In ethical debates about euthanasia, the focus is often exclusively on the involvement of physicians and the involvement of nurses is seldom given much attention. Yet nurses occupy a central position in the care of terminal patients, where being confronted with a euthanasia request is an ever present possibility. To assess the involvement of nurses in euthanasia, this article provides an overview of relevant findings from the scientific literature. From this it becomes apparent that nurses are involved in various phases (...) of the euthanasia process: observing the request for euthanasia, decision making, carrying out of euthanasia, and the aftercare for the patient’s family members. (shrink)

Over the course of its first seven editions, Principles of Biomedical Ethics has proved to be, globally, the most widely used, authored work in biomedical ethics. It is unique in being a book in bioethics used in numerous disciplines for purposes of instruction in bioethics. Its framework of moral principles is authoritative for many professional associations and biomedical institutions-for instruction in both clinical ethics and research ethics. It has been widely used in several disciplines for purposes of teaching in the (...) classroom, during conferences, etc. (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)

I have a hairstylist whose lover was very sick. I’d been seeing this stylist for ten years and we’re good friends. [His lover was] becoming an invalid, not able to get out of bed. He said “I hate to ask you this but would you mind writing a prescription to help us out?” [So] I wrote a prescription to a patient who I had never seen, and I sent it to him in the mail and I heard the next time (...) I went in to get my hair cut that it was the most beautiful experience that my stylist had ever had. It was Valentine’s Day and they had a lovely meal with champagne. And they held each other and then, you know, his partner took his pills and was released. (shrink)

Death cannot be mastered through a metaphysics of efficiency that interprets all actions in terms only of cause and effect, but it can be transcended if we leave the frame open to death’s ambiguityIn the second of this two part series, I describe how in shifting our frames from one of human purpose and meaning to one of efficiency, we shift the possible answers we get to our questions about voluntary active euthanasia and physician assisted suicide . Thus, by placing (...) VAE/PAS within the frame of efficiency, we narrow our focus to the final effect in the world of cause and effect—namely death. Thus, in ensconcing euthanasia within a legal framework meant to instrumentally and efficiently control euthanasia, we are in fact narrowing our focus on death. Thus, in legalising VAE/PAS we are not just adding one choice to a panoply of other choices, we are in fact changing the nature of all choices, for each choice conditions all others. We should therefore live with the lie that VAE/PAS do not happen as opposed to living with the lie that through efficient legal control we protect patients from medical dominance.AN ANECDOTESeveral years ago an acquaintance told me about a terrible situation in which he found himself during the Vietnam war. He was Green Beret—one of the elite special forces corps of the US army. He was in an area that was officially off limits to the US. His unit came under heavy fire and a buddy was shot in several places but was still alive. His comrade was in serious pain, but what scared him the most was that he might die in the jungle, be eaten by a wild animal, or be captured by the enemy. There was no way to get him out. The wounded soldier …. (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)

Since the Supreme Court of New Jersey decided the Quinlan case a quarter of a century ago, three American Supreme Court decisions and a host of state appellate decisions have addressed end-of-life issues. These decisions, as well as legislation addressing the same issues, have prompted a torrent of law journal articles analyzing every aspect of end-of-life law. In recent years, moreover, a number of law review articles, many published in this journal, have also specifically addressed legal issues raised by palliative (...) care. Much less is known in the United States, however, as to how other countries address these issues. Reflection on the experience and analysis of other nations may give Americans a better understanding of their own experience, as well as suggest improvements to their present way of dealing with the difficult problems in this area.This article offers a conceptual and comparative analysis of major legal issues relating to end-of-life treatment and to the treatment of pain in a number of countries. In particular, it focuses on the law of Australia, Canada, the United Kingdom, Poland, France, the Netherlands, Germany, and Japan. (shrink)

The ethical problems surrounding voluntary assisted suicide remain formidable, and are unlikely to be resolved in pluralist societies. An examination of historical attitudes to suicide suggests that modernity has inherited a formidable complex of religious and moral attitudes to suicide, whether assisted or not. Advocates usually invoke the ending of intolerable suffering as one justification for euthanasia of this kind. This does not provide an adequate justification by itself, because there are (at least theoretically) methods which would relieve suffering without (...) causing the physical death of the suffering person. Carried to extremes, these methods would finish the life worth living, but leave a being which was technically alive. Such acts, however, would provide no moral escape, since they would create beings without meaning. Arguments seeking to justify ending the lives of others need some grounding in concepts of the meaning of a life. The euthanasia discourse therefore needs to take at least some account of the meaning we construct for our lives and the lives of others. (shrink)

