The growing support for voluntary active euthanasia is evident in the recently approved Dutch Law on Termination of Life on Request. Indeed, the debate over legalized VAE has increased in European countries, the United States, and many other nations over the last several years. The proponents of VAE argue that when a patient judges that the burdens of living outweigh the benefits, euthanasia can be justified. If some adults suffer to such an extent that VAE is justified, then (...) one may conclude that some children suffer to this extent as well. In an attempt to alleviate the suffering of extremely ill neonates, the University Medical Center Groningen developed a protocol for neonatal euthanasia. In this article, I first present the ethical justifications for VAE and discuss how these arguments relate to euthanizing ill neonates. I then argue that, even if one accepts the justification for VAE in adults, neonatal euthanasia cannot be supported, primarily because physicians and parents can never accurately assess the suffering of children. I argue that without the testament of the patient herself as to the nature and magnitude of her suffering, physicians can never accurately weigh the benefits and burdens of a child’s life, and therefore any such system would condemn to death some children whose suffering is not unbearable. I conclude that because the primary duty of physicians is to never harm their patients, neonatal euthanasia cannot be supported. (shrink)

Active ending of the life of a newborn baby is a crime. Yet its clandestine practise is a reality in several European countries. In this paper, we defend the necessity to institute a proper legal frame for what we define as active neonatal euthanasia. The only legal attempt so far, the Dutch Groningen protocol, is not satisfactory. We critically analyse this protocol, as well as several other clinical practises and philosophical stances. Furthermore, we have tried to integrate our (...) opinions as clinicians into a law project, with the purpose of pinpointing several issues, specific of perinatality that should be addressed by such a law. In conclusion, we argue that the legalisation of neonatal euthanasia under exceptional circumstances is the only way to avoid all the “well-intentioned” malpractices associated with ending life at the very dawn of it. (shrink)

Despite tremendous advances in medical care for critically ill newborn infants, caregivers in neonatal intensive care units still struggle with how to approach those patients whose prognoses appear to be the most grim, and whose treatments appear to be the most futile. Although the practice of passive neonatal euthanasia, from a moral perspective, has been widely condoned, those clinicians and families involved in such cases may still be found legally guilty of child abuse or even manslaughter. Passive (...) neonatal euthanasia remains both a moral dilemma and a legal ambiguity. Even the definition of passive euthanasia remains unclear. This manuscript reviews the basic moral and legal considerations raised by the current practice of neonatal euthanasia, and examines the formal position statements of the American Medical Association and the American Academy of Pediatrics. The paper concludes by emphasising the need, at least in the United States, to clarify the legal status of this relatively common medical practice. (shrink)

The Dutch rules governing neonatal euthanasia, known as the Groningen Protocol, require parental consent for severely disabled infants with poor prognoses to have their lives terminated. This paper questions whether parental consent should be dispositive in such cases, and argues that the potential suffering of the neonate or pediatric patient should be the decisive factor under such unfortunate circumstances.

The Groningen Protocol aims at providing guidance in end-of-life decision-making for severely impaired newborns. Since its publication in 2005 many bioethicists and health care professionals have written articles in response. However, only very little is known about the opinion among the general population on this subject. The aim of this study was to present the general attitude towards neonatal euthanasia (NE) among the Austrian population and the factors associated with the respondents’ opinion.

In The Netherlands, neonatal euthanasia has become a legal option and the Groningen Protocol contains an approach to identify situations in which neonatal euthanasia might be appropriate. In the 5 years following the publication of the protocol, neither the prediction that this would be the first step on a slippery slope, nor the prediction of complete transparency and legal control became true. Instead, we experienced a transformation of the healthcare system after antenatal screening policy became a (...) part of antenatal care. This resulted in increased terminations of pregnancy and less euthanasia. (shrink)

The purposes of research were to describe the neonatal clinicians' personal views and attitudes on neonatal ethical decision-making, to identify factors that might affect these attitudes and to compare the attitudes between neonatal physicians and neonatal nurses in Taiwan. Research was a cross-sectional design and a questionnaire was used to reach different research purposes. A convenient sample was used to recruit 24 physicians and 80 neonatal nurses from four neonatal intensive care units in Taiwan. (...) Most participants agreed with suggesting a do not resuscitate (DNR) order to parents for dying neonates (86.5%). However, the majority agreed with talking to patients about DNR orders is difficult (76.9%). Most participants agree that review by the clinical ethics committee is needed before the recommendation of ‘DNR’ to parents (94.23%) and nurses were significantly more likely than physicians to agree to this (p=0.043). During the end-of-life care, most clinicians accepted to continue current treatment without adding others (70%) and withholding of emergency treatments (75%); however, active euthanasia, the administration of drug to end-of-life, was not considered acceptable by both physicians and nurses in this research (96%). Based on our research results, providing continuing educational training and a formal consulting service in moral courage for neonatal clinicians are needed. In Taiwan, neonatal physicians and nurses hold similar values and attitudes towards end-of-life decisions for neonates. In order to improve the clinicians' communication skills with parents about DNR options and to change clinicians' attitudes for providing enough pain-relief medicine to dying neonates, providing continuing educational training and a formal consulting service in moral courage are needed. (shrink)

