In her paper, The case for physician assisted suicide: not proven, Bonnie Steinbock argues that the experience with Oregon’s Death with Dignity Act fails to demonstrate that the benefits of legalising physician assisted suicide outweigh its risks. Given that her verdict is based on a small number of highly controversial cases that will most likely occur under any regime of legally implemented safeguards, she renders it virtually impossible to prove the case for physician (...) assisted suicide. In this brief paper, we suggest some ways that may enable us to weigh the risks and benefits of legalisation more fairly and, hopefully, allow us to close the case for physician assisted suicide. (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)

Advocates of physician-assisted suicide often argue that, although the provision of PAS is morally permissible for persons with terminal, somatic illnesses, it is impermissible for patients suffering from psychiatric conditions. This claim is justified on the basis that psychiatric illnesses have certain morally relevant characteristics and/or implications that distinguish them from their somatic counterparts. In this paper, I address three arguments of this sort. First, that psychiatric conditions compromise a person’s decision-making capacity. Second, that we cannot have (...) sufficient certainty that a person’s psychiatric condition is untreatable. Third, that the institutionalisation of PAS for mental illnesses presents morally unacceptable risks. I argue that, if we accept that PAS is permissible for patients with somatic conditions, then none of these three arguments are strong enough to demonstrate that the exclusion of psychiatric patients from access to PAS is justifiable. (shrink)

In this article, I argue that depression and suicide are natural kinds insofar as they are classes of abnormal behavior underwritten by sets of stable biological mechanisms. In particular, depression and suicide are neurobiological kinds characterized by disturbances in serotonin functioning that affect various brain areas (i.e., the amygdala, anterior cingulate, prefrontal cortex, and hippocampus). The significance of this argument is that the natural (biological) basis of depression and suicide allows for reliable projectable inferences (i.e., predictions) to (...) be made about individual members of a kind. In the context of assisted suicide, inferences about the decision-making capacity of depressed individuals seeking physician-assisted suicide are of special interest. I examine evidence that depression can hamper the decision-making capacity of individuals seeking assisted suicide and discuss some implications. (shrink)

Euthanasia and assisted suicide have proved to be very contentious topics in medical ethics. Some ethicists are particularly concerned that allowing physicians to carry out these procedures will undermine their professional obligations and threaten the very goals of medicine. However, I maintain that the fundamental goals of medicine not only do not preclude the practice of euthanasia and assisted suicide by physicians, but can in fact be seen to support these practices in some instances. I look (...) at two influential views of the goals of medicine, one based on the broad guiding principles of autonomy, beneficence and nonmaleficence, and the other focusing on several more concrete aims, concluding that both approaches can be seen to support euthanasia and assisted suicide. I then turn to the popular concern that allowing physicians to carry out euthanasia and assisted suicide will lead to widespread abuse. I argue that the possibility for abuse can be minimised if we make the patient's autonomous consent an essential requirement of the practice. (shrink)

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)

Addressing the question in the form of Kant’s maxim, this paper moves on to a more controversial topic in biomedical ethics, physician-assisted suicide. However, my conclusion is tentative, and what is worse, negative: I partially approve suicide. It does not imply a moral hazard. The situation is opposite: in the present times, terminal patients seriously wish it. I, as an author, put an emphasis on this very respect. Now suicide is, for certain circles, nothing but (...) justice. The arguments of thinkers who approve suicide are also cited from this angle. (shrink)

Kant has famously argued that human beings or persons, in virtue of their capacity for rational and autonomous choice and agency, possess dignity, which is an intrinsic, final, unconditional, inviolable, incomparable and irreplaceable value. This value, wherever found, commands respect and imposes rather strict moral constraints on our deliberations, intentions and actions. This paper deals with the question of whether, as some Kantians have recently argued, certain types of (physician-assisted) suicide and active euthanasia, most notably the intentional (...) destruction of the life of a terminally-ill, but rational and autonomous patient in order to prevent certain serious harms, such as enduring or recurring pain or the loss of the meaning in life, from befalling him really are inconsistent with respect for the patient’s human dignity. I focus on two independent, though interrelated explications of the rather vague initial idea that the patient (as well as the doctor), in intending and bringing about his death, treats his person or rational nature merely as a means and so denigrates his dignity: (i) that in doing what he is doing, he does not act for the sake of his person, but for the sake of something else; (ii) that, by trading his person for pain relief, he engages himself in an irrational and hence immoral exchange. After critically discussing some suggestions about how to understand this charge, I eventually find Kantian objections to suicide and (active) euthanasia, based on the idea of human dignity, less than compelling. For all the paper proves, suicide and (active) euthanasia may still be morally impermissible, but then this must be so for some other reason than the one given above. (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)

