Assisted dying in Germany: Ralf Bladt was 56 years old, loved his road haulier job and big cars

The appointment was for 10am but the two visitors were half an hour early at Petra Bladt’s door. Not to see her, but her husband, Ralf.

Once inside they set up their equipment quickly in the livingroom where Ralf had kept a solitary all-night vigil. Around 9:45am, with everything ready, Ralf said: “If we start now, we’ll be finished on time at 10.”

Minutes later, Ralf told Petra that he loved her, opened the valve on the drip attached to his arm and ended his life. His final words: “I feel it coming.”

Ralf Bladt was 56 years old, loved his road haulier job and big cars. On holiday in September 2020, however, he noticed something was wrong. A year later came the diagnosis of a form of motor neuron disease. It affects and impedes brain and spinal cord control over muscle movement and breathing. Medical treatments can extend – but not save – life. Ralf gave up work and, week by week, getting dressed or even slicing bread unassisted became impossible. Ralf feared his independence would slip away entirely before he could even end his life – should he wish.

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Dazed, he and Petra began looking for options. Palliative care would only extend his helplessness, he felt, while so-called assisted suicide in the Netherlands or Switzerland would mean dying away from home.

Then he heard of the German Society for Humane Dying (DGHS) and how, to his surprise, assisted dying was entirely legal in Germany after a constitutional court ruling on February 26th, 2020. Like many other Germans, Ralf had not noticed this landmark ruling given the other headlines that day: the first confirmed cases of Covid-19 in Germany’s two largest federal states.

Four weeks after first contact, a DGHS-affiliated doctor had compiled the required medical assessment confirming that his condition was incurable. Then the DGHS-affiliated doctor was at the door.

In conversations and emails with The Irish Times over several months, Petra remembers – and still feels – the burden of their impossible situation. Already on oxygen, Ralf’s focus shifted completely to ending his life – “like someone books a holiday”. She is grateful that they had a chance to say a proper goodbye unlike with a suicide “where you always go alone, in secret”.

On the other hand Ralf’s determination to end his life himself, while he still could, left their final weeks strained by urgency – and silence. He told none of his friends in case they intervened while Petra felt compelled to remain silent, too: outwards and inward.

“He was someone you couldn’t reach with tears,” she remembers, “so I cried in the car on the way to work and on the way home”.

When the doctor pronounced Ralf dead, the accompanying DGHS official called the police. Officers showed up to document the scene – what had happened and who was present – and left. No prosecution ever followed. The undertaker arrived, Petra’s visitors left and she called a friend.

Even four years on, Germany’s 2020 assisted dying constitutional court ruling remains, for many here, as obscure as it is far-reaching. Arising from a complaint from the DGHS and others, the ruling struck down section 217 of Germany’s criminal code with fines and up to three years in jail for helping someone end their life.

In its ruling, the federal constitutional court said that a “right to a self-determined death” was “an expression of personal autonomy”.

“This right entails not only the freedom to take one’s own life,” it said, “but also protects the freedom to seek and, if offered, utilise assistance from third parties to this end”.

The ruling reframed – radically – the first article of Germany’s postwar constitution, the Basic Law. After Nazi-era industrialised murder, euthanasia and persecution, postwar West Germany was founded on the simple, profound proposition: “Human dignity shall be inviolable. To respect and protect it shall be the duty of all state authority.”

In February 2020, a provision which many previously presumed was to preserve human life and dignity became something else.

“Where the protection of life runs counter to the protection of autonomy, it contradicts the central understanding of a community which places human dignity at the core of its order of values,” the judges ruled.

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How someone defines quality of life and a meaningful existence, the judges said, “eludes” religious dogmas, societal norms or “considerations of objective rationality”. It was not incumbent on an individual to justify ending their life, or to live in a way “fundamentally irreconcilable with their ideas of self and personal identity”.

Following this logic, the ruling concluded that “the self-determined act of ending one’s life is a direct, albeit final, expression of the pursuit of personal autonomy inherent in human dignity.”

After 40 years of sporadic end-of-life debate, but no real shift, the 2020 ruling sparked frenetic triggered political activity on assisted dying. As an Oireachtas committee in Dublin explores the issue, too, critics say Germany offers a blueprint on how not to proceed with this complex, emotive and divisive issue.

Last year, after lengthy discussion and parliamentary hearings, two different draft proposals were brought before the Bundestag parliament for a vote. One draft proposed a general ban on assisted suicide, allowing exceptions for adults after medical examination, counselling and waiting periods.

