Morphological Homogeneity and Interface Modification as Determinant Factors of the Efficiency and Stability for Upscaling Organic Solar Cell.

Morphological homogeneity and interfacial traps are essential issues to achieve high-efficiency and stable large-area organic solar cells (OSCs). Herein, by the investigation of three quinoxaline-based acceptors, i.e., PM6:Qx-1, PM6:Qx-2, and PM6:Qx-p-4Cl, the performance degradation in up-scaling OSCs is explored. The inhomogeneous morphology in PM6:Qx-2 induces a nonuniform spatial distribution of charge generation, showing a rapid decline in efficiency and stability in large-area OSCs. In comparison, the homogeneous morphology in PM6:Qx-1 and PM6:Qx-p-4Cl alleviates the stability drop. When utilizing 2-phenylethylmercaptan to fill the interfacial traps, the stability drop disappears for PM6:Qx-1 and PM6:Qx-p-4Cl, while it persists for PM6:Qx-2. The PM6:Qx-1 large-are device yields a high efficiency of 13.47% and superior thermal stability (T80 = 2888 h). Consequently, the interface modification dominates the performance degradation of large-area devices with homogeneous morphology, while it cannot eliminate the traps in inhomogeneous film. These results provide a clear understanding of degradation mechanisms in upscaling devices.

Widespread habitat loss leads to ecosystem-scale decrease in trophic function.

Natural and anthropogenic disturbances have led to rapid declines in the amount and quality of available habitat in many ecosystems. Many studies have focused on how habitat loss has affected the composition and configuration of habitats, but there have been fewer studies that investigate how this loss affects ecosystem function. We investigated how a large-scale seagrass die-off altered the distribution of energetic resources of three seagrass-associated consumers with varied resource use patterns. Using long-term benthic habitat monitoring data and resource use data from Bayesian stable isotope mixing models, we generated energetic resource landscapes (E-scapes) annually between 2007 and 2019. E-scapes link the resources being used by a consumer to the habitats that produce those resources to calculate a habitat resource index as a measurement of energetic quality of the landscape. Overall, our results revealed that following the die-off there was a reduction in trophic function across all species in areas affected by the die-off event, but the response was species-specific and dependent on resource use and recovery patterns. This study highlights how habitat loss can lead to changes in ecosystem function. Incorporating changes in ecosystem function into models of habitat loss could improve understanding of how species will respond to future change.

Robot-assisted laparoscopy does not have demonstrable advantages over conventional laparoscopy in endometriosis surgery: a systematic review and meta-analysis.

BACKGROUND: Endometriosis is a chronic condition affecting 6-10% of women of reproductive age, with endometriosis-related pain and infertility being the leading symptoms. Currently, the gold standard treatment approach to surgery is conventional laparoscopy (CL); however, the increasing availability of robot-assisted surgery is projected as a competitor of CL. This study aimed to compare the perioperative outcomes of robot-assisted laparoscopy (RAL) and CL in endometriosis surgery. OBJECTIVES: We aimed to compare the effectiveness and safety of these two procedures. METHODS: A systematic search was conducted in three medical databases. Studies investigating different perioperative outcomes of endometriosis-related surgeries were included. Results are presented as odds ratios (OR) or mean differences (MD) with 95% confidence intervals (CI). RESULTS: Our search yielded 2,014 records, of which 13 were eligible for data extraction. No significant differences were detected between the CL and RAL groups in terms of intraoperative complications (OR = 1.07, CI 0.43-2.63), postoperative complications (OR = 1.3, CI 0.73-2.32), number of conversions to open surgery (OR = 1.34, CI 0.76-2.37), length of hospital stays (MD = 0.12, CI 0.33-0.57), blood loss (MD = 16.73, CI 4.18-37.63) or number of rehospitalizations (OR = 0.95, CI 0.13-6.75). In terms of operative times (MD = 28.09 min, CI 11.59-44.59) and operating room times (MD = 51.39 min, CI 15.07-87.72;), the RAL technique remained inferior. CONCLUSION: RAL does not have statistically demonstrable advantages over CL in terms of perioperative outcomes for endometriosis-related surgery.

