ZusammenfassungDas Verfahren des Sterbefastens ) hat eine lange Tradition, die, soweit wir wissen, bis in die Antike zurückreicht. Besonders in jüngster Zeit findet es Interesse bei älteren Menschen, die dem Tode nahe sind und über Zeitpunkt und Umstände ihres Todes ein gewisses Maß an Gestaltungsspielraum behalten wollen. Unter den Befürwortern dieses Verfahrens ist allerdings u. a. strittig, wieweit Sterbefasten als eine „passive“ Form von Suizid gelten kann. Auf dem Hintergrund der WHO-Definition des Suizids verteidigt der Beitrag eine affirmative Antwort und (...) diskutiert, wieweit sich daraus Konsequenzen für die ethische Beurteilung des Sterbefastens ergeben. (shrink)

We are grateful to the commentators on our article1 for their thoughtful engagement with the ethical and clinical complexity of expanded terminal sedation (ETS) in end-of-life care. We will start by noting some points of common ground, before moving on to the more challenging ways in which TS might be permissibly expanded. First, several commentators pointed out, and we completely concur, that it is important to provide patients with full information about their end-of-life options, including the ‘outcomes, uncertainties and costs (...) of ETS’.2 Where possible, they should be given time to ‘process their feelings and to reflect on how they wish to live in their last few days, weeks or months’.3 Furthermore, where patients receive sedation, it will be critical that they receive appropriate medical and nursing care to prevent physical complications such as pressure ulcers.2 This would be no different from other patients who are in states of reduced consciousness from disease. We acknowledge that there are heightened risks with earlier and more rapid TS, including the potential loss of spiritual and social moments,4 as well as the meaning that can be derived from conscious existential distress.3 However, while these conscious experiences might be valuable to some, others might weigh them less highly against the foreseen …. (shrink)

In an article recently published in the Journal of Medical Ethics, I assessed the position that voluntary euthanasia and physician-assisted suicide can be appropriate only in cases of persons who are suffering unbearably because they are ill or injured, not in cases of unbearably distressed persons whose suffering is caused by their conviction that their life will never again be worth living. More precisely, I considered one possible way of defending that position, the argument that the latter kind of distress—to (...) which I referred to as existential suffering—does not qualify as grounds for VE and PAS because doctors are not experts on questions pertaining to the meaning, value and purpose of life: existential questions, as I called them. I maintained that cases of VE and PAS related to illness and injury involve existential questions relevantly similar to those faced in connection with existential suffering. Therefore, I concluded, if VE and PAS based on suffering arising from illness or injury falls within the domain of medical expertise, it is consistent that VE and PAS cannot be denied in cases of purely existential suffering by maintaining that the professional expertise of doctors does not extend to existential questions.1The article inspired some interesting discussion. Robert Young offered two reasons for thinking that its argument is of limited practical significance.2 Julian Savulescu maintained that, within current medical ethics and human rights, there already is a method of assisted suicide: voluntary palliated starvation , which allows that existential distress can sometimes provide grounds for assisted dying and which could fall within the limits of the law.3 The discussion by Young and Savulescu suggest that my argument, or rather the nature of the project of which it is purported to be a part, could benefit from some clarification. That …. (shrink)

The doctrine of double effect is a principle of crucial importance in law and medicine. In medicine, the principle is generally accepted to apply in cases where the treatment necessary to relieve pain and physical suffering runs the risk of hastening the patient’s death. More controversially, it has also been used as a justification for withdrawal of treatment from living individuals and physician-assisted suicide. In this paper, I will critique the findings of the controversial Victorian Civil and Administrative Tribunal hearing (...) Syme vs the Medical Board of Australia. In that hearing, Dr Rodney Syme, a urologist and euthanasia advocate, was defending his practice of prescribing barbiturates to terminally ill patients. Syme claimed that he prescribed the drugs with the intention of relieving their existential suffering and not to assist in suicide; he argued that the DDE could be applied. Pace VCAT, I argue that this is an illegitimate application of DDE. I argue that a close scrutiny of Syme’s actions reveals that, at the very least, he intended to give patients the option of suicide. He furthermore used what on a traditional definition of DDE would be considered a ‘bad’ means—the prescription of Nembutal—to achieve a ‘good’ end—the relief of suffering. The case demonstrates the crucial importance of analysing an agent’s ‘intention’ and the ‘effects’ of their actions when applying DDE. Ethicists and, indeed, the judiciary need to attend to the ethical complexities of DDE when they assess the applicability of DDE to end of life care. If they fail to do this, the doctrine risks losing its legitimacy as an ethical principle. (shrink)

The Royal College of Physicians of London published the 2013 national clinical guidelines on prolonged disorders of consciousness in vegetative and minimally conscious states. The guidelines acknowledge the rapidly advancing neuroscientific research and evolving therapeutic modalities in PDOC. However, the guidelines state that end-of-life decisions should be made for patients who do not improve with neurorehabilitation within a finite period, and they recommend withdrawal of clinically assisted nutrition and hydration . This withdrawal is deemed necessary because patients in PDOC can (...) survive for years with continuation of CANH, even when a ceiling on medical care has been imposed, i.e., withholding new treatment such as cardiopulmonary resuscitation for acute life-threatening illness. The end-of-life care pathway is centered on a staged escalation of medications, including sedatives, opioids, barbiturates, and general anesthesia, concurrent with withdrawal of CANH. Agitation and distress may last from several days to weeks because of the slow dying process from starvation and dehydration. The potential problems of this end-of-life care pathway are similar to those of the Liverpool Care Pathway. After an independent review in 2013, the Department of Health discontinued the Liverpool Care pathway in England. The guidelines assert that clinicians, supported by court decisions, have become the final authority in nonconsensual withdrawal of CANH on the basis of “best interests” rationale. We posit that these guidelines lack high-quality evidence supporting: 1) treatment futility of CANH, 2) reliability of distress assessment from starvation and dehydration, 3) efficacy of pharmacologic control of this distress, and 4) proximate causation of death. Finally, we express concerns about the utilitarian-based assessment of what constitutes a person’s best interests. We are disturbed by the level and the role of medical authoritarianism institutionalized by these national guidelines when deciding on the worthiness of life in PDOC. We conclude that these guidelines are not only harmful to patients and families, but they represent the means of nonconsensual euthanasia. The latter would constitute a gross violation of the public’s trust in the integrity of the medical profession. (shrink)