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.

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.

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.

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.

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.

Killing in the name of: A merciful death?

"Mercy" holds a well-established place in the discourse on assisted death (AD), with mercy rhetoric used by both proponents and opponents of AD alike. In this paper, I interrogate the relationship between mercy, mercy killing and AD. Appeals to mercy introduce an ambiguity that carries implications for the enduring debate about healthcare professionals' participation in this controversial practice. The term "mercy killing" is used at different times to mean all of the following: killings that are acts of punitive leniency, killings motivated by pity, killings motivated by compassion, and acts of voluntary, involuntary and nonvoluntary euthanasia. I argue that killings that are acts of punitive leniency "track" a conceptually useful understanding of mercy and, by extension, mercy killing. However, if mercy is understood in this way, then "mercy killing" is a problematic way of characterizing physician-AD. While reference to mercy killing has been weeded out of AD legislation over time, the same cannot be said of public discourse, where the debate about physicians' character-and the locus of power with respect to who gets to decide when a life can rightly be ended-continues.

"Discussion or silent accompaniment: a grounded theory study about voluntary stopping of eating and drinking in Switzerland".

BACKGROUND: Voluntary stopping of eating and drinking as an option to end life prematurely is gaining international attention, and health care professionals are increasingly confronted with the wish to die through voluntary stopping of eating and drinking by individuals. While to date, there are no guidelines in Switzerland to orient professional support, it is of interest how professionals and other people involved react to the situation. The aim of this qualitative study was to explore how health care professionals in Switzerland accompany individuals during voluntary stopping of eating and drinking and to analyze this decision-making process. METHODS: Charmaz's grounded theory constructivist methodology uses guidelines for systematic, theory-driven data analysis underpinned by a pragmatic philosophical perspective. Data were collected in autumn 2016 as part of a regional palliative care conference on voluntary stopping of eating and drinking. All participants of the expert meeting (N = 50, including nurses, counsellors, ethicists, medical doctors, politicians, volunteers, and relatives) were invited to the focus group interviews, of which N = 47 participated. We conducted five focus group interviews, each lasting one hour. RESULTS: The results showed that the accompaniment of those willing to die during voluntary stopping of eating and drinking was either discussed and cleared with one another or was unspoken and silently accompanied. CONCLUSIONS: The demands of participants for more knowledge must be heeded, and there is also a need for systematic instructions on how to proceed in the case of voluntary stopping of eating and drinking support and what needs to be considered.

Mutatis mutandis On Euthanasia and Advanced Dementia in the Netherlands.

Euthanasia and physician-assisted suicide are common practice in the Netherlands. In response to increasing requests from patients to end their lives, physicians are finding themselves placed in particularly precarious situations because of advance directives written by patients suffering from severe dementia. In April 2020, the Supreme Court of the Netherlands issued two judgments in the so-called Dormicum case: a case involving the deliberate termination of the life of a 74-year-old woman suffering from advanced dementia by a geriatrician in a nursing home in The Hague. The judgment of the lower criminal court was upheld, but the sanction imposed by the appellate disciplinary court was quashed. In this paper, the author reviews the two Supreme Court rulings, argues that both are fundamentally flawed and raises questions as to what they mean for Dutch criminal law, physicians, and patients going forward.

Public reasoning about voluntary assisted dying: An analysis of submissions to the Queensland Parliament, Australia.

The use of voluntary assisted dying as an end-of-life option has stimulated concerns and debates over the past decades. Although public attitudes towards voluntary assisted dying (including euthanasia and physician-assisted suicide) are well researched, there has been relatively little study of the different reasons, normative reasoning and rhetorical strategies that people invoke in supporting or contesting voluntary assisted dying in everyday life. Using a mix of computational textual mining techniques, keyword study and qualitative thematic coding to analyse public submissions to a parliamentary inquiry into voluntary assisted dying in Australia, this study critically examines the different reasons, normative reasoning and rhetorical strategies that people invoke in supporting or contesting voluntary assisted dying in everyday life. The analysis identified complex and potentially contradictory ethical principles being invoked on both sides of the debate. These findings deepen our understanding of the moral basis of public reasoning about end-of-life matters and will help to inform future discussions on policy and law reform. The findings underscore the importance of sound normative reasoning and the use of caution when interpreting opinion polls to inform policy.

