Legal Challenges to Restrictions on Assistance in Suicide in Italy, Germany and Austria: An Ethico-Legal Analysis.

This paper deals with a series of legal cases in Italy, Germany, and Austria, between September 2019 and December 2020, which ruled that laws prohibiting or restricting assistance in suicide were unconstitutional. There are similarities between these three cases, all of which are influenced by the practice of assisted suicide in Switzerland, but also differences, not least because of the antecedent legal contexts. Each case is based on flawed reasoning. They have in common an exaggerated account of autonomy or self-determination, insufficiently qualified by the duty to protect human life or by other ethical constraints. The Italian and Austrian Courts also appeal to the principle of equality and to a supposed analogy with refusal of life-sustaining treatments, both of which raise concerns in relation to further expansion of the provisions. In responding to these flawed judgements, legislators should favour proposals that prevent the normalisation of assisted and non-assisted suicide.

Infant Male Circumcision: A Catholic Theological and Bioethical Analysis.

Infant male circumcision (IMC) has become controversial among Catholics, and many have criticized the practice of routine IMC, still widely performed in the United States. Others have gone further, claiming that circumcision has been condemned explicitly by the Church and criticizing IMC as "mutilation" and, hence, prohibited implicitly by Catholic moral principles. However, closer examination of the Catholic tradition shows that the Church regards IMC as having been a means of grace under the Old Covenant and, more importantly, in the flesh of Jesus. This positive theological account of IMC cannot be evaded by invoking a supposed historical distinction between milah (a token cut) and periah (the complete removal of the foreskin). The Church has never condemned IMC as mutilation, and while IMC carries some risk, there is no evidence that it inflicts per se disabling mutilation. A reasonable body of medical opinion regards IMC as conferring net health benefits. Summary: This paper concerns the ethics of infant male circumcision especially, though not only, as this is practiced within contemporary Judaism. This topic is examined from a Catholic ethical and theological perspective. It is found that the Church has never sought to restrict Jews from practicing circumcision and has never condemned circumcision as "mutilation." Current evidence suggests that infant male circumcision confers net health benefits. Catholic theology since the Second Vatican Council has increasingly emphasized that God's covenant with the Jewish people remains valid. It has never been revoked. This covenant includes infant male circumcision.

How Does Legalization of Physician-Assisted Suicide Affect Rates of Suicide?

OBJECTIVES: Several US states have legalized or decriminalized physician-assisted suicide (PAS) while others are considering permitting PAS. Although it has been suggested that legalization could lead to a reduction in total suicides and to a delay in those suicides that do occur, to date no research has tested whether these effects can be identified in practice. The aim of this study was to fill this gap by examining the association between the legalization of PAS and state-level suicide rates in the United States between 1990 and 2013. METHODS: We used regression analysis to test the change in rates of nonassisted suicides and total suicides (including assisted suicides) before and after the legalization of PAS. RESULTS: Controlling for various socioeconomic factors, unobservable state and year effects, and state-specific linear trends, we found that legalizing PAS was associated with a 6.3% (95% confidence interval 2.70%-9.9%) increase in total suicides (including assisted suicides). This effect was larger in the individuals older than 65 years (14.5%, CI 6.4%-22.7%). Introduction of PAS was neither associated with a reduction in nonassisted suicide rates nor with an increase in the mean age of nonassisted suicide. CONCLUSIONS: Legalizing PAS has been associated with an increased rate of total suicides relative to other states and no decrease in nonassisted suicides. This suggests either that PAS does not inhibit (nor acts as an alternative to) nonassisted suicide, or that it acts in this way in some individuals but is associated with an increased inclination to suicide in other individuals.

'Assisted dying' as a comforting heteronomy: the rejection of self-administration in the purported act of self-determination.

'Assisted dying' (an umbrella term for euthanasia and/or assisted suicide) is frequently defended as an act of autonomous self-determination in death but, given a choice, between 93.3% and 100% of patients are reluctant to self-administer (median 99.5%). If required to self-administer, fewer patients request assisted death and, of these, a sizable proportion do not self-administer but die of natural causes. This manifest avoidance runs counter to the concept of autonomous self-determination, even on the supposition that suicide could truly be autonomous. The avoidance of self-administration does not show that self-administration, when it occurs, is necessarily autonomous. It suggests, rather, that there are other frames by which assisted dying is being understood. One such is desire for medical control, a desire shared by patients and doctors. Such a frame is not directed towards an exacting autonomy (self-directed action by the patient) but towards a comforting heteronomy (letting the doctor take control).

Is there a logical slippery slope from voluntary to nonvoluntary euthanasia?