Prof Lars Castellucci, an MP from the ruling Social Democratic Party (SPD) who proposed this draft, said it would protect people in crisis from being nudged into ending their life.

“Access to assisted suicided must be made possible without making it a model,” he said.

A second, more liberal draft proposal offered more direct access to lethal drugs to people who had received counselling – and in extreme cases, without.

“It’s important we don’t leave people alone again with their pain and fears ... and we cannot start threatening again with the criminal code,” argued Katrin Helling-Plahr an MP with the liberal FDP, in favour of the second proposal.

Neither proposal found a parliamentary majority and, amid vague promises to revisit the issue soon again, the uncertainty continues.

As before, the fronts remain clear after the vote. Catholic bishops said they in no way judge anyone who chooses to end their life, but vowed to “continue to provide every assistance in dying, but not assistance to die”.

Complicating matters still further was a second, parallel ruling from the federal administrative court last November, forbidding individuals access to life-ending substances under Germany’s current medicine guidelines.

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Amid these competing court rulings and political indecision, a survey from January 2023 by the Ipsos polling institute showed 55 per cent of Germans in favour of what is sometimes described here as so-called passive assisted dying: allowing access to drugs for people to end their lives.

Germany’s federal ethics council has warned of allowing a situation “where suicide is immaterial to us” as a society, and where people view ending their life as their only option.

It sees two concrete risks in the current stasis: that some are denied access to their constitutional right to end their life; while others may face increased, unregulated pressure to end theirs.

“There are good arguments to leave this unregulated, as some have suggested,” says Prof Alena Buyx, a medical ethics specialist and president of the ethics council. “But there are many others affected – doctors as well as clinics – who want legal certainty and a clear guideline on what they can and should do. I would be in favour of trying again [to legislate].”

Germany’s DGHS disagrees strongly. Founded in 1980, the country’s largest assisted suicide association says the 2020 ruling is clear. Any lingering uncertainty, it suggests, is less about legal concerns than cultural expectations in a country used to over-regulating every aspect of life – and death.

“There is no grey area here, we have complete clarity and freedom,” said Prof Dieter Birnbacher, DGHS vice-president. “Critics warned of a dam breach if assisted dying is permitted. Well it is permitted and there has been no dam breach.”

In 2022 the DGHS assisted in 229 cases while 2023 figures, to be unveiled next month, are likely to show twice that number. With around 30,000 members, the association says it is struggling to cope with growing awareness of the new situation. It attracts 1,000 new members a month, it says, each paying €60 annually for access to its information and intermediary services to doctors.

The DGHS says it attracts four main groups: roughly one-quarter are terminal cancer cases; one-quarter have incurable neurological conditions; one-quarter are elderly people who have “made their peace with life” and have no chronic or terminal medical condition; and one-quarter have a mixture of reasons, including mental health issues.

Such numbers fill Winfried Hardinghaus with dread. Since 1990 he has worked in palliative care and is president of Germany’s Hospice and Palliative Care Assocation. He sees the 2020 ruling as part of a shift in public discourse towards “hype around the individual, something which may change again”.

“This places a huge emphasis on autonomy but allowing yourself to be helped does not mean giving up autonomy,” said Prof Hardinghaus, also head of palliative care at Berlin’s St Francis Hospital, which sees 400 visitors a month.

Since the 2020 ruling he notices a rise in people expecting – some even demanding – assistance from him to end their lives. The most recent case: an older woman with chronic fatigue syndrome.

He declines to meet this wish, explaining instead palliative care options to manage pain and maintain dignity. In cases of imminent death or unbearable suffering, with no other medical options available, a German clinical team can, in rare cases, agree to offer so-called “palliative sedation” until the end.

As Germany’s uncertainty about the subject persists, along with its struggle to find trained nursing and care staff, Prof Hardinghaus sounds gloomy about the future: “My horror scenario is that, in 10 or 15 years, older people unhappy with their care will be told ‘you do have other options’.”

Between Germany’s two fixed assisted dying camps, some influential voices have shifted. Prof Frank Ulrich Montgomery, a former president of all of Germany’s big medical associations, agrees with critics that the 2020 ruling is “dangerous” for over-emphasising individual rights over other concerns.

