Facing a request for assisted death - views of Finnish physicians, a mixed method study.

BACKGROUND: Assisted death, including euthanasia and physician-assisted suicide (PAS), is under debate worldwide, and these practices are adopted in many Western countries. Physicians' attitudes toward assisted death vary across the globe, but little is known about physicians' actual reactions when facing a request for assisted death. There is a clear gap in evidence on how physicians act and respond to patients' requests for assisted death in countries where these actions are not legal. METHODS: A survey including statements concerning euthanasia and PAS and an open question about their actions when facing a request for assisted death was sent to all Finnish physicians. Quantitative data are presented as numbers and percentages. Statistical significance was tested by using the Pearson chi-square test, when appropriate. The qualitative analysis was performed by using an inductive content analysis approach, where categories emerge from the data. RESULTS: Altogether, 6889 physicians or medical students answered the survey, yielding a response rate of 26%. One-third of participants agreed or partly agreed that they could assist a patient in a suicide. The majority (69%) of the participants fully or partly agreed that euthanasia should only be accepted due to difficult physical symptoms, while 12% fully or partly agreed that life turning into a burden should be an acceptable reason for euthanasia. Of the participants, 16% had faced a request for euthanasia or PAS, and 3033 answers from 2565 respondents were achieved to the open questions concerning their actions regarding the request and ethical aspects of assisted death. In the qualitative analysis, six main categories, including 22 subcategories, were formed regarding the phenomenon of how physicians act when facing this request. The six main categories were as follows: providing an alternative to the request, enabling care and support, ignoring the request, giving a reasoned refusal, complying with the request, and seeing the request as a possibility. CONCLUSIONS: Finnish physicians' actions regarding the requests for assisted death, and attitudes toward euthanasia and PAS vary substantially. Open discussion, education, and recommendations concerning a request for assisted death and ethics around it are also highly needed in countries where euthanasia and PAS are not legal.

Euthanasia and End-of-Life Decisions: From the Empirical Turn to Moral Intuitionism.

Most medical learned societies have endorsed both "equivalence" between all forms of withholding or withdrawing treatment and the "discontinuity" between euthanasia and practices to withhold or withdraw treatment. While the latter are morally acceptable insofar as they consist in letting the patient die, the former constitutes an illegitimate act of actively interfering with a patient's life. The moral distinction between killing and letting die has been hotly debated both conceptually and empirically, most notably by experimental philosophers, with inconclusive results. This article employs a "revisionary" intuititionist perspective to discuss the results of a clinical ethics study about intensivists' perceptions of withhold or withdraw decisions. The results show that practitioners' moral experience is at odds with both the discontinuity and equivalence theses. This outcome allows us to revisit certain concepts, such as intention and causal relationship, that are prominent in the conceptual debate. Intensivists also regard end-of-life decisions as being on a scale from least to most active, and whether they regard active forms of end-of-life decisions as ethically acceptable depends on the overarching professional values they endorse: the patient's best chances of survival, or the patient's quality of life.

[Euthanasia: a wrong solution to an unrecognized problem?] / Eutanasia: ¿una solución equivocada a un problema no reconocido?

Organic Law 3/2021, of March 24, regulating euthanasia, has intensified a harsh debate. A priori, it is a conflict of bioethical values and a different anthropological vision between the different parties, however, we must not forget that perhaps before considering any debate, it is necessary to correctly interpret what the patient really wants when he states that he wants to die. In our health system and in our society, there are certain traits and needs of the person that are ignored, and that urgently require attention for the patient. Discovering the meaning of one's life, considering human transcendence, finding personal order and being able to experience love are vital elements of life, which at such a critical moment as high-grade suffering or imminent death, require all the attention of the health personnel. All this can contrast sharply with the values of our society, not dedicating adequate attention to it, among other reasons, due to the effort involved in carrying out comprehensive care of this type, thus making it much easier to carry out the procedures required by law regulation of euthanasia than addressing such intimate deficiencies of the being, despite the fact that these may be the real problem of the patient, who in his dramatic experience asks for help.

