회는 거의 모든 사회에서 사생활이 없는 공개적 생활을 하였으며 사생활은 인간의 생활에 반드시 필요한 '생득권'은 아니라고 주장하고 있습니다. 즉 우리가 지금 생각하는 사생활이란 개념은 문화가 변함에 따라 얼마든지 변할 수 있다는 것 이죠. (제러미 리프킨 「한계비용 제로사회」 p.123)

하지만 그렇다고 해서 요즘 젊은 세대가 사생활 침해를 환영한다는 말은 아닙니다. 물론 그들도 사생활을 중요시하죠. 그중 그들이 사생활 침해라고 느끼는 순간은 자신의 들키고 싶지 않은 것을 들키는 순간이라고 할 수 있습니다. 자신의 멋진 모습만을 골라 SNS에 불특정 다수에게 공개하는 건 문제가 되지 않지만, 나의 치부를 비자발적으로 공개하는 것은 사생활 침해의 문제가 된다는 것이죠. 반대로 이야기하자면 내가 공개하기를 원치 않는 것을 제외하면 나의 멋진 모습이 수많은 사람에게 공유되는 것은 자랑스러움마저 느껴질 정도로 현대의 젊은이들은 사생활 공개에 대해서 보다 유연해진 특성 이 있습니다.

그렇기 때문에 정보공유, SNS 문화에 익숙해진 어린 세대일수록 보다 사생활이란 개념에 유연한 모습을 보일 가능성이 있으며, 그에 따라 세대 간의 생각 차이 역시 예상할 수 있습니다. 기존 세대는 과거의 보다 견고했던 사생활이란 개념에 익숙한 나머지 새로운 세대보다 사생활의 공개에 대한 거부감이 더욱 클 수 있기 때문입니다.

상황이 이렇게 계속된다면 젊은 세대는 안전과 경제 성장 등을 이유로 초연결사회로의 진입과정에서 발생하는 사생활 문제에 관대한 데에 반해 기존 세대는 보다 보수적인 입장을 가지고 있어 갈등을 초래할지도 모르죠. 결국 이 문제의 해결을 위해서는 기존 세대들이 얼마만큼 사생활이란 개념에 유연해질 수 있는지 가 굉장히 중요한 부분이 될 수 있습니다.

또한 이러한 갈등을 조절하고 기존 세대를 설득시키는 것은 국가가 노력해야 할 부분이라고 할 수 있습니다. 국가가 개인의 사생활을 충분히 보호할 수 있으며 CCTV와 센서, 휴대용 디바이스 등을 통해 수집되는 정보가 오직 사회치안유지와 사회 발전 등 공익을 위해서만 사용이 될 것이라는 확신을 심어주어야 하는 것이죠. 만약 정부에 의한 개인 사생활 침해 사례 문제가 발생해 국민들에게 알려진다면 그만큼 불신은 더욱 커져 사생활 침해에 대한 논란은 더욱 가중될 것이 분명하기 때문입니다.

또한 마지막으로 기업에서도 자사의 개인 정보 활용과 제공 서비스가 소비자들에게 피해를 주지 않을 것이라는 강한 확신을 보여주어야 하겠죠. 하지만 초기 초연결사회로의 진입과정에는 제대로 된 법안과 제도가 마련되어 있지 않은 상태에서 기업들이 다양한 데이터를 수집하여 서비스를 제공하기 시작함에 따라 개인 정보 유출과 사생활 침해에 대한 문제는 피할 수 없을 것으로 예상됩니다. 그렇기 때문에 기업에서는 문제가 발생했을 때 그에 어떻게 대처할지, 그리고 얼마나 더 발전된 시스템을 갖출 수 있는지 소비자들에게 계속 설득시키는 과정이 상당히 중요해질 것입니다.

결국 초연결사회로의 진입과 그 과정에서 발생하는 사생활 침해 문제는 피할 수 없는 과정 이 될 것입니다. 하지만 인류는 언제나 그래 왔듯 변화에 적응하며 그 문제를 해결하는 방식으로 문명을 진화시켜왔습니다. 자동차가 발명되고 자동차 대중화 시대가 진행이 됨에 따라 발생하는 문제로 인해 신호등, 운전면허 등과 같은 보완 방법이 탄생했듯 앞으로 초연결사회가 진행이 됨에 따라 발생하는 문제들을 해결해줄 여러 장치와 방안들이 등장하게 될 것입니다.

미래는 예상되는 문제점은 대비하고 꿈꾸는 이상향을 위해 사회 구성원이 함께 노력하며 만드는 것입니다. 우리가 맞이할 초연결사회 역시 예상되는 문제점은 미리 함께 논의하고 초연결사회가 가져다 줄 안전과 성장 등을 위해 모두가 함께 노력하며 만들어 가야 하겠죠.

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『미래행복론』 변화하는 미래사회, 개인은 어떻게 행복할 것인가 | 사생활이냐 안전이냐 미래의 사회는 사람과 사람의 연결, 국가와 국가 간의 연결을 넘어서 모든 사물들이 데이터를 주고받으며 세상 대부분의 것들이 함께 연결되는 초연결사회를 향해 나아가고 있습니다. 그렇다면 이 초연결사회에는 어떤 일들이 일어날까요? 초연결사회의 빛과 그림자 빛 초연결사회에서 우리의 생활은 침대에서 일어나 다시 잠드는 순간.

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[서울=뉴시스] AI 2041 (사진=한빛비즈 제공) 2023.01.19. photo@newsis.com *재판매 및 DB 금지

[서울=뉴시스]신재우 기자 = "딥러닝은 그 엄청난 혜택에도 불구하고 결과물이 초래하는 여러 부작용으로 인해 대중으로부터 심각한 불신을 받고 있다. 그런데 사실 모든 신생 기술은 단점을 갖기 마련이다. 지난 역사를 보더라도 도입 초기의 신기술이 가진 오류는 시간이 지남에 따라 개선되거나 보완되었다." (58쪽 중)

인공지능과 인류의 미래를 예측하기 위해 AI 전문가와 SF 작가가 뭉쳤다.

'AI 2041'은 구글 차이나 대표를 역임한 리카이푸와 세계중국과학소설협회의 회장으로 활동하는 천치우판 작가가 상상하는 인공지능의 미래다.

책에 따르면 인공지능은 중대한 변곡점에 도달했다. 알파고가 이세돌 9단에게 승리를 거둔 것도 7년 전의 일이다. 생물학계의 해묵은 수수께끼였던 '단백질 접힘 구조'는 최대 90%까지 예측하는 수준에 이르렀고, 음성인식과 객체인식에서 인간의 능력을 뛰어넘은 인공지능은 특히 외모와 말소리에서 소름 끼칠 만큼 인간을 닮은 디지털 인간을 등장시켰다. 인공지능은 판사보다 훨씬 더 공정하고 객관적인 판결을, 폐암 진단에서 영상의학과 전문의보다 뛰어난 기량을 보여주고 있다.

두 저자는 이러한 현실에 대해 불안보다는 희망을 본다. 인공지능의 발전에 관한 여러 측면을 면밀하게 살펴보고 주의를 기울이되, 동시에 그 기술이 가진 잠재력과 큰 그림을 보는 것이 중요하다고 말한다. 그래야 인공지능과 인류의 미래에 관한 온갖 걱정과 우려들 사이에서 균형을 잡을 수 있기 때문이다. 책에는 세계 곳곳을 배경으로 한 SF소설 10편과 이에 대한 AI 전문가의 날카로운 기술분석을 바탕으로 우리가 맞이할 가까운 미래에 대한 예언과 다양한 시나리오를 전한다.

# data[].attributes.attachment_link.description
서울=뉴시스] AI 2041 (사진=한빛비즈 제공) 2023.01.19. photo@newsis.com *재판매 및 DB 금지 [서울=뉴시스]신재우 기자 = "딥러닝은 그 엄청난 혜택에도 불구하고 결과물이 초래하는 여러 부작용으로 인해 대중으로부터 심각한 불신을 받고 있다. 그런데 사실 모든 신생 기술은 단점을 갖기 마련이다. 지난 역사를 보더라도 도입 초기의 신기술이 가진 오류는 시간이 지남에 따라 개선되거나 보완되었다."

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울산매일 - 울산최초, 최고의 조간신문

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월급, 근무조건, 사회적 평판 등을 종합했을 때 자기 일에 가장 만족하는 직업군은 판사인 것으로 조사됐다. 고용정보원이 우리나라 주요 직업 621개 직업 재직자 직업 만족도를 조사한 결과다.

그러나 한국은 '죽은 법조인의 사회'라는 말과 함께 법률 기술자라는 말이 나돌더니 최후의 보루, 대법원마저 의심받는 지경이 되고 말았다. 법의 상식은 보편타당해야 한다. 그런데도 요즈음 법의 상식은 물론 일반 국민 상식과도 동떨어진 이상한 판결들이 잇달아 나오면서 사법 불신을 증폭시키고 있다. 심지어 "하루빨리 AI(인공지능) 판사가 등장해야 한다"는 말이 나올 정도가 됐다.

