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The scholarship of euthanasia indicates that in most cases, to date, non-voluntary euthanasia has been studied where euthanasia is legalized. Findings of these studies demonstrate the 'slippery slope' and reveal that non-voluntary euthanasia is pervasive in these countries. The research is aimed at answering two questions: (1) What are the common death hastening methods? (2) Is the acceptance of active non-voluntary euthanasia related to the legal status of euthanasia? A qualitative study was conducted in ICUs with 15 nurses. All of the interviewees refused to take part in the death hastening cases and did not obey any doctor's instruction that could hasten or cause death. Therefore, doctors who conducted NVE did it by themselves. The present study provides evidence of the phenomenon of illegal non-voluntary euthanasia as a routine practice by physicians in palliative care units in Israel. Interviews with 15 nurses employed in these units shed light on the means and methods used by these doctors to hasten terminal patients' death. We conclude that Nurses in various end-of-life care units persist in preserving their professional integrity and refuse to obey doctors' instructions for non-voluntary euthanasia. The slippery slope argument has been refuted in this context., Competing Interests: Declaration of competing interest The authors declare no conflict of interests., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Pope Francis's Address to the participants of the conference "Yes to Life! Taking Care of the Precious Gift of Life in Its Frailty" powerfully touches on multiple important aspects of the care of children experiencing "extreme frailty." It is a deeply moral account of the challenges that health-care providers, families, and patients confront in the technologically sophisticated and confusing world of modern medicine. This commentary draws upon a clinical case to contextualize the Pope's words in the hope of achieving a nuanced understanding of what pediatric palliative care offers to children experiencing extreme frailty. In his Address, the Pope asks health-care providers to consider an approach to frailty and suffering that allows for the opportunity to experience transcendent meaning and transpersonal value, and recognizes that it would be difficult to achieve these goals without the comprehensive and capable care offered by pediatric palliative care specialists.

The Ethics Subcommittee of AMDA-The Society for Post-Acute and Long-Term Care Medicine ("The Society") presents arguments for and against Stopping Eating and Drinking by Advance Directives (SED by AD). SED by AD is a type of advance directive in which a proxy is instructed to stop offering food and fluids to a person when they reach a certain stage of dementia. Although most conversations regarding SED by AD focus on patient autonomy and the right to determine one's care, we propose that the ethical principle of justice-the obligation to treat all individuals equally regardless of race, gender, and physical or cognitive ability-is the decisive principle in this controversy. We also suggest that implementing SED by AD can violate a physician's obligation to beneficence and nonmaleficence. On the other hand, we identify with the families of our patients who see the refusal to follow an advance directive as an injustice of the highest order. In the end, The Society is convinced that no choice can be made here without practicing an injustice: if one refuses to implement SED by AD, one violates the autonomy of the person who drew up the advance directive. If, on the other hand, one refuses food and fluid to a resident who still accepts food, one risks practicing an injustice against that person as they are now. Recognizing that we have the greatest responsibility to our patients as they present to us in the residential setting, The Society recommends against implementing SED by AD in residents who still accept food and fluids, implementing instead, a policy of comfort feeding for those with advanced dementia., (Copyright © 2019 AMDA – The Society for Post-Acute and Long-Term Care Medicine. Published by Elsevier Inc. All rights reserved.)

In the debate surrounding the morality and legality of the practices of physician-assisted death and euthanasia, a common logical argument regularly employed against these practices is the "slippery slope argument." One formulation of this argument claims that acceptance of physician-assisted death will eventually lead down a "slippery slope" into acceptance of active euthanasia, including its voluntary, non-voluntary, and/or involuntary forms, through psychological and social processes that warp a society's values and moral perspective of a practice over an extended period of time. This formulation is known as the psychological slippery slope argument. This paper analyzes the psychological slippery slope argument as it is applied to the practice of physician-assisted death, and utilizing recent empirical evidence from various nations around the world that practice physician-assisted death and/or euthanasia, the paper argues that (1) employing the psychological slippery slope argument against physician-assisted death is logically fallacious, (2) this kind of slippery slope is unfounded in practice, and thus (3) the psychological slippery slope argument is insufficient on its own to justify continued legal prohibition of physician-assisted death.

