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Dealing with dementia raises agonising ethical dilemmas A FEW MONTHS before Vera mistook her grandson for a coconut, her son came by with someone she did not recognise. He was [...]

A trio of speakers at the July 6 opening session of NRLC 2019 provided a human face to the issues of euthanasia/assisted suicide/rationing in three powerful presentations. Bobby Schindler, the [...]

An Abstract Discussion of a Concrete Issue. The extensive debate on euthanasia and assisted suicide has been surprisingly abstract. The actual deaths from euthanasia, the reality of death and of [...]

Even in the early days some observers warned that euthanasia was not just another procedure added to the medical practice but would change the physician's whole attitude and also their [...]

The date was January 8, 1997, I was on the witness stand at the Palm Beach Court, (401) and Judge Joseph Davis asked me: "Doctor, can you imagine some special [...]

Jeremy Bentham was born in 1748 and died 84 years later, but it was said that nothing ever happened to him; that he never experienced any human misfortunes or elations; [...]

In 1988, a baby born with Down syndrome vomited all nourishment and was admitted to one of Holland's leading centers for pediatric surgery, the Sophia Hospital in Rotterdam. It was [...]

Part Two: Medicine Versus Euthanasia Chapter XXIX. The Shaping of Public Opinion In Holland, the opinion polls conducted in the last three decades have shown an increasing acceptance of euthanasia [...]

David Shaw presents a new argument to support the old claim that there is not a significant moral difference between killing and letting die and, by implication, between active and passive euthanasia. He concludes that doctors should not make a distinction between them. However, whether or not killing and letting die are morally equivalent is not as important a question as he suggests. One can justify legal distinctions on non-moral grounds. One might oppose physician-assisted suicide and active euthanasia when performed by doctors on patients whether or not one is in favour of the legalisation of assisted suicide and active euthanasia. Furthermore, one can consider particular actions to be contrary to appropriate professional conduct even in the absence of legal and ethical objections to them. Someone who wants to die might want only a doctor to kill him or to help him to kill himself. However, we are not entitled to everything that we want in life or death. A doctor cannot always fittingly provide all that a patient wants or needs. It is appropriate that doctors provide their expert advice with regard to the performance of active euthanasia but they can and should do so while, qua doctors, they remain hors de combat. doi: 10.1136/jme.2009.033118

Objectives To explore attitudes and reasoning among Swedish physicians and the general public regarding the withdrawal of life-sustaining treatment at a competent patient's request. Design A vignette-based postal questionnaire including 1202 randomly selected individuals in the county of Stockholm and 1200 randomly selected Swedish physicians with various specialities. The vignettes described patients requesting withdrawal of their life-sustaining treatment: (1) a 77-year-old woman on dialysis; (2) a 36-year-old man on dialysis; (3) a 34-year-old ventilator-dependent tetraplegic man. Responders were asked to classify the act of terminating treatment and to prioritise arguments for/against. Results A majority in both groups prioritised arguments in favour of terminating treatment and classified the act as defensible in all vignettes. However, among the general public, 16% classified the act as euthanasia in all vignettes; among physicians this view was most expressed regarding ventilator treatment (26%). Some who classified the act as euthanasia prioritised arguments in favour of terminating treatment: among physicians 18% in vignette 1, 19% in vignette 2 and 34% in vignette 3; among the general public 35% in vignette 1, 20% in vignette 2 and 48% in vignette 3. Conclusion There is a widespread consensus regarding competent patients' right to abstain from life-sustaining treatment. An association between the hastening of death, caused by the withdrawal of life-sustaining treatment and the concept of euthanasia is proposed. The results also suggest that classifying the withdrawal of life-sustaining treatment as 'euthanasia' does not necessarily mean that the act is interpreted as ethically unacceptable. doi: 10.1136/jme.2009.034967

