Euthanasia, consensual homicide, and refusal of treatment.

Consensual homicide remains a crime in jurisdictions where active voluntary euthanasia has been legalized. At the same time, both jurisdictions, in which euthanasia is legal and those in which it is not, recognize that all patients (whether severely ill or not) have the right to refuse or withdraw medical treatment (including life-saving treatment). In this paper, I focus on the tensions between these three norms (the permission of active euthanasia, the permission to reject life-saving treatment, and the prohibition of consensual homicide), assuming a justification of euthanasia based on the right to (personal) autonomy. I argue that the best way to provide a coherent account of these norms is to claim that patients have two distinct rights: the right to autonomy and the right to bodily integrity. This solution has some relevant implications for the discussion of the legalization of active euthanasia.

Eutanásia Voluntária Ativa, Suicídio Assistido, Ortotanásia e os Cuidados Paliativos: um panorama das discussões no Poder Legislativo Federal Brasileiro / Eutanàsia Voluntària Activa, Suïcidi Assistit, Ortotanàsia i Cures Pal·liatives: un panorama de les discussions en el Poder Legislatiu Federal brasiler / Eutanasia Voluntaria Activa, Suicidio Asistido, Ortotanasia y Cuidados Paliativos: un panorama de las discusiones en el Poder Legislativo Federal brasileño / Voluntary Active Euthanasia, Assisted Suicide, Orthothanasia and Palliative Care: An overview of the discussions in the Brazilian Federal Legislative Power

No âmbito das proposições legislativas brasileiras, buscou-se compreender os desafiose obstáculos no percurso delimitativo das práticas de fim de vida. Analisou-se 193 documentos, desde 1981 até 2020, com base na metodologia hermenêutica-dialética. Evidenciou-se distintas propostas regulamentadoras das práticas de eutanásia e ortotanásia,na relação com os cuidados paliativos. As associações dos termos “cuidados paliativos” e “ortotanásia”, em oposição à “eutanásia/suicídio assistido, revelaram a conflituosa construção de valores que perpassa nossa sociedade. Com a tramitação de projetos relacionados à ortotanásia e eutanásia, compreendemos o sentido das decisões políticas que envolvem as possibilidades de escolhas e liberdade das pessoas, entre o direito à vida e o direito à morte digna. Compreendemos a problemática da legalização da ortotanásia, como forma do poder legislativo se furtar ao debate sobre a eutanásia/suicídio assistido, como alternativa à distanásia e ao sofrimento no processo de morrer.(AU)

En el context de les propostes legislatives brasileres, busquem comprendre els reptes i obstacles en el camí cap a la delimitació de les pràctiques al final de la vida. S'han analitzat 193 documents, des de 1981 fins a 2020, basant-se en la metodologia hermenèutica-dialèctica. S'han evidenciat diferents propostes normatives per a les pràctiques d'eutanàsia i ortotanàsia, en relació als cures pal·liatius. Les associacions dels termes "cures pal·liatius" i "ortotanàsia", en oposició a "eutanàsia/suïcidi assistit", revelen la construcció conflictiva de valors que impregna la nostra societat. Amb la tramitació dels projectes relacionats amb la ortotanàsia i l'eutanàsia, entenem el sentit de les decisions polítiques que implica les possibilitats de tria i llibertat de les persones, entre el dret a la vida i el dret a una mort digna. Comprenguem el problema de la legalització de la ortotanàsia com una forma que el poder legislatiu eviti el debat sobre l'eutanàsia/suïcidi assistit, com a alternativa a la distanàsia i al patiment en el procés de morir.(AU)

