In states where Physician Assisted Dying (PAD) is legal, physicians occasionally receive requests for this form of end-of-life care. Here, I describe the ethically ambiguous sphere and why PAD falls into it. I argue that, given the ethical ambiguity of PAD, physicians should consider patient autonomy as the highest value in the four principles approach and act as informers and educators.

Opponents of medically assisted dying have long appealed to ‘slippery slope’ arguments. One such slippery slope concerns palliative care: That the introduction of medically assisted dying will lead to a diminution in the quality or availability or palliative care for patients near the end of their lives. Empirical evidence from jurisdictions where assisted dying has been practiced for decades, such as Oregon and the Netherlands, indicate that such worries are largely unfounded. The failure of (...) the palliation slope argument is nevertheless instructive with respect to how slippery slope arguments can be appraised without having to await post-facto evidence regarding the effects of a proposed change in public policy. Close attention in particular to the norms operative in a given institution and how changes to policy will interact with those norms enable slippery slopes to be credibly appraised. (shrink)

... having succeeded in protecting and prolonging the life of many around the world for reasons which seem natural and intrinsically good to all, we are once again faced with the dilemma of confronting our patent inability to cure it all. -/- Faced with this recurring predicament, we somehow backtrack in our steps and decide the next best thing to assuage suffering is assisted dying and euthanasia. -/- No matter how many reasons we conjure up in their favour, (...) both assisted dying and euthanasia remain a stab into the unknown, into the supernatural, by patients, by its proponents, and by its practitioners both lay and medical. (shrink)

That Kant’s moral thought is invoked by both advocates and opponents of a right to assisted dying attests to both the allure and and the elusiveness of Kant’s moral thought. In particular, the theses that individuals have a right to a ‘death with dignity’ and that assisting someone to die contravenes her dignity appear to gesture at one of Kant’s signature moral notions, dignity. The purposes of this article are to outline Kant’s understanding of dignity and its implications (...) for the ethics of assisted dying. According to Kant, that which has dignity must be treated as an end in itself and may not permissibly be exchanged for that which merely has price. Kant’s reasoning thus seems to preclude acts of self-killing, including voluntary assisted dying, that rest on individual self-interest, since a person’s interests merely have price. However, a recognizably Kantian view of dignity can permit assisted dying under two sets of circumstances: First, it can be permissible for agents who anticipate a degradation of their rational agency due to conditions such as dementia to direct others to end their lives once sufficiently demented. In so doing, such agents in effect exercise a right to impose obligations on others regarding how their bodies, which will at some future point no longer be the vessels of their rational agency, are to be disposed of. Second, Kant errs in supposing that our dignity can stem solely from our moral personality, i.e., from our capacity to abide by universalizable moral principles. Rather, complete dignity also requires the capacity for setting discretionary ends and the means to those ends, i.e., the dignity of humanity. Individuals with prolonged and intense depression, in severe pain, or with serious disability may lack humanity while retaining their moral personality. In such cases, I propose that their opting to end their lives, with or without the assistance of others, does not amount to exchanging their dignified selves for something which merely has price and is therefore not objectionable on Kantian grounds. (shrink)

This article examines the subtle interconnection between the sanctity of life and individual autonomy within the context of assisted dying, as seen through the lens of Orthodox Christianity. It seeks to unravel the complex theological, ethical, and pastoral considerations that inform the Orthodox stance on end-of-life issues, particularly the nuanced understanding of suffering, death, and the redemptive potential encapsulated within them. Orthodox theology, with its profound veneration for life as a divine gift, offers a counter-narrative to contemporary discourses (...) that often prioritize personal autonomy and the alleviation of suffering above all. This tradition emphasizes the transformative power of suffering when united with Christ’s own redemptive suffering, proposing a vision of end-of-life care that is rooted in compassion, dignity, and hope for resurrection. The exploration begins with a historical and theological examination of the Orthodox perspective on life’s sanctity, engaging with the teachings of Church Fathers and contemporary theological and bioethical discussions. It highlights the foundational concepts of Orthodox anthropology, which perceives human beings as an indivisible unity of body and soul, reflecting the imago Dei. This anthropological understanding challenges reductionist views of human existence and informs the Orthodox approach to medical ethics, palliative care, and the spiritual accompaniment of the dying. By critically evaluating arguments for and against assisted dying, the article presents a balanced discourse that respects the depth of individual suffering while upholding the intrinsic value of life. It argues that Orthodox Christianity, through its rich theological heritage and pastoral practice, provides a compassionate and ethically nuanced framework for navigating the moral complexities of assisted dying. This framework advocates for an end-of-life care that honors the fullness of the human person, supports the spiritual journey toward eternal life, and fosters a communal embrace of life’s sacred threshold, offering a dignified passage that aligns with the faith’s deepest convictions about human destiny and divine grace. (shrink)

When medical assistance in dying (MAiD) was legalized in Canada in June 2016, the question of allowing decisionally capable persons to make advance requests in anticipation of later incapacity was reserved for further consideration during the mandatory parliamentary review originally scheduled to begin in June 2020 (but since delayed by COVID-19). In its current form the legislation does not permit such requests, since it stipulates that at the time at which the procedure is to be administered the patient must (...) give “express consent” to receiving it. Since express consent presupposes decisional capacity, this requirement rules out administering MAiD to a patient who has lost capacity. Amendments to the legislation passed by Parliament in March 2021 open the door slightly by allowing advance requests by patients after they have been approved for MAiD, if they fear losing capacity before the procedure can be administered. But this provision would apply only to patients whose natural death was deemed to be “reasonably foreseeable”, and would continue to exclude (a) requests made after diagnosis of a “grievous and irremediable medical condition” but in advance of approval for MAiD, and (b) requests made before such a diagnosis. My aim in this paper is twofold: to explore the ethical and legal issues concerning advance requests for MAiD, and to argue for expanding provision for such requests to include both of these further scenarios. (shrink)