Withdrawing Artificial Nutrition and Hydration in the neonatal intensive care units has long been controversial. In France, the practice has become a legal option since 2005. But even though, the question remains as to what the stakeholders’ experience is, and whether they consider it ethically appropriate. In order to contribute to the debate, we initiated a study in 2009 to evaluate parental and health care professionals perspectives, after they experienced WAHN for a newborn. The study included 25 cases from (...) 5 different clinical neonatology departments. We interviewed both the parents and some of the HCP who cared for the baby, at least 6 months after this latter deceased. We proceeded through in-depth individual qualitative interviews. Content was analyzed for themes and patterns that emerged from the data. Some parents expressed that WANH offered an opportunity to the family to spend a few demedicalized days with the baby before she dies, without any tubes and machines, and to be well supported by the HCP during this palliative stage. But others evaluated the practice in retrospect as a terrible ordeal. All said that, at least, the time of waiting for death to ensue should not last too long. After a few days, it becomes unbearable because of the transformation of the baby’s appearance and because they, as parents, began to wonder if she was not dying from starvation rather than from her initial disease. An important proportion of HCP also expressed some kind of ethical unease. This was due to the psychological violence involved in the decision for a human being to stop feeding a little one, and also to the difficulty to deal with the fundamental intention behind the decision of WANH: indeed, could it be claim that it does not presuppose the intention of provoking the infant’s death? The discussion focuses on the point to know if WANH can be considered as a source of progress from an ethical point of view, particularly in comparison with earlier practices—that in France could involve active euthanasia by lethal injection. We argue that when HCP are merely focused on avoiding that WAHN could be construed as a way of intending to hasten the baby’s death, the practice is at risk to be implemented in a way that becomes ethically counterproductive. Focusing on this intention easily distract the clinical teams from what should be their ultimate concern, namely the baby’s comfort during the dying process, as well as the support owned to her parents. To conclude, we suggest that the ethical priorities, when WANH is decided, should be the support due to the patient and her family on the one hand, and, on the other hand to implement it in such a way that at least the baby seems to have died of her initial disease and never of starvation. This means that HCP have a duty to control the timing of death, even though this might be incompatible with the worry to avoid the intention of hastening the baby’s death. (shrink)

The authors have undertaken a study to explore the views in non-Western cultures about ending the lives of newborns with genetic defects. This study consists of including active euthanasia alongside withdrawal and withholding of treatment as potential methods used.Apart from radicalising the support for active euthanasia in certain instances of neonatal diagnoses, is another interesting point that views of children and death are shaped by religion and culture and are especially highly charged with culturally specific symbolism/s. Furthermore, (...) this is augmented in the context of non-Western cultures—further polarising the positivist ethics of Western scientific medicine from the cultures that affect only those who are members of ‘other’ societies.From this starting point, the authors shift the focus from clinical explanations of the causation and prognosis of the genetic defects and enter a dialogue with cultural narratives. Consequently, their argument is, broadly, a reassessment of medical practice as a contextualisation of a particular culture/s rather than indifferent or independent from cultural forces or influences.This is a radical claim. …. (shrink)

The Dutch Paediatric Association reports consensus among its members regarding the necessity to take the future quality of life into account when reaching decisions regarding the continuation or dis-continuation of life-prolonging treatment. The paramount importance of the discussion with the parents is stressed. Dissension exists regarding active euthanasia in the newborn, both opinions being respected. If dissension exists within the profession parents should be informed and if necessary referred to a doctor who shares their moral views.

[From Euthanasia to Infanticide] The paper revisits the recent controversy over Dr. Mitlőhner’s defense of infanticide, published in this journal. In section 1, I point out the weaknesses of Mitlőhner’s paper. In sections 2 and 3 I turn to the most sophisticated defense of infanticide on offer today, that of Peter Singer’s. Section 2 sums up Singer’s description of the medical practice as already having abandoned the traditional ethic of equal value of all human lives, which motivates ethical revisionism. (...) However, an explicit justification of a revision is necessary. This is the job of Singer’s Replacement Argument, examined in section 3. I argue that this justification of infanticide in completely impersonal terms fails. In section 4, I reject it in favor of Ronald Dworkin’s distinction between experiential interests, possessed by infants, and critical interests that develop later. Hence, neonatal euthanasia can sometimes be justified in terms of a newborn‘s own interests (presumably, to relieve its suffering), not in impersonal terms. The only exception is those infants that lack any capacity for cognitive activity whatsoever, and who thus lack even experiential interests. It is an open question whether their “life” differs from death, and whether by killing them we perform infanticide. (shrink)