Objective: To describe the frequency of support for terminal sedation among internists, determine whether support for terminal sedation is accompanied by support for physician assisted suicide , and explore characteristics of internists who support terminal sedation but not assisted suicide.Design: A statewide, anonymous postal survey.Setting: Connecticut, USA.Participants: 677 Connecticut members of the American College of Physicians.Measurements: Attitudes toward terminal sedation and assisted suicide; experience providing primary care to terminally ill patients; demographic and religious characteristics.Results: 78% of respondents believed that if (...) a terminally ill patient has intractable pain despite aggressive analgesia, it is ethically appropriate to provide terminal sedation . Of those who favoured terminal sedation, 38% also agreed that PAS is ethically appropriate in some circumstances. Along a three point spectrum of aggressiveness in end of life care, the plurality of respondents were in the middle, agreeing with terminal sedation but not with PAS. Compared with respondents who were less aggressive or more aggressive, physicians in this middle group were more likely to report having more experience providing primary care to terminally ill patients and attending religious services more frequently .Conclusions: Support for terminal sedation was widespread in this population of physicians, and most who agreed with terminal sedation did not support PAS. Most internists who support aggressive palliation appear likely to draw an ethical line between terminal sedation and assisted suicide. (shrink)

Objectives: To analyse legislation and medical professional positions concerning the doctor’s role in assisted dying in western Europe, and to discuss their implications for doctors.Method: This paper is based on country-specific reports by experts from European countries where assisted dying is legalised , or openly practiced , or where it is illegal .Results: Laws on assisted dying in The Netherlands and Belgium are restricted to doctors. In principle, assisted suicide is not illegal in either Germany or Switzerland, but a doctor’s (...) participation in Germany would violate the code of professional medical conduct and might contravene of a doctor’s legal duty to save life. The Assisted Dying for the Terminally Ill Bill proposed in the UK in 2005 focused on doctors, whereas the Proposal on Assisted Dying of the Norwegian Penal Code Commission minority in 2002 did not.Professional medical organisations in all these countries except The Netherlands maintain the position that medical assistance in dying conflicts with the basic role of doctors. However, in Belgium and Switzerland, and for a time in the UK, these organisations dropped their opposition to new legislation. Today, they regard the issue as primarily a matter for society and politics. This “neutral” stance differs from the official position of the Royal Dutch Medical Association which has played a key role in developing the Dutch practice of euthanasia as a “medical end-of-life decision” since the 1970s.Conclusion: A society moving towards an open approach to assisted dying should carefully identify tasks to assign exclusively to medical doctors, and distinguish those possibly better performed by other professions. (shrink)

Objective: Little empirical evidence exists to support either side of the ongoing debate over whether legalising physician aid in dying would undermine patient trust.Design: A random national sample of 1117 US adults were asked about their level of agreement with a statement that they would trust their doctor less if “euthanasia were legal [and] doctors were allowed to help patients die”.Results: There was disagreement by 58% of the participants, and agreement by only 20% that legalising euthanasia would cause them to (...) trust their personal physician less. The remainder were neutral. These attitudes were the same in men and women, but older people and black people had more agreement that euthanasia would lower trust. However, overall, only 27% of elderly people and 32% of black people thought that physician aid in dying would lower trust. These views differed with physical and mental health, and also with education and income, with those having more of these attributes tending to view physician aid in dying somewhat more favourably. Again, however, overall views in most of these subgroups were positive. Views about the effect of physician aid in dying on trust were significantly correlated with participants’ underlying trust in their physicians and their satisfaction with care. In a multivariate regression model, trust, satisfaction, age, and white/black race remained independently significant.Conclusion: Despite the widespread concern that legalising physician aid in dying would seriously threaten or undermine trust in physicians, the weight of the evidence in the USA is to the contrary, although views vary significantly. (shrink)

Not everyone finds a in suffering. Indeed, even those who do subscribe to this interpretation recognize the responsibility of each individual to show not only sensitivity and compassion but render assistance to those in distress. Pharmacologic hypnosis, morphine intoxication, and terminal sedation provide their own type of medical to the terminally ill patient suffering unremitting pain. More and more states are enacting legislation that recognizes this need of the dying to receive relief through regulated administration of controlled substances. Wider legislative (...) recognition of this need would go far toward allowing physicians, in the exercise of their reasonable medical judgment, to administer a range of narcotics and barbiturates to the terminally ill without fear of legal sanctions. Sadly, social attitudes and governmental concerns about the spread of drug addiction provide an undeniable policy nexus that impedes unduly a rational approach or exception for the treatment of pain experienced by the dying. (shrink)

The relief of suffering is the great goal of medicine. That physicians give up on suffering when they can do nothing about the underlying condition is one of the contemporary criticisms of medicine. Yet even in irremediable suffering there is something noble, to which physicians should attend.