Gaining insight into the views of outpatients with Huntington's disease regarding their future and the way they deal with their poor prognosis: a qualitative study.

BACKGROUND: Huntington's disease (HD) has a poor prognosis. Decision-making capacity and communication ability may become lost as the disease progresses. Therefore, HD patients are encouraged to engage in advance care planning (ACP). To improve ACP for HD patients, there is a need to better understand how these patients face their poor prognosis. AIM: To gain insight into the views of HD patients who receive outpatient care regarding their future and the way they deal with the poor prognosis of their disease. METHODS: A qualitative study using semi-structured interviews with 12 patients with HD (7 outpatient clinic, 3 day care, 2 assisted living facility). Audio-recorded interviews were transcribed verbatim. Through reading and re-reading interviews, writing memos and discussions in the research team, strategies were identified. RESULTS: Three strategies emerged for facing a future with HD. Participants saw the future: 1) as a period that you have to prepare for; 2) as a period that you would rather not think about; 3) as a period that you do not have to worry about yet. Participants could adopt more than one strategy at a time. Even though participants realized that they would deteriorate and would need more care in the future, they tried to keep this knowledge 'at a distance', with the motivation of keeping daily life as manageable as possible. CONCLUSIONS: Official ACP guidelines recommend discussing goals and preferences for future treatment and care, but patients tend to want to live in the present. Further research is needed to elucidate the best approach to deal with this discrepancy.

Disability and the Complexity of Choice in the Ethics of Abortion and Voluntary Euthanasia.

In the polarized debates about abortion and voluntary euthanasia, disability advocates, who normally align with left-wing social forces, have tended to side with conservative and religious voices in expressing concerns about the impact of technological and sociopolitical developments on disabled futures. This paper draws on the social model of disability and the virtue ethics tradition to explain the alignment between the religious and disability perspectives, and the theory of transformative choice to highlight the limits and biases of the pro-choice logic. Yet, it also recognizes the inherent contradiction of disabled advocates taking a paternalistic position against the personal agency of women and people facing terminal illnesses. A disability perspective serves the discussion of abortion and euthanasia as an encouragement to work together for the building of a society that enables people with diverse disabilities to exist and flourish, and helps pregnant women, people facing disabling and terminal illnesses, and politicians and social influencers to make informed choices.

The people speak: social media on euthanasia/assisted dying.

In New Zealand, aiding and abetting a person to commit suicide or euthanasia even with consent is unlawful. The introduction of a third Bill on assisted dying to the House of Representatives following a high-profile court case afforded an opportunity for examining how assisted dying was discussed in the public sphere. In this article, we report on a discourse analysis of a selection of social media to illustrate the ways in which citizens participate in the voluntary euthanasia debate. The volume of social media posts that made up our data set suggests that the legalisation of assisted dying is a highly topical and deeply salient societal issue. Social media postings represent the voices of ordinary citizens who may not participate in formal public consultation processes. Based on our analysis, the assignment of binary conclusions about public opinion is simplistic and fails to adequately represent the intricacies of public debate. Contributors' posts reveal deeply held sociocultural values, as well as tensions about the relationship between citizens and the apparatus of government.

Euthanasia in Serbia: Attitudes of Students of Law and Medicine.

