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"Mercy" holds a well-established place in the discourse on assisted death (AD), with mercy rhetoric used by both proponents and opponents of AD alike. In this paper, I interrogate the relationship between mercy, mercy killing and AD. Appeals to mercy introduce an ambiguity that carries implications for the enduring debate about healthcare professionals' participation in this controversial practice. The term "mercy killing" is used at different times to mean all of the following: killings that are acts of punitive leniency, killings motivated by pity, killings motivated by compassion, and acts of voluntary, involuntary and nonvoluntary euthanasia. I argue that killings that are acts of punitive leniency "track" a conceptually useful understanding of mercy and, by extension, mercy killing. However, if mercy is understood in this way, then "mercy killing" is a problematic way of characterizing physician-AD. While reference to mercy killing has been weeded out of AD legislation over time, the same cannot be said of public discourse, where the debate about physicians' character-and the locus of power with respect to who gets to decide when a life can rightly be ended-continues.

In the polarized debates about abortion and voluntary euthanasia, disability advocates, who normally align with left-wing social forces, have tended to side with conservative and religious voices in expressing concerns about the impact of technological and sociopolitical developments on disabled futures. This paper draws on the social model of disability and the virtue ethics tradition to explain the alignment between the religious and disability perspectives, and the theory of transformative choice to highlight the limits and biases of the pro-choice logic. Yet, it also recognizes the inherent contradiction of disabled advocates taking a paternalistic position against the personal agency of women and people facing terminal illnesses. A disability perspective serves the discussion of abortion and euthanasia as an encouragement to work together for the building of a society that enables people with diverse disabilities to exist and flourish, and helps pregnant women, people facing disabling and terminal illnesses, and politicians and social influencers to make informed choices.

In June 2019 Victoria became the first state in Australia to permit "voluntary assisted dying" (VAD), with its governance detailed in the Voluntary Assisted Dying Act 2017 (Vic) ("VAD Act"). While taking lead from the regulation of medically assisted death practices in other parts of the world, Victoria's legislation nevertheless remains distinct. The law in Victoria only makes VAD available to persons determined to be "already dying": it is expressly limited to those medically prognosed to die "within weeks or months." In this article, we discuss the emergence of the Victorian legislation across key formative documents. We show how, in devising VAD exclusively for those "already at the end of their lives", the Victorian state mobilizes the medico-legal category of the already dying. We argue that this category functions to negotiate a path between what are seen as the unacceptable alternatives of violent suicide on the one hand, and an unlimited right to die on the other. Further, we argue that the category of the already dying operates to make medical practitioners the gatekeepers of this new life-ending choice and effectively limits the realization of autonomy at the end of life.

Background Under the Canadian Criminal Code, medical assistance in dying (MAiD) requires that patients give informed consent and that their ability to consent is assessed by 2 clinicians. In this study, we intended to understand how Canadian clinicians assessed capacity in people requesting MAiD. Methods This qualitative study used interviews conducted between August 2019 and February 2020, by phone, video and email, to explore how clinicians assessed capacity in people requesting MAiD, what challenges they had encountered and what tools they used. The participants were recruited from provider mailing listserves of the Canadian Association of MAiD Assessors and Providers and Aide medicale a mourir. Interviews were audio-recorded and transcribed verbatim. The research team met to review transcripts and explore themes as they emerged in an iterative manner. We used abductive reasoning for thematic analysis and coding, and continued to discuss until we reached consensus. Results The 20 participants worked in 5 of 10 provinces across Canada, represented different specialties and had experience assessing a total of 2410 patients requesting MAiD. The main theme was that, for most assessments, the participants used the conversation about how the patient had come to choose MAiD to get the information they needed. When the participants used formal capacity assessment tools, this was mostly for meticulous documentation, and they rarely asked for psychiatric consults. The participants described how they approached assessing cases of nonverbal patients and other challenging cases, using techniques such as ensuring a quiet environment and adequate hearing aids, and using questions requiring only "yes" or "no" as an answer. Interpretation The participants were comfortable doing MAiD assessments and used their clinical judgment and experience to assess capacity in ways similar to other clinical practices. The findings of this study suggest that experienced MAiD assessors do not routinely require formal capacity assessments or tools to assess capacity in patients requesting MAiD.