To act or not to act? Developments in prenatal and postnatal care for children with spina bifida aperta Until the middle of the twentieth century, newborns with spina bifida aperta had low chances of survival. Advances in the treatment of hydrocephalus, among other conditions, led to increased chances of survival during the 1960s. This also revealed the downsides of the treatment of spina bifida patients since some considered the quality of life of a number of these patients to be unacceptable. But withholding treatment also had negative consequences, leading to an ethical deadlock. Over the past thirty years - besides postnatal closure of the neural tube defect - more emphasis has been put on selective pregnancy termination and sporadic active termination of life in newborns with very severe forms of spina bifida. At the same time, new treatment strategies, such as foetal surgery, are being developed. With this historical overview, we illustrate the way in which technological developments and ethical dilemmas are constantly affecting each other.

Assisted dying is a highly controversial moral issue incorporating both physician-assisted dying (PAD) and voluntary active euthanasia. End-of-life practices are debated in many countries, with assisted dying receiving different consideration across various jurisdictions. In this paper, we provide an analytic framework of the current position and the main arguments related to the rights and moral principles concerning assisted dying. Assisted dying proponents focus on the respect of autonomy, self-determination and forestalling suffering. On the other hand, concerns are raised regarding the interpretation of the constitutional right to life and balancing this with the premise of assisted dying, alongside the impacts of assisted dying on the doctor-patient relationship, which is fundamentally based on trust, mutual respect and the premise of 'first do no harm'. Our review is underpinning the interpretation of constitutional rights and the Hippocratic Oath with the premise of assisted dying, alongside the impacts of assisted dying on the doctor-patient relationship. Most clinicians remain untrained in such decision making, with fears against crossing key ethical divides. Due to the increasing number of cases of assisted dying and lack of consensus, our review enables the integration of ethical and legal aspects and facilitates decision making.

In 2002, The Netherlands continued its leadership in developing rules and jurisdiction regarding euthanasia and end-of-life decisions by implementing the Euthanasia Act, which allows euthanasia for patients 12 years of age and older. Subsequently, in 2005, the regulation on active ending of life for newborns was issued. However, more and more physicians and parents have stated that the age gap between these two regulations-children between 1 and 12 years old-is undesirable. These children should have the same right to end their suffering as adults and newborn infants. An extended debate on pediatric euthanasia ensued, and currently the debate is ongoing as to whether legislation should be altered in order to allow pediatric euthanasia. An emerging major question regards the active ending of life in the context of palliative care: How does a request for active ending of life relate to the care that is given to children in the palliative phase? Until now, the distinction between palliative care and end-of-life decisions continues to remain unclear, making any discussion about their mutual in- and exclusiveness hazardous at best. In this report, therefore, we aim to provide insight into the relationship between pediatric palliative care and end-of-life decisions, as understood in the Netherlands. We do so by first providing an overview of the (legal) rules and regulations regarding euthanasia and active ending of life, followed by an analysis of the relationship between these two, using the Dutch National Guidelines for Palliative Care for Children. The results of this analysis revealed two major and related features of palliative care and end-of-life decisions for children: (1) palliative care and end-of-life decisions are part of the same process, one that focuses both on quality of living and quality of dying, and (2) although physicians are seen as ultimately responsible for making end-of-life decisions, the involvement of parents and children in this decision is of the utmost importance and should be regarded as such.

With regard to ethics and legislation, what is the significant difference between a doctor terminating the life-supporting treatment of a patient in the course of his job and a greedy relative of the patient doing the same thing to inherit his wealth? Merkel offers an interesting and inventive answer to this question in terms of the improper violation of personal boundaries. However, despite Merkel's claim to the contrary, his answer does not directly address the question of the relevant ethical similarities and differences between killing and letting die in general. Furthermore, it does not provide the basis a plausible rationale for legislation concerning killing and letting die. The questions of whether letting someone die is ethically the same as killing someone and whether it should be treated the same way by the criminal law are not the same as or tantamount to the question of whether or not it involves the transgression of another person's boundaries., Competing Interests: Competing interests: None declared., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.)

The Groningen Protocol, introduced in the Netherlands in 2005 and accompanied by revised guidelines published in a report commissioned by the Royal Dutch Medical Association in 2014, specifies conditions under which the lives of severely ill newborns may be deliberately ended. Its publication came four years after the Netherlands became the first nation to legalize the voluntary active euthanasia of adults, and the Netherlands remains the only country to offer a pathway to protecting physicians who might engage in deliberately ending the life of a newborn (DELN). In this paper, I offer two lines of argument. The first is a positive argument for the Protocol, grounded in the good of the newborn as unanimously determined by those in a position to determine it. The second addresses the widely shared belief that the killing of newborns is morally prohibited, where I offer two arguments-one grounded in the fact that the kinds of cases the Protocol is meant to govern are very rare and highly unusual, and the other focused more broadly on the role of pre-theoretical beliefs in moral reasoning-meant to undermine the strong role that the critic of the Protocol affords this belief. I argue that, given this second line of argument, the beliefs underlying my positive argument for the Protocol are in fact more secure than the widely shared belief underlying the critic's position.

