There are an infinite variety of attitudes to euthanasia, each individual response to the concept being influenced by many factors. Consequently there is a literature on the subject ranging from the popular article to papers in specialized journals. This study, however, has taken a well defined sample of people, inviting them to answer a questionnaire which was designed to elicit their attitudes to euthanasia in a way which could be analysed statistically. Nor surprisingly attitudes appeared to 'harden' as those answering (...) the questionnaire grew more experienced in dealing with patients and also more professionally established. Thus it was found that of the seven groups questioned practising physicians showed more positive attitudes to euthanasia and their responses did not differ significantly from those of senior medical students. It is these groups which actually or potentially have to resolve the clinical dilemma posed by the dying patient. (shrink)

In response to the paper by Keown and Jochemsen in which the latest empirical data concerning euthanasia and other end-of-life decisions in the Netherlands is discussed, this paper discusses three points. The use of euthanasia in cases in which palliative care was a viable alternative may be taken as proof of a slippery slope. However, it could also be interpreted as an indication of a shift towards more autonomy-based end-of-life decisions. The cases of non-voluntary euthanasia are a serious problem in (...) the Netherlands and they are only rarely justifiable. However, they do not prove the existence of a slippery slope. Persuading the physician to bring euthanasia cases to the knowledge of the authorities is a problem of any euthanasia policy. The Dutch notification procedure has recently been changed to reduce the underreporting of cases. However, many questions remain. (shrink)

Background: Debates over legalisation of physician-assisted suicide or euthanasia often warn of a “slippery slope”, predicting abuse of people in vulnerable groups. To assess this concern, the authors examined data from Oregon and the Netherlands, the two principal jurisdictions in which physician-assisted dying is legal and data have been collected over a substantial period.Methods: The data from Oregon comprised all annual and cumulative Department of Human Services reports 1998–2006 and three independent studies; the data from the Netherlands comprised all four (...) government-commissioned nationwide studies of end-of-life decision making and specialised studies. Evidence of any disproportionate impact on 10 groups of potentially vulnerable patients was sought.Results: Rates of assisted dying in Oregon and in the Netherlands showed no evidence of heightened risk for the elderly, women, the uninsured , people with low educational status, the poor, the physically disabled or chronically ill, minors, people with psychiatric illnesses including depression, or racial or ethnic minorities, compared with background populations. The only group with a heightened risk was people with AIDS. While extralegal cases were not the focus of this study, none have been uncovered in Oregon; among extralegal cases in the Netherlands, there was no evidence of higher rates in vulnerable groups.Conclusions: Where assisted dying is already legal, there is no current evidence for the claim that legalised PAS or euthanasia will have disproportionate impact on patients in vulnerable groups. Those who received physician-assisted dying in the jurisdictions studied appeared to enjoy comparative social, economic, educational, professional and other privileges. (shrink)

This volume complements two highly successful previously published volumes of Richard Rorty's philosophical papers: Objectivity, Relativism, and Truth, and Essays on Heidegger and Others. The essays in the volume engage with the work of many of today's most innovative thinkers including Robert Brandom, Donald Davidson, Daniel Dennett, Jacques Derrida, Jürgen Habermas, John McDowell, Hilary Putnam, John Searle, and Charles Taylor. The collection also touches on problems in contemporary feminism raised by Annette Baier, Marilyn Frye, and Catherine MacKinnon, and considers issues (...) connected with human rights and cultural differences. Anyone with a serious interest in contemporary philosophy and what it can do for us in the modern world will enjoy this invaluable collection. (shrink)

In assisted dying, the end-of-life trajectory is shortened to relieve unbearable suffering. Unbearable suffering is defined broadly enough to include cognitive (early dementia), psychosocial or existential distress. It can include old-age afflictions that are neither life-threatening nor fatal in the “vulnerable elderly”. The voluntary refusal of food and fluids (VRFF) combined with continuous deep sedation (CDS) for assisted dying is legal. Scientific understanding of awareness of internal and external nociceptive stimuli under CDS is rudimentary. CDS may blunt the wakefulness component (...) of human consciousness without eradicating internal affective awareness of thirst and hunger. Patients may suffer because of the slow dying process following dehydration and starvation. The difficulty to adequately control distress, without bringing the dying process to a rapid conclusion by lethal pharmacological interventions, can cause feelings of guilt among hospice and medical staff. Furthermore, the double-effect principle is not applicable in these situations because the primary objective of VRFF is to hasten death. Legal and societal debate should focus on sharpening the boundaries between assisted dying and palliative care. This separation is necessary to: 1) uphold trust in the patient-phyician relationship, and 2) preserve integrity and ethics of the medical profession. (shrink)