Prolonging neonatal lifeThe paradox that medicine’s success breeds medicine’s problems is well known to readers of the Journal of Medical Ethics. Advances in neonatal medicine have worked wonders. Not long ago, extremely premature birth babies, or those born with very serious health problems, would inevitably have died. Today, neonatologists can resuscitate babies born at ever-earlier stages of gestation. And very ill babies also benefit from advances in neonatal intensive care. Infant lives can be prolonged. Unfortunately, several such (...) babies will not survive for long whatever is done for them. Others will live to leave hospital, but face severe health problems. Doctors have gained the ability to prolong neonatal life. But should they always do so? This question is central to the recent report of the Nuffield Council on Bioethics, Critical care decisions in fetal and neonatal medicine.1 In many quarters, the report received a very positive response, commended in The Lancet as “thoughtful, sensitive and sensible” and welcomed by the premature baby charity BLISS. Critics attacked on both flanks. The report goes too far—ushering in a culture of “throw away babies”. Or it does not go far enough—failing to endorse the Dutch precedent to sanction active neonatal euthanasia.TOO FAR?One of the key recommendations of the report is that guidelines be developed in relation to the institution of intensive neonatal care. It is these guidelines, which have been savaged by some parts of the media. The BMA called them “blanket rules” smothering clinical discretion. The guidelines on resuscitation at birth apply to babies born at the borderline of viability, that is, at or before a gestational age of 25 weeks 6 days. The earlier the baby is born, the lower are the chances that he/she will survive to leave hospital. Before 21 weeks 6 days, none of …. (shrink)

Ethical dilemmas are common in the neonatal intensive care setting. The aim of the present study was to investigate the opinions of Swedish physicians and the general public on treatment decisions regarding a newborn with severe brain damage. We used a vignette-based questionnaire which was sent to a random sample of physicians (n = 628) and the general population (n = 585). Respondents were asked to provide answers as to whether it is acceptable to discontinue ventilator treatment, and when (...) it actually is discontinued whether or not it was acceptable to use drugs which hasten death unintentionally or intentionally. The response rate was 67 % of physicians and 46 % of the general population. A majority of both physicians [56 % (CI 50–62)] and the general population [53 % (CI 49–58)] supported arguments for withdrawing ventilator treatment. A large majority in both groups supported arguments for alleviating the patient’s symptoms even if the treatment hastened death, but the two groups display significantly different views on whether or not to provide drugs with the additional intention of hastening death, although the difference disappeared when we compared subgroups of those who were for or against euthanasia-like actions. The study indicated that physicians and the general population have similar opinions regarding discontinuing life-sustaining treatment and providing effective drugs which might unintentionally hasten death but seem to have different views on intentions. The results might be helpful to physicians wanting to examine their own intentions when providing adequate treatment at the end of life. (shrink)

Abortion for life-limiting foetal anomaly is often an intensely painful choice for the parents; though widely offered and supported, it is surprisingly difficult to defend in ethical terms. Abortion on this ground is sometimes defended as foetal euthanasia but has features which sharply differentiate it from standard non-voluntary euthanasia, not least the fact that any suffering otherwise anticipated for the child may be neither severe nor prolonged. Such abortions may be said to reduce suffering for the family including (...) siblings – a consideration rarely stated so explicitly in defences of postnatal euthanasia – or for the woman who must in any case face the eventual loss of her baby, and for whom the abortion is seen as therapeutic in minimising pain. Finally, the abortion may be said to constitute the cessation of morally optional life support on the part of the woman, and/or to be a ‘social’ choice she is entitled to make, whether or not this in fact promotes her interests or those of her child. These defences need honest exploration: the intense parental suffering caused by the choice to end an often much-wanted pregnancy should not preclude but rather encourage the question whether this choice can indeed be ethically proposed to couples, especially compared with the neonatal palliative care (‘perinatal hospice’) approach so well received by parents who experience it. (shrink)

Huang and colleagues provide some intriguing insights into the attitudes about end of life care of practising Taiwanese neonatal doctors and nurses.1 There are some similarities with surveys from other parts of the world. Most Taiwanese neonatologists and nurses agreed that it was potentially appropriate to withhold or limit treatment for infants who were dying. A very high proportion was opposed to active euthanasia of such infants. But there were also some striking differences. Only 21% of Taiwanese doctors (...) ‘agreed’ with withdrawal of mechanical ventilation for dying newborn infants. This proportion is lower than reported in any European country.2 More than 90% of neonatologists surveyed in the UK, the USA, The Netherlands and Sweden found withdrawal of mechanical ventilation acceptable.2 ,3 Taiwanese doctors also seemed reluctant to give analgesia or sedatives to such infants, with almost 60% disagreeing with their use in dying infants where there was a risk of hastening death.1 In contrast, two-thirds or more of European neonatologists thought this was acceptable .2The results of the survey of Huang et al highlight three beliefs about end-of-life care that are widespread, but all of which are seriously mistaken1. None are new, but …. (shrink)

The prelims comprise: Death and Democracy Political Philosophy and Choosing Death Historical Roots Brain Death Abortion and Decisions for Neonates and Other Children Letting Die and Terminal Sedation Euthanasia and Physician‐Assisted Suicide Conclusion Notes.