Since the Netherlands produced the Groningen protocol describing the methods to be used for pediatric euthanasia and Belgium passed laws authorizing euthanasia for children who consent to it, the issue of pediatric euthanasia has become a relevant topic to discuss. Most rejections of pediatric euthanasia fall into 1 or more of 3 categories, each of which has problems. This article shows how several recent arguments against pediatric euthanasia fail to prove that pediatric euthanasia is unacceptable. It does not follow from this that the practice is permissible but rather that if one is to reject such a practice, stronger arguments will need to be made, especially in countries where adult euthanasia or assisted suicide is already permitted., (© The Author(s) 2015.)

Dutch law permits physicians to perform euthanasia, provided they fulfil six criteria of due care. Prominent among these is the requirement that they are convinced that the patient is suffering unbearably. But how can they be sure of that? The problem seems to be that this criterion is too subjective on two scores: it makes the patient dependent on the empathic capacities of his physician, and it would be arrogant for the physician to deny that the patient is suffering unbearably if that is what the patient tells them. In this paper I suggest that this criterion is far less arbitrary than it seems.

Background: Attitudes towards active euthanasia by request of competent patients who are seriously or incurable ill people are common in public debates. There is still a lack of knowledge on how people with care experience differ in their attitudes towards active euthanasia from those without., Aim: The aim of this study is to find out if and how care experience has an effect on the attitude toward voluntary active euthanasia., Method: In spring 2014 a cross-sectional survey was conducted among the Austrian population by a self-developed questionnaire (on basis of a qualitative pilot study). An online-survey was distributed among persons aged 16 to 65 years and a postal survey among those aged 65 years and older (n=725). Descriptive data was analysed with IBM SPSS Version 2.0. Ethical approval has been provided by the Medical University Graz., Results: 48% of the respondents have experience with care, 8.6% as physicians or nurses, 43.7% as family caregiver and 50% as not caring relatives. Multiple answers were possible. People with caring experience–as nurses or family caregiver–show a significantly lower approval of voluntary active euthanasia (p=0.04)., Conclusions: Care experiences have an impact on the attitude towards voluntary active euthanasia. Thus, experiences of caring should be better included in end-of-life debates.

This paper considers the problems that arise when death, which is a philosophically difficult concept, is incorporated into healthcare metrics, such as the quality-adjusted life year (QALY). These problems relate closely to the debate over euthanasia and assisted suicide because negative QALY scores can be taken to mean that patients would be 'better off dead'. There is confusion in the literature about the meaning of 0 QALY, which is supposed to act as an 'anchor' for the surveyed preferences on which QALYs are based. In the context of the debate over euthanasia, the QALY assumes an ability to make meaningful comparisons between life-states and death. Not only is this assumption questionable, but the ethical debate is much more broad than the question of whether death is preferable to a state of living. QALYs are derived from preferences about health states, so do not necessarily reflect preferences about events (eg, dying) or actions (eg, killing). This paper presents a new kind of problem for the QALY. As it stands, the QALY provides confused and unreliable information when it reports zero or negative values, and faces further problems when it appears to recommend death. This should preclude its use in the debate over euthanasia and assisted suicide. These problems only apply where the QALY involves or seems to involve a comparison between life-states and death, and are not relevant to the more general discussion of the use of QALYs as a tool for comparing the benefits derived from treatment options., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)

The Liverpool Care Pathway for the Dying Patient (LCP), a framework introduced for providing comfortable care at the last stage of life, has recently become highly contentious. Among the most serious allegations levelled against it, has been that the LCP may be used as a covert form of euthanasia by withdrawal of clinically assisted hydration (CAH). This concern has been raised, in particular by a number of Catholic medical professionals, who have asserted that the LCP is incompatible with Catholic ethics. This paper examines the key Catholic ethical principles relevant to treatment and care towards the end of life (the sanctity/inviolability of life principle, the distinction between ordinary and extraordinary means). Relevant current clinical evidence regarding CAH in relation to terminal thirst, dehydration, prolongation of life and possible negative impacts on the dying is also scrutinised. It is argued that for some patients at the very end of life it may be permissible and even desirable to withhold or withdraw it. Thus, as administration of CAH may become extraordinary, forgoing it in some situations is fully compatible with Catholic ethics. The article therefore concludes that the stance of the LCP in respect of provision of CAH is fully in alignment with Catholic teaching., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)

