Physicians' attitudes towards euthanasia and correlation with their spirituality.

"Suffering" patients' wishes concerning hastening their own death by means of euthanasia, raised by personal, psychological, social and other motives, are becoming increasingly common. This raises controversies and marks challenges within both the scientific community and the public. The aim of this study is to investigate physicians' attitudes towards euthanasia and its correlation with their spirituality. The final sample consisted of 93 physicians (64.5% men), whose attitudes on euthanasia who were evaluated using Euthanasia Attitude Scale (EAS) and Daily Spiritual Experience Scale (DSES). Physicians' attitudes correlate with their specialty (p=0.037), years of service (p=0.037), as well as the number of end stage patients they cared for and died within the last 12 months (p=0.016). Oncologists and other physicians with similar specialty, those with longer clinical experience and those who treat more end-stage patients to strongly oppose to the above practices. Spirituality, estimated with Daily Spiritual Experience Scale -DSES, is correlated with a negative attitude toward euthanasia (p<0.001). Finally, a considerable gap in physicians' training regarding the management of end stage patients has been highlighted. Physicians are opposed to euthanasia and they require the acquisition of competencies in end-of-life care in order to fulfill their profession's current and future demands in the domain of palliative care.

Dimensions of religion and attitudes toward euthanasia.

Understanding the role of religion in attitudes toward euthanasia requires viewing religion as a multidimensional construct. In this study, four dimensions operationalized religion: religiosity, spirituality, afterlife beliefs (afterlife, heaven, and hell), and religious denomination. Using data from 1066 adults interviewed in the 2018 General Social Survey, a logistic regression showed religiosity, belief in afterlife and heaven, and religious denomination were significantly associated with opposition to euthanasia. Although most studies have shown a negative influence of religion, we found that not all dimensions of religion have a negative association with opposition to euthanasia and the role of each dimension differs.

Examining the religiosity of nursing caregivers and their attitudes toward voluntary and involuntary euthanasia.

BACKGROUND: Nurses play an important role in taking care of people who have a terminal illness. AIMS: To examine nursing caregivers' religiosity as the mediator between voluntary and involuntary euthanasia, and to compare nursing caregiver religiosity groups and the voluntary and involuntary euthanasia attitudes of nurses and nursing students. METHODS: A cross sectional design was applied and 298 nursing caregivers voluntarily participated and completed the questionnaire. FINDINGS: Religiosity partially contributes as mediator between voluntary and involuntary euthanasia. All nursing caregiver religiosity groups show more support for voluntary euthanasia. Moreover, nursing students and nurses differ with respect to support for euthanasia in extreme situations, such as patients that are clinically brain-dead. CONCLUSION: Findings may be attributed to the clash of religious values, due to the common injunction against taking a life especially as regards involuntary euthanasia.

Nurses' Perceptions and Attitudes About Euthanasia: A Scoping Review.

AIM: Nurses have a critical role in providing holistic care for people with life-limiting conditions. However, they experience internal moral conflict and powerlessness when patients request them to assist in the dying process. A scoping review was undertaken to determine what is known about nurses' perceptions and attitudes of euthanasia. Review Methods: Several databases were searched that yielded both qualitative and quantitative primary peer-reviewed research studies that focused on nurses, their perceptions and attitudes about euthanasia. Descriptive and explorative analyses of the data set from the research studies were undertaken. Results: A total of 23 studies were included in the review. Opinions about euthanasia were mixed. Two key concepts emerged from the review: some nurses were positive and/or supportive of euthanasia, while some were negative and/or unsupportive of euthanasia. The main factors associated with being positive and/or supportive were because of (a) extreme uncontrollable pain, unbearable suffering, or other distressing experiences of the patient, (b) legality of euthanasia, and (c) right of the patient to die. The factors that determined nurses' negative and/or unsupportive attitude included (a) religion, (b) moral/ethical dilemmas, (c) role of gender of the health professional, and, (d) poor palliative care. Conclusions: The matter of euthanasia has challenged nurses considerably in their aim to deliver holistic care. There were several crucial factors influencing nurses' perceptions and attitudes, and these were affected by their personal, professional and transpersonal perspectives. The potential implications to nurses relate to education, practice, and research. Nurses need to be informed of existing legislation and provided in-depth education and professional guidelines to help direct action. Further research is needed to explore the impact on nurses' emotional well-being, clarify their role/s and determine the support they might require when involved with euthanasia.

Medical assistance in dying: just an ethical or legal issue?