The state of transience, and its influence on the wish to die of advanced disease patients: insights from a qualitative phenomenological study.

BACKGROUND: The experience of Wish to Die is common in patients living with Advanced Disease. It has been studied worldwide and qualitative studies have contributed to the understanding of the complexity of the phenomenon of the WTD but a deeper understanding on the individual's views is still needed. The objective of this study was to identify common characteristics of the experience of wish to die in advanced disease. METHODS: A phenomenological study was carried out with multicenter participation of patients with advanced disease who had expressed their wish to die to health professionals. Semi-structured interviews were employed to obtain an in-depth perspective of each patient's lived experience. A phenomenological analysis of the data collected was performed to describe and explore the characteristic aspects of the phenomenon under study. RESULTS: Fourteen patients with advanced disease were interviewed. Most of them had cancer. In the analysis of the patients' accounts of their experiences, three common characteristics were identified: a) experiencing a state of transience; b) the attempt to reconnect with oneself; and c) additional disease-related aspects that influence the wish to die. Patients expressed the need for a safe space to address the wish to die and the importance of receiving care that considers both 'being' and 'doing'. CONCLUSIONS: Patients with advanced disease and wish to die experience a state of transience where the patient lives and ephemeral state of existence. Interventions focused on reinforcing the intrinsic value of the individual emerge as essential components of a compassionate accompaniment of those facing the wish to die.

A bioethical perspective on the meanings behind a wish to hasten death: a meta-ethnographic review.

BACKGROUND: The expressions of a "wish to hasten death" or "wish to die" raise ethical concerns and challenges. These expressions are related to ethical principles intertwined within the field of medical ethics, particularly in end-of-life care. Although some reviews were conducted about this topic, none of them provides an in-depth analysis of the meanings behind the "wish to hasten death/die" based specifically on the ethical principles of autonomy, dignity, and vulnerability. The aim of this review is to understand if and how the meanings behind the "wish to hasten death/die" relate to and are interpreted in light of ethical principles in palliative care. METHODS: We conducted a meta-ethnographic review according to the PRISMA guidelines and aligned with Noblit and Hare's framework. Searches were performed in three databases, Web of Science, PubMed, CINAHL, with no time restrictions. Original qualitative studies exploring the meanings given by patients, family caregivers and healthcare professionals in any context of palliative and end-of-life care were included. A narrative synthesis was undertaken. PROSPERO registration CRD42023360330. RESULTS: Out of 893 retrieved articles, 26 were included in the analysis, accounting for the meanings of a total of 2,398 participants. Several factors and meanings associated with the "wish to hasten death" and/or "wish to die" were identified and are mainly of a psychosocial and spiritual nature. The ethical principles of autonomy and dignity were the ones mostly associated with the "wish to hasten death". Ethical principles were essentially inferred from the content of included articles, although not explicitly stated as bioethical principles. CONCLUSIONS: This meta-ethnographic review shows a reduced number of qualitative studies on the "wish to hasten death" and/or "wish to die" explicitly stating ethical principles. This suggests a lack of bioethical reflection and reasoning in the empirical end-of-life literature and a lack of embedded ethics in clinical practice. There is a need for healthcare professionals to address these topics compassionately and ethically, taking into account the unique perspectives of patients and family members. More qualitative studies on the meanings behind a wish to hasten death, their ethical contours, ethical reasoning, and implications for clinical practice are needed.

Circadian Activity Rhythms and Psychopathology in Major Depressive Episodes.

