Petition: Request for the legalization of euthanasia, first draft, supplementary materials ③ System design risks and preventative measures

[Petition: Request for the Legalization of Euthanasia, First Draft, Supplementary Material ③, System Design Risks and Preventive Measures]

第一稿補足資料　３.pdf

Download PDF • 345KB

I. Overview (Summary) (Petition Request for the Legalization of Euthanasia, First Draft, Supplementary Materials)

While the institutionalization of euthanasia and assisted suicide guarantees patients' dignity and self-determination, society is concerned about the risks of abuse, pressure, expansion of applicable standards (the so-called "slippery slope"), and the impact on vulnerable people .

However, these risks can be significantly reduced through strict requirements in the design of the system, an independent review and reporting system, ensuring transparency, and educating medical professionals and society.

Below we summarize the major risks and effective measures being implemented internationally. Important points are indicated with reference to relevant international documents.

II. Anticipated major risks (classification and explanation)

Risk A — Abuse/Deviation (relaxation of standards/expansion of scope)

Some people who are concerned about euthanasia have raised concerns that the scope of eligibility will expand beyond the initially limited criteria (e.g., terminal illness) (a "slippery slope" concept), but our proposal does not include the concept of expansion (see the final page for details).

Even in countries where it is legal, changes in the number of cases and targets are constantly monitored in each country.

Risk B — Direct/indirect pressure on patients (family, financial, and medical resource constraints)

The elderly, people with disabilities, and the economically vulnerable may face unspoken pressure from those around them (family, medical institutions, and institutional expectations), which could undermine their "freedom of choice." This has been cited as a major concern by academic and disability groups.

Risk C — Difficulties in assessing mental illness and capacity

The review of requests where mental illness is the primary cause ("mental only" cases) is particularly difficult. It can be difficult to assess decision-making capacity, reversibility, and confirm the possibility of alternative treatments. Each country adopts a cautious approach.

Risk D — Incomplete reporting and auditing (lack of transparency)

Incomplete notification and reporting makes post-mortem verification impossible and delays the detection of abuse. Countries such as the Netherlands have legally mandated reporting obligations and established local review committees, and monitor abuse through annual reports.

Risk E — Lack of professional ethics and education in the medical field

If medical professionals lack the training and ethical education to make appropriate decisions, this can lead to inconsistent and incorrect decisions.

III. Internationally recognized preventive measures (principles and specific examples)

Below are common best practices derived from the operation of systems in the Netherlands, Belgium, Canada, Switzerland, etc. Representative sources are cited in each section.

Preventative Measure 1: Strict and Written Enforcement Requirements

-Examples: Legal requirements include irreversible conditions, unbearable suffering, and a voluntary and considered request.

Reason: To prevent arbitrary application and provide uniform criteria for judgment.

Preventive measure 2: Independent evaluation by multiple doctors (interviews and written opinions by independent doctors)

For example, a system in which at least one (or two) independent physicians other than the patient's primary physician meet with the patient and provide a written opinion. The Dutch system and the standards of local review committees are typical examples.

Preventive measure 3: Notification to and follow-up inspection by a third-party (independent) inspection organization

• For example, requiring pre- and post-implementation notification to an independent review board (or regional review body) and verifying after the fact whether statutory standards were met. The annual reporting system in the Netherlands is a good example of ensuring transparency.

Prevention Measure 4: Documentation, Waiting Periods, and Repeated Checks

• For example, impulsive decisions can be prevented by requiring written consent, a certain waiting period (opportunity for reconfirmation), and multiple confirmations of intentions.

Prevention Measure 5: Psychiatric Evaluation and Identification of Alternative Treatments

• For example, if a mental disorder is involved, an evaluation by a psychiatric professional should be made mandatory, and it should be confirmed whether alternative interventions (treatment and support) have been exhausted. In Canada, there are also expert reports that caution is needed when handling requests based solely on mental illness.

Preventive measure 6: Mandatory reporting and annual publication (preparation of statistics)

• For example, annual reports and publications including the number of cases performed, breakdown of diseases, age groups, review process, and reasons for judgments will be made mandatory. This will enable policy monitoring and review.

Preventive measure 7: Rules for protecting the vulnerable (protection of the elderly and people with disabilities)

• For example, clarify the criteria for determining consent capacity, prohibit coercion by agents or related parties, and incorporate the presence or absence of social and economic pressure into the review requirements. Actively reflect the opinions of disability organizations and others in the design of the system.

Preventive measure 8: Education and ethics training for medical professionals and clarification of veto power

• For example, while ensuring respect for medical professionals who do not wish to participate (conscientious objection), standardized education and training should be mandatory for those who do. It is important to officially create practical guidelines for medical practice.

Measure 9: Phase-in (pilot) and periodic review

• For example, first conduct a trial with limited application (limited to terminal illnesses), and then address any problems that arise in operation by amending laws and guidelines based on annual reports. The key to international experience is "continuous evaluation after implementation."

Ⅳ. Recommended design for domestic introduction

Below is a checklist of items that should be considered at a minimum when designing legislation and systems in Japan. We recommend that these be incorporated into bills, supplementary resolutions, and implementing regulations.

1. Clarification of legal requirements (eligibility conditions, intent requirements, consent format)

2. Obligation to interview by an independent physician (written evaluation/interview by another physician)

3. Establishment of a third-party inspection organization (notification, post-inspection, annual report)

4. Psychiatric Evaluation Protocol (Special Procedures for Mental Illness-Related Requests)

5. Clarification of documentation, waiting periods, and reconfirmation procedures

6. Vulnerability protection clause (checking the existence of economic pressure, offering alternative support)

7. Training requirements for medical professionals and guarantees of conscientious objection

8. Collection and publication of public data (ensuring transparency)

9. Trial introduction and legal and administrative review mechanism (review every three years, etc.)

10. Conducting public deliberations involving relevant ministries and agencies (Ministry of Health, Labor and Welfare, Ministry of Justice, etc.), civil society groups, and disability groups

V. Rules for monitoring, verification, and ensuring transparency (post-operational governance)

- Mandatory annual reporting :

Detailed statistics, including the number of cases and the review process, should be published. This could be similar to the annual reports in Canada and the Netherlands.

