It is often claimed that the intentions of physicians are multiple, ambiguous, and uncertain—at least with respect to end-of-life care. This claim provides support for the conclusion that the principle of double effect is of little or no value as a guide to end-of-life pain management. This paper critically discusses this claim. It argues that proponents of the claim fail to distinguish two different senses of “intention,” and that, as a result, they are led to exaggerate the extent to which (...) clinical intentions in end-of-life contexts are ambiguous and uncertain. It argues further that physicians, like others who make life and death decisions, have a duty to get clear on what their intentions are. Finally, it argues that even if the principle of double effect should be rejected, clinical intentions remain ethically significant because they condition the meaning of extraordinary clinical interventions, such as that of palliative sedation. (shrink)

This article analyses domestic and foreign reactions to a 2008 report in the British Medical Journal on the complementary and, as argued, synergistic relationship between palliative care and euthanasia in Belgium. The earliest initiators of palliative care in Belgium in the late 1970s held the view that access to proper palliative care was a precondition for euthanasia to be acceptable and that euthanasia and palliative care could, and should, develop together. Advocates of euthanasia including author Jan Bernheim, independent from but (...) together with British expatriates, were among the founders of what was probably the first palliative care service in Europe outside of the United Kingdom. In what has become known as the Belgian model of integral end-of-life care, euthanasia is an available option, also at the end of a palliative care pathway. This approach became the majority view among the wider Belgian public, palliative care workers, other health professionals, and legislators. The legal regulation of euthanasia in 2002 was preceded and followed by a considerable expansion of palliative care services. It is argued that this synergistic development was made possible by public confidence in the health care system and widespread progressive social attitudes that gave rise to a high level of community support for both palliative care and euthanasia. The Belgian model of so-called integral end-of-life care is continuing to evolve, with constant scrutiny of practice and improvements to procedures. It still exhibits several imperfections, for which some solutions are being developed. This article analyses this model by way of answers to a series of questions posed by Journal of Bioethical Inquiry consulting editor Michael Ashby to the Belgian authors. (shrink)

After a review of terminology, I identify—in addition to Margaret Battin’s list of five primary arguments for and against aid-in-dying—the argument from functional equivalence as another primary argument. I introduce a novel way to approach this argument based on Bernard Lonergan’s generalized empirical method. Then I proceed on the basis of GEM to distinguish palliative sedation, palliative sedation to unconsciousness when prognosis is less than two weeks, and foregoing life-sustaining treatment from aid-in-dying. I conclude that aid-in-dying must be justified on (...) its own merits and not on the basis of these well-established palliative care practices; and that societies must decide, in weighing the merits of aid-in-dying, whether or not to make the judgment that no life is better than life-like-this part of their operative value structure. (shrink)

In 2017, Italy passed a law that provides for a systematic discipline on informed consent, advance directives, and advance care planning. It ranges from decisions contextual to clinical necessity through the tool of consent/refusal to decisions anticipating future events through the tools of shared care planning and advance directives. Nothing is said in the law regarding the issue of physician assisted suicide. Following the DJ Fabo case, the Italian Constitutional Court declared the constitutional illegitimacy of article 580 of the criminal (...) code in the part in which it does not exclude the punishment of those who facilitate the suicide when the decision has been freely and autonomously made by a person kept alive by life-support treatments and suffering from an irreversible pathology, the source of physical or psychological suffering that he/she considers intolerable, but fully capable of making free and conscious decisions. Such conditions and methods of execution must be verified by a public structure of the national health service, after consulting the territorially competent ethics committee. This statement admits, within strict and regulated bounds, physician assisted suicide, so widening the range of end-of-life decisions for Italian patients. Future application and critical topics will be called into question by the Italian legislator. (shrink)

In Australian end-of-life care, practicing euthanasia or physician-assisted suicide is illegal. Despite this, death hastening practices are common across medical settings. Practices can be clandestine or overt but in many instances physicians are forced to seek protection behind ambiguous medico-legal imperatives such as the Principle of Double Effect. Moreover, the way they conceptualise and experience such practices is inconsistent. To complement the available statistical data, the purpose of this study was to understand the reasoning behind how and why physicians in (...) Australia will hasten death. (shrink)