BACKGROUND: Identifying suicidal risk based on clinical assessment is challenging. Suicidal ideation fluctuates, can be downplayed or denied, and seems stigmatizing if divulged. In contrast, vitality is foundational to subjectivity in being immediately conscious before reflection. Including its assessment may improve detection of suicidal risk compared to relying on suicidal ideation alone. We hypothesized that objective motility measures would be associated with vitality and enhance assessment of suicidal risk. METHODS: We evaluated 83 adult-psychiatric outpatients with a DSM-5 bipolar (BD) or major depressive disorder (MDD): BD-I (n = 48), BD-II (20), and MDD (15) during a major depressive episode. They were actigraphically monitored continuously over 3 weekdays and self-rated their subjective states at regular intervals. We applied cosinor analysis to actigraphic data and analyzed associations of subjective psychopathology measures with circadian activity parameters. RESULTS: Actigraphic circadian mesor, amplitude, day- and nighttime activity were lower with BD versus MDD. Self-rated vitality (wish-to-live) was significantly lower, self-rated suicidality (wish-to-die) was higher, and their difference was lower, with BD versus MDD. There were no other significant diagnostic differences in actigraphic sleep parameters or in self-rated depression, dysphoria, or anxiety. By linear regression, the difference between vitality and passive suicidal ideation was strongly positively correlated with mesor (p < 0.0001), daytime activity (p < 0.0001), and amplitude (p = 0.001). CONCLUSIONS: Higher circadian activity measures reflected enhanced levels of subjective vitality and were associated with lesser suicidal ideation. Current suicidal-risk assessment might usefully include monitoring of motility and vitality in addition to examining negative affects and suicidal thinking.

Handling the desire to die- evaluation of an elective course for medical students.

BACKGROUND: The desire to die can occur in palliative care patients with a prevalence of up to 22%. Not every desire to die is accompanied by a pressure to act, but usually by a burden that can arise from various factors. To address this burden appropriately, health care workers should be trained. Based on an evaluated course on handling the desire to die, an elective course for medical students was developed and evaluated. In order to identify the impact of the elective course's content, a comparison of attitudes towards assisted dying with two other participant groups was conducted. Therefore, three questions from the evaluation of the elective course were used. METHOD: Online evaluation of the elective and questions addressing attitude were assessed using a five-point Likert scale. The specific outcome-based assessment was determined using the Comparative Self-Assessment Gain. The main participant group (group 1) were students who took the elective. The additional survey on attitudes towards assisted dying included undergraduate medical students who had taken compulsory palliative care courses (group 2) and physicians who had taken an introductory course in intensive care or emergency medicine (group 3). RESULTS: Group 1 (n = 13, response rate rr = 86.7%) was very satisfied with the blended learning format (100%) and the course itself (100%). They were able to deepen their knowledge (81.0%) and train skills (71.2%) through the course. In the additional surveys, there were 37 students in group 2 (rr = 66.1%) and 258 physicians in group 3 (rr = 73.6%). Willingness to assist with or accompany the various options for assisted dying varied according to the type of assistance. Among the participants, it can be summarised that the highest willingness was shown by the students of group 2 followed by the physicians of group 3 and the students of group 1. CONCLUSIONS: A course on handling the desire to die of palliative patients can deepen knowledge and train communication skills and thus support self-confidence. Dealing with the background of the desire to die, knowledge about assisted dying, but also one's own attitudes and responsibilities can influence the attitude towards assisted dying.

Improving Recognition of Defective Epoxy Images in Integrated Circuit Manufacturing by Data Augmentation.

This paper discusses the problem of recognizing defective epoxy drop images for the purpose of performing vision-based die attachment inspection in integrated circuit (IC) manufacturing based on deep neural networks. Two supervised and two unsupervised recognition models are considered. The supervised models examined are an autoencoder (AE) network together with a multi-layer perceptron network (MLP) and a VGG16 network, while the unsupervised models examined are an autoencoder (AE) network together with k-means clustering and a VGG16 network together with k-means clustering. Since in practice very few defective epoxy drop images are available on an actual IC production line, the emphasis in this paper is placed on the impact of data augmentation on the recognition outcome. The data augmentation is achieved by generating synthesized defective epoxy drop images via our previously developed enhanced loss function CycleGAN generative network. The experimental results indicate that when using data augmentation, the supervised and unsupervised models of VGG16 generate perfect or near perfect accuracies for recognition of defective epoxy drop images for the dataset examined. More specifically, for the supervised models of AE+MLP and VGG16, the recognition accuracy is improved by 47% and 1%, respectively, and for the unsupervised models of AE+Kmeans and VGG+Kmeans, the recognition accuracy is improved by 37% and 15%, respectively, due to the data augmentation.

