The debate rages on: physician-assisted suicide in an ethical light.

The British Medical Association and some Royal Colleges have recently changed their stance on physician-assisted suicide from 'opposed' to forms of 'neutral'. The Royal College of Anaesthetists will poll members soon on whether to follow suit. Elsewhere neutrality amongst professional bodies has preceded legalisation of physician-assisted suicide. We examine the arguments relevant to the anaesthesia community and its potential impact in the UK.

Expanding the Use of Continuous Sedation Until Death and Physician-Assisted Suicide.

The controversy over the equivalence of continuous sedation until death (CSD) and physician-assisted suicide/euthanasia (PAS/E) provides an opportunity to focus on a significant extended use of CSD. This extension, suggested by the equivalence of PAS/E and CSD, is designed to promote additional patient autonomy at the end-of-life. Samuel LiPuma, in his article, "Continuous Sedation Until Death as Physician-Assisted Suicide/Euthanasia: A Conceptual Analysis" claims equivalence between CSD and death; his paper is seminal in the equivalency debate. Critics contend that sedation follows proportionality protocols for which LiPuma's thesis does not adequately account. Furthermore, sedation may not eliminate consciousness, and as such LiPuma's contention that CSD is equivalent to neocortical death is suspect. We not only defend the equivalence thesis, but also expand it to include additional moral considerations. First, we explain the equivalence thesis. This is followed by a defense of the thesis against five criticisms. The third section critiques the current use of CSD. Finally, we offer two proposals that, if adopted, would broaden the use of PAS/E and CSD and thereby expand options at the end-of-life.

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.

Should Physician-Assisted Suicide or Euthanasia be Legalized in the United States? A Medically Informed Perspective.

There is a pressing debate in the United States concerning the implied physicians' obligation to do no harm and the status of legalizing physician-assisted suicide (PAS). Key issues that underpin the debate are important to consider. These include: (1) foundational medical beginnings; (2) euthanasia's historical and legal background context; and (3) the key arguments held by those for and against legalization of PAS. This paper reviews the major claims made by proponents for the legalization of PAS and the associated complexities and concerns that help underscore the importance of conscience freedoms. Relief of suffering, respect for patient autonomy, and public policy arguments are discussed in these contexts. We argue here that the emphasis by healthcare providers should be on high quality and compassionate care for those at the end of life's journey who are questioning whether to prematurely end their lives. If medicine loses its chief focus on the quality of caring-even when a cure is not possible-it betrays its objective and purpose. In this backdrop, legalization of PAS harms not only healthcare professionals, but also the medical profession's mission itself. Medicine's foundation is grounded in the concept of never intentionally to inflict harm. Inflicting death by any means is not professional or proper, and is not trustworthy medicine.

Current Challenges for Conscientious Objection by Physicians in Spain.

The College of Physicians of Madrid organized an open debate on conscientious objection (CO) in the medical profession on September 14, 2022. We summarize here the main arguments discussed. CO is defined as the right to raise exceptions to the performance of legal duties when they involve a contravention of personal convictions, whether religious, moral, or philosophical. It is not insubordination. Some authors contend that any decision by elected authorities should be uniformly followed by all citizens, physicians not being an exception. However, suppressing the ethical dimension of medical care may have an unacceptable cost with harm to physicians, their patients, and ultimately society. Health professionals are not blind instruments or mere "executors." The practice of medicine must follow the aim of the profession, namely the pursuit of the patient's good. Medical care must conform to medical ethics, which was first defined twenty-five centuries ago in the Hippocratic oath, and summarized with the triad of precepts "cure, relief, accompaniment." Since then and particularly in light of the Nuremberg trials, most medical declarations have highlighted the duty of defending human life and the importance of CO. In modern societies, there may be medical services that are not health care, even if they are legal. Then, which comes first law or ethics? Ultimately, CO is the tool that protects the freedom of the physician to refuse to perform actions that go against the values of medical ethics. With respect to the recent Spanish laws on abortion, euthanasia, and sex re-assignment of minors, if administrators want to know who is available for a health service that raises issues of conformity to medical ethics, requesting a list of volunteers is preferable to producing an objector list. Asking for registration of conscientious objectors goes against the right to privacy and is coercive, intrusive, and abusive.