According to current vital statistics suicide appears as a growing public health problem in most Western countries. However, suicide is rarely discussed in scientific journals, possibly because of a persisting moral stigma. As a consequence, the diverse bases of suicidal behavior are little understood while the role of Chronic-Degenerative Terminal Diseases (CDTD) has been poorly investigated. In the present study, the topic of suicidality was addressed in a clinical, holistic, perspective in an attempt to clarify how, in some chronically ill patients, the decision to end their own life is taken independently from mental disorders, being conversely, the expression of a rational psychological pattern which copes with the burden of chronic illnesses to become an integral part of their clinical spectrum. An assisted suicide (AS) request should therefore be considered from a clinical point of view and not only as an ethical or legal issue, in fact a holistic evaluation of the patient's situation must be performed, conferring the decisions making process a further in-depth line of thinking. In this study we first examined the relationship between suicide and CDTD as reported in the medical literature; then we reviewed the psychological theories which allegedly explain suicidal behavior; finally we discussed the possible role of a full-fledged palliative care in preventing suicide and in managing death requests by CDTD patients.

The origins of criminal law.

Laws against wrongdoing may originate in justice intuitions that are part of universal human nature, according to the adaptationist theory of the origins of criminal law. This theory proposes that laws can be traced to neurocognitive mechanisms and ancestral selection pressures. According to this theory, laypeople can intuitively recreate the laws of familiar and unfamiliar cultures, even when they lack the relevant explicit knowledge. Here, to evaluate this prediction, we conduct experiments with Chinese and Sumerian laws that are millennia old; stimuli that preserve in fossil-like form the legal thinking of ancient lawmakers. We show that laypeople's justice intuitions closely match the logic and content of those archaic laws. We also show covariation across different types of justice intuitions: interpersonal devaluation of offenders, judgements of moral wrongness, mock-legislated punishments and perpetrator shame-suggesting that multiple justice intuitions may be regulated by a common social-evaluative psychology. Although alternative explanations of these findings are possible, we argue that they are consistent with the assumption that the origin of criminal law is a cognitively sophisticated human nature.

Euthanasia requests in a Canadian psychiatric outpatient clinic: A case series part 2 of the McGill University euthanasia in psychiatry case series.

The Canadian province of Quebec enacted in 2014 a legislation that permitted medical assistance in dying (MAID) under specific conditions and the rest of Canada followed suit in June 2016. In this article, which is the second in a set of case series of requests for MAID in Canadian psychiatry, we present the cases of two patients who made a request for MAID to their treating psychiatrist in an outpatient clinic. While one is advanced in age and suffering from intense physical and psychic pain with little if any psychiatric comorbidity, the other is a young and medically healthy woman who nonetheless suffers from extensive psychiatric comorbidity. This article discusses both cases in light of recent scientific literature and case law that is slowly emerging in Canada, focusing on the concepts of the end of life and its legal definition as well as psychic suffering and its management in those wishing to receive physician-assisted dying. In our conclusion, we stress the need to clarify the definition of treatment resistance, the necessity to determine each physician's role when many are involved, as well as the importance of treating psychic pain holistically, which can sometimes require going beyond standard psychiatric care.

Family members' experiences of assisted dying: A systematic literature review with thematic synthesis.

BACKGROUND: Families' experiences of assisted dying are under-investigated and families are rarely considered in clinical guidelines concerning assisted dying. AIM: To systematically review family experiences of assisted dying. DESIGN: A systematic literature review using thematic synthesis. DATA SOURCES: MEDLINE, Embase, CINAHL, AMED (Allied and Complementary Medicine) and PsycINFO databases (January 1992 to February 2019). Studies investigating families' experiences on the practice of legalised assisted dying were included. We excluded studies prior to legalisation within the jurisdiction, secondary data analysis and opinion papers. RESULTS: Nineteen articles met the inclusion criteria. Publications were derived from four countries: The Netherlands, United States (Oregon, Washington and Vermont), Canada and Switzerland. Dutch studies predominately investigated family involvement in euthanasia, while Swiss and American studies only reported on assisted suicide. Eleven studies had a qualitative design, using predominately in-depth interviews; seven were retrospective surveys. Five analytical themes represented families' experiences in assisted dying: (1) context of the decision, (2) grounding the decision, (3) cognitive and emotional work, (4) experiencing the final farewell and (5) grief and bereavement. The results showed that families can be very involved in supporting patients seeking assisted dying, where open communication is maintained. Family involvement appeared to be influenced by the type of legislation in their country and the families' perception of the social acceptability of assisted dying. CONCLUSION: Our data confirm that families across all jurisdictions are involved in assisted suicide decision and enactment. Family needs are under-researched, and clinical guidelines should incorporate recommendations about how to consider family needs and how to provide them with evidence-based tailored interventions.