Definition and validation of the nursing diagnosis label "wish to die": a research protocol.

BACKGROUND: Euthanasia has been incorporated into the health services of seven countries. The legalisation of these practices has important repercussions for the competences of nurses, and it raises questions about their role. When a patient with advanced disease expresses a wish to die, what is expected of nurses? What are the needs of these patients, and what kind of care plan do they require? What level of autonomy might nurses have when caring for these patients? The degree of autonomy that nurses might or should have when it comes to addressing such a wish and caring for these patients has yet to be defined. Recognising the wish to die as a nursing diagnosis would be an important step towards ensuring that these patients receive adequate nursing care. This study-protocol aims to define and validate the nursing diagnosis wish to die in patients with advanced disease, establishing its defining characteristics and related factors; to define nursing-specific interventions for this new diagnosis. METHODS: A prospective three-phase study will be carried out. Phase-A) Foundational knowledge: an umbrella review of systematic reviews will be conducted; Phase-B) Definition and validation of the diagnostic nomenclature, defining characteristics and related factors by means of an expert panel, a Delphi study and application of Fehring's diagnostic content validation model; Phase-C) Definition of nursing-specific interventions for the new diagnosis. At least 200 academic and clinical nurses with expertise in the field of palliative care or primary health care will be recruited as participants across the three phases. DISCUSSION: The definition of the wish to die as a nursing diagnosis would promote greater recognition and autonomy for nurses in the care of patients who express such a wish, providing an opportunity to alleviate underlying suffering through nursing-specific interventions and drawing attention to the needs of patients with advanced disease. The new diagnosis would be an addition to nursing science and would provide a framework for providing care to people with advanced disease who express such a wish. Nurses would gain professional autonomy about identifying, exploring and responding clinically to such a wish.

A nose for trouble: ecotoxicological implications for climate change and disease in Saiga antelope (S. t. tatarica).

In recent decades, Saiga antelope (Saiga t. tatarica) mass die-offs have become more common. The mass die-off of 2015 in central Kazakhstan, recorded 140,000 individual deaths across multiple herds. Previously, research has shown atmospheric humidity, the bacterium Pasteurella multocida serotype B, and resultant haemorrhagic septicaemia, were the primary cause. However, other synergistic factors may have impacted this process. Here we use a multivariate compositional data analysis (CoDA) approach to assess what other factors may have been involved. We show a pollutant linkage mechanism where relative humidity and dewpoint temperature combine with environmental pollutants, potentially toxic elements (e.g., Hg, As), complex carbon compounds (e.g., Acetone, Toluene), and inorganic compounds (e.g., CHx, SO2) which affected the Saiga during the calving season (start and peak) and at the onset of the mass die-off. We suggest a mechanism for this process. Upon arrival at their carving grounds, the Saiga experienced a sudden precipitation event, a spike in temperatures, and resultant high humidity occurs. The infectious bacterium P. multocida serotype B then spreads. Further, environmental pollutants contained within steppe soils are released to the air, forming localised smog events, these synergistically combine, and mass die-off occurs.

End-of-life conversations about death and dying from volunteer perspectives: A qualitative study.