Beneficence cannot justify voluntary euthanasia and physician-assisted suicide.

The patient's autonomy and well-being are sometimes seen as central to the ethical justification of voluntary euthanasia (VE) and physician-assisted suicide (PAS). While respecting the patient's wish to die plausibly promotes the patient's autonomy, it is less obvious how alleviating the patient's suffering through death benefits the patient. Death eliminates the subject, so how can we intelligibly maintain that the patient's well-being is promoted when she/he no longer exists? This article interrogates two typical answers given by philosophers: (a) that death confers a well-being benefit in the sense that it actualises a comparatively better life course for the patient (ie, a shorter life with less net suffering), and (b) that death is beneficial because non-existence which entails no suffering is superior to an existence filled with suffering. A close examination of the two senses in which the patient might incur a well-being benefit reveals problems that preclude physicians delivering VE/PAS in the name of beneficence.

The Relationship of Intensive Care Nurses' Attitudes Towards Organ Donation With Their Attitudes Towards Euthanasia and Moral Sensitivity.

Determination of the relationship between nurses' attitudes towards issues, such as end-of-life care that is specific to intensive care, euthanasia, and organ donation and their moral sensitivity levels is one of the important points for working out ethical problems encountered in intensive care units and increasing the quality of care. This study was conducted to determine the relationship between the attitudes of intensive care nurses towards organ donation, euthanasia, and terminal patients and their moral sensitivity. The study was completed with 175 nurses who agreed to participate in the study. Informed consent of the participants was obtained. While nurses' attitudes towards euthanasia, death, and caring for the dying patient did not correlate with their moral sensitivities, their attitudes towards organ donation did.

Spanish regulation of euthanasia and physician-assisted suicide.

In March 2021, the Spanish Congress approved the law regulating euthanasia, that regulates both euthanasia and physician-assisted suicide (PAS). In this article, we analyse the Spanish law regulating euthanasia and PAS, comparing it with the rest of the European laws on euthanasia and PAS (Netherlands, Belgium and Luxembourg). Identified strengths of the Spanish law, with respect to other norms, are that it is a law with many safeguards, which broadly recognises professionals' right to conscientious objection and the specification that it makes on the prior comprehensive care of the patient, including the approach to care dependency. Regarding its shortcomings, the law does not differentiate well between euthanasia and PAS; it barely assigns a role to the healthcare team as a whole (similar to other regulations); it does not clarify the functions of the different professionals involved; it does not detail the specific composition and duration of theevaluation commission; it has not been accompanied by a prior or simultaneous regulation of palliative care; and, lastly, the period of time to implement the law is too short.

'Witness in White' medical ethics learning tours on medicine during the Nazi era.

During the Nazi era, physicians provided expertise and a veneer of legitimacy enabling crimes against humanity. In a creative educational initiative to address current ethical dilemmas in clinical medicine, we conduct ethics learning missions bringing senior physicians to relevant Nazi era sites in either Germany or Poland. The tours share a core curriculum contextualising history and medical ethics, with variations in emphasis. Tours to Germany provide an understanding of the theoretical origins of the ethical violations and crimes of Nazi physicians. Tours to Poland address the magnitude of the Nazi physician's atrocities as well as displays of heroism by Jewish and righteous among the nations' physicians. Exemplary as well as shameful physician behaviour is analysed from an ethical perspective. A combination of unique educational methodologies maximises learning and personal growth, enabling participants to examine ethically complex clinical situations with extrapolation to modern-day medical practice. Learning is designed with relevance to contemporary medical ethics dilemmas such as beginning and end-of-life issues, providing tenets from which participants can develop as more ethical and informed physicians. Participant feedback confirms efficacy and worth of these growth-promoting ethics learning tours which should be expanded to other international groups and settings (see online film Witness in White Berlin 2019 available at https://www.youtube.com/watch?v=75VUZvo3Bec).