BackgroundPalliative sedation and analgesia are employed in patients with refractory and intractable symptoms at the end of life to reduce their suffering by lowering their level of consciousness. The doctrine of double effect, a philosophical principle that justifies doing a “good action” with a potentially “bad effect,” is frequently employed to provide an ethical justification for this practice. Main textWe argue that palliative sedation and analgesia do not fulfill the conditions required to apply the doctrine of double effect, and therefore (...) its use in this domain is inappropriate. Furthermore, we argue that the frequent application of the doctrine of double effect to palliative sedation and analgesia reflects physicians’ discomfort with the complex moral, intentional, and causal aspects of end-of-life care. ConclusionsWe are concerned that this misapplication of the doctrine of double effect can consequently impair physicians’ ethical reasoning and relationships with patients at the end of life. (shrink)

The American Journal of Bioethics, Volume 11, Issue 6, Page 48-49, June 2011.

The aim of this pilot study was to develop a realistic clinical case for identifying Knobe's asymmetric effect, ie, the tendency to ascribe intentions to a larger extent when an act is considered wrong, as well as to compare medical students at the beginning and end of their curriculum. A vignette about a critically ill 72-year-old patient in need of an operation was used, with two different outcomes: the patient dies or the patient recovers. Approximately half of the students received (...) the ‘recovery case’ and half the ‘death case’. The questions asked were whether it was right to perform the risky operation and whether the head of the clinic brought about the patient's death/recovery intentionally. Among students in their first term an asymmetry in response pattern was identified. This asymmetry was not found among students in their final term. The difference between term 1 and term 11 students is believed to be due to the socialisation of medical students towards clinical reasoning regarding the moral role of intentions. Although no Knobe effect could be detected among term 11 students, a related adaptation effect was detected, indicating that students at the end of their medical school also tend to adapt their ascription of intentions to their moral evaluation of the act. By using clinically relevant cases a new effect has thus been identified that might be useful when investigating experienced clinicians and their views on intentions. The cases and effect merit further investigation. (shrink)

This paper explores early Australasian philosophy in some detail. Two approaches have dominated Western philosophy in Australia: idealism and materialism. Idealism was prevalent between the 1880s and the 1930s, but dissipated thereafter. Idealism in Australia often reflected Kantian themes, but it also reflected the revival of interest in Hegel through the work of ‘absolute idealists’ such as T. H. Green, F. H. Bradley, and Henry Jones. A number of the early New Zealand philosophers were also educated in the idealist tradition (...) and were influential in their communities, but produced relatively little. In Australia, materialism gained prominence through the work of John Anderson, who arrived in Australia in 1927, and continues to be influential. John Anderson had been a student of Henry Jones, who might therefore be said to have influenced both main strands of Australian philosophical thought. (shrink)

Background Studies describing physicians’ experiences with sedation at the end of life are indispensible for informed palliative care practice, but they are scarce. We describe the accounts of physicians from the USA and the Netherlands, two countries with different regulations on end-of-life decisions regarding their use of sedation.Methods Qualitative face-to-face interviews were held in 2007–2008 with 36 physicians , including primary care physicians and specialists. We applied purposive sampling and conducted constant comparative analyses.Results In both countries, the use of sedation (...) was described in diverse terms, especially in the USA, and was often experienced as emotionally challenging. Respondents stated different and sometimes multiple intentions for their use of sedation. Besides alleviating severe suffering, most Dutch respondents justified its use by stating that it does not hasten death, while most American respondents indicated that it might hasten death but that this was justifiable as long as that was not their primary intention. While many Dutch respondents indicated that they initiated open discussions about sedation proactively to inform patients about their options and to allow planning, the accounts of American respondents showed fewer and less-open discussions, mostly late in the dying process and with the patient's relatives.Conclusions The justification for sedation and the openness with which it is discussed were found to differ in the accounts of respondents from the USA and the Netherlands. Further clarification of practices and research into the effect and effectiveness of the use of sedation is recommended to enhance informed reflection and policy making. (shrink)