OBJECTIVES: Although often unrecognized, volunteers fulfill many essential roles in hospices and other end-of-life care settings. Volunteers complement the actions of professionals in fulfilling many extra care needs, such as delivering newspapers and tidying bedsides. We explored end-of-life conversations about death and dying between hospice volunteers and terminally ill people, with a particular emphasis on any expressed desire to die. Our 2 research questions were as follows: (1) What is the nature of end-of-life conversations between hospice patients and hospice volunteers? and (2) How do hospice volunteers experience conversations about death and dying with patients who are at the end-of-life? METHODS: We conducted semi-structured interviews using an interpretive phenomenological analysis. We recruited hospice volunteers from 4 hospices in Calgary, Edmonton, and Red Deer; 3 larger cities in the province of Alberta, Canada. RESULTS: We interviewed 12 participants to saturation. Four themes emerged: (1) trusting conversations about death and dying in the context of a safe place; (2) normalcy of conversations about death and dying; (3) building meaningful relationships; and (4) end-of-life conversations as a transformative experience. Our results emphasize the importance of preparing volunteers for conversations about death and dying, including the desire to die. SIGNIFICANCE OF RESULTS: The safe environment of the hospice, the commitment to patient confidentiality, and the ability of volunteers to meet the basic and emotional needs of dying people or simply just be present without having formal care duties that need to be completed contribute to volunteers being able to participate in timely and needed conversations about death and dying, including the desire to die. In turn, hospice experiences and end-of-life conversations provide a transformative experience for volunteers.

No (true) right to die: barriers in access to physician-assisted death in case of psychiatric disease, advanced dementia or multiple geriatric syndromes in the Netherlands.

Even in the Netherlands, where the practice of physician-assisted death (PAD) has been legalized for over 20 years, there is no such thing as a 'right to die'. Especially patients with extraordinary requests, such as a wish for PAD based on psychiatric suffering, advanced dementia, or (a limited number of) multiple geriatric syndromes, encounter barriers in access to PAD. In this paper, we discuss whether these barriers can be justified in the context of the Dutch situation where PAD is legally permitted for those who suffer unbearably and hopelessly as a result of medical conditions. Furthermore, we explore whether there are options to address some of the barriers or their consequences, both within the Dutch legal framework or by adjusting the legal framework, and whether these options are feasible. We conclude that although there are insufficient arguments to overrule the doctor's freedom of conscience in the Netherlands, there are ways to address some of the barriers, mainly by offering support to doctors that would be willing to support a request. Moreover, we believe it is morally required to reduce or mitigate where possible the negative consequences of the barriers for patients, such as the long waiting time for those who suffer from psychiatric disorders, because it is unlikely the adjustments suggested to the system will ensure reasonable access for these patient groups.

[The provision of assisted death in the context of the desire to anticipate death]. / La prestación de ayuda a morir en el contexto del deseo de anticipar la muerte.

The entry into force of the Organic Law on the Regulation of Euthanasia in June 2021 obliges clinicians to reconsider their professional work, in the face of a new service that expands the limits of what was considered correct until then. This new service affects the entire healthcare system, but especially primary care professionals. Beyond the procedural and moral aspects, it is necessary to rethink the assessment of the patient who expresses a wish to die. In this review, we start with the relatively recent definition of the wish to hasten death (WTHD), its causes, epidemiology and differential diagnosis. Then, we examine the different mental frameworks found in the process of dying and the concept of a «good death¼. Finally, we analyse the paths that can lead to the provision of aid in dying within the framework of current legislation. The WTHD is specific to requests in case of «serious and advanced illness¼, not in other cases contemplated by the Law. When faced with a request to activate the Aid in Dying Prestation in the context of WTHD (that is, in the proximity of death), it becomes necessary to increase the patient's sense of control and begin to work on grief. Besides, in the face of an administrative process that will necessarily be long, adapting the therapeutic efforts and sedation should be considered as possible options. We understand that it is essential not to create false expectations for patients/families and not to overload healthcare professionals with administrative tasks that will be futile. It is difficult to balance these in the face of a request for a right to which the patient should always have access.

New Generation of Benzidine Wide-Gap Conjugated Materials: Solution Processing a Classic Evaporated Scaffold.