External review and public engagement :

Regular review meetings will be held by third parties (academic experts and citizen representatives) to improve the system.

・Audits and penalties for violations :

Clarify legal measures and penalties for violations of standards and reporting obligations.

・Public consultation desk and complaint handling :

We will establish a system where those involved and their families can seek advice and lodge complaints anonymously.

VI. Supplementary Notes (Lessons and Points to Note from International Cases)

- In countries such as the Netherlands, mandatory reporting and local review committees are at the core of operations, and inappropriate cases are discovered and corrected through post-mortem examinations.

The fact that this supports the credibility of the entire system is an important lesson for Japan.

On the other hand, the increase in the number of cases and the increase in cases involving mental illness are signs of caution, and careful monitoring is necessary even during operation.

International views indicate the importance of continuously evaluating and improving both institutional design and operation .

Ⅶ. Our Society's Approach to Euthanasia

① Application stage:

　The stage where the patient's doctor first clarifies the patient's wishes (first check)

⇩

② Evaluation stage:

The second check is when another doctor determines compliance with legal standards .

⇩

③ Consultation stage:

　Reassessment by an external organization (a specialist doctor or committee on euthanasia) (third check)

⇩

④ Implementation and reporting stage:

Euthanasia and submission of a detailed report to the local review committee (provisional) (fourth check)

VIII. Conclusion (Recommendations)

When introducing euthanasia, it is essential to incorporate legal clarity and multiple layers of safeguards (multi-physician evaluation, independent review, reporting requirements, psychiatric evaluation, protection of vulnerable persons, training, etc.) into legislation.

The introduction of a system is not enough; it is essential to have a mechanism for continuous improvement through transparent annual reporting and regular external reviews .

We strongly recommend that the Diet proceed with detailed legislative drafting based on the checklist provided in this supplementary material.

---

*Note about the "slippery slope"

Among those concerned about the euthanasia system, there are references to the "slippery slope argument" that denies euthanasia itself.

However, the term "slippery slope" itself is a form of sophistry and is used as a means to delay discussion.

*The slippery slope argument is a typical argument that "jumps to the worst case scenario without providing any evidence," and is considered one of the least reliable forms of argument in policy discussions.

The slippery slope argument in euthanasia: Expanding the 'eligibility criteria' for euthanasia

(Image)

--------------------------------------------------

Initially, only patients with less than six months to live (mainly those in the terminal stage of cancer)

⇩

The condition of having less than six months to live has changed to less than 12 months due to illness.

⇩

Eliminate life expectancy restrictions - "non-terminal illness (patients with unbearable pain but no predictable life expectancy)"

⇩

Also covers existential pain such as cervical spinal cord injury (inability to move below the neck)

⇩

Patients whose physical abilities have been significantly reduced due to stroke or other reasons are also eligible.

⇩

Targeted at patients with physical disabilities in general

⇩

Euthanasia for dementia patients is also included

⇩

Both mental illness and euthanasia are covered

⇩

Also covers pediatric diseases (e.g., 1 to 11 years old)

⇩

Duo euthanasia is also possible (e.g. simultaneous euthanasia for an elderly couple)

⇩

※This is where the essence of the slippery slope argument comes into play.

In other words, it is a paranoid fallacy .

From this stage onwards, actual system operation and statistical evidence will be completely ignored, and only fictitious "runaway scenarios" will be discussed.

⇩

(※ The scope of application is expanding.)

⇩

People with physical illnesses are a “nuisance” → candidates for euthanasia

⇩

People with inferior genes are also candidates for euthanasia

⇩

Countries can also "eliminate troublemakers"

⇩

Nazi-era eugenic practices revived

(→ "The very concept of euthanasia is dangerous"

--------------------------------------------------

These claims...

It's nothing more than emotional rhetoric (a cover-up).

This does not match the actual operation of the system in countries where it is legal. Rather, the data from countries where it is legal consistently shows that "runaway expansion has not occurred."

For example, in the case of the Netherlands, which our association uses as a model, the criterion is "individual suffering," so the scope is "loose" (although the scope is broad from the start).

However, the system has been updated little by little based on the past and track record of case studies that have been accumulated since before the legislation in 2001, so it did not take on its current form all at once.

This "step-by-step, gradual system design" is the biggest factor in preventing the system from getting out of control.

The German Euthanasia Society (DGHS) was founded in 1980 and has provided euthanasia as a non-profit organization (civic group), but no problems have arisen and it continues to operate to this day.

This is in stark contradiction to the aforementioned "return to the practice of eugenics during the Nazi era."

In over 40 years of operation, there has been no evidence that the system has led to the exclusion of the weak.

The euthanasia system will not be expanded all at once , but will be carefully adjusted over time , following public debate and ethical review .

It is reasonable to assume that the expansion of the scope of application is not a disorderly one , but rather a humanitarian decision made in response to suffering. Looking squarely at the actual operation of the system, the "slippery slope" is merely a hypothetical threat, and is an assertion lacking empirical evidence.

The dangers of the system should be discussed based on evidence and data , not speculation and fear.

Slippery slope reasoning is the opposite: a "debate-stopper" that prioritizes fear over facts.

reference:

一般社団法人日本ケアラー連盟代表理事『児玉 真美』氏