화천대유에서 대리와 과장으로 6년 일한 곽상도 전 의원 아들은 성과급 명목으로 50억원의 퇴직금을 챙겼다. 곽 전 의원의 뇌물혐의에 무죄가 선고됐다. 검찰은 화천대유가 하나은행과 컨소시엄을 구성하는 과정에서 곽 전 의원이 힘을 써준 대가로 의심했다. 그런데 언제, 누구에게 청탁했는지 입증하지 못해 알선수재는 성립않고 남은 것은 뇌물 혐의였다.

곽 전 의원이 국민의힘 부동산특위 위원이었던 만큼 대장동 개발과 직무 관련성이 있다는 점은 법원도 인정했다. 법원은 그 아들이 독립해 생계를 유지했다며 곽 전 의원에 대한 뇌물은 아니라고 결론을 내렸다. 세간에선 '신종 편법 증여 수단'이라는 말까지 나온다.

윤미향 의원의 위안부 후원금 횡령 의혹 사건 역시 1심 법원의 소극적인 법리 적용으로 횡령 혐의액 1억여원 중 1,700만원을 제외한 나머지 혐의에서 무죄가 선고됐다. 법원의 판결이 언제나 사회 통념과 같을 수 없다. 하지만 상식이나 통념과 현격한 차이가 있다면 법원의 판결은 물론 검찰수사에도 잘못이 없는지 검토해야 한다.

게다가 50억원 무죄 재판부는 대장동 사건 1심도 맡고 있다. 호사가들 사이엔 '50억원 무죄는 이재명 무죄를 위한 밑밥 깔기'라는 소리도 들린다. 판결은 법과 양심에 따라 한다지만 상식에 너무 어긋나지 말아야 권위가 생긴다. 최고의 직업 만족도를 자랑하는 판사들의 판결이 국민 법 감정과 크게 괴리되고 있다는 사실이 판사는 물론 사법부의 신뢰도를 땅에 떨어뜨리고 있다.

기자의 다른기사 보기

저작권자 © 울산매일 - 울산최초, 최고의 조간신문 무단전재 및 재배포 금지

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[반구대] 판사와 판결

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월급, 근무조건, 사회적 평판 등을 종합했을 때 자기 일에 가장 만족하는 직업군은 판사인 것으로 조사됐다. 고용정보원이 우리나라 주요 직업 621개 직업 재직자 직업 만족도를 조사한 결과다. 그러나 한국은 '죽은 법조인의 사회'라는 말과 함께 법률 기술자라는 말이 나돌더니 최후의 보루, 대법원마저 의심받는 지경이 되고 말았다. 법의 상식은 보편타당해야 한다.

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인공지능, AI판사가 활약하는 세상이 머지않은 것 같은데요.

타이완이 출발선에서 먼저 한 발 나갔습니다.

<오! 클릭> 세 번째 검색어는 '현실로 다가온 AI판사 시대'입니다.

타이완 최고법원이 이달부터 AI 양형 정보시스템을 전면 가동하기 시작했습니다.

이 시스템은 다량의 재판 기록들이 실시간으로 업데이트되기 때문에 유사 사건에 대한 양형 추세와 양형 사유를 쉽게 파악할 수 있는데요.

음주운전, 사기, 절도, 상해 같은 범죄에는 '사실형 모델'이, 총기류, 마약 사건 등에는 '평가형 모델'이 적용 가능하다고 하네요.

일치된 양형 기준으로 재판이 공정하고 투명해질 것이라는 기대와 함께, 보편적 평등은 이룰 수 있어 보이지만, 개별 사안의 특수성까지 고려할 수 없다며 우려하는 목소리도 적지 않습니다.

아직 이 AI시스템, 법률적 효력은 없고, 판사가 선고할 때 참고할지 정할 수 있다고 합니다.

누리꾼들은 "인공지능에 다 내주면 이제 사람은 무슨 일을 하죠?", "잘 키운 AI 하나가 편협한 판사 10명보다 나을수도" 등의 반응을 보였습니다.

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타이완에선 AI가 판사...범죄별 '맞춤 모델' 적용까지

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인공지능, AI판사가 활약하는 세상이 머지않은 것 같은데요. 타이완이 출발선에서 먼저 한 발 나갔습니다. 세 번째 검색어는 '현실로 다가온 AI판사 시대'입니다. 타이완 최고법원이 이달부터 AI 양형 정보시스템을 전면 가동하기 시작했습니다. 이 시스템은 다량의 재판 기록들이 실시간으로 업데이트되기 때문에 유사 사건에 대한 양형 추세와 양형 사유를 쉽게 파악할 수 있는데요.

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경북일보 - 굿데이 굿뉴스

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졸업생 55만354명 대상 조사...수도권과 비수도권 격차 여전

교육부와 한국교육개발원이 28일 발표한 '2019년 고등교육기관 졸업자 취업통계조사' 결과 지난해 대학교·대학원 졸업자의 취업률이 전년보다 소폭 감소한 67.1%로 나타났다.

성별과 지역별 취업률 차이는 전년보다 크게 벌어졌다.

이번 조사는 전국 대학과 일반대학원의 2018년 8월·2019년 2월 졸업자 55만354명을 대상으로 실시됐으며 지난해 12월 31일 기준 취업·진학 여부와 급여 수준, 취업 준비기간 등을 파악했다.

조사 대상자 중 취업자는 32만3천38명으로 졸업생 중 취업대상자 48만1천599명의 67.1%였다. 2019년 취업률은 전년(67.7%)보다 0.6%포인트 감소했다.

분야별로 보면 건강보험 직장가입자가 29만1929명, 해외취업자가 2853명, 1인 창업자(사업자)가 6137명, 프리랜서가 1만8347명이었으며, 건강보험 직장가입자 비율은 전년보다 1.2%포인트, 프리랜서는 0.1%포인트 각각 줄었고 해외취업자나 1인 창업자 비율은 변동이 없었다.

남성과 여성의 취업률 격차는 2016년 이후 4년 연속 증가했다.

지난해 남성 졸업자의 취업률은 69.0%로 평균 이상이었으나 여성 졸업자는 65.2%로 평균보다 낮았으며, 전년과 비교하면 남성과 여성 졸업자 취업률이 모두 감소했지만, 남성 취업률 감소 폭은 0.6%포인트로 여성 취업률 감소 폭(0.8%포인트)보다 작았다.

남녀 취업률 차이는 2016년 2.6%포인트, 2017년 3.0%포인트, 2018년 3.6%포인트, 2019년 3.8%포인트로 점차 벌어지고 있다.

수도권과 비수도권의 취업률도 매년 더 커져 수도권 취업률은 68.7%, 비수도권 취업률은 66.0%로 2.7%포인트 차이를 보였다. 수도권과 비수도권 취업률 격차는 2016년 1.6%포인트, 2017년 2.1%포인트, 2018년 2.2%포인트로 매년 커지고 있다.

계열별로도 취업률에 차이가 있었다.

공학계열(69.9%), 의약계열(83.7%)의 취업률은 평균보다 높았으나 반대로 인문계열(56.2%), 사회계열(63.4%), 교육계열(62.7%), 자연계열(63.8%), 예체능계열(64.5%)은 낮았다.

전년과 비교하면 의약계열(0.4%포인트), 예체능계열(0.3%포인트)은 취업률이 상승했고 공학계열(-1.8%포인트), 교육계열(-1.4%포인트), 인문계열(-0.9%포인트), 사회계열(-0.8%포인트), 자연계열(-0.4%포인트)은 하락했다.

지난해 졸업자 중 직장에 취업했던 사람이 11개월 후 직장 취업자 자격을 유지하는 비율인 유지취업률은 80.2%로 나타나 전년(79.0%)보다 1.2%포인트 상승했다.

성별 유지취업률은 남성 졸업자가 83.1%, 여성 졸업자가 77.2%로 5.9%포인트 차이가 났으며, 지역별로는 수도권이 81.0%, 비수도권이 79.6%로 1.4%포인트의 차이를 보였다.

계열별로 유지취업률을 보면 공학계열(84.8%), 의약계열(84.1%), 교육계열(82.1%)은 전체 유지취업률보다 높게 나타났으나 인문계열(75.0%), 사회계열(79.1%), 자연계열(77.6%), 예체능계열(65.8%)은 낮게 나타났다.

학부 졸업자의 월평균 소득은 241만6000 원, 일반대학원 졸업자의 월평균 소득은 446만2000 원이었다.

취업자 중에는 졸업 전에 취업한 사람이 35.8%로 가장 많았고 졸업 후 3개월 이내(25.9%), 6개월(15.1%), 9개월(14.3%), 10개월 이상(8.9%) 순으로 나타났으며, 직장 취업자를 기업 유형별로 보면 중소기업이 46.0%로 가장 많았고 비영리법인(16.8%), 대기업(10.9%), 중견기업(8.4%), 공공기관 및 공기업(8.2%), 국가 및 지방자치 단체(6.1%), 기타(3.6%)가 그 뒤를 이었다.

정형기 기자의 다른기사 보기

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작년 대학·대학원 졸업자 취업률 67.1%

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교육부와 한국교육개발원이 28일 발표한 '2019년 고등교육기관 졸업자 취업통계조사' 결과 지난해 대학교·대학원 졸업자의 취업률이 전년보다 소폭 감소한 67.1%로 나타났다. 성별과 지역별 취업률 차이는 전년보다 크게 벌어졌다. 이번 조사는 전국 대학과 일반대학원의 2018년 8월·2019년 2월 졸업자 55만354명을 대상으로 실시됐으며 지난해 12월 31일 기준 취업·진학 여부와 급여 수준, 취업 준비기간 등을 파악했다.