But his fear of a surge in legalised dying? Unfounded, he thinks. While most of German doctors, citing duty of care, remain vehemently opposed to assisted suicide, Dr Montgomery says around 15-20 per cent have signalled in surveys a readiness to participate.

“If we can trust in a healthy patient-doctor relationship I think that, all in all, we should leave things as they are – without legislation,” he said. “The legislative proposals so far either interfere in that relationship or would create a bureaucratic monster.”

He dismisses concerns that, for example, a Catholic hospital could be forced to carry out assisted suicides. The 2020 ruling makes clear that “there can never be an obligation, on anyone, to assist in another person’s suicide”.

The constitutional court is not opposed to legislative limits on its ruling, once it is “guided by the notion of humans as intellectual-moral beings capable of pursuing and exercising their freedom in self-determination”, calling them “unfounded”.

Next Saturday marks the second anniversary of the day Ralf Bladt ended his life. Petra is confident the day “won’t pull the rug out from under me”. Since we last spoke, she has completed a DGHS training course and now works as a volunteer.

“Many people in my circle didn’t know of the possibility of accompanied suicide and I noticed how difficult it was to get help at the time,” she said. “I’m just happy now that I can help people know their options.”

If you are affected by any of the issues in raised in this article, please text HELLO to 50808, or contact The Samaritans at free phone 116 123 or email jo@samaritans.ie

The situation in Ireland

In Ireland, the issue of assisted dying is a live political issue after years of indecision.

A decade ago, Marie Fleming catapulted the issue to the top of the news agenda when she took a landmark right-to-die challenge to the courts.

She was in the final stages of multiple sclerosis and went to court to be lawfully assisted to have a peaceful death without putting her loved ones at risk of prosecution. She lost a Supreme Court challenge and died in December 2013.

People Before Profit TD Gino Kenny then introduced the Dying with Dignity Bill into the Oireachtas in 2020. This would have provided for people with progressive terminal illness to decide the timing of their own death and avail of assistance to end their lives under controlled and monitored circumstances.

Given the complicated and sensitive nature of the topic, it was decided instead to set up a cross-party Committee on Assisted Dying which is examining possible policy and legislative changes.

The committee has held 16 meetings, and there only a handful of hearings remaining until members compile a report for the consideration of Government.

The politicians have engaged with a huge range of stakeholders, most recently people with disabilities. At that hearing, organisations argued that facilitating assisted dying or suicide should not be about people feeling that they must end their lives because of a lack of supports and services.

In response, Gino Kenny said there are a variety of opinions. He said that in other jurisdictions where assisted dying legislation has been introduced, the law has excluded the grounds of disability as a means to access the services.

The question then became whether any proposed law could include only those with terminal illnesses.

But providing a medical definition of terminal illness could prove problematic.

Committee members also held a hearing on palliative care, where representative association for consultants in palliative medicine said they were fundamentally opposed to the introduction of assisted dying, assisted suicide, or euthanasia.

They said that most physical and psychological suffering can be well-managed by comprehensive expert care.

Much of the focus of the committee has been around potential safeguards, if laws are introduced.

The committee has been told by a range of witnesses that there would need to be measures in any proposed law to ensure there can be no inducement, incitement, pressure or force on a person to seek assisted dying, and that these measures would need to be enforceable by An Garda Síochána. The Irish Human Rights and Equality Commission told the committee that it wanted to see strong measures including: the exclusion of disability as grounds for eligibility; informed consent for disabled people; access to alternatives, including appropriate palliative care and provision of accurate information about the prognosis on an illness.

Other key issues being explored by the committee include ensuring there are no unintended consequences in the law, such as elderly or vulnerable people being coerced into making a decision or people who may take the decision because they feel they are a burden to their families. TDs have also spoken about safeguarding mentally vulnerable people and ensuring any new law is ethical and doesn’t lead to incrementalism.

There is a feeling among politicians on the committee if they do recommend change, it will be a highly restricted and focused piece of legislation that addresses the concerns of everyone who has been involved in the process.

What is the current law here?

Article 40.3.2 of the Constitution guarantees that the State in its laws safeguards the right to life of every citizen, while article 40.1 guarantees that all citizens shall be held equal before the law. Meanwhile, under 1993 legislation, it is an offence for a person to assist in the suicide of another person. The offence has a maximum penalty of 14 years’ imprisonment. Officials from the Department of Justice told committee members, however, that to the best of their knowledge there has only been one prosecution and no conviction was secured. - Jennifer Bray

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