A Systematic Review of Stakeholder Perspectives of Dignity and Assisted Dying.

INTRODUCTION: The debate on assisted dying and its components, euthanasia and physician-assisted suicide has evolved with the emergence of the right to dignity and the wish to hasten death (WTHD). Whilst shaped by local legal and sociocultural considerations, appreciation of how patients, healthcare professionals and lawmakers relate notions of dignity to self-concepts of personhood and the desire for assisted dying will better inform and direct support of patients. METHODS: Guided by the Systematic Evidence Based Approach, a systematic scoping review (SSR in SEBA) on perspectives of dignity, WTHD and personhood featured in PubMed, Embase, PsycINFO, Cochrane Database of Systematic Reviews, CINAHL, Scopus databases and four key Palliative Care journals was conducted. The review hinged on the following questions: "what is the relationship between dignity and the wish to hasten death (WTHD) in the assisted dying debate?", "how is dignity conceptualised by patients with WTHD?" and "what are prevailing perspectives on the role of assisted dying in maintaining a dying patient's dignity?" RESULTS: 6947 abstracts were identified, 663 full text articles reviewed, and 88 articles included. The four domains identified include 1) concepts of dignity through the lens of the Ring Theory of Personhood (RToP) including their various definitions and descriptions; 2) the relationship between dignity, WTHD and assisted dying with loss of dignity and autonomy foregrounded; 3) stakeholder perspectives for and against assisted dying including those of patient, healthcare provider and lawmaker; and 4) other dignity-conserving measures as alternatives to assisted dying. CONCLUSION: Concepts of dignity constantly evolve throughout the patient's end of life journey. Understanding when and how these concepts of personhood change and trigger the fear of a loss of dignity or intractable suffering could direct timely, individualised and appropriate person-centred dignity conserving measures. We believe an RToP-based tool could fulfil this role and further study into the design of this tool is planned.

Algunos aspectos esenciales para el enfoque bioético de la eutanasia / Some Essential Aspects for a Bioethical Approach to Euthanasia

Introducción: Aunque la vida es un valor moral que ha de ser respetado por encima de todo, la Eutanasia se continúa practicando hoy día en muchos países, y con ello persisten discrepancias en torno a su enfoque bioético. Objetivos: Describir algunos aspectos históricos, legales y conceptuales esenciales relacionados con la eutanasia, como posibles aristas a tomar en cuenta para su enfoque bioético. Métodos: Se realizó un estudio de revisión descriptivo observacional con componente analítico, empleando una exhaustiva revisión bibliográfica, con el uso de los descriptores en Ciencias de la Salud: eutanasia AND ética donde se compararon las posiciones de diferentes países en torno a la eutanasia y se contrastaron conceptos como calidad de vida y su expresión en la edad pediátrica. Conclusiones: El estudio sistemático de todas las posibles aristas de la eutanasia es fundamental para lograr un adecuado enfoque bioético de la misma, lo cual contribuye a que podamos ser más consecuentes y humanistas en el momento de hacer cumplir una muerte digna(AU)

Introduction: Although life is a moral value that must be respected above anything else, euthanasia is still practiced today in many countries; with this, discrepancies persist regarding its bioethical approach. Objectives: To describe some essential historical, legal and conceptual aspects related to euthanasia, as possible aspects to take into account for its bioethical approach. Methods: An observational and descriptive review study with an analytical component was carried out, using an exhaustive bibliographic review, with the use of the following health sciences descriptors: eutanasia [euthanasia], ADN [DNA] ética [ethics]; thus, the positions of different countries regarding euthanasia were compared and some concepts were contrasted, such as quality of life and its expression in pediatric age. Conclusions: The systematic study of all the possible aspects of euthanasia is essential for achieving an adequate bioethical approach to it, which contributes to our being more consistent and humanistic when making a dignified death possible(AU)

Eutanasia, un planteo desde la perspectiva de la teoría de los principios / Euthanasia, an approach from the perspective of the theory of principles