Some form of assisted dying (voluntary euthanasia and/or assisted suicide) is lawful in the Netherlands, Belgium, Oregon, and Switzerland. In order to be lawful in these jurisdictions, a valid request must precede the provision of assistance to die. Non-adherence to the criteria for valid requests for assisted dying may be a trigger for civil and/or criminal liability, as well as disciplinary sanctions where the assistor is a medical professional. In this article, we review the criteria (...) and evidence in respect of requests for assisted dying in the Netherlands, Belgium, Oregon, and Switzerland, with the aim of establishing whether individuals who receive assisted dying do so on the basis of valid requests. We conclude that the evidence suggests that individuals who receive assisted dying in the four jurisdictions examined do so on the basis of valid requests and third parties who assist death do not act unlawfully. However, further research on the elements that may undermine the validity of requests for assisted dying is warranted. More research on the reasons why requests for assisted dying are refused is also desirable. (shrink)

Ethical debates about assisted dying typically assume that only medical professionals should be able to provide patients with assisted dying. This assumption partially rests on the unstated principle that assisted dying providers may not be motivated by pecuniary considerations. Here I outline and defend a mixed provider model of assisted dying provision that contests this principle. Under this model, medically competent non-physician professionals could receive fees for providing assisted dying under (...) the same terms and conditions as physicians can in those juris- dictions where medically assisted dying is lawful. The mixed provider model blunts objections to assisted dying rooted in supposed clashes with medical values. In addition to generating a market likely to expand access to assisted dying, the mixed provider model would not create markets that are unjust because they are “noxious” in Satz’ sense or because they raise “semiotic” concerns about the value of human life. (shrink)

ABSTRACT Objectives There is little research on moral uncertainties and distress of palliative and hospice care providers (PHCPs) working in jurisdictions anticipating legalising voluntary assisted dying (VAD). This study examines the perception and anticipated concerns of PHCPs in providing VAD in the State of Queensland, Australia prior to legalisation of the practice in 2021. The findings help inform strategies to facilitate training and support the health and well-being of healthcare workers involved in VAD. Design The study used a (...) qualitative approach to examine and analyse the perception and anticipated concerns of PHCPs regarding challenges of providing assisted dying in Queensland. Fourteen PHCPs were recruited using a purposive sampling strategy to obtain a broad representation of perspectives including work roles, geographical locations and workplace characteristics. Data were collected via one in-depth interview per participant. The transcripts were coded for patterns and themes using an inductive analysis approach following the tradition of Grounded Theory. Setting The study was conducted in hospital, hospice, community and residential aged care settings in Queensland, Australia. These included public and private facilities, secular and faith-based facilities, and regional/rural and urban facilities. Participants Interviews were conducted with fourteen PHCPs: 10 nurses and 4 physicians; 11 female and 3 male. The median number of years of palliative care practice was 17, ranging from 2 to 36 years. For inclusion, participants had to be practising palliative and hospice care providers. Results PHCPs are divided on whether VAD should be considered part of palliative care. Expectations of moral distress and uncertainty about practising VAD were identified in five areas: handling requests, assessing patient capacity, arranging patient transfers and logistical issues, managing unsuccessful attempts, and dealing with team conflicts and stigma. Conclusions The possibility of having to practise VAD causes moral distress and uncertainty for some PHCPs. Procedural clarity can address some uncertainties; moral and psychological distress, however, remains a source of tension that needs support to ensure ongoing care of both patients and PHCPs. The introduction of VAD post-legalisation may present an occasion for further moral education and development of PHCPs. (shrink)

Ethical debates about assisted dying typically assume that only medical professionals should be able to provide patients with assisted dying. This assumption partially rests on the unstated principle that assisted dying providers may not be motivated by pecuniary considerations. Here I outline and defend a mixed provider model of assisted dying provision that contests this principle. Under this model, medically competent non-physician professionals could receive fees for providing assisted dying under (...) the same terms and conditions as physicians can in those jurisdictions where medically assisted dying is lawful. The mixed provider model blunts objections to assisted dying rooted in supposed clashes with medical values. In addition to generating a market likely to expand access to assisted dying, the mixed provider model would not create markets that are unjust because they are “noxious” in Satz’ sense or because they raise “semiotic” concerns about the value of human life. (shrink)

This article examines the reporting requirements in four jurisdictions in which assisted dying (euthanasia and/or assisted suicide) is legally regulated: the Netherlands, Belgium, Oregon and Switzerland. These jurisdictions were chosen because each had a substantial amount of empirical evidence available. We assess the available empirical evidence on reporting and what it tells us about the effectiveness of such requirements in encouraging reporting. We also look at the nature of requirements on regulatory bodies to refer cases not meeting (...) the legal criteria to either prosecutorial or disciplinary authorities. We assess the evidence available on the outcomes of reported cases, including the rate of referral and the ultimate disposition of referred cases. (shrink)

Evidence from jurisdictions that allow assisted dying is frequently used in the debate about assisted dying in the UK, since it provides important information about how assisted suicide and voluntary euthanasia work in practice. However, in order to interpret these data meaningfully, it is essential that they are understood in the context of the different legal and regulatory frameworks in operation in these countries. -/- The Commission on Assisted Dying has commissioned this expert (...) briefing paper in order to help unpick these complexities, and identify evidence for the effectiveness of the various legal safeguards that have been employed in jurisdictions that allow assisted dying. In the briefing paper the authors identify and explain the features of the legal regimes that regulate assisted dying in four target jurisdictions: the Netherlands, Belgium, Oregon and Switzerland. -/- They explore the evidence for the effectiveness of individual safeguards in each of these regimes in turn. Then they evaluate the evidence for the effectiveness of each safeguard, drawing on a detailed examination of the evidence, and, where possible, make recommendations on how these regimes could implement and regulate assisted dying more effectively. (shrink)

Patients in Quebec can legally obtain medical assistance in dying (MAID) if they are able to give informed consent, have a serious and incurable illness, are at the end of their lives and are in a situation of unbearable suffering. Since the Supreme Court of Canada’s 2015 Carter decision, access to MAID, under certain conditions, has become a constitutional right. Quebec physicians are now likely to receive requests for MAID from their patients. The Quebec and Canadian laws recognize a (...) physician’s right to conscientious objection, but this right is contested both in the medical ethics literature and in the public sphere. This paper presents the results of a qualitative study conducted with twenty Quebec physicians who did not integrate MAID into their medical practice, either because they were opposed to or deeply ambivalent about MAID. The interviews aimed to explore the reasons – religious and secular – for opposition to or ambivalence towards MAID. The secular reasons given by participants were grouped into four main categories: 1) the ends of medicine and professional identity, 2) the philosophy of palliative medicine and resource allocation in palliative care, 3) benevolent paternalism, the “good death”, and the interests of future selves, 4) the risk of a slippery slope and the protection of vulnerable people. (shrink)