Belgium has recently extended its euthanasia legislation to minors, making it the first legislation in the world that does not specify any age limit. I consider two strands in the opposition to this legislation. First, I identify five arguments in the public debate to the effect that euthanasia for minors is somehow worse than euthanasia for adults--viz, arguments from weightiness, capability of discernment, pressure, sensitivity and sufficient palliative care--and show that these arguments are wanting. Second, there is another position in the public debate that wishes to keep the current age restriction on the books and have ethics boards exercise discretion in euthanasia decisions for minors. I interpret this position on the background of Velleman's 'Against the Right to Die' and show that, although costs remain substantial, it actually can provide some qualified support against extending euthanasia legislation to minors., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)

Objective: To assess Dutch pediatricians' views on neuromuscular blockers for dying neonates., Study Design: Qualitative study involving in-depth interviews with 10 Dutch pediatricians working with severely ill neonates. Data were analyzed using appropriate qualitative research techniques., Result: Participants explained their view on neuromuscular blockers for neonates with a protracted dying process. Major themes were the interpretation of gasping, the role of (the suffering of) the parents, the need for judicial review and legislation's impact on the care participants provide for dying neonates., Conclusion: The interviews show no consensus between pediatricians and provide insights into the points of disagreement. Interviews also suggest friction between the convictions of pediatricians and legislation, which seems to have an undesirable impact on Dutch care for dying neonates and their parents. This study raises important questions for pediatricians worldwide to reflect upon, such as: 'what constitutes 'dying well'?' and 'what role should the parents' perspective play?'.

In this article we will be arguing in favour of legislating to protect doctors who bring about the deaths of PVS patients, regardless of whether the death is through passive means (e.g. the discontinuation of artificial feeding and respiration) or active means (e.g. through the administration of pharmaceuticals known to hasten death in end-of-life care). We will first discuss the ethical dilemmas doctors and lawmakers faced in the more famous PVS cases arising in the US and UK, before exploring what the law should be regarding such patients, particularly in Australia. We will continue by arguing in favour of allowing euthanasia in the interests of PVS patients, their families, and finally the wider community, before concluding with some suggestions for how these ethical arguments could be transformed into a set of guidelines for medical practice in this area.

Nowadays, most of the deaths in neonatal ages take place in neonatal intensive care units and a significative number of these are involved in decisions of withholding or withdrawing medical care. The growing complexity of the health care in neonatal settings entails that end-of-life decision-making occurs more frequently. Personal views and attitudes on the best care of the severely ill newborns can be different, since to define objectively the ″best interests″ for the infant is not easy at all. The question of how to best care for such infants is ongoing, and there remain deep divisions within the field. The aim of this issue is to review the different criteria used in the western world, Europe, especially in the Netherlands, and the EEUU and the current debate on neonatal euthanasia. Poor vital prognosis, current and future quality of life and, after the Groningen protocol, unbearable suffering are the criteria commonly used in neonatal end-of-life decisions, including euthanasia. It is necessary to distinguish the decisions, in which euthanasia is chosen, of which they are an appropriate limit of therapeutic effort.

Since its inceptions, the standard of best interest of the child was linked to decisions about suspend life-sustaining treatments in neonatal units and evaluation of treatments applied to children in terms of their quality of life. This origin has conditioned the interpretation of the standard from two extremes: a vitalistic one, and a non vitalistic interpretation that triumphed in Western bioethics and has led to the consecration of the standard of best interest of the child in the Convention on the Rights of the Child of United Nations. A detailed analysis reveals a simplistic, utilitarian and proportionalist standard, which change the basis of parenthood. We therefore believe that the standard of the best interest of the child is not the best for the child in neonatal intensive care units and especially not in the process of withhold or withdrawal life-sustaining treatments.

