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Anaesthesia. 2019 May;74(5):630-637. doi: 10.1111/anae.14532. Epub 2019 Feb 20.

Legal and ethical implications of defining an optimum means of achieving unconsciousness in assisted dying.

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Department of Anaesthesia, Northwick Park Hospital, London North West Healthcare NHS Trust, London, UK.
University of Kent, UK.
l'Aix-Marseille Université, Marseille, France.
Department of Neurology and Neurotherapeutics, The University of Texas Southwestern Medical Center, Dallas, TX, USA.
Department of Anesthesiology, Leiden University Medical Center, Leiden, the Netherlands.
Department of Anaesthesia, Intensive Care and Resuscitation Spitalregion Rheintal Werdenberg Sarganserland, Grabs, Switzerland.
University of Bern, Bern, Switzerland.
Kantonsspital St. Gallen and Former Head of Research Ethics Committee, Kanton St Gallen, Switzerland.
Human Health Sciences and Chief Executive Officer, University of California, UC Davis Health, USA.
Nuffield Department of Anaesthetics, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.


A decision by a society to sanction assisted dying in any form should logically go hand-in-hand with defining the acceptable method(s). Assisted dying is legal in several countries and we have reviewed the methods commonly used, contrasting these with an analysis of capital punishment in the USA. We expected that, since a common humane aim is to achieve unconsciousness at the point of death, which then occurs rapidly without pain or distress, there might be a single technique being used. However, the considerable heterogeneity in methods suggests that an optimum method of achieving unconsciousness remains undefined. In voluntary assisted dying (in some US states and European countries), the common method to induce unconsciousness appears to be self-administered barbiturate ingestion, with death resulting slowly from asphyxia due to cardiorespiratory depression. Physician-administered injections (a combination of general anaesthetic and neuromuscular blockade) are an option in Dutch guidelines. Hypoxic methods involving helium rebreathing have also been reported. The method of capital punishment (USA) resembles the Dutch injection technique, but specific drugs, doses and monitoring employed vary. However, for all these forms of assisted dying, there appears to be a relatively high incidence of vomiting (up to 10%), prolongation of death (up to 7 days), and re-awakening from coma (up to 4%), constituting failure of unconsciousness. This raises a concern that some deaths may be inhumane, and we have used lessons from the most recent studies of accidental awareness during anaesthesia to describe an optimal means that could better achieve unconsciousness. We found that the very act of defining an 'optimum' itself has important implications for ethics and the law.


accidental awareness; assisted suicide; euthanasia; medical ethics

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