To fulfill their crucial duty of relieving suffering in their patients, physicians may have to administer palliative sedation when they implement treatment-limitation decisions such as the withdrawal of life-supporting interventions in patients with poor prognosis chronic severe brain injury. The issue of palliative sedation deserves particular attention in adults with serious brain injuries and in neonates with severe and irreversible brain lesions, who are unable to express pain or to state their wishes. In France, treatment limitation decisions for these patients (...) are left to the physicians. Treatment-limitation decisions are made collegially, based on the presence of irreversible brain lesions responsible for chronic severe disorders of consciousness. Before these decisions are implemented, they are communicated to the relatives. Because the presence and severity of pain cannot be assessed in these patients, palliative analgesia and/or sedation should be administered. However, palliative sedation is a complex strategy that requires safeguards to prevent a drift toward hastening death or performing covert euthanasia. In addition to the law on patients' rights at the end of life passed in France on April 22, 2005, a recent revision of Article 37 of the French code of medical ethics both acknowledges that treatment-limitation decisions and palliative sedation may be required in patients with severe brain injuries and provides legal and ethical safeguards against a shift towards euthanasia. This legislation may hold value as a model for other countries where euthanasia is illegal and for countries such as Belgium and Netherlands where euthanasia is legal but not allowed in patients incapable of asking for euthanasia but in whom a treatment limitation decision has been made. (shrink)

Background: Lay persons’ judgements of the acceptability of the not uncommon practice of ending the life of a damaged neonate have not been studied. Methods: A convenience sample of 1635 lay people in France rated how acceptable it would be for a physician to end a neonate’s life—by withholding care, withdrawing care, or active euthanasia—in 54 scenarios in which the neonate was diagnosed either with perinatal asphyxia or a genetic abnormality. The scenarios were all combinations of four factors: three (...) levels of maturity or immaturity, three levels of severity of the health problem, three levels of parents’ preference concerning prolonging care and two levels of decision-making (with or without consulting the other caregivers). Analyses: Analyses of variance of the participants’ responses were performed to determine the importance of each factor; the interactions among factors, with methods of ending life and with other patient characteristics; and the differences between asphyxia and genetic abnormality. A cluster analysis was performed to look for groups with different patterns of responses. Results: Lay people assigned most importance to the parents’ request and to the severity of the problem. Except for a small group (12%) always opposed to ending life, they used a simple additive-type rule in integrating the information. Implications: Most of this sample of French lay people are not categorically for or against ending the life of a damaged neonate, but judge its degree of acceptability by adding up those factors that seem most salient to them. (shrink)

Death and grief in the ancient world -- Predictions and disability in Rome.

This article questions social constructionists' claims to introduce Wittgenstein's philosophy to psychology. The philosophical fiction of a neonate Crusoe is introduced to cast doubt on the interpretations and use of the private language argument to support a new psychology developed by the constructionists. It is argued that a neonate Crusoe's viability in philosophy and apparent absence in psychology offends against the integrity of the philosophical contribution Wittgenstein might make to psychology. The consequences of accepting Crusoe's viability are explored as they (...) appear in both philosophy and psychology. (shrink)

Slippery slope arguments appear regularly whenever morally contested social change is proposed. Such arguments assume that all or some consequences which could possibly flow from permitting a particular practice are morally unacceptable.Typically, “slippery slope” arguments claim that endorsing some premise, doing some action or adopting some policy will lead to some definite outcome that is generally judged to be wrong or bad. The “slope” is “slippery” because there are claimed to be no plausible halting points between the initial commitment to (...) a premise, action, or policy and the resultant bad outcome. The desire to avoid such projected future consequences provides adequate reasons for not taking the first step.Thus the legalization of abortion in limited circumstances is asserted to lead down the slippery slope towards abortion on demand and even infanticide; and the legalization of assisted suicide to lead inexorably to the acceptance of voluntary euthanasia and subsequently to the sanctioning of the practice of nonvoluntary euthanasia – even involuntary euthanasia of “undesirable” individuals. (shrink)

In the debate surrounding the morality and legality of the practices of physician-assisted death and euthanasia, a common logical argument regularly employed against these practices is the “slippery slope argument.” One formulation of this argument claims that acceptance of physician-assisted death will eventually lead down a “slippery slope” into acceptance of active euthanasia, including its voluntary, non-voluntary, and/or involuntary forms, through psychological and social processes that warp a society’s values and moral perspective of a practice over an extended (...) period of time. This formulation is known as the psychological slippery slope argument. This paper analyzes the psychological slippery slope argument as it is applied to the practice of physician-assisted death, and utilizing recent empirical evidence from various nations around the world that practice physician-assisted death and/or euthanasia, the paper argues that employing the psychological slippery slope argument against physician-assisted death is logically fallacious, this kind of slippery slope is unfounded in practice, and thus the psychological slippery slope argument is insufficient on its own to justify continued legal prohibition of physician-assisted death. (shrink)