Objectives: To investigate why physicians label end-of-life acts as either 'euthanasia/ending of life' or 'alleviation of symptoms/palliative or terminal sedation', and to study the association of such labelling with intended reporting of these acts. Methods: Questionnaires were sent to a random, stratified sample of 2100 Dutch physicians (response: 55%). They were asked to label six hypothetical end-of-life cases: three 'standard' cases and three cases randomly selected (out of 47), that varied according to (1) type of medication, (2) physician's intention, (3) type of patient request, (4) patient's life expectancy and (5) time until death. We identified the extent to which characteristics of cases are associated with physician's labelling, with multilevel multivariable logistic regression. Results: The characteristics that contributed most to labelling cases as 'euthanasia/ending of life' were the administration of muscle relaxants (99% of these cases were labelled as 'euthanasia/ending of life') or disproportional morphine (63% of these cases were labelled accordingly). Other important factors were an intention to hasten death (54%) and a life expectancy of several months (46%). Physicians were much more willing to report cases labelled as 'euthanasia' (87%) or 'ending of life' (56%) than other cases. Conclusions: Similar cases are not uniformly labelled. However, a physicians' label is strongly associated with their willingness to report their acts. Differences in how physicians label similar acts impede complete societal control. Further education and debate could enhance the level of agreement about what is physician-assisted dying, and thus should be reported, and what not. doi: 10.1136/jme.2009.030155

Background: Lay persons' judgements of the acceptability of the net uncommon practice of ending the life of a damaged neonate have not been studied. Methods: A convenience sample of 1635 lay people in France rated how acceptable it would be for a physician to end a neonate's life--by withholding care, withdrawing care, or active euthanasia--in 54 scenarios in which the neonate was diagnosed either with perinatal asphyxia or a genetic abnormality. The scenarios were all combinations of four factors: three levels of maturity or immaturity, three levels of severity of the health problem, three levels of parents' preference concerning prolonging care and two levels of decision-making (with or without consulting the other caregivers). Analyses: Analyses of variance of the participants' responses were performed to determine the importance of each factor; the interactions among factors, with methods of ending life and with other patient characteristics; and the differences between asphyxia and genetic abnormality. A cluster analysis was performed to look for groups with different patterns of responses. Results: Lay people assigned most importance to the parents' request and to the severity of the problem. Except for a small group (12%) always opposed to ending life, they used a simple additive-type rule in integrating the information. Implications: Most of this sample of French lay people are not categorically for or against ending the life of a damaged neonate, but judge its degree of acceptability by adding up those factors that seem most salient to them. J Med Ethics 2009:35:701-708. doi: 10.1136/jme.2009.029686

Introduction: In The Netherlands, physicians have to be convinced that the patient suffers unbearably and hopelessly before granting a request for euthanasia. The extent to which general practitioners (GPs), consulted physicians and members of the euthanasia review committees judge this criterion similarly was evaluated. Methods: 300 GPs, 150 consultants and 27 members of review committees were sent a questionnaire with patient descriptions. Besides a 'standard case' of a patient with physical suffering and limited life expectancy, the descriptions included cases in which the request was mainly rooted in psychosocial or existential suffering, such as fear of future suffering or dependency. For each case, respondents were asked whether they recognised the case from their own practice and whether they considered the suffering to be unbearable. Results: The cases were recognisable for almost all respondents. For the 'standard case' nearly all respondents were convinced that the patient suffered unbearably. For the other cases, GPs thought the suffering was unbearable less often (2-49%) than consultants (25-79%) and members of the euthanasia review committees (24-88%). In each group, the suffering of patients with early dementia and patients who were 'tired of living' was least often considered to be unbearable. Conclusions: When non-physical aspects of suffering are central in a euthanasia request, there is variance between and within GPs, consultants and members of the euthanasia committees in their judgement of the patient's suffering. Possible explanations could be differences in their roles in the decision-making process, differences in experience with evaluating a euthanasia request, or differences in views regarding the permissibility of euthanasia.