Cuando el final de la vida acaece con manifestaciones de dolencias extremas es una de las situaciones en las cuales se debe priorizar la autonomía del paciente y respetar, como en todo momento, su dignidad. Es allí donde se expresa la palabra eutanasia, la cual proviene etimológicamente del término griego que significa "buena muerte". Esta palabra cuya definición etimológica es relativamente simple nos pone frente a dilemas que oscilan entre lo ético, lo moral, lo legal y lo social. La muerte es el resultado de la práctica de la eutanasia. Y a esta debemos analizarla como una práctica optativa en la actualidad en determinadas circunstancias y bajo el respeto de principios bioéticos respaldados legalmente. En el presente artículo se procura plasmar desde los principios bioéticos argumentos a favor y en contra de la eutanasia (AU)

When the end of life occurs with manifestations of extreme ailments, it is one of the situations in which the autonomy of the patient must be prioritized and his dignity respected, as at all times. It is there where the word euthanasia is expressed, which comes etymologically from the Greek term that means "good death". This word whose etymological definition is relatively simple puts us in front of dilemmas that oscillate between the ethical, the moral, the legal and the social. Death is the result of the practice of euthanasia. And we must analyze this as an optional practice at present in certain circumstances and under the respect of legally supported bioethical principles. This article attempts to capture from bioethical principles arguments for and against euthanasia (AU)

British laypeople's attitudes towards gradual sedation, sedation to unconsciousness and euthanasia at the end of life.

BACKGROUND: Many patients at the end of life require analgesia to relieve pain. Additionally, up to 1/5 of patients in the UK receive sedation for refractory symptoms at the end of life. The use of sedation in end-of-life care (EOLC) remains controversial. While gradual sedation to alleviate intractable suffering is generally accepted, there is more opposition towards deliberate and rapid sedation to unconsciousness (so-called "terminal anaesthesia", TA). However, the general public's views about sedation in EOLC are not known. We sought to investigate the general public's views to inform policy and practice in the UK. METHODS: We performed two anonymous online surveys of members of the UK public, sampled to be representative for key demographic characteristics (n = 509). Participants were given a scenario of a hypothetical terminally ill patient with one week of life left. We sought views on the acceptability of providing titrated analgesia, gradual sedation, terminal anaesthesia, and euthanasia. We asked participants about the intentions of doctors, what risks of sedation would be acceptable, and the equivalence of terminal anaesthesia and euthanasia. FINDINGS: Of the 509 total participants, 84% and 72% indicated that it is permissible to offer titrated analgesia and gradual sedation (respectively); 75% believed it is ethical to offer TA. Eighty-eight percent of participants indicated that they would like to have the option of TA available in their EOLC (compared with 79% for euthanasia); 64% indicated that they would potentially wish for TA at the end of life (52% for euthanasia). Two-thirds indicated that doctors should be allowed to make a dying patient completely unconscious. More than 50% of participants believed that TA and euthanasia were non-equivalent; a third believed they were. INTERPRETATION: These novel findings demonstrate substantial support from the UK general public for the use of sedation and TA in EOLC. More discussion is needed about the range of options that should be offered for dying patients.

The ongoing discussion on termination of life on request. A review from a German/European perspective.

BACKGROUND: Interest in the topic of termination of life has been growing for 2 decades. After legalisation of active euthanasia and assisted suicide (EAS) in the Netherlands in 2002, movements to implement similar laws started in other European countries. However, many people objected to legalisation on the basis of the experiences in the Netherlands and as a matter of principal. METHODS: This selected and focussed review presents the theoretical discussions about EAS and describes the respective parliamentary discussions in Germany and the data and experiences in the Netherlands. It also considers people with mental disorders in the context of termination-of-life services. RESULTS: So far, only a few European countries have introduced legislation on EAS. Legalisation of EAS in the Netherlands resulted in an unexpectedly large increase in cases. The number of people with mental disorders who terminate their lives on request remains low. CONCLUSIONS: Experience from the Netherlands shows that widening criteria for EAS has problematic consequences.KEY POINTSTermination of life on request, which a subgroup of people support, is a matter of ongoing debate.Because of several problematic aspects, including ethical considerations, only a few countries in the world allow active euthanasia or assisted suicide.Even if euthanasia is well regulated, legalising it can have problematic consequences that are difficult to control, such as an unwanted excessive increase in euthanasia cases.The well-documented experiences with the euthanasia law in the Netherlands serve as an example of what is to be expected when euthanasia is legalised.We need to pay close attention to the relationship between suicide and suicide prevention on the one hand and euthanasia acts and promotion of euthanasia on the other.Further ethical, psychological and legal research is needed. In particular, the role of palliative medicine in societies' approach to end-of-life care must be explored in much more detail.