Recent empirical work on the concept of intentionality suggests that people’s assessments of whether an action is intentional are subject to uncertainty. Some researchers have gone so far as to claim that different people employ different concepts of intentional action. These possibilities have motivated a good deal of work in the relatively new field of experimental philosophy. The findings from this empirical research may prove to be relevant to medical ethics. In this article, we address this issue head on. We (...) first describe a study we conducted on intention ascription. Drawing on recent work in experimental philosophy, we investigated the possibility that the ascription of intentions to clinical actors in clinical settings is influenced by prior judgments about the goodness or badness of the consequences of the action in question. Our study was modeled on experimental studies in other contexts that have shown that people, when presented with a range of scenarios, are more likely to classify a side effect of an action as intended if the side effect is negative or reflects poorly on the actor than if it is positive or reflects well on the actor. We investigated whether this asymmetry in intention ascriptions was also present among physicians who were asked to ascribe intentions to clinical actors in certain well-defined clinical scenarios. After describing the study and its results, we discuss its implications for medical ethics. (shrink)

The American Journal of Bioethics, Volume 11, Issue 6, Page 49-51, June 2011.

There has been contentious debate over the years about whether there are morally relevant similarities and differences between the three practices of continuous deep sedation until death, physician-assisted suicide, and voluntary euthanasia. Surprisingly little academic attention has been paid to a comparison of the uses of these practices in the two types of circumstances in which they are typically performed. A comparative domains of ethics analysis methodological approach is used in the paper to compare 1) the use of the three (...) practices in paradigm circumstances, and 2) the use of the practices in paradigm circumstances to their use in non-paradigm circumstances. The analytical outcomes suggest that a bright moral line cannot be demonstrated between any two of the practices in paradigm circumstances, and that there are significant, morally-relevant distinctions between their use in paradigm and non-paradigm circumstances. A thought experiment is employed to illustrate how these outcomes could possibly inform the decisions of hypothetical deliberators who are engaged in the collaborative development of assisted dying regulatory frameworks. (shrink)

Two studies reported in the Journal of Medical Ethics add to the growing body of qualitative evidence relating to the use of sedatives at the end of life.1 ,2 Respondents in the two studies affirm a number of important concerns, most of which have been elaborated in the philosophy and palliative care literature, relating to the use of sedation. There seems little doubt that the common moral thread to most of these concerns is the possibility that end-of-life sedation can resemble (...) assisted death.Most of the Dutch respondents in the paper by Reitjens et al1 were reported to believe that sedation does not hasten death. That is an oversimplification. Were it not for the potential to hasten death, I doubt we would be discussing the use of sedatives so frequently in ethics journals. It is true that there is little evidence that sedation significantly hastens death when doses are carefully titrated against symptoms—giving only that amount of a drug necessary to make the patient feel less distressed, and preserving consciousness as far as possible.3 Probably most sedative …. (shrink)

In contemplating any life and death moral dilemma, one is often struck by the possible importance of two distinctions; the distinction between killing and “letting die”, and the distinction between an intentional killing and an action aimed at some other outcome that causes death as a foreseen but unintended “side-effect”. Many feel intuitively that these distinctions are morally significant, but attempts to explain why this might be so have been unconvincing. In this paper, I explore the problem from an explicitly (...) consequentialist point of view. I first review and endorse the arguments that the distinctions cannot be drawn with perfect clarity, and that they do not have the kind of fundamental significance required to defend an absolute prohibition on killing. I go on to argue that the distinctions are nonetheless important. A complete consequentialist account of morality must include a consideration of our need and ability to construct and follow rules; our instincts about these rules; and the consequences that might follow if the agent breaks a good general rule, particularly if this involves acting contrary to moral instinct. With this perspective, I suggest that the distinctions between killing and letting die and between intending and foreseeing do have moral relevance, especially for those involved in the care of the sick and dying. (shrink)

This paper explores how using a domains of ethics analysis approach might constructively contribute to an enhanced understanding (among those without specialized ethics training) of ethically-complex health care practices through the consideration of one such sample practice, i.e., deep and continuous palliative sedation (DCPS). For this purpose, I select four sample ethics domains (from a variety of possible relevant domains) for use in the consideration of this practice, i.e., autonomous choice, motives, actions and consequences. These particular domains were choosen because (...) of their relevance to the analysis of DCPS and their relative ease of access to those without ethics training. The analysis demonstrates that such an approach could facilitate the emergence of accessible arguments and discussion points that could enhance the understanding and appreciation of this and other health care practices with strong ethics dimensions. (shrink)