BACKGROUND: Voluntary active euthanasia represents one of the key topics in the contemporary world medicine, law, religious, ethical and moral issues. Serbia considers legalization of this procedure. Between the others, it is important to examine the student's attitudes regarding this issue. METHODS: Data were obtained from the faculties of law and medicine, from the universities of Kragujevac and Nis, Serbia. Data were collected during the second half of 2017. The research included 214 students. Due to the nature, subject and hypothesis of the research, the authors used descriptive method and the method of the theoretical content analysis. RESULTS: Generally, 54% of the students are in favor of legalization of the voluntary active euthanasia. 62, 4% would take part in the referendum on the legalization euthanasia. CONCLUSION: The results obtained in the survey on euthanasia on a sample of law and medical students in Nis and Kragujevac indicate that choice of the faculty (law or medicine) influences the structure (share) of responses to particular questions to some extent. However, this influence does not provide ground for conclusion that students' opinion on legalization and application of euthanasia depends on fact they study law or medicine.

First prosecution of a Dutch doctor since the Euthanasia Act of 2002: what does the verdict mean?

On 11 September 2019, the verdict was read in the first prosecution of a doctor for euthanasia since the Termination of Life on Request and Assisted Suicide (Review Procedures) Act of 2002 was installed in the Netherlands. The case concerned euthanasia on the basis of an advance euthanasia directive (AED) for a patient with severe dementia. In this paper we describe the review process for euthanasia cases in the Netherlands. Then we describe the case in detail, the judgement of the Regional Review Committees for Termination of Life on Request and Euthanasia (RTE) and the judgement of the medical disciplinary court. Both the review committees and the disciplinary court came to the conclusion there were concerns with this case, which mainly hinged on the wording of the AED. They also addressed the lack of communication with the patient, the absence of oral confirmation of the wish to die and the fact that the euthanasia was performed without the patient being aware of this. However, the doctor was acquitted by the criminal court as the court found she had in fact met all due care criteria laid down in the act. We then describe what this judgement means for euthanasia in the Netherlands. It clarifies the power and reach of AEDs, it allows taking conversations with physicians and the testimony of the family into account when interpreting the AED. However, as a practical consequence the prosecution of this physician has led to fear among doctors about prosecution after euthanasia.

Conscientious objection and moral distress: a relational ethics case study of MAiD in Canada.

Conscientious objection has become a divisive topic in recent bioethics publications. Discussion has tended to frame the issue in terms of the rights of the healthcare professional versus the rights of the patient. However, a rights-based approach neglects the relational nature of conscience, and the impact that violating one's conscience has on the care one provides. Using medical assistance in dying as a case study, we suggest that what has been lacking in the discussion of conscientious objection thus far is a recognition and prioritising of the relational nature of ethical decision-making in healthcare and the negative consequences of moral distress that occur when healthcare professionals find themselves in situations in which they feel they cannot provide what they consider to be excellent care. We propose that policies that respect the relational conscience could benefit our healthcare institutions by minimising the negative impact of moral distress, improving communication among team members and fostering a culture of ethical awareness. Constructive responses to moral distress including relational cultivation of moral resilience are urged.

What passive euthanasia is.

BACKGROUND: Euthanasia can be thought of as being either active or passive; but the precise definition of "passive euthanasia" is not always clear. Though all passive euthanasia involves the withholding of life-sustaining treatment, there would appear to be some disagreement about whether all such withholding should be seen as passive euthanasia. MAIN TEXT: At the core of the disagreement is the question of the importance of an intention to bring about death: must one intend to bring about the death of the patient in order for withholding treatment to count as passive euthanasia, as some sources would indicate, or does withholding in which death is merely foreseen belong to that category? We may expect that this unclarity would be important in medical practice, in law, and in policy. The idea that withholding life-sustaining treatment is passive euthanasia is traced to James Rachels's arguments, which lend themselves to the claim that passive euthanasia does not require intention to end life. Yet the argument here is that Rachels's arguments are flawed, and we have good reasons to think that intention is important in understanding the moral nature of actions. As such, we should reject any understanding of passive euthanasia that does not pay attention to intent. SHORT CONCLUSION: James Rachels's work on active and passive euthanasia has been immensely influential; but this is an influence that we ought to resist.