Old problems in need of new (narrative) approaches? A young physician-bioethicist's search for ethical guidance in the practice of physician-assisted dying in the Netherlands.

The current empirical research and normative arguments on physician-assisted dying (PAD) in the Netherlands seem insufficient to provide ethical guidance to general practitioners in the practice of PAD, due to a gap between the evidence and arguments on the one hand and the uncertainties and complexities as found in everyday practice on the other. This paper addresses the problems of current ethical arguments and empirical research and how both seem to be profoundly influenced by the Dutch legislative framework on PAD and a certain view on ethics. Furthermore, the paper elaborates on how other approaches to empirical research in bioethics, such as found in the broad field of narrative research, could supplement the empirical and ethical evaluation of PAD in the Netherlands. This paper also addresses the challenging question of how empirical data-in this case narratives-relate to normativity. The paper is written in the form of a personal narrative of the author, a young Dutch general practitioner and researcher in bioethics. This style is intentionally chosen, to illustrate how work context and professional background influence the observations one makes and the questions one may ask about the topic of PAD. In addition, by using this style, this paper not only gives a different perspective on a much-contested bioethical issue, but also on the challenges faced when a physician-bioethicist has to navigate different disciplinary fields and (moral) epistemological paradigms, especially since the 'empirical turn' in bioethics.

Embracing slippery slope on physician-assisted suicide and euthanasia could have significant unintended consequences.

In a recent article Joshua James Hatherley argues that, if physician-assisted suicide (PAS) is morally permissible for patients suffering from somatic illnesses, it should be permissible for psychiatric patients as well. He argues that psychiatric disorders do not necessarily impair decision-making ability, that they are not necessarily treatable and that legalising PAS for psychiatric patients would not diminish research and therapeutic interest in psychiatric treatments or impair their recovery through loss of hope. However, by erasing distinction between somatic and psychiatric disorders on those grounds, he also erases distinction between healthy adults and patients (whether somatic or psychiatric) essentially implying that PAS should be available to all, for all reasons or, ultimately no reason. Furthermore, as psychiatric patients are much more likely to be a source of usable organs for transplantation, their broad inclusion would strengthen the link between PAS/euthanasia and organ donation, potentially undermining both as well as diminishing already declining general trust in medical authorities and professionals and public health authorities and activists.

Conscientious participants and the ethical dimensions of physician support for legalised voluntary assisted dying.

The Australian state of Victoria legalised voluntary assisted dying (VAD) in June 2019. Like most jurisdictions with legalised VAD, the Victorian law constructs physicians as the only legal providers of VAD. Physicians with conscientious objection to VAD are not compelled to participate in the practice, requiring colleagues who are willing to participate to transact the process for eligible applicants. Physicians who provide VAD because of their active, moral and purposeful support for the law are known as conscientious participants. Conscientious participation has received scant attention in the bioethics literature. Patient access to VAD is contingent on the development of a sufficient corpus of conscientious participants in permissive jurisdictions. This article reports the findings of a small empirical study into how some Victorian physicians with no in-principle opposition towards the legalisation of VAD, are ethically orientating themselves towards the law, in the first 8 months of the law's operation. It finds that in-principle-supportive physicians employ bioethical principles to justify their position but struggle to reconcile that approach with the broader medical profession's opposition. This study is part of the first tranche of empirical research emerging from Australia since the legalisation of VAD in that country for the first time in over 20 years.

Assessment of patient decision-making capacity in the context of voluntary euthanasia for psychic suffering caused by psychiatric disorders: a qualitative study of approaches among Belgian physicians.