Carbazole- and fluorene-substituted benzidine blocks have been functionalized with two different solubilizing pendant groups, in order to enhance the material's solubility in greener solvents. Preserving the optical and electrochemical properties, the aromatic function and substitution showed an important influence on the solvent affinity, achieving concentrations up to 150 mg/mL in o-xylenes for the glycol-containing materials and decent solubility in alcohols for the compounds functionalized with ionic chains. The latter solution proved to be ideal for the preparation of luminescence slot-die coating film on top of flexible-substrates up to 33 cm×2 cm. As a proof of concept, the materials have been implemented in different organic electronic devices, highlighting the low turn-on voltage (4 V) presented by organic light-emitting diodes (OLEDs), which is comparable with vacuum-processed devices. A structure-solubility relationship and a synthetic strategy are disentangled in this manuscript to tailor organic semiconductors and adapt their solubility towards the desired solvent and application.

Drought then wildfire reveals a compound disturbance in a resprouting forest.

The frequency and intensity of forest disturbances, such as drought and fire, are increasing globally, with an increased likelihood of multiple disturbance events occurring in short succession. Disturbances layered over one another may influence the likelihood or intensity of subsequent events (a linked disturbance) or impact response and recovery trajectories (a compound disturbance), with substantial implications for ecological spatiotemporal vulnerability. This study evaluates evidence for disturbance interactions of drought followed by wildfire in a resprouting eucalypt-dominated forest (the Northern Jarrah Forest) in southwestern Australia. Sites were stratified by drought (high, low), from previous modeling and ground validation, and fire severity (high, moderate, unburnt), via remote sensing using the relative difference normalized burn ratio (RdNBR). Evidence of a linked disturbance was assessed via fine fuel consumption and fire severity. Compound disturbance effects were quantified at stand scale (canopy height, quadratic mean diameter, stem density) and stem scale (mortality). There was no evidence of prior drought influencing fine fuel consumption or fire severity and, hence, no evidence of a linked disturbance. However, compound disturbance effects were evident; stands previously affected by drought experienced smaller shifts in canopy height, quadratic mean diameter, and stem density than stands without prior drought impact. At the stem scale, size and fire severity were the strongest determinants of stem survival. Proportional resprouting height was greater in high drought sites than in low drought sites (p < 0.01), meaning, structurally, the low drought stands decreased in height more than the high drought stands. Thus, a legacy of the drought was evident after the wildfire. Although these resprouting eucalypt forests have been regarded as particularly resilient, this study illustrates how multiple disturbances can overwhelm the larger tree component and promote an abundance of smaller stems. We suggest that this is early evidence of a structural destabilization of these forests under a more fire-prone, hotter, and drier future climate.

Survival, mobilization, and transport of Escherichia coli from sheep faeces.

AIMS: This study looked at the survival, mobilization, and transport of Escherichia coli from sheep faeces over an extended period, which was then repeated for all four seasons. METHODS AND RESULTS: Rain simulation was used to measure E. coli mobilization directly from faecal pats and subsequent transport across a soil surface. The rain simulation experiments were conducted over the same 90-day period and for the four seasons as per the survival experiments conducted to determine E. coli survival in faecal pats. The survival experiments demonstrated up to three orders of magnitude increase of E. coli in sheep faeces. Peak E. coli concentrations in the faeces were observed on Day 2 through to Day 30, with no significant effect of seasons or weather patterns. The E. coli concentrations in the runoff followed the survival pattern of E. coli concentrations in the faeces. CONCLUSIONS: There was a statistically significant relationship between the E. coli concentrations in the faeces and the runoff. SIGNIFICANCE AND IMPACT OF STUDY: The data generated on the relationship between Escherichia coli concentrations in the faeces and in the runoff can support the development of runoff risk models for sheep grazing pastureland to support catchment modelling, land use decisions, and public health.

End of life in patients attended by pediatric palliative care teams: what factors influence the place of death and compliance with family preferences?

