Should euthanasia and assisted suicide for psychiatric disorders be permitted? A systematic review of reasons.

BACKGROUND: Euthanasia and assisted suicide (EAS) based on a psychiatric disorder (psychiatric EAS) continue to pose ethical and policy challenges, even in countries where the practice has been allowed for years. We conducted a systematic review of reasons, a specific type of review for bioethical questions designed to inform rational policy-making. Our aims were twofold: (1) to systematically identify all published reasons for and against the practice (2) to identify current gaps in the debate and areas for future research. METHODS: Following the PRISMA guidelines, we performed a search across seven electronic databases to include publications focusing on psychiatric EAS and providing ethical reasons. Reasons were grouped into domains by qualitative content analysis. RESULTS: We included 42 articles, most of which were written after 2013. Articles in favor and against were evenly distributed. Articles in favor were mostly full-length pieces written by non-clinicians, with articles against mostly reactive, commentary-type pieces written by clinicians. Reasons were categorized into eight domains: (1) mental and physical illness and suffering (2) decisional capacity (3) irremediability (4) goals of medicine and psychiatry (5) consequences for mental health care (6) psychiatric EAS and suicide (7) self-determination and authenticity (8) psychiatric EAS and refusal of life-sustaining treatment. Parity- (or discrimination-) based reasons were dominant across domains, mostly argued for by non-clinicians, while policy reasons were mostly pointed to by clinicians. CONCLUSIONS: The ethical debate about psychiatric EAS is relatively young, with prominent reasons of parity. More direct engagement is needed to address ethical and policy considerations.

Lo realmente importante no es vivir, sino vivir bien: una discusión sobre eutanasia, autonomía y autorrespeto / The really important thing is not to live, but to live well: a discussion about euthanasia, autonomy and self-respect / O realmente importante não é viver, mas sim viver bem: uma discussão sobre eutanásia, autonomia e auto-respeito

Este artículo tiene por objetivo introducir la noción de "autorrespeto" en el marco de la discusión sobre la eutanasia. Para ello muestra brevemente, en primer lugar, dos rasgos que caracterizan gran parte de los debates morales contemporáneos sobre temas de ética aplicada, rasgos que permitirán explicar, con mayor claridad, la necesidad de ampliar las razones que permitan a las personas estar en condiciones de adelantar su muerte. En segundo término, se expone una de las primeras reflexiones de Platón acerca de la diferencia entre el mero hecho de estar vivos (to zen) y el vivir bien (to eu zen), y cuyos argumentos podemos trasladar en parte al debate sobre la eutanasia. Luego de discutir la idea de "persona", el artículo aborda finalmente la noción de "autorrespeto" como criterio para considerar la legitimidad moral de poner anticipadamente fin a nuestra vida.

This paper aims to introduce the notion of self-respect in the context of the discussion on euthanasia. First, I briefly show two features that characterize much of the contemporary moral debates on issues of applied ethics, features that will allow me to explain more clearly the discussion about euthanasia. Looking back at the history of Philosophy, in the second part, I will show how Plato offered one of the first reflections on the difference between the mere fact of being alive (to zen) and living well (to eu zen), and whose arguments we can use to discuss euthanasia. Third, I will examine what we understand by a person and how a particular comprehension of this notion will allow me to elaborate arguments in favour of euthanasia based on the idea of self-respect.

Este artigo tem por objetivo introduzir a noção de "auto-respeito" no contexto da discussão sobre eutanásia. Para isto, mostra brevemente, em primeiro lugar, dois aspectos que caracterizam grande parte dos debates morais contemporâneos sobre temas de ética aplicada, aspectos estes que permitirão explicar, com maior clareza, a necessidade de ampliar as razões que permitam às pessoas estarem em condições de adiantar sua morte. Em segundo lugar, expõe-se uma das primeiras reflexões de Platão acerca da diferença entre o mero fato de estar vivos (to zen) e o viver bem (to eu zen), e cujos argumentos podemos transferir em parte ao debate sobre a eutanásia. Depois de discutir a ideia de "pessoa", o artigo aborda finalmente a noção de "auto-respeito" como critério para considerar a legitimidade moral de por antecipadamente fim à nossa vida.

To die well: the phenomenology of suffering and end of life ethics.

The paper presents an account of suffering as a multi-level phenomenon based on concepts such as mood, being-in-the-world and core life value. This phenomenological account will better allow us to evaluate the hardships associated with dying and thereby assist health care professionals in helping persons to die in the best possible manner. Suffering consists not only in physical pain but in being unable to do basic things that are considered to bestow meaning on one's life. The suffering can also be related to no longer being able to be the person one wants to be in the eyes of others, to losing one's dignity and identity. These three types of suffering become articulated by a narrative that holds together and bestows meaning on the whole life and identity of the dying person. In the encounter with the patient, the health-care professional attempts to understand the suffering-experience of the patient in an empathic and dialogic manner, in addition to exploring what has gone wrong in the patient's body. Matters of physician assisted suicide and/or euthanasia-if it should be legalized and if so under which conditions-need to be addressed by understanding the different levels of human suffering and its positive counterpart, human flourishing, rather than stressing the respect for patient autonomy and no-harm principles, only. In this phenomenological analysis the notions of vulnerability and togetherness, ultimately connecting to the political-philosophical issues of how we live together and take care of each other in a community, need to be scrutinized.