Introduction: In The Netherlands, physicians have to be convinced that the patient suffers unbearably and hopelessly before granting a request for euthanasia. The extent to which general practitioners (GPs), consulted physicians and members of the euthanasia review committees judge this criterion similarly was evaluated. Methods: 300 GPs, 150 consultants and 27 members of review committees were sent a questionnaire with patient descriptions. Besides a “standard case” of a patient with physical suffering and limited life expectancy, the descriptions included (...) cases in which the request was mainly rooted in psychosocial or existential suffering, such as fear of future suffering or dependency. For each case, respondents were asked whether they recognised the case from their own practice and whether they considered the suffering to be unbearable. Results: The cases were recognisable for almost all respondents. For the “standard case” nearly all respondents were convinced that the patient suffered unbearably. For the other cases, GPs thought the suffering was unbearable less often (2–49%) than consultants (25–79%) and members of the euthanasia review committees (24–88%). In each group, the suffering of patients with early dementia and patients who were “tired of living” was least often considered to be unbearable. Conclusions: When non-physical aspects of suffering are central in a euthanasia request, there is variance between and within GPs, consultants and members of the euthanasia committees in their judgement of the patient’s suffering. Possible explanations could be differences in their roles in the decision-making process, differences in experience with evaluating a euthanasia request, or differences in views regarding the permissibility of euthanasia. (shrink)

In April 2002 a new law regarding euthanasia came into effect in the Netherlands. This law holds that euthanasia remains a criminal offence unless it is performed by a physician who acts according to six specified rules of due care and reports the case to a review committee. The six rules of due care are similar to those of the previous regulation and are largely based on jurisprudence. Completely new, however, is the article concerning a competent patient who (...) has written an advance directive requesting euthanasia under certain circumstances. The law stipulates that a physician may act according to that written request, as long as he or she fulfils all other rules of due care. The author defends the view that these requests are neither feasible nor ethically justifiable, and presents both moral and practical arguments for this, claiming that for consistency reasons one cannot act on the basis of a written statement and fulfil the other rules of due care at the same time. The author also examines a difficult case of a demented, severely depressed woman who had written a living will requesting euthanasia before she became demented. (shrink)

This article discusses the nature of euthanasia, and the way in which redevelopment of the concept of euthanasia in some influential recent philosophical writing has led to morally less discriminating killing/letting die/not saving being misdescribed as euthanasia. Peter Singer's defence of non-voluntary ‘euthanasia’of defective infants in his influential book Practical Ethics is critically evaluated. We argue that Singer's pseudo-euthanasia arguments in Practical Ethics are unsatisfactory as approaches to determining the legitimacy of killing, and that these (...) arguments present a total utilitarian improvement policy—not a case for non-voluntary euthanasia. (shrink)

Thomas Riisfeldt’s essay1 is a valuable contribution to the literature on palliative sedation, appropriately titrated administration of opioids (ATAOs) and euthanasia. In this response, I will not deal with the author’s empirical claim about the relationship between opioid use, palliative sedation and survival time. Rather, I will briefly critique the author’s discussion of doctrine of double effect (DDE) and its application to palliative sedation and opioid use at the end of life. That is, I will focus on the ethical (...) claims made by the author. Riisfeldt argues that DDE is incompatible with both Kantian deontology and Millian consequentialism. Yet, I will argue that the DDE is coherent and defensible when interpreted from the perspective of the philosophy of Thomas Aquinas, the theorist who first proposed the doctrine. I will also argue that Riisfeldt mischaracterises ATAOs and palliative sedation as procedures that hasten death as a means to relieve pain. While death may indeed be hastened by ATAOs and palliative sedation, it is not at all clear that clinicians intend to hasten death as a means to relieve pain. Indeed, clinical guidelines explicitly prohibit the intentional hastening of death. Riisfeldt provides a brief summary of the DDE. He describes DDE as a ‘strange hybrid of four principles’. He lists the four criteria that must be met for an act with a good and a bad effect to be permissible. These criteria are the ‘intention and means criteria’ and the ‘intrinsic and proportionality criteria’ (p.127). The author uses Kant and Mill as lens through which to highlight a tension between the intrinsic and proportionality criteria of DDE. The author claims that ‘the intrinsic criterion is derived from deontology, the predominant form of which is championed by Kant’, and that ‘the proportionality criterion is derived from consequentialism, the predominant form of …. (shrink)

