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Child euthanasia is a form of euthanasia that is applied to children who are gravely ill or have significant birth defects. In 2005, the Netherlands became the first country since the fall of Nazi Germany to decriminalize euthanasia for infants with a hopeless prognosis and unrelievable pain.[1] Nine years later, Belgium amended its 2002 Euthanasia Act to extend the rights of euthanasia to minors.[2] Like adult euthanasia, there is world-wide public controversy and ethical debate over the moral, philosophical, and religious issues of child euthanasia.
A 24 July 1939 killing of a severely disabled infant in Nazi Germany was described in a BBC "Genocide Under the Nazis Timeline" as the first "state-sponsored euthanasia".[3] Parties that consented to the killing included Hitler's office, the parents, and the Reich Committee for the Scientific Registration of Serious and Congenitally Based Illnesses.[3]The Telegraph noted that the killing of the disabled infant—whose name was Gerhard Kretschmar, born blind, with missing limbs, subject to convulsions, and reportedly "an idiot"— provided "the rationale for a secret Nazi decree that led to 'mercy killings' of almost 300,000 mentally and physically handicapped people".[4] While Kretschmar's killing received parental consent, most of the 5,000 to 8,000 children killed afterwards were forcibly taken from their parents.[3][4]
Bente Hindriks, born in 2001 at Groningen University Medical Center in the Netherlands, was immediately diagnosed at birth with the rare genetic disorderHallopeau-Siemens syndrome. The disease features chronic blistering and peeling of the epidermis and mucous membranes. There is no effective treatment, and the damage on the top layer of the skin comes with severe, unmitigated pain. Hindriks's diagnosis was impossible to treat and her prognosis of skin cancer would take her life in five to six years. Her pediatrician, Dr. Eduard Verhagen, could do nothing to help. Though illegal at the time, Hindriks's parents wished to end her suffering with active euthanasia. Ultimately, it is believed that the high dose of morphine that Dr. Verhagen administered to ease her pain killed Bente.[1]
Four years after Bente Hindriks' death, Dr. Verhagen began campaigning for policy change that called for permitting infant euthanasia under specifically strict guidelines. While engaged in this pursuit, Dr. Verhagen publicly stated that he terminated the lives of four more infants, all with severe cases of spina bifida. Called "Dr. Death"[1] and "a second Hitler"[1] by some, he continued along with his hope for a "nationwide protocol that allows each pediatrician this delicate question with due care, knowing he followed the criteria,"[1] to end his patients' lives simply out of compassion. He felt that strict regulations on infant euthanasia would prevent uncontrolled and unjustified instances of euthanasia. In 2005, Dr. Verhagen and Dr. Sauer, with a team of prosecutors, formalized the Groningen Protocol.[1]
The agreement follows that no charges shall be pressed against physicians who perform end-of-life procedures on infants who meet the following five criteria:[1]
Furthermore, neonates and infants who might be considered candidates for end-of-life decisions are divided into three categories:[1]
Belgium legalized euthanasia for terminally ill adults in 2002. As it stood then, euthanasia could only be applied to citizens over eighteen years of age or, in rare accounts, a category of individuals called "emancipated minors."[2] In years to follow, the debate on euthanasia opened up to the idea of this same law being extended to minors. On February 13, 2014, an amendment to the 2002 Euthanasia Act made it legally permissible for minors, regardless of age, to pursue euthanasia as long as they fit a few specific criteria. The amendment states that minors who request euthanasia must exhibit the ability to judge their current state of affairs when in a "medically futile condition of constant and unbearable physical suffering that cannot be alleviated and that will, within a short period of time, result in death, and results from serious and incurable disorder caused by illness or accident."[5]
