This chapter contains sections titled: The Traditional Prejudice Killing Suicide Assisted Suicide and Euthanasia From Morality to Public Policy Conclusion References Further reading.

Euthanasia and assisted suicide have been legally possible in the Netherlands since 2001, provided that statutory due care criteria are met, including: voluntary and well-considered request; unbearable suffering without prospect of improvement; informing the patient; lack of a reasonable alternative; independent second physician’s opinion. ‘Unbearable suffering’ must have a medical basis, either somatic or psychiatric, but there is no requirement of limited life expectancy. All EAS cases must be reported and are scrutinised by regional review committees. (...) The purpose of this study was to investigate whether any particular difficulties arise when the EAS due care criteria are applied to patients with an intellectual disability and/or autism spectrum disorder. The 416 case summaries available on the RTE website were searched for intellectual disability and autism spectrum disorder. Direct content analysis was used on these nine cases. Assessment of decisional capacity was mentioned in eight cases, but few details given; in two cases, there had been uncertainty or disagreement about capacity. Two patients had progressive somatic conditions. For most, suffering was due to an inability to cope with changing circumstances or increasing dependency; in several cases, suffering was described in terms of characteristics of living with an autism spectrum disorder, rather than an acquired medical condition. Some physicians struggled to understand the patient’s perspective. Treatment refusal was a common theme, leading physicians to conclude that EAS was the only remaining option. There was a lack of detail on social circumstances and how patients were informed about their prognosis. Autonomy and decisional capacity are highly complex for patients with intellectual disabilities and difficult to assess; capacity tests in these cases did not appear sufficiently stringent. Assessment of suffering is particularly difficult for patients who have experienced life-long disability. The sometimes brief time frames and limited number of physician-patient meetings may not be sufficient to make a decision as serious as EAS. The Dutch EAS due care criteria are not easily applied to people with intellectual disabilities and/or autism spectrum disorder, and do not appear to act as adequate safeguards. (shrink)

In the Netherlands, in 1995 approximately 9700 people explicitly requested euthanasia or assisted suicide, and EAS was performed approximately 3600 times. The most important reasons for not performing EAS when requested by a patient were that the patient died before EAS was performed, or that the physician refused the request.

Euthanasia and physician assisted-suicide are terms used to describe the process in which a doctor of a sick or disabled individual engages in an activity which directly or indirectly leads to their death. This behavior is engaged by the healthcare provider based on their humanistic desire to end suffering and pain. The psychiatrist's involvement may be requested in several distinct situations including evaluation of patient capacity when an appeal for euthanasia is requested on grounds of terminal (...) somatic illness or when the patient is requesting euthanasia due to mental suffering. We compare attitudes of 49 psychiatrists towards euthanasia and assisted suicide with a group of 54 other physicians by means of a questionnaire describing different patients, who either requested physician-assisted suicide or in whom euthanasia as a treatment option was considered, followed by a set of questions relating to euthanasia implementation. When controlled for religious practice, psychiatrists expressed more conservative views regarding euthanasia than did physicians from other medical specialties. Similarly female physicians and orthodox physicians indicated more conservative views. Differences may be due to factors inherent in subspecialty education. We suggest that in light of the unique complexity and context of patient euthanasia requests, based on their training and professional expertise psychiatrists are well suited to take a prominent role in evaluating such requests to die and making a decision as to the relative importance of competing variables. (shrink)

The majority of Dutch physicians feel pressure when dealing with a request for euthanasia or physician-assisted suicide. This study aimed to explore the content of this pressure as experienced by general practitioners. We conducted semistructured in-depth interviews with 15 Dutch GPs, focusing on actual cases. The interviews were transcribed and analysed with use of the framework method. Six categories of pressure GPs experienced in dealing with EAS requests were revealed: emotional blackmail, control and direction by others, (...) doubts about fulfilling the criteria, counterpressure by patient’s relatives, time pressure around referred patients and organisational pressure. We conclude that the pressure can be attributable to the patient–physician relationship and/or the relationship between the physician and the patient’s relative, the inherent complexity of the decision itself and the circumstances under which the decision has to be made. To prevent physicians to cross their personal boundaries in dealing with EAS request all these different sources of pressure will have to be taken into account. (shrink)

Most quantitative studies that survey nurses’ attitudes toward euthanasia and/or assisted suicide, also attempt to assess the influence of religion on these attitudes. We wanted to evaluate the operationalisation of religion and world view in these surveys. In the Pubmed database we searched for relevant articles published before August 2008 using combinations of search terms. Twenty-eight relevant articles were found. In five surveys nurses were directly asked whether religious beliefs, religious practices and/or ideological convictions influenced their attitudes, (...) or the respondents were requested to mention the decisional basis for their answers on questions concerning end-of-life issues. In other surveys the influence of religion and world view was assessed indirectly through a comparison of the attitudes of different types of believers and/or non-believers toward euthanasia or assisted suicide. In these surveys we find subjective religious or ideological questions (questions inquiring about the perceived importance of religion or world view in life, influence of religion or world view on life in general, or how religious the respondents consider themselves) and objective questions (questions inquiring about religious practice, acceptance of religious dogmas, and religious or ideological affiliation). Religious or ideological affiliation is the most frequently used operationalisation of religion and world view. In 16 surveys only one religious or ideological question was asked. In most articles the operationalisation of religion and world view is very limited and does not reflect the diversity and complexity of religion and world view in contemporary society. Future research should pay more attention to the different dimensions of religion and world view, the religious plurality of Western society and the particularities of religion in non-Western contexts. (shrink)

Most quantitative studies that survey nurses’ attitudes toward euthanasia and/or assisted suicide, also attempt to assess the influence of religion on these attitudes. We wanted to evaluate the operationalisation of religion and world view in these surveys. In the Pubmed database we searched for relevant articles published before August 2008 using combinations of search terms. Twenty-eight relevant articles were found. In five surveys nurses were directly asked whether religious beliefs, religious practices and/or ideological convictions influenced their attitudes, (...) or the respondents were requested to mention the decisional basis for their answers on questions concerning end-of-life issues. In other surveys the influence of religion and world view was assessed indirectly through a comparison of the attitudes of different types of believers and/or non-believers toward euthanasia or assisted suicide. In these surveys we find subjective religious or ideological questions (questions inquiring about the perceived importance of religion or world view in life, influence of religion or world view on life in general, or how religious the respondents consider themselves) and objective questions (questions inquiring about religious practice, acceptance of religious dogmas, and religious or ideological affiliation). Religious or ideological affiliation is the most frequently used operationalisation of religion and world view. In 16 surveys only one religious or ideological question was asked. In most articles the operationalisation of religion and world view is very limited and does not reflect the diversity and complexity of religion and world view in contemporary society. Future research should pay more attention to the different dimensions of religion and world view, the religious plurality of Western society and the particularities of religion in non-Western contexts. (shrink)

Arguments concerning central issues of contemporary Medical Ethics often not only bear similarities, but also derive their sheer essence from notions which belong to the celebrated history of Ethics. Thus, argumentation pro euthanasia and assisted suicide which focus on the detainment of dignity and the ensuring of posthumous reputation on behalf of the moral agent is shown to echo stoic views on arête and the subordination of life to the primary human goal, namely the achievement of virtue. (...) The progress made in palliative care when seen alongside the — steadily increasing — requests for suicide, is indicative of the fact that, though pain now days can be effectively controlled, moral agents often consider the preservation of their life detrimental to the detainment of virtue or posthumous reputation. The stoic view is considered to justify elective death as a personal choice, but is deemed inadequate as well as inconsistent in the broader context of a coherent value theory. (shrink)

