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 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.

Stopping Eating and Drinking by Advance Directives (SED by AD) in Assisted Living and Nursing Homes.

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.

[To act or not to act? Developments in prenatal and postnatal care for children with spina bifida aperta]. / Handelen of niet handelen?

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.

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.

Euthanasia and assisted dying: what is the current position and what are the key arguments informing the debate?

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.

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.

Dutch Protocols for Deliberately Ending the Life of Newborns: A Defence.

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.

[Assessing unbearable suffering in relation to euthanasia]. / Beoordeling ondraaglijk lijden bij euthanasieverzoek.

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.

Pediatric Euthanasia and Palliative Care Can Work Together.

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.

[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.

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.

[Analysis of the Debate on Neonatal Euthanasia Using Present Bioethical Literature]. / Análisis del Debate Sobre la Eutanasia Neonatal a Través de la Literatura Actual.

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.

[The Best Interest of the Child in Neonatology: Is It Best for the Child?]. / El Mejor Interés del Niño en Neonatología: ¿Es lo Mejor para el Niño?

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.

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.

[Assessment of euthanasia request by SCEN physicians]. / Beoordeling van euthanasieverzoek door SCEN-artsen.

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.