BackgroundVoluntary stopping of eating and drinking as an option to end life prematurely is gaining international attention, and health care professionals are increasingly confronted with the wish to die through voluntary stopping of eating and drinking by individuals. While to date, there are no guidelines in Switzerland to orient professional support, it is of interest how professionals and other people involved react to the situation. The aim of this qualitative study was to explore how health care professionals in Switzerland accompany individuals during voluntary stopping of eating and drinking and to analyze this decision-making process.MethodsCharmaz's grounded theory constructivist methodology uses guidelines for systematic, theory-driven data analysis underpinned by a pragmatic philosophical perspective. Data were collected in autumn 2016 as part of a regional palliative care conference on voluntary stopping of eating and drinking. All participants of the expert meeting (N = 50, including nurses, counsellors, ethicists, medical doctors, politicians, volunteers, and relatives) were invited to the focus group interviews, of whichN = 47 participated. We conducted five focus group interviews, each lasting one hour.ResultsThe results showed that the accompaniment of those willing to die during voluntary stopping of eating and drinking was either discussed and cleared with one another or was unspoken and silently accompanied.ConclusionsThe demands of participants for more knowledge must be heeded, and there is also a need for systematic instructions on how to proceed in the case of voluntary stopping of eating and drinking support and what needs to be considered.

Background Voluntary active euthanasia represents one of the key topics in the contemporary world medicine, law, religious, ethical and moral issues. Serbia considers legalization of this procedure. Between the others, it is important to examine the student’s attitudes regarding this issue. Methods Data were obtained from the faculties of law and medicine, from the universities of Kragujevac and Niš, Serbia. Data were collected during the second half of 2017. The research included 214 students. Due to the nature, subject and hypothesis of the research, the authors used descriptive method and the method of the theoretical content analysis. Results Generally, 54% of the students are in favor of legalization of the voluntary active euthanasia. 62, 4% would take part in the referendum on the legalization euthanasia. Conclusion The results obtained in the survey on euthanasia on a sample of law and medical students in Niš and Kragujevac indicate that choice of the faculty (law or medicine) influences the structure (share) of responses to particular questions to some extent. However, this influence does not provide ground for conclusion that students’ opinion on legalization and application of euthanasia depends on fact they study law or medicine.

After years of heated debate about the issue, medical assistance in dying (MAiD) was legalized in Canada in 2016. Canada became the first jurisdiction where MAiD may be delivered by nurse practitioners as well as physicians. Experience has revealed significant public demand for the service, and Canadians expect nurses to advocate for safe, high-quality, ethical practice in this new area of care. Pesut et al. offer a superb analysis of the related Canadian nursing regulatory documents and the challenges in creating a harmonized approach that arise in a federation where the Criminal Code is a federal entity and the regulation of health care providers and delivery of care fall under provincial and territorial legislation. Organizations like the Canadian Nurses Association contribute to the development of good legislation by working with partners to present evidence to help legislators consider impacts on public health, health care, and providers. Nursing regulators across Canada responded quickly to the unfolding policy landscape as the federal legislation evolved and will face that task again: In February 2020, the federal government tabled legislation to relax conditions related to MAiD requests that will force regulators and professional associations back to public advocacy and legislative tables. The success of the cautious approach exercised by nursing bodies throughout this journey should continue to reassure Canadians that their high trust in the profession is well placed.

