The management of patients suffering from chronic disorders of consciousness inevitably raises important ethical questions about the end of life decisions. Some ethical positions claim respect of human life sacredness and the use of good medical practices require allowing DOC patients to live as long as possible, since no one can arbitrarily end either his/her or others’ life. On the other hand, some currents of thought claim respect of human life dignity, patients’ wishes, and the right of free choice entail (...) allowing the withdrawal of life sustaining therapy. This could happen when patients believe their own life to be not worth living, or if therapy is not very beneficial, excessively burdensome, or even futile. Indeed, the decision to withdraw therapies in a DOC patient should be guided by reliable information about DOC diagnosis and prognosis and on how the patient would wish to be treated in such a condition. Taking into account such issues, it would be possible to make the decision that more adequately fits a DOC patient’s best interest. This review aims to overview the range of ethical issues referring to end-of-life decisions in DOC patients, with regard to the thorny debate on the sacredness and dignity of human life. (shrink)

Background According to some medical ethicists and professional guidelines, there is no ethical difference between withholding and withdrawing life-sustaining treatment. However, medical professionals do not always agree with this notion. Patients and their families may also not regard these decisions as equivalent. Perspectives on life-sustaining treatment potentially differ between cultures and countries. This study compares Japanese physicians’ and citizens’ attitudes toward hypothetical cases of withholding and withdrawing life-sustaining treatment.Methods Ten vignette cases were developed. A web-based questionnaire was administered to 457 (...) citizens and 284 physicians to determine whether they supported withholding or withdrawing treatment.Results In a case where a patient had an advance directive refusing ventilation, 77% of the physicians and 68% of the citizens chose to withhold treatment. In a case where there was an advance directive but the patient’s family requested treatment, 55% of the physicians and 45% of the citizens chose to withhold the ventilator. When a family requested withdrawal of the ventilator but patient wishes were unknown, 19% of the physicians and 48% of the citizens chose to withdraw the ventilator. However, when the patient had also indicated their wishes in writing, 49% of the physicians and 66% of the citizens chose to withdraw treatment. More physicians were prepared to withdraw dialysis (84%) and artificial nutrition (81%) at a patient’s request than mechanical ventilation (49%).Conclusions A significant proportion of Japanese physicians and citizens were reluctant to withhold or withdraw life-sustaining treatment, even in cases where the patient had indicated their wishes in writing. They were more likely to withhold than withdraw treatment, and more likely to withdraw artificial nutrition than mechanical ventilation. Japanese physicians gave significant weight to family views about treatment but were less likely to agree to withdraw treatment than citizens, indicating a potential source of conflict in clinical settings. (shrink)

The ethics of hastened death are complex. Studies on physicians’ opinions about assisted dying exist, but changes in physicians’ attitudes towards hastened death in clinical decision-making and the background factors explaining this remain unclear. The aim of this study was to explore the changes in these attitudes among Finnish physicians. A questionnaire including hypothetical patient scenarios was sent to 1182 and 1258 Finnish physicians in 1999 and 2015, respectively. Two scenarios of patients with advanced cancer were presented: one requesting an (...) increase in his morphine dose to a potentially lethal level and another suffering a cardiac arrest. Physicians’ attitudes towards assisted death, life values and other background factors were queried as well. The response rate was 56%. The morphine dose was increased by 25% and 34% of the physicians in 1999 and 2015, respectively. Oncologists approved the increase most infrequently without a significant change between the study years. Oncological specialty, faith in God, female gender and younger age were independent factors associated with the reluctance to increase the morphine dose. Euthanasia, but not assisted suicide, was considered less reprehensible in 2015. In both years, most physicians withheld cardiopulmonary resuscitation. Finnish physicians accepted the risk of hastening death more often in 2015 than in 1999. The physicians’ specialty and many other background factors influenced this acceptance. They also regarded euthanasia as less reprehensible now than they did 16 years ago. (shrink)

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)

A wide variety of bioethical themes have recently been debated and researched in Sweden, including genetic screening, HPV vaccination strategies, end-of-life care, injustices and priority setting in healthcare, dual-use research, and the never-ending story of scientific fraud. Also, there are some new events related to Swedish biobanking that might be of general interest. Here we will concentrate on four themes: end-of-life care, dual-use research, scientific fraud, and biobanking.

Background: This study attempts to understand if medical providers beliefs about the moral permissibility of honoring patient-directed refusals of life-sustaining treatment (LST) are tied to their beliefs about the patient’s decision-making capacity. The study aims to answer: 1) does concern about a patient’s treatment decision-making capacity relate to beliefs about whether it is morally acceptable to honor a refusal of LST, 2) are there differences between provider types in assessments of decision-making capacity and the moral permissibility to refuse LST, and (...) 3) do provider demographics impact beliefs about decision-making capacity and the moral permissibility to refuse LST. Methods: A mixed-methods survey using Likert assessment and vignette-based questions was administered to medical providers within a single health system in the upper Midwest (N = 714) to assess their perspectives on the moral acceptance and decision-making capacity in cases of withholding and withdrawing treatment and suicide. Results: Behavioral health providers report accepting of the moral permissibility of suicide (91.2%) more than either medical providers (77.2%) or surgeons (74.4%) (n = 283). Decision-making capacity was questioned more in the vignettes of the patients refusing life-saving surgery (36%) and voluntarily starvation (40.8%) than in the vignette of the patient requesting to deactivate a pacemaker (13%) (n = 283). Behavioral health providers were more concerned about the capacity to refuse life-saving surgery (55.9%) than medical providers (33.8%) or surgeons (23.1%) (n = 283). Conclusions: Respondents endorse the moral permissibility of persons to withhold or withdraw from treatment regardless of motive. Clinical concerns about a patient’s treatment decision-making capacity do not strongly correlate to views about the moral permissibility of honoring refusals of LST. Different provider types appear to have different thresholds for when to question treatment decision-making capacity. Behavioral health providers tend to question treatment decision-making capacity to refuse LST more than non-behavioral health providers. (shrink)