The key to the euthanasia debate lies in how best to regulate what doctors do. Opponents of euthanasia frequently warn of the possible negative consequences of legalising physician assisted suicide and active euthanasia while ignoring the covert practice of PAS/AE by doctors and other health professionals. Against the background of survey studies suggesting that anything from 4% to 10% of doctors have intentionally assisted a patient to die, and interview evidence of the unregulated, idiosyncratic nature of underground PAS/AE, this paper (...) assesses three alternatives to the current policy of prohibition. It argues that although legalisation may never succeed in making euthanasia perfectly safe, legalising PAS/AE may nevertheless be safer, and therefore a preferable policy alternative, to prohibition. At a minimum, debate about harm minimisation and the regulation of euthanasia needs to take account of PAS/AE wherever it is practised, both above and below ground. (shrink)

In the case of Ms B, the High Court ruled that as Ms B was a competent adult patient, her doctors acted unlawfully in overriding her refusal of life-preserving ventilation. This commentary considers whether this case supports the proposition that in English law the right to refuse treatment extends even to refusals which are clearly suicidal.

Objectives: To discover the current state of opinion and practice among doctors in Victoria, Australia, regarding end-of-life decisions and the legalisation of voluntary euthanasia. Longitudinal comparison with similar 1987 and 1993 studies.Design and participants: Cross-sectional postal survey of doctors in Victoria.Results: 53% of doctors in Victoria support the legalisation of voluntary euthanasia. Of doctors who have experienced requests from patients to hasten death, 35% have administered drugs with the intention of hastening death. There is substantial disagreement among doctors concerning the (...) definition of euthanasia.Conclusions: Disagreement among doctors concerning the meaning of the term euthanasia may contribute to misunderstanding in the debate over voluntary euthanasia. Among doctors in Victoria, support for the legalisation of voluntary euthanasia appears to have weakened slightly over the past 17 years. Opinion on this issue is sharply polarised. (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)

In two recent court cases, Ms B, a paralysed competent adult, was allowed to end her life; Mrs Pretty, another paralysed competent adult, was not. In legal terms, the essential difference between the two cases is that Ms B was seeking the withdrawal of treatment, whereas Mrs Pretty was asking for assistance in ending her life. I argue that while this distinction may accurately state the law that governs these situations, it does not rest on a defensible moral basis. Both (...) the women should have been allowed to choose the manner in which they would die. (shrink)

This article discusses the place of sedation in the care of the terminally ill, as used in the practice of palliative care using case studies, clinical pragmatism forms the theoretical framework from which to elucidate the varying part that sedation plays in the overall management of a person facing the end of life. We contend that when used appropriately, sedation is an ethical and legitimate intervention that enhances comfort at the end of life and ought not sedate the person onto (...) “oblivion”. (shrink)

The topic is physician assisted death, and there is no easy way to transition into it except to say that it is a subject of importance to every person in this room, and for that matter, every person in America. We all face death at some point, and we all have friends or relatives who are either facing death or have already done so. And so this is a part of our lives. The subject of assisting people to die is (...) particularly close to me because my state, Oregon, has adopted what is, in the world, the only legislative authorization for physicians to assist people to die.Ten years ago, actually this month, November of 1997, Oregon's legislation became effective. It was adopted by referendum two years earlier, and as everything does, it wound its way through the courts. An injunction was dissolved in 1997 and the legislation became effective. For a second time, as well, in 1997 it was reaffirmed by yet a second referendum. Thus, on two separate occasions, we Oregonians voted that we wanted this option to be available to Oregonians who are facing a terminal illness. It is ten years this month, November of 2007, that we have been living with what is, in all the world, a unique legislative experience and experiment. As we approach this subject, we will first discuss the place of death in life, then we will review the statute and the experience under it, and then we'll return to some of the criticisms of the statute, and conclude with the present and future legal status of the Oregon legislation. (shrink)