Contains fulltext : 251401.pdf (Publisher’s version ) (Open Access) BACKGROUND: The practice of euthanasia in dementia has thus far been described both in terms of its empirical patient characteristics and its ethical questions. However, 40 new cases have been published since the last study. METHODS: A qualitative content analysis of all 111 Dutch case summaries of euthanasia in dementia patients between 2012 and 2020, selected from the total of 1117 cases published by the Regional Euthanasia Review Committees (RTE). Our initial analytical framework consists of six due care criteria and five ethical principles. RESULTS: 111 case summaries were analyzed, from which we distilled seven recurring ethical questions: (1) How voluntary is a request? (2) Can an incapacitated patient make well-considered requests? (3) What constitutes "unbearable suffering"? (4) What if the unbearableness of suffering solely consists of "the absence of any prospect of improvement"? (5) What if a euthanasia request is meant to prevent future suffering (now for then)? (6) How (well) can a patient with cognitive limitations be informed? (7) What are "reasonable alternatives" and what if patients decline available alternatives? CONCLUSIONS: Beyond these questions, however, we also see some serious challenges for the future: (a) narrowing the gap between perceived and real nursing home quality, since many advance euthanasia directives refer to nursing homes as sources of unbearable suffering; (b) making information to incompetent patients and their relatives about end of life options more tailor made, since it is questionable whether patients with dementia currently understand all of the euthanasia procedure; (c) involving patients' own physician as long as possible in a euthanasia request. Training may help physicians to deal better with euthanasia requests by patients suffering from dementia; (d) longitudinal research is required that encompasses all dementia euthanasia cases, not only those selected by the RTE.

On 11 September 2019, the verdict was read in the first prosecution of a doctor for euthanasia since the Termination of Life on Request and Assisted Suicide (Review Procedures) Act of 2002 was installed in the Netherlands. The case concerned euthanasia on the basis of an advance euthanasia directive (AED) for a patient with severe dementia. In this paper we describe the review process for euthanasia cases in the Netherlands. Then we describe the case in detail, the judgement of the Regional Review Committees for Termination of Life on Request and Euthanasia (RTE) and the judgement of the medical disciplinary court. Both the review committees and the disciplinary court came to the conclusion there were concerns with this case, which mainly hinged on the wording of the AED. They also addressed the lack of communication with the patient, the absence of oral confirmation of the wish to die and the fact that the euthanasia was performed without the patient being aware of this. However, the doctor was acquitted by the criminal court as the court found she had in fact met all due care criteria laid down in the act. We then describe what this judgement means for euthanasia in the Netherlands. It clarifies the power and reach of AEDs, it allows taking conversations with physicians and the testimony of the family into account when interpreting the AED. However, as a practical consequence the prosecution of this physician has led to fear among doctors about prosecution after euthanasia.

A Commonwealth law poses legal risks for practitioners acting under state and territory voluntary assisted dying laws

Physician-assisted death is becoming legal in an increasing number of jurisdictions, but psychiatric patients are often explicitly excluded. However, in some countries, including the Netherlands, physician-assisted death of psychiatric patients is allowed. This Open Forum describes a patient with schizophrenia and symptoms diagnosed as refractory musical hallucinations. The patient requested assistance in dying only to recover after a mandatory second opinion, where his complaints were recognized as intrusive thoughts and treated accordingly. This case is used to reflect on how to deal with uncertainty about physician-assisted death of psychiatric patients and to argue for implementation of a due-diligence procedure, such as the one proposed in the Dutch Psychiatric Association's recent guideline concerning this issue.

Objective Medical assistance in dying (MAiD) is the medical provision of substances to end a patient’s life at their voluntary request. While legal in several countries, the implementation of MAiD is met with ethical, legislative and clinical challenges, which are often overshadowed by moral discourse. Our aim was to conduct a scoping review to explore key barriers for the integration of MAiD into existing health systems. Methods We searched electronic databases (CINAHL, Embase, MEDLINE, and PsycINFO) and grey literature sources from 1990 to 2017. Studies discussing barriers and/or challenges to implementing MAiD from a health system’s perspective were included. Full-text papers were screened against inclusion/exclusion criteria for article selection. A thematic content analysis was conducted to summarize data into themes to highlight key implementation barriers. Results The final review included 35 articles (see online Appendix 1). Six categories of implementation challenges emerged: regulatory (n = 26), legal (n = 15), social (n = 9), logistical (n = 9), financial (n = 3) and compatibility with palliative care (n = 3). Within four of the six identified implementation barriers (regulatory, legal, social and logistical) were subthemes, which described barriers related to legalizing MAiD in more detail. Conclusion Despite multiple challenges related to its implementation, MAiD remains a requested end-of-life option, requiring careful examination to ensure adequate integration into existing health services. Comprehensive models of care incorporating multidisciplinary teams and regulatory oversight alongside improved clinician education may be effective to streamline MAiD services.