Until the 1970s, models of early infancy tended to depict the young child as internally preoccupied and incapable of processing visual-tactile data from the external world. Meltzoff and Moore's groundbreaking studies of neonatal imitation disprove this characterization of early life: They suggest that the infant is cognizant of its external environment and is able to control its own body. Taking up these experiments, theorists argue that neonatal imitation provides an empirical justification for the existence of an innate ability (...) to engage in social communication. Since later imitation is taken as a benchmark for self- and other-awareness, theorists claim that a proto- or primitive self must exist in the infant. This paper takes up the issue of whether or not neonatal imitation does provide us with a ground to argue against developmental accounts that consider self-awareness to be a later acquisition. I argue that the enthusiasm over neonatal imitation is premature. Psychological studies that claim to prove neonatal imitation do not provide sufficient grounds for dismissing alternate philosophical and psychological theories about the self as being a post-birth "event" rather than an intrinsic condition. Therefore, I argue that there is no compelling reason to suppose that we come to the world with a primitive sense of self- or other-awareness. (shrink)

The essays in this volume, with the exception of Gary Ferngren's, derive from ancestral versions originally presented at a symposium, 'Conflicts with Newborns: Saving Lives, Scarce Resources, and Euthanasia: held May 10-12,1984, at the Mercer University School of Medicine, Macon, Georgia. We wish to express our gratitude to the Georgia Endowment for the Humanities for a generous grant for the symposium and to Mercer University and the Medical Center of Central Georgia for additional financial support. The vit:ws expressed in (...) this volume do not necessarily represent those of the Georgia Endowment for the Humani ties, Mercer University, or the Medical Center of Central Georgia. We have endeavored to bring together a group of individuals with contrast ing viewpoints to display some of the range of approaches to a major problem in public policy: medical decisions regarding the treatment of defective newborns. So many persons contributed to the symposium that acknowledg ment of each would be impossible. Although unnamed, we express our sincere appreciation to each. Three individuals, however, must be recognized: R. Kirby Godsey, President, Mercer University; William P. Bristol, Dean, Mercer University School of Medicine; and Kenneth C. Henderson, Medical Director and Director of Medical Education, Medical Center of Central Georgia. Without their support, the symposium could not have succeeded and this volume would not have been possible. We wish also to express our gratitude to S. G. M. (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: Although nurses worldwide are confronted with euthanasia requests from patients, the views of palliative care nurses on their involvement in euthanasia remain unclear.Objectives: In depth exploration of the views of palliative care nurses on their involvement in the entire care process surrounding euthanasia.Design: A qualitative Grounded Theory strategy was used.Setting and participants: In anticipation of new Belgian legislation on euthanasia, we conducted semistructured interviews with 12 nurses working in a palliative care setting in the province (...) of Vlaams-Brabant.Results: Palliative care nurses believed unanimously that they have an important role in the process of caring for a patient who requests euthanasia, a role that is not limited to assisting the physician when he is administering life terminating drugs. Nurses’ involvement starts when the patient requests euthanasia and ends with supporting the patient’s relatives and healthcare colleagues after the potential life terminating act. Nurses stressed the importance of having an open mind and of using palliative techniques, also offering a contextual understanding of the patient’s request in the decision making process. Concerning the actual act of performing euthanasia, palliative care nurses saw their role primarily as assisting the patient, the patient’s family, and the physician by being present, even if they could not reconcile themselves with actually performing euthanasia.Conclusions: Based on their professional nursing expertise and unique relationship with the patient, nurses participating as full members of the interdisciplinary expert team are in a key position to provide valuable care to patients requesting euthanasia. (shrink)

Patients who are imminently dying sometimes experience symptoms refractory to traditional palliative interventions, and in rare cases, continuous sedation is offered. Samuel H. LiPuma, in a recent article in this Journal, argues that continuous sedation until death is equivalent to physician-assisted suicide/euthanasia based on a higher brain neocortical definition of death. We contest his position that continuous sedation involves killing and offer four objections to the equivalency thesis. First, sedation practices are proportional in a way that physician-assisted suicide/euthanasia (...) is not. Second, continuous sedation may not entirely abolish consciousness. Third, LiPuma’s particular version of higher brain neocortical death relies on an implausibly weak construal of irreversibility—a position that is especially problematic in the case of continuous sedation. Finally, we explain why continuous sedation until death is not functionally equivalent to neocortical death and, hence, physician-assisted suicide/euthanasia. Concluding remarks review the differences between these two end-of-life practices. (shrink)