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올해로 시행 5년째를 맞은 공공기관 지역인재 채용 제도가 '수도권 대졸자 역차별'로 논란이 되고 있다. 공공기관의 특정 대학 출신 편중이 심화한다는 지적도 나온다.

13일 국토교통부에 따르면 혁신도시 조성 및 발전에 관한 특별법(혁신도시법)상 지방으로 이전한 공공기관의 지역인재 채용 비율은 2018년 18%에서 시작해 매년 3%포인트씩 목표치를 올려 잡아 올해 30%까지로 높아진다. 지역인재 채용이란 공공기관이 소재지 대학 졸업자를 의무적으로 채용하는 제도를 말한다. 2013년부터 지역 균형발전 정책에 따라 109개 공공기관이 지방으로 이전했고, 이에 따라 서울에 인재가 몰리는 현상을 완화하기 위해 지역인재 채용 제도를 도입했다.

지역인재 전형은 공정한 채용을 보장하기는커녕 수도권 대졸자를 역차별하고 심한 경우 지역 출신자에게 불이익을 준다는 지적이 끊이지 않고 있다. 지역 공공기관들이 채용 때 '지역 출신자'가 아니라 '지역 소재 대학 졸업자'를 우대하기 때문이다. 가령 지방에서 태어나 초·중·고등학교를 해당 지역에서 졸업한 뒤 대학 진학을 서울에서 한 사람은 지역인재 제도의 혜택을 받지 못한다. 서울에 있는 대학을 졸업해 취업을 준비 중인 제주 출신 A씨(27)는 "학생 때 지역에서 '인재' 소리를 들으면서 서울로 대학 진학을 했는데, 막상 졸업해서 고향에 있는 공무원연금공단에 취직하려고 하니 지역인재가 아니라고 한다"며 "반대로 서울에서 쭉 살다가 대학만 지역에서 졸업하면 지역인재가 되는 것이 공정하냐"고 따져 물었다.

지역인재 채용이 도입 의도와는 다르게 공공기관의 특정 대학 출신 편중을 낳는다는 비판도 나온다. 공공기관의 특정 대학 출신 편중이 지속되면 지역 혹은 기관 내에서 이들이 새로운 기득권을 형성할 것이라는 우려가 크다.

지난해 국정감사에서 김교흥 더불어민주당 의원이 국토교통부로부터 제출받은 '혁신도시 공공기관 지역인재 채용 현황'에 따르면 지방 혁신도시로 이전한 주요 18개 기관의 2020년 신규 채용 현황 분석 결과 경북 지역에서는 한국가스공사(대구·77.2%), 한국장학재단(대구·70%), 한국도로공사(김천·47.7%), 한국수력원자력(경주·46.6%) 등의 기관에서 경북대 출신 쏠림 현상이 두드러졌다. 전남 지역에서는 한국전력공사(나주·55.4%), 한국전력거래소(나주·83.3%), 한국농어촌공사(나주·68.4%) 등에서 전남대 출신 비중이 높게 나타났다.

이런 가운데 지역 대학들은 현재 30% 수준인 지역인재 채용 비율을 50%까지 확대해 달라고 요구하는 상황이다. 지역 26개 4년제 대학 입학처장 협의회는 지난 3월 대통령선거를 앞두고 '공공기관 2차 이전과 지역인재 채용 50% 확대'를 촉구한 바 있다.

김소현 기자 alpha@hankyung.com

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"지역인재 무조건 30% 이상 뽑아라"..커지는 수도권 졸업자 역차별 논란

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올해로 시행 5년째를 맞은 공공기관 지역인재 채용 제도가 '수도권 대졸자 역차별'로 논란이 되고 있다. 공공기관의 특정 대학 출신 편중이 심화한다는 지적도 나온다. 13일 국토교통부에 따르면 혁신도시 조성 및 발전에 관한 특별법(혁신도시법)상 지방으로 이전한 공공기관의 지역인재 채용 비율은 2018년 18%에서 시작해 매년 3%포인트씩 목표치를 올려 잡아

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1위 해커스잡 : 네이버 블로그

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공기업 지역인재 채용 제도를 둘러싸고 취업준비생들 사이에서 역차별 논란이 일고 있다. 지방 균형발전의 일환으로 도입됐지만 정작 지역인재를 선별하는 기준이 대학교 위치다 보니 지방 출신이라도 수도권 대학을 나온 학생은 혜택을 받을 수 없다. 지역인재 제도가 공공기관의 특정 대학 출신 편중을 심화시킨다는 비판도 제기됐다.

지역인재는 선발예정인원의 일부를 지역별 인구비례로 선발하거나 해당지역대학출신자를 일정비율 이상 선발하는 채용제도를 의미한다. 지역인재의 대상은 최종학력 기준 해당 소재 고등학교 또는 대학 졸업(예정)자이다. 다시 말해 해당 지역의 고졸 또는 그 지역의 대학교를 졸업해야한다.

지역인재는 1차 서류심사부터 최종 4차 면접까지 3% 가산점의 혜택을 받는다. 또, 각 모집단위 전형별 지역인재 합격인원이 목표합격률(30%) 미달시 합격인원 외 추가 선발이 가능하다. 합격 커트라인이 80점일때 지역인재는 75점이더라도 추가합격 가능한 것이다.

지역인재는 공기업이 해당 지역인재를 의무적으로 채용하도록 해 지방대학의 역량을 높이는 취지로 시작됐다. 지역인재 여부의 판단기준은 주로 대학교다. 지역에서 초‧중‧고를 나와 소위 서울의 명문대학교에 진학했던 지역인재들이 취업 시기가 돼 지방으로 돌아오면 지역인재의 이름을 박탈당하는 것이다. 반대로 서울에서 초‧중‧고를 나와 지방대학에 진학하면 해당 지역인재의 권리를 갖게 된다.

지역인재는 취업준비생들 사이에서 수도권 인재를 역차별하는 정책이라며 반발하는 목소리가 높아지고 있다. 이들은 '서울에서 대학 나온 게 죄'라며 정부 정책을 비난하고 있다. 대구에서 초‧중‧고를 나와 서울로 대학을 온 김정록(25) 씨는 "지역인재라는 타이틀을 지역에 위치한 대학을 졸업했다는 이유로 다른 주변인이 차지하는 것을 보면 공정함이 무엇인지에 대해 회의감까지 생긴다"고 밝혔다.

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"인서울 나오면 불리"...공기업 지역인재 채용 역차별 논란

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수도권, 비수도권 채용공고 비율

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https://www.kado.net/news/articleView.html?idxno=1165880

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https://news.mt.co.kr/mtview.php?no=2021091822570599762

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[수원=뉴시스] 김종택기자 = 국내 주요기업의 공개채용 시즌을 앞둔 8일 오후 경기도 수원시 성균관대학교 자연과학캠퍼스 도서관에서 학생들이 공부에 열중하고 있다. 2021.09.08.

"막상 졸업을 앞두고 취업을 준비하는 입장에선 지방대가 유리해진 측면이 많다고 느껴요."

서울 주요 상위권 대학 4학년에 재학 중인 A씨(22)는 최근 공공기관 지역인재 의무채용에 대해 이렇게 말했다. 그는 "수능을 준비하는 수험생 입장이라면 여전히 인서울에 있는 대학교를 선호할 것 같다"면서도 "하지만 졸업을 앞두고 있는 입장에선 주요 지방대보다 유리한 점이 거의 없다"고 말했다.

앞으로 정부는 현재 30% 수준인 공공기관 지역인재 의무채용을 50%까지 확대할 방침이다. 이에 대해 공공기관 취업문을 두드리는 수도권 대학 취준생들의 불만이 크다. 블라인드 채용이 아닌 현재와 같은 지역인재 할당은 오히려 수도권 대학생에 대한 역차별이라는 것이다. 특히 이른바 스카이(서울·고려·연세대)도 아니고 지방대도 아닌 인서울 또는 수도권 대학생들이 이같은 공공기관 지역인재 의무채용에서 가장 불리해졌다는 말도 나온다.

공기업 취업을 준비 중인 수도권 대학 4학년에 재학 중인 B씨(23) 역시 불만을 나타냈다. 그는 "지역인재 채용은 수도권과 비수도권의 격차를 없애고자 만든 정책인데 취지에 맞는지 의문"이라면서 "수도권 대학생들이 비수도권 대학생들보다 기득권이라고 볼 수가 없고, 그렇다고 수도권에 있는 공공기관 취업에 수도권 대학생들이 유리하지도 않다면 정책의 취지와 맞지 않다고 본다"고 말했다.

앞으로 이 같은 추세는 계속 이어질 것으로 보인다. 정부가 지역 혁신도시 중심의 취업정책을 펼치는 사이 수도권 주요대학들은 정부의 재정지원이 끊기는 사상 초유의 사태를 맞았기 때문이다. 특히 이번에 3년간 재정지원을 받지 못하는 52개 대학 가운데 인하대학교와 성신여자대학교의 충격이 크다. 전문가들도 전혀 예상하지 못했다는 반응이다.