[Bioethics theories, the protection of life and natural law]. / Teorías bioéticas, protección de la vida y ley natural.

Principlist Bioethics by Beauchamp and Childress has reached a prominent status in contemporary Bioethics. Nevertheless, it includes some important theoretical problems: some lacks when defining some concepts, a tendency to ethical relativism, etc. Among the ethical alternative approaches from which such problems can be solved, we think that the most appropiate is the Natural Law theory. It offers a reasoned reflection on the concept of good and on human basic goods and their relation with moral general principles. From such goods, this ethical theory supports the existence of actions that are always maleficent acts, that is, intrinsically and universally evil acts. The article applies the Natural Law theory to issues related to the protection of human life (abortion, euthanasia, self-defense and genetic manipulation)..

A Phronetic Inquiry into the Australian Euthanasia Experience: Challenging Paternalistic Medical Culture and Unrepresentative Health Policy.

Australia's intermittent attempts to legalise euthanasia are typically fraught with brief, polarised, and often sensationalised, public debate. Yet beyond the sensitive arguments in favour and in opposition of reform, the practical antecedents of change that may determine Australia's genuine aptitude to enact reforms have been largely neglected. Phronetic legal inquiry thus offers insights into the euthanasia law reform experience, using Australian and international case comparisons to examine covert power dynamics, cultural discourses, and social and institutional structures that affect the practices of the legislature. On this basis, it is argued that Australia's medical profession, and particularly its dominant providers of palliative care, are hampered by an entrenched culture of medicalisation and paternalism, within which patient autonomy provides only a veneer of self-determination. This can be strikingly contrasted with the Dutch approach of patient-centred care, which seeks to produce collaborative, respectful dialogue between physician and patient and to integrate the principles of autonomy and beneficence. Furthermore, these contrasting medical cultures represent issues in the broader policymaking context, as Australia's health policy remains unduly subject to the pressure of unrepresentative yet influential conservative interest groups, most prominently including the Australian Medical Association. This pressure serves to suppress public opinion on the issue of euthanasia in a parliamentary climate that remains stifled by bipartisan alliances and political inertia. It is therefore argued that Australia's prospects for successful voluntary euthanasia law reform rest on the dual pillars of developing a more patient-centred medical culture and challenging the prevailing paternalistic approach to health policymaking in Australia's currently unrepresentative political landscape.

[The Hypertrophy of Autonomy in the Bioethical Debate]. / La Hipertrofia del Principio de Autonomía en el Debate Bioético.

In the current bioethical debate personal autonomy is frequently used as an argument to justify the legalization of new options for the subject. This is the case, for instance, of the controversies around surrogated motherhood, organ free market, euthanasia or egg freezing in order to postpone motherhood. This paper aims to show how legalizing certain options can be harmful to people, and would justify and perpetuate situations of domination of some human beings over others. In this regard, the importance of recognizing the unavailability of certain goods and human rights is underlined.

Assisted Suicide in Switzerland: Clarifying Liberties and Claims.

Assisting suicide is legal in Switzerland if it is offered without selfish motive to a person with decision-making capacity. Although the 'Swiss model' for suicide assistance has been extensively described in the literature, the formally and informally protected liberties and claims of assistors and recipients of suicide assistance in Switzerland are incompletely captured in the literature. In this article, we describe the package of rights involved in the 'Swiss model' using the framework of Hohfeldian rights as modified by Wenar. After outlining this framework, we dissect the rights involved in suicide assistance in Switzerland, and compare it with the situation in England and Germany. Based on this approach, we conclude that in Switzerland, claim rights exist for those requesting suicide assistance, and for those who are considering providing such assistance, even though no entitlements exist toward suicide assistance. We then describe the implementation of the 'Swiss model' and difficulties arising within it. Clarifying these issues is important to understand the Swiss situation, to evaluate what features of it may or may not be worth correcting or emulating, and to understand how it can impact requests for suicide assistance in other countries due to 'suicide tourism'. It is also important to understand exactly what sets Switzerland apart from other countries with different legislations regarding suicide assistance.

Legal and ethical aspects of organ donation after euthanasia in Belgium and the Netherlands.

Organ donation after euthanasia has been performed more than 40 times in Belgium and the Netherlands together. Preliminary results of procedures that have been performed until now demonstrate that this leads to good medical results in the recipient of the organs. Several legal aspects could be changed to further facilitate the combination of organ donation and euthanasia. On the ethical side, several controversies remain, giving rise to an ongoing, but necessary and useful debate. Further experiences will clarify whether both procedures should be strictly separated and whether the dead donor rule should be strictly applied. Opinions still differ on whether the patient's physician should address the possibility of organ donation after euthanasia, which laws should be adapted and which preparatory acts should be performed. These and other procedural issues potentially conflict with the patient's request for organ donation or the circumstances in which euthanasia (without subsequent organ donation) traditionally occurs.