OBJECTIVE: In Belgium, people with an incurable psychiatric disorder can file a request for euthanasia claiming unbearable psychic suffering. For the request to be accepted, it has to meet stringent legal criteria. One of the requirements is that the patient possesses decision-making capacity. The patient's decision-making capacity is assessed by physicians.The objective of our study is to provide insight in the assessment of decision-making capacity in the context of euthanasia for patients with psychic suffering caused by a psychiatric disorder. METHOD: Twenty-two semistructured interviews with psychiatrists and neurologists were analysed with NVivo, a qualitative analysis software to code and organise transcribed data. RESULTS: Different views and approaches regarding decision-making capacity in the context of euthanasia emerged from the data.Most of the physicians have some knowledge of the cognitive ability approach on decision-making capacity. According to this approach, four abilities constitute decision-making capacity: communication, understanding, appreciation and reasoning. We observed differences in the way these abilities are valued in relation to competence. Some physicians take additional elements into consideration when assessing decision-making capacity.Physicians acquired their knowledge on the subject in many different ways. Most of the physicians reported that decision-making capacity was not part of their training. CONCLUSION: We conclude that physicians assess decision-making capacity in different ways and that personal values and beliefs influence their approach. As such, a common approach in assessing the decision-making capacity of a patient among the interviewed physicians is lacking. Less arbitrariness could be obtained by consistently implementing the cognitive ability approach.

[Neurologists and neuroscientists during the "Third Reich": attempt at an assessment]. / Neurologen und Neurowissenschaftler in der NS­Zeit: Versuch einer Bewertung.

On behalf of the German Neurological Society (DGN) former presidents, honorary presidents and honorary members were checked for possible formal or ideological affiliations with National Socialism (NS) 75 years after the NS dictatorship. When the DGN was reformed in 1950, 6 of the 7 "founding fathers" were former members of the National Socialist German Workers' Party (NSDAP), which is in strong contrast with the traditional narrative of a "new beginning". The first four (Pette, Schaltenbrand, Vogel and Döring) and in total 10 out of 13 incumbent presidents until 1976 (Zülch, Bay, Hirschmann, Jung, Bauer, Behrend) as well as honorary president Bodechtel had belonged to the NSDAP, Storm Troopers (SA), or "Schutzsstaffel" (SS). Approximately two thirds of the German and Austrian honorary members appointed until 1985 had been associated with the NS system or the NS ideology (e.g. Becker, Birkmayer, Jacob, Reichardt, Seitelberger, Tönnis and von Weizsäcker). The individual attitude of neuroscientists towards eugenics ranged from approval to refusal and a few had been involved with (Appellate) Hereditary Health Courts. None of the physicians considered here were directly involved in killing patients but several of them knew of the "concomitant research" in the context of "euthanasia". Others used research resources generated during the "euthanasia"-programme and after 1945. The only professor of neurology who conducted ethically inacceptable human experiments was Georg Schaltenbrand. Almost all neurologists could pursue their career after the war, sometimes after having undergone lengthy denazification trials but very few of them were willing to face up to their past. Categorizations, such as "collaborators", "beneficiaries" and "physicians with ambivalent roles" should be replaced by a more differentiated assessment. When dealing with the past of German neurology it would be advisable to resort to a categorization of remembrance instead of naming awards after incriminated persons.

Physician-hastened death in young children: Getting to underlying assumptions.

Significant changes are occurring in Canada's health care system regarding physician-hastened death (PHD). In the Netherlands, where the Groningen Protocol is in place, euthanasia in now legal for infants and children. The present article considers whether PHD should be applied to young children in Canada and how these paediatric cases differ from adult cases. The discussion analyzes and critiques the underlying assumptions necessary to believe that PHD is good. The role of worldviews in the deliberation of any moral question and the importance of recognizing personal bias are highlighted. The authors present common issues regarding PHD, including suffering, parental autonomy and future quality of life, and examine the basic assumptions on which these arguments are made. Finally, they conclude that the assumptions required are incorrect and that PHD should not be allowed in the case of children. Instead, policies should continue to strive for the protection and promotion of health in all children.