지방 주요 대학 2022학년도 수시모집 경쟁률. /자료제공=유웨이

◆공공기관 지역인재 의무채용 추세 입시에 반영 시작, "너무 서두른다" 지적도
이 같은 흐름은 이미 입시에도 반영되기 시작했다고 전문가들은 보고 있다. 재정지원에서 제외된 인하대의 올해 수시모집 경쟁률은 14.27로 지난해 14.76보다 소폭 하락했고, 성신여대의 올해 수시모집 경쟁률 역시 11.82로 지난해 12.93보다 1.11 하락했다.

반면 지방국립대들의 경쟁률은 치솟았다. 부산대의 올해 수시모집 경쟁률은 14.03으로 지난해 10.81보다 3.22나 올랐다. 이는 주요 지방대학 가운데 가장 많이 오른 수치다. 충북대의 수시경쟁률은 10.65로 지난해 8.10보다 2.55가 오르면서 경북대 부산대와 함께 유일한 두 자릿수 경쟁률을 기록했다. 강원대 역시 7.17로 지난해 5.39보다 1.78이 올랐다.

앞으로 공공기관의 지역인재 의무채용 비중이 높아진다면 경기권 대학보다 지방국립대학의 선호도가 확실히 높게 나타날 수 있다는 분석도 나온다. 이만기 유웨이 교육평가연구소장은 "이미 공공기관 지역인재 의무채용은 지방국립대의 선호로 입시에 반영되고 있다고 본다"며 "앞으로 의무채용 비중이 높아지면 특히 경기권 대학생들의 기회가 많이 줄어들 수 있어 우려된다"고 전망했다. 그러면서 그는 "지역인재 의무채용 비율을 너무 서둘러 높이고 있다는 생각이 든다"고 지적했다.

정부가 무작정 공공기관 의무채용을 늘려가기보단 지금까지 추진해온 정책을 한 번 되짚어볼 시점이라는 지적도 있다. 이병훈 중앙대 사회학과 교수는 "혁신도시 중심 공공기관 지역인재 의무채용은 지방대의 소멸을 막기 위한 취지라는 점에서 불가피한 측면이 있다"면서도 "하지만 수도권 대학생들의 기회가 줄어든다는 사실도 무시할 수 없는 만큼 무조건 지역인재 할당비율을 늘리기보단 지금까지 정책이 어떤 효과를 가져왔고, 어떤 역기능이 있었는지도 살펴볼 시점"이라고 말했다.
울산 지역인재 80% 차지한 대학도...쏠림현상에 고개든 광역선발 지역인재 선발 광역화 추진...지자체별 이해관계는 엇갈려

울산 혁신도시에 있는 한국석유공사 등 7개 공공기관은 지난해 35명의 지역인재를 채용했다. 채용목표제 대상인원의 29.2%에 해당한다. 균형발전 차원에서 도입한 혁신도시 지역인재 채용목표 비율을 웃도는 '우수한 실적'이다. 하지만 우여곡절이 없는 건 아니다.

혁신도시의 지역인재는 해당 공공기관이 위치한 지역의 대학을 졸업한 사람으로 한정한다. 울산의 경우 4년제 대학이 울산대와 울산과학기술원 등 2곳밖에 없다. 울산의 한 공공기관 관계자는 "인재풀이 한정된 상황에서 채용목표 비율을 채우는 게 만만치 않다"고 말했다. 지역인재 광역화가 추진되는 이유다.

18일 관계부처에 따르면 국토교통부는 올해 안으로 '혁신도시 조성 및 발전에 관한 법률'(이하 혁신도시법) 시행령을 개정한다. 시행령 개정안에는 경남과 울산의 지역인재 광역 선발 근거를 담는다. 이에 따라 경남에서 대학을 졸업해도 울산의 공공기관에 지역인재로 채용할 수 있게 된다. 그 반대 역시 가능하다.

이는 지난 7월 경남과 울산이 체결한 업무협약의 결과다. 경남과 울산의 공공기관들은 지역인재 선발 과정에서 특정 대학의 편중현상을 호소해왔다.

전국혁신도시노조협의회는 지난해 발표한 성명서에서 "자체적으로 확인한 결과 대부분 지역에서 특정대학 출신이 과반을 넘고, 80% 이상 상회하는 지역도 있다"며 "일부 기관에서는 특정대학의 세력화로 조직운영 및 갈등을 호소하고 있다"고 밝혔다.

실제로 울산 공공기관 지역인재의 80% 이상을 울산대가 차지하고 있는 것으로 알려져 있다. 이에 따라 울산과 경남이라는 권역의 '울타리'를 없애고 지역인재를 공유하는 방안이 마련됐다.

경남과 울산의 지역인재 통합 채용은 다소 늦은 감이 있다. 부산이라는 변수 탓이다. 지역인재 광역화 논의에는 경남과 울산 뿐 아니라 부산도 참여했다. 부산은 통합 채용에 찬성했다. 하지만 경남과 울산이 부산의 참여를 반대했다. 부산에 위치한 대학들이 지역인재를 잠식할 수 있다는 우려에서다.

반면 이해관계가 비교적 비슷한 광주·전남, 대구·경북은 이미 2016년부터 통합 채용을 진행하고 있다. 대전·충청권 역시 지난해부터 지역인재 광역화에 나섰다. 정부 관계자는 "장기적인 관점에서 호남권 지역인재 광역화의 가능성도 열어놓고 있다"고 말했다.

정치권에선 지역인재 채용률을 확대하자는 움직임도 나온다. 대선주자인 이낙연 전 더불어민주당 대표는 "지역 공공기관 신규 채용 시 50%를 비(非)수도권 출신으로 채용하도록 할 계획"이라고 언급하기도 했다. 2018년 18%였던 지역인재 채용목표 비율은 매년 3%포인트씩 상승해 올해 기준 27%다. 내년 이후에는 30%의 채용목표 비율을 지켜야 한다.

최인호 민주당 의원이 대표발의한 혁신도시법 개정안은 이전 공공기관의 채용목표 비율(30%) 외에 추가로 25%를 이전지역 외 지역인재로 채용하는 내용도 담고 있다. 권역의 울타리를 아예 없애고 비수도권 전체로 지역인재의 개념을 확대하자는 취지다.

김태환 국토연구원 국가균형발전지원센터 소장은 "지역인재 할당제는 비교적 성공적인 효과를 보이고 있다"며 "비수도권의 지역인재 개념을 확대하게 되면 수도권 쏠림 현상을 조금 지연시키거나 억제하는 효과가 있을 것으로 보인다"고 말했다.

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수원=뉴시스] 김종택기자 = 국내 주요기업의 공개채용 시즌을 앞둔 8일 오후 경기도 수원시 성균관대학교 자연과학캠퍼스 도서관에서 학생들이 공부에 열중하고 있다. 2021.09.08. "막상 졸업을 앞두고 취업을 준비하는 입장에선 지방대가 유리해진 측면이 많다고 느껴요." 서울 주요 상위권 대학 4학년에 재학 중인 A씨(22)는 최근 공공기관 지역인재 의무채용에 대해 이렇게 말했다.

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네이버 블로그 | 혁이씨의 프리드로우

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찬반토론

[찬반토론, 잊혀질 권리 찬반]

' 잊혀질 권리 찬반토론 '
잊혀질 권리는 개인이 온라인 사이트에 올라가 있는 자신과 관련된 각종 정보의 삭제를 요구할 수 있는 권리를 뜻한다 . 이러한 잊혀질 권리는 유럽연합 (EU) 를 중심으로 도입이 추진되고 있다 . 곤잘레스 사건을 계기로 유럽연합의 최고법원인 유럽사법재판소 (ECJ) 가 잊혀질 권리를 인정했다 .

이 사건은 스페인의 변호사 곤잘레스가 자신의 이름을 검색하다 자신이 지난 1998 년 빚 때문에 집을 강제 경매당한 기사를 보게 된다 . 구글에 삭제 요청을 했지만 거절당한 곤잘레스는 소송을 제기했고 , 유럽사법재판소는 구글 검색 결과에 나오는 링크를 삭제하라는 판결을 내렸다 . 구글이 잊혀질 권리를 인정하자 페이스북 , 마이크로소프트의 빙 등의 검색 엔진 등에서도 개인정보 삭제를 추진 중인 것으로 밝혀졌다 .
→ 잊혀질 권리 찬성입장 → 잊혀질 권리 반대입장
인터넷 기술의 발단으로 인해서 정보의 재생산성이 높아졌으며 , 한번 생성된 정보는 반영구적으로 보존이 가능이 가능한 실정이다 . 이렇게 변화된 상황에서 개인은 이러한 인터넷의 특성을 잘 이해하고 인터넷에 정보를 남기는데 있어서 신중을 기하는 습관을 기를 필요성이 있으며 , 타인의 신상이 담긴 정보를 확대 , 재생산 하는데 있어서 관련 관계자와의 사전 동의를 의무화를 통해 잊혀질 권리에 의지하지 않고 사전에 피해를 예방할 수 있을 것이다 .