In Nazi Germany, approximately 200 000 mentally ill people were murdered under the guise of euthanasia. Relatively little is known regarding the fate of the Jewish mentally ill patients targeted in this process, long before the Holocaust officially began. For the Nazis, Jewish mentally ill patients were doubly cursed since they embodied both 'precarious genes' and 'racial toxin'. To preserve the memory of the victims, Yad Vashem, the leading institution dedicated to documentation of the Holocaust, actively collects information and documents the fate of victims in an open online database. Recently, a list of approximately 1200 names of Jewish mentally ill euthanasia victims has been compiled from hospital archives. Their fate remains unknown to surviving family members. Given the duty to preserve medical confidentiality, can this list be publicised for public interest and for notifying families--publicising names and death circumstances, including where 'killed' would immediately indicate that the person had had a mental illness? Does the right to medical confidentiality lapse upon death? Is time elapsed since death a factor? Can opposing obligations of preserving victims' memory over-ride medical confidentiality? What if a family member objects to a grandparent's name being exposed on the list of mentally ill patients? This article considers these issues as well as the 'rational' and 'non-rational' factors in ethical decisional making surrounding this unique dilemma. Several possible solutions are proposed including preserving the list in a locked database for access by families and researchers, publicising in the media that such a list exists, publishing the information online without any identifiers and submitting the information to historians, allowing them to process the data as they see fit.

The difficulty in discovering a difference between killing and letting die has led many philosophers to deny the distinction. This paper seeks to develop an argument defending the distinction between killing and letting die. In relation to Rachels' cases, the argument is that (a) even accepting that Smith and Jones may select equally heinous options from the choices they have available to them, (b) the fact that the choices available to them are different is morally relevant, and (c) this difference in available choices can be used to distinguish between the agents in certain circumstances. It is the principle of justice, as espoused by Aristotle, which requires that equal things are treated equally and that unequal things are treated unequally that creates a presumption that Smith and Jones should be treated differently. The magnitude of this difference can be amplified by other premises, making the distinction morally relevant in practical reality.

Background: Hospital nurses are frequently the first care givers to receive a patient's request for euthanasia or physician-assisted suicide (PAS). In France, there is no consensus over which medical practices should be considered euthanasia, and this lack of consensus blurred the debate about euthanasia and PAS legalisation. This study aimed to investigate French hospital nurses' opinions towards both legalisations, including personal conceptions of euthanasia and working conditions and organisation. Methods: A phone survey conducted among a random national sample of 1502 French hospital nurses. We studied factors associated with opinions towards euthanasia and PAS, including contextual factors related to hospital units with random-effects logistic models. Results: Overall, 48% of nurses supported legalisation of euthanasia and 29%, of PAS. Religiosity, training in pallative care/pain management and feeling competent in end-of-life care were negatively correlated with support for legalisation of both euthanasia and PAS, while nurses working at night were more prone to support legalisation of both. The support for legalisation of euthanasia and PAS was also weaker in pain treatment/palliative care and intensive care units, and it was stronger in units not benefiting from interventions of charity/religious workers and in units with more nurses. Conclusions: Many French hospital nurses uphold the legalisation of euthanasia and PAS, but these nurses may be the least likely to perform what proponents of legalisation call 'good' euthanasia. Improving professional knowledge of palliative care could improve the management of end-of-life situations and help to clarify the debate over euthanasia.

Recent evaluation of the practice of euthanasia and related medical decisions at the end of life in the Netherlands has shown a slight decrease in the frequency of physician-assisted death since the enactment of the Euthanasia Law in 2002. This paper focuses on the absence of euthanasia cases concerning patients with dementia and a written advance euthanasia directive, despite the fact that the only real innovation of the Euthanasia Law consisted precisely in allowing physicians to act upon such directives. The author discusses two principal reasons for this absence. One relates to the uncertainty about whether patients with advanced dementia truly experience the suffering they formerly feared. There is reason to assume that they don't, as a consequence of psychological adaptation and progressive unawareness (anosognosia). The second, more fundamental reason touches upon the ethical relevance of shared understanding and reciprocity. The author argues that, next to autonomy and mercifulness, 'reciprocity' is a condition sine qua non for euthanasia. The absence thereof in advanced dementia renders euthanasia morally inconceivable, even if there are signs of suffering and notwithstanding the presence of an advance euthanasia directive. This does not mean, however, that advance euthanasia directives of patients with dementia are worthless. They might very well have a role in the earlier stages of certain subtypes of the disease. To illustrate this point the author presents a case in which the advance directive helped to create a window of opportunity for reciprocity and shared decision-making.

