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Edmund Pellegrino and David Thomasma's writings have had a worldwide impact on discourse about the philosophy of medicine, professionalism, bioethics, healthcare ethics, and patients' rights. Given their works' importance, it is surprising that commentators have ignored their admission of an unresolved and troubling dilemma and inconsistency in their theory. The purpose of this article is to identify and state what problems worried them and to consider possible solutions. It is argued that their dilemma stems from their concerns about how to justify professional rules restricting colleagues from performing acts they view as direct, active, and formal (intentional) killings, such as physician-assisted suicide, mercy killing, and abortion. It is further argued that their inconsistency is that they both assert and deny that professional colleagues should not use their moral or theological values to impose professional restrictions on other colleagues without adequate philosophical grounds. At risk are their arguments about the nature of an internal morality for medicine, a secular and multicultural basis for medical ethics, and a nonarbitrary way to determine what acts fall outside the ends of medicine. These are arguments they claim also apply to other healthcare professions. The article begins with a brief overview of their key positions to provide the context in which they make their admission. [ABSTRACT FROM AUTHOR]

Christianity's opposition to euthanasia and assisted suicide is grounded in its recognition of such actions as serious violations of the prohibition against murder and self-murder, even in cases where those individuals consent or otherwise signal their willingness to die as in cases of voluntary euthanasia. Fully to appreciate the implications of assimilating assisted death into medical practice, one must recognize the spiritual significance of killing on the physicians who euthanize patients or who aid and abet patients in killing themselves. One will also need to appreciate the spiritual importance of such actions on the patients killed. Physician-assisted suicide and voluntary euthanasia are not neutral actions. Moreover, that the patient desired or requested the killing does not change the moral character of the act or its spiritual significance. This issue of Christian Bioethics explores the implications for medicine and society as physician-assisted suicide and voluntary euthanasia are assimilated into contemporary healthcare practice. [ABSTRACT FROM AUTHOR]

In its landmark decision Carter v Canada (Attorney General), the Supreme Court of Canada ruled that the criminal prohibition on physician-assisted suicide and euthanasia for certain persons in certain circumstances violated their rights to life, liberty, and security of the person in sec. 7 of the Canadian Charter of Rights and Freedoms and thus was unconstitutional. The Supreme Court in effect overruled its earlier decision, Rodriguez v British Columbia (Attorney General), which upheld the prohibition as constitutionally valid, on the basis of changes in Charter jurisprudence and in the social facts since Rodriguez was decided. We argue that the Supreme Court's Carter decision shows conceptual disagreements with its Rodriguez decision concerning the nature and scope of the sec. 7-protected interests and the accompanying principles of fundamental justice. Not only do these conceptual differences have little to do with the changes that the Court in Carter invoked for 'revisiting' Rodriguez, the Court's articulation of the sec. 7 interests, particularly the right to life, and the principles of fundamental justice, especially the principle of over breadth, are problematic on their own terms. Furthermore, the way in which the Court dealt with evidence regarding abuses in permissive jurisdictions is also subject to criticism. We recommend that if, as now seems inevitable, legislation is introduced, it should mandate that assisted suicide and euthanasia be performed by specially licensed non-medical personnel and only on the authorization of a Superior Court judge. We also reject the key recommendations recently issued by the Provincial- Territorial Expert Advisory Group on Physician-Assisted Dying. [ABSTRACT FROM AUTHOR]

This paper provides a reflective analysis of the nature of normative critiques of law generally, and within medical law specifically. It first seeks to establish the context within which critical analysis of law and legal measures takes place, and develops an argument that critiques should focus on political norms. Entailed in this claim is the contention that positions that seek to address controversial social problems can not resort simply to moral philosophy. It then provides a brief account of political liberalism that can contain and expose normative constraints on questions of moral and social contention. The focus then moves to a more direct reflection on medico-legal analysis. Considering both medical law as a discipline, and the study of end-of-life issues, the argument highlights the range of relevant issues that must be accounted for, and addresses the question of whether these are well conceived as ones of medical law. It is argued that a political framing offers a good general analytic context, but that when working in legal sub-disciplines analysts risk allowing ‘locally’ pertinent norms to dominate or unduly constrain wider debate. Thus it is questioned whether ‘medical law’ provides a coherent frame for social questions related to assisted-dying. [ABSTRACT FROM PUBLISHER]