The provisions of this amendment to the 2002 Euthanasia Act have distinguishable differences between the act applied to adults and minors. First, the law establishes that only physical suffering may be valid for minors, while physical and psychological suffering is plausible reasoning for adults and the "emancipated minors" to pursue end-of-life care by euthanasia. Second, it states that the presumed death of a minor should result within a short period of time, whereas no timeframe of expected death is needed for adult cases. Finally, it requires that multiple physicians and legal representatives sign-off on the mental capacity of the patient, reinforcing that the minor is competent of their condition and decision to die.[2]
The concept of child euthanasia has sparked heavy debate. The ethical debate can be broken down into two categories:
Dr. Eduard Verhagen, who developed the Groningen Protocol, has made clear his stance in endorsing the motivation for the protocol. Verhagen clarifies that his protocol does not include infants with ordinary, and otherwise, treatable conditions. Rather, the protocol was created to relieve the burden that both the infant and its parents would face in a "life of agonizing pain."[1] Others, such as Joseph Fletcher, founder of situational ethics and a euthanasia proponent, proposed that infanticide be permitted in cases of severe birth defects. Fletcher says that unlike the sort of infanticide perpetrated by very disturbed people, in such cases child euthanasia could be considered humane; a logical and acceptable extension of abortion.[6] Bioethicists Alberto Giubilini and Francesca Minerva go one step further, arguing that killing a newborn "should be permissible in all the cases where abortion is, including cases where the newborn is not disabled."[7]
Dr. Alan Jotkowitz, professor of medicine at Ben-Gurion University of the Negev, argues strongly against the Groningen Protocol on the basis that idea of a "life not worth living" does not exist. He claims that nowhere in the protocol does it mention only pertaining to terminally ill infants and the developers of the protocol value the future quality of life more than the current being of the infant. Jotkowitz also draws comparisons to the practice of child euthanasia employed by Nazi rule through the 1940s.[8] Eric Kodish and Daniel A. Beals[9] have compared child euthanasia to infanticide. Kodish says "the very notion that there is an "accepted medical standard" for infanticide calls for resistance in the form of civil disobedience."[10]
カリフォルニア大学サンディエゴ校医学部の小児集中治療医学および生命倫理の分野で国内をリードするアレクサンダー・A・コン博士は、新生児安楽死の倫理的意味合いは、乳児が成人に比べて「自己決定」能力を欠いている点にあると概説している。[ 11 ]コン博士は、したがって、正当化は患者の幸福のみに基づいて行われるべきだと述べている。コン博士は、フローニンゲン・プロトコルに関する自身の立場を表明していないが、フェルハーゲン氏の乳児における麻痺剤の使用について懸念を抱いている。フェルハーゲン氏の報告によると、「5例において、主に親の要望により、あえぎ呼吸を防ぐために死亡直前に神経筋遮断薬が投与された」。[ 12 ]コン博士によれば、これらの薬剤を用いて安楽死をより受け入れやすくする行為は正当化できないが、新生児安楽死を支持する人々は、乳児をできる限り助けたいという真摯な動機を持っていると信じている。[ 11 ]
一般的に、新生児の生命が争われる場合、両親が子供の将来を決定します。両親と医師の両方が決定に参加します。意見の相違が続く場合は、裁判所に持ち込まれ、そこで決定が下されることがあります。考慮される事項には、治療費と新生児の生活の質が含まれます。治療費には、医療資源とその利用可能性が含まれます。[ 13 ]新生児の生活の質は、治療が適用されるか、継続されるか、中止されるかによって決まり、受動的安楽死につながる可能性があります。これは、両親の同意なしに特定の法律の下で犯罪として分類されることもあります。子供の安楽死を選択する際の両親の役割、そしてそれが自発的安楽死とみなされるか非自発的安楽死とみなされるかについては、現在も議論が続いています。自発的安楽死とみなされる場合は、両親がそれを承認し、子供の人生について発言権を持っているからです。一方、非自発的安楽死とみなされる場合は、乳児が処置に対する患者の同意を与えることができないからです。[ 14 ]