Each year, more than 8 million children worldwide require specialized palliative care, yet there is little evidence available in pediatrics on the characteristics of the end of life in this context. Our aim is to analyze the characteristics of patients who die in the care of specific pediatric palliative care teams. This is ambispective, analytical observational, multicenter study conducted between 1 January and 31 December 2019. Fourteen specific pediatric palliative care teams participated. There are 164 patients, most of them suffering from oncologic, neurologic, and neuromuscular processes. The follow-up time was 2.4 months. The parents voiced preferences in respect of the place of death for 125 of the patients (76.2%). The place of death for 95 patients (57.9%) was at the hospital and 67 (40.9%) was at home. The existence of a palliative care team for over 5 years is more likely to be related to families voicing preferences and their fulfillment. Longer follow-up times by pediatric palliative care teams were observed in families with whom preferences regarding the place of death were discussed and in patients who died at home. Patients who did not receive home visits, when the pediatric palliative care team did not provide full care and when preferences regarding the place of death were not discussed with parents, were more likely to die in the hospital.   Conclusions: Advance planning of end-of-life care is one of the most important aspects of pediatric palliative care. The provision of services by the teams and the follow-up time are related to parents' expressed preferences and the place of death. What is Known: • Various studies have shown how the availability of pediatric palliative care services improves the quality of life of patients and their families while reducing costs. • The place of death is an important factor influencing the quality of end-of-life care for dying people. The increase in palliative care teams increases the number of deaths in the home and having this care available 24/7 increases the probability of dying at home. What is New: • Our study identifies how a longer follow-up time of patients by palliative care teams is significantly associated with death at home and with express and comply with the preferences expressed by families. • Home visits by the palliative care team increase the likelihood that the patient will die at her home and that the preferences expressed by the palliative care team families will be cared for.

Dying in a terminal society: a response to Maung.

Maung argues that an externalist understanding of mental disorder exposes how, if society was more just for the most deprived, patterns of access to assisted dying might be different. I counter that reducing inequality lacks relevance to the immediate permissibility of assisted dying for mental disorder, owing to the need for solutions for those in distress. I suggest that the question of assistance in death for mental disorders is one of pragmatic politics, not for obfuscatory philosophy.

An autonomy-based approach to assisted suicide: a way to avoid the expressivist objection against assisted dying laws.

In several jurisdictions, irremediable suffering from a medical condition is a legal requirement for access to assisted dying. According to the expressivist objection, allowing assisted dying for a specific group of persons, such as those with irremediable medical conditions, expresses the judgment that their lives are not worth living. While the expressivist objection has often been used to argue that assisted dying should not be legalised, I show that there is an alternative solution available to its proponents. An autonomy-based approach to assisted suicide regards the provision of assisted suicide (but not euthanasia) as justified when it is autonomously requested by a person, irrespective of whether this is in her best interests. Such an approach has been put forward by a recent judgment of the German Federal Constitutional Court, which understands assisted suicide as an expression of the person's right to a self-determined death. It does not allow for beneficence-based restrictions regarding the person's suffering or medical diagnosis and therefore avoids the expressivist objection. I argue that on an autonomy-based approach, assisted suicide should not be understood as a medical procedure but rather as the person's autonomous action.

Choosing death in unjust conditions: hope, autonomy and harm reduction.

In this essay, we consider questions arising from cases in which people request medical assistance in dying (MAiD) in unjust social circumstances. We develop our argument by asking two questions. First, can decisions made in the context of unjust social circumstance be meaningfully autonomous? We understand 'unjust social circumstances' to be circumstances in which people do not have meaningful access to the range of options to which they are entitled and 'autonomy' as self-governance in the service of personally meaningful goals, values and commitments. People in these circumstances would choose otherwise, were conditions more just. We consider and reject arguments that the autonomy of people choosing death in the context of injustice is necessarily reduced, either by restricting their options for self-determination, through their internalisation of oppressive attitudes or by undermining their hope to the point that they despair.Second, should MAiD be available to people in such circumstances, even when a sound argument can be made that the agents in question are autonomous? In response, we use a harm reduction approach, arguing that even though such decisions are tragic, MAiD should be available. Our argument engages with relational theories of autonomy as well as recent criticism raised against them and is intended to be general in application, although it emerges in response to the Canadian legal regimen around MAiD, with a focus on recent changes in Canada's eligibility criteria to qualify for MAiD.