Medical assistance in dying, which includes voluntary euthanasia and assisted suicide, is legally permissible in a number of jurisdictions, including the Netherlands, Belgium, Switzerland and Canada. Although medical assistance in dying is most commonly provided for suffering associated with terminal somatic illness, some jurisdictions have also offered it for severe and irremediable psychiatric illness. Meanwhile, recent work in the philosophy of psychiatry has led to a renewed understanding of psychiatric illness that emphasises the role of the relation (...) between the person and the external environment in the constitution of mental disorder. In this paper, I argue that this externalist approach to mental disorder highlights an ethical challenge to the practice of medical assistance in dying for psychiatric illness. At the level of the clinical assessment, externalism draws attention to potential social and environmental interventions that might have otherwise been overlooked by the standard approach to mental disorder, which may confound the judgement that there is no further reasonable alternative that could alleviate the person’s suffering. At the level of the wider society, externalism underscores how social prejudices and structural barriers that contribute to psychiatric illness constrain the affordances available to people and result in them seeking medical assistance in dying when they otherwise might not have had under better social conditions. (shrink)

In a recent Response published in the Journal of Medical Ethics,1 Buturovic provides two criticisms of my argument in ‘Is the exclusion of psychiatric patients from access to physician-assisted suicide discriminatory?’2 First, Buturovic argues that my argument effectively ‘erases the distinction between healthy adults and patients (whether somatic or psychiatric) essentially implying that PAS [physician-assisted suicide] should be available to all, for all reasons or, ultimately no reason’ (Buturovic,1 pg. 1). Second, Buturovic argues that opening the doors to (...) medical assistance in dying (MAID) for psychiatric patients could have a number of undesirable implications. In particular, Buturovic highlights the potential negative implications for relations of trust in medicine—psychiatry in particular—along with potential effects on the rate of organ donation. I would here like to respond to these two criticisms. In short, my response to Buturovic’s first argument is that the slope is not nearly as slippery as Buturovic suggests. The reason for this is that the plausibility of Buturovic’s argument rests on a significant misinterpretation of my argument, along with an important equivocation in her own. Buturovic argues that, under the three criteria that I propose for the provision of MAID—sufficient decision-making capacity, demonstrated treatment resistance, and a lack of substantially negative implications for existing standards of psychiatric treatment and research—the provision of MAID for trivial reasons, even no reason at all, is justifiable. The main problem with this argument is that I propose no such positive criteria. My argument is that none of the three arguments addressed in my previous paper are sufficient to justify the exclusion of any and all psychiatric patients from access to MAID. I do not claim, in other words, that any individual …. (shrink)

Staff reported paranormal experiences in connection with the outpatient Medical Assistance in Dying room at the hospital. This case study reports on staff experiences and illustrates how the Ethics team’s role expanded to deal with this novel situation by facilitating an interdisciplinary response.

Many participants in debates about the morality of assisted dying maintain that individuals may only turn to assisted dying as a ‘last resort’, i.e., that a patient ought to be eligible for assisted dying only after she has exhausted certain treatment or care options. Here I argue that this last resort condition is unjustified, that it is in fact wrong to require patients to exhaust a prescribed slate of treatment or care options before being (...) eligible for assisted dying. The last resort condition effectively pits one right of patients, their right to refuse medical treatment or interventions, against another patient right acknowledged by advocates of assisted dying, the right to die. Drawing on an analogy with the legal notion of an unconstitutional condition, I argue that the last resort condition unjustly demands that an arguably more fundamental right—the right to refuse medical treatment or intervention—be foregone in order to acquire a less fundamental right—the right to die. I then address three rationales for the last resort condition and find that they subject individuals to arbitrarily stringent standards for exercising the right to die, standards to which those who seek to end their lives by voluntarily ending life-sustaining treatments are not subject. Subjecting those who seek assisted dying to the last resort condition therefore wrongfully infringes on their right to refuse medical treatment or interventions. (shrink)

This letter was submitted to the Senate Standing Committee on Legal and Constitutional Affairs, Government of Canada, on 29th January, 2021, as final debate over Bill C-7 was being undertaken in the Senate regarding MAiD and the strong opposition to the legislation expressed across the Canadian disability community. It draws on our individual and joint work on eugenics, well-being, and disability.

At the end of 2015, the German parliament passed a new law, entitled "Business-like Suicide Assistance", that effectively ended a rather liberal legal take on assisted suicide in Germany. §217 of the German Criminal Code was based on a proposal drafted by members of the parliament Michael Brand, Kerstin Griese, et all., The drafters’ goal was to prohibit Right-to-Die organisations such as Sterbehilfe Deutschland e.V. as well as repeatedly acting individuals from assisting people in ending their lives. The goal (...) of this article is to outline the new law in broad brushstrokes and raise some concerns. (shrink)

As medical technology advances and severely injured or ill people can be kept alive and functioning long beyond what was previously medically possible, the debate surrounding the ethics of end-of-life care and quality-of-life issues has grown more urgent. In this lucid and vigorous book, Craig Paterson discusses assisted suicide and euthanasia from a fully fledged but non-dogmatic secular natural law perspective. He rehabilitates and revitalises the natural law approach to moral reasoning by developing a pluralistic account of just why (...) we are required by practical rationality to respect and not violate key demands generated by the primary goods of persons, especially human life. Important issues that shape the moral quality of an action are explained and analysed: intention/foresight; action/omission; action/consequences; killing/letting die; innocence/non-innocence; person/non-person. Paterson defends the central normative proposition that ‘it is always a serious moral wrong to intentionally kill an innocent human person, whether self or another, notwithstanding any further appeal to consequences or motive’. (shrink)

The euthanasia literature typically discusses the difference between “active” and “passive” means of ending a patient’s life. Physician-assisted suicide differs from both active and passive forms of euthanasia insofar as the physician does not administer the means of suicide to the patient. Instead, she merely prescribes and dispenses them to the patient and lets the patient “do the rest” – if and when the patient chooses. One supposed advantage of this process is that it maximizes the patient’s autonomy with (...) respect to both her decision to die and the dying process itself. Still, despite this supposed advantage, Oregon is the only state to have legalized physician-assisted suicide. After summarizing the most important Supreme Court opinions on euthanasia (namely, Cruzan v. Director, Missouri Dep’t of Health; Vacco v. Quill; Washington v. Glucksberg; and Gonzales v. Oregon), this paper argues that while there are no strong ethical reasons against legalizing physician-assisted suicide, there are some very strong policy reasons for keeping it criminal in the other forty-nine states. (shrink)