American bioethicistJacob M. Appel argues that pediatric euthanasia may be ethical even in the absence of parental consent.[15] Dr. Douglas S. Diekema, most known for his role in the Ashley Treatment, argues that in cases where parents act against the best interests of their child, that the state should have ability to intervene. Diekema continues on his support of the Harm Principle being the basis for state intervention, which would allow physicians of the state to override the decisions made by parents if it is determined that their position does not represent the best interests of their child, and rather, is the more harmful procedure.[16]
Extension of the 2002 Euthanasia Act to Belgian minors received both heavy criticism and large applause, launching another ethical debate centered around child euthanasia.[2]Luc Bovens, professor of philosophy at the London School of Economics, explains the three fields of thought opposing this amendment to the 2002 Euthanasia Act. First, some believe that euthanasia is morally impermissible in general. Second, some believe the law was sufficient as is, and that hospital ethics boards should deal with the "emancipated minors" on a case-by-case event. Third, some believe euthanasia for minors is more impermissible than adults. Bovens outlines the five most used arguments in support of this third point:[17]
Bovens believes these five arguments do not carry much weight in the debate; however, he does support arguments defending the wish to retain age restriction and ownership of hospital ethics boards in dealing with individual requests from minors.[17]
新法の支持者は、この改正により差別が回避され、法的問題が明確化され、医療行為と意思決定の一貫性が向上すると主張している。以前は、「未成年者解放」は可能であったが、その他の判断能力はあるものの未成年者解放されていないとみなされた未成年者には安楽死はできなかった。児童安楽死を支持する人々は、これは不公平だと考え、未成年者解放されていない未成年者は判断能力のレベルが未成年者解放されている未成年者と同程度であり、したがって同じ程度に苦しんでいる可能性があると主張した。 [ 2 ] Verhagen は、特定の年齢制限は恣意的であり、「自己決定には年齢制限はない」と主張してこれを支持している。 [ 18 ]さらに、支持者は、この拡大により末期症状の未成年者を治療する医師にとって問題の合法性が明確になり、違法行為が減り、医療上の意思決定の一貫性が高まると考えている。[ 2 ]
極度の未熟児や神経障害があり将来的に生活の質が低い重度の障害児の医療上の意思決定を任された医師にとっての大きな課題は、小児安楽死という生命倫理のテーマの別の側面を示している。 [ 19 ] 2017年の研究では、アルゼンチンの新生児科医が行った終末期医療の決定について調査した。このアンケートでは、重篤な新生児への対応における彼らの行動方法を調査した。結果によると、新生児の生存可能性に基づいて、予後不明の未熟児に対して治療を開始する新生児科医は75%以上であった。その後、80%以上の医師が、肯定的な結果が得られなかった治療を中止した。シルベルベルグとガロの分析によると、乳児安楽死に関する医師の現在の考え方は、治療的積極主義の何らかのバリエーションを適用しているが、進歩が見られない場合、同じ医師の大多数が延命治療を中止するだろう。[ 20 ]
宗教的な聖典や教えから得られる道徳観は、安楽死に対する見方に大きな影響を与える。ベルギーで行われた最近の心理学的研究では、児童の安楽死の合法化に反対する人々は、宗教的であり、実存的な問題に対する柔軟性が低く、集団主義的な道徳観（忠誠心や純粋さの価値観）を支持し、内集団志向の向社会的傾向を示す傾向があることが示された。[ 21 ]
On February 13, 2014, Belgium became the first country to allow voluntary child euthanasia without any age restriction.[22] However, a child must ask for the procedure and verify that they understand what will happen. The parents must also consent to euthanasia of the child. The child's doctor must confirm that they are "in a hopeless medical situation of constant and unbearable suffering that cannot be eased and which will cause death in the short term." As of 2018, three children have died by euthanasia in Belgium.[23]
Euthanasia is currently legal in the Netherlands for children between 12 and 16 years old, with mandatory consent from the patient and their parents. Children between 16 and 18 years old do not need consent from their parents, but the parents should be included in the decision-making process.[24] It is also legal for babies up to a year old with parental consent. The patient must be enduring "unbearable and endless suffering" and at least two doctors must agree to the procedure. Eduard Verhagen has documented several cases of infant euthanasia. Together with colleagues and prosecutors, he has developed a protocol to be followed in those cases. Prosecutors will refrain from pressing charges if this "Groningen Protocol" is followed.[25][26]
This Protocol prompted a very critical response from Elio Sgreccia, the head of the Pontifical Academy for Life.[27]
The Nuffield Council on Bioethics launched an enquiry in 2006 into critical care in fetal and neonatal medicine, looking at the ethical, social and legal issues which may arise when making decisions surrounding treating extremely premature babies.