Photo ID 71252867© Stepan Popov| Dreamstime.com Abstract While Medical Assistance in Dying (MAiD) has been legalized in Canada since 2016, it still excludes eligibility for persons who have mental illness as a sole underlying medical condition. This temporary exclusion was set to expire on March 17th, 2024, but was set 3 years further back by the Government of Canada to March 17th, 2027. This paper presents a critical appraisal of the case of MAiD for individuals with mental illness as the (...) sole underlying medical condition through the analysis of three ethical theories: principlism, deontology, and utilitarianism. Through evidence and discussion, it will be demonstrated that MAiD, in this context, may be ethically justifiable on the grounds of upholding human rights, protecting dignity, and minimizing suffering. Introduction In June of 2016, Medical Assistance in Dying (MAiD) was legalized in Canada.[1] Throughout the first six years, a temporary exclusion of eligibility for persons suffering solely from mental illness was extended.[2] The exclusion of mental illness as a sole underlying medical condition was set to expire on March 17, 2024.[3] However, on February 1, 2024, just over a month before the set expiration, the Government of Canada once again extended the exclusion, this time setting it back three years to March 17, 2027. There are currently several countries that allow MAiD for mental illness, including Belgium, the Netherlands, and Luxembourg.[4] Some countries, like Spain,[5] do not give specific guidance, leaving the matter under discussion by ethicists and courts. In these countries, there are specific (although different) requirements for the process; overall, for mental illness, the illness must be verifiable and not simply related to a perception of satisfaction with the length of life. This extension ignited discussion on whether MAiD for persons who have mental illness as a sole underlying medical condition in Canada is ethically acceptable. As a complex, multi-faceted, and interdisciplinary issue, ethicists assessing MAiD must take into account various moral obligations and considerations. This paper analyses MAiD in this context through the application of three ethical theories: principlism, deontology, and utilitarianism. This paper concludes that, based on the current evidence and knowledge of this developing situation, MAiD for persons with mental illness in Canada may be ethically justified on the grounds of upholding human rights, labour obligations, and dignity. Through the exploration of research and discussions, it will be demonstrated that society at large ought to protect liberty and act towards relieving suffering, thereby supporting the potential eligibility of MAiD for persons who have mental illness. Principlism: The Capacity and Ability to Assess and Decide for One’s Own Life Principlism is the application of four principles: autonomy, beneficence, non-maleficence, and justice. Principlism supports permitting MAiD for mental illness due to the importance of autonomy in decision-making, equitable and just practices for MAiD assessors, and reducing suffering for patients and their family member(s) and/or friend(s). Carter v. Canada, the Canadian Supreme Court ruling of 2015—which changed Canadian law to allow for MAiD—held that the prohibition of MAiD infringed on Canadians’ right to “life, liberty, and the security of the person.” In a unanimous decision, the Supreme Court of Canada decided that the criminal prohibition of MAiD violates the Canadian Charter of Rights and Freedoms.[6] The Court concluded that the criminal law prohibiting MAiD interfered with people’s autonomy and dignity, which are protected by the rights of liberty and security of the person.[7] The ruling emphasized that Canada’s constitution reflects the fundamental importance of individual autonomy in personal decision-making. Research provides evidence that MAiD improves autonomy: A study among psychiatric patients found that 8 of 48 psychiatric patients said the mere option of accessing MAiD was enough to assess their future options for living wholly.[8] These findings complement a study entailing interviews with 30 adults who have mental illness, which emphasized that the ability to access MAiD allows individuals to analyze their quality of life, envision their desired future, and make decisions accordingly.[9] Although not all participants agreed that mental illness as the only underlying medical condition was appropriate for MAiD eligibility, many participants agreed that patient autonomy in decision-making was paramount and should be respected. However, autonomy as an ethical principle does not immediately grant all persons with mental illness the option to access MAiD. There are multiple eligibility criteria for those who wish to receive MAiD, which still must be approved and assessed. Currently, eligibility criteria for MAiD states that individuals must “give informed consent to receive MAiD, meaning that the person has consented to receiving MAiD after they have received all information needed to make this decision.”[10] Consent requires capability or capacity, which is the ability to understand relevant information, appreciate its potential consequences, and make an informed decision for oneself.[11] Like for many other diseases, disabilities, and conditions, patient capability is determined on a case-by-case basis.[12] Given the stigma surrounding those struggling with mental health, this thorough case-by-case examination of an individual patient’s capability and capacity without prejudice or partiality should lead to equitable and fair treatment. Without appropriate testing, those with mental illness could be wrongly stripped of their decision-making power. Arguments against MAiD for those with mental illness have raised concerns about the potential for individuals to harm themselves and others. A survey of MAiD providers demonstrated that physicians believed that the bereavement experience following MAiD is challenging and profoundly distinct and that bereavement support for all members involved should be required.[13] However, while watching one die (of MAiD) may cause harm to their families, friends, and support system at large, it is also important to recognize that watching someone suffer and struggle through their mental health journey also poses significant harm. Qualitative studies in Ontario, Canada, have interviewed family members of persons with mental illness as a sole medical condition, and interviewees shared that witnessing the illness and its impacts on their close one's lives was a very difficult experience.[14] As it relates to MAiD, participants emphasized that those living with mental illness are in the best position to understand their own pain and suffering and, in turn, make their own decisions about relief.[15] In an interview, a MAiD provider stated that MAiD may provide less suffering and more peace, and that, although it “depends on the family,... usually the family is more prepared and at peace.”[16] On the contrary, a person who has mental illness may perceive choosing MAiD as beneficial to their family member(s) and/or friend(s). Among those who died by MAiD in 2021, 35.7 percent reported that they perceived themselves as a burden on their family and friends.[17] While some authors report their concerns regarding such social burden as a potential driving factor for MAiD requests, others report that there are other additional burdens associated with requesting MAiD that may be financial, societal, and personal.[18] As such, the extension of MAiD eligibility to those with mental illness will likely only allow a small number of people to be granted MAiD.[19] Many others will be diverted to appropriate services and treatments. Patients’ decision to choose MAID noted their ability to make choices about their own care, reflecting the value of autonomy.[20] Although it is difficult to determine what is good for families in individual cases, MAiD presents an option that is both beneficent and non-maleficent. Therefore, these arguments satisfy the principles which do not necessarily conflict with MAiD. Deontology: The Duty to Recognize Vulnerability and Relieve Suffering The argument here begins with the fundamental focus of deontology—that moral duty lies in an action rather than in its consequences. Further discussion is required to analyze the impact of MAiD on healthcare workers. The Canadian Medical Association (CMA) Code of Ethics and Professionalism requires physicians to abide by virtues, commitments, and responsibilities in delivering health care and service.[21] The code states that “a compassionate physician recognizes suffering and vulnerability, … and alleviate[s] the patient’s suffering.”[22] In the context of MAiD for persons with mental illness as a sole underlying medical condition, vulnerabilities could be wide in range. Many Canadians are concerned with the interaction between mental health and other social determinants of health, such as the lack of medical, disability, financial, housing, and social support and resources.[23] As a result, another layer to the ethical issue arises: Does permitting MAiD for mental illness treat the symptoms of the issue rather than the root problem itself (social, economic, and systemic inequities)? Some argue against MAiD, stating that the nation should first focus on developing better quality care and service.[24] Others support MAiD as a potential harm reduction approach, given that most of these unjust conditions require a higher level of long-term structural and public policy overhaul.[25] The CMA Code also calls upon physicians to recognize and alleviate patients’ suffering. Some argue that while physicians and medical professionals do work to relieve suffering, they are trained to do so through a primary care-based diagnose-and-treat approach.[26] Studies that have captured Canadian physicians’ experiences providing MAiD report that, although physicians stated that the work was rewarding, it came with many challenges, including strained relationships with coworkers, increased workload, and inadequate compensation.[27] Physicians report that a part of the problem is that MAiD rules are written by lawyers and experts who are removed from its reality in medical practice. As a result, there is a lack of clarity surrounding practice norms and a lack of support for physicians.