Although Kirk Lougheed recognises the need to integrate diverse frameworks into its predominantly Anglo-American tradition,1 his argument contains a limited understanding of vital force as well as a restricted view of communal relationships. We therefore suggest a broader framework for understanding vitality, community and what is permissible by emphasising how African beliefs by the Akan, advance care directives and Afro-Caribbean religious practice such as Santería expand perspectives within global bioethics and thus encourage more inclusive approaches to addressing bioethical dilemmas. For (...) the Akan (in Ghana), the fundamental concept of ‘being’ is construed on the belief that Okra (considered as soul, or the life-giving spirit in man) and Nkrabea (considered as destiny) determine the life of every individual. Individual autonomy in the matter of ‘death’ is linked to the collective responsibility for the preservation of life. For a terminally ill person, his family and community members, this responsibility is upheld by allowing Nkrabea (destiny) to take its natural course without any human intervention especially in matters of ‘death’. Thus, the Akan belief and conviction concerning Nkrabea or destiny run contrary to the approval of euthanasia.2 The impermissibility of euthanasia, from this perspective …. (shrink)

There has been no informed or honest debate in North America over the issue of liberalized euthanasia. Despite thousands of newspaper stories, scores of learned academic articles, a handful of closely analyzed legal decisions, and hours of broadcast news and talk show imagery, a full discussion is yet to begin.

Background: Although nurses worldwide are confronted with euthanasia requests from patients, the views of palliative care nurses on their involvement in euthanasia remain unclear.Objectives: In depth exploration of the views of palliative care nurses on their involvement in the entire care process surrounding euthanasia.Design: A qualitative Grounded Theory strategy was used.Setting and participants: In anticipation of new Belgian legislation on euthanasia, we conducted semistructured interviews with 12 nurses working in a palliative care setting in the province (...) of Vlaams-Brabant .Results: Palliative care nurses believed unanimously that they have an important role in the process of caring for a patient who requests euthanasia, a role that is not limited to assisting the physician when he is administering life terminating drugs. Nurses’ involvement starts when the patient requests euthanasia and ends with supporting the patient’s relatives and healthcare colleagues after the potential life terminating act. Nurses stressed the importance of having an open mind and of using palliative techniques, also offering a contextual understanding of the patient’s request in the decision making process. Concerning the actual act of performing euthanasia, palliative care nurses saw their role primarily as assisting the patient, the patient’s family, and the physician by being present, even if they could not reconcile themselves with actually performing euthanasia.Conclusions: Based on their professional nursing expertise and unique relationship with the patient, nurses participating as full members of the interdisciplinary expert team are in a key position to provide valuable care to patients requesting euthanasia. (shrink)

In this essay, I examine the arguments against physician-assisted suicide Susan Wolf offers in her essay, “Gender, Feminism, and Death: Physician-Assisted Suicide and Euthanasia.” I argue that Wolf's analysis of PAS, while timely and instructive in many ways, does not require that feminists reject policy approaches that might permit PAS. The essay concludes with reflections on the relationship between feminism and questions of agency, especially women's agency.

Historically, the care of hospitalized children has evolved from being performed in isolation from parents to a situation where the parents and the child are regarded as a unit, and parents and nurses as equal partners in the child’s care. Parents are totally dependent on professionals’ knowledge and expertise, while nurses are dependent on the children’s emotional connection with their parents in order to provide optimal care. Even when interdependency exists, nurses as professionals hold the power to decide whether and (...) to what extent parents should be involved in their child’s care. This article focuses on nurses’ responsibility to act ethically and reflectively in a collaborative partnership with parents. To illuminate the issue of nurses as moral practitioners, we present an observation of contemporary child care, and discuss it from the perspective of the Danish moral philosopher KE Løgstrup and his book The ethical demand. (shrink)

This text focuses on selected basic arguments of libertarianism that could be found in certain debates on the moral issues of euthanasia and the application of moral fictionalism in bioethics. Firstly, I devote my article to the criticism of libertarian arguments (as one of the dominant discourses related to the debate over euthanasia) in a wider perspective of moral philosophy. The article is based on an approach that understands morality as a kind of social practice and the primary (...) goal is to grasp the key theoretical concepts which are included in the mechanism for identifying and assessing our moral intuitions. This text is primarily an analysis of selected arguments of current normative theories of libertarianism on two levels: first it examines the idea of self-ownership in connection with certain debates over euthanasia, while the latter part of the article concerns an analysis of the critique of libertarian arguments and a comparison of the alternative arguments of moral fictionalism. The last part of this text, focusing on moral fictionalism and its general application in bioethics, is the core of the article. (shrink)

The slippery slope argument has been the mainstay of many of those opposed to the legalisation of physician-assisted suicide and euthanasia. In this paper I re-examine the slippery slope in the light of two recent studies that examined the prevalence of medical decisions concerning the end of life in the Netherlands and in Australia. I argue that these two studies have robbed the slippery slope of the source of its power--its intuitive obviousness. Finally I propose that, contrary to the (...) warnings of the slippery slope, the available evidence suggests that the legalisation of physician-assisted suicide might actually decrease the prevalence of non-voluntary and involuntary euthanasia. (shrink)