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찬반토론 [찬반토론, 잊혀질 권리 찬반] ' 잊혀질 권리 찬반토론 ' 잊혀질 권리는 개인이 온라인 사이트에 올라가 있는 자신과 관련된 각종 정보의 삭제를 요구할 수 있는 권리를 뜻한다 . 이러한 잊혀질 권리는 유럽연합 (EU) 를 중심으로 도입이 추진되고 있다 . 곤잘레스 사건을 계기로 유럽연합의 최고법원인 유럽사법재판소 (ECJ) 가 잊혀질 권리를 인정했다 .

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‘인공지능 판사’는 사람보다 공정하게 판결할까

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[사법영역의 인공지능 적용 확대]에스토니아·중국·호주서 잇단 도입학습 데이터 따라 차별·편견 드러내‘답없는 문제’는 미래에도 사람의 일

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https://www.aitimes.com/news/articleView.html?idxno=140115

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[편집자 주] '이세돌과 알파고' 이후 5년 남짓, 인공지능은 낯설고 새로운 미래가 아닌 이미 익숙한 일상이 되어가고 있다. 가전제품에서부터 자율주행차에 이르기까지, 간단한 온라인 상거래부터 신약개발에 이르기까지 인공지능은 우리 삶과 세상에 물처럼 스며들고 있다.

변화에 가장 잘 적응하는 방법은 변화를 쫒지 않고 변화를 만들어내는 것이다.

이에 AI타임스는 각계 전문가들과 함께 인공지능의 현재를 톺아봄으로써 미래의 변화를 예측하고, 수동적 변화가 아닌 능동적 혁신으로 이끌 수 있는 길찾기의 하나로 '인공지능백서 2021-AI와 우리사회의 변화' 특집기획을 시작한다.

지난해 10월 청와대 국민청원 게시판에 "AI판사를 채용하여 주세요"라는 청원이 올라왔다. 세계최대 아동 성 착취물 사이트를 운영하고도 고작 1년 6개월의 징역형에 그친 판결에 분노한 목소리였다. 검찰과 법원에 대한 국민의 신뢰도가 얼마나 낮은지 상징적으로 보여주는 일이다. 차라리 인공지능이라면 "기계적" 중립이나마 지킬 수 있을 것이라는 기대. 그 편이 더 정의롭지 않을까 하는 질문인 것이다.

법원은 복잡한 인간사에서 일어나는 갈등의 최종 해결 기관이다. 그런 역할을 과연 인공지능이 대신할 수 있을 것인가? 피와 눈물이 없는 대신 어떤 선입견이나 편견도 없이 공정할 것인가? 과연 가능한 일인지, 필요한 일인지, 한계는 없을 것인지, 미래를 위한 사회적 고민이 시작된 것이다.

법원의 재판은 크게 사실을 인정하는 과정과 그에 대한 가치 판단으로 이뤄진다. 누군가의 복부를 오른손과 왼손으로 번갈아 한 차례씩 때렸다. 다행히 맞은 쪽이 크게 다치지는 않아 병원에 가야 할 정도는 아니었다. 사람의 신체에 대한 유형력을 행사한 것이지만 자연적으로 나을 정도에 그쳤다는 사실이다. 형법에 따라 2년 이하의 징역형에 처하여야 하는 폭행죄라는 가치 판단을 내리는 것이다. 쉽다. 얼마든지 인공지능으로 가능할 것이다. 듣는 사람이 겁을 먹을 만큼 해악을 고지하면 협박죄이다. 막연하게 "가만두지 않겠다"는 정도로는 부족하다. 어느 정도에 이르러야 위협을 느끼는지 인간의 감정에 대한 판단이 필요하다.

단순하게 정리하자면 인공지능은 과거 재판의 판결문들을 모아, 판결에 쓰인 단어들을 학습하는 방법으로 만들어진다. 인간들이 누군가를 협박하는데 사용하는 어휘라는 게 얼마나 다양하고 창의적이겠는가. 가능할 것이다. 실제로 2017년 미국 연방 대법원이 200년 가까이 내렸던 판결 2만 8천여건을 인공지능에게 다시 판단하도록 한 결과 70퍼센트 가까이 같은 결론을 내렸다고 한다. 당장 완전히 대체하지는 못하더라도 보조 역할은 충분히 할 수 있을 것이다. 유럽사법재판위원회는 이미 2018년 인공지능 사법제도 헌장을 발표했다. 인공지능 판사가 가능하느냐에 대한 답은 내려졌다. 현실이다.

(출처=셔터스톡)

그렇다 하더라도 발달한 데이터 베이스(DB) 수준의, 업무효율을 위한 보조수단을 넘어 독립적인 판단까지 내리는 인공지능 판사가 필요할 것인가? 2021년 7월 법조계는 판사 지원 자격을 둘러 싼 논란에 휩싸였다. 10년 이상의 경력이 있어야 판사로 임용할 수 있도록 높여 놓았던 기준을 5년으로 다시 낮추자는 법원조직법 개정안 때문이다. 이유는 단순하다. 일손이 딸려서이다. 판사가 부족하면 재판이 미뤄지고 피해는 고스란히 국민들이 입는다.

법조계가 눈을 감고 있는 문제도 있다. 민사소송의 70퍼센트 가량은 이른바 소액사건이다. 소송가액이 3천만원 이하일 때 소액사건으로 분류한다. 대부분 3천만원까지 이르지도 않는다. 사회생활을 하다보면 몇 십 만원, 몇 백 만원을 둘러싼 갈등을 겪기 쉽다. 비율로만 따지자면 절대 다수이지만 변호사의 도움을 받기 어렵다. 배 보다 배꼽이 크니까. 변호사 없이 당사자들이 법정에 나오다보면 판사 입장에서도 반가운 사건들이 아니다. 법률전문가가 아닌 만큼 진행하는 일이 어렵다. 게다가 아무리 많은 숫자를 처리해도 경력에 도움도 안된다. 국민들의 고충의 크기와 법원의 입장은 반비례인 셈이다.

비단 소액 사건이 아니더라도 쟁점이 크게 복잡하지 않으면서 단순 반복되는 일들도 많다. 회사를 운영하며 상법상 등기를 게을리했다거나, 파산을 위해 재산 조회를 신청했을 때, 분할 비율이 정해진 이혼 사건의 재산분할 내역을 정하는 일처럼, 도장만 찍으면 되는 일들이 있다.

다른 나라들도 사정은 비슷한 모양이다. 에스토니아 사법부는 그래서 2020년부터 분쟁 가능성이 적은 소액재판을 인공지능 판사에게 맡기기로 했다. 중국도 온라인으로 질의응답을 통해 형사소송 진행을 돕는 서비스를 도입했다. 오스트레일리아 가정법원은 이혼하는 부부의 재산분할도 인공지능이 담당하기 시작했다. 필요성도 입증이 된 셈이다. 우리 법무부도 인공지능으로 생활법률 서비스를 제공하는 챗봇 "버비"를 선보이고 있다.

그렇다면 그 보다 복잡한 사건들을 맡길 수 있을 것인가? 그 결과는 과연 인간 판사보다 공정하고 정의로울 수 있을 것인가의 문제로 돌아가 보자. 인공지능을 개발하는 방법은 기존 판례와 법령들을 검토하는데서 시작한다고 했다. 국민청원은 판결이 잘못됐다는 문제의식에서 나왔다.

여기서 첫번째 문제점이 있다. 입력하는 원래의 자료 자체가 잘못돼 있다면 결론이 달라지기 어렵다. 좋은 내용만 선별하는 것도 불가능하다. 누가 어떤 기준으로 하느냐에 따라 공정성의 문제는 여전히 남는다. 더구나 법원이 가진 근본적인 한계가 있다. 법을 만드는 것은 국회다. 판사들이 내세우는 가장 큰 항변은 만들어진 법에 따라 판결할 수밖에 없다는 것이다. 정치의 영역이다.

사회가 끊임없이 변화하고 있다는 사실도 간과해서는 안된다. 대법원은 2021년 6월 양심적 병역거부에 대해 최초로 무죄 판결을 내렸다. 병역법 위반으로 실형을 선고했던 기존 판례를 바꾸는 것이다. 그냥 나온 결정이 아니다. 지방법원 하급심들에서 무죄 판결이 잇따르면서 법 해석을 달리하기로 입장을 바꾼 것이다. 기존 판례를 바탕으로 만들어질 인공지능이 이런 변화를 이끌 수 있을까?

인공지능 판사는 가능하고, 필요한 일일 수 있다. 정치적 중립성을 갖출 것이고, 누군가와의 특별한 이해관계에 휘둘리지도 않을 것이다. 받아들여야 할 변화이다. 중요한 것은 변화의 중심이 국민이어야 한다는 사실이다. 청원은 국민이 바라는 바를 국가에 호소하는 일이다. 법원이 존재하는 이유이기도 하다. 정확한 판결 못지않게 중요하다. 억울함을 호소하는 당사자들의 목소리에 충실하게 귀를 기울이는 판사를 좋은 판사로 꼽는 이유이다.

인공지능의 한계는 인간의 한계를 어디까지 극복하도록 도울 것이냐에서 찾아야 할 것이다. 판사들 편하자는 일이 아니다. 공정하고 정의로운 판결을 돕는 일이어야 한다. 새로운 법과 제도로 인공지능을 도입해야 할 정치권이, 때로는 사람보다 똑똑해 보이는 조수를 두게 될 법원이 잊지 말아야 할 청원이다.