In 1975, The New England Journal of Medicine published James Rachels' article 'Active and Passive Euthanasia'. The argumentative method that Rachels introduced, the Bare Difference Argument (also known as the Contrast Strategy), became one of the most widely used tools in ethical reasoning. The argument, however, fails to show active euthanasia being morally permissible. It fails because Rachels takes the intuitions from the case where letting die is morally impermissible and applies the intuitions to cases where letting die is morally (...) permissible. While it is possible to create thought-experiments that are more analogous to euthanasia, in this respect, than Rachels' cases, they too are disanalogous to euthanasia with some of the relevant features. Creating the perfect analogy, however, would be a mistake too. Such a case would be too analogous; people would simply be divided on what kind of moral intuitions they would have. The problem thus highlights a methodological limit in philosophical bioethics and raises questions related to the roles of philosophical ethicists in the context of assisted dying. (shrink)

The article examines from an historical perspective some of the key ideas used in contemporary bioethics debates both for and against the practices of assisted suicide and euthanasia. Key thinkers examined--spanning the Ancient, Medieval and Modern periods--include Plato, Aristotle, Augustine, Aquinas, Hume, Kant, and Mill. The article concludes with a synthesizing summary of key ideas that oppose or defend assisted suicide and euthanasia.

Melancholia is an attunement of despair and despondency that can involve radical disruptions to temporal experience. In this article, I extrapolate from the existing analyses of melancholic time to examine some of the important existential implications of these temporal disruptions. In particular, I focus on the way in which the desynchronization of melancholic time can complicate the melancholic’s relation to death and, consequently, to the meaning and significance of their life. Drawing on Heidegger’s distinction between death and demise, I argue (...) that melancholic time leaves the melancholic in an impossible state of existing, where they are both unable to live and unable to die. Turning to the role of the physician, I consider the significant role that clinical interventions might have in resynchronizing the melancholic with time and examine these ideas further through a case study on physician-assisted suicide. In so doing, I demonstrate that the desynchronization of melancholic time should indeed be understood as a matter of life and death. (shrink)

The book attempts to conceptualize the “ancient” issues of human death and human mortality in connection to the timely and vital subject of euthanasia. This subject forces the meditation to actually consider those ideological, ethical, deontological, legal, and metaphysical frameworks which guide from the very beginning any kind of approach to this question. This conception – in dialogue with Heideggerian fundamental ontology and existential analytics – reveals that, on the one hand, the concepts and ethics of death are originally determined (...) by the ontology of death, and, on the other hand, that, on this account, the question of euthanasia can only be authentically discussed in the horizon of this ontology. It is only this that may reveal to whom dying – our dying – pertains, while it also reveals our relationship to euthanasia as a determined human potentiality or final possibility. Thus euthanasia is outlined in the analysis as the possibility of becoming a mortal on the one hand, while on the other hand it appears in relation to the particularities of its existential structure, which essentially differ from the existential and ontological structure of any other possibility of dying. This is why it should not be mixed up with, or mistaken for, any of these. (shrink)

The reemergence of the question of suicide in the medical context of physician-assisted suicide seems to me one of the most interesting and fertile facets of late modernity. Aside from the disruption which this issue may cause in the traditional juridical relationship between individuals and the state, it may also help to transform the dominant conception of subjectivity that has been erected upon modernity's medicalized order of death. To enhance this disruptive potential, I am going to examine the perspectives (...) on death offered by two contemporary writers: Zygmunt Bauman and Jean Baudrillard. Each of these writers recognizes the centrality of death to modern culture, as Heidegger did, but they also go beyond him in specifying the ways in which death maintains a presence in late modernity, despite efforts to conceal it. In particular, both of these writers recognize the important role that medicine has played in ordering the modern conception of death. After situating these two perspectives in relation to each other, and in relation to Heidegger, who will serve here as a sort of benchmark, I will return to the issue of suicide. Given the differences in their readings of the role that death and medicine play in modern culture, these post-Heideggerians take strikingly different positions on this issue. By engaging these perspectives, I intend not only to point out the tremendous potential which this issue holds for a fundamental rethinking of modern subjectivity, but also reveal some of the dangers that may beset any naive optimism about the right to die. (shrink)

In recent history, the Social Model has crucially contributed to an emancipatory perspective on disability, not least as a rebuttal to deficit oriented views focused on suffering. Several overstated notions of “social construction“ this family of models relies on, however, presently threaten to unduly narrow reflections on “disability”-situations and the self-reflection of disabled people. These notions tend to obscure social and ecological issues an emerging just social order will need to address. The roots of any sociocultural formation in external (physical) (...) reality thus remain underrecognised. -/- This paper adumbrates an alternative approach rooted in (External) Realism. The argument is based on a critique of social constructivist notions employed in models of disability overemphasising sociocultural elements, and capitalises on work by T. Shakespeare and S. Vehmas.. Implications of the proposed approach for debates on 1.) social issues and issues of human(e) interaction, especially personal assistance- relationships and 2.) ecological issues and human dealings with nature, are briefly explored. -/- (Paper in German, long version with examples from two domains and additional explanations. Originally presented at DisKo18.). (shrink)

My question in the chapter is this: could (and should) the role of the physician be construed as that of a friend to the patient? I begin by briefly discussing the “friendship model” of the physician-patient relationship—according to which physicians and patients could, and perhaps should, be friends—as well as its history and limitations. Given these limitations, I focus on the more one-sided idea that the physician could, and perhaps should, be a friend to the patient (a “physician-qua-friend model” of (...) the physician-patient relationship). I show that given recent developments in our understanding of the physician-patient relationship, this idea is far from asinine. I then make the case that the most plausible conception of the physician-qua-friend model incorporates the following components: (a) a common goal, that is, one that physician and patient share; (b) certain forms of equality between physician and patient; (c) an ideal of a caring physician. Finally, I show how the model can be instantiated in a certain type of physician-patient interaction, namely, in physician-assisted dying. (shrink)