Euthanasia, religiosity and the valuation of health states: results from an Irish EQ5D5L valuation study and their implications for anchor values.

BACKGROUND: The Quality Adjusted Life Year influences the allocation of significant amounts of healthcare resources. Despite this surprisingly little research effort has been devoted to analysing how beliefs and attitudes to hastening death influence preferences for health states anchored at "dead" and "perfect health". In this paper we examine how, inter alia, adherence to particular religious beliefs (religiosity) influences attitudes to euthanasia and how, inter alia, attitudes to euthanasia influences the willingness to assign worse than dead (WTD) values to health states using data collected as part of the Irish EQ5D5L valuation study. METHODS: A sample of 160 respondents each supplied 10 composite time trade-off valuations and information on religiosity and attitudes to euthanasia as part of a larger national survey. Data were analysed using a recursive bivariate probit model in which attitudes to euthanasia and willingness to assign WTD values were analysed jointly as functions of a range of covariates. RESULTS: Religiosity was a significant determinant of attitudes to euthanasia and attitudes to euthanasia were a significant determinant of the likelihood of assigning WTD values. A significant negative correlation in errors between the two probit models was observed indicative of support for the hypothesis of endogeneity between attitudes to euthanasia and readiness to assign WTD values. CONCLUSION: In Ireland attitudes and beliefs play an important role in understanding health state preferences. Beyond Ireland this may have implications for: the construction of representative samples; understanding the values accorded health states and; the frequency with which value sets must be updated.

The efficacy of clove oil as an anaesthetic and in euthanasia procedure for small-sized tropical fishes / A eficiência do óleo de cravo como anestésico e em procedimentos de eutanaisa em peixes de pequeno porte

Abstract Clove oil is used as a fish anesthetic because it is a natural and inexpensive product with low toxicity risks. The goal of the present study was to determine the appropriate concentration of clove oil for small-sized tropical fish to be used in mark-recapture studies or when individuals are to be sacrificed. We applied three different clove oil concentrations (D1=0.05 mL, D2=0.10 mL and D3=0.20 mL per 500 mL of water) on three small-sized fish species. We found a negative relationship between induction time and treatment for two species (Hyphessobrycon sp.1 and Hemigrammus sp.), while concentration was unrelated to recovery time. Fish body length was positively related to induction time in the D2 treatment for Hemigrammus sp., and negatively for Hyphessobrycon sp.1 in the D1 treatment, but was unrelated to recovery time for three species and treatments. Mortality rates varied across treatments, but higher rates were observed with higher clove oil concentrations. We conclude that 0.05 mL of clove oil per 500 mL of water is the most efficient dose for studies where fish will be released back to their natural habitats, while 0.20 mL of clove oil is recommended for studies that require fish euthanization for further laboratory analyses.

Resumo O óleo de cravo é recomendado como anestésico para peixes por ser produto de origem natural, baixo custo e apresentar poucos riscos de intoxicação. O objetivo deste trabalho foi determinar concentrações adequadas de óleo de cravo para anestesiar ou eutanasiar peixes de pequeno porte em ambiente natural. Foram testadas três concentrações do anestésico (D1=0,05 mL, D2=0,10 mL e D3=0,20 mL) em três espécies de peixes de pequeno. Houve uma relação negativa entre o tempo para a sedação dos indivíduos e a concentração para duas espécies (Hyphessobrycon sp.1 e Hemigrammus sp.), porém não foi encontrada relação entre o tempo para recuperação e as concentrações. Os exemplares maiores de Hemigrammus sp. levaram mais tempo para serem sedados no tratamento D2, já o contrário foi observado para Hyphessobrycon sp.1 no tratamento D1, enquanto que não houve efeito do comprimento no tempo de recuperação das três espécies. A mortalidade dos indivíduos variou entre as três concentrações do anestésico e as maiores taxas de mortalidade ocorreram nas maiores concentrações. Desse modo, a concentração de 0,05 mL é eficiente para estudos que envolvem manuseio e a soltura dos peixes, enquanto que a concentração de 0,20 mL é recomendada em estudos onde os peixes precisam ser sacrificados.

The relation between cultural values, euthanasia, and spiritual care in the Netherlands.