양지열 변호사는 고려대에서 철학을 전공했고, 사법연수원 40기로 수료했다. 중앙일보 기자로 5년간 근무했으며, 출판도시 문화재단 이사다. 현재 법무법인 에이블 변호사로 활동 중이다.

교통방송, YTN, SBS 등 여러 방송 매체에 출연해 시사 분야에 대한 법률적 분석이나 평론을 하고 있다.

양지열 변호사 법무법인 에이블 consultyjy@naver.com

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[양지열 칼럼] 인공지능(AI) 판사는 정의로울까?

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편집자 주] '이세돌과 알파고' 이후 5년 남짓, 인공지능은 낯설고 새로운 미래가 아닌 이미 익숙한 일상이 되어가고 있다.

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"알 권리" vs "인권" 거듭된 신상공개 논란의 역사
아무도 못 알아보는 증명사진이 논란 불씨 키워
무죄추정의 원칙에 반한다는 지적도
"본인이 원한다고 저런 보정된 옛날 사진을 공개하다니, 흉악범 인권이 우선인가요?" "이미 구속된 피의자인데 '머그샷'을 공개한들 사람들 속이 시원한 것 외에 실익이 있을까요?"
전 동거 여성과 택시 기사를 살해한 혐의로 구속된 이기영(31)의 사진 한 장이 신상공개 제도 실효성 등에 대한 공방을 가열시켰다. 이기영 본인이 최근 모습이 아닌 증명사진 공개를 고집한데다, 마스크를 벗는 일도 거부한 것이 알려지면서 절차상 '당사자 의사'가 중시된다는 사실 자체에 거부감을 표하는 이들도 적지 않다.

피의자나 범죄자의 초상권 등 헌법상 권리는 어디까지 보장돼야 할까? 신상공개 제도는 어떤 논란 속에 언제 어떻게 등장했을까? 공개 여부, 방식, 범위, 절차 등에 이르기까지 격론이 거듭된 논란사(史)와 다섯가지 주요 쟁점을 돌아 봤다.

시작은 미성년 대상 성범죄자

국내에서 피의자 및 범죄자 신상공개의 찬반론이 본격 맞붙은 것은 2001년 무렵이다. 앞서 일괄 기준 없이 당국이나 언론을 통해 공개되기도 했던 피의자 및 범죄자 신상정보는 2000년대에 들어서 인권 감수성이 높아지며 비공개 방침이 통상 기준으로 여겨졌다.

다만 미성년자 대상 성범죄에 관해서는 분위기가 달랐다. 성범죄 전반이 뿌리 뽑힐 기미를 보이지 않는데다, 미성년자를 대상으로 한 성범죄 문제까지 심각해지자 신상공개제를 골자로 한 청소년성보호법이 마련됐고, 2000년 1월 국회를 통과했다. 국무총리 산하 청소년보호위원회는 이를 토대로 이듬해 8월 30일 미성년자 대상 성범죄자 169명의 신상을 인터넷과 관보, 전국 16개 시도게시판 등에 최초 공개했다. 주소는 시군구 단위까지만, 직업은 회사원 등으로 광범위하게 분류되는 방식이다.

당시 반대론자들은 이중처벌, 인격에 대한 사형 선고 등을 언급하며 의문을 표했지만, 여론의 70% 이상이 찬성 의견이었다. 오히려 동명이인의 피해를 줄이기 위해 직업과 주소를 보다 자세히 기입해야 한다는 주장도 힘을 얻었다.

당시 한국성폭력상담소 등 여성사회단체들은 집회를 열고 "피해자에게 돌이킬 수 없는 피해를 남기는 청소년 대상 성범죄의 형이 확정된 사람은 모두 신상을 전면 공개해야 한다"며 보다 강력한 조치를 요구했다. 이후 2차 공개와 소송전이 거듭되는 과정에서 법률가들의 '성범죄자 신상공개' 지지 선언이 이어지기도 했다.

2003년에는 미성년자 대상 성범죄자 신상공개가 합헌이라는 헌법재판소 결정이 나오면서 논란이 일단락됐다. 4차례에 걸쳐 대상자 1,926명의 명단이 공개된 상태였다.

사진과 세부주소 공개가 검토된 것은 2004년부터다. 미성년 대상 성범죄 가해자 중 상당수가 상습범인데다, 공개 이후에도 재범을 저지른 사례까지 나오면서다. 1996년 제정된 미국의 메건법(Megan's Law)을 참고한 강화 입법 필요성이 대두된 것이다. 논의가 가열되자 2005년 국가인권위원회는 성폭력범 정보를 주소ㆍ사진까지 확대하는 청소년성보호법 개정에 반대 의견을 내놓기도 했다.

이 같은 찬반 격론은 상당 기간 지속됐다. 하지만 `밀양 여중생 집단성폭행' 사건이나, 이웃 초등학생을 성폭행하려다 살해하고 불태워 유기하는 등 충격적 범행이 끊이질 않자 조치 강화 요구는 거세졌다. 특히 신상공개 조치 후 2006년 성범죄 발생건수가 3년만에 감소세로 돌아선 것이 신상공개 강화 여파로 풀이되면서 눈길을 끌기도 했다. 이 과정에서 적어도 형이 확정된 성범죄자 신상은 공개하는 것이 마땅하다는 공론이 형성된 것이다. 단순 신상은 물론 구체주소, 얼굴공개, 전자발찌 등 처벌 및 관리 강화 방안도 쏟아졌다.

앞서 기자회견과 관보 등록 등으로 공개되던 방식은 2008년 2월 개정 청소년성보호법이 발효되면서 관할 경찰서에서 법적 처벌 절차가 종료된 성범죄자 신상을 열람할 수 있도록 변경됐다. 이후 열람 방식이나 범위의 한계 등이 꾸준히 지적되면서, 2013년 6월 이후로는 일부 단순 성매매 등을 뺀 모든 성범죄는 유죄판결 후 신상등록을 해야 하며 공개 여부는 법원이 판단한다. 공개 정보는 '성범죄자 알림e' 사이트에서 열람 가능하며, 공개 대상자는 1년마다 새로운 증명사진을 내야 한다. 성범죄자의 전출입시 인근 주민에게 우편고지도 이뤄진다. 적어도 성범죄에 관해서는 신상공개가 당연시 되는 시대가 열린 것이다.

쟁점② 범죄자만? 피의자도?

성범죄 외 흉악범을 포함해 형이 확정되지 않은 피의자 신상공개는 한결 더 복잡한 논쟁을 통과했다. 2000년대 후반까지도 국민 관심도에 따라 공분 속에 곧바로 이름이 언론을 타는 경우와 끝내 A씨, 정모씨 등으로 남는 경우가 뒤섞인 상태였다. 논쟁에 본격 불이 붙은 것은 2009년 조선일보와 중앙일보가 연쇄살인범 강호순의 실명과 얼굴을 공개하면서다. 공개하는 매체와 아닌 매체가 나뉘었고, 전문가들 입장도 엇갈렸다.

공개 측은 범죄의 사회적 해악을 고려해 얼굴 공개가 경각심 제고 등의 효과를 줄 수 있다고 봤고, 비공개 측은 사진 공개에 따라 얻을 공익과 이를 위해 치러야 할 사회적 비용을 둘러싼 국민적 합의가 아직은 충분치 않다는 입장이었다. 무죄추정원칙도 거론됐다. 자백이 나왔어도 모든 변수가 사라진 것은 아닌데다 수사가 진행 중인 상태에서의 공개가 감정적 카타르시스를 일으키는 것 외의 효과가 있는지 등에 대한 격론이 오갔다.

쟁점③ 오히려 공개수배 때나 필요?

2009년 국회 입법조사처 역시 `피의자 및 용의자 신상공개에 대한 법적 검토보고서'에서 "경찰은 피의자의 공개수배 등을 제외하고는 피의자 얼굴을 공개할 수 없도록 돼 있다"며 신중을 기해야 한다는 검토의견을 내놨다.

오히려 공개 수배의 경우 추가 범행을 막기 위한 급박한 조치로 실명과 몽타주 등을 공개하는 데 이견이 없지만, 이미 구속된 피의자의 경우 상황이 다르다는 것이다. 특히 △헌법에 무죄 추정 원칙이 명문화 돼있는 데다 △사진 공개가 가족에게 정신적 피해를 초래할 경우, 헌법상 자기책임의 원칙이나 연좌제 금지 원칙을 위반할 가능성이 문제가 됐다.

이런 가운데 수사가 진행 중이라도 흉악범 얼굴을 공개할 수 있도록 한 법적 근거가 마련된 것은 2010년 4월이다. 당시 성폭력범죄의 처벌 등에 관한 특례법과 특정강력범죄의 처벌에 관한 특례법 개정안이 시행됐고, 법무부는 흉악범에 한해 수사 중이라도 얼굴과 신상정보를 언론에 공개할 수 있도록 '인권보호를 위한 수사공보준칙'을 개정하고 나섰다.

이후 오원춘, 안인득, 고유정, 이춘재, 전주환 등의 실명이 모두 공개됐고, 미성년자 등을 협박해 성착취 동영상을 찍은 뒤 텔레그램에 유포한 혐의를 받는 '박사방' 운영자 조주빈 신상이 공개된 것도 이 같은 피의자 신상공개 효과였다.