D'importants changements se produisent à l'égard de l'aide médicale à mourir (AMM) au sein du système de santé canadien. Aux Pays-Bas, où le protocole de Groningen est en vigueur, l'euthanasie est désormais légale pour les nourrissons et les enfants. Le présent article évalue si l'AMM devrait s'appliquer aux jeunes enfants du Canada et en quoi les cas d'âge pédiatriques diffèrent de ceux des adultes. L'exposé contient une analyse et une critique des hypothèses sous-jacentes nécessaires pour trouver l'AMM positive. Il souligne le rôle des diverses visions du monde dans les délibérations sur des questions morales et l'importance d'admettre les préjugés personnels. Les auteurs présentent des enjeux courants liés à l'AMM, y compris la souffrance, l'autonomie parentale et la future qualité de vie, et ils examinent les hypothèses fondamentales sur lesquelles reposent ces arguments. Enfin, ils concluent que les hypothèses nécessaires sont fausses et que l'AMM ne devrait pas être autorisée chez les enfants. Les politiques devraient plutôt continuer à privilégier la protection et la promotion de la santé chez tous les enfants.

Non-faith-based arguments against physician-assisted suicide and euthanasia.

This article is a complement to "A Template for Non-Religious-Based Discussions Against Euthanasia" by Melissa Harintho, Nathaniel Bloodworth, and E. Wesley Ely which appeared in the February 2015 Linacre Quarterly. Herein we build upon Daniel Sulmasy's opening and closing arguments from the 2014 Intelligence Squared debate on legalizing assisted suicide, supplemented by other non-faith-based arguments and thoughts, providing four nontheistic arguments against physician-assisted suicide and euthanasia: (1) "it offends me"; (2) slippery slope; (3) "pain can be alleviated"; (4) physician integrity and patient trust. Lay Summary: Presented here are four non-religious, reasonable arguments against physician-assisted suicide and euthanasia: (1) "it offends me," suicide devalues human life; (2) slippery slope, the limits on euthanasia gradually erode; (3) "pain can be alleviated," palliative care and modern therapeutics more and more adequately manage pain; (4) physician integrity and patient trust, participating in suicide violates the integrity of the physician and undermines the trust patients place in physicians to heal and not to harm.

Investigation on the Attitudes and Perspectives of Medical and Nursing Staff About Euthanasia: Data From Four Regional Greek Hospitals.

INTRODUCTION: The good and benefit of the patient are the main drivers of the decisions that health professionals are asked to make. However, the definition of the good and the actions required for benefit are not always simple and self-evident. The intractable ethical dilemma of euthanasia has been the subject of extensive debates over the years, and numerous studies have been carried out in an attempt to record the attitudes and opinions of both health professionals and the general population. METHOD: This research aims to investigate the opinions and perspectives of the medical and nursing staff of the four regional hospitals regarding euthanasia and to detect the factors that advocate for and against it. Two hundred and eighteen medical and nursing staff members from four regional hospitals in Lasithi participated in the research, whose opinions and influencing factors were investigated using a questionnaire consisting of four sections. The first included demographic and general characteristics questions; the second was the Euthanasia Attitude Scale (EAS); the third was the Death Attitude Profile-Revised (DAP-R); and the last was the Daily Spiritual Experience Scale (DSES). The SPSS software version 25.0 (IBM Corp., Armonk, NY) was used to analyse the data. RESULTS: Of the total, 78.0% of the participants were women, with an average sample age of 44.5 years. 65.1% were married, 23.4% were physicians, while 76.6% were nurses. The mean Euthanasia Attitude score (70.89) is moderate, ranging from 30 to 120, with higher scores suggesting more favourable sentiments. Euthanasia was viewed positively by 24.3% of respondents. There was no significant difference in positive attitudes between medical and nursing staff. However, the nursing staff had significantly lower average levels of General Orientation for Euthanasia, for the Role of Healthcare Professionals in Euthanasia, Values & Ethics, or Daily Spiritual Experience, and conversely higher levels of scores on Patients' Rights Issues for Euthanasia or Death Acceptance. CONCLUSIONS: Health professionals were found to have moderate attitudes about euthanasia, with no significant difference between them, as well as moderate degrees of death and everyday spiritual experience. Overall, a more favourable euthanasia attitude was shown to be strongly associated with individuals who were single, divorced, or widowed, with less death acceptance or more neutral acceptance, but not with daily spiritual experience.