[28] Thus, while healthcare practitioners have a duty to relieve patients’ suffering, they should feel adequately trained and supported in doing so. If physicians and healthcare professionals recognize vulnerability and relieve suffering, then they should act accordingly, regardless of potential associations or outcomes. Making persons with mental illness eligible for MAiD ensures that treatment to relieve their suffering is available. However, it is imperative that there are sufficient resources and support available to healthcare professionals to ensure that they feel prepared and supported to provide MAiD, should they wish to do so. Utilitarianism: Minimizing Intolerable Suffering and Dying with Dignity Overall, utilitarianism is largely concerned with the greatest happiness principle—to increase the amount of happiness for the greatest number of people. So far, this paper has analyzed individual, family, and practitioner-based ethical considerations. But if MAiD were to be extended to those with mental illness as a singular underlying medical condition, what implications would this have for the world and society at large? There is a global drive toward authorizing organized ending of life, with an increasing number of countries legalizing MAiD.[29] The medical system is generally seen as a safe and appropriate system to carry out MAiD, especially when suicide and self-harm are regarded as “alternatives.” Yet despite these worldwide efforts, many argue through the theory of utilitarianism that the inability to see long-term consequences renders MAiD a premature solution, particularly for those who are unable or unwilling to seek other forms of potentially healing treatment or for those who may undergo MAiD only for a technological innovation or biomedical advancement to later come along as a potential cure.[30] While it is true that MAiD does not prevent these “premature deaths,” it is also true that it does not claim to.[31] MAiD provides an option to alleviate intolerable suffering. Some individuals with severe mental illness do describe their condition as intolerable suffering. MAiD is seen as an option to minimize suffering. It can also be seen as a way to die with dignity and relief.[32] While predicting outcomes is difficult, extending MAiD eligibility for persons experiencing mental illness does not undermine its ability to end suffering. It allows eligible individuals to take charge of their health, their life, and their future. Conclusion Based on the current evidence, allowing MAiD for persons with mental illness as their sole underlying medical condition presents as an ethically justifiable action. The right to self-determination and fair accessibility demonstrates that there is more harm done by prohibiting MAiD for mental illness than allowing it. Such liberty is a right, and in the context of relieving suffering, it is a duty that healthcare workers must uphold, although the ability to opt out of providing MAiD is well established. Thus, to recognize vulnerability and relieve suffering means to provide methods, such as MAiD, for those deeply impacted by mental illness. These justifications stand at both the individual level and for society at large. Nevertheless, it remains imperative to take an upstream approach that addresses the social determinants of health and aims to prevent mental illness and promote long-term, beneficial social change for those suffering, struggling, and vulnerable in our communities. - [1] Jaro Kotalik and David W. Shannon, Medical Assistance in Dying (MAID) in Canada Key Multidisciplinary Perspectives, 1st ed. 2023., The International Library of Bioethics, 104 (Cham: Springer International Publishing, 2023), https://doi.org/10.1007/978-3-031-30002-8. [2] Department of Justice Government of Canada, “Canada’s Medical Assistance in Dying (MAID) Law,” February 21, 2024, https://www.justice.gc.ca/eng/cj-jp/ad-am/bk-di.html. [3] Health Canada, “Final Report of the Expert Panel on MAiD and Mental Illness,” transparency - other, May 13, 2022, https://www.canada.ca/en/health-canada/corporate/about-health-canada/public-engagement/external-advi sory-bodies/expert-panel-maid-mental-illness/final-report-expert-panel-maid-mental-illness.html. [4] Federal Public Service (FPS) Health Belgium, “Federal Commission for the Control and Evaluation of Euthanasia,” n.d., https://consultativebodies.health.belgium.be/en/advisory-and-consultative-bodies/federal-commission- control-and-evaluation-euthanasia.; Government of Netherlands, “Is Euthanasia Allowed in the Netherlands?,” n.d., https://www.government.nl/topics/euthanasia/is-euthanasia-allowed.; “Information on Requesting Euthanasia or Assisted Suicide,” n.d., https://guichet.public.lu/en/citoyens/sante/fin-vie/euthanasie/euthanasie-assistance-suicide.html. [5] Luis Espericueta, First official report on euthanasia in Spain: A comparison with the Canadian and New Zealand experiences, Medicina Clínica (English Edition), Volume 161, Issue 10, 2023, Pages 445-447, ISSN 2387-0206, https://doi.org/10.1016/j.medcle.2023.06.021. [6] Government of Canada, “The Canadian Charter of Rights and Freedoms,” March 15, 2021, https://www.justice.gc.ca/eng/csj-sjc/rfc-dlc/ccrf-ccdl/. [7] Supreme Court of Canada, “Carter v. Canada,” Constitutional Law, 2015, https://scc-csc.lexum.com/scc-csc/scc-csc/en/item/14637/index.do.; Kotalik and Shannon, Medical Assistance in Dying (MAID) in Canada Key Multidisciplinary Perspectives. [8] Karandeep Sonu Gaind, “What Does ‘Irremediability’ in Mental Illness Mean?,” Canadian Journal of Psychiatry. Revue Canadienne de Psychiatrie 65, no. 9 (September 2020): 604–6, https://doi.org/10.1177/0706743720928656; Lieve Thienpont et al., “Euthanasia Requests, Procedures and Outcomes for 100 Belgian Patients Suffering from Psychiatric Disorders: A Retrospective, Descriptive Study,” BMJ Open 5, no. 7 (July 27, 2015): e007454, https://doi.org/10.1136/bmjopen-2014-007454. [9] Hamer Bastidas-Bilbao et al., “Walking Alongside: Views of Family Members on Medical Assistance in Dying for Mental Illness as the Sole Underlying Medical Condition,” Qualitative Health Research 33 (September 29, 2023), https://doi.org/10.1177/10497323231197365. [10] Government of Canada, “Canada’s Medical Assistance in Dying (MAID) Law.” [11] Commission sur les soins de fin de vie, “Les conditions de l’admissibilité à l’aide médicale à mourir au Québec: la constance dans l’évolution de la loi concernant les soins de fin de vie,” June 9, 2023, https://csfv.gouv.qc.ca/ fileadmin/docs/autres_rapports/csfv_lcsfv_conditions_ amm_2023-06-29.pdf.; Trudo Lemmens, “When Death Becomes Therapy: Canada’s Troubling Normalization of Health Care Provider Ending of Life,” The American Journal of Bioethics 23, no. 11 (November 2, 2023): 79–84, https://doi.org/10.1080/15265161.2023.2265265. [12] Justine Dembo, Udo Schuklenk, and Jonathan Reggler, “‘For Their Own Good’: A Response to Popular Arguments Against Permitting Medical Assistance in Dying (MAID) Where Mental Illness Is the Sole Underlying Condition,” Canadian Journal of Psychiatry. Revue Canadienne De Psychiatrie 63, no. 7 (July 2018): 451–56, https://doi.org/10.1177/0706743718766055. [13] Konia Trouton et al., “Attitudes and Expectations Regarding Bereavement Support for Patients, Family Members, and Friends: Findings from a Survey of MAID Providers,” British Columbia Medical Journal 62, no. 1 (2020). [14] Bastidas-Bilbao et al., “Walking Alongside.” [15] Bastidas-Bilbao et al. [16] Trouton et al., “Attitudes and Expectations Regarding Bereavement Support for Patients, Family Members, and Friends: Findings from a Survey of MAID Providers,” 2020. [17] Ramona Coelho et al., “The Realities of Medical Assistance in Dying in Canada,” Palliative & Supportive Care 21, no. 5 (October 2023): 871–78, https://doi.org/10.1017/S1478951523001025; Health Canada, “Third Annual Report on Medical Assistance in Dying in Canada 2021,” report on plans and priorities;transparency - other, July 26, 2022, https://www.canada.ca/en/health-canada/services/publications/health-system-services/annual-report-me dical-assistance-dying-2021.html; Lemmens, “When Death Becomes Therapy.” [18] Coelho et al., “The Realities of Medical Assistance in Dying in Canada,” October 2023.; Bastidas-Bilbao et al., “Walking Alongside.” [19] Olivia Stefanovich, “Opposition Parties Call for Indefinite Pause to MAID Expansion for Mental Illness | CBC News,” Canadian Broadcasting Corporation, January 28, 2024, https://www.cbc.ca/news/politics/special-joint-committee-maid-mental-illness-report-1.7095679; Benjamin Lopez Steven, “Number of Assisted Deaths Jumped More than 30 per Cent in 2022, Report Says | CBC News,” Canadian Broadcasting Corporation, October 27, 2023, https://www.cbc.ca/news/politics/maid-canada-report-2022-1.7009704. [20] Hamer Bastidas-Bilbao et al., “Searching for Relief from Suffering: A Patient-Oriented Qualitative Study on Medical Assistance in Dying for Mental Illness as the Sole Underlying Medical Condition,” Social Science & Medicine 331 (August 1, 2023): 116075, https://doi.org/10.1016/j.socscimed.2023.116075. [21] Canadian Medical Association, “Canadian Medical Association Code of Ethics and Professionalism” (Canada: Canadian Medical Association, December 8, 2018), https://policybase.cma.ca/link/policy13937. [22] Canadian Medical Association. [23] Coelho et al., “The Realities of Medical Assistance in Dying in Canada,” October 2023; Stefanovich, “Opposition Parties Call for Indefinite Pause to MAID Expansion for Mental Illness | CBC News.” [24] John Paul Tasker, “Liberal Government Promoting a ‘culture of Death’ with Medical Assistance in Dying Law, Conservative MP Says | CBC News,” Canadian Broadcasting Corporation, March 6, 2023, https://www.cbc.ca/news/politics/culture-of-death-medical-assistance-in-dying-mental-illness-1.67695 04. [25] Coelho et al., “The Realities of Medical Assistance in Dying in Canada,” October 2023; Kayla Wiebe and Amy Mullin, “Choosing Death in Unjust Conditions: Hope, Autonomy and Harm Reduction,” Journal of Medical Ethics, April 26, 2023, https://doi.org/10.1136/jme-2022-108871. [26] Ramona Coelho et al., “The Realities of Medical Assistance in Dying in Canada,” Palliative & Supportive Care 21, no. 5 (October 2023): 871–78, https://doi.org/10.1017/S1478951523001025. [27] Konia Trouton et al., “Attitudes and Expectations Regarding Bereavement Support for Patients, Family Members, and Friends: Findings from a Survey of MAID Providers,” British Columbia Medical Journal 62, no. 1 (2020), https://bcmj.org/articles/attitudes-and-expectations-regarding-bereavement-support-patients-family-m embers-and.; William Robert Nielsen, “MAiD in Canada: Ethical Considerations in Medical Assistance in Dying,” Canadian Journal of Bioethics 4, no. 2 (December 9, 2021): 93–98, https://doi.org/10.7202/1084456ar. [28] Coelho et al., “The Realities of Medical Assistance in Dying in Canada,” October 2023. [29] Lemmens, “When Death Becomes Therapy.” [30] William Robert Nielsen, “MAiD in Canada: Ethical Considerations in Medical Assistance in Dying,” Canadian Journal of Bioethics 4, no. 2 (December 1, 2021): 93–98, https://doi.org/10.7202/1084456ar. [31] Steven, “Number of Assisted Deaths Jumped More than 30 per Cent in 2022, Report Says | CBC News.” [32] A. Plaisance et al., “Quebec Population Highly Supportive of Extending Medical Aid in Dying to Incapacitated Persons and People Suffering Only from a Mental Illness: Content Analysis of Attitudes and Representations,” Ethics, Medicine and Public Health 21 (April 1, 2022): 100759, https://doi.org/10.1016/j.jemep.2022.100759. (shrink)