이후 공개 기준이 지역마다, 사례마다 제각각이라는 지적이 이어지자 2021년에는 경찰청 인권위원회가 '피의자 얼굴 등 신상공개 지침' 개선안을 마련해 각종 기준을 정비했다. △범죄 예방과 수사 상 목적이 있는 경우에 한해 최소한 범위에서 신상을 공개하고 △신상공개위원회의 심의 과정에서 피의자에게도 의견진술 및 소명 기회를 부여한다는 내용이 골자다.

쟁점④ 흉악범 동의를 왜 받아?

이기영 사건에서 많은 이들이 납득하기 어려운 지점으로 여기는 것은 바로 이렇게 '피의자에게도 의견 및 소명 진술 기회'가 있다는 점이었다. 이에 대해 경찰청 인권위가 지목한 것은 △낙인 효과 △재사회화에 끼치는 악영향 △가족 및 지인의 피해 △인격권 등이다. 2021년 당시 개선안 권고 결정문은 "한번 언론 등에 신상이 공개되면 유죄 확정 여부와 무관하게 범죄자로 낙인찍히게 되는 만큼 신상공개 필요성이 인정되더라도 헌법상 적법절차 원칙은 준수돼야 하는만큼 체포돼 구속 송치되기까지 물리적으로 짧은 기간이지만 자신의 의견과 소명자료를 신속히 제출할 수 있어야 한다"고 권고했다.

신상공개 때는 피의자 가족이 입는 피해도 부인할 수 없는데, 이 대목이 위헌 논란을 불러일으킬 여지가 크다는 점도 '제한적 공개'의 근거가 됐다. 경찰청 인권위는 "우리 헌법이 연좌제를 공식적으로 금지했지만 언론을 통해 대중에게 신상이 공개되면 피의자의 명예는 물론 그 가족과 친지, 친구 등의 피해도 자명하다"며 "이를 방지하기 위한 '2차 피해 방지 가이드라인'을 제작 등도 필요하다"고 했다.

쟁점⑤ 효과는 있는 거야?

무엇보다 당시 경찰청 인권위는 효과 측면에 방점을 찍었다. 신상을 공개했을 때, 인격권, 초상권은 크게 제약하는데 비해 실제 형 집행 후 과연 사회 복귀나 재사회화를 돕는데 효과가 있을 것이냐는 의문이다. 오히려 이를 곤란하게 해 재범 가능성만 키운다는 우려다. 당시 권고문은 "일반예방 측면에서도 국내외를 포함하여 지금까지 시행된 피의자 신상공개를 통해 사회안전망이 나아졌음을 뒷받침하는 객관적인 자료나 근거를 찾기 어렵다"며 큰 예방 효과 기대에는 선을 그었다.

지난달 경찰청 인권위원장에 위촉된 장영수 고려대 법학전문대학원 교수는 3일 MBC 라디오 '김종배의 시선집중' 인터뷰에서 "단순하게 국민의 호기심만 가지고 얘기하긴 곤란한데다 기준 자체가 추상적인 면이 있다"며 "넓게 얘기해서 '국민의 알 권리를 위해 필요하다'는 것을 너무 넓게 이야기하면 한도 끝도 없이 공개가 이뤄져야 한다"고 언급했다. 이어 "소위 머그샷을 공개하려면 별도의 법률적인 근거가 필요한 상황인데 획일적으로 적용하려 들수록 위헌 문제가 제기될 수 있다"고 분석했다.

공개가 가져오는 경고 효과를 부정할 수 없는만큼 효과에 대해서도 여전히 이견이 오간다. 한국형사정책연구원은 2020년 '성범죄자 신상공개고지 제도 효과성 제고를 위한 법제정비 방안' 연구에서 "범죄자 신상을 공개하고 고지하는 이유는 무엇보다 피해 예방과 재범 방지"라며 "이에 용이한 방식인지에 대한 개선 방안이 끈임없이 마련돼야 한다"고 강조했다.

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"흉악범 인권부터?" vs "가족도 있는데" 신상공개 논란 5대 쟁점은 | 한국일보

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"본인이 원한다고 저런 보정된 옛날 사진을 공개하다니, 흉악범 인권이 우선인가요?" "이미 구속된 피의자인데 '머그샷'을 공개한들 사람들 속이 시원한 것 외에 실익이 있을까요?" 전 동거 여성과 택시 기사를 살해한 혐의로 구속된 이기영(31)의 사진 한 장이 신상공개 제도 실효성 등에 대한 공방을 가열시켰다. 이기영 본인이 최근 모습이 아닌 증명사진

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수도권, 비수도권 취업률

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수도권, 비수도권 취업률

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http://news.unn.net/news/articlePrint.html?idxno=127230

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[한국대학신문 최성욱 기자] 교육부가 한국교육개발원에서 조사한 '2013년 고등교육기관 졸업자 건강보험DB연계 취업통계' 결과를 29일 발표했다. 이번에 공개된 취업통계는 지난 6월 1일을 기준으로 각종 교육기관의 지난해 8월 졸업자와 올해 2월 졸업자를 대상으로 졸업 후 취업현황을 조사한 결과다. 교육기관은 △전문대학 △4년제 대학 △교육대학 △산업대학 △각종학교 △기능대학 △일반대학원 등이다.

전체 고등교육기관 졸업자 55만5142명 중 취업자는 28만6896명(51.7%)으로 전년 대비 9755명(3.3%p)이 감소했다. 반면 해외취업자는 1637명으로 지난해보다 313명(23.6%p)이 증가한 것으로 나타났다.

대학 취업률의 경우 전문대학이 소폭 상승한 반면 4년제 대학은 소폭 하락했다. 전문대학 취업률은 61.2%로 전년대비 0.4%p 상승했다. 대학과 일반대학원 취업률은 각각 55.6%, 68.9%로 전년대비 0.6%p, 0.8%p 하락한 것으로 집계됐다.

■계열별·전공별 취업률= 7대 계열별 취업률 증감현황을 보면, 전문대학은 자연계열에서 전년대비 2.9%p가 증가했고, 대학은 0.3%p 올랐다. 의약계열은 전년대비 3.4%p 떨어졌다. 일반대학원은 인문계열이 전년대비 1.9%p 증가했으며, 자연계열은 1.6%p 하락했다.

7대 계열별 진학률 증감을 살펴보면, 진학률이 지난해와 달리 눈에 띄게 오른 계열은 전문대학의 경우 인문계열(2.7%p), 대학은 자연계열(1.2%p), 일반대학원은 의약계열(0.9%p)이었다.

■취업률 높은 전공은?= 취업이 잘 되는 전공은 어디일까. 전문대학은 유아교육, 유럽・기타어, 농수산, 재활, 간호, 금속 계열의 취업률이 높았다. 지난해와 올해 모두 취업률 70% 이상을 달성했다.

대학은 의학, 치의학, 해양공학, 유아교육학, 한의학, 기계공학 계열에서 역시 지난해와 올해 모두 취업률 70% 이상을 기록했다. 일반대학원은 의학, 간호학, 반도체・세라믹, 한의학, 치의학, 전자공학 계열이 취업률 70%를 넘겼다.

■지역별 취업률= 학교 소재지별 취업률을 살펴보면 수도권 취업률은 58.9%로 지난해보다 0.1%p 증가했다. 비수도권은 59.6%로 0.3%p 하락했다.

■ 설립주체별 취업률= 국․공립 교육기관의 취업률은 0.5%p 떨어졌고 사립은 지난해와 비슷한 양상을 보였다. 국공립은 교육대학이 7.3%p, 사립은 각종학교가 3.5%p로 가장 많이 상승한 것으로 나타났다.

■ 여성 취업률 '주목'= 여성들이 남성들보다 6.6%p(남성 62.7%, 여성 56.1%) 취업을 못하는 결과가 나왔다. 지난해도 남녀 취업률 차이는 6.6%p로 동일했다. 대부분의 교육기관에서 여성의 취업률이 남성에 비해 낮은 반면 교육대학만 여성 취업률이 남성을 앞지른 것으로 집계됐다.

특히 전문대학에서 여성 취업률이 높은 전공은 유아교육, 유럽・기타어, 해양, 재활, 간호, 보건, 기계, 비서 분야다. 이들 전공은 지난해와 올해 모두 취업률 70%를 넘었다. 대학은 의학, 치의학, 초등교육학, 유아교육학, 기계공학, 재활학, 약학전공자들의 취업률이 70% 이상이었다.

저작권자 © 한국대학신문 - 409개 대학을 연결하는 '힘' 무단전재 및 재배포 금지

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한국대학신문 최성욱 기자] 교육부가 한국교육개발원에서 조사한 '2013년 고등교육기관 졸업자 건강보험DB연계 취업통계' 결과를 29일 발표했다. 이번에 공개된 취업통계는 지난 6월 1일을 기준으로 각종 교육기관의 지난해 8월 졸업자와 올해 2월 졸업자를 대상으로 졸업 후 취업현황을 조사한 결과다. 교육기관은 △전문대학 △4년제 대학 △교육대학 △산업대학 △각종학교 △기능대학 △일반대학원 등이다.