Treatment-resistant depression (TRD) holds centrality in many debates regarding psychiatric euthanasia. Among the strongest reasons cited by opponents of psychiatric euthanasia is the uncertainty behind the irremediability of psychiatric illnesses. According to this argument, conditions that cannot be considered irremediable imply that there are possible remedies that remain for the condition. If there are possible remedies that remain for the condition, then patients with that condition cannot be considered for access to euthanasia. I call this the irremediability (...) requirement (IR). I argue that patients with TRD can, indeed, meet the operationalisation of irremediability in the IR. This is because the irremediability it asks for is not some global or absolute irremediability, but rather a present irremediability based on the current state of medical science. I show this by considering irremediability relating to (1) possible future treatments and (2) not trying presently available alternative treatments. I extend Schuklenk nd van de Vathorst’s argument from parity to terminal malignancies, to show that (1) is an unreasonable expectation for all cases of euthanasia. Taking (2) as a more serious opponent to psychiatric euthanasia, I show how the IR, based on how it is presently operationalised, can be realistically applied to cases of TRD. I do this by further developing Tully’s argument on broad-sense treatment resistance with the robust empirical data from the STAR*D trials. If my argument from Tully’s is valid, then we have reasons to, again, seek parity between the operationalisations of irremediability in terminal malignancies and TRD. (shrink)

Background Nurses have an essential role in caring for end-of-life patients. Nevertheless, the nurse’s involvement in the passive euthanasia decision-making process is insufficient and lower than expected. Objectives To explore factors associated with nurses’ intention to be involved in non-treatment decisions (NTD) regarding passive euthanasia decision-making versus their involvement in the palliative care of patients requesting euthanasia, using the Theory of Planned Behavior (TPB) framework. Design A cross-sectional study utilizing a random sample. Participants and research context The (...) study was conducted in one of the largest hospitals in Israel among 125 nurses employed in internal and surgical care wards. Data was collected through face-to-face interviews between March and April 2019. Method A closed structured questionnaire was developed according to TPB instructions. A paired sample t test and two multiple hierarchical regressions were conducted. Variance explained (R2) and the significance of F change were calculated for each regression. The study used the STROBE statement guideline. Ethical considerations The study was approved by the hospital’s Helsinki Committee (#20.11.2017). Findings A paired sample t test revealed that nurses’ involvement in the palliative care of patients requesting passive euthanasia was significantly higher than in NTD regarding euthanasia. Regression analyses revealed that nurses’ position and attitudes explain their intention to be involved in decision-making; attitudes and perceived behavioral control explain nurses’ intention to be involved in the care of patients requesting euthanasia. Conclusions According to the TPB, nurses’ attitudes explained their intention to participate in decision-making regarding passive euthanasia. It is recommended to enhance open discussion of this complex issue to encourage nurses’ willingness to participate in NTD decision-making regarding euthanasia. (shrink)

In Nazi Germany, approximately 200 000 mentally ill people were murdered under the guise of euthanasia. Relatively little is known regarding the fate of the Jewish mentally ill patients targeted in this process, long before the Holocaust officially began. For the Nazis, Jewish mentally ill patients were doubly cursed since they embodied both “precarious genes” and “racial toxin”. To preserve the memory of the victims, Yad Vashem, the leading institution dedicated to documentation of the Holocaust, actively collects information and (...) documents the fate of victims in an open online database. Recently, a list of approximately 1200 names of Jewish mentally ill euthanasia victims has been compiled from hospital archives. Their fate remains unknown to surviving family members. Given the duty to preserve medical confidentiality, can this list be publicised for public interest and for notifying families—publicising names and death circumstances, including where “killed” would immediately indicate that the person had had a mental illness? Does the right to medical confidentiality lapse upon death? Is time elapsed since death a factor? Can opposing obligations of preserving victims’ memory over-ride medical confidentiality? What if a family member objects to a grandparent’s name being exposed on the list of mentally ill patients? This article considers these issues as well as the “rational” and “non-rational” factors in ethical decisional making surrounding this unique dilemma. Several possible solutions are proposed including preserving the list in a locked database for access by families and researchers, publicising in the media that such a list exists, publishing the information online without any identifiers and submitting the information to historians, allowing them to process the data as they see fit. (shrink)

Argues that considerations central to the justification of euthanizing humans do not readily extrapolate to the euthanasia of pets and companion animals; that the comparative account of death's badness can be successfully applied to such animals to ground the justification of their euthanasia and its timing; and proposes that companion animal guardians have authority to decide to euthanize such animals because of their epistemic standing regarding such animals' welfare.

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)

The distinction between 'kill' and 'help to die' is argued by analogy with the distinction between 'rape' and 'make love to'. The difference is the consent of the receiver of the act, therefore 'kill' is the wrong word for an act of active voluntary euthanasia. The argument that doctors must not be allowed by law to perform active voluntary euthanasia because this would recognise an infringement of the sanctity of life ('the red light principle') is countered by comparing (...) such doctors with the drivers of emergency vehicles, who are allowed to drive through red lights. (shrink)