The aim of this paper is to gain some understanding of euthanasia as a Dutch cultural practice, focusing on value orientations that lie beneath the surface of what is made visible in the many national surveys done in the Netherlands. In order to reach this aim, I take 2 steps. In the first place, I give a short sketch of euthanasia as it is understood and practiced in the Netherlands. This is followed by a cultural analysis by the American­Dutch historian James Kennedy who studied the euthanasia debate in the Netherlands from the 1960s until 1985. Having arrived at some cultural understanding of Dutch mentality, I dive deeper into the understanding of the Dutch value orientations by focusing on the dimension of spiritual care at the end of life. After having defined the concept of spirituality, I sketch the contemporary state of affairs in this area and report how spiritual care in the Netherlands is understood and practiced by discussing the consensus­based Dutch guideline on spiritual care in palliative care, recent research on hope among palliative care patients in the Netherlands, and an often used Dutch tool for spiritual care: the Ars moriendi model. I end this contribution by sketching how I think that spiritual care at the end of life should be developed further in the Netherlands from a palliative care perspective.

Eutanasia, empatía, compasión y Derechos Humanos / Euthanasia, empathy, compassion and Human Rights

Lo problemático en el estudio de la empatía es su ausencia ante el sufrimiento ajeno. La eutanasia resalta el conflicto moral sobre sufrir o dejar de sufrir frente una enfermedad irreversible y dolorosa. Analizaré el conflicto que presenta el respeto pleno por el principio de dignidad humana, establecido en el artículo 51 del Código Civil y Comercial de la Nación Argentina, en relación con las directivas médicas anticipadas que impliquen una práctica eutanásica que, en función del artículo 60 del mismo cuerpo legal, se deberán tener por no escritas. Dos preguntas cerradas guiarán el análisis: ¿Menoscaba a la dignidad humana la eutanasia, en su modalidad activa? ¿Resulta justa o injusta la restricción a la autonomía personal en relación a la eutanasia? Finalmente, exploraré el rol de la compasión en la eutanasia (AU)

What is problematic in the study of empathy is his absence to the suffering of others. Euthanasia highlights the moral conflict about suffering or stop suffering facing at an irreversible and painful illness. I will analyze the conflict that has full respect of human dignity, laid down in Article 51 of the Civil and Commercial Code of Argentina, in relation to advance medical directives that involve a practice euthanasia, according to the Article 60 of the same legal body, should not be written. Two closed questions will guide this analysis in order to reflect on them: Does euthanasia undermines the human dignity, in its active mode? Is it fair or unfair the restriction of personal autonomy in relation to euthanasia? Finally, I will explore what the role of compassion in euthanasia (AU)

The efficacy of clove oil as an anaesthetic and in euthanasia procedure for small-sized tropical fishes.

Clove oil is used as a fish anesthetic because it is a natural and inexpensive product with low toxicity risks. The goal of the present study was to determine the appropriate concentration of clove oil for small-sized tropical fish to be used in mark-recapture studies or when individuals are to be sacrificed. We applied three different clove oil concentrations (D1=0.05 mL, D2=0.10 mL and D3=0.20 mL per 500 mL of water) on three small-sized fish species. We found a negative relationship between induction time and treatment for two species (Hyphessobrycon sp.1 and Hemigrammus sp.), while concentration was unrelated to recovery time. Fish body length was positively related to induction time in the D2 treatment for Hemigrammus sp., and negatively for Hyphessobrycon sp.1 in the D1 treatment, but was unrelated to recovery time for three species and treatments. Mortality rates varied across treatments, but higher rates were observed with higher clove oil concentrations. We conclude that 0.05 mL of clove oil per 500 mL of water is the most efficient dose for studies where fish will be released back to their natural habitats, while 0.20 mL of clove oil is recommended for studies that require fish euthanization for further laboratory analyses.

Vida e morte na UTI: a ética no fio da navalha / Life and death in the ICU: ethics on the razor’s edge / Vida y muerte en la UCI: la ética en el filo de la navaja

Este artigo busca abordar algumas questões éticas vivenciadas nas fronteiras de vida e morte, nas unidades de terapia intensiva (UTI). Esses são locais especiais no âmbito hospitalar onde é obrigatória a presença de tecnologia médica de última geração, para preservar e sustentar a vida de pacientes em estado grave ou em risco. É nesse contexto complexo que emergem difíceis questões éticas: ausência critérios objetivos para internações em UTI; superlotação das UTI, com pacientes sem indicação; até as dificuldades de limitar a terapêutica, que se transforma em práticas distanásicas. Analisamos um caso de suicídio assistido, da jovem estadunidense Brittany Maynard, bem como a necessidade de cuidados paliativos, o dever ético de cuidar da dor e sofrimento humanos, a valorização do paradigma do cuidar para além do curar e a polêmica questão da ortotanásia, em busca de um final de vida sem dor ou sofrimento, mas em paz e com dignidade.