Aspectos bioéticos de la muerte medicamente asistida y su relación con la medicina legal: revisión bibliográfica / Bioethical aspects of medically assisted death and its relationship with legal medicine: bibliographic review

Introducción: la eutanasia y el suicidio asistido son temas muy controvertidos en los que además de las consideraciones morales, las consideraciones clínicas, legales, políticas, religiosas y éticas juegan un papel importante. Objetivo: determinar los aspectos bioéticos relacionados con la eutanasia, el suicidio asistido y su relación con la medicina legal. Metodología: se realizó una búsqueda en las bases de datos Ibecs, Pubmed, Medline y LILACS sobre "aspectos bioéticos de la eutanasia, el suicidio asistido y su relación con la medicina forense". Las palabras clave fueron: Muerte asistida, Suicidio asistido, Bioética, Eutanasia y Medicina legal. Se revisaron artículos relevantes al tema en inglés y español, procedentes de los países de España, Italia, Suiza, India, Alemania, Colombia, Chile, Brasil, Argentina, Venezuela, Uruguay, Perú, México, Estados Unidos de Norte América y Canadá. Resultados: se encontraron 111 artículos; 34 fueron incluidos en esta revisión, en IBECS se encontraron 29, 12 seleccionados y 17 descartados. PubMed se encontraron 45 artículos, 13 fueron seleccionados y 32 descartados. Medline se encontraron cinco artículos, uno fue seleccionado y cuatro descartados. LILACS se encontraron 32 artículos, ocho seleccionados y 24 descartados. Además, se incluyeron siete fuentes adicionales: cuatro libros y tres códigos hondureños. Conclusión: Los aspectos bioéticos relacionados con la eutanasia, el suicidio asistido no son temas ampliamente discutidos, sin embargo, en las legislaciones de Holanda, y Suiza es obligatorio la investigación y el análisis forense para la toma de decisiones en casos específicos, apegados a los aspectos bioéticos y legales que beneficien al paciente...(AU)

Euthanasia: trends and opinions in Spain.

OBJECTIVE: Analyse the evolution of opinions about euthanasia by the general public and clinical physicians from 1995 to 2019 and their influence at the present time. MATERIAL AND METHOD: Bibliographical review based on relevance and quality of publications in open access and academic access platforms. Main surveys review of public and private institutions. Congress and Senate Official Journal Sessions. RESULTS: Recent surveys show that clinicians support the regulation of euthanasia. This position matches the general public's belief, which has grown steadily in recent decades. DISCUSSION: Social and clinical support for the regulation of euthanasia has been fundamental. In the last two decades political parties have changed their positions, thus creating a window of opportunity.

Agency, Autonomy and Euthanasia.

Agency is the human capacity to freely choose one's thoughts, motivations and actions without undue internal or external influences; it is distinguished from decisional capacity. Four well-known conditions that can deeply affect agency are depression, demoralization, existential distress, and family dysfunction. The study reviews how they may diminish agency in persons whose circumstances may lead them to consider or request euthanasia or assisted suicide. Since agency has been a relatively neglected dimension of autonomous choice at the end of life, it is argued that to respect the autonomy of individuals, it is essential to establish their agency.

Chapter 6. French and Chinese regulatory approaches to end-of-life and euthanasia.