Introduction: Most physicians are against active euthanasia. Very little is known about the possible changes in the attitudes of physicians., Methods: A questionnaire was sent to a random sample of 1003 Finnish physicians of working age. A similar questionnaire had been sent to a random sample of Finnish physicians also in 1993 and 2003. The questionnaire consisted of statements about euthanasia, for which the participants were asked to express their agreement or disagreement on a 5-point Likert scale., Results: In general, Finnish physicians' attitudes towards active euthanasia have become considerably more positive. In 2003, 61% of the respondents were against the legalisation of euthanasia and 29% supported it. In 2013, both groups were of equal size (46%). The willingness to perform active euthanasia has not, however, increased significantly, even in a legalised setting., Conclusions: The attitudes of Finnish physicians towards active euthanasia became considerably more positive between 2003 and 2013. There was no significant change, however, in the willingness to practice euthanasia if it became legal., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)

Objective: To determine how uniformly Support and Consultation on Euthanasia in the Netherlands (SCEN) doctors assess a euthanasia request in patients not in the final stages of a terminal illness., Design: Qualitative research., Method: Internal survey among SCEN doctors in the 'SCEN-Drenthe' peer group, who were asked to provide an opinion on the requirements of due care, items a to d, of the Termination of life on request and assisted suicide act (WTL) in three fictitious patients., Results: Sixty assessments were received from 20 SCEN physicians. Half of the reviews were assessed as 'due care requirements not met". 45% of these were for a patient whose request was based on the grounds of a "completed life", 50% for a patient with Alzheimer's, and 55% for a patient with a reduced level of consciousness. Uncertainty about the place of Article 2.2 of the WTL, personal assessment of the unbearable nature of hopeless suffering and the rejection of alternative solutions were responsible for the heterogeneous assessments., Conclusion: Uniformity of assessment is important to avoid legal disparity in this patient group. We found no medical or ethical benchmarks for determining the unbearable nature of suffering. A verifying assessment by the SCEN physician can only provide an opinion regarding the presence of hopeless pain that is classified as "unbearable". A negative SCEN assessment undermines a person's sense of justice at a difficult time, while the hopeless suffering may well be accepted as unbearable in comparable cases. Adapting the KNMG "Guidelines on euthanasia for patients in a state of reduced consciousness" so that they are in line with the WTL could also contribute to greater uniformity.

This paper summarises the features of my paper, 'Voluntary Active Euthanasia', and a later jointly authored paper, 'Moral Fictions', which I believe are examples of good medical ethics., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)

The Rule of Double Effect (RDE) holds that it may be permissible to harm an individual while acting for the sake of a proportionate good, given that the harm is not an intended means to the good but merely a foreseen side-effect. Although frequently used in medical ethical reasoning, the rule has been repeatedly questioned in the past few decades. However, Daniel Sulmasy, a proponent who has done a lot of work lately defending the RDE, has recently presented a reformulated and more detailed version of the rule. Thanks to its greater precision, this reinvented RDE avoids several problems thought to plague the traditional RDE. Although an improvement compared with the traditional version, we argue that Sulmasy's reinvented RDE will not stand closer scrutiny. Not only has the range of proper applicability narrowed significantly, but, more importantly, Sulmasy fails to establish that there is a morally relevant distinction between intended and foreseen effects. In particular, he fails to establish that there is any distinction that can account for the alleged moral difference between sedation therapy and euthanasia., (© 2012 John Wiley & Sons Ltd.)

The passive form of euthanasia is legalized almost in every civilized country. Its active form is not a generally accepted legal institution. In Europe, active euthanasia is legalized only in The Netherlands, Belgium, Luxembourg and Switzerland. In Australia, the Act on the Rights of the Terminally Ill of 1995 legalized the institution of assisted suicide, which is not identical to active euthanasia. The difference lies in the fact that legalized active euthanasia means that the author of a murder is not punishable (under certain circumstances), whilst assisted suicide is not about murder, rather about suicide. In the first case, the patient is killed on his or her request by someone else. In the second case, the patient himself or herself executes the act of self-killing (by the assistance of a healthcare worker). In Australia, the institution of assisted suicide was repealed in 1997. Assisted suicide is legal in four USA member states: in Vermont, Washington, Montana and Oregon. In Uruguay, the active form of euthanasia has been legal since 1932.