The Royal College of Obstetricians and Gynaecologists recommended that a public debate be started around the options of "non-resuscitation, withdrawal of treatment decisions, the best interests test and active euthanasia" for "the sickest of newborns".[28] The college stated that there should be discussion over whether "deliberate intervention" to cause death in severely disabled newborn babies should be legalised; it stated that while it was not necessarily in favour of the move, it felt the issues should be debated. The college stated in this submission that having these options would save some families from years of emotional and financial suffering; it might also reduce the number of late abortions, "as some parents would be more confident about continuing a pregnancy and taking a risk on outcome".[28] In response to this proposal, Pieter Sauer, a senior paediatrician in the Netherlands, argued that British neonatologists already perform "mercy killings" and should be allowed to do so openly.[28]
The Church of England submission to the enquiry supported the view that doctors should be given the right to withhold treatment from seriously disabled newborn babies in exceptional circumstances, and the Christian Medical Fellowship stated that when treatment would be "a burden" this was not euthanasia.[28][29][30]
In the United States, euthanasia remains illegal for all children regardless of age.[31]
Baby Bollinger was born in 1915 at the German-American Hospital in Chicago, Illinois.[32] Characterized by various physical abnormalities, surgeon Harry J. Haiselden advised the Bollinger parents to forgo the surgery that could have saved the baby's life. Dr. Haiselden believed it is "our duty to defend ourselves and future generations against the mentally defective." Five days after foregoing surgery, Baby Bollinger died.
Haiselden, then, brought this case to the public through a press conference and argued in defense of the Bollinger case: first, a merciful death is more humane than a life of suffering, and second, it is our responsibility to protect our society from the burden of certain disabilities.[33] Haiselden drew supporters and critics alike through his support for euthanasia in the United States. Unlike Jack Kevorkian, Haiselden did not assist patients who wished to be euthanized. Instead, Haiselden chose to euthanize babies who were born with deformities and began advocating aggressively.[34] Following the Bollinger case, Haiselden began withholding life-saving treatment from other disabled babies, in addition to campaigning for the euthanizing of the terminally ill.[33]
On April 9, 1982, in Bloomington, Indiana, "Baby Doe" was born with Down syndrome and a tracheoesophogeal fistula (TEF). While knowing surgical intervention to resolve the TEF is a relatively standard procedure and essential to live, the baby's parents and obstetrician chose against it. This decision, met with resistance from other attending physicians, ultimately led to a court trial. The court determined that the parents were free to decline the surgery their baby needed because of mixed expert opinions of the hospital doctors. Baby Doe died six days later. This case quickly became a nationwide debate in the U.S. and garnered the attention from then U.S. Surgeon General, Dr. C. Everett Koop. Koop, a pro-life proponent and retired pediatric surgeon, condemned the court ruling.[11]
1年後、レーガン政権は、障害のある乳児への虐待の可能性に関する苦情に対応するため、「ベビー・ドゥ・スクワッド」とフリーダイヤルのホットラインを創設する新たな規制を策定した。ベビー・ドゥ規制として知られるこれらの規制は、最終的に覆された。1984年、議会は児童虐待防止治療法（CAPTA）に追加の修正を加え、障害のある新生児に対する必要に基づく医療、特に「適切な栄養、水分補給、投薬」[ 11 ]の提供を拒否することを違法とした。ただし、以下の場合は例外とする。「(A) 乳児が慢性的に不可逆的な昏睡状態にある場合。(B) そのような治療の提供が、(i) 単に死期を延ばすだけであり、(ii) 乳児の生命を脅かすすべての状態を改善または矯正するのに効果的ではなく、(iii) 乳児の生存に関して無益である場合。(C) そのような治療の提供が乳児の生存に関して事実上無益であり、そのような状況下での治療自体が非人道的である場合」。[ 11 ]