This chapter addresses the close association between withholding and withdrawing futile life-sustaining medical treatments and assisting patients with hastening ending their lives. Section 12.2 sets forth a definition of medical futility and places this concept in the broader context of bioethical principles of autonomy, beneficence, nonmaleficence and justice. Section 12.3 draws out futility’s ethical implications and considers the view that physicians are ethically permitted to refrain from medically futile treatments, should be encouraged to refrain, or have a duty to refrain. (...) Section 12.4 examines ethical arguments that physicians also have a positive duty to assist patients with terminal conditions who are imminently dying to end their lives. It explores ethical arguments for assisted dying that appeal to the physicians’ significant responsibility and relationship with patients, the claimed moral equivalence of actions and omissions, and the medical goal of helping patients have a peaceful and dignified death. (shrink)

Proponents of the legalization of assisted suicide often appeal to our supposed right to "die with dignity" to defend their case. I examine and assess different notions of "dignity" that are operating in many arguments for the legalization of assisted suicide, and I find them all to be deficient. I then consider an alternative conception of dignity that is based on Aristotle's conception of the conditions on the best life. I conclude that, while such a conception of dignity (...) fits best with our intuitions about the conditions under which a life has dignity, it supports the legalization of assisted suicide only under very limited circumstances. (shrink)

[For an Ethics without Theology] This study is a critical reflection on Marek Vácha's article on the ethics of euthanasia. In the first part the author offers a short consideration of the reasons for the moribund state of ethics in Czech philosophy, after which, in the second part, he presents a critique of Vácha's article. The article in question is, above all, lacking in a philosophical approach to the problem of euthanasia, and we find in it not so much arguments (...) as rhetoric. The only line of argument that is detectable in the article is founded on natural theology, something that Vácha elsewhere repudiates, and it offers the reader a false dilemma between accepting theistic ethics on the one hand or total subjectivism on the other. In reality, of course, there is a wide range of kinds of objective secular ethics. In the third part, one of these forms is summarised--a system of "everyday morality" which is founded on the concept of harm, and which treats conduct as immoral primarily when it causes unjustifiable harm to others. This form of ethics does not presuppose any controversial theory of value, and it constitutes the viewpoint from which the author then defends physician-assisted suicide. A doctor who helps a patient die--or who causes the patient's death on his own request--does not cause that individual harm if she has only a period of life filled with pain left. In conclusion the author indentifies certain points of contact between secular and theistic ethics. (shrink)

I respond to Jeffrey Bishop’s article ‘Arts of Dying and the Statecraft of Killing’, in this issue, and in particular to his remarks in support of the claim that assisted death should not be legalised.

What I call medically enabled suicides have four distinctive features: 1. They are instigated by actions of a suicidal individual, actions she intends to result in a physiological condition that, absent lifesaving medical interventions, would be otherwise fatal to that individual. 2. These suicides are ‘completed’ due to medical personnel acting in accordance with recognized legal or ethical protocols requiring the withholding or withdrawal of care from patients (e.g., following an approved advance directive). 3. The suicidal individual acts purposefully to (...) ensure that medical personnel will act on these protocols. 4. These suicides do not involve medical personnel providing aid in dying in the standard sense, either through (a) active voluntary euthanasia, or (b) assistance by means of prescriptions, etc. -/- Regardless of how common medically enabled suicides are, they raise compelling questions at the interface of medicine and individual choice. After first clarifying the concept of medically enabled suicide and exploring some of the reasons why it might be attractive to suicidal individuals, I then investigate two apparent dilemmas that medically enabled suicides raise for medical care providers. The first alleges that medical care providers may not contribute to harming their patients, and so they may not contribute to their patients’ suicides. The second alleges that if care providers, as a matter of personal conscience, believe that suicide is wrong, then they may not be compelled to contribute to their patient’s acting wrongly by assenting to the wishes of a patient pursuing medically enabled suicide. Both dilemmas arise from the fact that while medical personnel are bound by widely accepted precepts of medical ethics to honor the competent wishes of their patients, medically enabled suicides entangle them in their patients’ suicidal plans in ways that result in their contributing to those suicides. I conclude that neither dilemma should be resolved in the direction of medical personnel having the right to refrain from involvement in medically enabled suicides. Thus, while we may find medically enabled suicide distasteful or exploitative, a strong case cannot be made that medical personnel refusing to involve themselves in such suicides is ethically permissible. (shrink)

The available resources for global health assistance are far outstripped by need. In the face of such scarcity, many people endorse a principle according to which highest priority should be given to the worst off. However, in order for this prioritarian principle to be useful for allocation decisions, policy-makers need to know what it means to be badly off. In this article, we outline a conception of disadvantage suitable for identifying the worst off for the purpose of making health resource (...) allocation decisions. According to our total advantage view: the worst off are those who have the greatest total lifetime disadvantage; advantage foregone due to premature death should be treated in the same way as other ways of being disadvantaged at a time; how badly off someone is depends on the actual outcomes that will befall her without intervention, not her prospects at a time; and all significant forms of disadvantage count for determining who is worst off, not just disadvantage relating to health. We conclude by noting two important implications of the total advantage view: first, that those who die young are among the globally worst off, and second, that the epidemiological shift in the global burden of disease from communicable to non-communicable diseases should not lead to a corresponding shift in global health spending priorities. (shrink)

Human dignity—is it a useful concept in bioethics, one that sheds important light on the whole range of bioethical issues, from embryo research and assisted reproduction, to biomedical enhancement, to care of the disabled and the dying? Or is it, on the contrary, a useless concept—at best a vague substitute for other, more precise notions, at worst a mere slogan that camouflages unconvincing arguments and unarticulated biases?

