The Pope and the Possibilities of the Path Less Traveled.

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.

Grave new world: The conspiracy of silence surrounding non-voluntary euthanasia.

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.

The psychological slippery slope from physician-assisted death to active euthanasia: a paragon of fallacious reasoning.

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.

Quality of Living and Dying: Pediatric Palliative Care and End-of-Life Decisions in the Netherlands.

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.

The ethics of and the appropriate legislation concerning killing people and letting them die: a response to Merkel.

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.

Good medical ethics.

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.

Finnish physicians' attitudes towards active euthanasia have become more positive over the last 10†years.

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.

Clinically assisted hydration and the Liverpool Care Pathway: Catholic ethics and clinical evidence.

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.

QALYs, euthanasia and the puzzle of death.

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.

Child euthanasia: should we just not talk about it?

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.

Should patients in a persistent vegetative state be allowed to die? Guidelines for a new standard of care in Australian hospitals.

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.

[Effects of care experience to the attitude of active euthanasia among the Austrian population­a cross sectional study]. / Auswirkungen von Pflegeerfahrung auf die Einstellung zur aktiven Sterbehilfe in der österreichischen Bevölkerung--eine Querschnittstudie.

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 experience­as nurses or family caregiver­show 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.

Attitudes towards euthanasia in Iran: the role of altruism.

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.

The acceptability among young Hindus and Muslims of actively ending the lives of newborns with genetic defects.

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.

[When letting-be is more important than actions. Plea for a new culture of dying]. / Wenn das Annehmen wichtiger wird als das Machen. Plädoyer für eine neue Kultur des Sterbens.

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.

End-of-life decisions and the reinvented Rule of Double Effect: a critical analysis.

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.

Exploring the positions of German and Israeli patient organizations in the bioethical context of end-of-life policies.

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.

[Attitudes towards euthanasia: The impact of experiencing end-of-life care]. / Einstellungen zur Sterbehilfe.Welchen Einfluss hat die Pflege eines sterbenskranken Angehörigen?

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.

[Euthanasia outside Europe]. / Eutanázia Európán kívül.

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 Groningen Protocol for newborn euthanasia; which way did the slippery slope tilt?

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.