In the Netherlands, euthanasia and assisted suicide are formally forbidden by criminal law, but, under certain strictly formulated conditions, physicians are excused for administering these to patients on the basis of necessity. These conditions are bound up with a long process of criteria development. Therefore, physicians still live in uncertainty. Future court decisions may change the criteria. Apart from that, physicians can always be prosecuted. The position of nurses, however, is perfectly clear; they are never allowed (...) to administer euthanasia or assisted suicide. Nevertheless, they should be involved in the decision-making process because they are an important source of information and have consultation skills. The openness of the discussion about these issues in the Netherlands may prevent an escalation of medical or nursing responsibility and falling victim to the ‘slippery slope’. (shrink)

Aim To study the views of people in a largely Muslim country, Kuwait, of the acceptability of a life-ending action such as physician-assisted suicide (PAS). Method 330 Kuwaiti university students judged the acceptability of PAS in 36 scenarios composed of all combinations of four factors: the patient's age (35, 60 or 85 years); the level of incurability of the illness (completely incurable vs extremely difficult to cure); the type of suffering (extreme physical pain or complete dependence) and (...) the extent to which the patient requests a life-ending procedure, euthanasia or PAS (no request, some form of request, repeated requests). In all scenarios, the patients were women who were receiving the best possible care. The ratings were subjected to cluster analysis and analyses of variance. Results Five clusters were found. For 44%, PAS was always very unacceptable, no matter what the circumstances. For 23%, it was unacceptable, but less so if the patient was older or requested it repeatedly. For 16%, it was unacceptable if the patient was young but was acceptable if the patient was elderly. For 5%, it was unacceptable if the patient had extreme pain but was acceptable if completely dependent. For 11%, it was unacceptable if the patient did not request it but acceptable if she did. Conclusion The majority of the Kuwaiti university students opposed PAS either categorically or with a slight variation according to circumstances. Nonetheless, a minority approved of PAS in some cases, particularly when the patient was elderly. (shrink)

Euthanasia and assisted suicide was openly permitted but not technically legal in the Netherlands for decades. In 2002, it was formally legalised through the Termination of Life on Request and Assisted Suicide Review Procedures Act, subject to two main criteria: the patient had to be capable of making voluntary decisions and the patient had to experience unbearable suffering without prospect of improvement. Within the Netherlands, EAS has wide acceptance, and the public in general seems to (...) favour a liberal interpretation of both of these requirements. Physicians are expected to use ‘their own moral compass’ to decide about personal participation, and it is generally possible and permissible to find a substitute physician if the patient meets the legally required criteria but the physician is not comfortable assisting. Over the years, multiple quantitative and qualitative studies have explored the Dutch practice of EAS,1–3 but relatively little is known about the edges of what counts as meeting these criteria and how acceptable the practice is for physicians who participate. The study by Snijdewind et al gives a glimpse of these boundaries and suggests that at least sometimes the criteria are being stretched and adapted to meet the perceived needs of patients, and some participating physicians are relatively uncomfortable with some of the requests with which they are faced.4 Just how rare or common these ‘edgy’ cases are within the larger practice of EAS in the Netherlands cannot be answered by …. (shrink)

Objective—Consultation of another physician is an important method of review of the practice of euthanasia. For the project “support and consultation in euthanasia in Amsterdam” which is aimed at professionalising consultation, a protocol for consultation was developed to support the general practitioners who were going to work as consultants and to ensure uniformity. Participants—Ten experts (including general practitioners who were experienced in euthanasia and consultation, a psychiatrist, a social geriatrician, a professor in health law and a public (...) prosecutor) and the general practitioners who were going to use the protocol. Evidence—There is limited literature on consultation: discursive articles and empirical studies describing the practice of euthanasia. Consensus—An initial draft on the basis of the literature was commented on by the experts and general practitioners in two rounds. Finally, the protocol was amended after it had been used during the training of consultants. Conclusions—The protocol differentiates between steps that are necessary in a consultation and steps that are recommended. Guidelines about four important aspects of consultation were given: independence, expertise, tasks and judgment of the consultant. In 97% of 109 consultations in which the protocol was used the consultant considered the protocol to be useful to a greater or lesser extent. Although this protocol was developed locally, it also employs universal principles. Therefore it can be of use in the development of consultation elsewhere. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Active Euthanasia and Assisted SuicidePat Milmoe McCarrick (bio)Although the President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research in its 1983 report, Deciding to Forego Life-Sustaining Treatment, described the words and terms "euthanasia," "right to die," and "death with dignity" as slogans or code words—"empty rhetoric," (I, p. 24), the literature reviewed for this Scope Note continues to use these (...) terms. Therefore, to discuss the termination of a patient's life by a physician at the patient's request, the phrase active euthanasia is used, and the supplying of a means by a physician whereby a patient can end his or her life is referred to as assisted suicide.Euthanasia, either as the "good death" from classical Greek or "mercy killing" to end unbearable suffering in the dying, has long been a topic of interest in western civilization (III, Brody 1989). In recent years, public awareness of this discussion about control over the time of one's death has been informed by a series of well-publicized events. They include the November 1991 rejection by a vote of 54 percent to 46 percent of the Washington state Initiative 119, which would have allowed the option of requesting one's physician to "aid-in-dying" for adult patients in a "medically terminal condition" (V, Gross 1991); two medical journal articles describing physician's actions in helping bring death to two patients (V, Anonymous 1988; V, Quill 1991); Dr. Jack Kevorkian's assistance in the suicide of three women (V, Belkin 1990; V, Wilkerson 1991); and the best seller status of a how-to book on committing suicide with opiates obtained from a physician (III, Humphry 1991).For the most part, material included in the annotated bibliography in Scope Note 18 has been chosen from works published in the four years since "It's Over, Debbie" (V, Anonymous 1988) appeared in early January 1988 in the Journal of the American Medical Association.Dr. Edmund D. Pellegrino (V, 1991, pp. 3118-19) presented opposing views about active voluntary euthanasia as follows:Those who favor voluntary euthanasia argue that it is a beneficent and compassionate act; it respects autonomy by preserving the patient's control of the manner, method, [End Page 79] and timing of death; it takes the matter outside the reach of "medical power" (accessed in this Scope Note's bibliography at V, Fletcher 1973; V, Nowell-Smith 1989) and scrupulosity; and it prevents the injustice that allows some patients to choose death by refusal of life-support measures, while denying others the right to do so by active euthanasia....The opponents of active euthanasia argue that it undermines the value of, and respect for, all human life (V, Kass 1989; V, Coyle 1990; V, Singer 1990). They fear that guidelines cannot avoid sliding down the "slippery slope" to involuntary euthanasia and selective devaluation of the lives of the most vulnerable among us.... If euthanasia is legal, it is predicted that patients will feel subtle pressure to conform so as to relieve the economic and emotional burdens they impose on family and friends.Euthanasia, its opponents further argue, is socially destructive: it undermines trust in physicians, desensitizes society to killing, and imperils the ground already gained in legitimating passive euthanasia(IV, Wolf 1989).Physicians were not particularly involved with a patient's death until after World War II when participation grew in proportion to the growth of technology. Since the complex, life-sustaining equipment that could forestall death was located in a hospital, death itself became almost completely medicalized (V, Dagi 1991). For terminally ill persons who would like to die a painless death, either by their own hand or with assistance, physicians have almost a monopoly on obtaining strong drugs for distribution to patients (V, Abrams 1990).Active euthanasia for human beings is not legalized anywhere in the world (V, VonDrehle 1991). It is classified as homicide or murder in all fifty states and in Great Britain, Canada, Australia, and the Phillippines (V, Nerland 1989). Twentysix states in the United States prohibit assisted suicide by statute (V, Rosenblum 1990).In 1969 in the Netherlands, a physician named Jan Hendrik van... (shrink)

Next SectionPublic and healthcare professionals differ in their attitudes towards euthanasia and physician-assisted suicide (PAS), the legal status of which is currently in the spotlight in the UK. In addition to medical training and experience, religiosity, locus of control and patient characteristics (eg, patient age, pain levels, number of euthanasia requests) are known influencing factors. Previous research tends toward basic designs reporting on attitudes in the context of just one or two potentially influencing factors; we (...) aimed to test the comparative importance of a larger range of variables in a sample of nursing trainees and non-nursing controls. One hundred and fifty-one undergraduate students (early-stage nursing training, late-stage nursing training and non-nursing controls) were approached on a UK university campus and asked to complete a self-report questionnaire. Participants were of mixed gender and were on average 25.5 years old. No significant differences in attitude were found between nursing and non-nursing students. There was a significant positive correlation between higher religiosity and positive attitude toward euthanasia (r=0.19, p<0.05) and a significant negative relationship between internal locus of control and positive attitude toward PAS (r=−0.263, p<0.01). Multivariate analyses revealed differing predictor models for attitudes towards euthanasia and PAS, and confirm the importance of individual differences in determining these attitudes. The unexpected direction of association between religiosity and attitudes may reflect a broader cultural shift in attitudes since earlier research in this area. Furthermore, these findings suggest it possible that experience, more than training itself, may be a bigger influence on attitudinal differences in healthcare professionals. (shrink)

Objective: To explore the experiences of people with a “terminal illness”, focusing on the patients’ perspective of euthanasia and assisted suicide.Method: A qualitative study using narrative interviews was conducted throughout the UK. The views of the 18 people who discussed euthanasia and assisted suicide were explored. These were drawn from a maximum variation sample, who said that they had a “terminal” illness, malignant or non-malignant.Results: That UK law should be changed to allow assisted (...) suicide or voluntary euthanasia was felt strongly by most people. Those who had seen others die were particularly convinced that this should be a right. Some had multiple reasons, including pain and anticipated pain, fear of indignity, loss of control and cognitive impairment. Those who did not want to be a burden also had other reasons for wanting euthanasia. Suicide was contemplated by a few, who would have preferred a change in the law to allow them to end their lives with medical help and in the company of family or friends. The few who opposed a change in UK law, or who felt ambivalent, focused on involuntary euthanasia, cited religious reasons or worried that new legislation might be open to abuse.Conclusion: Qualitative research conducted on people who know they are nearing death is an important addition to the international debate on euthanasia and assisted suicide. Those who had seen others die were particularly convinced that the law should be changed to allow assisted death. (shrink)