The fact of "being mortal" and mortality are of an existential meaning for every human being. The knowledge of death and the imagination of a finiteness of life have a crucial impact on the whole life. Today it has become a common approach to plan death, to organize and to regulate it. We tend to reduce death to a duty of management. With this rationalization of death we try to get within distance of it. Active euthanasia and assisted suicide seem to be the adequate answers to this approach but is death really well understood if we only try to handle it this way? Is autonomy really the only relevant principle to respect the concerns of dying individuals or desperate people who want to die? This contribution pleads for an emphasis on a new ethics of caring, because a truly human medicine is not possible without caring. It shows that care does not necessarily get in conflict with autonomy but that it is the prerequisite for autonomy.

Patient organizations are increasingly involved in national and international bioethical debates and health policy deliberations. In order to examine how and to what extent cultural factors and organizational contexts influence the positions of patient organizations, this study compares the positions of German and Israeli patient organizations (POs) on issues related to end-of-life medical care. We draw on a qualitative pilot study of thirteen POs, using as a unit of analysis pairs comprised of one German PO and one Israeli PO that were matched on the basis of organizational category. Bioethical positions that emanated from the interviews concerned advance directives--general views, recent legal framework, and formalization; as well as active and passive euthanasia, withholding and withdrawing of treatment, and physician-assisted suicide. In addition to the unifying, within-country impact of cultural factors, we found that constituency-based organizations and partner organizations in both countries often share common views, whereas disease-based support organizations have very heterogeneous positions. We conclude by discussing how organizational contexts provide a source of uniformity as well as diversity in the positions of POs.

Aim: To explore the views in non-Western cultures about ending the lives of damaged newborns., Method: 254 university students from India and 150 from Kuwait rated the acceptability of ending the lives of newborns with genetic defects in 54 vignettes consisting of all combinations of four factors: gestational age (term or 7 months); severity of genetic defect (trisomy 21 alone, trisomy 21 with serious morphological abnormalities or trisomy 13 with impending death); the parents' attitude about prolonging care (unknown, in favour or opposed); and the procedure used (withholding treatment, withdrawing it or injecting a lethal substance)., Results: Four clusters were identified by cluster analysis and subjected to analysis of variance. Cluster I, labelled 'Never Acceptable', included 4% of the Indians and 59% of the Kuwaitis. Cluster II, 'No Firm Opinion', had little variation in rating from one scenario to the next; it included 38% of the Indians and 18% of the Kuwaitis. In Cluster III, 'Parents' Attitude+Severity+Procedure', all three factors affected the ratings; it was composed of 18% of the Indians and 16% of the Kuwaitis. Cluster IV was called 'Severity+Parents' Attitude' because these had the strongest impact; it was composed of 40% of the Indians and 7% of the Kuwaitis., Conclusions: In accordance with the teachings of Islam versus Hinduism, Kuwaiti students were more likely to oppose ending a newborn's life under all conditions, Indian students more likely to favour it and to judge its acceptability in light of the different circumstances.

Objective: Altruism is arguably the quintessential moral trait, involving willingness to benefit others and unwillingness to harm them. In this study, I explored how altruism and other personality variables relate to acceptance of euthanasia. In addition, I investigated the role of culture in attitudes to subcategorical distinctions of euthanasia., Methods: 190 Iranian students completed the Attitude Towards Euthanasia scale, the HEXACO Personality Inventory-Revised, and an interest in religion measure., Results: Higher scores on altruism, Honesty-Humility, Agreeableness, Conscientiousness and religiousness were associated with viewing euthanasia as unacceptable. As expected, altruism explained unique variance in euthanasia attitude beyond gender, religiosity and broad personality factors., Conclusions: Cultural and individual differences should be taken into consideration in moral psychology research and end-of-life decision-making.

Introduction: Prematurity is one of the etiologies for severe neurological complications. Decisions to withdraw therapeutics, including artificial nutrition and hydration (ANH), are sometimes discussed. But can one withdraw ANH if the patient is a child suffering from severe neurological conditions, based on his best interests? The aim of this study was to further the understanding of the complexity of the withdrawal of ANH and its implementation in the neonatal intensive care unit (NICU)., Method: This qualitative preliminary study based on a questionnaire was conducted on the staff in the NICU of the Pontoise medical center (France) in February 2012. The results were compared with the current knowledge on this issue and sociological data., Results: Ten of the hospital staff members responded to the questionnaire: 60% considered ANH as a treatment, but the status of ANH (i.e., treatment or care) remained undefined for several respondents. Comparison with the withdrawal of mechanical ventilation or adult practices seemed to be inadequate. The staff had little experience in the domain and therefore few certainties on practices. Half of the respondents indicated that terminal sedation needed to be used. For the other half, it depended on the patient's pain. Timing was also an important notion given that the newborn is a being developing and evolving each in its own way., Conclusion: The withdrawal of ANH remains controversial in the NICU. Humanity, culture, and the relationship to others are ever present in the decision-making process, creating a moral opposition above and beyond ethical reflection., (Copyright © 2013 Elsevier Masson SAS. All rights reserved.)