[On the Ethics of Euthanasia Again: A Reply to Critics] The article is a reply to three critics of a previous piece on the ethics of euthanasia in which I defended physician-assisted suicide. According to Ingrid Strobachová it is necessary to give a greater attention to the significance of pain, which, she claims, may benefit from a phenomenological description. According to Marta Vlasáková my argument is not valid because two principles on which it is founded – i.e. (...) the conception of life as of fundamental value and the autonomy of the patient – are not in mutual harmony. Jakub Jirsa criticises the very concept of assisted suicide and the moral legitimacy and need for the legalisation of assisted suicide. To Dr Strobachová I reply that phenomenological description is as acceptable a method as any other – as long, that is, as it is not only a verbal game, but constitutes a real source of knowledge. To Dr. Vlasáková I argue that a more charitable reading of my argument is possible. The arguments of Dr. Jirsa against assisted suicide are beset with various inconsistencies, including the fact that he himself allows that doctors should tolerate suicide by the refusal of food and drink. Such an act does not, however, differ in any relevant way from doctor-assisted suicide. (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)

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)

Abstract: In Vacco v. Quill, 521 U.S. 793 (1997), the Supreme Court for the first time in American case law explicitly applied the principle of double effect to reject an equal protection claim to physician-assisted suicide. Double effect, traced historically to Thomas Aquinas, proposes that under certain circumstances it is permissible unintentionally to cause foreseen evil effects that would not be permissible to cause intentionally. The court rejected the constitutional claim on the basis of a distinction marked (...) out by the principle, i.e., between directly intending the death of a terminally ill patient as opposed to merely foreseeing that death as a consequence of medical treatment. The Court held that the distinction comports with fundamental legal principles of causation and intent. Id. at 802. -/- Critics allege that the principle itself is intrinsically flawed and that, in any event, its employment in Vacco is without legal precedent. I argue in response to contemporary objections that double effect is a valid principle of ethical reflection (Part II); claims to the contrary notwithstanding, double effect analysis is a pervasive, albeit generally unacknowledged principle employed regularly in American case law (Part III); and drawing on the preceding two sections, Vacco's application of the principle of double effect is appropriate (Part IV). -/- My conclusion is that [o]peration of some form of the principle, by whatever name, is inevitable. In an imperfect world where duties and interests collide, the possibility of choices of action foreseen to have both good and evil consequences cannot be avoided. In rare circumstances, ethics and the law require that a person refrain from acting altogether. More often, however, they provide that a determination of whether an actor may pursue a good effect although knowing it will or may unintentionally cause an harmful effect requires a more complex analysis - a double effect analysis. -/- Keywords: Equal protection, double effect, intention, physician-assisted suicide, Constitutional Law, Bioethics. (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 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.

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)

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 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.

Arguments concerning central issues of contemporary Medical Ethics often not only bear similarities, but also derive their sheer essence from notions which belong to the celebrated history of Ethics. Thus, argumentation pro euthanasia and assisted suicide which focus on the detainment of dignity and the ensuring of posthumous reputation on behalf of the moral agent is shown to echo stoic views on arête and the subordination of life to the primary human goal, namely the achievement of virtue. The (...) progress made in palliative care when seen alongside the — steadily increasing — requests for suicide, is indicative of the fact that, though pain now days can be effectively controlled, moral agents often consider the preservation of their life detrimental to the detainment of virtue or posthumous reputation. The stoic view is considered to justify elective death as a personal choice, but is deemed inadequate as well as inconsistent in the broader context of a coherent value theory. (shrink)

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)

Most people who defend physician-assisted death (PAD) endorse the Joint View, which holds that two conditions—autonomy and welfare—must be satisfied for PAD to be justified. In this paper, we defend an Autonomy Only view. We argue that the welfare condition is either otiose on the most plausible account of the autonomy condition, or else is implausibly restrictive, particularly once we account for the broad range of reasons patients cite for desiring PAD, such as “tired of life” cases. Moreover, (...) many of the common objections to an Autonomy Only view fail once we understand the extent of the autonomy condition’s requirements—in particular, the importance of one’s values for autonomous choices. If our view is correct, then the scope of permissible PAD is broader than is currently accepted in both the philosophical literature and the law, and therefore poses an important challenge to this widely accepted view on justified PAD. (shrink)

Extended review of Assisted Suicide and Euthanasia: A Natural Law Ethics Approach by Craig Paterson. Ashgate, 2008.