En el ámbito de las propuestas legislativas brasileñas, se buscó comprender los desafíos y obstáculos en el camino de la regulación de las prácticas al final de la vida. Se analizaron 193 documentos desde 1981 hasta 2020, utilizando la metodología hermenéutica-dialéctica. Se evidenciaron diferentes propuestas regulatorias relacionadas con la eutanasia y la ortotanasia, en relación con los cuidados paliativos. La asociación de los términos "cuidados paliativos" y "ortotanasia", en contraposición a "eutanasia/suicidio asistido", reveló la conflictiva construcción de valores que atraviesa nuestra sociedad. Con la tramitación de proyectos relacionados con la ortotanasia y la eutanasia, comprendemos el sentido de las decisiones políticas que involucran las posibilidades de elección y libertad de las personas, entre el derecho a la vida y el derecho a una muerte digna. También comprendemos la problemática de la legalización de la ortotanasia como una forma de que el poder legislativo evite el debate sobre la eutanasia/suicidio asistido, como una alternativa a la distanasia y al sufrimiento en el proceso de morir.(AU)

Within the scope of Brazilian legislative proposals, we sought to understand the challenges and obstacles in the delimiting path of end-of-life practices. 193 documents were analyzed, from 1981 to 2020, based on the hermeneutic-dialectical methodology. Different regulatory proposals for the practices of euthanasia and orthothanasia, in relation to palliative care, were evidenced. The associations of the terms “palliative care” and “orthothanasia”, as opposed to “euthanasia/assisted suicide, revealed the conflicting construction of values that permeates our society. With the processing of projects related to orthothanasia and euthanasia, we understand the meaning of political decisions that involve the possibilities of choices and freedom of people, between the right to life and the right to a dignified death. We understand the problem of legalizing orthothanasia as a way for the legislative power to evade the debate on euthanasia/assisted suicide, as an alternative to dysthanasia and suffering in the dying process.(AU)

La regulación de la eutanasia en España y el farmacéutico de hospital: estado de la cuestión / The regulation of euthanasia in Spain and the hospital pharmacist: state of the art

Objetivo: Conocer la realidad del farmacéutico de hospital en relación a la Ley Orgánica 3/2021 de regulación de la eutanasia. Método: Se diseñó una encuesta de 22 preguntas acerca de la Ley de regulación de la eutanasia y se difundió via on-line a los farmacéuticos hospitalarios pertenecientes a la Sociedad Española de Farmacia Hospitalaria. La solicitud de participación se llevó a cabo en mayo 2022. Resultados: Se recopilaron 242 respuestas siendo un 66% facultativos especialistas de área. Cabe destacar que el 81% afirmaban conocer la Ley Orgánica 3/2021 de regulación de la eutanasia y el 63% no se declararía objetor de conciencia. Los protocolos de actuación para la prestación de ayuda para morir sólo existían antes de tener el primer caso en el 31% de los hospitales. Conclusiones: Solo conociendo el pronunciamiento del profesional facultativo ante la prestación de ayuda para morir puede conocerse la realidad y mejorar la asistencia. Ante las incógnitas y falta de desarrollo normativo se crea la necesidad de contar con equipos de profesionales formados que lleven a cabo esta prestación. (AU)

Objective: To know the reality of the hospital pharmacist in relation to the Spanish Law 3/2021, of regulation of euthanasia Methods: A 22-question survey regarding the Law that regulates euthanasia in Spain was designed and spread online to hospital pharmacists belonging to the Spanish Society of Hospital Pharmacy. The request for participation was sent in May 2022. Results: 242 responses were collected, 66% of which came from area specialists. It is important to highlight that 81% claimed to be aware of the Spanish Law 3/2021 and the results showed that 63% of the respondents would not declare themselves a conscientious objector. The action protocols for the provision of Aid in Dying only existed before the first case was carried out in 31% of the hospitals in Spain. Conclusions: Only by knowing the pronouncement of the health professionals regarding the provision of Aid in Dying, the current situation can be known and, therefore, the patient care been improved. Given the unknowns and lack of normative development, the need for teams of trained professionals to carry out the provision for the service is needed. (AU)

Overcoming Conflicting Definitions of "Euthanasia," and of "Assisted Suicide," Through a Value-Neutral Taxonomy of "End-Of-Life Practices".