For patients in critical or terminal situations, the approach to death is a situation that raises many ethical and legal issues of importance. Health professionals and families of the person at the end-of-life are obviously at the forefront of the concerns generated by these situations, all wishing to act in the best interest of the patient. Some States have regulated the various situations encountered on the ground in order to provide stakeholders with clear and appropriate procedures to ensure human dignity in practice by elaborating the rules of an end-of-life ethics aimed at supporting health professionals involved in carrying out certain acts while setting limits in respect of the persons concerned. What are the alternatives? Is euthanasia tolerable? What role for health professionals? And for the family? The content of the regulations differs according to countries, to cultural sensitivities and ethical and legal traditions, like the political will to regulate this topic. The regulatory experience of countries like France and China can be useful to other countries and serve as a basis for discussing the topic. Therefore, we analyze the current French framework and the situation in China in order to highlight main elements of ethical discussions, adopted positions and rules, eventual joint considerations, remaining issues and challenges in a comparative approach.

[Forensic implications of humane self-chosen death in the Netherlands]. / Zelfgekozen levenseinde: een forensisch dilemma.

Euthanasia is legal in the Netherlands. Nevertheless, some individuals decide to plan their self-chosen death without the help of a physician. 'Right-to-die' organisations provide advice about humane deaths, which include voluntary refusal of food and fluids, the helium method and use of a lethal overdose of medication. It is known that suicides are sometimes influenced by the media and internet. Since 2013, 'right-to-die' organisations have informed individuals about the use of a deadly barbiturate overdose and the helium method. A rise in suicides resulting from these methods has subsequently been observed in the Netherlands. Suicides are recorded as deaths resulting from unnatural causes and are therefore investigated by a forensic physician, forensic investigator and tactical investigator. Investigation should determine the cause of death and rule out a staged crime, 'criminal' assisted suicide or an accident.

[Moral case deliberation in complex euthanasia requests]. / Moreel beraad bij complexe euthanasieverzoeken.

Dealing with euthanasia requests can be a complex matter for a doctor. How to determine whether the due diligence criteria of the Dutch Euthanasia Act are met in cases that are not straightforward? We argue that moral case deliberation (MCD), methodically structured reflective discussions on concrete moral dilemmas, can provide support in dealing with complex euthanasia requests. In this article, we discuss a case that was talked about during a MCD (in particular the CURA method, where CURA stands for 'concentrating, postponing, reflecting and action') by a group of GPs and nurses who met in the context of a network for ambulatory palliative care.This was about an older patient with multiple chronic conditions who lost any prospects of quality of life.Among other things, it was examined whether requests could be 'well-considered' (one of the due diligence criteria) when the patients are in doubt as to when euthanasia should be carried out.The importance of recognising one's own emotions as a doctor and the quality of communication between patient and doctor were also considered.For that reason, we try to show that MCD can assist in making careful and well-considered decisions when determining a course of action in the case of complex euthanasia requests and can encourage collaborative learning processes.

[Choosing for euthanasia in advanced dementia; an analysis of the decisions by the Supreme Court]. / Euthanasie bij gevorderde dementie.

For many yearsthere has been confusion in the Netherlands about the question of whether doctors are entitled to end the life of incompetent patients with advanced dementia. The euthanasia control commission, the disciplinary courts and the penal court all answered this question differently after a doctor had performed euthanasia on a 74-year-old woman with advanced dementia and an advance directive made at an earlier stage. On 21 April 2020 the Supreme Court provided clarity, at least to a certain extent. This contribution presents an analysis of the decisions made by the Supreme Court and their implications for self-chosen death in patients with advanced dementia.

Indeterminacy of identity and advance directives for death after dementia.

A persistent question in discussions of the ethics of advance directives for euthanasia is whether patients who go through deep psychological changes retain their identity. Rather than seek an account of identity that answers this question, I argue that responsible policy should directly address indeterminacy about identity directly. Three sorts of indeterminacy are distinguished. Two of these-epistemic indeterminacy and metaphysical indeterminacy-should be addressed in laws/policies regarding advance directives for euthanasia.