Physicians' Professionally Responsible Power: A Core Concept of Clinical Ethics.

The gathering of power unto themselves by physicians, a process supported by evidence-based practice, clinical guidelines, licensure, organizational culture, and other social factors, makes the ethics of power--the legitimation of physicians' power--a core concept of clinical ethics. In the absence of legitimation, the physician's power over patients becomes problematic, even predatory. As has occurred in previous issues of the Journal, the papers in the 2016 clinical ethics issue bear on the professionally responsible deployment of power by physicians. This introduction explores themes of physicians' power in papers from an international group of authors who address autonomy and trust, the virtues of perinatal hospice, conjoined twins in ethics and law, addiction and autonomy in clinical research on addicting substances, euthanasia of patients with dementia in Belgium, and a pragmatic approach to clinical futility.

Ethical considerations in the regulation of euthanasia and physician-assisted death in Canada.

On February 6th 2015 the Supreme Court of Canada (SCC) released their decision on Carter v Canada (Attorney General) to uphold a judgment from a lower court which determined that the current prohibition in Canada on physician-assisted dying violated the s. 7 [Charter of Rights and Freedoms] rights of competent adults whose medical condition causes intolerable suffering. The purpose of this piece is to briefly examine current regulations from Oregon (USA), Belgium, and the Netherlands, in which physician-assisted death and/or euthanasia is currently permitted, as well as from the province of Quebec which recently passed Bill-52, "An Act Respecting End-of-Life Care." We present ethical considerations that would be pertinent in the development of policies and regulations across Canada in light of this SCC decision: patient and provider autonomy, determining a relevant decision-making standard for practice, and explicating challenges with the SCC criteria for assisted-death eligibility with special consideration to the provision of assisted-death, and review of assisted-death cases. [It is not the goal of this paper to address all questions related to the regulation and policy development of euthanasia and assisted death in Canada, but rather to stimulate and guide the conversations in these areas for policy makers, professional bodies, and regulators.].

[Bioethics is dead. Long live medical ethics!]. / La Bioética ha Muerto. ¡Viva la Ética Médica!

The purpose of this paper is to show a paradigmatic crisis in academic bioethics. Since an important part of bioethicists began to relativize the ethical prohibition of killing an innocent human being, one way or another they began to ally with the death industry: the business of abortion, and then that of euthanasia. The thesis of this paper is that by crossing that Rubicon bioethics has been corrupted and has lost its connection to the ethical, political and legal discourse. One can only hope that it will revive from its ashes if it retakes the ″taboo″ of the sacredness of human life, something for which medical ethics could provide invaluable help, because it still keeps the notion that ″a doctor should not kill″, although in an excessively ″discreet″ and somehow ″ashamed″ way. However, conscientious doctors know more about ethics than most bioethicists.

Medical students and controversial ethical issues: results from the multicenter study SBRAME.

BACKGROUND: Medical students(MS) will face ethical issues throughout their lives as doctors. The present study aims to investigate medical students' opinions on controversial ethical issues and factors associated with these opinions. METHODS: SBRAME (Spirituality and Brazilian Medical Education) is a multicenter study involving 12 Brazilian medical schools with 5950 MS. Participants completed a questionnaire that collected information on socio-demographic data, medical schools characteristics, religious beliefs and opinions on controversial ethical issues. Of all MS, 3630 participated in the survey (61.0%). RESULTS: The sample was 53.8% women and the mean age was 22.5 years. In general, most MS have no objections to prescription of birth control (90.8%), adult stem cell use (87.5%), embryonic stem cell use (82.0%) and abortion for genetic reasons (51.2%). Approximately half of students have no objections to human cloning (47.3%), 45.7% to withdrawal of artificial life support, 41.4% to euthanasia and 23.3% to abortion for failed contraception. Socio-demographic data such as age, gender and income had little influence on MS opinions. On the other hand, medical schools characteristics (number of medical students in the university, year of medical school foundation, location of the university and type of university) and religious aspects (religious affiliation, religious attendance, non-organizational religiousness and intrinsic religiousness) were highly correlated with their opinions. In general, MS with more supportive opinions on controversial ethical issues were less religious and from non-traditional (newer), urban, public and bigger universities. CONCLUSION: The current study reveals MS have different opinions regarding controversial ethical issues. Noteworthy, these opinions seem to be shaped more by university characteristics and religious beliefs than socio-demographic data.

Rich, white, and vulnerable: rethinking oppressive socialization in the euthanasia debate.

Anita Silvers (1998) has criticized those who argue that members of marginalized groups are vulnerable to a special threat posed by physician-assisted suicide (PAS) and voluntary active euthanasia (VAE). She argues that paternalistic measures prohibiting PAS/VAE in order to protect these groups only serve to marginalize them further by characterizing them as belonging to a definitively weak class. I offer a new conception of vulnerability, one that demonstrates how rich, educated, white males, who are typically regarded as having their autonomy enhanced by their social status, are just as, if not more, vulnerable to threats posed by PAS/VAE as a result of the harmful social messages at work just below the surface of contemporary Western culture. I use this new conception of vulnerability to reinforce arguments for continued statutory prohibitions on PAS/VAE.