This article seeks to address some ethical issues experienced on the borders of life and death in Intensive Care Units (ICUs). These are special places in hospitals, where there is the mandatory presence of cutting-edge medical technology and support for the preservation of life of a patient in a critical condition or risk. It is in this complex context that difficult ethical issues emerge: there are no objective criteria for admissions to the ICU, ICUs can be overcrowded with patients without diagnosis and there are difficulties in limiting treatment, which results in medical procedures that only prolong the dying process of the patient. We analyzed a case of assisted suicide, the young American Brittany Maynard, the need for Palliative Care, the ethical duty to care for pain and human suffering, the need to rediscover the paradigm of care, in search of an end to life without pain and suffering, and to avoid the practice of “medical futility”, which only prolongs the dying process and only imposes more suffering on the patient, family members and health care professionals.

Este artículo intenta abordar algunas cuestiones éticas vivenciadas en las fronteras entre la vida y la muerte en las Unidades de Cuidados Intensivos (UCI). Estos son lugares especiales en los hospitales, donde existe una presencia obligatoria de tecnología médica de vanguardia, para preservar y mantener la vida de un paciente en estado grave o en riesgo. Es en este contexto complejo que surgen cuestiones éticas difíciles: ausencia de criterios objetivos para la admisión en la UCI; condiciones de hacinamiento de pacientes sin indicación; dificultades para limitar los tratamientos que se convierten en prácticas distanásicas. Se analizaron: un caso de suicidio asistido, de la joven estadounidense Brittany Maynard; la necesidad de cuidados paliativos; el deber ético de cuidar del dolor y del sufrimiento humano; la recuperación del paradigma de la atención más allá de la cura y la controvertida cuestión de la ortotanasia, que apunta al fin de la vida sin dolor ni sufrimiento, pero en paz y con dignidad.

Determinants of favourable opinions about euthanasia in a sample of French physicians.

BACKGROUND: The question whether euthanasia should be legalised has led to substantial public debate in France. The objective of this study in a sample of French physicians was to establish the potential determinants of a favourable opinion about euthanasia in general and when faced with a specific situation as embodied in the Humbert affair. METHODS: The study was a cross-sectional survey investigating two different samples of medical doctors: (1) those specialised in palliative care and affiliated to the French Society for Patient Accompaniment and Palliative Care; (2) medical interns (medical doctors in training course) in a French medical university (Marseille). A questionnaire was sent (email) to each voluntary participant including sociodemographics, professional status, mention of believing in God, and opinion about euthanasia (the question was designed to assess the general opinion about euthanasia and the opinion about a specific case, the Vincent Humbert' case (a man who was rendered quadriplegic, blind, and mute after an accident and has requested euthanasia). RESULTS: A total of 413 physicians participated in the research (participation rate: 48.5%). Less than half of the population were favourable to euthanasia in general and almost two-thirds of the population were favourable to Vincent Humbert's request for euthanasia. Based on the multivariate analysis, individuals believing in God and being a medical intern were significant independent factors linked to having a favourable opinion about euthanasia in general and about the Vincent Humbert's request. DISCUSSION: There is still no study in France on the development of opinion about euthanasia and its impact. The issue goes beyond the strictly professional sphere and involves broader socio-political stakes. These stakes do not necessarily take into account medical practices and experiences or the desires of end-of-life patients. The professional upheaval that the future French legal framework will doubtlessly trigger will require further research. CONCLUSION: The professional upheaval that the future French legal framework will doubtlessly trigger will require further research.

Addressing the Concerns Surrounding Continuous Deep Sedation in Singapore and Southeast Asia: A Palliative Care Approach.

The application of continuous deep sedation (CDS) in the treatment of intractable suffering at the end of life continues to be tied to a number of concerns that have negated its use in palliative care. Part of the resistance towards use of this treatment option of last resort has been the continued association of CDS with physician-associated suicide and/or euthanasia (PAS/E), which is compounded by a lack clinical guidelines and a failure to cite this treatment under the aegis of a palliative care approach. I argue that reinstituting a palliative care-inspired approach that includes a holistic review of the patient's situation and the engagement of a multidisciplinary team (MDT) guided by clearly defined practice requirements that have been lacking amongst many prevailing guidelines will overcome prevailing objections to this practice and allow for the legitimization of this process.

[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.