The term "euthanasia" is used in conflicting ways in the bioethical literature, as is the term "assisted suicide," resulting in definitional confusion, ambiguities, and biases which are counterproductive to ethical and legal discourse. I aim to rectify this problem in two parts. Firstly, I explore a range of conflicting definitions and identify six disputed definitional factors, based on distinctions between (1) killing versus letting die, (2) fully intended versus partially intended versus merely foreseen deaths, (3) voluntary versus nonvoluntary versus involuntary decisions, (4) terminally ill versus non-terminally ill patients, (5) patients who are fully conscious versus those in permanent comas or persistent vegetative states, and (6) patients who are suffering versus those who are not. Secondly, I distil these factors into six "building blocks" and combine them to develop an unambiguous, value-neutral taxonomy of "end-of-life practices." I hope that this taxonomy provides much-needed clarification and a solid foundation for future ethical and legal discourse.

Identifying practical clinical problems in active euthanasia: A systematic literature review of the findings in countries where euthanasia is legal.

OBJECTIVES: Currently, active euthanasia is legalized in only 7 countries worldwide. These countries have encountered problems in its implementation. The study aims to summarize the practical clinical problems in the literature on active euthanasia. METHODS: A systematic literature review was conducted using 140 works consisting of 130 articles from PubMed and EthxWeb and data from 10 euthanasia laws. RESULTS: After reviewing the specific problems reported to be associated with euthanasia in each country, 5 problems were extracted: many ambiguous conditions with room for interpretation, insufficient assurance of voluntariness, response to requests for euthanasia due to psychological distress, conscientious objection, and noncompliance by medical professionals. SIGNIFICANCE OF RESULTS: Multiple ambiguous conditions that are open to interpretation can result in a "slippery slope phenomenon." An insufficient guarantee of voluntariness violates the principle of respect for autonomy, which is the underlying justification for euthanasia. In cases of euthanasia due to mental anguish, a distinction between a desire for death caused by psychological pain alone prompted by mental illness and a desire for death caused by mental symptoms prompted by physical illness is essential. Conscientious objection should remain an option because of the heavy burden placed on doctors who perform euthanasia. Noncompliance by medical professionals due to ignorance and conflicts regarding euthanasia is contrary to procedural justice.

What About Us? Experiences of Relatives Regarding Physician-Assisted Death for Patients Suffering from Mental Illness: A Qualitative Study.

Physician-assisted death (PAD) for patients suffering from mental illness is legally permitted in the Netherlands. Although patients' relatives are not entrusted with a legal role, former research revealed that physicians take into account the patient's social context and their well-being, in deciding whether or not to grant the request. However, these studies focussed on relatives' experiences in the context of PAD concerning patients with somatic illness. To date, nothing is known on their experiences in the context of PAD concerning the mentally ill. We studied the experiences of relatives with regard to a PAD request by patients suffering from mental illness. The data for this study were collected through 12 interviews with relatives of patients who have or had a PAD request because of a mental illness. We show that relatives are ambivalent regarding the patient's request for PAD and the following trajectory. Their ambivalence is characterised by their understanding of the wish to die and at the same time hoping that the patient would make another choice. Respondents' experiences regarding the process of the PAD request varied, from positive ('intimate') to negative ('extremely hard'). Some indicated that they wished to be more involved as they believe the road towards PAD should be a joint trajectory. To leave them out during such an important event is not only painful, but also harmful to the relative as it could potentially complicate their grieving process. Professional support during or after the PAD process was wanted by some, but not by all.

An international expansion in voluntary euthanasia/assisted dying: The implications for nursing.