Recently, organ donation after euthanasia has been a topic of discussion in the Dutch media and scientific literature. Unfortunately, both the articles in question and the media interviews contained several unsubstantiated statements. This article describes the background of organ donation after euthanasia and refutes some of the recent statements. It discusses why it is expected that organ donation after euthanasia will result in a far fewer additional organ donors that originally stated. In conclusion, euthanasia is a topic that should be handled with great care.

Background: It is a matter of debate whether euthanasia should be part of medical practice., Objectives: The current study investigates the attitudes of bereaved family members of cancer patients towards euthanasia., Materials and Methods: We conducted a survey with 211 people who had recently lost a close relative to cancer. Participants were asked whether euthanasia should be part of medical practice.Two logistic regression models were calculated in order to determine the factors influencing the attitude towards active euthanasia and assisted suicide., Results: About 70% and 75% of the respondents approved active euthanasia and assisted suicide, respectively. Religious denomination and psychological distress had a significant impact on the attitude towards active euthanasia. About 10%of the deceased patients had asked for active euthanasia., Conclusions: There was no difference between bereaved family members and the general population regarding the acceptance of euthanasia. Attitudes towards active euthanasia are associated with psychological distress and shaped by cultural values rather than by the experience of end-of-life care.

There is a continuing intense medico-ethico-legal debate around legalized euthanasia and physician assisted suicide such that ethically informed clinicians often agree with the arguments but feel hesitant about the conclusion, especially when it may bring about a change in law. We argue that this confusion results from the convergence of two continua that underpin the conduct of a clinician and are especially prominent in psychiatry. The two continua concern the duty of care and the importance of patient autonomy and they do not quite map into traditional divides in debates about sanctity of life, paternalism, and autonomy. As ethical dimensions, they come into sharp focus in the psychological complexities of end-of-life care and they form two key factors in most ethical and legal or disciplinary deliberations about a clinician's actions. Whereas both dimensions are important when a clinician reflects on what s/he has done or should do, they need careful balancing in a request for euthanasia or physician assisted suicide where the patient wants to take a decisive role in his or her own end-of-life care. However, end-of-life is also a situation where clinicians often encounter 'cries for help' so that both continua are importantly in play. Balancing these two continua without using blunt legal instruments is often required in psychiatric care in such a way as to problematize the idea that patient decisions should dominate the care options available. A simplistic approach to that issue arguably plays into what has been called an 'impoverished construction of life and death' and, some would say, devalues the basic commitments fundamental to medical care., (Copyright © 2013 Elsevier Ltd. All rights reserved.)

In debates about euthanasia and assisted suicide, it is rare to find an article that begins with an expression of neutral interest and then proceeds to examine the various arguments and data before drawing conclusions based upon the results of a scholarly investigation. Although authors frequently give the impression of being impartial in their introduction, they invariably reach their prior conclusions. Positions tend to be clearly dichotomized: either one believes that the practice of euthanasia or assisted suicide is totally acceptable or completely unacceptable in a just and moral society. Where there is some admission of a gray zone of incertitude, authors attempt to persuade us that their beliefs (preferences) are the only sensible way to resolve outstanding dilemmas. The practice of vehemently promoting a "pro" or "con" position may be useful when societies must decide to either legalize certain practices or not. Although only a handful of countries have thus far accepted the legal practice of euthanasia or assisted suicide (Belgium, Luxembourg, The Netherlands, the U.S. states of Montana, Oregon, Vermont and Washington, and Switzerland), scholarly articles in recent trends mainly promote legalization, to the point of recommending expansion of the current practices. Is this a case of the philosophers being ahead of their time in promoting and rationalizing the wave of the future? Alternatively, does the small number of countries that have legalized these practices indicate a substantial gap between the beliefs and desires of common citizens and the universe of the 'abstracted realm'? For the time being, what we do know is that more countries and states are debating legalization of euthanasia or assisted suicide, the nature of laws and legal practices vary greatly and both ethical and empirical assessments of current practices are the subject of much controversy. This article presents an examination of the premises and evidence in the rhetoric of assisted suicide and euthanasia. Inasmuch as any analysis cannot be totally impartial, we do not contend that our analysis is without influence from our experiences and philosophical affinities. Notwithstanding this caveat, we venture to propose that our scrutiny of the arguments and empirical data may offer some guidance to individuals who are attempting to reach practical conclusions based upon the available evidence, whether empirical or rationalized., (© 2013.)