Background: Hospital nurses are frequently the first care givers to receive a patient’s request for euthanasia or physician-assisted suicide (PAS). In France, there is no consensus over which medical practices should be considered euthanasia, and this lack of consensus blurred the debate about euthanasia and PAS legalisation. This study aimed to investigate French hospital nurses’ opinions towards both legalisations, including personal conceptions of euthanasia and working conditions and organisation. Methods: A phone survey conducted among (...) a random national sample of 1502 French hospital nurses. We studied factors associated with opinions towards euthanasia and PAS, including contextual factors related to hospital units with random-effects logistic models. Results: Overall, 48% of nurses supported legalisation of euthanasia and 29%, of PAS. Religiosity, training in pallative care/pain management and feeling competent in end-of-life care were negatively correlated with support for legalisation of both euthanasia and PAS, while nurses working at night were more prone to support legalisation of both. The support for legalisation of euthanasia and PAS was also weaker in pain treatment/palliative care and intensive care units, and it was stronger in units not benefiting from interventions of charity/religious workers and in units with more nurses. Conclusions: Many French hospital nurses uphold the legalisation of euthanasia and PAS, but these nurses may be the least likely to perform what proponents of legalisation call “good” euthanasia. Improving professional knowledge of palliative care could improve the management of end-of-life situations and help to clarify the debate over euthanasia. (shrink)

We have always had the ability to commit suicide or request euthanasia in times of serious illness. Yet these acts have been prohibited by the Christian tradition from early times. Some Christians, as they see relatives and friends kept alive too long and in poor condition through the use of current medical powers, however, are beginning to question that tradition. Are assisted suicide and euthanasia compassionate Christian responses to those in pain and suffering who face (...) death? Or are they ways of isolating and abandoning them, of fleeing from Christian compassion, rather than expressing it?The Committee on Medical Ethics of the Episcopal Diocese of Washington recently issued a report addressing assisted suicide and euthanasia. These matters cry out for religious contributions and perspectives, the Committee believes. The group recognizes that religious voices should not determine public policy, but believes they should be heard as we develop a social consensus about assisted suicide and euthanasia. (shrink)

Aim To study the views on the acceptability of physician-assisted-suicide of lay people and health professionals in an African country, Togo.Method In February–June 2012, 312 lay people and 198 health professionals in Togo judged the acceptability of PAS in 36 concrete scenarios composed of all combinations of four factors: the patient's age, the level of incurability of the illness, the type of suffering and the patient's request for PAS. In all scenarios, the patients were women receiving the best (...) possible care. The ratings were subjected to cluster analysis and analyses of variance.Results Most lay people were not systematically opposed to PAS, whereas most health professionals were systematically opposed to it. The most important factors in increasing acceptability among people not systematically opposed were advanced age of the patient and incurability of the illness. Additional acceptability was provided by the patient's request to have her life ended, although much less so than in studies in Western countries, and by suffering characterised by complete dependence rather than by extreme physical pain.Conclusions These empirical findings—the first ones gathered in the African continent—suggest that most Togolese lay people are not categorically for or against PAS, but judge its degree of acceptability as a function of concrete circumstances. (shrink)

Next SectionBackground There is an established link between depression and interest in hastened death in patients who are seriously ill. Concern exists over the extent of depression in patients who actively request euthanasia/physician-assisted suicide (PAS) and those who have their requests granted. Objectives To estimate the prevalence of depression in refused and granted requests for euthanasia/PAS and discuss these findings. Methods A systematic review was performed in MEDLINE and PsycINFO in July 2010, identifying studies (...) reporting rates of depression in requests for and cases of euthanasia/PAS. One author critically appraised the strength of the data using published criteria. Results 21 studies were included covering four countries. There was considerable heterogeneity in methods of assessing depression and selecting patients. In the highest quality studies, in the Netherlands and Oregon, 8–47% of patients requesting euthanasia/PAS had depressive symptoms and 2–17% of completed euthanasia/PAS cases had depressive symptoms. In the Netherlands, depression was significantly higher in refused than granted requests, and there was no significant difference in the rate of depression between euthanasia cases and similar patients who had not made a request for euthanasia. Conclusion It is unclear whether depression increases the probability of making a request for euthanasia/PAS, but in the Netherlands most requests in depressed patients are rejected, leaving a depression rate in cases that is similar to the surrounding population. Less evidence is available elsewhere, but some level of depression has been identified in patients undergoing euthanasia/PAS in all the countries studied. Whether the presence of depression is ever compatible with an ethical decision on euthanasia/PAS is discussed. (shrink)

Gibson, Robin The concept of dying by euthanasia and indeed physician-assisted suicide is a highly emotive one. Assisted dying arouses intense feelings both in favour and against. The prospect of enduring a long drawn out dying process generates both fear and apprehension in both terminally ill and chronically ill patients. Many of them wish to choose the time and manner of their death. On the other side, passionate, mainly religious groups have campaigned long and hard to (...) deny suffering people assistance to die. As the law currently stands in Australia, there is a complete ban on both euthanasia and assistance in suicide. Even following a request by a patient, a medical practitioner who directly takes the life of his or her patient, can be charged with murder or manslaughter. Despite the repeal of laws that forbade committing or attempting to commit suicide, laws still exist which proscribe the provision of assistance to another to commit or attempt to commit suicide. (shrink)

For more than two decades euthanasia and assisted suicide have been openly debated in the Netherlands. This development started in 1973 when the Regional Court in Leeuwarden decided a case in which a physician had administered a deadly dose of morphine to her terminally ill mother on the mother's serious and persistent request. In this case the court concluded that the average Dutch physician no longer considered it his or her duty to prolong a patient's life under (...) all circumstances. The court accepted that in specific cases a physician is allowed to prevent serious and irreversible suffering, even if the patient's life is short ened. This case was the first in which a legal opening for euthanasia or assisted suicide was created. In this specific case the physician was formally declared guilty, but the court gave her a suspended sentence of one week imprisonment. This decision started a debate on euthanasia and assisted suicide throughout all levels of Dutch society. (shrink)

Belgium and the Netherlands are the first countries in the world that have legalized euthanasia and assisted suicide. Since September 23, 2002, Belgian physicians can perform an act of euthanasia without at the same time performing a criminal act. In the Netherlands, the act on euthanasia went into force already on April 1, 2002. This special issue of Ethical Perspectives on ‘Euthanasia in the Low Countries’ offers a forum for critical dialogue on the different (...) aspects of this new legal situation in Belgium and the Netherlands.First, the legal situation will be introduced. In his contribution, Herman Nys makes a careful comparison of both laws. In spite of the fact that Belgium and the Netherlands are the first countries in the world that legalized euthanasia, the differences between the Belgian and Dutch law are fundamental. As Nys indicates, the scope of the Dutch law is more specified since it explicitly includes physician-assisted suicide while it remains unclear whether the Belgian act is also applicable in cases of assisted suicide. There are also fundamental differences regarding the persons regulated by the law, the health condition of the patient, the obligations of the physician with respect to the request and the health status of the patient, and the notification procedure.However, not only are there fundamental differences between Belgium and the Netherlands on the level of the law. Also the public debate and the values underlying the the debate show dissimilarities. In the Netherlands this debate took more than twenty years and the subsequent law on euthanasia reflected an existing medical practice. In Belgium, on the contrary, the parliament came to vote on the euthanasia law after only half a decade of debate. In our contribution , we identify the right to autonomy understood as ‘self-possession’ as the central value in the Belgian debate. Guy Widdershoven asserts that the moral basis of euthanasia in the Netherlands is different. He argues that the Dutch debate — and by now Dutch practice — cannot be reduced to the "principlist canon of autonomy and beneficence". Instead, the values of responsibility, deliberation and care are claimed to be central to Dutch euthanasia practice.In his contribution, Daniel Sulmasy offers an exhaustive analysis of the notion of dignity that constantly arises in the debate on euthanasia. For Christian churches and Catholic healthcare institutions, the recent legalization of euthanasia and assisted suicide is at least challenging. Jan Jans describes the way in which the main Christian churches in Belgium and the Netherlands engaged in the debate and reacted to the eventual legalization. Chris Gastmans presents the view of the Flemish Association of Catholic Healthcare Institutions.Law-making with respect to euthanasia is one thing. Bringing the law into practice is somewhat different. The question arises to what extent the new legal situation will bear upon the medical practice. Particularly, the responses of physicians are difficult to assess in advance. Physicians face the dilemma to report or not to report. They can take up their responsibility and report their practices of euthanasia, thereby exposing themselves to critical examination and possibly criminal prosecution. On the other hand, the physician can opt for safety and decide not to report his involvement in one of his patients’ euthanasia. In the latter case, the introduction of new legislation would have missed the mark. To this day, the only available data with regard to physicians’ reactions to an established legal framework wherein euthanasia is legalized come from the Netherlands. In his contribution, Albert Klijn presents the reactions of Dutch physicians to the new legal situation in their country and, particularly, the performance of their duty to report cases of euthanasia. Since the vote on the law in 2000 and the establishment of ‘regional review committees for termination of life on request and assisted suicide’ in 2001, the reports of euthanasia have declined. Klijn considers two possible explanations. On the one hand, there is insecurity about how the newly established regional review committees will evaluate physician' reports. On the other hand, the increased investment in research on palliative care and the availability of palliative sedation are held responsible for the drop in reported cases.This very interesting suggestion by Klijn needs further clarification. Therefore, the meaning of palliative care and the possibility of palliative sedation are elaborated in the contribution of Bert Broeckaert and Rien Janssens.With this special issue on ‘Euthanasia in the Low Countries’ we hope to have answered the numerous requests for further information on the Belgian and Dutch situation. Data, clarification and critical review may shed more light on the development of a practice, which some still consider as non-medical behaviour. This issue may therefore also function as a catalyst for further medical, ethical and legal debate. (shrink)