Background: Nurses play a major role in providing end-of-life care, and euthanasia is considered to be one of the most important ethical challenges that care providers can face. Aim: To assess the nurses' attitude towards euthanasia in Iran. Methods: The cross-sectional study included nurses who worked in intensive and critical care, as well as dialysis units of a teaching hospital affiliated to Zahedan University of Medical Sciences, who were selected by the census sampling technique. Data were collected using a two-part questionnaire encompassing the demographic characteristics of nurses and the 20-item Euthanasia Attitude Scale. Results: The overall score of nurses' attitudes towards euthanasia, ranging from one to five, was 2.71±0.45, indicating a negative attitude and opposition towards euthanasia. Alongside this, the results demonstrated that there was no significant relationship between demographic characteristics and nurses' attitudes toward euthanasia. Conclusion: In general, nurses in Iran oppose euthanasia. This can be attributed to the context of religious beliefs and culture in Iran as an Islamic country.

RÉSUMÉLa légalisation de l’aide médicale à mourir (AMM) au Canada a permis aux médecins, aux décideurs politiques et aux patients de réexaminer les soins de fin de vie. Cet article présente les principales caractéristiques du programme albertain d’AMM, dans le contexte des programmes d’AMM mis en place dans les autres provinces. Nous avons également comparé les politiques et les pratiques en matière d’AMM dans différentes provinces et territoires du Canada. De plus, nous avons utilisé la base de données de l’AMM de l’Alberta pour dresser un portrait des données démographiques sur les patients et l’accès aux services d’AMM en Alberta en 2017-2018. Des différences significatives ont été relevées dans les processus et les pratiques des divers programmes provinciaux et territoriaux d’AMM. Les programmes de l’Alberta, de l’Ontario et du Québec sont plus complets. L’Alberta a mis en place des ressources dédiées pour l’AMM. L’âge médian des personnes qui ont reçu des services d’AMM en Alberta de juillet 2017 à avril 2018 était de 70 ans. Les bénéficiaires étaient majoritairement des hommes (55 %) et des patients ayant un cancer (70 %). Environ 39 % des prestations d’AMM ont été réalisées en milieu hospitalier et 38 % au domicile des patients.Nous concluons avec quelques recommandations sur le développement, la mise en œuvre et l’évaluation du programme d’AMM, en nous fondant sur l’expérience de l’Alberta dans ce domaine au cours des deux dernières années.

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.

In New Zealand, aiding and abetting a person to commit suicide or euthanasia even with consent is unlawful. The introduction of a third Bill on assisted dying to the House of Representatives following a high-profile court case afforded an opportunity for examining how assisted dying was discussed in the public sphere. In this article, we report on a discourse analysis of a selection of social media to illustrate the ways in which citizens participate in the voluntary euthanasia debate. The volume of social media posts that made up our data set suggests that the legalisation of assisted dying is a highly topical and deeply salient societal issue. Social media postings represent the voices of ordinary citizens who may not participate in formal public consultation processes. Based on our analysis, the assignment of binary conclusions about public opinion is simplistic and fails to adequately represent the intricacies of public debate. Contributors’ posts reveal deeply held sociocultural values, as well as tensions about the relationship between citizens and the apparatus of government.

Suppose that a young athlete has just become quadriplegic. He expects to live several more decades, but out of self-interest he autonomously chooses to engage in physician-assisted suicide (PAS) or voluntary active euthanasia (VAE). Some of us are unsure whether he or his physician would be acting rightly in ending his life. One basis for such doubt is the notion that persons have dignity in a Kantian sense. This paper probes responses that David Velleman and Frances Kamm have suggested to the question of whether participating in PAS or VAE to benefit oneself, as the young man might, respects the dignity of persons, specified in an orthodox Kantian way. Velleman claims that it does not, while Kamm insists that, in certain circumstances, it does. I argue against Kamm's position. I go on to contend that while orthodox Kantianism might provide a basis for moral concern regarding the case of the young quadriplegic, it suffers from two serious shortcomings. First, it implies that terminally ill patients are wrong to request VAE or engage in PAS to avoid intense suffering, at least when this suffering has not yet overwhelmed their reason. Second, orthodox Kantianism implies that it is wrong for physicians to withdraw such patients from life-sustaining treatments, even if they request it. To remedy these shortcomings, I sketch an unorthodox Kantian account of respect for the dignity of persons. This account promises to capture the idea that it would be morally problematic for doctors to help the young quadriplegic to die, but to avoid the shortcomings of an orthodox Kantian account.