AIM: To provide an update on the international position of assisted dying legislation and its implications for nursing policy. BACKGROUND: Assisted dying legislation has been introduced in health systems in Europe, North America and Australasia (Australia and New Zealand). Despite contributions in research literature, this remains focussed on medical practitioners, with limited acknowledgement of the need for policy development in nursing. DISCUSSION: There is a need for critical evaluation of this contemporary issue and the significance for nursing practice of the lack of unified nursing perspective and robust policy guidance is identified. An overview of the existing role of voluntary euthanasia/assisted dying with recent developments is provided and the resulting concerns for nurses regarding the scope of practice, role confusion and conflicting professional values is considered. CONCLUSION: Despite a long history of assisted dying and the continued expansion of these practices, limited and highly variable nursing policy highlights the lack of clear guidance available to nurses. The growing inclusion of nurse practitioners and recognition of registered nurse involvement in the care of individuals on an assisted dying pathway merits clearer support from regulatory authorities and professional organisations. IMPLICATIONS FOR NURSING PRACTICE: Nurses are the most likely health professionals to be approached with questions regarding assisted dying; they are intimately involved in patient experiences and need to understand what is possible, expected and legal in terms of their scope of practice regarding assisted dying. IMPLICATIONS FOR NURSING POLICY: Nursing regulators and professional representatives need to provide clear policy statements and guidance identifying the nursing role and recognising where protections and support are necessary.

Externalist argument against medical assistance in dying for psychiatric illness.

Medical assistance in dying, which includes voluntary euthanasia and assisted suicide, is legally permissible in a number of jurisdictions, including the Netherlands, Belgium, Switzerland and Canada. Although medical assistance in dying is most commonly provided for suffering associated with terminal somatic illness, some jurisdictions have also offered it for severe and irremediable psychiatric illness. Meanwhile, recent work in the philosophy of psychiatry has led to a renewed understanding of psychiatric illness that emphasises the role of the relation between the person and the external environment in the constitution of mental disorder. In this paper, I argue that this externalist approach to mental disorder highlights an ethical challenge to the practice of medical assistance in dying for psychiatric illness. At the level of the clinical assessment, externalism draws attention to potential social and environmental interventions that might have otherwise been overlooked by the standard approach to mental disorder, which may confound the judgement that there is no further reasonable alternative that could alleviate the person's suffering. At the level of the wider society, externalism underscores how social prejudices and structural barriers that contribute to psychiatric illness constrain the affordances available to people and result in them seeking medical assistance in dying when they otherwise might not have had under better social conditions.

Death as "benefit" in the context of non-voluntary euthanasia.

I offer a principled objection to arguments in favour of legalizing non-voluntary euthanasia on the basis of the principle of beneficence. The objection is that the status of death as a benefit to people who cannot formulate a desire to die is more problematic than pain management care. I ground this objection on epistemic and political arguments. Namely, I argue that death is relatively more unknowable, and the benefits it confers more subjectively debatable, than pain management. I am not primarily referring to the claim that it is difficult to make comparisons between live and post-mortem states, but rather to the fact that it is epistemically and metaphysically problematic to impute a "life-worse-than-death" or a state of "suffering-calling-for-death" to people who cannot subjectively wish to die, as though this kind of suffering were a medically observable fact rather than a belief- and value-laden notion. On the contrary, people enduring similar causes of pain may have different experiences of suffering and views on how it affects the worthwhileness of their existence or the desirability of death or of continuing their lives. The projection of a "suffering-calling-for-death" onto infants or people with severe intellectual disabilities may not be indefensible, but it is more controversial than judging that pain management will improve their well-being from the perspective of beneficence. My argument also relies on our society's liberal endeavour to avoid endorsing unverifiable beliefs about life and death or controversial conceptions of the good life. My goal is not to suggest we should not attend the suffering of cognitively disabled people. On the contrary, I only cast doubt on too quick an assumption that ending their lives is the best way of caring for them, when robust palliative treatments are available. Moreover, I express the concern that a lack of attention to distinctions between "pain-calling-for-relief" and "suffering-calling-for-death" may be based on ableist projections and assumptions. I conclude that it is imperative to continue research into the nature of pain and suffering experienced by individuals with mental or cognitive impairments preventing them from expressing autonomous wishes about the kind of treatment that would most benefit them.