Currently, euthanasia is officially allowed only in a number of countries, in most countries, as well as in the Russian Federation, it is prohibited by law. However, in clinical practice, there are a large number of incurable patients who experience intractable pain, so the problem of euthanasia is relevant. Aim: to analyze the current state of the problem of euthanasia and palliative care in pulmonology. Material and methods: review of domestic and foreign literature on the problem (...) of euthanasia over the past 10 years has been carried out. Literature search was carried out using the e-library and PubMed databases. Results: We present a medical and philosophical perspective. Currently, euthanasia is a way to quickly and painlessly die if there is a serious illness that is incurable, suffering and pain. The best and perhaps the only alternative to euthanasia is palliative care. In pulmonology, palliative care focuses on early detection of respiratory failure, dyspnea, fear and pain relief. The effective organization of palliative care in respiratory medicine depends on the well-coordinated work of pulmonologists, physiotherapists, nurses, and psychologists. Conclusion: The problem of euthanasia to date still remains controversial from both medical and ethical points of view. The adoption of euthanasia by law may be a deterrent to governments from funding research into new treatments. The risk of abuse of euthanasia in order to obtain organs for transplantation or to get rid of seriously ill burdensome relatives cannot be ruled out. It is necessary to consider the issue of introducing additional educational cycles on the issues of modern achievements in palliative medicine, technical means of rehabilitation and the peculiarities of their use in patients with various diseases in the terminal stage in the training of doctors and nurses. (shrink)

The article examines whether countries should legalize euthanasia and assisted suicide. Firstly, context of the debate is provided by defining the key terms and giving the overview of how the debate evolved throughout history. The arguments in favor of legalizing euthanasia and assisted suicide are addressed, namely the argument from autonomy and self–determination and the claim for the “right to die with dignity”. The consequences which were showed to occur in the countries which legalized (...) euthanasia and/or assisted suicide are analyzed, and the case study on the Netherlands and Belgium is made. Finally, the model for the dignity–respecting health–care is proposed followed by the call for bigger accessibility and funding for palliative care. (shrink)

To describe the content of practice guidelines on euthanasia and assisted suicide (EAS) and to compare differences between settings and guidelines developed before or after enactment of the euthanasia law in 2002 by means of a content analysis. Most guidelines stated that the attending physician is responsible for the decision to grant or refuse an EAS request. Due care criteria were described in the majority of guidelines, but aspects relevant for assessing these criteria were not always (...) described. Half of the guidelines described the role of the nurse in the performance of euthanasia. Compared with hospital guidelines, nursing home guidelines were more often stricter than the law in excluding patients with dementia (30% vs 4%) and incompetent patients (25% vs 4%). As from 2002, the guidelines were less strict in categorically excluding patients groups (32% vs 64%) and in particular incompetent patients (10% vs 29%). Healthcare institutions should accurately state the boundaries of the law, also when they prefer to set stricter boundaries for their own institution. Only then can guidelines provide adequate support for physicians and nurses in the difficult EAS decision-making process. (shrink)

Some form of assisted dying (voluntary euthanasia and/or assisted suicide) is lawful in the Netherlands, Belgium, Oregon, and Switzerland. In order to be lawful in these jurisdictions, a valid request must precede the provision of assistance to die. Non-adherence to the criteria for valid requests for assisted dying may be a trigger for civil and/or criminal liability, as well as disciplinary sanctions where the assistor is a medical professional. In this article, we review the (...) criteria and evidence in respect of requests for assisted dying in the Netherlands, Belgium, Oregon, and Switzerland, with the aim of establishing whether individuals who receive assisted dying do so on the basis of valid requests. We conclude that the evidence suggests that individuals who receive assisted dying in the four jurisdictions examined do so on the basis of valid requests and third parties who assist death do not act unlawfully. However, further research on the elements that may undermine the validity of requests for assisted dying is warranted. More research on the reasons why requests for assisted dying are refused is also desirable. (shrink)

Although euthanasia and assisted suicide in people with psychiatric disorders is relatively rare, the increasing incidence of EAS requests has given rise to public and political debate. This study aimed to explore support of the public and physicians for euthanasia and assisted suicide in people with psychiatric disorders and examine factors associated with acceptance and conceivability of performing EAS in these patients. A survey was distributed amongst a random sample of Dutch 2641 citizens (...) and 3000 physicians. Acceptance and conceivability of performing EAS, demographics, health status and professional characteristics were measured. Multivariable logistic regression analyses were performed. Of the general public 53% were of the opinion that people with psychiatric disorders should be eligible for EAS, 15% was opposed to this, and 32% remained neutral. Higher educational level, Dutch ethnicity, and higher urbanization level were associated with higher acceptability of EAS whilst a religious life stance and good health were associated with lower acceptability. The percentage of physicians who considered performing EAS in people with psychiatric disorders conceivable ranged between 20% amongst medical specialists and 47% amongst general practitioners. Having received EAS requests from psychiatric patients before was associated with considering performing EAS conceivable. Being female, religious, medical specialist, or psychiatrist were associated with lower conceivability. The majority of the psychiatrists were of the opinion that it is possible to establish whether a psychiatric patient’s suffering is unbearable and without prospect and whether the request is well-considered. The general public shows more support than opposition as to whether patients suffering from a psychiatric disorder should be eligible for EAS, even though one third of the respondents remained neutral. Physicians’ support depends on their specialization; 39% of psychiatrists considered performing EAS in psychiatric patients conceivable. The relatively low conceivability is possibly explained by psychiatric patients often not meeting the eligibility criteria. (shrink)

Objectives: To discover what factors affect lay people’s judgments of the acceptability of physician assisted suicide and euthanasia and how these factors interact.Design: Participants rated the acceptability of either physician assisted suicide or euthanasia for 72 patient vignettes with a five factor design—that is, all combinations of patient’s age ; curability of illness ; degree of suffering ; patient’s mental status , and extent of patient’s requests for the procedure .Participants: Convenience sample of (...) 66 young adults, 62 middle aged adults, and 66 older adults living in western France.Main measurements: In accordance with the functional theory of cognition of N H Anderson, main effects, and interactions among patient factors and participants’ characteristics were investigated by means of both graphs and ANOVA.Results: Patient requests were the most potent determinant of acceptability. Euthanasia was generally less acceptable than physician assisted suicide, but this difference disappeared when requests were repetitive. As their own age increased, participants placed more weight on patient age as a criterion of acceptability.Conclusions: People’s judgments concur with legislation to require a repetition of patients’ requests for a life ending act. Younger people, who frequently are decision makers for elderly relatives, place less emphasis on patient’s age itself than do older people. (shrink)

In advanced technological societies there is growing concern about the prospect of protracted deaths marked by incapacitation, intolerable pain and indignity, and invasion by machines and tubing. Life prolongation for critically ill cancer patients in the United States, for example, literally costs a fortune for very little benefit, typically from $82,845 to $189,339 for an additional year of life. Those who return home after major interventions live on average only 3 more months; the others live out their days in a (...) hospital intensive care unit. (shrink)

This study explores the perceptions of Norwegian nurses who have received assisted dying requests from terminally ill patients. Assisted dying is illegal in Norway, while in some countries, it is an option. Nurses caring for terminally ill patients may experience ethical challenges by receiving requests for euthanasia and assisted suicide. We applied a qualitative research design with a phenomenological hermeneutic approach using open individual interviews. A total of 15 registered nurses employed in pulmonary (...) and oncology wards of three university hospitals and home care in one municipality were recruited. Four themes emerged from the analysis: (1) unprepared for the request; (2) meeting direct, indirect, and nonverbal requests; (3) working in a gray zone, and (4) feeling alone and powerless. The study found that nurses were unsure how to handle such requests due to professional uncertainty about assisted dying. Working in an environment where the topic is taboo made nurses morally uncertain, and some perceived this as moral distress. The hospital chaplain played a significant role in providing support to these nurses. (shrink)

In suicidology, the common view is that ‘rational’ suicides occur only rarely, because the competence of people who want to end their lives is compromised by mental illness. In the Netherlands and Flanders, however, patients’ requests for euthanasia or assistance in suicide are granted in 5300 and 1400 cases a year respectively, and in all these cases at least two doctors have confirmed the patient's competence. The combination of these two findings is puzzling. In other countries one (...) would expect at least some of these people to end their own lives. The article argues that we can distinguish between two types of suicide with clustering characteristics. In cases of the first type, the agent doesn't carefully plan his action, doesn't communicate his plans to relatives or others, and uses violent means. In such cases it is reasonable to presume lack of competence. The other type has the opposite characteristics. The most plausible explanation of our problem is that suicides of the second kind are invisible to suicidology, because they tend not to be registered as suicides at all. (shrink)