According to Aristotle, the medical art aims at health, which is a virtue of the body, and does so in an unlimited way. Consequently, medicine does not determine the extent to which health should be pursued, and “mental health” falls under medicine only via pros hen predication. Because medicine is inherently oriented to its end, it produces health in accordance with its nature and disease contrary to its nature—even when disease is good for the patient. Aristotle’s politician understands that this (...) inherent orientation can be systematically distorted, and so would see the need for something like the Hippocratic Oath. (shrink)

[Utilitarism, Nazism, and Euthanasia] The article is an answer to Prof. Munzarová who criticised my defence of physician-assisted suicide. The article points to shortcomings in the reply of prof. Munzarová which flow from the author’s underestimation of normative theory. Among these shortcomings are the ignoring of the arguments of her opponent; her calling into question the moral credit of the proponents of the competing theory (utilitarianism) rather than a critical analysis; unclear theoretical principles (a switching between paternalism (...) and autonomy, the presentation of the “principle of double-effect” as the standpoint of common sense); an unconvincing version of the “argument of the slippery slope” (ignoring the diametrical differences between the contemporary demand of some patients for assisted death and the Nazi programme of involuntary euthanasia). (shrink)

Typical philosophical discussions of physician-assisted death have focused on whether the practice can be permissible. We address a different question: assuming that pad can be morally permissible, how far does that permission extend? We will argue that granting requests for pad may be permissible even when the pad recipient can no longer speak for themselves. In particular, we argue against the ‘competency requirement’ that constrains pad-eligibility to presently-competent patients in most countries that have legalized pad. We think pad (...) on terminally ill, incapacitated patients can be morally permissible in cases where advance directives or suitable surrogate decision-makers are available, and should be legally permissible in such cases as well. We argue that this view should be accepted on pain of inconsistency: by allowing surrogate decision-makers to request withdrawal of life-sustaining care on behalf of patients and by allowing patients to request pad, we rule out any plausible justification for imposing a competency requirement on pad. (shrink)

There are common concepts between euthanasia and suicide because euthanasia is historically connected with the discourse on suicide. In widespread literature on euthanasia there is confusion over the concepts and definitions. These definitions are analyzed in this paper and along with other conclusions and distinctions the researcher has substantially defended his definition of euthanasia. There are two different usages of the term euthanasia: a narrow construal of euthanasia and broad construal of euthanasia. Contrary to other researches, the researcher (...) agrees only with the narrow construal of euthanasia, i.e. active euthanasia. The researcher’s definition of euthanasia is: intentionally causing a terminally ill person’s death through an action performed by a physician. As a result, passive euthanasia is expunged from the definition of euthanasia. In addition to that, the definition excludes suicide, assisted suicide, and physician-assisted suicide. (shrink)

Commentary on the European Court of Human Rights judgment in Haas v Switzerland.

There has been much debate regarding the 'double-effect' of sedatives and analgesics administered at the end-of-life, and the possibility that health professionals using these drugs are performing 'slow euthanasia.' On the one hand analgesics and sedatives can do much to relieve suffering in the terminally ill. On the other hand, they can hasten death. According to a standard view, the administration of analgesics and sedatives amounts to euthanasia when the drugs are given with an intention to hasten death. In this (...) paper we report a small qualitative study based on interviews with 8 Australian general physicians regarding their understanding of intention in the context of questions about voluntary euthanasia, assisted suicide and particularly the use of analgesic and sedative infusions (including the possibility of voluntary or non-voluntary 'slow euthanasia'). We found a striking ambiguity and uncertainty regarding intentions amongst doctors interviewed. Some were explicit in describing a 'grey' area between palliation and euthanasia, or a continuum between the two. Not one of the respondents was consistent in distinguishing between a foreseen death and an intended death. A major theme was that 'slow euthanasia' may be more psychologically acceptable to doctors than active voluntary euthanasia by bolus injection, partly because the former would usually only result in a small loss of 'time' for patients already very close to death, but also because of the desirable ambiguities surrounding causation and intention when an infusion of analgesics and sedatives is used. The empirical and philosophical implications of these findings are discussed. (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 (...) class='Hi'>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)

Without doctors being able to explain medical decisions to patients, I argue their use of black box AIs would erode the effective and respectful care they provide patients. In addition, I argue that physicians should use AI black boxes only for patients in dire straits, or when physicians use AI as a “co-pilot” (analogous to a spellchecker) but can independently confirm its accuracy. I respond to A.J. London’s objection that physicians already prescribe some drugs without knowing why they work.

