JERUSALEM -- The Hadassah-University Hospital neurologist, who in October put a terminal patient under sedation and disconnected him from a respirator 24 hours before he died, said yesterday he had performed passive, not active, euthanasia.
Prof. Avinoam Rechess said he had acted with district court and Health Ministry backing and hoped a public debate on the issue would result.
Much controversy was aroused yesterday by the case, which was revealed by Ha'aretz investigative reporter Ran Resnick, who claimed that, "For the first time in Israel, euthanasia was performed at Hadassah-Ein Kerem."
However, the story falsely implied that neurologist Rechess had performed the "mercy killing" of Itai Arad, a victim of amyotrophic lateral sclerosis (ALS, or Lou Gehrig's disease) by active euthanasia.
"Prof. Rechess injected into Arad large amounts of narcotics and disconnected the ventilation machine to which he was attached. About 24 hours after the respirator was disconnected, when Arad's heart stopped beating, Rechess pronounced him dead," Resnick wrote.
"Active euthanasia has not, and will not, be performed in Israel," declared Health Minister Yehoshua Matza and Director-General Gabi Barabash yesterday in reaction to the Ha'aretz story.
Rechess, whom Resnick interviewed for five hours after hearing his description of the case before the ethics committee of the Israel Medical Association, was distressed by the false impression. "I didn't kill Itai; his disease did. He was given the chance to die with dignity, without suffering, with his family around him," Rechess declared.
Arad, a former fighter pilot and computer expert, was diagnosed with the incurable, degenerative, neurological disease five years ago and became totally helpless. "He endured terrible suffering. When he came to Hadassah from Meir Hospital with end-stage disease, already connected to a respirator, he was unable to speak, swallow or even move a finger. He was able to communicate by a system of blinking his eyes, and he repeated over and over that he wanted to die," Rechess said.
In January 1996, Judge Moshe Telgam, deputy president of the Tel Aviv District Court, issued a ruling giving his doctor permission not to connect Arad to a respirator, or if already connected, to disconnect if the case were hopeless and only artificial means were keeping him alive. The Health Ministry expressed the intention to appeal the ruling, but has not done so.
Arad was able to breathe on his own from time to time, but he feared that when the time came to disconnect the ventilator, he would suffer terribly from suffocation before dying. In October, Telgam issued an additional ruling, saying the patient's dignity is most important and it is in the hands of his doctor to disconnect him from a respirator if he thought it necessary.
Rechess refused to perform active euthanasia that would immediately cause Arad's death, but he consulted with many doctors, including Barabash, Health Ministry deputy director-general Dr. Boaz Lev, Hadassah neurology department chairman Prof. Oded Abramsky, and Israel Medical Association ethics chief Prof. Eran Dolev.
Rechess said he called in experts about the amount of narcotics that he could administer to put Arad into "terminal sedation" (make him unconscious) without having the drugs cause his death. Then he disconnected the respirator, "knowing for certain that he wouldn't die as a result. He had breathed alone many times before, but not efficiently. And he died 24 hours later."
Rechess conceded that if he had erred in his expectations, and Arad would have died immediately from suffocation, he would have felt "terrible." He said that "passive euthanasia is carried out every day, in hospitals around the country. It's better than the active euthanasia, which is known to occur in oncology departments and other wards - when a doctor gives a fatal injection when no one is looking. But this was the first case of passive euthanasia that was completely transparent and approved by the authorities according to a specified process. We have to put this issue on the table."
Rechess said that such interventions should be allowed only in extreme cases, when the patient is suffering greatly, has been examined by two other senior doctors who confirm the patient is in the terminal stage of a hopeless disease, repeatedly demands to die, and does not suffer from dementia or depression. "There must be personal accountability and full transparency," he maintained.
But Prof. Avraham Steinberg, a pediatric neurologist at Shaare Zedek Hospital and a medical ethicist at the HU-Hadassah Medical School, said that while Rechess was "covered from a legal point of view, the case overstepped the line from a public point of view. A law has to be set down with what is permitted or forbidden - now, or it we won't be able to stop it. If not, any hospital in the periphery could do this without the requisite controls and transparency.
"Who says Prof. Rechess could be sure that his patient wouldn't have died immediately when the respirator was connected after being fully sedated? I know of no such accepted parameter. Would the result be the same for every patient? It was a mistake for Meir Hospital to connect him to a ventilator in the first place. The patient could have been given full sedation, and then if he suffocated he wouldn't have suffered at all. There's a difference between not giving a patient a means of staying alive and taking away one that's already been given."
Steinberg said that while he usually opposes legislation on medical matters because the technology is so dynamic, "in this case society must set down the rules and limits to prevent its going down the slippery slope."
Legislator Yitzhak Cohen has submitted a bill to ban euthanasia even with permission from a court or medical ethics committee. Under the bill, an amendment to the Penal Code, a person would be held criminally responsible for causing a death either by a deed or a failure to act even if a higher authority ordered it or if it was for medical purposes.
Source: Dec. 03 Jerusalme Post
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