Book synopsis: Dying and death are topics of deep humane concern for many people in a variety of circumstances and contexts. However, they are not discussed to any great extent or with sufficient focus in order to gain knowledge and understanding of their major features and aspects. The present volume is an attempt to bridge the undesirable gap between what should be known and understood about dying and death and what is easily accessible. Included in the present volume (...) are chapters arranged in three sections. First, there are chapters on aspects of dying, written by people who have professional experience and personal insights into the nature of the processes at work and the ways it should be treated. Secondly, there are chapters on assisted death (Euthanasia) that illuminate the practices involved in the professional assistance given to persons who suffer from an incurable illness and who do not want their painful life to be medically extended. Thirdly, there are chapters on mourning, examined in a variety of cultural contexts. These provide insights for different ways of maintaining the presence of the dead in the life of the living: “life in the hearts”. (shrink)

Die Frage nach der Verantwortung für globale Armut laesst sich auf mindestens zwei Weisen stellen – als Frage nach der (retrospektiven) Verantwortung für das Auftreten dieses Problems oder als Frage nach der (prospektiven) Verantwortung für dessen Behebung. Dieses Kapitel wird sich vor allem auf die zweite Frage konzentrieren: Inwiefern sollte die Verantwortung, Armut zu bekaempfen, als kollektive Verantwortung verstanden werden? Für viele von uns werden diese Pflichten nur im weiten (schwachen) Sinne kollektiv sein, naemlich in dem Sinne, dass die kollektive (...) Ebene für die Entscheidungsfindung und die Handlungsbewertung primaer ist. Kollektivitaet von Verantwortung im engen Sinn erfordert hingegen staerkere epistemische Verknüpfungen der Gruppenmitglieder sowie eine Bekenntnis zum gemeinsamen Ziel. Wo diese bereits bestehen, da koennen wir von kollektiver Verantwortung in diesem starken Sinn sprechen und entsprechend von den Mitgliedern dieser Gruppen einen groesseren Einsatz für das Endresultat erwarten. (shrink)

Presenting the case against legalizing euthanasia, this paper refers mainly to two clinical facts. First that, in the majority of cases, a wish to die is a symptom of depression; and second, that depression affects rational decision making. Since a depressive individual is not fully competent, it is a mistake to resort to that individual's autonomy. One should recall that a subclinical depressive state is an object of treatment, and safeguards are necessary lest this state should be an object of (...) euthanasia or assisted suicide. (shrink)

This chapter provides empirical evidence about everyday attitudes concerning euthanasia. These attitudes have important implications for some ethical arguments about euthanasia. Two experiments suggested that some different descriptions of euthanasia have modest effects on people’s moral permissibility judgments regarding euthanasia. Experiment 1 (N = 422) used two different types of materials (scenarios and scales) and found that describing euthanasia differently (‘euthanasia’, ‘aid in dying’, and ‘physician assisted suicide’) had modest effects (≈3 % of the total variance) on permissibility (...) judgments. These effects were largely replicated in Experiment 2 (N = 409). However, in Experiment 2, judgments about euthanasia’s moral permissibility were best predicted by the voluntariness of the treatment. Voluntariness was a stronger predictor than some demographic factors and some domain general elements of moral judgments. These results help inform some debates about the moral permissibility of euthanasia (e.g., the slippery slope argument) suggesting that some of the key premises of those arguments are unwarranted. (shrink)

In a recent paper, I argued that an externalist understanding of mental disorder from the philosophy of psychiatry presents an ethical challenge to the practice of medical assistance in dying (MAiD) for psychiatric illness, because it highlights the ways in which the suffering associated with psychiatric illness is sustained by features of the external environment wherein the person is embedded, including social barriers and injustices. In a response to my paper, Harry Hudson argues that addressing social inequality lacks relevance (...) to the immediate permissibility of psychiatric MAiD and that the issue of psychiatric MAiD should be informed by ‘pragmatic politics’ rather than by ‘obfuscatory philosophy’. Herein, I contend that Hudson’s response misconstrues my position and ascribes to me views I neither express nor endorse. My paper does not claim that psychiatric MAiD should be denied to people who are presently in intolerable distress. Rather, it suggests that the provision of psychiatric MAiD comes along with social responsibilities of the state to attend to the barriers and injustices that sustain and exacerbate psychiatric illness, as well as ethical responsibilities of clinicians to consider a wider range of presently available psychological and social interventions which may have been neglected under a traditional internalist approach. (shrink)

Suppose that we think it important that people have the chance to enjoy autonomous lives. An obvious corollary of this thought is that people should, if they want it, have control over the time and manner of their deaths, either ending their own lives, or by securing the help of others in doing so. So, generally, and even if we overall think that the practice should not be legalized on other grounds, it looks like common sense to think that considerations (...) of autonomy tell at least somewhat in favour of legalizing at least some acts of suicide and voluntary euthanasia. In this paper, I argue that, in fact, when we scrutinize the reasons for most end of life decisions, it turns out that they are seriously problematic from the point of view of autonomy. Full autonomy requires that we are responsible for the consequences of our decisions, and responsibility is precluded by non-voluntariness, which is to say decisions made because there are no acceptable alternatives. Since most end of life decisions are made for precisely this reason, it looks as though most such decisions are non-voluntary, and therefore undermine our autonomy: a discomforting and paradoxical claim. I argue that we should respond by taking the paradox to illuminate the context required by an autonomy-respecting framework for legalizing assisted suicide and euthanasia. People should have a legal right to a reasonable choice about when and how to die. However, this must go hand in hand with institutions that ensure, as far as possible, that such choices are made against a background which ensures, as far as possible, that people choose death clear-sightedly and not because nothing else is acceptable. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Affect Attunement in the Caregiver-Infant Relationship and Across SpeciesExpanding the Ethical Scope of ErosCynthia WillettCompelling glimpses into the ethical capacities of our animal kin reveal new possibilities for ethical relationships encompassing humans with other animal species. Consider the remarkable report of a female bonobo in a British zoo who assists a bird found in her cage by retrieving the fallen bird, and spreading its wings so that this fellow (...) creature might fly away to its freedom. Or the report of a cat in a nursing home who curls up around dying elderly patients, and remains steadily by their side as they, unbeknownst to the medical personnel, pass away.1 Or of a sacred moment of silence by a stream for baboons in East Africa.2 Or of the ethics that spontaneously emerges among wolves at play.3 On the basis of extensive studies, biologist Frans de Waal argues that such anecdotes are far from rare, and that some core elements of moral understanding and compassion occur among a significant range of nonhuman as well as the human animal species. Apes, monkeys, and perhaps all nonhuman animals fail to display a distinctly human capacity for abstract moral reasoning. As de Waal (2006) remarks, it is difficult to tell (173–75). But our furry and feathery kin do without a doubt demonstrate rich elements of ethical response, and they often enough extend their moral concern to creatures beyond their own species. Of course, they will also bite each other’s heads off or eat their own young as well. But this is just to say that animals are neither natural [End Page 111] innocents nor savage brutes. Like us, they belong to what post-Nietzschean philosophers might frame, somewhat ironically, as a postlapsarian world of good and evil.What kind of philosophical approach could account for these postlapsarian genealogies of ethics? Biologists, primatologists, and anthropologists are drawing upon investigations of prosocial behavior to remap the boundaries of ethics, as for example in Isabelle Stengers’s call for cosmopolitical ecologies of relationships (2010, 33). Such a cosmopolitics aims to encompass our kin and kind from diverse species within the ethical boundaries of common worlds. Donna Haraway discovers an opening for Stengers’s ecology of relationships in the intimate encounters among co-evolving species, especially those she calls companion species (2008, 83). She argues, following Derrida, that the abstract reasoning processes of Stoic and Kantian cosmopolitan ethics remain closed to the participation of nonhuman animals as anything more than dependents, failing to observe the ways in which they act as companions, if not moral subjects. But then, what normative force might bind together an ethically attuned biosocial sphere that we as humans co-inhabit with other animal species?To explore this question, this essay takes its cues from well-established research on the responsive, preverbal connection of the human infant and adult caregiver (Bateson 1979; Trevarthen 1984; Stern 1985, 2010; Gibbs 2001, 2010; Hansen 2004; Anderson 2006; Papoulias and Callard 2010; Willett 1995, 2001). To this research we can add new animal studies (Smuts 1999, 2001; Fudge 2002; de Waal 2006, 2009; Bekoff 2007; Molnar 2008; Haraway 2008). These animal studies provide a basis for extending an “ethics of eros” with roots in Luce Irigaray, Michel Foucault, Enrique Dussel, Africana feminism, Freudo-Marxist critical theory, and Plato (for discussions of this tradition, see Bergoffen 1997; Huffer 2009; Willett 2001)—but reconfigured in terms of social bonds across multiple animal species. In this tradition of ethics, the lack of a cognitive-based moral subjectivity that can translate into human terms does not consign nonhuman species to a mute moral status. On the contrary, some more primordial basis for relationship and meaning may weave thin but substantial threads of a postmoral ethics across regions of the biosphere.Given the diverse modes of subjectivity among animal species, and even the lack of what we call a moral subject altogether in many species, neither ordinary modes of empathy nor of moral understanding go very far in forging multispecies social bonds. For this reason, we turn to research on “the attunement of affects” in the infant-caregiver relationship (Stern 1985). As we shall see, this... (shrink)