When terminally ill patients have had enough suffering they often turn to euthanasia. The Assisted suicide is still unethical and illegal in most countries. As of now it is practiced in the Netherlands but still considered illegal. The few that still use euthanasia have to go through a certain legal route. Often patients have had enough and find it easier to take matter into their own hands or in this case let the doctors help in assisting with ending (...) their life. There are many different reasons why it is bad to euthanize patients and by writing this article I will explain a few of those reasons. My report will help understand why euthanasia is still illegal in most countries. Using euthanasia is unethical for physicians and goes against the oath they took to protect and do no harm to patients and no matter under what circumstances it is still illegal. Euthanasia is an unnatural way to end life. Using Euthanasia to end one patients life is still considered murder and unethical. (shrink)

Sports physicians are continuously confronted with new biotechnological innovations. This applies not only to doping in sports, but to all kinds of so-called enhancement methods. One fundamental problem regarding the sports physician's self-image consists in a blurred distinction between therapeutic treatment and non-therapeutic performance enhancement. After a brief inventory of the sports physician's work environment I reject as insufficient the attempts to resolve the conflict of the sports physician by making it a classificatory problem. Followed by a (...) critical assessment of some ideas from the US President's Council on Bioethics, the formulation of ethical codes and attempts regarding a moral topography, it is argued that the sports physician's conflict cannot be resolved by the distinction between therapy and enhancement. Instead, we also have to consider the possibility that the therapy-based paradigm of medicine cannot do justice to the challenges of the continuously increasing technical manipulability of the human body and even our cognitive functions as well. At the same time we should not adhere to transhumanist ideas, because non-therapeutic interventions require clear criteria. Based on assistive technologies an alternative framework can be sketched that allows for the integration of therapeutic and non-therapeutic purposes. After a thorough definition of standards and criteria, the role of the sports physician might be defined as that of an assistant for enhancement. Yet the process of defining such an alternative framework is a societal and political task that cannot be accomplished by the sports physicians themselves. Until these questions are answered sports physicians continue to find themselves in a structural dilemma that they partially can come to terms with through personal integrity. (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)

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)

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)

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)

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)

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)

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)

The aim of this study is to elucidate Burton’s conception of suicide. To understand it, it is first necessary to find out how Burton understood its main cause, melancholy. The first part of the study is therefore dedicated to an analysis of the concept of melancholy elaborated in his Anatomy of Melancholy. Conclusions drawn from this analysis are then used in the second part of this work to explain Burton’s notion of suicide and the treatment or prevention he (...) suggests. In both parts, the main focus is on the Anatomy of Melancholy, which is used to explain both Burton’s position and intentions which motivated the writing of this treatise and his lifelong interest in the subject. The study is thus a contribution to research which views Burton’s thoughts and work within a historical, cultural, and conceptual context of Early Modern world but also to investigations of the impact of the work and Burton’s strategy regarding the effect the work should have on readers. Conclusions of this study point out the complexity and sophistication of Burton’s concept of suicide and show that it significantly diverges from the view commonly taken by contemporary judges, coroners, clergy, and physicians who also sometimes dealt with this issue. (shrink)

This study investigated changes in the prevalence of depression, stress, and suicidal attempts during the COVID-19 pandemic. The ≥19-year-old population in the Korea National Health and Nutrition Examination Survey in 2019 and 2020 was included. The histories of depression, stress, and suicidal attempts were compared between the 2019 and 2020 cohorts using multiple logistic regression analysis with complex sampling. The prevalence of depression was not significantly different between the 2019 and 2020 groups (4.1% vs. 4.5%, p = 0.326). The prevalence (...) of stress and suicide attempts was also not significantly different between groups (all p > 0.05). The rates of depression, stress, and suicide attempts were not associated with the 2020 group compared to the 2019 group (all p > 0.05). The 19- to 39-year-old group in the 2020 group indicated a higher rate of depression (diagnosed by physicians) than the 19- to 39-year-old group in the 2019 group (adjusted odds ratio = 1.58, 95% confidence intervals = 1.00–2.50, p = 0.049). The risks of depression, stress, and suicidal attempts were not related to the COVID-19 pandemic in Korean adults. A young adult population demonstrated an increased risk of depression associated with the COVID-19 pandemic. (shrink)

In their insightful article, Brent Kious and Margaret Battin (2019) correctly identify an inconsistency between an involuntary psychiatric commitment for suicide prevention and physician aid in dying (PAD). They declare that it may be possible to resolve the problem by articulating “objective standards for evaluating the severity of others’ suffering,” but ultimately they admit that this task is beyond the scope of their article since the solution depends on “a deep and difficult” question about comparing the worseness of (...) two possible scenarios: letting someone die (who could have been helped) with not letting someone die (whose suffering could only be alleviated by death). In our commentary, we argue that creating such standards is more difficult than the authors assume because of the many types of deep uncertainties we have to deal with: (1) diagnostic, (2) motivational, and (3) existential. (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)