Based on the fieldwork at two Norwegian Intensive Care Units, we wish to discuss the sometimes inconsistent manner in which death is handled, determined and made real by nurses and other healthcare personnel in high-tech hospital situations. These discrepancies draw our attention towards different ways of attending to the dying and dead and views about appropriate or inappropriate codes of professional behaviour. As we will argue below, the analytical tools developed by Annemarie Mol are useful for sharpening our understanding of the enactment of multiple ontologies of death as they are enacted within the ICU. Annemarie Mol and John Law's notion of 'ontological politics' increases our awareness about the non-arbitrary way some but not other practices are considered self-evident whereas others are denigrated as muddled and illogical., (© 2012 John Wiley & Sons Ltd.)

The objective of this paper is to understand from a sociological perspective how the moral question of euthanasia, framed as the "right to die", emerges and is dealt with in society. It takes France and Germany as case studies, two countries in which euthanasia is prohibited and which have similar legislation on the issue. I presuppose that, and explore how, each society has its own specificities in terms of practical, social and political norms that affect the ways in which they deal with these issues. The paper thus seeks to understand how requests for the "right to die" emerge in each society, through both the debate (analysis of daily newspapers, medical and philosophical literature, legal texts) and the practices (ethnographic work in three French and two German hospitals) that elucidate the phenomenon. It does so, however, without attempting to solve the moral question of euthanasia. In spite of the differences observed between these two countries, the central issue at stake in their respective debates is the question of the individual's autonomy to choose the conditions in which he or she wishes to die; these conditions depend, amongst others, on the doctor-patient relationship, the organisation of end-of-life care in hospital settings, and more generally, on the way autonomy is defined and handled in the public debate.

In The Netherlands, neonatal euthanasia has become a legal option and the Groningen Protocol contains an approach to identify situations in which neonatal euthanasia might be appropriate. In the 5 years following the publication of the protocol, neither the prediction that this would be the first step on a slippery slope, nor the prediction of complete transparency and legal control became true. Instead, we experienced a transformation of the healthcare system after antenatal screening policy became a part of antenatal care. This resulted in increased terminations of pregnancy and less euthanasia.

The problem of euthanasia emerges again and again in today's Europe. The Dutch type of regulation of euthanasia could be introduced into the Hungarian legal system. Today, in Hungary, the ethical guidelines of the chamber of medicine, the criminal law and the administrative health law also forbid active euthanasia. In Hungary, the criminal code reform of 2012 missed to liberalise the regulation of euthanasia. Such liberalisation awaits bottom-up support from the part of the society. In Europe, active euthanasia is legal only in the Netherlands, Belgium, Luxemburg and Switzerland. In Hungary, a passive form of euthanasia is legal, i.e. a dying patient may, under strict procedural circumstances, refuse medical treatment. The patient is not allowed to refuse medical treatment, if she is pregnant and foreseeably capable to give birth to her child.

This article deals with the euthanasia debate in light of new life-sustaining technologies such as the left ventricular assist device (LVAD). The question arises: does the switching off of a LVAD by a doctor upon the request of a patient amount to active or passive euthanasia, i.e. to 'killing' or to 'letting die'? The answer hinges on whether the device is to be regarded as a proper part of the patient's body or as something external. We usually regard the switching off of an internal device as killing, whereas the deactivation of an external device is seen as 'letting die'. The case is notoriously difficult to decide for hybrid devices such as LVADs, which are partly inside and partly outside the patient's body. Additionally, on a methodological level, I will argue that the 'ontological' arguments from analogy given for both sides are problematic. Given the impasse facing the ontological arguments, complementary phenomenological arguments deserve closer inspection. In particular, we should consider whether phenomenologically the LVAD is perceived as a body part or as an external device. I will support the thesis that the deactivation of a LVAD is to be regarded as passive euthanasia if the device is not perceived by the patient as a part of the body proper., (© 2011 Blackwell Publishing Ltd.)