Debates about end of life decisions should accept that public opinion on these matters is still fluidChanges in the past half century in the attitudes of the American public regarding euthanasia and suicide in the case of incurable disease have been dramatic, and they attest to the success of a social movement that has been in part a phenomenon “of the times” . But they are also in part a consequence of a highly visible social movement and vigorous deliberate actions (...) intended to shape public opinion, moving it in a direction favourable to concrete changes in law, public policy, and precepts of the profession of medicine.During much of this period, a bewildering plethora of polls has been conducted, related in one way or another to the question of how the public has viewed the issues about end of life decisions. End of life decisions have an important bioethical component, especially as they raise questions of who makes choices and how those choices can be made in an ethical manner. Does the individual have complete control of his or her own fate? Who can act as surrogate? What role, if any, should physicians play, and what are the interests of the state in such decisions? Anyone who wants to write a justification for, or promote advocacy of, any kind of policy regarding these issues ought to be seriously acquainted with trends in public attitudes. While public opinion cannot be the final arbiter of what is ethically correct, knowledge of it will help us to address the issues in a way that will best benefit the public discourse. Unfortunately, hardly any presentation of the polls related to the subject has attempted to reconcile the …. (shrink)

In their account of passive euthanasia, Garrard and Wilkinson present arguments that might lead one to overlook significant moral differences between killing and letting die. To kill is not the same as to let die. Similarly, there are significant differences between active and passive euthanasia. Our moral duties differ with regard to them. We are, in general, obliged to refrain from killing each and everyone. We do not have a similar obligation to try to prevent each and everyone from dying. (...) In any case, to be morally obliged to persist in trying to prevent their deaths would be different from being morally obliged to refrain from killing all other people even if we had both obligations. (shrink)

This paper questions the relevance of distinguishing acts and omissions in moral argument. It responds to an article by McLachlan, published in this issue of the Journal of Medical Ethics .1 I argue that McLachlan fails to establish that there is a moral difference between active and passive euthanasia and that he instead merely asserts that the difference exists. I suggest that McLachlan’s paper relies on a false commitment to general rules that do not apply in every case. Furthermore, I (...) question the lack of a moral framework provided in his argument. Finally, I briefly argue why some omissions may well be considered equivalent to some actions. I conclude that until McLachlan demonstrates that it would be wrong, we should focus on agency and responsibility, rather than seek to derive normative conclusions from contrasts between active and passive causes.In bioethical debates relating to euthanasia and associated end-of-life issues, commentators dispute the relevance of distinctions between so-called active and passive euthanasia. As a general means of assisting analysts in their studies of different practices, a taxonomy that distinguishes active and passive euthanasia can be useful, principally as we can not usefully argue about these matters unless we are clear about what our arguments touch upon.2 Although it seems to have become received wisdom from ethicists of quite conflicting views that moral propriety can not hang merely on whether a situation obtains because of an agent’s action or inaction, there continue to be defences of the act/omission distinction.3 4 In his paper,1 McLachlan has attempted to add support to those who argue that the distinction between active and passive euthanasia is a moral one. Here I respond to McLachlan’s paper, arguing that in it he fails to do more …. (shrink)

People have concerns, and ethicists often respond to them with philosophical arguments. But can conceptual constructions properly address fears and anxieties? It is argued in this paper that while it is possible to voice, clarify, create and—to a certain extent—tackle concerns by arguments, more concrete practices, choices, and actions are normally needed to produce proper responses to people’s worries. While logical inconsistencies and empirical errors can legitimately be exposed by arguments, the situation is considerably less clear when it comes to (...) moral, cultural, and emotional norms, values, and expectations. (shrink)