This is the second edition of the textbook Bioethics in Canada. It is the most up to date bioethics textbook on the Canadian market. Twenty-nine of its 54 contributions are by Canadians. All the chapters carried over from the first edition are revised in full (especially the chapters on obligations to the global poor, on medical assistance in dying, and on public health). It comprises *new* chapters on emerging genetic technologies and on indigenous peoples' health. It contains *new* case (...) studies focusing on ethical issues and problems of relevance to Canadians. From the Preface: This anthology is designed for those teaching bioethics in colleges and universities in Canada. It comprises articles from researchers exploring the main problems of bioethics from a diversity of perspectives and ethical traditions. It includes in particular articles by Canadian researchers who appear in anthologies less often than they should. The hope is that the reader will, as a result, better appreciate the rich reservoir of talent present among those working in bioethics in Canada and Canadian bioethicists working abroad. In addition, this volume intentionally aims to educate the reader about the policies and laws regulating the most important and pressing bioethical problems facing Canadians. The hope is that the reader will develop a nuanced view of the nature, importance, and impact of bioethics in Canada. (shrink)

Abstract: This working paper focuses on the question whether there is a therapeutic imperative that, in specific situations, would oblige us to perform genome editing at the germline level in the context of assisted reproduction. The answer to this central question is discussed primarily with reference to specific scenarios where preimplantation genetic diagnosis (PGD) does not represent an acceptable alternative to germline genome editing based on either medical, or ethical, or – from the perspective of the potential parents – (...) moral or religious grounds. This article deals with four different types of case constellations that result from these possible reasons against PGD as well as from the necessity or dispensability of a subsequent “control PGD.” These cases are discussed based on hypotheses concerning contextual factors and theoretical assumptions. In conclusion, we point out that if our assumptions are correct, there is probably no therapeutic imperative for genome editing at the germline level. We draw this rationale from the fact that germline interventions are likely not person-affecting. However, we caution the reader that our result is preliminary and needs to be more carefully examined in future work in light of the bioethical debate and potential objections. -/- // Abstract: Im Zentrum dieses Working Papers steht die Frage, ob es einen therapeutischen Imperativ geben kann, der uns, in bestimmten Situationen, verpflichten würde, eine Genomeditierung (genome editing) auf Keimbahnebene im Rahmen der assistierten Befruchtung vorzunehmen. Die Antwort auf diese zentrale Frage wird insbesondere mit Bezug auf Fälle diskutiert, in denen das Verfahren der Präimplantationsdiagnostik (PID) keine aus entweder medizinischen oder ethischen oder – aus Sicht der potentiellen Eltern – moralischen bzw. religiösen Gründen akzeptable Alternative zu einem Keimbahneingriff darstellt. Die möglichen Gründe gegen die PID sowie die Erforderlichkeit oder Verzichtbarkeit einer nachfolgenden «Kontroll-PID» ergeben vier verschiedene Fallkonstellationen, denen sich der Beitrag zuwendet. Auf Grundlage von Hypothesen zu kontextuellen Faktoren und theoretischen Annahmen diskutieren wir diese Fälle. Im Ergebnis verweisen wir darauf, dass es, wenn unsere Annahmen zutreffen, vermutlich keinen therapeutischen Imperativ zum genome editing auf Keimbahnebene gibt. Dies begründet sich daraus, dass der Keimbahneingriff vermutlich nicht als personenbezogen (person-affecting) zu bezeichnen ist. Wir weisen jedoch darauf hin, dass unser Ergebnis vorläufig ist und unter Berücksichtigung der bioethischen Debatte und möglicher Einwände genauer geprüft werden muss. -/- // Résumé: Ce Working Paper se concentre sur la question de l’existence d’un impératif thérapeutique qui, dans des situations spécifiques, nous obligerait à réaliser une édition du génome au niveau de la lignée germinale dans le cadre de la procréation assistée. Afin de répondre à cette question centrale nous développons quatre scénarios spécifiques dans lesquels le diagnostic préimplantatoire (DPI) ne représente pas une alternative acceptable à l’édition du génome germinal pour des raisons médicales, éthiques ou – du point de vue des futurs parents – morales ou religieuses. Cet article traite de quatre constellations différentes de cas résultant des raisons mises en avant pour s'opposer au DPI ainsi que de la nécessité ou de l’inutilité d’un ultérieur « DPI de contrôle » Ces cas sont discutés sur la base d’hypothèses portant sur les facteurs contextuels et sur les présupposés théoriques. En conclusion, nous soulignons que si nos hypothèses sont correctes, il n’y a probablement aucun impératif thérapeutique justifiant l’édition du génome au niveau de la lignée germinale. Nous arrivons à cette conclusion parce qu’une intervention au niveau de la lignée germinale n’est probablement pas susceptible d’affecter la personne. Cependant, nous mettons en garde le lecteur sur le fait que notre conclusion est préliminaire et qu’elle doit être examinée avec soin dans des futurs travaux instruits par le débat bioéthique et par les éventuelles objections. (shrink)