Kant has famously argued that human beings or persons, in virtue of their capacity for rational and autonomous choice and agency, possess dignity, which is an intrinsic, final, unconditional, inviolable, incomparable and irreplaceable value. This value, wherever found, commands respect and imposes rather strict moral constraints on our deliberations, intentions and actions. This paper deals with the question of whether, as some Kantians have recently argued, certain types of (physician-assisted) suicide and active euthanasia, most notably the intentional (...) destruction of the life of a terminally-ill, but rational and autonomous patient in order to prevent certain serious harms, such as enduring or recurring pain or the loss of the meaning in life, from befalling him really are inconsistent with respect for the patient’s human dignity. I focus on two independent, though interrelated explications of the rather vague initial idea that the patient (as well as the doctor), in intending and bringing about his death, treats his person or rational nature merely as a means and so denigrates his dignity: (i) that in doing what he is doing, he does not act for the sake of his person, but for the sake of something else; (ii) that, by trading his person for pain relief, he engages himself in an irrational and hence immoral exchange. After critically discussing some suggestions about how to understand this charge, I eventually find Kantian objections to suicide and (active) euthanasia, based on the idea of human dignity, less than compelling. For all the paper proves, suicide and (active) euthanasia may still be morally impermissible, but then this must be so for some other reason than the one given above. (shrink)

The American Medical Association opposes physician-assisted suicide on the grounds that it “would ultimately cause more harm than good,” because it is “fundamentally incompatible with the physician’s role as healer,” and because it “would be difficult or impossible to control and would pose serious societal risks”. It condemns the practice of euthanasia as conducted by physicians for these reasons as well, and adds, by way of clarifying the serious risks at hand, that “euthanasia could readily be (...) extended to incompetent patients and other vulnerable populations”. In this essay I will attempt to rebut these charges. I will devote most of my attention to the... (shrink)

The question of legalizing physician-assisted suicide has become a serious public debate. Growing interest in assisted suicide reflects a public increasingly fearful of the process of dying, particularly the prospect of dying a painful, protracted, or undignified death. PAS has been proposed as a compassionate response to unrelievable suffering, designed to give terminally or incurably ill individuals direct control over the timing, manner, and circumstances of their death. Although the American Medical Association remains firmly opposed to (...) legalizing PAS, many physicians have begun to express support for the practice, and some have acknowledged that they have helped patients commit suicide despite the existing legal ban.As support for PAS grows, it becomes increasingly likely that the practice will be legalized in at least some states in the not-too-distant future. In 1994, Oregon voters approved a referendum legalizing PAS for competent, terminally ill patients; a federal court injunction preventing the referendum from going into effect is currently on appeal, and it is widely expected that the injunction will be lifted. (shrink)

Background: Issues concerning legislation and regulation with respect to the role of nurses in euthanasia and physician-assisted suicide gave the Minister for Health reason to commission a study of the role of nurses in medical end-of-life decisions in hospitals, home care and nursing homes.Aim: This paper reports the findings of a study of the role of nurses in euthanasia and physician-assisted suicide, conducted as part of a study of the role of nurses in medical (...) end-of-life decisions. The findings for hospitals, home care and nursing homes are described and compared.Method: A questionnaire was sent to 1509 nurses, employed in 73 hospitals, 55 home care organisations and 63 nursing homes. 1179 responses were suitable for analysis. The questionnaire was pilot-tested among 106 nurses, with a response rate of 85%.Results: In 37.0% of cases, the nurse was the first person with whom patients discussed their request for euthanasia or physician-assisted suicide. Consultation between physicians and nurses during the decision-making process took place quite often in hospitals and nursing homes and less frequently in home care situations . In some cases , nurses administered the euthanatics.Conclusions: The results show substantial differences between the intramural sector and the extramural sector , which are probably linked to the organisational structure of the institutions. Consultation between physicians and nurses during the decision-making process needs improvement, particularly in home care. Some nurses had administered euthanatics, although this task is by law exclusively reserved to physicians. (shrink)

Family members do not have an official position in the practice of euthanasia and physician assisted suicide in the Netherlands according to statutory regulations and related guidelines. However, recent empirical findings on the influence of family members on EAS decision-making raise practical and ethical questions. Therefore, the aim of this review is to explore how family members are involved in the Dutch practice of EAS according to empirical research, and to map out themes that could serve as (...) a starting point for further empirical and ethical inquiry. A systematic mixed studies review was performed. The databases Pubmed, Embase, PsycInfo, and Emcare were searched to identify empirical studies describing any aspect of the involvement of family members before, during and after EAS in the Netherlands from 1980 till 2018. Thematic analysis was chosen as method to synthesize the quantitative and qualitative studies. Sixty-six studies were identified. Only 14 studies had family members themselves as study participants. Four themes emerged from the thematic analysis. 1) Family-related reasons to request EAS. 2) Roles and responsibilities of family members during EAS decision-making and performance. 3) Families’ experiences and grief after EAS. 4) Family and ‘the good euthanasia death’ according to Dutch physicians. Family members seem to be active participants in EAS decision-making, which goes hand in hand with ambivalent feelings and experiences. Considerations about family members and the social context appear to be very important for patients and physicians when they request or grant a request for EAS. Although further empirical research is needed to assess the depth and generalizability of the results, this review provides a new perspective on EAS decision-making and challenges the Dutch ethical-legal framework of EAS. Euthanasia decision-making is typically framed in the patient-physician dyad, while a patient-physician-family triad seems more appropriate to describe what happens in clinical practice. This perspective raises questions about the interpretation of autonomy, the origins of suffering underlying requests for EAS, and the responsibilities of physicians during EAS decision-making. (shrink)

The ethical problems surrounding voluntary assisted suicide remain formidable, and are unlikely to be resolved in pluralist societies. An examination of historical attitudes to suicide suggests that modernity has inherited a formidable complex of religious and moral attitudes to suicide, whether assisted or not. Advocates usually invoke the ending of intolerable suffering as one justification for euthanasia of this kind. This does not provide an adequate justification by itself, because there are (at least theoretically) (...) methods which would relieve suffering without causing the physical death of the suffering person. Carried to extremes, these methods would finish the life worth living, but leave a being which was technically alive. Such acts, however, would provide no moral escape, since they would create beings without meaning. Arguments seeking to justify ending the lives of others need some grounding in concepts of the meaning of a life. The euthanasia discourse therefore needs to take at least some account of the meaning we construct for our lives and the lives of others. (shrink)

Survival is obviously important, but sometimes, under particular circumstances, life can become miserable, difficult, or intolerable; at that point, survival can seem like a punishment or misfortune. A patient who is in a vegetative state, unable to sustain life with dignity, and who is suffering from a terminal illness, has freedom to choose between life and death. The practice of "mercy killing," or euthanasia is an ongoing debate in the discussion of medical ethics. When it comes to making (...) class='Hi'>euthanasia decisions for their incompetent patients, medical practitioners are faced with a problem. The moral dilemma of whether something is morally acceptable or not is moral in nature. The "end of life" issue is related to euthanasia should be legally acceptable under specific circumstances, such as when a patient is terminally sick, death is imminent, and treatment is unsuitable and ineffective. It is morally acceptable when a patient makes the autonomous decision to end his life or asks someone else to help him. In order to make an informed decision, the patient needs to be thoroughly informed about the diagnosis and prognosis of an incurable, deadly condition. However, in the context of a Muslim-majority population, where any argument for the legality of suicide (and, by extension, physician-assisted suicide) would be automatically rejected as contrary to Islamic moral and jurisprudential principles, this is an extraordinary request for the health service authorities of a developing country to consider. This paper discusses mainly non-voluntary active euthanasia. The discussion is conducted by giving a case study from Bangladesh. The situation in Bangladesh will also be examined in the paper's last section with regard to the permissibility of active euthanasia, specifically whether it can be done in our state given the socio-cultural-religious practices that are now in place. (shrink)

Chapter one argues for the important contribution that a natural law based framework can make towards an analysis and assessment of key controversies surrounding the practices of suicide, assisted suicide, and voluntary euthanasia. The second chapter considers a number of historical contributions to the debate. The third chapter takes up the modern context of ideas that have increasingly come to the fore in shaping the 'push' for reform. Particular areas focused upon include the value of (...) human life, the value of personal autonomy, and the rejection of double effect reasoning. Chapter four engages in the task of pointing out structural weakness in utilitarianism and deontology. The thesis argues that major systemic weaknesses in both approaches can be overcome by a teleology of basic human goods. John Finnis' work becomes the underpinning of subsequent applied natural law analysis. Chapter five proceeds to argue for the defence of the intrinsic good of human life from direct attack. The thesis holds out for the proposition "that it is always a serious moral wrong to intentionally kill a human person, whether self or another, regardless of a further appeal to consequences or motive." In support of this, it defends the validity of double effect reasoning as an indispensable part of applied moral decision making. Chapter six critically assesses the arguments of anti-perfectionists that it is not the business of the state to enforce deep or substantive conceptions of the 'good life.' The chapter moves on to argue that the natural law conception of the person in society, centred on the common good, provides a solid framework for assessing both the justification for, as well as the limits on, the role of the state to use its power to legally impose certain moral standards. Chapter seven addresses the concrete relationship between natural law and legal policy by exploring the issue of assisted suicide in the constitutional context of the United States.















