For, against, and beyond: healthcare professionals' positions on Medical Assistance in Dying in Spain.

BACKGROUND: In 2021, Spain became the first Southern European country to grant and provide the right to euthanasia and medically assisted suicide. According to the law, the State has the obligation to ensure its access through the health services, which means that healthcare professionals' participation is crucial. Nevertheless, its implementation has been uneven. Our research focuses on understanding possible ethical conflicts that shape different positions towards the practice of Medical Assistance in Dying, on identifying which core ideas may be underlying them, and on suggesting possible reasons for this disparity. The knowledge acquired contributes to understanding its complexity, shedding light into ambivalent profiles and creating strategies to increase their participation. METHODS: We conducted an exploratory qualitative research study by means of semi-structured interviews (1 h) with 25 physicians and nurses from primary care (12), hospital care (7), and palliative care (6), 17 women and 8 men, recruited from Madrid, Catalonia, and Andalusia between March and May 2023. Interviews were recorded, transcribed, and coded in Atlas.ti software by means of thematic and interpretative methods to develop a conceptual model. RESULTS: We identified four approaches to MAiD: Full Support (FS), Conditioned Support (CS), Conditioned Rejection (CR), and Full Rejection (FR). Full Support and Full Rejection fitted the traditional for and against positions on MAiD. Nevertheless, there was a gray area in between represented by conditioned profiles, whose participation cannot be predicted beforehand. The profiles were differentiated considering their different interpretations of four core ideas: end-of-life care, religion, professional duty/deontology, and patient autonomy. These ideas can intersect, which means that participants' positions are multicausal and complex. Divergences between profiles can be explained by different sources of moral authority used in their moral reasoning and their individualistic or relational approach to autonomy. CONCLUSIONS: There is ultimately no agreement but rather a coexistence of plural moral perspectives regarding MAiD among healthcare professionals. Comprehending which cases are especially difficult to evaluate or which aspects of the law are not easy to interpret will help in developing new strategies, clarifying the legal framework, or guiding moral reasoning and education with the aim of reducing unpredictable non-participations in MAID.

[Feminist public health, another view on the pandemic.] / Por una salud pública feminista, otra lectura sobre la pandemia.

Theorists of the ethics and politics of care, with their feminist and intersectional analyses, have spent decades trying to leave their mark on clinical practice and political structures . In them, extensive processes of humanization of the relationship between professionals and people who need their care are required, without neglecting inequalities due to gender, social class or belonging to vulnerable minority groups that go through health and disease experiences in the community. society. It is evident that our institutions must be extensively rethought in their foundations; from nursing homes to highly technological ICUs; from the saturation of primary care to the lack of specialized personnel. In areas such as nursing, great emphasis is placed on models based on interdependence and the particular context to generate another care framework , while fighting for hierarchies and invisibilities related to highly feminized professions . Not surprisingly, the reflections that follow are signed by three women with hybrid profiles who have dedicated part of our working life to the field of primary and hospital care (both in nursing and in physiotherapy) and, in turn, to research and teaching in bioethics, philosophy and humanities. We have experienced in our flesh the contradictions between a will to serve and some axes of oppression connatural to the institutions.

Las teóricas de las éticas y políticas del cuidado, con sus análisis en clave feminista e interseccional, llevan décadas intentando dejar huella en la práctica clínica y en las estructuras políticas . En ellas, se requieren amplios procesos de humanización de la relación entre profesionales y personas que necesitan su atención, sin dejar de lado las desigualdades por motivos de género, clase social o pertenencia a colectivos vulnerables minoritarios que atraviesan las vivencias de salud y enfermedad en la sociedad. Es evidente que nuestras instituciones deben ser ampliamente repensadas en sus fundamentos; desde las residencias de ancianos a las UCI altamente tecnologizadas; desde la saturación de la atención primaria a la falta de personal especializado. En ámbitos como la enfermería se hace gran hincapié en los modelos basados en la interdependencia y el contexto particular para generar otro marco de asistencia , a la vez que se lucha por las jerarquías e invisibilidades relacionadas con las profesiones altamente feminizadas . No en vano las reflexiones que siguen las firman tres mujeres con perfiles híbridos que hemos dedicado parte de nuestra vida laboral al ámbito de la atención primaria y hospitalaria (tanto en enfermería como en fisioterapia) y, a su vez, a la investigación y la docencia en bioética, filosofía y humanidades. Hemos vivido en nuestras carnes las contradicciones entre una voluntad de servicio y unos ejes de opresión connaturales a las instituciones.