Recently, Bonnie Steinbock has argued that there is still not a convincing case to support the legalisation of doctor-assisted suicide.1 The argument is framed in consequentialist terms: rather than contend that there is something intrinsically wrong with mercy killing itself, caution is recommended because of the risk that a system may be open to sufficient abuse to warrant its non-implementation. A welcome criticism is made of partisanship that obstructs useful progress in the debate, which she suggests should be based on (...) objective, empirical evidence on both the need for, and the risks associated with, legalised doctor-assisted suicide.1 The main presumption underlying Professor Steinbock’s argument is that a proportionately large number of people would become vulnerable to great and unacceptable harm under a regime that was not strictly regulated. She asserts certain values, which, on a consequentialist calculation, support her conclusion that currently the case for legalisation is not made.Here I would like to question how useful objective, empirical data can be. Although data that show some assertions to be objectively right or wrong may be obtained and are doubtless valuable, I will show that the debate on assisted suicide is unavoidably partisan and that the protagonists will therefore receive data differently, necessarily because of their moral and philosophical convictions. Steinbock would like the question of legalisation to “turn on objective, empirical evidence about both the need for PAS [physician-assisted suicide] and the risk of mistake and abuse.”1 But to be understood, the concepts of “need” and “abuse” require pre-existing value judgements. Furthermore, even if the values of these concepts are quantifiable, they are probably parts of distinct metrics, so offsetting one against the other will become a matter of qualitative assessment. This does not entirely disvalue the use of objective data, but it means that the …. (shrink)

Slow euthanasia or a good palliative intervention?There are many ways in which doctors influence the circumstances and/or the timing of a patient’s death. Some of these are accepted as normal medical practice—for instance, when a disproportional treatment is forgone, others are considered tolerable only under strict conditions or even intolerable, such as non-voluntary active euthanasia. A relatively new phenomenon in the ethical discussion on end-of-life decisions is terminal sedation. Terminal sedation is used in patients with terminal illnesses where normal medical (...) treatments cannot relieve severe symptoms such as pain and agitation, and no option is left but to take away the perception of these symptoms. Often, the decision to start terminal sedation is accompanied by the decision to forgo the provision of artificial nutrition and hydration in these patients. In The Netherlands, terminal sedation was estimated to be applied in 4–10% of all deaths in 2001.1 The combination of these two decisions have made the moral status of terminal sedation the subject of fierce ethical debates. Is it slow euthanasia2,3 or is it a good palliative intervention that should be sharply distinguished from euthanasia?4,5 One of the characteristics of this debate is that it is a very confused one: people disagree about the meaning of the term, the appropriateness of it and, of course, about the conditions under which it would be morally justified. As a matter of fact, these three discussions are deeply connected: as is often the case, a discussion about terms is a discussion about norms in disguise.The first observation to be made is that many seemingly descriptive definitions of terminal sedation contain normative claims. Examples of this are definitions of terminal sedation in which only …. (shrink)

In considering the patient's right to a certain quality of dying, this essay outlines how the legal and ethical justifications for passive euthanasia depend on the doctrine of acts and omissions. It is suggested that this doctrine is untenable and that alternative justifications are needed. The development of the modern mechanistic approach to death is traced, showing that a possible basis for an humane way of death lies in a reacceptance of a metaphysical concept of life.

Nineteen ninety-six saw the publication of a major Dutch survey into euthanasia in the Netherlands. This paper outlines the main statistical findings of this survey and considers whether it shows that voluntary euthanasia is under effective control in the Netherlands. The paper concludes that although there has been some improvement in compliance with procedural requirements, the practice of voluntary euthanasia remains beyond effective control.

In discussions about the legalisation of active, voluntary euthanasia it is sometimes claimed that what should happen in a liberal society is that the two sides in the debate “agree to disagree”. This paper explores what is entailed by agreeing to disagree and shows that this is considerably more complicated than what is usually believed to be the case. Agreeing to disagree is philosophically problematic and will often lead to an unstable compromise.

Access to abortion services in the United States continues to decline. It does so not because of significant changes in legislation or court rulings but because fewer and fewer physicians wish to perform abortions and because most states now have "conscientious objection" legislation that makes it easy for physicians to refuse to do so. We argue in this paper that physicians have an obligation to perform all socially sanctioned medical services, including abortions, and thus that the burden of justification lies (...) upon those who wish to be excused from that obligation. That is, such persons should have to show how requiring them to perform abortions would represent a serious threat to their fundamental moral or religious beliefs. We use current California law as an example of legislation that does not take physicians' obligations into account and thus allows them too easily to declare conscientious objection. (shrink)