One third of physicians discuss exit strategies with patients with amyotrophic lateral sclerosis: Results from nationwide surveys among German and Polish neurologists.

OBJECTIVE: This paper examines neurologists' approaches to exit strategies (ESs), such as euthanasia and physician-assisted suicide, in patients with amyotrophic lateral sclerosis (PALS) in two European countries. METHODS: In a nationwide anonymous survey, we collected responses from 237 Polish and 228 German neurologists, focusing on their practices and beliefs about ESs, as well as their viewpoints on life-sustaining measures (LSMs) (percutaneous endoscopic gastrostomy, non-invasive, and invasive ventilation). To analyze the data, we employed statistical methods, including Mann-Whitney U, Kruskal-Wallis, chi-square tests, Spearman's rank correlation, and multiple regression analysis. RESULTS: One third of the neurologists initiated the discussion about ESs with PALS. Half were ready to have this conversation upon patient's request. Age, gender, religiousness, and nationality were closely associated with this approach. One in 9 neurologists received a request to terminate an LSM, whereas 1 in 10 to implement an ES. German neurologists and palliative care trainees acquired both demands more commonly. Neurologists quoted a low quality of life, decreased mood, and being a burden to the family/closest ones as primary reasons for a wish to hasten death among PALS. Although the majority expressed a willingness to terminate an LSM at a request of the patient, most opposed the legalization of euthanasia. Younger and less religious individuals were more likely to favor accepting euthanasia. CONCLUSION: Neurologists vary significantly in their approaches to terminal care. Complex relationships exist among personal indices, shared beliefs, and current practices.

[PAL-PRAT study: Healthcare workers' knowledge and perception of palliative practices in a Cancer Center]. / Quelle connaissance et quelle perception ont les professionnels de santé d'un Centre de lutte contre le cancer à propos des pratiques palliatives encadrées par la loi Claeys-Leonetti : étude PAL PRAT.

INTRODUCTION: The issue of end-of-life care is the subject of a sensitive debate in French society, particularly regarding the possibility for certain patients to have access to medical assistance in dying. The aim of this study was to assess the knowledge and opinion of healthcare providers on the care practices for patients at the end of life, as well as to highlight any specificities in their discourse. METHOD: A survey of healthcare providers' opinions, composed of closed and open questions, that were analyzed using a lexicometric approach, was distributed in a cancer center. RESULTS: The results of the study reveal a good knowledge of the different procedures. Professionals considered that advance directives should be systematically collected; a majority of them differentiated euthanasia from deep continuous sedation and perceived the latter as a means of relieving patients' suffering without inducing death. The different procedures related to the active assistance in dying were known by a majority of professionals and the survey did not identify a dominant trend concerning the will to practice euthanasia if the legal framework allowed it. Half of the participants considered their training insufficient, indicating the need to fill this gap. DISCUSSION: This survey underlines the importance of training and support for the professionals caring for patients in palliative situation and their relatives in France.

Ethical Issue of Physician-Assisted Suicide and Euthanasia.

With the implementation of Act on Hospice and Palliative Care and Decisions on Life-Sustaining Treatment for Patients at the End of Life, interests of the general public on self-determination right and dignified death of patients have increased markedly in Korea. However, "self-determination" on medical care is misunderstood as decision not to sustain life, and "dignified death" as terminating life before suffering from disease in terminal stage. This belief leads that physician-assisted suicide should be accommodated is being proliferated widely in the society even without accepting euthanasia. Artificially terminating the life of a human is an unethical act even though there is any rational or motivation by the person requesting euthanasia, and there is agreement thereof has been reached while there are overseas countries that allow euthanasia. Given the fact that the essence of medical care is to enable the human to live their lives in greater comfort by enhancing their health throughout their lives, physician-assisted suicide should be deemed as one of the means of euthanasia, not as a means of dignified death. Accordingly, institutional organization and improvement of the quality of hospice palliative care to assist the patients suffering from terminal stage or intractable diseases in putting their lives in order and to more comfortably accept the end of life physically, mentally, socially, psychologically and spiritually need to be implemented first to ensure their dignified death.