Background: Caring for terminally ill patients is a meaningful task, however the patient's suffering can be a considerable burden and cause of frustration. Objectives: The aim of this study is to describe the experiences of general practitioners (GPs) in The Netherlands in dealing with a request for euthanasia from a terminally ill patient. Methods: The data, collected through in-depth interviews, were analysed according to the constant comparative method. Results: Having to face a request for euthanasia when attempting to relieve a patient's suffering was described as a very demanding experience that GPs generally would like to avoid. Nearly half of the GPs (14/30) strive to avoid euthanasia or physician assisted suicide because it was against their own personal values or because it was emotional burdening to be confronted with this issue. They explained that by being directed on promoting a peaceful dying process, or the quality of end-of-life of a patient by caring and supporting the patient and the relatives it was mainly possible to shorten patient's suffering without 'intentionally hastening a patient's death on his request'. The other GPs (16/30) explained that as sometimes the suffering of a patient could not be lessened they were open to consider a patient's request for euthanasia of physician assisted suicide. They underlined the importance of a careful decision-making process, based on finding a balance between the necessity to shorten the patient's suffering through euthanasia and their personal values. Conclusion: Dealing with requests for euthanasia is very challenging for GPs, although they feel committed to alleviate a patient's suffering and to promote a peaceful death.

Objectives: To discover the current state of opinion and practice among doctors in Victoria, Australia, regarding end-of-life decisions and the legalisation of voluntary euthanasia. Longitudinal comparison with similar 1987 and 1993 studies. Design and participants: Cross-sectional postal survey of doctors in Victoria. Results: 53% of doctors in Victoria support the legalisation of voluntary euthanasia. Of doctors who have experienced requests from patients to hasten death, 35% have administered drugs with the intention of hastening death. There is substantial disagreement among doctors concerning the definition of euthanasia. Conclusions: Disagreement among doctors concerning the meaning of the term euthanasia may contribute to misunderstanding in the debate over voluntary euthanasia. Among doctors in Victoria, support for the legalisation of voluntary euthanasia appears to have weakened slightly over the past 17 years. Opinion on this issue is sharply polarised.

One of the most recent controversies to arise in the field of bioethics concerns the ethics for the Groningen Protocol: the guidelines proposed by the Groningen Academic Hospital in The Netherlands, which would permit doctors to actively euthanise terminally ill infants who are suffering. The Groningen Protocol has been met with an intense amount of criticism, some even calling it a relapse into a Hitleresque style of eugenics, where people with disabilities are killed solely because of their handicaps. The purpose of this paper is threefold. First, the paper will attempt to disabuse readers of this erroneous understanding of the Groningen Protocol by showing how such a policy does not aim at making quality-of-life judgements, given that it restricts euthanasia to suffering and terminally ill infants. Second, the paper illustrates that what the Groningen Protocol proposes to do is both ethical and also the most humane alternative for these suffering and dying infants. Lastly, responses are given to some of the worries expressed by ethicists on the practice of any type of non-voluntary active euthanasia. doi: 10.1136/jme.2005.014845

An agent who takes his own life acts in violation of the moral law, according to Kant; suicide, and, by extension, assisted suicide are therefore wrong. By a similar argument, and with a few important exceptions, killing is wrong; implicitly, then, voluntary euthanasia is also wrong. Kant's conclusions are uncompelling and his argument in these matters is undermined on considering other areas of his thought. Kant, in forbidding suicide and euthanasia, is conflating respect for persons and respect for people, and assuming that, in killing a person (either oneself or another), we are thereby undermining personhood. But an argument along these lines is faulty according to Kant's own standards. There is no reason why Kantians have to accept that self-killing and euthanasia are contrary to the moral law. Even if some Kantians adhere to this doctrine, others can reject it.

It was a wonderful life--until illness and pain intervened. But unlike most, patients in Oregon can legally end their lives if they choose. Attorney General John Ashcroft is struggling to […]