Dylan Dog, l’Indagatore dell’Incubo (the nightmare investigator), lives and works at 7 Craven Road in London. The comic book character is English, but he was created in Italy by Tiziano Sclavi in 1986, and it is still published today monthly. Dylan had enormous success, not only in Italy but worldwide. His job is to investigate, together with his assistant, Groucho, the paranormal, the irrational, the nightmare that can assume different forms and aspects. Dylan fights against all types of monsters: vampires, (...) zombies, werewolves, witches, even against Death itself. However, the horror that he faces is not always paranormal. The monsters are often extremely human. Maybe that is the reason why Dylan remains extremely skeptical and rational. Everything in Dylan Dog’s world revolves around the absurd, the chaos without explanation, without sense, and the need to find meaning in it. This chaos can take different forms: the horror that Dylan fights, but also the satirical and nonsense humor of Groucho. This irrational dimension manifests itself also through Dylan’s love and sexual life: in almost every story, Dylan falls in love with a different woman, who usually will die or will break his heart. Love and sex are strongly connected with horror and death in Dylan Dog’s narrative: they are irrational forces, from which it is not possible to escape. The purpose of this essay is to analyze the irrational and fearful dimension in Dylan Dog: l’orrore, as he calls it, but also its connection to sexuality and the comic relief provided by Groucho. This chaotic and monstrous reality will be analyzed mainly—but not only—through the Nietzschean concepts of Apollonian and Dionysian related to the concept of absurd as described by Albert Camus. In this frame, the analysis of René Girard’s Violence and the Sacred will also be helpful. Violence is an irrational and uncontrollable force, and its manifestation is tightly linked with the horror and the monstrous reality that it unveils. (shrink)

Social developments/events of three different periods (Elizabethan Period (1558-1603), Jacobean Period (1603-1625) and Caroline Period (1625-1649) might have had great impact on Ben Jonson’s writing the play Volpone. In this qualitative study (conducted with literature research on the topic), Volpone through which he best reflected his corrupted society at that time will be examined. The play will be analysed to illuminate the native features related to the market economy. The economic sight based on commodity has such a great power in (...) changing the characters of the people, losing their morals because of their greed towards the power and wealth during the mentioned period. Another point to be discussed is to reckon whether Ben Jonson as a Dramatist had contrary opinions against the developing capitalist world. In the study, it has been found that the play of Volpone (the fox) depicts one of the best evidence how the characters can be changed through materialism. As a main character, he is a wealthy Venetian nobleman and exceptionally cunning, who devises a plan (pretending to die) with the assistance of his henchman (Mosca/ fly) to exploit his relatives waiting to be an heir of him. The play shows how his relatives flatter him and give him the most expensive gifts. He deceives each of them at the end. The play draws attention to the materialistic power of the 16th century. (shrink)

D’après Heidegger, chaque époque/épochè est caractérisé par un certain mode de révélation des étants, qui est à la fois une dissimulation d’une façon de l’Être. Ce mode particulier paraît ne venir de nulle part en ce qu’il se base sur un certain oubli. Dana S. Belu le met en scène pour son livre en faisant valoir la tendance de Heidegger « to treat the history of being (Seinsgeschichte) as a noncausal succession of universal principles of intelligibility that presupposes the forgetting (...) (Seinsvergessenheit) of the clearing (die Lichtung) as their source » (p. 15). L’oubli de notre époque est marqué par une divulgation technologique dans le mode de l’arraisonnement (Gestell) où les étants se révèlent comme partie du fonds (Bestand) d’être calculés, manipulés, exploités, et mis en réserve pour un usage ultérieur. La phénoménologie féministe de l’A. essaie de faire sens à la gestation, la maternité et la procréation médicalement assistée (PMA) qui font aux femmes faire partie de ce fonds et ouvre, parmi les paramètres du Gestell, la porte à une ère « sans mère ». (shrink)

The review of this anthology of essays shows the lifelessness of the contributors. They systematically misread everyone from Plato to Kierkegaard. The false ratiocination about love is also foregrounded in this review. Earlier this reviewer had the misfortune to review The Oxford Handbook of the Philosophy of Death . Then an American cloistered Benedictine Abbot wrote to this author in an email this: ""Yes, indeed, the book is not very serious. When the authors die some day, they will understand better, (...) as we all shall see". And this same Abbot has written this after reading this review: "Yes, Professor, for some time now, our Western culture, having lost its reference to authentic Christianity, prefers to indulge in the self-pity of a kind of false heroism of resignation in the face of death. There is no sense of immortality, therefore, the modern Hamlet perceives himself as a tragic hero who glories in his empty agnosticism and admires his own resolution in the face of the inevitable. Neither East nor West ever really lived from such a Philosophy: only the decadent Christian or Jew. But the reality is elsewhere. Thanks. " It must be remarked I am just a tenured Assistant Professor but the Abbot does not listen. Further, this book along with that earlier book this author reviewed on the philosophy of death can now be contextualized in the light of the resurgence of Covid 19. Basic epidemiology says its going nowhere soon. Therefore everyone everywhere has experienced death in ways we never imagined. The contributors to this anthology too were too glib in their times. And now, they have experienced death. These books arise from loveless lives which hover around departmental chairs and absurd academic flip-flops to gain brownie points. Perhaps, they were all as prescient as the Abbot. The editor, for reasons known alone to him, has given the meaning of facile in square brackets. (shrink)