John Keown has constructed a logical slippery slope argument from voluntary euthanasia (VAE) to nonvoluntary euthanasia (NVAE). VAE if justified implies that death can be of overall benefit, in which case it should also be facilitated in those who cannot consent (NVAE). Hallvard Lillehammer asserts that Keown's argument rests on a fallacy. However, pace Lillehammer, it can be restated to escape this fallacy. Its validity is confirmed by applying to VAE some well-established general principles of medical decision making. Thus, either VAE and NVAE must be accepted together or, if NVAE is regarded as unacceptable, VAE should also be rejected.

The "special status" of the human embryo in the United Kingdom: an exploration of the use of language in public policy.

There is an apparent gap between public policy on embryo research in the United Kingdom and its ostensible justification. The rationale is respect for the "special status" of the embryo, but the policy actively promotes research in which embryos are destroyed Richard Harries argues that this is consistent because, the "special status" of the human embryo is less than the absolute status of persons. However this intermediate moral status does no evident work in decisions relating to the human embryo. Rather, public policy seems to be based on a different account of "special status": that developed by Mary Warnock. According to this, the embryo has no inherent status and the language of "special status" serves rather to accommodate the feelings of those who object to embryo research. This "emotivist" account is highly problematic, not so much for its attitude to the embryo as for its subversion of public moral reasoning.

Is the creation of admixed embryos "an offense against human dignity"?

The controversy over the creation of admixed human-nonhuman embryos, and specifically of what have been termed "cybrids," involves a range of ethical and political issues. It is not reducible to a single question. This paper focuses on one question raised by that controversy, whether creating admixed human-nonhuman entities is "an offense against human dignity. "In the last decade there has been sustained criticism of the use of the concept of human dignity within bioethics. The concept has been criticized as "vague" and "useless." Nevertheless, the concept continues to be invoked in bioethical discussion and in international instruments. This paper defends a concept of human dignity that is coherent but that is wider than contemporary post-Kantian approaches. "Human dignity" is best regarded as having a set of analogically related meanings, more than one of which is relevant to the field of bioethics. A more subtle understanding of the concept of human dignity can help identify what is ethically problematic in human-nonhuman combinations and so shed light on one aspect of the admixed embryo debate.

Sin, suffering, and the need for the theological virtues.

This article examines the account of the relationship between sin and suffering provided by J. L. A. Garcia in "Sin and Suffering in a Catholic Understanding of Medical Ethics," in this issue. Garcia draws on the (Roman) Catholic tradition and particularly on the thought of Thomas Aquinas, who remains an important resource for Catholic theology. Nevertheless, his interpretation of Thomas is open to criticism, both in terms of omissions and in terms of positive claims. Garcia includes those elements of Thomas that are purely philosophical, such as natural law and acquired virtue, but neglects the theological and infused virtues, the gifts and fruits of the Holy Spirit, and the beatitudes. These omissions distort his account of the Christian life so that he underplays both the radical problem posed by sin (and suffering), and the radical character of the ultimate solution: redemption in Christ through the grace of the Holy Spirit.

An Unholy Mess: Why 'The Sanctity of Life Principle' Should Be Jettisoned.

The aim of this article is to present an account of an important element of medical ethics and law which is widely cited but is often confused. This element is most frequently referred to as 'the principle of the sanctity of life', and it is often assumed that this language has a religious provenance. However, the phrase is neither rooted in the traditions it purports to represent nor is it used consistently in contemporary discourse. Understood as the name of an established 'principle' the 'sanctity of life' is virtually an invention of the late twentieth century. The language came to prominence as the label of a position that was being rejected: it is the name of a caricature. Hence there is no locus classicus for a definition of the terms and different authors freely apply the phrase to divergent and contradictory positions. Appeal to this 'principle' thus serves only to perpetuate confusion. This language is best jettisoned in favour of clearer and more traditional ethical concepts.

Human Dignity in Healthcare: A Virtue Ethics Approach.

The term 'dignity' is used in a variety of ways but always to attribute or recognize some status in the person. The present paper concerns not the status itself but the virtue of acknowledging that status. This virtue, which Thomas Aquinas calls 'observantia', concerns how dignity is honoured, respected, or observed. By analogy with justice (of which it is a part) observantia can be thought of both as a general virtue and as a special virtue. As a general virtue observantia refers to that respect for human dignity that is implicit in all acts of justice. As a special virtue it concerns the specific way we show esteem for people. Healthcare represents a challenge to observantia because those in need of healthcare are doubly restricted in expressing their dignity in action: in the first place by their ill health, and in the second place by the conditions required by healthcare (hence the sick are termed 'patients' rather than 'agents'). To be understood properly, especially in the context of healthcare, the virtue of observantia needs both to qualify and to be qualified by the virtue of misericordia, empathy, or compassion for affliction. The unity of the virtues requires a simultaneous recognition of the common dignity and common neediness of human existence.