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Whether the law should permit voluntary euthanasia or physician-assisted suicide is one of the most vital questions facing all modern societies. Internationally, the main obstacle to legalisation has proved to be the objection that, even if they were morally acceptable in certain 'hard cases', voluntary euthanasia and physician-assisted suicide could not be effectively controlled; society would slide down a 'slippery slope' to the killing of patients who did not make a free and informed (...) request, or for whom palliative care would have offered an alternative. How cogent is this objection? This book provides the general reader with a lucid introduction to this central question in the debate, not least by reviewing the Dutch euthanasia experience. It will interest all in any country whether currently for or against legalisation, who wish to ensure that their opinions are better informed. (shrink)

This paper introduces a series of papers dealing with the topic of euthanasia as an introduction to a variety of attitudes by health-care professionals and philosophers interested in this issue. The lead in paper—and really the lead in idea—stresses the fact that what we are discussing concerns only a minority of people lucky enough to live in conditions of acceptable sanitation and who have access to medical care. The topic of euthanasia and PAS really has three questions: (1) (...) is killing another ever ethically acceptable; (2) is the participation of health professionals ethically different and (3) is it wiser to permit and set criteria (being fully aware of some dangers that lurk in such a move) or to forbid (knowing that it will occur clandestinely and uncontrolled). This paper takes no definite stand although it is very troubled by useless suffering (not only pain) by many who would wish their life and with it their suffering ended. (shrink)

The article examines from an historical perspective some of the key ideas used in contemporary bioethics debates both for and against the practices of assisted suicide and euthanasia. Key thinkers examined--spanning the Ancient, Medieval and Modern periods--include Plato, Aristotle, Augustine, Aquinas, Hume, Kant, and Mill. The article concludes with a synthesizing summary of key ideas that oppose or defend assisted suicide and euthanasia.

Although in Italy there is currently no effective law on physician-assisted suicide or euthanasia, Decision No. 242 issued by the Italian Constitutional Court on September 25, 2019 established that an individual who, under specific circumstances, has facilitated the implementation of an independent and freely-formed resolve to commit suicide by another individual is exempt from criminal liability. Following this ruling, some citizens have submitted requests for assisted suicide to the public health system, generating a (...) situation of great uncertainty in the application processes. As a matter of fact, shared and defined procedures are lacking as Decision 242/2019 merely added some principles on which the legislature will have to base its future intervention. This paper analyses the advisory role that the Decision attributes to territorial ethics committees with the aim of stimulating discussions on their role in oversight mechanisms. The proposed conclusion is that the envisaged role does not appear consistent with the functions of these bodies and is ultimately substantially undefined and unjustified. (shrink)

Euthanasia and physician-assisted suicide (PAS) by request and/or based on an advance directive are legal in The Netherlands under strict conditions, thus providing options for patients with Huntington's disease (HD) and other neurodegenerative diseases to stay in control and choose their end of life. HD is an inherited progressive disease characterised by chorea and hypokinesia, psychiatric symptoms and dementia. From a qualitative study based on interviews with 15 physicians experienced in treating HD, several ethical issues (...) emerged. Consideration of these aspects leads to a discussion about the professional role of a physician in relation to the personal autonomy of a patient. Such a discussion can raise awareness that talking about end-of-life wishes with an HD patient is part of the legal, professional and moral responsibility of the physician, and that a letter of intent on behalf of the physician can improve active participation in the process. Discussion of these issues can help to advance the debate on euthanasia and PAS in HD and other neurodegenerative diseases. (shrink)

Background: Due to recent legislations on euthanasia and its current practice in the Netherlands and Belgium, issues of end-of-life medicine have become very vital in many European countries. In 2002, the Ethics Working Group of the German Association for Palliative Medicine (DGP) has conducted a survey among its physician members in order to evaluate their attitudes towards different end-of-life medical practices, such as euthanasia (EUT), physician-assisted suicide (PAS), and terminal sedation (TS). Methods: An anonymous questionnaire was (...) sent to the 411 DGP physicians, consisting of 14 multiple choice questions on positions that might be adopted in different hypothetical scenarios on situations of “intolerable suffering” in end-of-life care. For the sake of clarification, several definitions and legal judgements of different terms used in the German debate on premature termination of life were included. For statistical analysis t-tests and Pearson-correlations were used. Results: The response rate was 61% (n=251). The proportions of the respondents who were opposed to legalizing different forms of premature termination of life were: 90% opposed to EUT, 75% to PAS, 94% to PAS for psychiatric patients. Terminal sedation was accepted by 94% of the members. The main decisional bases drawn on for the answers were personal ethical values, professional experience with palliative care, knowledge of alternative approaches, knowledge of ethical guidelines and of the national legal frame. Conclusions: In sharp contrast to similar surveys conducted in other countries, only a minority of 9.6% of the DGP physicians supported the legalization of EUT. The misuse of medical knowledge for inhumane killing in the Nazi period did not play a relevant role for the respondents’ negative attitude towards EUT. Palliative care needs to be stronger established and promoted within the German health care system in order to improve the quality of end-of-life situations which subsequently is expected to lead to decreasing requests for EUT by terminally ill patients. (shrink)

This article explores the use of empirical data when considering whether to legalize physician-assisted suicide (PAS) and voluntary euthanasia. In particular, it focuses on the evidence available to the Select Committee for the Assisted Dying for the Terminally Ill Bill on whether or not covert euthanasia is taking place in the UK under the current prohibition of PAS and voluntary euthanasia. The article shows that there is an insufficient evidentiary basis to make any (...) claims about the extent of covert euthanasia within the UK, although there is sufficient evidence to conclude that instances of covert euthanasia do happen. The article also calls for more research to be conducted in order to determine the rate of covert euthanasia in order to inform debate about the legalization of end-of-life decisions such as PAS and voluntary euthanasia. (shrink)

It is plausible that what possible courses of action patients may legitimately expect their physicians to take is ultimately determined by what medicine as a profession is supposed to do and, consequently, that we can determine the moral acceptability of voluntary euthanasia and physician-assisted suicide on the basis of identifying the proper goals of medicine. This article examines the main ways of defining the proper goals of medicine found in the recent bioethics literature and argues that (...) they cannot provide a clear answer to the question of whether or not voluntary euthanasia and physician-assisted suicide are morally acceptable. It is suggested that to find a plausible answer to this question and to complete the task of defining the proper goals of medicine, we must determine what is the best philosophical theory about the nature of prudential value. (shrink)

Suppose that a young athlete has just become quadriplegic. He expects to live several more decades, but out of self‐interest he autonomously chooses to engage in physician‐assisted suicide (PAS) or voluntary active euthanasia (VAE). Some of us are unsure whether he or his physician would be acting rightly in ending his life. One basis for such doubt is the notion that persons have dignity in a Kantian sense. This paper probes responses that David Velleman and Frances (...) Kamm have suggested to the question of whether participating in PAS or VAE to benefit oneself, as the young man might, respects the dignity of persons, specified in an orthodox Kantian way. Velleman claims that it does not, while Kamm insists that, in certain circumstances, it does. I argue against Kamm's position. I go on to contend that while orthodox Kantianism might provide a basis for moral concern regarding the case of the young quadriplegic, it suffers from two serious shortcomings. First, it implies that terminally ill patients are wrong to request VAE or engage in PAS to avoid intense suffering, at least when this suffering has not yet overwhelmed their reason. Second, orthodox Kantianism implies that it is wrong for physicians to withdraw such patients from life‐sustaining treatments, even if they request it. To remedy these shortcomings, I sketch an unorthodox Kantian account of respect for the dignity of persons. This account promises to capture the idea that it would be morally problematic for doctors to help the young quadriplegic to die, but to avoid the shortcomings of an orthodox Kantian account. (shrink)

Introduction: The Dutch Euthanasia Act states that euthanasia is not punishable if the attending physician acts in accordance with the statutory due care criteria. These criteria hold that: there should be a voluntary and well-considered request, the patient’s suffering should be unbearable and hopeless, the patient should be informed about their situation, there are no reasonable alternatives, an independent physician should be consulted, and the method should be medically and technically appropriate. This study investigates whether physicians experience problems (...) with these criteria in medical practice.Methods: In 2006, questionnaires were sent to a random, stratified sample of 2100 Dutch physicians . Physicians were asked about problems in their decision-making related to requests for euthanasia or assisted suicide after enforcement of the 2002 Euthanasia Act.Results: Of all physicians who had received a request for euthanasia or assisted suicide , 25% had experienced problems in the decision-making with regard to at least one of the criteria of due care. Physicians who had experienced problems mostly indicated to have had problems related to evaluating whether or not the patient’s suffering was unbearable and hopeless and whether or not the patient’s request was voluntary or well considered .Discussion: Physicians in The Netherlands most frequently reported problems related to aspects in which they have to evaluate the patient’s subjective perspective. However, it can be questioned whether placing emphasis on these subjective aspects is an adequate fulfilment of the duties imposed on physicians, as laid down in the Dutch Euthanasia Act. (shrink)