It is plausible that what possible courses of action patients may legitimately expect their physicians to take is ultimately determined by what medicine as a profession is supposed to do and, consequently, that we can determine the moral acceptability of voluntary euthanasia and physician-assisted suicide on the basis of identifying the proper goals of medicine. This article examines the main ways of defining the proper goals of medicine found in the recent bioethics literature and argues that they cannot provide a clear answer to the question of whether or not voluntary euthanasia and physician-assisted suicide are morally acceptable. It is suggested that to find a plausible answer to this question and to complete the task of defining the proper goals of medicine, we must determine what is the best philosophical theory about the nature of prudential value. [ABSTRACT FROM AUTHOR]

Proponents of the legalization of assisted suicide often appeal to our supposed right to "die with dignity" to defend their case. I examine and assess different notions of "dignity" that are operating in many arguments for the legalization of assisted suicide, and I find them all to be deficient. I then consider an alternative conception of dignity that is based on Aristotle's conception of the conditions on the best life. I conclude that, while such a conception of dignity fits best with our intuitions about the conditions under which a life has dignity, it supports the legalization of assisted suicide only under very limited circumstances. [ABSTRACT FROM AUTHOR]

The cardinal question in Christian moral theory and bioethics is whether the knowledge that Christians have (1) by grace and (2) by revelation (e.g., regarding the character of human and cosmic history as reaching from creation through the Incarnation and the Redemption to the Second Coming and the restoration of all things) makes a crucial contribution to understanding morality, as for example issues such as the good death and the morality of physician-assisted suicide and euthanasia. This article argues that Such a Contribution is made by grace and revelation. The reduction of Roman Catholic moral theology and bioethics to secular bioethics is explored, as well as the necessity of the unique knowledge possessed by Christians for adequate end-of-life decision-making. [ABSTRACT FROM AUTHOR]

Discussions in Germany regarding appropriate end-of-life decision-making have been heavily influenced by the liberalization of access to physician-assisted suicide and voluntary active euthanasia in the Netherlands and Belgium. These discussions disclose conflicting moral views regarding the propriety of physician-assisted suicide and euthanasia, threatening conflicts within not only the medical profession, but also the mainline churches in Germany, whose membership now entertains views regarding end-of-life decision-making at odds with traditional Christian doctrine. On the surface, there appears to be a broad consensus supporting the hospice movement and condemning physician-assisted suicide and euthanasia, The German Supreme Court has held that treatment decisions should, in absence of known patients' wishes, be made in light of commonly shared values, unless these violate the principle of "in dubio pro vita". The Roman Catholic church and the Evangelical Lutheran church in Germany have developed an advance directive for treatment choices at the end of life, while condemning physician-assisted suicide and euthanasia. This stance is in tension with the strong emerging support for physician-assisted suicide and euthanasia, a development that promises to open up foundational disagreements within mainline German Christianity regarding the appropriate approach to intentionally terminating human life. [ABSTRACT FROM AUTHOR]

Adequate response to physician-assisted suicide and euthanasia depends on fundamental philosophical and theological issues, including the character of an appropriate philosophically and theologically anchored anthropology, where the central element of traditional Christian anthropology is that humans are created to worship God. As I will argue, Christian morality and moral epistemology must be nested within and understood through this background Christian anthropology. As a result, I will argue that physician-assisted suicide and euthanasia can only be one-sidedly and inadequately appreciated through rational appeal to central values, such as "human dignity" and "self-determination", or through "sola scriptura" biblical interpretation, or individual judgments of conscience. Adequately addressing physician-assisted suicide and euthanasia will depend on a more fundamental spiritual-therapeutic approach. This cluster of moral, epistemological, anthropological, and bioethical claims will be explored by drawing on the texts of St. Basil the Great, St. Maximos the Confessor, and St. Isaac the Syrian. Their reflections on medicine, the human good, and its relationship to worship, spiritual therapy, and God will be used as a basis to indicate a broader philosophical perspective, which will be needed to avoid a one-sided, incomplete approach to the challenges of physician-assisted suicide and euthanasia. Medical morality, I argue, is best understood within categories that transcend the fight, the good, the just, and the virtuous: namely, the holy. [ABSTRACT FROM AUTHOR]

In this essay I shall describe and analyse the current debate on physician assisted suicide in contemporary German Protestant church and theology. It will be shown that the Protestant (mainly Lutheran) Church in Germany together with her Roman Catholic sister church has a specific and influential position in the public discussion: The two churches counting the majority of the population in Germany among their members tend to "organize" a social and political consensus on end-of-life questions. This cooperation is until now very successful: Speaking with one voice on end-of-life questions, the two churches function as the guardians of a moral consensus which is appreciated even by many non-believers. Behind this joint service to society the lines of the theological debate have to be re-discovered. First it will he argued that a Protestant reading of the joint memoranda has to be based on the concept of individual conscience. The crucial questions are then: Whose conscience has the authority to decide? and: Can physician assisted suicide be desired faithfully? Prominent in the current debate are Ulrich Eibach as a strict defender of the sanctity of life. and on the other side Waiter Jens and Hans Küng, who argue for a right to physician assisted suicide under extreme conditions. I shall argue that it will he necessary to go beyond this actual controversy to the works of Gerhard Eheling and Karl Barth for a clear and instructive account of conscience and a theological analysis of the concepts of life and suicide. On the basis of their considerations, a conscience-related approach to physician assisted suicide is developed. [ABSTRACT FROM AUTHOR]