Long-term care nurses' attitudes and the incidence of voluntary stopping of eating and drinking: A cross-sectional study.

AIMS: To assess the incidence of voluntary stopping of eating and drinking (VSED) in long-term care and to gain insights into the attitudes of long-term care nurses about the VSED. DESIGN: A cross-sectional study. METHODS: Heads of Swiss nursing homes (535; 34%) answered the Online-Survey between June - October 2017, which was evaluated using descriptive data analysis. RESULTS: The incidence of patients who died in Swiss nursing homes by voluntarily stopping eating and drinking is 1.7% and 67.5% of participants consider this phenomenon highly relevant in their daily work. Most participants (64.2%) rate VSED as a natural death accompanied by health professionals and patients are also granted the right to care (91.9%). This phenomenon is expected by the participants less at a young age and more in old age. CONCLUSION: Participants' overall views on the VSED are very positive, whereas it is assumed that VSED is a phenomenon of old age. Professionals still lack sufficient knowledge about this phenomenon, which could be clarified through training. IMPACT: Voluntary stopping of eating and drinking is much discussed interprofessional, but there is a lack of knowledge on how this is perceived in the context of long-term care and about the incidence of the phenomenon. Voluntary stopping of eating and drinking is rare but noticeable end-of-life practises that is considered by professionals to be mainly dignified and peaceful, although moral concerns make it difficult to accompany. These findings call on long-term care institutions to discuss VSED as an end-of-life practice. Positioning on the issue provides clarity for staff and patients and promotes to develop standardized care. International Registered Report Identifier (IRRID): DERR1-10.2196/10358.

And What About the Pharmacist?

In the Netherlands, euthanasia has been decriminalized. Termination of life on request and assisted suicide are criminal offences under Dutch law; but if physicians comply with the due care requirements of the Euthanasia Act and report their actions in the manner prescribed by law, they will not be prosecuted. One of the requirements relates to the act of euthanasia itself. If this is to be performed with due medical care, the physician relies on the services of a pharmacist. However, the responsibilities of the pharmacist with respect to euthanasia are not laid down in law. At present, Dutch pharmacists have to make do with professional rules that do not offer adequate solutions for the problems that may arise when euthanasia is performed.

Suicide-related Materials and Voluntary Assisted Dying.

This column discusses the potential for conflict between the Federal laws forbidding the use of telecommunications to spread "suicide-related materials" and the laws in Victoria and Western Australia which have legalised forms of voluntary assisted dying. The column argues that the effect of the State laws is to differentiate the legal forms of voluntary assisted dying from suicide and assisted suicide, with the effect that Federal prohibitions do not apply to telecommunications between health practitioners and their patients regarding voluntary assisted dying.

Medical Assistance in Dying: A Review of Canadian Regulatory Documents.

After years of heated debate about the issue, medical assistance in dying (MAiD) was legalized in Canada in 2016. Canada became the first jurisdiction where MAiD may be delivered by nurse practitioners as well as physicians. Experience has revealed significant public demand for the service, and Canadians expect nurses to advocate for safe, high-quality, ethical practice in this new area of care. Pesut et al. offer a superb analysis of the related Canadian nursing regulatory documents and the challenges in creating a harmonized approach that arise in a federation where the Criminal Code is a federal entity and the regulation of health care providers and delivery of care fall under provincial and territorial legislation. Organizations like the Canadian Nurses Association contribute to the development of good legislation by working with partners to present evidence to help legislators consider impacts on public health, health care, and providers. Nursing regulators across Canada responded quickly to the unfolding policy landscape as the federal legislation evolved and will face that task again: In February 2020, the federal government tabled legislation to relax conditions related to MAiD requests that will force regulators and professional associations back to public advocacy and legislative tables. The success of the cautious approach exercised by nursing bodies throughout this journey should continue to reassure Canadians that their high trust in the profession is well placed.