Voluntary euthanasia and physician assisted suicide has been legally performed in several countries. However, little is known about how decision-making occurs. We undertook this study to describe trends in officially reported cases of voluntary euthanasia or physician assisted suicide and to explore the decision-making procedures and understand relevant criteria. Thematic analysis of the official reports from several countries was performed. Differences in the number of reported deaths from hasten death practices between countries was found, with higher numbers in countries who performed voluntary euthanasia. Patients profiles follow the trends in the literature (the majority is aged between 70 and 89 years old, men die more often than women in most countries, most prevalent underlying disease is cancer, most people died at home). Despite there being little detail in the reports, decision is explored in the majority of countries and states (exploration of acceptable alternatives and verification of the voluntariness of the request). The importance of collecting data on this topic around the world and establishing a firm evidence-base to support professionals' practice is highlighted.

Background Huntington’s disease (HD) has a poor prognosis. Decision-making capacity and communication ability may become lost as the disease progresses. Therefore, HD patients are encouraged to engage in advance care planning (ACP). To improve ACP for HD patients, there is a need to better understand how these patients face their poor prognosis. Aim To gain insight into the views of HD patients who receive outpatient care regarding their future and the way they deal with the poor prognosis of their disease. Methods A qualitative study using semi-structured interviews with 12 patients with HD (7 outpatient clinic, 3 day care, 2 assisted living facility). Audio-recorded interviews were transcribed verbatim. Through reading and re-reading interviews, writing memos and discussions in the research team, strategies were identified. Results Three strategies emerged for facing a future with HD. Participants saw the future: 1) as a period that you have to prepare for; 2) as a period that you would rather not think about; 3) as a period that you do not have to worry about yet. Participants could adopt more than one strategy at a time. Even though participants realized that they would deteriorate and would need more care in the future, they tried to keep this knowledge ‘at a distance’, with the motivation of keeping daily life as manageable as possible. Conclusions Official ACP guidelines recommend discussing goals and preferences for future treatment and care, but patients tend to want to live in the present. Further research is needed to elucidate the best approach to deal with this discrepancy.

In palliative care, it is not uncommon for people with serious illnesses to wish to hasten their death. These wishes present considerable challenges for health care professionals. The purpose of this review is to support healthcare professionals in their understanding and apprehension of patients' wishes to hasten their death. In order to do so, we will present the definition of this wish, and then we will study it, based on three main components, which are intentions, motivations and interactions. The common thread of this review lies in the following question: how to best support the human who faces death?

This column discusses the potential for conflict between the Federal laws forbidding the use of telecommunications to spread "suicide-related materials" and the laws in Victoria and Western Australia which have legalised forms of voluntary assisted dying. The column argues that the effect of the State laws is to differentiate the legal forms of voluntary assisted dying from suicide and assisted suicide, with the effect that Federal prohibitions do not apply to telecommunications between health practitioners and their patients regarding voluntary assisted dying.

Euthanasia in patients with dementia is legally permitted, but many physicians experience it as (too) complex. They are frightened of the legal consequences and do not know how to assess the nature of the suffering. They also find it difficult to assess the patient's ability to provide consent.Here we describe two cases of patients who were registered at Euthanasia Expertise Centre by a family member: a 72-year-old woman who had been diagnosed with Alzheimer disease 18 months previously and a 67-year-old man with Lewy body dementia. During the various consultations we had with them we were given a distinct picture of the nature of their suffering, and it became clear to us why they found this suffering unbearable.By paying extra attention to the assessment of the ability to give consent and by exploring the degree of suffering experienced it is possible to meet the request for euthanasia by a patient with dementia within the framework of the law.