In pluralistic modern societies, moral dissent will, to an increasing extent, be an inescapable fact in our lives. Moral dissent, however, involves various serious dangers: escalation of conflicts, the use of violence, flourishing of radical extremism and even civil war. There are basically two ways in which these threats can be addressed: coercive enforcement of consensus or tolerance. First, we could try to eliminate moral dissent by using more dictatorial forms of consensus formation, like propaganda, indoctrination and terror. This, however, would endanger or even destroy the open society. Therefore, from a moral point of view, tolerance appears to be the more desirable antidote to the unwanted effects of moral dissent. This paper aims to contribute to the discussions about the regulation of moral dissent and the formation of moral consensus by analyzing one of the most important and idiosyncratic elements of the Dutch way of handling these issues: pragmatic tolerance. First, some general thoughts are developed about moral consensus, moral dissent and tolerance as a means of regulating dissent. In addition, the characteristic Dutch policy of pragmatic tolerance is described. Finally, some of the pros and cons of pragmatic tolerance are analyzed from an ethical perspective. [ABSTRACT FROM AUTHOR]

Dutch euthanasia and physician-assisted suicide stand on the eve of important legal changes. In the summer of 1999, a new government bill concerning euthanasia and physician-assisted suicide was sent to Parliament for discussion. This bill legally embodies a ground for exemption from punishment for physicians who conduct euthanasia or physician-assisted suicide and comply with certain requirements. On November 28, 2000, the Dutch parliament approved an adapted version of this bill. Since the approval by the Dutch Senate can be regarded as a formality, it is expected that the bill will come into force in the course of this year (2001). In this paper we discuss these new developments. [ABSTRACT FROM AUTHOR]

In September 1998 the Bundes„rztekammer, i.e., the German Medical Association, published new principles concerning terminal medical care. Even before publication, a draft of these principles was very controversial, and prompted intense public debate in the mass media. Despite some of the critics' suspicions that the principles prepared the way for liberalization of active euthanasia, euthanasia is unequivocally rejected in the principles. Physician-assisted suicide is considered to violate professional medical rules. In leaving aside some of the notions customarily used in the euthanasia debate, e.g., passive euthanasia, the principles emphasize the obligation of physicians to offer and the right of patients to receive palliative care. The principles explicitly list modalities of basic treatment that are indispensable in all cases, such as the obligation to satisfy hunger and thirst. This statement is meant to resolve the dispute on nutrition and hydration at the end of life, as it shifts the focus of care from maintaining physiological parameters to satisfying subjective needs. For patients in a persistent vegetative state, artificial feeding is held to be obligatory. Yet, the principles make reference to recent German jurisdiction which permit the stopping of artificial feeding if it is in accordance with the patient's presumed will. Additionally, the wording concerning this issue is found to remain unclear. Patients' autonomy is strengthened by explicitly welcoming advance directives as a means to ascertain patients' wills. The principles mark some changes compared to earlier documents. They deserve careful analysis and should be considered in the international debate on issues concerning the end of life. [ABSTRACT FROM AUTHOR]

The historic or traditional Christian view of pain (suffering) and death, especially as preserved by the Christian East (i.e., the Orthodox), is radically opposed to the modern secular obsession with avoidance of pain. Everything about this life has its goal or aim in a mystical reality, the Kingdom of Heaven, for which earthly life is a preparation. While neither illness nor health are seen as ends in themselves, both are viewed as proceeding from the will of God for our benefit and have no ultimate meaning or purpose outside of eternal life. Death may be a relief or an ending of suffering, but in itself it is not "good" but evil. Because they are the embodiment of lived theology, saints' lives can be a sure guide to understanding how to die as a traditional Christian. To illustrate this, I have chosen some examples from the lives of relatively recent saints. I myself am from the Russian Orthodox spiritual tradition, so all but one of my examples come from pre-Revolutionary Russia. The question is not so much whether or not a traditional Christian can countenance physician-assisted suicide, but rather, what is the meaning or purpose of pain and suffering in general. Is it part of the "work of perfection" required of those who wish to enter the Kingdom of Heaven and therefore not to be completely denied? [ABSTRACT FROM AUTHOR]