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네이버 블로그 | 과학커뮤니케이터 박종현

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적극적 안락사란 불치병 또는 난치병에 의해 생명을 유지하는 게 무의미하다고 판단될 경우, 약물과 같은 직접적 방법을 이용해서 생명을 고통 없이 죽음에 이르게 하는 행위를 말합니다.

일반적인 안락사와는 개념이 조금 다릅니다. 단순히 치료를 중단하여 자연적으로 목숨을 잃게 하는 것도 안락사가 되지만, 적극적 안락사는 치사량의 약물이나 독극물을 직접적으로 주사하여 환자를 죽음으로 이끄는 것이거든요. 즉, 죽음을 적극적으로 돕는 행위가 이루어지고, 이러한 행위를 하는 사람이 존재한다는 게 결정적인 차이라고 말씀드릴 수 있을 것 같습니다.

우리나라를 포함하여 대부분의 나라에서는 단순히 치료를 중단하고 방치하여 죽음에 이르게 하는 소극적 안락사가 주를 이루고 있습니다. 하지만 적극적 안락사는 사람을 특정 수단을 동원하여 죽음에 이르게 한다는 점에서 대부분의 나라에서 위법으로 규정하고 있죠.

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적극적 안락사 :: 의미와 찬성 반대 근거 설명!

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적극적 안락사란 불치병 또는 난치병에 의해 생명을 유지하는 게 무의미하다고 판단될 경우, 약물과 같은 직접적 방법을 이용해서 생명을 고통 없이 죽음에 이르게 하는 행위를 말합니다. 일반적인 안락사와는 개념이 조금 다릅니다. 단순히 치료를 중단하여 자연적으로 목숨을 잃게 하는 것도 안락사가 되지만, 적극적 안락사는 치사량의 약물이나 독극물을 직접적으로 주사하여 환자를 죽음으로 이끄는 것이거든요.

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https://www.law.go.kr/법령/호스피스ㆍ완화의료및임종과정에있는환자의연명의료결정에관한법률/(20220322,18627,20211221)/제3조

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이웃집 토토론 : 네이버 블로그

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네이버 블로그 | 박력이의 박력 넘치는 베이킹 일기‍

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적극적 안락사 찬성, 반대 - 토론자료

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포대님들 안녕하세요!ㄹ 오늘은 제가 토론면접을 준비하면서 모아봤던 '적극적 안락사 찬성, 반대&#x2...

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세상 돌아가는 이야기 : 네이버 블로그

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소스케의 소소한 일상 : 네이버 블로그

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https://www.hani.co.kr/arti/society/schooling/622427.html

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사생활 보호와 알 권리, 무엇이 우선일까요

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[NIE 홈스쿨] 디지털 시대 ‘잊혀질 권리’ 논란

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국내 상장법인의 여성임원 비율은 지난해보다 0.7%포인트 증가한 5.2%에 그친 것으로 나타났다. 여성임원이 한 명도 없는 기업 비율은 63.7%에 달했다. 기업 경영의 흐름을 주도하는 글로벌 기업들은 이에스지(ESG·환경, 사회, 기업지배구조를 중시하는 경영·투자 전략)와 임원의 성별 다양성의 확보를 중시하는 경향을 보이고 있다. 국내에서도 관련 법이 마련되는 등 변화가 있으나 여성임원 비율의 개선은 더디다.

여성가족부는 5일 2021년 3월까지 사업보고서를 낸 2246개 상장법인의 성별 임원 현황 조사결과를 발표했다. 여가부는 2019년부터 양성평등기본법 제20조3항에 근거해 해마다 같은 조사를 해 발표 한다. 올해는 자산 총액 2조원 이상 기업의 성별 임원 현황도 발표했다. 이 기업들은 내년 8월 5일부터 이사회의 이사를 특정 성으로만 구성할 수 없도록 한 '자본시장과 금융투자업에 관한 법률(자본시장법) 제165조의20(이사회의 성별 구성에 관한 특례)'의 적용을 받는다.

상장법인 임원의 성별을 보면, 2246개 기업의 전체 임원 3만2005명 가운데 여성 비율은 5.2%(1668명)인 것으로 나타났다. 지난해 4.5%보다 0.7%p 올랐다. 임원 형태별로 보면, 등기임원 가운데 여성 비율은 4.8%, 미등기임원은 5.5%였다. 여성임원이 1명도 없는 기업 비율은 63.7%(1431개)였다. 올해 가 발표한 유리천장지수 내 경영진과 이사회의 여성 비율을 보면 경제협력개발기구(OECD) 회원국의 평균은 25.6%다. 국내 상장기업의 여성임원 비율은 지난해보다 개선됐지만, 국외 평균에 견줘 한참 낮다. 클리오(75%), 솔본(60%), 에스엠(SM)라이프디자인(60%), 키이스트(57.1%)는 여성임원 비율이 높았다.

전체 조사 대상 기업에서 일하는 여성노동자는 40만6631명, 여성임원은 1668명으로 여성 노동자 대비 여성임원 비율은 0.41%였다. 남성임원은 남성노동자 118만1047명 가운데 3만337명으로, 남성노동자 대비 남성임원 비율은 2.57%였다. 여성임원은 여성 노동자 244명당 1명꼴인데, 남성임원은 남성노동자 39명당 1명인 셈이다. 노동자 대비 임원 비율의 성별 격차는 6.3배에 달했다.

김경선 여가부 차관은 "여가부가 개별 기업들의 임원 현황을 공개하는 것 자체가 기업에 상당한 자극이 될 수 있을 것"이라면서 "자본시장법에 제재 규정은 없지만, 최근에 국제적으로도 이에스지 투자, 피어 프레셔(Peer Pressure·동료집단으로부터 받는 사회적 압력)를 중시하는 경향을 봤을 때 기업들이 많은 부담을 느낄 것으로 보인다"고 말했다.

산업별 성별 임원 현황에서는 '유리 에스컬레이터'의 존재를 확인할 수 있는 수치가 나왔다. 유리 에스컬레이터는 여성이 더 많은 직업이나 직종에서 임원직 진출 가능성이 여성은 낮고, 남성은 높은 걸 가리킨다. 여성임원 비율이 비교적 높은 산업은 교육 서비스업(15.3%), 전문·과학 및 기술 서비스업(8.5%), 정보통신업(7.5%), 도매 및 소매업(7.0%) 순으로 나타났다. 그러나 교육 서비스업, 도매 및 소매업의 경우 여성 노동자 대비 여성임원 비율은 각각 0.34%, 0.22%로 평균 0.41%보다 낮았다. 교육 서비스업과 도매 및 소매업은 여성 노동자 비중이 각각 64.5%, 52.5%로 높은 산업이다.

문미경 한국여성정책연구원 선임연구위원은 "기업이 다양성, 창의성, 유연성 등을 요구하는 사회 변화에 따라가지 못하면 장기적으로는 경쟁력을 잃게 될 것"이라고 지적했다. 그는 "여성 노동자의 비중이 높은 산업이라면 여성 소비자를 타깃으로 한 상품이나 서비스에 치중하고 있을 텐데, 그런 기업에서조차 임원 구성에서 여성을 배제한다면 경쟁력을 갖춰나갈 수 없을 것"이라고 덧붙였다.

자산 총액 2조원 이상 기업 152개의 여성임원 비율은 5.7%로 전년 대비 1.2%p 증가했다. 임원 형태별로 보면 등기임원 중 여성은 8.3%, 미등기임원은 5.3%다. 여가부는 전체 상장법인보다 자산 총액 2조원 이상 기업에서 등기임원 여성 비율이 더 개선된 이유를 내년부터 적용될 자본시장법 제도의 영향으로 봤다. 그러나 자본시장법 적용 대상 기업 중 44.1%(67개)는 여성 등기임원이 없어 아직 법 기준에 부합하지 못한 것으로 나타났다.

자산 총액 2조원 이상 기업 가운데 여성임원이 1명도 없는 기업 비율은 22.4%(34개)였다. , 국내 최대 전자제품전문점인 롯데하이마트, 아파트 브랜드 아이파크를 건설하는 에이치디시(HDC)현대산업개발 등에는 여성임원이 없었다. 여성임원 비율이 높은 기업은 카카오(28.6%), 아모레퍼시픽(23.9%), CJ제일제당(23.2%), LG생활건강(18.8%), 코웨이(18.4%) 등이었다.

정영애 여가부 장관은 "점진적으로나마 상장법인의 여성임원 비율이 증가하고 있는 점은 의미 있으나, 여성의 사회진출이 확대됐음을 고려할 때 여전히 부족한 수준"이라며 "기업이 의사결정 직위의 성별 균형을 제고할 수 있도록 지속해서 기업의 변화수준을 분석·발표하는 등 노력을 이어가겠다"고 했다.

박고은 기자 euni@hani.co.kr

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국내 상장법인의 여성임원 비율은 지난해보다 0.7%포인트 증가한 5.2%에 그친 것으로 나타났다. 여성임원이 한 명도 없는 기업 비율은 63.7%에 달했다. 기업 경영의 흐름을 주도하는 글로벌 기업들은 이에스지(ESG·환경, 사회, 기업지배구조를 중시하는 경영·투자 전략)와 임원의 성별 다양성의 확보를 중시하는 경향을 보이고 있다. 국내에서도 관련 법이 마련되는 등 변화가 있으나 여성임원 비율의 개선은 더디다.

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